Abstract
Background
The Ponseti method is the gold standard for managing congenital idiopathic clubfoot. Recent modifications, such as the accelerated Ponseti protocol, aim to shorten treatment duration without compromising outcomes. However, evidence comparing its efficacy and safety to the standard protocol remains inconclusive.
Objective
To compare the efficacy and safety of the accelerated versus standard Ponseti method in the treatment of congenital idiopathic clubfoot.
Methods
Eligible studies included randomized controlled trials and prospective comparative studies involving patients with idiopathic clubfoot treated with either accelerated or standard Ponseti methods.
Results
Sixteen studies involving 957 patients were included. There was no significant difference between groups in post-treatment Pirani score [MD =-0.03, 95 % CI (-0.24–0.17), p = 0.75], tenotomy rate [RR = 1.04, 95 % CI (0.99–1.09), p = 0.14], or relapse rate [RR = 1.11, 95 % CI (0.80–1.55), p = 0.54]. However, the accelerated group required slightly more casts [MD = 0.38, p = 0.032] but achieved significantly shorter treatment duration [MD =-20.43 days, p < 0.001]. Subgroup and sensitivity analyses confirmed the robustness of the findings. No major methodological flaws were detected, though blinding was generally lacking.
Conclusion
The accelerated Ponseti method is as effective and safe as the standard protocol, with the advantage of significantly shorter treatment duration. It may be a preferable alternative in appropriate clinical settings, though standardized implementation and long-term follow-up are recommended.
1
Introduction
Congenital idiopathic clubfoot (talipes equinovarus) is a common pediatric deformity characterized by four components (equinus, varus, adductus, and cavus) that result in inward and downward rotation of the foot. It affects approximately 1–2 per 1000 live births, with a higher prevalence in males and bilateral involvement in nearly half of cases. Despite decades of research, the exact etiology remains multifactorial, involving genetic and environmental influences .
The Ponseti method, introduced in the 1940s by Ignacio Ponseti, remains the gold-standard nonoperative treatment for idiopathic clubfoot. It relies on gentle manipulation and weekly serial casting to correct the deformity, often followed by percutaneous Achilles tenotomy and maintenance bracing. This technique achieves excellent long-term correction rates and has largely replaced surgical approaches , .
To reduce treatment duration and improve compliance, a modified version known as the accelerated Ponseti method has been proposed. It follows the same manipulation and casting principles as the standard protocol but shortens the interval between cast changes—typically from once weekly to every 2–3 days. The rationale is that faster correction may reduce caregiver burden and dropout without increasing complications. However, evidence regarding its comparative efficacy and safety remains inconsistent .
Ignacio Ponseti created a non-operative method of treating clubfoot in the early 1940s . The gold standard treatment is the Ponseti technique. Weekly casting and manipulation are required, either with or without percutaneous tenotomy , . Except for ankle equinus, all of the deformity’s components are typically fixed during the first six Ponseti operations and casting sessions , .
While the accelerated Ponseti method is gaining clinical interest for its time efficiency, the evidence comparing it to the standard protocol remains limited and inconsistent. Prior studies vary in design, follow-up duration, and outcome reporting, and few have systematically evaluated key clinical outcomes such as tenotomy rates and relapse. Additionally, the long-term durability of accelerated correction remains underexplored.
Therefore, this systematic review and meta-analysis aimed to evaluate and compare the efficacy (Pirani score improvement, number of casts, treatment duration) and safety (relapse and tenotomy rates) of the accelerated versus standard Ponseti method in the treatment of congenital idiopathic clubfoot by synthesizing data from available prospective and randomized comparative studies. Accordingly, our null hypothesis was that the accelerated and standard Ponseti methods yield equivalent outcomes across these efficacy and safety parameters.
2
Methods
2.1
Study protocol and registration
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines , we carried out this systematic review and meta-analysis. We followed the recommendations of the Cochrane Handbook of Systematic Reviews of Interventions at every turn . With the protocol ID: CRDXXXXXXXXXX , we registered the protocol in PROSPERO.
2.2
Search strategy and data collection
Web of Science (WoS), Scopus, PubMed, and Medline are the four electronic databases that we searched. We searched through every study released up until January 2025 using the keywords mentioned in Supplementary files.
