title: Results of clubfoot management using the Ponseti method: do the details matter? A systematic review.
abstract: BACKGROUND
  Although the Ponseti method is accepted as the best choice for treatment of clubfoot, the treatment protocol is labor intensive and requires strict attention to details. Deviations in strict use of this method are likely responsible for the variations among centers in reported success rates.
  
  
  OBJECTIVE
  We wished to determine (1) to what degree the Ponseti method was followed in terms of manipulation, casting, and percutaneous Achilles tenotomy, (2) whether there was variation in the bracing type and protocol used for relapse prevention, and (3) if the same criteria were used to diagnose and manage clubfoot relapse.
  
  
  METHODS
  We conducted a systematic review of MEDLINE, EMBASE(TM), and the Cochrane Library. Studies were summarized according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. Five hundred ninety-one records were identified with 409 remaining after deduplication, in which 278 irrelevant studies and 22 review articles were excluded. Of the remaining 109 papers, 19 met our inclusion criteria. All 19 articles were therapeutic studies of the Ponseti method.
  
  
  RESULTS
  The details of manipulation, casting, or percutaneous Achilles tenotomy of the Ponseti method were poorly described in 11 studies, whereas the main principles were not followed in three studies. In three studies, the brace type deviated significantly from that recommended, whereas in another three studies the bracing protocol in terms of hours of recommended use was not followed. Furthermore no unified criteria were used for judgment of compliance with brace use. The indication for recognition and management of relapse varied among studies and was different from the original description of the Ponseti method.
  
  
  CONCLUSIONS
  We found that the observed clinically important variation may have been the result of deviations from the details regarding manipulation, casting, percutaneous Achilles tenotomy, use of the bar-connected brace, and indication for relapse recognition and management recommended for the classic Ponseti approach to clubfoot management. We strongly recommend that clinicians follow the Ponseti method as it initially was described without deviation to optimize treatment outcomes.
authors.affiliation: Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, China.
authors.forename: Dahang
authors.initials: D
authors.lastname: Zhao
authors.forename: Hai
authors.initials: H
authors.lastname: Li
authors.forename: Li
authors.initials: L
authors.lastname: Zhao
authors.forename: Jianlin
authors.initials: J
authors.lastname: Liu
authors.forename: Zhenkai
authors.initials: Z
authors.lastname: Wu
authors.forename: Fangchun
authors.initials: F
authors.lastname: Jin
mesh_terms: D000125:Achilles Tendon / Q000601:surgery*; D001915:Braces; D002370:Casts, Surgical; D003025:Clubfoot / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D019983:Guideline Adherence; D006801:Humans; D019637:Orthopedic Procedures / Q000295:instrumentation / Q000379:methods / Q000592:standards; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D055502:Secondary Prevention; D058971:Tenotomy; D016896:Treatment Outcome