Clinical comment

In the presenting case, the patient has no evidence of any neuromuscular or syndromic etiology to explain his isolated foot deformities. Around the world, the Ponseti method has largely replaced other methods of casting, such as those described by Kite, and intra‐articular surgical releases as the treatment of choice of idiopathic clubfeet.¹ What is the evidence that justifies this dramatic change in practice? How often is correction achieved by the Ponseti method maintained? What are the recurrence rates compared with other methods?

Available literature and quality of the evidence

• Level II: 5 studies⁵–⁹
  
• Level III: 5 studies¹⁰–¹⁴
  
• Level IV: 4 studies.¹⁵–¹⁸

Findings

Reviewing the literature for CTEV reveals several important limitations. There is little consensus amongst clinicians about how to categorize and quantify the severity of CTEV. Treatment algorithms and casting and/or surgical techniques differ between providers and even evolve for a single provider. There is little clarity about what constitutes residual (partially treated) or recurrent (relapsed) deformity, and the indications for and timing of further intervention, and how we define a good outcome. Therefore, most studies have mixed cohorts of patients, loosely defined criteria for a relapse, and variable indications for additional surgical procedures, and a lack of validated patient/parent‐reported outcomes.

How does the Ponseti method of casting compare with the Kite and other methods?

The two randomized controlled trials (RCTs) comparing the Ponseti method to the Kite method showed significantly faster rates of correction of deformity.⁸,⁹ Sud et al. reported correction in 33 of 36 feet (91.7%) in the Ponseti group with seven (21%) relapses,⁹ while the Kite method achieved correction in 21 of 31 feet (67.7%) with 10 patients (32.2%) of feet requiring conventional surgery. In a prospective cohort study reported by Halanski et al.,¹⁰ 40 clubfeet (26 children) treated by the Ponseti method group were compared with 46 feet (29 children) treated with below‐knee casting. The Ponseti group required an average of six casts compared with 11 in the below‐knee group. At an average of a 3.8‐year follow‐up, 12/26 patients in the Ponseti group needed more than a percutaneous tenotomy compared with 27/29 patients in the below‐knee casting group. However, major posterior or posteromedial releases (PMRs) were only required in 4/40 feet in the Ponseti group compared with 43/46 in the below‐knee group. Herzenberg et al. showed only one of 34 feet (3%) required a PMR in the Ponseti group versus 34 feet (94%) in the traditional casting method group.¹⁴ Derzsi et al. showed a failure rate of 30.3% in the Kite group and of 8.5% in the Ponseti group.¹³

Steinman et al. compared the results of the French method of manipulation and taping by daily physical therapy in 80 children (119 feet) with the Ponseti method for 176 patients (267 feet) at an average of a 4.3‐year follow‐up.¹¹ The initial correction rates and relapse rates were 94.4 and 37% for the Ponseti method and 95 and 29% for the French functional method. Two‐thirds of the relapsed feet in the Ponseti group and all of the relapses in the French method group required operative intervention. At the time of the latest follow‐up, the outcomes for the feet treated with the Ponseti method were good for 72%, fair for 12%, and poor for 16%. The outcomes for the feet treated with the French functional method were good for 67%, fair for 17%, and poor for 16%. When offered both treatments, parents preferred the Ponseti method to the French method at a ratio of 2 : 1.

How do the outcomes of the Ponseti method (casting and percutaneous tendo Achilles tenotomy) compare with surgical releases of idiopathic clubfeet?

The meta‐analysis (mostly of cases series) by Lykissas et al. reviewed 12 studies from 1950 to 2011 that included 835 idiopathic clubfeet in 516 patients treated with either Ponseti method or surgical release with outcomes measured by the Laaveg‐Ponseti Function Rating System (L‐P FRS) score, and at least three radiographic outcome measures.⁵ Average follow‐up was 15.7 ± 10.8 years (range 1–42 years). Patients managed with the Ponseti method had a higher rate of excellent or good outcomes over those with open surgery. Zwick et al. randomized 19 infants with 28 CTEV to the Ponseti method and 10 infants with 16 CTEV to a surgical method that included limited pre‐ and postoperative casting.⁶ The L‐P FRS and PODCI scores at an average of 3.3‐year follow‐up revealed good to excellent results for both groups, but parental satisfaction and passive mobility were better in the Ponseti method group. In a prospective case series, Smythe et al. reported excellent initial correction with 337 feet in 218 children showing that 85% of feet reached a Pirani score of 1 or less at the end of the correction phase.¹⁸

With respect to motor functional outcomes, Aulie et al. in a retrospective cohort study, compared the motor function of 89 children treated with primary surgery, 93 children treated with the Ponseti method, and 45 age‐matched normative peers, using the Motor Assessment Battery for Children (MABC‐2).¹² There was no difference between the Ponseti and surgical groups. However, in the clubfoot groups, only 76% had normal abilities compared with 96% of children without clubfeet.

What are the rates of recurrence following the Ponseti method?

In a systematic review by Thomas et al. looking at relapses, the studies included were all case series and showed a wide range of recurrence rates from 3.7 to 67.3%.¹⁵

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