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1 3
International Orthopaedics
https://doi.org/10.1007/s00264-021-05092-4
REVIEW ARTICLE
Is themodified Ponseti method effective intreating atypical
andcomplex clubfoot? Asystematic review
OmarA.Al‑Mohrej1,2 · FawazN.Alshaalan3· ThamerS.Alhussainan3
Received: 3 May 2021 / Accepted: 24 May 2021
© SICOT aisbl 2021
Abstract
Purpose In 2006, Ponseti modified the standard technique to treat cases of “atypical” and “complex” clubfoot. To deter-
mine the outcomes of Ponseti’s modified method to treat complex idiopathic clubfoot patients, we asked the following: (1)
What is the deformity correction success rate? (2) What is the relapse rate after the correction? (3) What is the incidence
of complications?
Materials and methods We performed a systematic review by searching the EMBASE, MEDLINE, Cochrane Library, and
Web of Science databases from inception to March 1, 2021. All studies on idiopathic, complex, and atypical clubfoot that
assessed Ponseti’s modified technique were included. Of 699 identified articles, ten met the inclusion criteria. The mean
index for non-randomized studies score for the included studies was 11.8 ± 1.7.
Results Early detection of the deformity and modifying the standard protocol, as described by Ponseti, resulted in a high rate
of success. Initial correction occurred in all children, with a mean ankle dorsiflexion of 15°. Relapse occurred often ranging
between 10.5 and 55%. The incidence of complications associated with the modified Ponseti method ranged from 6 to 30%.
Conclusions Studies using the modified Ponseti technique have shown high initial correction rates and a smaller number of
relapses. However, studies with prospective designs and long-term follow-up are required to conclude whether these obser-
vations are due to properly performing the modified method or if higher rates of relapse increase with further follow-up.
Keywords Clubfoot· Idiopathic· Atypical· Complex· Modified Ponseti· Relapse· Systematic review
Introduction
Since the emergence of the Ponseti method, the idiopathic
clubfoot surgical release rate has decreased significantly [1,
2]. Idiopathic clubfoot is a group of deformities that involve
the hindfoot varus, cavus, metatarsus adductus, and equi-
nus. The estimated incidence of idiopathic clubfoot ranges
from 0.5 to 2 per 1000 live births [3]. Within the idiopathic
clubfoot designation, “atypical” and “complex” clubfeet
have been identified [4]. Atypical idiopathic clubfeet are
distinguished by significant features that are not present in
“simple” idiopathic clubfeet. These include severe plantar
flexion of all metatarsals, a rigid equinus with a deep crease
above the heel, and a deep plantar crease across the full
width of the sole of the foot with high cavus and a short
hyperextended big toe [5, 6]. The exact incidence of atypical
clubfoot remains unclear, ranging from 6.5 to 21% accord-
ing to various studies [7, 8]. As for complex clubfoot, it
has been postulated that improper casting of predisposed
feet can convert a typical clubfoot into a one that resembles
the features of atypical idiopathic clubfoot termed “complex
iatrogenic clubfoot” [10].
The aetiology of atypical clubfeet remains inadequately
understood. Nevertheless, shortening and tightness of the
gastrocsoleus muscles and fibrosis of the deep plantar
intrinsic muscles of foot are attributable for this deformity
[9]. Moreover, risk factors for complex deformity include
Level of evidence: Level III
* Omar A. Al-Mohrej
mohrejo@gmail.com
1 Division ofOrthopaedics, Department ofSurgery, McMaster
University, Hamilton, ON, Canada
2 Section ofOrthopedic Surgery, Department ofSurgery,
King Abdullah Bin Abdulaziz University Hospital,
Princess Nourah Bint Abdul Rahman University, Riyadh,
SaudiArabia
3 Department ofOrthopedic Surgery, King Faisal Specialist
Hospital andResearch Centre, Riyadh, SaudiArabia
International Orthopaedics
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a severe clubfoot based on the Pirani classification system,
which includes a short, stubby clubfoot. Furthermore, many
of the complex clubfeet cases appear to be iatrogenic, occur-
ring after the typical idiopathic clubfoot slips in its stretch-
ing casts [10].
