Interventions for congenital talipes equinovarus (clubfoot)

Abstract

Congenital talipes equinovarus (CTEV), which is also known as clubfoot, is a common congenital orthopaedic condition. It is characterised by an excessively turned in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain.Interventions can be conservative (such as splinting or stretching) or surgical. To evaluate the effectiveness of interventions for CTEV. We searched CENTRAL (2011, Issue 2), NHSEED (2011, Issue 2), MEDLINE (January 1966 to April 2011), EMBASE (January 1980 to April 2011), CINAHL Plus (January 1937 to April 2011), AMED (1985 to April 2011) and the Physiotherapy Evidence Database (PEDro to April 2011). We checked the references of included studies. Randomised and quasi-randomised controlled trials evaluating interventions for CTEV. Participants were people of all ages with CTEV of either one or both feet. Two authors independently assessed risk of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available. We identified 13 trials in which there were 507 participants. The use of different outcome measures prevented pooling of data for meta-analysis even when interventions and participants were comparable. All trials displayed bias in four or more areas. One trial reported on the primary outcome of function, though raw data were not available to be analysed. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials. The Pirani score is scored from zero to six, in which higher is worse. Two of the trials involved participants at initial presentation. One of them reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 (95% confidence interval 0.98 to 1.32) lower than that of the Kite group. The second trial found the Ponseti technique to be superior to a traditional technique, with average total Pirani scores of the Ponseti participants 1.50 lower (95% confidence interval 0.72 to 2.28) after serial casting and Achilles tenotomy. A trial in which the type of presentation was not reported found no difference between an accelerated Ponseti or standard Ponseti treatment. At the end of serial casting, the average total Pirani scores in the standard group were 0.31 lower (95% confidence interval -0.40 to 1.02) than the accelerated group. Adverse events were not compared in the trial. There is a lack of evidence for different plaster casting products or the addition of botulinum toxin A during the Ponseti technique. There is also a lack of evidence for different types of major foot surgery for CTEV, continuous passive motion treatment following major foot surgery, or treatment of relapsed or neglected cases of CTEV. Most trials did not report on adverse events. In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas) and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting. From the limited evidence available, the Ponseti technique may produce better short-term outcomes compared to the Kite technique. An accelerated Ponseti technique may be as effective as a standard technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and lack of available raw data. Future randomised controlled trials should address these issues.