SLR - April 2012 - Jennifer Gerres
Reference: Ramirez N, Flynn JM, et al. J Pediatr Orthop 31:6, 710-15, 2011.
Scientific Literature Review
Reviewed by: Jennifer Gerres, DPM
Residency Program: Cleveland Clinic/Kaiser-Permanente
Podiatric Relevance:
Idiopathic clubfoot is a common congenital defect encountered among the pediatric population, and the Ponseti Method of gentle manipulation through serial casting and possible Achilles tenotomy, is a conservative means to obtain correction. The technique also requires maintenance of correction through the use of bracing until four years of age. While this provides excellent immediate correction, long-term studies demonstrate a high recurrence rate in regard to the post-treatment brace protocol. The examiners sought to explore this area of post-treatment failure by assessing brace compliance during the Ponseti casting technique: therefore, to evaluate if the root of poor compliance was the complexity of orthotic use, or socioeconomic and education factors.
Methods:
Fifty-three patients with 73 affected feet were treated using the Ponseti technique. The mean age at presentation was one month with the mean time of manipulative casting of six weeks. 38 (72 percent) patients required Achilles tenotomy. Once serial casting was completed, use of the Dennis Brown Bar full time for three months and then during the night until age 4 was encouraged. Parents were educated on the technique and the post-treatment protocol by the treating physicians and provided a handbook. Brace compliance was self-reported by the families. The average follow up was 48 months. The evaluators defined recurrence as the increase in the Dimeglio-Bensahel score, which required repeat casting. Sex, age, affected limb, severity, family education, income, insurance, and brace compliance were evaluated in regards to recurrence using unadjusted odds ratio with a 95 percent confidence interval and P values. Furthermore, these same factors were evaluated using the unadjusted odds ratio and P values to predict factors that influence noncompliance.
Results:
16 of 53 patients (24 of 73 feet) demonstrated recurrence. 25 of 53 patients were noncompliant with post-treatment bracing, and of those, 13 of the 25 showed recurrence. Noncompliance in post-treatment bracing was significant for recurrence risk (odds ratio=0.1111, P=0.026). No correlation among patient demographic data, parent education level, or socioeconomic factors and noncompliance were observed. Furthermore, correlation with recurrence risk was not significant when sex, age, affected limb, severity, family education, income, and insurance were examined.
Conclusions:
Post-treatment bracing is important in the Ponseti Method to avoid recurrence. In this study, no correlation exists between socioeconomic and educational factors and noncompliance.