Many clinicians, including Ponseti, have attempted vari-
ous methods to treat complex clubfoot. In 2006, Ponseti
modified his standard technique [5]. In comparison to the
standard Ponseti method, plantar flexion of the metatarsals
is corrected by holding the ankle with both hands while the
thumbs are placed under the metatarsals, which are pushed
dorsally to correct the forefoot plantar flexion. Furthermore,
to avoid slippage of the cast, the knee is flexed at least 110
degrees in comparison to the usual 90 degrees [5].
The number of studies regarding complex and atypical
idiopathic clubfoot has increased rapidly since Ponseti modi-
fied his technique to treat these subgroups, and most have
shown consistent success in initial correction rates [5, 9–16].
However, most of the available literature reports wide varia-
tions in relapse and complication rates that are not defined in
a consistent fashion, which may limit appropriate treatment
decisions [11]. Moreover, in most of the available litera-
ture, including the original paper by Ponseti, there seems
to be a lack of clear differentiation between the two sub-
groups which might be the main reason for such discrepan-
cies in recurrence/complications. Therefore, we performed
a systematic review to determine the outcomes of Ponseti’s
modified method to treat complex iatrogenic and atypical
idiopathic clubfoot patients and answer the following ques-
tions: (1) What is the success rate for correcting the deform-
ity? (2) What is the rate of relapse after the correction? (3)
What is the incidence of complications?
Materials andmethods
The study was conducted according to the Cochrane Hand-
book for Systematic Reviews of Interventions Version 6.0
[17] and reported as per the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guide-
lines [18]. This review was not pre-registered. Our institu-
tional review board waived the requirement for approval for
the reporting of this study. All investigations were conducted
in conformity with ethical principles of research.
Search strategy
On March 1, 2021, the authors searched the electronic data-
bases EMBASE, MEDLINE, Cochrane Library, and Web
of Science from database inception. The search included
the following keywords without any limits: “clubfoot” OR
“congenital talipes equinovarus” OR “CTEV” AND “Pon-
seti” OR “modified Ponseti.” Through consultations with
clinical epidemiologists and librarians, such terms were
generated. The search strategy, adapted to each database,
included terms representing the modified Ponseti concept
along with terms addressing idiopathic clubfoot.
Study selection was performed manually by the two
authors (OAM, TSH). The selection of studies was per-
formed in a stepwise manner, first by title, then abstract,
and then full-text review. A resolve-by-consensus strategy
was utilized for all discrepancies. If consensus could not be
reached, a third senior, independent, blinded reviewer was
consulted. This reviewer was not part of the study.
Using the search strategy described above, 699 studies
were identified from the electronic databases. Following
removal of duplicates, irrelevant articles, and articles with
incomplete data, ten articles were included for quantitative
synthesis. Figure1 contains the PRISMA flow diagram.
Inter-rater agreement at each stage of the screening pro-
cess was calculated using Cohen’s Kappa (κ). Based on
previous literature, interpretation of κ values was set and
ranged from κ ≤ 0.20 = no agreement to 0.90 < κ ≤ = almost
perfect agreement [19]. There was strong agreement for the
title/abstract (k = 0.7, 95% confidence interval: 0.6–0.9) and
full-text screening stages (k = 0.9, 95% confidence interval:
0.7–1.0).
Eligibility criteria
All studies on idiopathic, complex, and atypical clubfoot
that assessed Ponseti’s modified technique as an intervention
were included. All patients, regardless of age and ethnic-
ity, were eligible. Studies that reported at least one outcome
related to Ponseti’s modified technique for complex clubfoot
were eligible for inclusion. To maximize potentially eligible
data, there were no restrictions based on publication date,
study design, language, or follow-up. All bibliographies of
the included articles were assessed for further relevant stud-
ies. Also, we performed manual search of pertinent journals
in the field as well as conference proceedings. Studies that
included clubfoot with any known etiology including but
not limited to myelomeningocele and arthrogryposis were
excluded.
