Current Clubfoot Practices: POSNA Membership Survey

Abstract

Clubfoot management has advanced in the 21st century with increases in formal training, practitioner experience, and improved casting/bracing constructs. The Ponseti method is the gold standard, yet variations in application persist. This survey aims to identify current treatment practices among clubfoot practitioners within the Pediatric Orthopaedic Society of North America (POSNA). A 23-question online survey of members was conducted between June and August 2021. Eighty-nine respondents self-identified as clubfoot providers. Of these, 93.1% had an MD degree, 23.6% possessed >30 years’ experience, and the majority (65.6%) worked in a teaching hospital associated with a medical school. Most responders (92.0%) were pediatric fellowship trained. A total of 51.7% had participated in a clubfoot training course. More than half (57.5%) noted changes to clubfoot management practices throughout their training. A majority used between four and seven (88.7%) long leg casts (98.4%), changed at seven-day intervals (93.4%). Plaster (69.4%) was most commonly used. The most common bracing device was Mitchell–Ponseti (72.9%). A mean 84.8% of clubfeet required tenotomy. The most common anesthetic agent was numbing gel (43.0%). Tenotomies mostly occurred in patients aged <6 months (63.1%). Tenotomy locations were operating room (46.5%), clinic (45.4%) and procedure room (8.1%). Cast removal was primarily performed with saws (54.7%). The mean incidence of observed cast burns was 5.5%. Most providers did not use a device to prevent cast burns (76.6%). Reported cast complications included slippage (85.9%), skin irritation (75.8%), and saw-related injuries (35.9%). Clubfoot management variations exist in orthotics, tenotomy indications and practices, and cast material. Casting complications continue to be a problem. Further studies are warranted to determine if certain practices predispose patients to specific complications.

Duration and outcome of orthotic treatment in children with clubfoot – a four-year follow-up national register study of Swedish children born between 2015 and 2017

“…Results of this study demonstrate that the vast majority of children are prescribed and treated with an FAO during the maintenance phase. This aligns well with the results of a recent survey conducted among clubfoot practitioners within the Pediatric Orthopedic Society of North America (POSNA) that aimed to identify current treatment practices [28]. The maintenance phase is often highlighted as the most important treatment phase, where longer duration of treatment period results in less recurrences [29,30].…”

Initial clubfoot treatment in Sweden from 2016 to 2019: A national register study

“…On average, 76% of the children with an isolated clubfoot underwent an achillotenotomy and slightly larger numbers in the non-isolated population, albeit not statistically significant, were seen. These numbers are slightly low compared with the current literature, commonly above 80% [ 9 , 32 ] However, others state that over 90% of the feet require an achillotenotomy and, in the light of this, the numbers from the Swedish cohort require further investigation [ 13 , 17 ]. A few children, classified as Pirani 5 or 6 in both the isolated and non-isolated groups, were reported as not having an achillotenotomy.…”

“…This is also true for other adverse events (e.g. pressure areas, cast slippage and skin irritation) [ 32 ] and the number of children transferred to other hospitals due to problems during treatment. As a result, we do not know the frequency of these events.…”

“…However, we have no control over the education or experience level of the orthopedic surgeons or physiotherapists treating the children [ 35 ] nor of whether some centres apply the accelerated Ponseti method [ 36 ]. To the best of our knowledge, achillotenotomies are most often performed under local anaesthesia, but this information is not available in the clubfoot register [ 5 , 32 ]. One strength of the current study is the national prospective approach and, close to the total cohort, of the clubfoot register with well-predefined prerequisites for registration, excluding other subtypes of foot abnormality or postural clubfoot.…”