In two screening processes, we evaluated every study that was retrieved for our eligibility requirements. Included are studies that satisfied our eligibility requirements. The references to the earlier reviews and the studies we included were manually screened. Two authors completed all screening, and a third reviewer settled all conflicts.
2.3
Eligibility criteria
We included comparative prospective studies that fulfilled the illustrated PICOs criteria as follows: Population (P): Patients with Congenital Idiopathic Club Foot, Intervention (I): Accelerated Ponseti, Comparison (C): Standard Ponseti, Outcome (O): Efficacy and Safety, and S: study design: RCTs.
2.4
Data extraction and outcome measurement
Any discrepancies in study inclusion or data extraction were discussed, and consensus was reached. When consensus was not possible, a third reviewer adjudicated the decision in accordance with PRISMA recommendations.
2.5
Quality assessment
Two authors assessed the methodology of the included studies using the methodological index for non-randomized studies (MINORS) criteria were employed .
The revised Joanna Briggs Institute (JBI) critical appraisal tool for the assessment of risk of bias for randomized controlled trials was used by two authors to evaluate the methodology of the included studies . A third reviewer settled any disagreements between the authors. The results of the risk of bias assessment were presented in tabular format. The overall risk of bias for each study was not used to exclude studies but was considered during the interpretation of findings.
2.6
Data analysis
The 95 % confidence interval (CI), mean difference (MD), and standardized mean difference (SMD) were used to analyze continuous outcomes throughout the entire record. Risk ratio (RR) and 95 % CI were used to assess dichotomous data. In addition to using chi-squared (Chi²) and I-squared (I²) statistics, statistical heterogeneity between the studies was evaluated visually by examining the forest plot. Significant heterogeneity was indicated by an I2 result of 50 % or more. In the event of significant heterogeneity, a random effect model is employed. Subgroup analyses were conducted based on predefined study characteristics, including study design (RCT vs. non-randomized), follow-up duration, and geographic region, to explore potential sources of heterogeneity. If 10 or more studies are included in a meta-analysis, publication bias was assessed using funnel plots and Egger’s test (p < 0.05 considered significant). The Review Manager (RevMan 5.4) application was used for the analysis.
3
Results
3.1
Screening
A total of 4061 records were identified through database searches. After removing duplicates, 1894 studies were screened during the title and abstract screening. Full-text screening was conducted for 196 studies, of which 180 were excluded. Ultimately, 16 studies met the inclusion criteria and were included in this review. More details are presented in Fig. 1 .
PRISMA flow diagram showing the selection process of studies included in the systematic review and meta-analysis.
3.2
Studies and patient characteristics
This systematic review included 16 studies that compared the standard and accelerated Ponseti methods for the management of congenital idiopathic clubfoot ,,,,,,,,,,,,,,, . The studies were conducted across diverse regions, including Egypt, Pakistan, Iraq, India, Malawi, and North India, with the majority originating from South Asia. Most studies employed a randomized controlled trial (RCT) design, while a few were prospective observational or non-randomized studies.
Sample sizes varied, ranging from 14 to 52 patients per group. The number of treated feet ranged between 20 and 52 per group, reflecting cases of bilateral involvement in some patients. The mean age at treatment initiation was consistently within the early infancy period, although it varied considerably across studies, from as young as 9.84 ± 8.97 days to as high as 117.6 days . Some studies reported age in months, such as Hussain et al. (2022), with a mean of 5.2 ± 1.8 months for the standard group and 5.8 ± 2.4 months for the accelerated group. 16
The sex distribution across studies was generally balanced, with a slight male predominance in most cohorts. Singh et al. (2021) reported a near-equal distribution (10 males and 9 females in the standard group) , while Islam et al. (2020) included 36 males and 14 females in the standard group . A few studies, including Doski et al. (2021) and Ahmad et al. (2019), did not report sex breakdowns for both groups clearly , .
Follow-up durations ranged widely from as short as 3 months , to as long as 71 months . Notably, Elgohary et al. (2015) and Sharma et al. (2016) provided intermediate follow-up periods of 23.38 ± 9.21 and 7.77 months, respectively , . However, 2 studies either did not report follow-up duration , or lacked standard deviation values, limiting precise interpretation.