Data collection
Data were extracted by each reviewer independently from
eligible papers into a collaborative web-based spreadsheet
(Google Sheets, 2021. CA, USA: Google LLC.). To ensure
accuracy, the results were audited by both reviewers.
Extracted data included information on basic study char-
acteristics including first author, study design, level of evi-
dence, sex, mean age upon presentation, number of feet,
previous treatment of any kind, number of casts required for
correction, bracing, period of follow-up, follow-up scores,
International Orthopaedics
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final outcomes, number of relapsed feet after initial treat-
ment, and complications. The authors of the studies were
contacted if there were any uncertainties regarding the data.
Risk ofbias andquality assessment
The Methodological Index for Non-Randomized Studies
(MINORS) was used to assess risk of bias in the included
studies [20]. The MINORS scale assigns a score of 0, 1, or
2 for a list of eight questions in non-comparative studies.
Owing to their observational nature, the identified studies
were considered to be of very low-grade to low-grade quality
according to the GRADE criteria [21].
The mean MINORS score for the included studies was
11.8 ± 1.7 out of 16 (median of 12.0 with a range of 8–14).
The majority of the included studies were rated down due
to retrospective data collection and lack of sample size
calculations, and. Table1 contains the detailed MINORS
assessment.
Results
Most of the included studies used a case series study design
to investigate the effects of the modified Ponseti technique
on the correction of complex clubfoot. A total of 266
patients and 360 feet were included in the ten studies; the
collective male to female ratio in all studies was 2.6:1. More-
over, the geographical location varied among the studies and
spanned five continents. Table2 shows the characteristics of
the included studies.
A high rate of initial correction (76.4–100%), which was
achieved in all patients with a mean of five casts (range 5
to 7 casts), was noted [5, 9, 10, 12–16]. The initial correc-
tion became evident with a mean ankle dorsiflexion of 15°
(range, 10–25°) in seven studies [5, 9, 12–15]. Dragoni etal.
[10] and Duman etal. [16] achieved initial correction with
excellent to good results on the ICFSGS scale. Three studies
reported decreases in the mean Pirani scores at the treatment
start time, first application of braces, and final visit [2, 6,
16], with statistically significant differences in Pirani scores
at the follow-up periods. The most commonly used bracing
tool was the Mitchell–Ponseti brace, which was used in three
studies, and the Dennis-Browne abduction type, which was
used in two studies.
Among the studies, the follow-up duration was
7.5–86.4months, with an average follow-up duration of
39.7months. Although all of the studies have not consist-
ently included the term, relapse occurred often and its inci-
dence ranged at 10.5–55% [5, 9, 10, 12–16]. A relapse was
reported in every other patient (53% and 55%) in two studies
that had longer follow-up periods [9, 10].
Records identified from:
EMBASE (n = 146)
MEDLINE (n = 346)
Cochrane Library (n = 153)
Web of Science (n = 54)
Total (n = 699)
Records removed before
screening:
Duplicate records removed
(n = 124)
Records screened
(n = 575)
Records excluded after
title/abstract screening
(n = 541)
Reports sought for retrieval
(n = 34)
Reports assessed for
eligibility
(n = 8)
Reports excluded:
Using methods other than
Ponseti modified technique
(n = 28)
Data were mixed with
other subgroups (n = 1)
Diagnosis other than
idiopathic complex club
foot (n = 5)
Records identified from:
Citation searching (n = 22)
Reports excluded:
Using methods other than
Ponseti modified technique
(n = 6)
Reports assessed for
eligibility
(n = 2)
Studies included in review
(n = 10)
Identification of studies via databasesIdentification of studies via other methods
Identification
Screening
Included
Reports sought for retrieval
(n = 8)
Fig. 1 PRISMA flow diagram
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The rate of these complications varied among the stud-
ies [5, 12, 14, 15, 22], at 6–30%, although five studies did
not report complications. Of the remaining studies, only
two defined their complications, which included erythema,
swelling, midfoot deformities, or cast slippage [5, 14].
Table3 provides the details of the modified Ponseti tech-
nique that was performed in each study.
