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.

Key Words: 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.

INTRODUCTION

Clubfoot deformity (CFD) is one of the most common musculoskeletal birth defects, with a pooled birth prevalence of 1.18 per 1000 live births, predominantly higher in low and middle-income countries (LMICs)[1,2]. In Pakistan, with an estimated population of about 241 million (2025 estimate) and a crude birth rate of approximately 27.81 per 1000, the annual birth cohort is estimated at 7.09 million, and the annual projected clubfoot burden is 8366, with a range of 0.8-1.8 per 1000[3,4]. Additionally, there are thousands of untreated and surgically mal-treated individuals, leading to a major social, disability and economic burden on the parents, public and the national exchequer. To overcome this CFD burden world has moved forward to adopt non-surgical methods of treating CFD, commenced soon after birth and developed various national and international programs for clubfoot disability prevention[5]. In Pakistan, however, management historically remained favourable to extensive surgical “Turco procedure” and “Hiram Kite” casting with bracing without abduction splint till mid 2000’s. That conceptually delayed commencement of treatment with various superstitious beliefs among community elders and ignorant health care caregivers that: “surgery is a better option than cumbersome long duration conservative treatment”; “surgery is better to be done once the child is old enough”[4-6]. These barriers were observed mostly among low and middle-socio-economic family groups, mostly related to non-affordability of time and money, rural-urban disparities of access to health facilities, non-compliance (35%-70%) to treatment, malnutrition, consanguinity (42%-78%)[7-11]. Because of these barriers and social taboos, the ratio of late presentations with rigid deformities, abandoning the treatment midway (dropout 35%-69%), and early extensive surgeries has been reported significantly higher than reported worldwide[12-16].

To keep pace with the global paradigm shift, from extensive surgical release to Ponseti management, the native orthopedic community established the “Pakistan Clubfoot Disability Prevention Program” in 2006[5]. This program was adopted in III phases. Phase I (2006-2012); sensitization of the orthopedic community, family physicians and folks by holding seminars, workshops and public camps to create awareness of “Earliest the Ponseti clubfoot treatment! Best the outcome”, under a slogan banner: “Born with deformity! Why to live with disability”. While in phase-II (2013-2016), a capacity building program was implemented, and in phase-III continued to date, the capacity building and scale-up programs have continued to date. The phase II (2013-2016) capacity building program was a part of “Clubfoot Disability Model for Sustainable Health System programs” in three countries: Pakistan, Peru and Nigeria[5]. This capacity-building program was sponsored by the United States Agency for International Development’s leadership, management and governance initiative and Ponseti International Association of Professional Insurance Agents (University of Iowa). The program titled “Ponseti International Mentorship Opportunity (PIMO)” was manned exclusively by champions of “Ponseti International Pakistan and Pediatric Orthopedic Society of Pakistan”. Wherein, 98 orthopedic surgeons from all over Pakistan were trained through a two-week intensive “hands-on skill Ponseti technique training” on rotation at four dedicated Ponseti clinics and training centres at Karachi and Hyderabad[5]. Additionally, over 110 postgraduate residents were also given hands-on training at these centres with a mandatory rotation for six months. The legacy of PIMO mentees thereafter continued, hands-on skill training, Ponseti opportunities, phase III program till date and established a network of 168 dedicated “Ponseti Clubfoot Clinics” across Pakistan[5]. Moreover, during the phase II-PIMO program, the mentees were also trained to secure their patients’ data at the “International Clubfoot Registry” and publish as well. In effect, a huge surge in Ponseti native publications was noticed during the post-2005 era, which constitutes 93.6% share of 125 papers on CFD published during the last 35 years (1990-2025)[5].

To date, no comprehensive systematic review and meta-analysis has been synthesized to evaluate native literature to highlight this evolution of paradigm shift, to compare with international benchmarks (global neonatal referral vs Pakistan’s delayed), and to assess the effectiveness of Ponseti methodology. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020-compliant systematic review and meta-analysis study was therefore designed to evaluate research papers published over the last 35 years. The study aimed to address the following questions: What evidence-based paradigm shift in the management of CFD has occurred during the last 35 years? How effective has this shift been in terms of adoption of gold standard Ponseti management, breaking the barriers, its outcomes in terms of success and relapse rate, and its alignment with global standards? What are the key demographics and risk factors? And thereafter to provide concrete recommendations to overcome barriers and gaps that hinders establish evidence-based policy for birth screening and early referral, perpetuating disability burdens estimated at 7000-8000 untreated cases annually.

