Paradigm shift in clubfoot care strategies in Pakistan: A meta-analysis over three decades

Abstract

BACKGROUND

Clubfoot is one of the most common musculoskeletal birth defects, compounded by the historical approach to managing idiopathic clubfeet in Pakistan with extensive surgical interventions till mid twenties. To keep pace with the global evidence-based shift from extensive surgical release to a Ponseti conservative management, the native orthopedic community manned a national initiative, “Pakistan Clubfoot Disability Prevention Program”. This review evaluates native literature published during the last 35 years, its effectiveness and outcomes, its comparison with global standards, and hypothesizes that Ponseti adoption reduced referral age and enhanced short-term success rates. Encouraging findings guide scaling clubfoot prevention and neonatal screening nationwide.

AIM

To evaluate the paradigm shift in clubfoot management strategies in Pakistan over 35 years and assess the Ponseti method outcomes.

METHODS

This meta-analysis includes studies conducted in Pakistan related to clubfoot management, published globally, between 1990 and June 2025. The study was carried out at Ziauddin University Hospital, Clifton, Karachi, after PROSPERO registration and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 2020. The electronic databases search was made through multiple search engines and a manual search of the reference list from included studies and institutional repositories. The publications’ eligibility criteria included: Peer-reviewed studies carried at Pakistan, related to clubfoot management strategies and outcomes.

RESULTS

Of the 125 included studies, major surgical procedures were 26 (20.8%), conservative 76 (60.8%), and non-clinical procedures were 23 (18.4%). A clear shift occurred from surgical dominance in the pre-2005 era [87.5%; 95% confidence interval (CI): 61.2-96.8] to Ponseti-led conservative approaches in the post-2005 era (94.7% of conservative studies by 2025). Mean referral age declined from 52.3 months pre-2005 era to 6.3 months by 2024-2025. Publication activity peaked in 2020-2024 (58 studies; 70.7% conservative). Bracing non-compliance observed as 35%-69.5%. Pooled proportions were: Surgical 20.8% (95%CI: 14.9-28.2; I² = 93.7%); conservative 60.8% (95%CI: 52.2-68.7; I² = 95.2%), of which Ponseti comprised 94.7%. Ponseti success 87.2% (95%CI: 84.8-89.6; I² = 88%); vs Kite 69.1% (95%CI: 62.3-75.9; I² = 85%), risk ratio of 1.26 (95%CI: 1.18-1.35, P < 0.001), relapsed rate was18.4% (95%CI: 14.2-23.6), and percutaneous tenotomy rate 81.2%. High heterogeneity (I² > 90%) precluded reliable pooling; results are presented narratively.

CONCLUSION

Clubfoot management in Pakistan revealed a significant paradigm shift to Ponseti-dominant treatment, aligning with global standards and yielding high success, a progressive and significant decline in referral age and breaking the barriers.

Keywords: Clubfoot; Orthopaedic procedures; Surgery; Conservative treatment; Pakistan; Treatment outcome; Congenital abnormalities; Health services accessibility; Paediatrics; Ponseti method

Core Tip: This meta-analysis synthesizes 35 years of clubfoot management literature from Pakistan, documenting a complete paradigm shift from predominantly surgical approaches (pre-2005) to the Ponseti method as the dominant strategy (96% adoption by 2025). Pooled short-term success reached 87.2% (approaching global benchmarks of 90%-95%), with referral age declining to 6.3 months, highlighting the impact of national training programs. However, very short follow-up (mean 1.8 years) represents a major limitation, as global evidence shows relapse rates rise significantly after age 4-5 years, emphasizing the need for long-term studies to confirm durable correction in resource-limited settings.