Discussion
Satisfactory clinical outcomes have been reported for the
Ponseti technique in treating clubfoot, which entails a series
of manipulations and serial sets of casting [23–25]. Studies
have demonstrated that outcomes of the modified Ponseti
method for treating complex clubfoot and atypical club-
foot report widely different percentages of success, relapse,
and complications. Therefore, we performed a systematic
review of the outcomes of Ponseti’s modified method to treat
patients with complex idiopathic clubfoot to clarify the fol-
lowing: the deformity correction success rate, relapse rate
after the correction, and incidence of complications.
In 1994, Turco referred to this condition as “atypical
idiopathic clubfoot”; since then, the terms, atypical and
complex, have been used interchangeably [7]. Most of the
included studies did not distinguish between these terms
[5, 9, 12–15], which creates doubt regarding whether the
included cases were atypical at birth or if they were typi-
cal at birth but became complex after improper treatment
[10]. Although the modified Ponseti method is successful
irrespective of aetiology, specific definitions are required
to distinguish complex from atypical clubfoot. This raises
an important question regarding whether these subgroups
have different outcomes. Most of the studies clearly agree
that atypical clubfoot shares the following features: severe
plantar flexion of all metatarsals, a rigid equinus with a deep
crease above the heel, and a deep plantar crease across the
full width of the sole of the foot with high cavus and a short
hyperextended big toe. As for complex clubfoot, Dragoni
etal. [10] found that indeed complex clubfoot started as a
typical clubfoot but iatrogenically converted into complex
clubfoot with improper casting and slippage. This slippage
forces the foot into severe equinas and cavus. However, he
also noticed that most of the complex clubfoot cases were
Table 1 Quality assessment results of the included studies according to the Methodological Index for Non-Randomized Studies scale (MINORS)
Study Clearly
stated
aim
Inclusion of
consecutive
patients
Prospective
collection of
data
Endpoint
appropriate
to the study
design
Unbiased
evaluation of
endpoints
Follow-
up period
appropriate
to the major
endpoint
Loss to
follow-up not
exceeding
5%
Prospective
calculation
of sample
size
Total score
Ponseti etal.,
2006 [5]
2 2 0 2 2 2 2 0 12
Yoshioka
etal., 2010
[12]
2 2 0 2 2 1 2 0 11
Gupta etal.,
2015 [13]
2 2 0 1 0 1 2 0 8
Matar etal.,
2017 [9]
2 2 0 2 2 2 2 0 12
Elseddik
etal., 2018
[14]
2 2 2 1 2 1 2 0 12
Mandlecha
etal., 2019
[22]
2 2 2 1 2 1 2 0 12
Dragoni
etal., 2018
[10]
2 2 2 2 2 2 2 0 14
Allende
etal., 2020
[15]
2 2 0 2 2 2 2 0 12
Duman etal.,
2020 [16]
2 2 0 2 2 2 2 0 12
Bozkurt
etal., 2021
[26]
2 2 2 2 2 1 2 0 13
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initially short, stubby feet which might contribute to the risk
of cast slippage.
The outcomes of modified Ponseti protocol were mainly
defined based on ankle dorsiflexion [5, 9, 12–15]. Two of the
included studies used International Clubfoot Study Group
Classification System (ICFSGS) scores [10, 16], while three
used the Pirani score [15, 22, 26]. Early detection of the
deformity and modifying the standard protocol, described
by Ponseti etal. [5], resulted in a high rate of success at
final follow-up despite of the outcome tools used [5, 9, 10,
12–16]. Although the modified Ponseti method has a suc-
cess reaching to 100%, several studies have proposed dif-
ferent modifications and management plans for complex
clubfoot [4, 11, 27, 28]. To our knowledge, no study has
compared the different methods; therefore, conclusions
cannot be drawn regarding the modified Ponseti protocol
in comparison with others. However, the key to treating
atypical and complex clubfoot is first to recognize it, then
apply the modified Ponseti technique without variation [5].
The included studies did not provide comprehensive details
regarding casting, manipulation, relapse management, and
bracing protocols. Zhao etal. found strict adherence to the
principles and technical details was highly related to the
treatment outcome using the Ponseti method [29]. Detailed
descriptions of the modified Ponseti technique should be
provided to aid comparison among the studies and to deter-
mine whether the authors strictly adhered to the technique’s
technical details [30].