MATERIALS AND METHODS

This meta-analysis was conducted at Ziauddin University Hospital, Clifton, Karachi, with a prior PROSPERO registration, dated October 4, 2025. The protocol outlined with a focus on evaluating the paradigm shift in clubfoot management in Pakistan and meta-analyzing Ponseti technique efficacy, where feasible, following the PRISMA guidelines 2020. Studies included were: Peer-reviewed publications[17-132] (Supplementary Table 1) published during January 1, 1990 to June 30, 2025, based on studies carried at Pakistan, focusing on congenital CFD. No restrictions on sample size, design or follow-up length. The population comprised children born with CFD, irrespective of age and gender. Interventions included extensive surgical; postero-medial release (PMR), modified PMR, Attanborough procedure, window multiple tenotomy procedure, Ilizarov correction, and open Achilles tendon lengthening. The conservative-non-operative methods included Ponseti, Kite, French manipulation-strapping and Lovell techniques, with or without foot abduction bracing and ankle foot orthosis. Comparators focused on surgical vs conservative approaches, and Ponseti vs Kite/French. The parameters of the study included basic demographics, related risk factors, treatment efficacy, defined as success rates, relapse and complications. Exclusion criteria were: Duplicate studies; grey literature (e.g., abstracts, theses, narrative review of literature); and clubfoot deformities associated with neuro-muscular disorders and trauma.

The information source and variables search included bibliographic databases search through search engines: PubMed, Google Scholar, PakMediNet, Global clubfoot initiatives, and for older references by a direct contact with authors/officials of local journals. The last search was conducted on June 30, 2025. No language restrictions were applied. The search strategy key variables used were: Clubfoot, talipes, talipes equinovarus, congenital talipes equinovarus, Ponseti, Kite, Turco, PMR, percutaneous achilles tenotomy, achilles tendon lengthening, foot abduction bracing and Pakistan.

Full PubMed search strategy

[“clubfoot” (MeSH Terms) OR “talipes equinovarus” (MeSH Terms) OR “clubfoot” (Title/Abstract) OR “talipes equinovarus” (Title/Abstract) OR “congenital talipes equinovarus” (Title/Abstract) OR “CTEV” (Title/Abstract) OR “congenital clubfoot” (Title/Abstract)] AND [“Pakistan” (MeSH Terms) OR “Pakistan” (Title/Abstract) OR “Pakistani” (Title/Abstract) OR “Karachi” (Title/Abstract) OR “Lahore” (Title/Abstract) OR “Sindh” (Title/Abstract) OR “Punjab” (Title/Abstract) OR “Khyber Pakhtunkhwa” (Title/Abstract)] AND [“Ponseti” (Title/Abstract) OR “Ponseti method” (Title/Abstract) OR “Ponseti technique” (Title/Abstract) OR “treatment” (Title/Abstract) OR “management” (Title/Abstract) OR “therapy” (Title/Abstract) OR “casting” (Title/Abstract) OR “bracing” (Title/Abstract) OR “surgery” (Title/Abstract) OR “surgical” (Title/Abstract) OR “posteromedial release” (Title/Abstract) OR “Kite” (Title/Abstract) OR “conservative” (Title/Abstract) OR “non-surgical” (Title/Abstract) OR “nonoperative” (Title/Abstract)] AND [“outcome” (Title/Abstract) OR “success” (Title/Abstract) OR “relapse” (Title/Abstract) OR “recurrence” (Title/Abstract) OR “correction” (Title/Abstract) OR “efficacy” (Title/Abstract) OR “effectiveness” (Title/Abstract) OR “complication” (Title/Abstract) OR “Pirani” (Title/Abstract) OR “Dimeglio” (Title/Abstract) OR “follow-up” (Title/Abstract)] AND [“1990/01/01” (Date - Publication): “2025/12/31” (Date - Publication)].

