SLR - March 2020 - Jennifer A. Skolnik

Brace Yourselves: Outcomes of Ponseti Casting and Foot Abduction Orthosis Bracing in Idiopathic Congenital Talipes Equinovarus

Reference: Kuzma AL, Talwalkar VR, Muchow RD, Iwinski HJ, Milbrandt TA, Jacobs CA, Walker JL. Brace Yourselves: Outcomes of Ponseti Casting and Foot Abduction Orthosis Bracing in Idiopathic Congenital Talipes Equinovarus. J Pediatr Orthop. 2020 Jan; 40(1): e25-29.

Scientific Literature Review

Reviewed By: Jennifer A. Skolnik, DPM
Residency Program: Temple University Hospital – Philadelphia, PA

Podiatric Relevance: Treatment of idiopathic congenital talipes equinovarus can present numerous challenges to the treating physician particularly including the risk of recurrence of deformity after initial treatment. Initial treatment typically includes serial Ponseti casting with or without Achilles tenotomy followed by foot abduction orthosis bracing for the first few years of life. Bracing is first worn full time and later weaned to part time. The aim of this study was to evaluate outcomes of casting and foot abduction bracing in the treatment of idiopathic congenital talipes equinovarus. The authors hypothesized that patients who demonstrated less compliance with bracing would have higher rates of recurrence.

Methods: This study followed a previously identified prospective cohort of patients with idiopathic clubfoot deformity. Patients were followed until age 5 or recurrence of the deformity was noted. Forty-two patients or 64 feet met inclusion criteria for the study. Deformity severity was documented at initial treatment as was patient demographic information. Duration of casting and the age which casting was initiated and completed were recorded. Compliance was also documented through the use of diaries or sensors in the braces in a smaller, randomized cohort of patients. Statistical analysis was completed and binary regression was used to determine if any factors were predictive of recurrence.

Results: In the present study, 26/64 or 40 percent of patients were noted to have recurrence of deformity which necessitated additional treatment. Additionally, 20 patients could not tolerate the initial Denis-Browne Bar and were switched to the Mitchell-Ponseti Brace. Seventy percent of those patients were noted to have recurrence. Age of patients at start of bracing and duration of casting were found to be significantly associated with recurrence. Regression analysis demonstrated that the number of casts, specifically nine or more casts, was predictive of recurrence. This may be an indirect measure reflecting the severity of deformity.  Dimeglio score was not noted to be a predictor of recurrence. Compliance with bracing was also not seen to be related to recurrence in the current study.

Conclusions: Based on the results of the study, the authors note that compliance was not a predictive factor of recurrence, despite this being noted in previous studies. In the present study, only the number of casts was found to be predictive and therefore the authors believe this may provide important information regarding overall prognosis for these patients. Additionally, given the high rate of recurrence in patients requiring a change in bracing during treatment, this may not be the most efficacious approach. This article demonstrates that additional factors aside from compliance should be considered when determining the cause of deformity recurrence for patients with idiopathic clubfoot, particularly if the patient requires a greater number of casts. Specifically, if greater than nine casts are required, this may be indicative of poorer prognosis and higher recurrence and these patients should be followed more closely. 

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