Also, the studies lacked any definition of relapse; how-
ever, all studies reported a wide range of relapse occurrence
rate. The variations in reported outcomes and relapse rates
might be attributed to the lack of a definition. Relapse has
been defined as the reappearance of any of the components
of the deformity [31]. The reported causes of relapse were
numerous and entailed decreased function of the evertor
muscles, initial deformity severity, and concurrent foot
deformities [5, 7, 10]. Modifications to the Ponseti protocol
were based on a detailed knowledge of the pathoanatomical
Table 2 General characteristics of the included studies
IQR interquartile range
Study Study type Level of
evidence
County Num-
ber of
patients
Sex Mean age upon pres-
entation
Number of
feet
Previous treat-
ments
Ponseti etal.,
2006 [5]
Retrospective
study
Level III Multi-center
study based
in US
50 31M, 19F 3months
(1week–9months)
75 Yes (plaster
casting 31
patients)
Yoshioka
etal., 2010
[12]
Case series
study
Level IV Single-center
study based
in US
5 3M, 2F 17.7months
(2–47months)
5 Yes (plaster
casting ± ten-
otomies)
Gupta etal.,
2015 [13]
Case series
study
Level IV Single-center
study based
in India
16 10M, 6F 3.2months
(1–5months)
16 Yes (plaster
casting)
Matar etal.,
2017 [9]
Case series
study
Level IV Single-center
study based
in UK
11 9M, 2F 3months
(1week–9months)
17 Yes (Ponseti in
3 patients)
Elseddik
etal., 2018
[14]
Case series
study
Level IV Single-center
study based
in Egypt
19 14M, 5F 2.5months
(2weeks–4months)
28 Not reported
Mandlecha
etal., 2019
[22]
Case series
study
Level IV Single-center
study based
in India
16 13M, 3F 4.7months
(1–12months)
27 Not reported
Dragoni etal.,
2018 [10]
Case series
study
Level IV Single-center
study based
in Italy
38 26M, 12F 2.5months
(6weeks–5months)
9 Yes (plaster
casting ± ten-
otomies)
Allende etal.,
2020 [15]
Retrospective
study
Level III Multi-center
study based
in South
America
79 44M, 35F 7months (15, 1–53)—
median (IQR, min–
max)
124 Yes, (plaster
casting ± ten-
otomies)
Duman etal.,
2020 [16]
Retrospective
study
Level III Multi-center
study based
in Turkey
21 15M, 6F 4months
(4–14months)
32 Yes, Achilles
tenotomy in
23 feet
Bozkurt etal.,
2021 [26]
Prospective
study
Level III Single-center
study based
in Turkey
11 10M, 1F 2months (range,
0–6months)
16 Yes (plaster
casting ± ten-
otomies)
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Table 3 Details of the modified Ponseti technique undertaken in each study
Study Number of casts
required
Bracing Period of follow-up Follow-up method/
outcomes
Satis-
factory
outcomes
Number of relapsed
feet/recurrence after
initial treatment
Complications
Ponseti etal., 2006 [5] 5 (1–10) Soft premolded foot–
ankle abduction brace
23months (6 to
46months)
Initial correction was
achieved with mean
ankle dorsiflexion of
15° (range, 10–25°)
75 Seven patients (14%)
had a relapse after
initial successful
treatment, and two
patients had a second
relapse. The average
time from correction
until diagnosis of
the first relapse was
1.5months (range,
2weeks–3months)
Eleven patients (22%)
had complications
including erythema,
slight swelling of the
forefoot and toes, mild
rocker-bottom deform-
ity, midfoot hyperab-
duction, or repeated
downward cast slippage
Yoshioka etal., 2010
[12]
5 (1–8) Foot abduction
brace ± foot–ankle
orthosis
15.8months (6 to
26months)
Initial correction was
achieved with mean
ankle dorsiflexion of
15° (range, 5–20°)
5 One patient had a
relapse after initial
successful treatment
All patients had consider-
able atrophy of the
calf muscles due to the
peroneal dysfunction.
