Editor’s note: The following content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting, but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage at aaos.org/VirtualAAOS2020.

The Ponseti method was introduced in 1948 and is the most effective treatment for clubfoot; however, relapse can occur and result in significant long-term morbidity for patients if inappropriately managed.

A study found that, when performed correctly, the Ponseti method is an effective nonsurgical treatment for clubfoot. Malynda Wynn, MD, of the University of Iowa Hospitals and Clinics, presented the study as part of the Annual Meeting Virtual Experience.

The researchers noted that family education on the importance of bracing is necessary. “Bracing is crucial for prevention of relapses in idiopathic clubfoot,” Dr. Wynn told AAOS Now. “Without proper brace use, children have a significantly greater risk of relapse. Therefore, an appropriate and comfortable brace and family education about the importance of bracing is paramount.”

Researchers retrospectively reviewed the medical records of patients with congenital idiopathic clubfoot treated at a single institution between 1948 and 2013. Multivariate analysis was used to assess the effect bracing compliance had on relapse rates. Patients were categorized as those who received treatment prior to presentation at the institution and those who had not received prior intervention.

Researchers assessed the average rate of relapse by decade over the 65-year period. Adherence was determined by parent-reported brace use, while nonadherence with bracing protocol was defined as parents reporting that the brace had not been worn continuously since last follow-up.

The study included 1,012 patients (mean age, 3.5 months; range, 3.0 days to 8.8 years; 67.8 percent were male patients), with 1,581 total clubfeet. Family history of clubfoot was reported in nearly a quarter (23.5 percent) of patients. Researchers observed bilateral clubfoot in 29.1 percent of patients, isolated right sided clubfoot in 52.1 percent of patients, and isolated left sided clubfoot in 18.9 percent of patients.

More than half of patients (60.1 percent) had received prior treatment before presentation at the institution, including 13.5 percent who underwent prior surgery. The average number of casts for initial correction was 5.3 for patients who did not undergo prior treatment versus 3.8 for patients who did.

Among those who did not undergo prior treatment and who were compliant with bracing, relapse rates decreased over time, with a rate of 13.8 percent in the most recent data collection from 2000 to 2013.

“The most staggering finding was the difference in relapse rates seen between patients who followed bracing protocol and those who did not,” Dr. Wynn. “Brace noncompliance occurred in most patients (94.1 percent) who relapsed. However, among those who properly adhered to the bracing protocol and did not receive prior treatment, the overall relapse rate was just 11.9 percent.” Brace nonadherence was observed in 28.6 percent of patients (Table 1). Among patients who relapsed, 87.1 percent experienced one relapse, while 12.9 percent experienced two or more relapses.

Age, gender, family history, unilateral versus bilateral clubfoot, and prior treatment did not have a statistically significant impact on relapse. However, increasing number of casts and brace compliance did statistically significantly impact relapse (P < 0.0001) (Table 2).

Regardless of prior treatment or bracing adherence, the risk of clubfoot relapse significantly decreases after six years of age in all patients, according to the study. The most common age during which relapse was seen was at 5 years of age (15 percent), likely due to brace discontinuation at this age, said the authors.

“Most families will follow the provider’s recommendations, but some may not, and these families require more effort for them to understand the critical importance of bracing,” Dr. Wynn said. “Blaming families for not adhering to the bracing and moving to a decision for surgical correction is not in the best interest of these patients. Furthermore, following the details and protocols as originally described by Dr. Ponseti does lead to consistent outcomes. It is when deviations occur that relapses most often occur.”

The study is limited by its retrospective design.

Dr. Wynn’s coauthors of “Clubfoot Relapse Rates Using the Ponseti Method: A 65-Year Follow Up from a Single Institution” are Jill Corlette, MS; Andrew Holte, MD; Erin S. Wilson, BS; Natalie Glass, PhD; and Jose A. Morcuende, MD, PhD.

Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at kefitzgerald@aaos.org.