Study selection followed a two-stage process

Initially, two independent reviewers (Jaffri K, Bhatti MY) screened titles and abstracts, retrieved records for relevance. In phase II, full texts were assessed by the next three authors (Bhatti A, Mazar Baloch S, Morcuende JA). While Bhatti A and Mazar Baloch S assessed the articles independently, with Morcuende JA acting as arbitrator in cases of disagreement, for eligibility against the inclusion criteria. Inclusion criteria comprised of peer-reviewed publications on idiopathic clubfoot management in Pakistan, 1990-2025; no restrictions on design/size/follow-up, while exclusions were duplicates, grey literature and non-idiopathic cases. A total of 125 native publications were identified and included in the qualitative synthesis; 72 of these were found eligible for further meta-analysis of efficacy outcomes. The PRISMA flow diagram for the documentation process is given in Figure 1.

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram adopted for documentation process.

Statistical analysis

The review synthesized data from the extracted studies for Ponseti success and relapse. Subgroup analyses were carried out by era, treatment, age, region, and follow-up. Demographics used weighted averages; barriers (e.g., non-compliance) were analyzed qualitatively. Quantitative synthesis used random-effects meta-analysis (Der Simonian-Laird) with Freeman-Tukey double arcsine transformation for proportions and inverse-variance weighting for means. Heterogeneity was assessed via the I² statistic (> 75% high), due to I² > 90% in all meta-analyses, results interpreted cautiously; primary synthesis narrative. Forest and funnel plots were generated; publication bias was assessed qualitatively through visual inspection of funnel plots. Analyses were performed in R (version 4.3.2; packages: Meta, metafor). Sensitivity analyses excluded high-risk-of-bias studies.

Data were assessed for risk of bias using the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool for non-randomized studies of interventions. Two reviewers (Jaffri K, Bhatti MY) independently assessed each study for key outcomes (success rates, relapse), with discrepancies resolved by Bhatti A or Morcuende JA. Pre-specified confounders included age at presentation, baseline severity (Pirani/Dimeglio scores), consanguinity, and bracing compliance. Judgments: Low (comparable to randomized controlled trial), moderate (sound non-randomized studies of interventions), serious (flaws), critical (problematic), or no information. Overall risk: Low (all low), moderate (low/moderate), serious (≥ 1 serious), critical (≥ 1 critical). Studies at critical risk were excluded from primary meta-analyses; sensitivity analyses tested the impact. Grading of recommendations assessment, development and evaluation assessed certainty (high, moderate, low, very low) for key outcomes (Ponseti success: Moderate; relapse: Low due to bias/heterogeneity) (Figure 1).

RESULTS

The basic demographics across 95 studies with extractable data showed 64.9% male [95% confidence interval (CI): 62.1-67.6], 44.8% bilateral (95%CI: 41.3-48.4), and a progressive decline in mean referral age from 52.3 months pre-2005 to 6.3 months in 2025 (overall: 11.4 ± 14.2 months). Risk factors: Consanguinity (42%-78%), family history (4%-15%), parental smoking (47%), malnutrition, and high bracing non-compliance (35%-69.5% dropout). Table 1 presents a systematic analysis of all 125 studies: Extensive surgical interventions in 26 (20.8%; PMR, Turco, modified Turco, Attenborough), conservative in 76 (60.8%; 72 Ponseti, 4 other), and nonclinical in 23 (18.4%; e.g., epidemiology, risk factors). A clear paradigm shift occurred from surgical dominance pre-2005 (87.5%; 7/8 studies) to Ponseti-led conservative care post-2005 (94.7% of conservative studies; 72/76), with no surgical studies in 2025. Publication activity peaked in 2020-2024 (58 studies), with 70.7% conservative (95%CI: 58.2-81.0; 41/58). Nonclinical focus increased over time, emphasizing barriers like bracing non-compliance. Pooled proportions: Surgical 20.8% (95%CI: 14.9-28.2; I² = 93.7%; 26/125), conservative 60.8% (95%CI: 52.2-68.7; I² = 95.2%; 76/125; Ponseti 94.7% of conservative), nonclinical 18.4% (95%CI: 12.6-26.1; I² = 94.8%; 23/125). Figure 2 illustrates this transition, with exponential Ponseti adoption post-2005 (OR per 5-year increment: 3.84, 95%CI: 2.91-5.06). Risk of bias assessments using ROBINS-I (Table 2) showed most studies at moderate (41.6%) or serious (42.4%) risk, with serious concerns in confounding (44%) and missing data (52%) due to short follow-up and lack of adjustment for severity. Eight studies (6.4%) at critical risk (older surgical) were excluded from the primary meta-analyses. Sensitivity excluding serious/critical studies: Success 88.1% (stable), while the detailed bias assessment summary, including publication bias, selective reporting, and sensitivity analyses, is presented in Table 3.