One patient recovered a
little from the peroneal
nerve dysfunction, but
the others did not. No
other complications
were reported
Gupta etal., 2015 [13] 7 (4–9) Dennis-Browne abduc-
tion brace
2years (1 to 3years) Initial correction was
achieved with mean
ankle dorsiflexion of
15° (range, 10–25°)
16 Not reported Not reported
Matar etal., 2017 [9] 7 (5–10) Mitchell–Ponseti brace 7years (3 to 11years) Initial correction was
achieved with mean
ankle dorsiflexion of
15° (range, 10–25°)
13 The overall relapse rate
was 53%
Not reported
Elseddik etal., 2018
[14]
6 (5–9) Locally manufactured
version of Markell
splint
Mean period of
7.5months post brace
removal
Initial correction was
achieved with mean
ankle dorsiflexion of
15° (range, 10–25°)
28 The incidence of
relapse was 10.5%.
Average time from
correction until
diagnosis of the
first relapse was
2.75months
Four patients (21%) had
complications includ-
ing erythema, slight
swelling of the forefoot
and toes, mild rocker-
bottom deformity, mid-
foot hyperabduction, or
repeated downward cast
slippage
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Table 3 (continued)
Study Number of casts
required
Bracing Period of follow-up Follow-up method/
outcomes
Satis-
factory
outcomes
Number of relapsed
feet/recurrence after
initial treatment
Complications
Mandlecha etal., 2019
[22]
7 (6–10) Steenbeek foot abduc-
tion brace
1.2year (6months to
1.8year)
Correction was
achieved with a mean
Pirani score at latest
follow-up being
0.0556
27 The incidence of
relapse was 11.1%
Overall some or the other
complication occurred
in 8 out of 27 feet
(29.63%)
Dragoni etal., 2018
[10]
6 (4–8) Mitchell–Ponseti brace 7.2years (range:
6–9.6years)
Of the nine complex
clubfeet, two showed
an excellent result and
five showed a good
result (77%) accord-
ing to the ICFSGS
scale
9 The incidence of
relapse was 55% at
an average age of
3.6years (range:
3–5years)
Not reported
Allende etal., 2020
[15]
5 (5, 3–13)—median
(IQR, min–max)
Mitchell–Ponseti brace
or standard abduction
brace
49months (12–
132months)
Median ankle dorsiflex-
ion at the last follow-
up was 20 degrees
(IQR, 10 degrees;
min–max, − 5 to − 30
degrees)
122 Thirty-seven feet
(29.8%) had a relapse
after initially success-
ful treatment
Seven feet (6%) presented
minor complications
Duman etal., 2020 [16] 5 (3–6) Dennis-Browne abduc-
tion brace
56months (24–
144months)
Initial correction with
25 (78.1%) showed an
excellent result, and
seven (21.9%) showed
good result according
to the ICFSGS scale
32 Relapse of pathology
occurred in four
feet (12.5%) of two
patients
Not reported
Bozkurt etal., 2021
[26]
7 (5–8) Foot abduction brace 13.3months (10–
16months)
Initial correction was
achieved with mean
a Pirani score of
0.4 ± 0.4 and mean
dorsiflexion of
20.2° ± 4.5
13 Three patients (18.8%)
experienced a relapse,
which was treated
with two to three
casts. However, plan-
tar creases persisted
on two feet (12.5%)
Not reported
ICFSGS the International Clubfoot Study Group Score, IQR interquartile range
International Orthopaedics
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features of complex clubfoot; therefore, meticulous atten-
tion must be paid to the details of this method. Accordingly,
such “a world of difference” in relapse rates could be related
to imprecise adherence to Ponseti’s recommendations [32,
33]. Our review found that relapse rates in complex clubfoot
patients increased with time. Studies with a long follow-up
duration, including those by Matar etal. [17] and Dragoni
etal. [10], had much higher occurrences of relapse. Thus,
studies with longer follow-up time periods are required
[34]. Nevertheless, relapse occurred in many cases due to
treatment noncompliance as shown by Göksan etal. who
examined a subgroup of patients with complex clubfoot [35].
