Recurrent Casting for Recurrent Clubfoot . . . A Triumph of Technique Over Reason or the New Norm?: Commentary on an article by Veroniek M. van Praag, MD, MA, et al.: "Casting Is Effective for Recurrence Following Ponseti Treatment of Clubfoot".

Abstract

Commentary We have all had recurrences among our patients after the Ponseti method of clubfoot correction. Even Ponseti himself reported a substantial number of recurrences. First, as noted by van Praag et al., recurrence rates of up to 40% have been documented in high-quality studies and reviews. Second, are these really failures of the technique or simply a relapse in a foot that only required a longer period of corrective casting and orthotic management? Van Praag et al. set out to examine this question in a well-documented study at The Hospital for Sick Children in Toronto, where all of the recurrences (19% in this study of 382 children) were routinely treated with recasting rather than with surgical intervention. Why these recurrences occurred appears to be an enigma to both the researchers and their readers. Could it be that these were familial clubfeet, which are noted to be more rigid? Or were they all from a certain ethnic background such as Arabic people from the Middle East, where clubfeet are more severe? In a dedicated clubfoot clinic in an academic center, it is doubtful that improper technique was a cause; hence, the answer is that we do not know why they recurred, providing that the parents were compliant with the bracing protocol. In my experience, parental shortcuts in brace use are a major cause of recurrence. A concern here is that the authors had 71 patients who had a recurrence, but less than half, i.e., 35 patients, returned for recasting. Were these the patients with the worst recurrences and, if so, does this throw some doubt on the results of the subsequent Ponseti castings, which may have been skewed to higher severity? It may throw into question the statement that “. . . the results are not the same as those for patients who do not have recurrent clubfoot.” We do not know, of course, and thus a larger study group with more statistical power is needed. However, the authors have kicked the door a bit ajar for us and have shown that recasting can obviously be successful the second, third, and even more times out. Since our world is now becoming an even greater melting pot of humanity, authors of studies related to clubfeet should be encouraged to record ethnicity and genetic (familial) inheritance, which may turn out to have a bearing on recurrence rates. For several years, I practiced in the Middle East, where clubfeet are very common among Arabic people and the condition is more severe than that seen in North America. It is of interest that a recurrence rate of 17% was uncovered in the authors’ “corrected” control group, which had been followed for as long as 7 years. I personally have made it a practice to follow all my patients with clubfoot until they are 12 years old. An imbalance between the peroneal tendons and invertors may develop well after 5 years of age, requiring a rebalancing of the foot with an anterior tibial tendon transfer. Whether repeat casting will improve the results from that after anterior tibial tendon transfer (i.e., decrease the need for further surgical procedures) is enticing and awaits further study. The authors have convinced me that if our next grandchild is born with a clubfoot that relapses after the first series of Ponseti casts, recurrent casting would be my recommendation. Is it the new norm? The authors provided very good evidence that it is, at least for up to 3 recurrences. Recasting is certainly not a triumph of technique over reason and may well, with larger numbers and longer follow-up, be accepted as the new norm.