510 Med J Malaysia Vol 75 No 5 September 2020 ABSTRACT Introduction: Most of the authors currently agree that congenital talipes equinovarus (CTEV) or idiopathic clubfoot can be effectively treated with the Ponseti method instead of extensive soft tissue surgery. This study was conducted to investigate whether there is a difference in the outcome between starting treatment before one month of age or after that age. Methods: This is a retrospective study on babies with CTEV treated in University Malaya Medical Centre from 2013 to 2017. The 54 babies (35 boys and 19 girls) were divided into two cohorts, Group 1 that had treatment before the age of one month, and Group 2 that had treatment after one month old. The number of cast changes, rate of full correction, and rate of relapse after treatment were compared between the two groups. Results: Of the 54 babies, with 77 CTEV treated during the period, our outcome showed that the mean number of cast change was 5.9 for Group 1 and 5.7 for Group 2. The difference was not statistically significant. All the affected feet (100%) achieved full correction. One foot in the Group 1 relapsed, while three feet in Group 2 relapsed, but the difference was also not statistically significant. All of the relapsed feet were successfully treated with repeated Ponseti method. Conclusions: Treating CTEV using Ponseti method starting after one month was not associated with more casting change of higher rate of relapse. KEYWORDS: Clubfoot, serial casting, Ponseti, relapse, starting treatment INTRODUCTION Clubfoot is a general term for foot deformities characterized by forefoot adductus, midfoot varus and hindfoot equinus. This deformity can be associated with various conditions such as myelodysplasia, arthrogryposis and other congenital or acquired pathologies. Congenital talipes equinovarus (CTEV), also known as idiopathic clubfoot is a common congenital foot deformity with a global incidence of about 1 per 1000 live births. 1,2 A recent systematic review based on 48 studies from 20 low and middle income countries reported birth prevalence of CTEV of between 0.51 to 2.03/1000 live births. 3 Serial manipulation and casting, as described by Ponseti IV has become the mainstay of treatment for CTEV worldwide over the last two decades. 4,5 Ponseti’s method describes weekly serial manipulation and casting following a prescribed protocol. The final cast is applied after a percutaneous tenotomy in a majority of cases. This is then followed by bracing in a foot-abduction-orthosis. This method has demonstrated good short-term 6 and long-term outcomes. 7,8 Evidence of undesirable outcomes following extensive open surgery 9 has also resulted in the decline in the use of this method of treatment for CTEV, in favour of the Ponseti method. It is generally recommended that treatment of CTEV should be initiated as soon as possible after birth. 4,8,10 In the first European consensus meeting on Ponseti clubfoot treatment, Stephanie Bohm stated that treatment for clubfoot should start not later than within the first months of life, without giving any evidence to support this consensus. 11 With the increasing usage of the Ponseti treatment, successful treatments have also been reported in older children. In 2009, Alves et al., compared treatment outcome between clubfoot children treated before and after six months of age, and reported mean relapsed rates of 8% in both groups, suggesting no difference in the treatment outcome. 12 However, in the following year, Iltar et al., reported that children treated within the first month of life had poorer outcome compared to those who began treatment later than the first month of life 13 postulating that bones in new born babies may be too soft to produce effective stretching of the soft tissue. This finding apparently does not support the recommendation for starting treatment as soon as possible. However, most centres still strongly recommend treatment as early as possible. In many developing countries, babies with CTEV were usually referred to centres where the Ponseti method of treatment is available, and it is not uncommon for treatment to be started more than one month after birth. In addition, some traditional practices forbid mothers to leave their homes during the “confinement” period, resulting in delay in starting treatment. Most hospitals try to initiate treatment as early as possible based on the protocol adapted by many established centres in the Western world. Thus, it is important to compare the treatment outcome between the two practices and the aim to conduct this study to provide evidence to support the practice that treating CTEV after one month of age can still have a favourable outcome was initiated. Ponseti method of treating clubfoot - Is there difference if treatment is started before or after one month of age? Bryan Lee Yen Pei, MBBS, Mazelan Ali, Sg Tech, Roshan Gunalan, MS Orth, Mohammed Ziyad Albaker, MS Orth, Saw Aik, FRCS Department of Orthopaedic Surgery, University Malaya Medical Centre (NOCERAL), Kuala Lumpur, Federal Territory, Malaysia ORIGINAL ARTICLE This article was accepted: 20 July 2020 Corresponding Author: Dr. Saw Aik Email: sawaik@hotmail.com