The findings showed reduced patient compliance, with high
relapse rates based on 11 cases of complex clubfoot [35].
Substantial deviations were noted in the details reported by
the studies regarding compliance with braces, the types of
braces, application time, period of application, and weaning
off. These differences should be analyzed to determine the
effects of different bracing protocols on the final outcomes.
A stepwise pattern of treatment for relapse is recommended
and involves repeated casting, tenotomies, tendon transfer,
and posterior release, if necessary. Ponseti etal. [5] noted
that after successful intervention, seven patients relapsed,
three of whom underwent a second Achilles tenotomy.
Dragoni etal. [10] treated a case of relapse with Achilles
tenotomy; however, three patient underwent Achilles tendon
lengthening. Bozkurt etal. [26] and Mandlecha etal. [22]
required application of a further two to four casts. Matar
etal. treated approximately half of those with relapses with
soft-tissue releases [9]. Due to a lack of sufficient details,
more studies on relapse management are required as well.
We suggest conducting studies with a prospective design that
examine the causes of relapse after performing the modified
Ponseti method because they may offer a reliable, valuable,
and effective understanding and management of such cases.
In our review, the complications associated with the
modified Ponseti method included casting complications,
slippage, and pressure sores. The later suggests that poor-
fitting casts can cause a complex deformity [7]. Five studies
did not report complications [9, 10, 13, 16, 26], which might
have introduced errors in the reported incidence of compli-
cations. Studies that reported complications most commonly
reported those related to casting. Slipping of casts was the
most common complication; consequently, it is recom-
mended to bend the knee more than 110 degrees. None of
the studies reported complications related to the tenotomy.
Complex and atypical clubfoot, even though still uncom-
mon, represent a challenge for paediatric orthopaedic surgeons.
Studies regarding modified Ponseti technique have shown high
initial correction rates and a smaller number of relapses.
Our review has several limitations. The lack of randomized
controlled trials (RCTs) and prospective and comparative
studies on this topic impeded statistical data pooling and
meta-analysis. The level of evidence of the included stud-
ies was low due to inadequate prospective studies and RCTs.
However, it is difficult to conduct RCTs for a rare disease
entity. The included studies were associated with several
important types of bias. These biases may lead to overesti-
mation of treatment benefits, non-reporting may minimize the
complication rate, and a very short follow-up may increase
survival estimates. Also, one of the most important limita-
tions of the included studies was their lack of clarity regard-
ing whether the patients had atypical or iatrogenic complex
clubfoot due to previous standard Ponseti treatment failure
[10]. Studies with prospective designs and long-term follow-
up are required to determine whether our observation of a
wide range of relapse rates is due to performing the modified
method properly or whether this deformity has higher relapse
rates with further follow-up. However, satisfactory outcomes
might only be achieved if the method is followed without vari-
ation, with proper compliance, and brace protocol adherence.
Acknowledgements We would like to thank prof. Nassser Al-Sanea
general director at King Abdullah Bin Abdulaziz University, Riyadh,
Saudi Arabia, for allowing us to perform the investigations at his center.
We sincerely acknowledge Prof. Al-Sanea for his support and the con-
structive feedback that he always provides. His willingness to give his
time so generously has been very much appreciated.
Author contribution OAM: Study design, data analysis, and process-
ing, writing, and approval of final draft.
FNA: Data collection and processing and writing—original draft.
TSA: Data curation, methodology, validation, visualization, project
administration, and approval of final manuscript.
Data availability The datasets used and/or analyzed during the current
study are available from the corresponding author on request.
Code availability Not aplicable.
Declarations
Ethics approval Each author certifies that his institution waived
approval for the reporting of this investigation and that all investiga-
tions were conducted in conformity with ethical principles of research.
Investigation was performed at Section of Orthopedic Surgery, Depart-
ment of Surgery, King Abdullah Bin Abdulaziz University Hospital,
Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia.
Consent to participate Not applicable.
Consent for publication Not applicable.
Competing interests The authors declare no competing interests.
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