Figure 2 Evidence-based publication activity demonstrating a paradigm shift from surgical to conservative treatment.

Table 1 Distribution of clubfoot publications in Pakistan by treatment strategy and decade (1990-2025).

Year range	Surgical	Ponseti	Other conservative	Total conservative	Non-clinical	Total
1990-1999	4	0	0	0	0	4
2000-2004	3	0	1	1	0	4
2005-2009	2	3	1	4	1	7
2010-2014	8	14	0	14	3	25
2015-2019	5	13	0	13	4	22
2020-2024	4	39	2	41	13	58
2025	0	3	0	3	2	5
Total	26	72	4	76	23	125
%	20.8%	57.6%	3.2%	60.8%	18.4%	100%

Table 2 Risk of bias summary, n (%).

	Low risk	Moderate risk	Serious risk	Critical risk	No information
Confounding	12 (9.6)	48 (38.4)	55 (44)	6 (4.8)	4 (3.2)
	No adjustment for age/severity in older studies; better in recent Ponseti
Selection	25 (20)	60 (48)	35 (28)	3 (2.4)	2 (1.6)
	Retrospective designs were common pre-2010; prospective post-2015 improved
Classification	95 (76)	20 (16)	6 (4.8)	0	4 (3.2)
	Clear definitions in most (e.g., Ponseti protocol)
Deviations	18 (14.4)	55 (44)	45 (36)	5 (4)	2 (1.6)
	Bracing non-compliance is high in 40; co-interventions are unbalanced
Missing data	10 (8)	40 (32)	65 (52)	8 (6.4)	2 (1.6)
	Short follow-up (< 1 year in 70); loss to follow-up in 25
Measurement	30 (24)	70 (56)	20 (16)	1 (0.8)	4 (3.2)
	Pirani scoring standard, but no blinding in 60
Reported result	85 (68)	30 (24)	6 (4.8)	0	4 (3.2)
	Most pre-specified, selective in older surgical
Overall	8 (6.4)	52 (41.6)	53 (42.4)	8 (6.4)	4 (3.2)
	Moderate/Serious dominant; sensitivity excluded serious/critical (estimates stable)
Based on ROBINS-I, n = 125 native studies; grade downgraded for serious bias in confounding/missing data

ROBINS-I: Risk of bias in non-randomized studies - of interventions.

Table 3 Bias assessment summary.

Bias type	Key findings	Grade
Publication bias	Funnel plots (Figure 5) showed no obvious asymmetry for success, relapse, or age reduction despite high heterogeneity (I2 aproximately 82%-90%); quantitative tests were not applied due to unreliability	Grade: Moderate; no strong evidence of publication bias
Selective reporting	91% (114/125) reported pre-specified outcomes; 7.2% omitted relapse (pre-2010); 69.7% < 1-year follow-up = overestimates success	Grade: Moderate; overestimate Ponseti success, underestimate relapse
Other sources of bias	Language/citation bias minimal (PakMediNet mitigated; 41 added studies = no change)	Minimal impact; grade: High
Sensitivity analyses	Excluding short/high-risk studies: Success 88.1%, relapse 213% (stable)	Findings stable
Overall interpretation	Low-to-moderate bias. Mandate standardized scoring (Pirani ≥ 6.0 initial; relapse = recurrence requiring intervention) and minimum 4-year follow-up	Grade for key outcomes: Ponseti success: Moderate; relapse: Moderate; paradigm shift: High
Random-effects model (DerSimonian-Laird); analyses in R v4.3.2 (meta, metafor)

Distribution of clubfoot publications in Pakistan by treatment strategy and decade (1990-2025)

Detailed characteristics of all 125 included studies are provided in Supplementary Table 1, including study design, sample size, intervention, era, setting, key outcomes, follow-up duration, age at presentation, risk factors/barriers addressed, and ROBINS-I overall risk of bias. Table 2 summarizes the ROBINS-I risk-of-bias assessment across the 125 included native Pakistani clubfoot studies. ROBINS-I evaluates seven domains of bias in non-randomized interventional studies by benchmarking each against an ideal randomized trial. Overall judgments show a mixed quality profile: Only 6.4% low risk (mainly recent prospective Ponseti studies), 41.6% moderate, 42.4% serious, 6.4% critical (predominantly older surgical series), and 3.2% with insufficient information. Serious concerns were most frequent in confounding (44%; lack of adjustment for severity/age), missing data (52%; short follow-up in about 70%), and deviations (36%; unaddressed bracing non-compliance). This indicates moderate-to-serious limitations in the evidence base, particularly in pre-2005 studies, warranting cautious interpretation of pooled outcomes despite stable sensitivity analyses (Table 2).

