title: Orthosis noncompliance after the Ponseti method for the treatment of idiopathic clubfeet: a relevant problem that needs reevaluation.
abstract: BACKGROUND
  Idiopathic talipes equinovarus is the most common congenital defect characterized by the presence of a congenital dysplasia of all musculoskeletal tissues distal to the knee. For many years, the treatment has been based on extensive surgery after manipulation and cast trial. Owing to poor surgical results, Ponseti developed a new treatment protocol consisting of manipulation with cast and an Achilles tenotomy. The new technique requires 4 years of orthotic management to guarantee good results. The most recent studies have emphasized how difficult it is to comply with the orthotic posttreatment protocol. Poor compliance has been attributed to parent's low educational and low income level. The purpose of the study is to evaluate if poor compliance is due to the complexity of the orthotic use or if it is related to family education, cultural, or income factors.
  
  
  METHODS
  Fifty-three patients with 73 idiopathic talipes equinovarus feet were treated with the Ponseti technique and followed for 48 months after completing the cast treatment. There was a male predominance (72%). The mean age at presentation was 1 month (range: 1 wk to 7 mo). Twenty patients (38%) had bilateral involvement, 17 patients (32%) had right side affected, and 16 patients (30%) had the left side involved. The mean time of manipulation and casting treatment was 6 weeks (range: 4 to 10 wk). Thirty-eight patients (72%) required Achilles tenotomy as stipulated by the protocol. Recurrence was considered if there was a deterioration of the Dimeglio severity score requiring remanipulation and casting.
  
  
  RESULTS
  Twenty-four out of 73 feet treated by our service showed the evidence of recurrence (33%). Sex, age at presentation, cast treatment duration, unilateral or bilateral, severity score, the necessity of Achilles tenotomy, family educational, or income level did not reveal any significant correlation with the recurrence risk. Noncompliance with the orthotic use showed a significant correlation with the recurrence rate. The noncompliance rate did not show any correlation with the patient demographic data or parent's education level, insurance, or cultural factors as proposed previously.
  
  
  CONCLUSIONS
  The use of the brace is extremely relevant with the Ponseti technique outcome (recurrence) in the treatment of idiopathic talipes equinovarus. Noncompliance is not related to family education, cultural, or income level. The Ponseti postcasting orthotic protocol needs to be reevaluated to a less demanding option to improve outcome and brace compliance.
authors.affiliation: Pediatric Orthopaedic Department, Hospital de la Concepción, San Germán. normanpipe@aol.com
authors.forename: Norman
authors.initials: N
authors.lastname: Ramírez
authors.forename: John M
authors.initials: JM
authors.lastname: Flynn
authors.forename: Samuel
authors.initials: S
authors.lastname: Fernández
authors.forename: Wallace
authors.initials: W
authors.lastname: Seda
authors.forename: Raul E
authors.initials: RE
authors.lastname: Macchiavelli
mesh_terms: D000125:Achilles Tendon / Q000601:surgery; D002370:Casts, Surgical; D003025:Clubfoot / Q000601:surgery / Q000628:therapy*; D003131:Combined Modality Therapy; D004522:Educational Status; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009989:Orthotic Devices; D010290:Parents / Q000523:psychology*; D010349:Patient Compliance; D012008:Recurrence; D012189:Retrospective Studies; D012720:Severity of Illness Index; D058971:Tenotomy / Q000379:methods; D016896:Treatment Outcome