Across all studies, both treatment arms (standard and accelerated) had comparable baseline characteristics in terms of age and sex, which supports the internal validity of outcome comparisons. The variation in study designs and follow-up durations highlights potential heterogeneity that should be considered in further quantitative analyses. More details were presented in Table 1 .
Table 1
Characteristics of included studies comparing standard and accelerated Ponseti methods.
| Study ID | Region | Study Design | Sample Size (Patients) | Age (Mean, SD)- Days | Sex (M/F, %) | Follow-Up (Mean, SD)- Months | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Standard Ponseti method | Accelerated Ponseti method | Standard Ponseti method | Accelerated Ponseti method | Standard Ponseti method | Accelerated Ponseti method | Standard Ponseti method | Accelerated Ponseti method | |||
| Fatah et al. 2024 | Egypt | RCT | 30 | 30 | 31.43 ± 24.31 Days | 31.17 ± 16.43 Days | 15/15 | 15/15 | 6 | 6 |
| Hussain et al. 2022 | Pakistan | RCT | 52 | 52 | 5.2 ± 1.8 Months | 5.8 ± 2.4 Months | 36/16 | 32/20 | N/A | N/A |
| Doski et al. 2021 | Iraq | Prospective RCT | 23 | 25 | 15.09 ± 19.58 Days | 15.09 ± 19.58 Days | 32/16 | 6 | 6 | |
| Singh et al. 2021 | North India | Prospective RCT | 19 | 21 | 21 ± 10.25 Days | 29 ± 11.25 Days | 10/9 | 12/9 | 12 | 12 |
| Ahmad et al. 2020 | India | Double-blind, prospective RCT | 27 | 28 | 117.6 Days | 94.5 Days | 18/9 | 18/10 | 15 | 15 |
| Islam et al. 2020 | India | Prospective RCT | 50 | 50 | 29.2 ± 8.1 Days | 18.2 ± 4.7 Days | 36/14 | 34/16 | 12 | 12 |
| Kumar et al. 2020 | India | Prospective Observational Study | 35 | 35 | 27.5 Days | 24.9 Days | 22/13 | 18/17 | 3 | 3 |
| Ahmad et al. 2019 | Pakistan | RCT | 40 | 40 | 1.6.±0.79 Months | 1.58 ± 0.79 Months | 24/16 | 18/22 | N/A | N/A |
| Dutta et al. 2019 | India | RCT | 32 | 32 | 3.42 + 3.14 Months | 2.89 + 2.62 Months | 19/13 | 17/15 | 6 | 6 |
| Solanki et al. 2019 | Indore, India | Prospective partily RCT | 15 | 14 | 4.71 Months | 2.7 Months | 11/4 | 8/3 | 6.66 ± 2.1 | 7.84 ± 1.9 |
| Barik et al. 2018 | South India | Prospective non-RCT | 15 | 15 | 12.35 ± 16.37 Days | 9.84 ± 8.97 Days | 11/4 | 11/4 | 71 | 68 |
| Mageshwaran et al. 2016 | India | Prospective RCT | 20 | 20 | 28.4 Days | 28.1 Days | 12-Aug | 11/9 | 3 | 3 |
| Sahu et al. 2016 | India | Prospective non-RCT | 27 | 26 | 39.2 Days | 36.8 Days | 23/4 | 15/11 | N/A | N/A |
| Sharma et al. 2016 | India | Prospective Experimental RCT | 20 | 20 | 22.95 ± 11.12 Days | 23.54 ± 11.54 Days | 12/8 | 12/8 | 8.2 | 7.77 |
| Elgohary et al. 2015 | Egypt | Prospective RCT | 20 | 21 | 74.9 ± 43.96 Days | 80.99 ± 48.3 Days | 14/6 | 12/9 | 25.25 ± 8.67 | 23.38 ± 9.21 |
| harnett et al. 2011 | Malawi | Prospective RCT | 21 | 19 | 29 ± 35.77 Days | 21 ± 32.8 Days | 10/11 | 10/9 | 8.6 | 8.13 |
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