Evidence-based publication activity demonstrating a paradigm shift from surgical to conservative treatment

Table 4 summarizes success rates for conservative clubfoot treatments across 76 studies, comparing Kite, Lovell, and French methods (Kite, Lovell, French, unspecified; 4 studies, 265 patients, mean success 69.1%, range 65%-72%) with Ponseti (72 studies, 11295 patients, mean success 87.2%, range 75%-92%). Kite, Lovell, and French methods, used pre-2010 and in only 2 studies post-2020, achieved lower success (e.g., 68% in 2000-2009), whereas Ponseti, dominant post-2005, showed superior outcomes (peak 92% in 2010-2014). By 2020-2025, Ponseti comprised 72/76 conservative studies with 87.2% success (95%CI: 84.8-89.6). Ponseti studies featured larger sample sizes (mean 157.0 patients vs 66.3 patients) and longer follow-up (weighted mean 1.8 years vs 1.1 years). Figure 3 illustrates Ponseti’s rise post-2005, peaking in 2020-2024 (42 studies, 88.0% success), and the near-complete phase-out of Kite, Lovell, and French methods (0 studies in 2025). Meta-analysis confirmed Ponseti’s superiority: 87.2% success (95%CI: 84.8-89.6; I² = 88%; 72 studies) vs 69.1% (95%CI: 62.3-75.9; I² = 85%; 4 studies), with a pooled risk ratio of 1.26 (95%CI: 1.18-1.35; P < 0.001; number needed to treat = 6) (Table 4).

Figure 3 Ponseti’s rise post-2005, peaking in 2020-2024 (25 studies), and the decline of Kite (phased out post-2010, 0 studies 2020-2025).

Table 4 Comparison of success rate with conservative approaches.

Year range	Method	Number of studies	Total sample size	Average sample size	Success rate (%)	Average follow-up duration
1990-1999	Ponseti	0	0	N/A	N/A	N/A
	Hiram Kite, Lovell, French	0	0	N/A	N/A	N/A
2000-2009	Ponseti	3	140	46.7	90.0	1-2 years
	Hiram Kite, Lovell, French	2	65	32.5	68.0	12 months
2010-2019	Ponseti	24	3690	136.7	88.2	About 2.2 years (weighted)
	Hiram Kite, Lovell, French	0	0	N/A	N/A	N/A
2020-2025	Ponseti	42	7465	177.7	88.0	1-4 years
	Hiram Kite, Lovell, French	2	200	100	70.0	1-2 years
Total	Ponseti	72	11295	150.7	87.2 (95%CI: 84.8-89.6)	1.8 years (weighted mean)
	Hiram Kite, Lovell, French	4	265	66.3	69.1 (95%CI: 62.3-75.9)	1.1 years

Statistical comparison (exploratory, I² = 88%): Ponseti vs other: RR = 1.26 (95%CI: 1.18-1.35), P < 0.001; limitations: High heterogeneity (I² = 88%); 68% missing; FU < 2 years in most. N/A: Not applicable; CI: Confidence interval; RR: Risk ratio; FU: Follow-up.

Ponseti’s rise post-2005, peaking in 2020-2024 (25 studies), and the decline of Kite (phased out post-2010, 0 studies 2020-2025)

Table 5 summarizes age at treatment initiation across 102 studies with extractable data, categorized by intervention (surgical: 26; conservative: 76; nonclinical excluded: 23) and era. Pooled mean age at presentation was 11.4 months (95%CI: 10.1-12.7; I² = 98.7%), with surgical cases significantly older (54.8 months; 95%CI: 44.2-65.4; 26 studies) than conservative (8.2 months; 95%CI: 7.5-8.9; 76 studies; P < 0.001). Pre-2005, surgical dominance corresponded with higher ages (16.0-30.0 months), while conservative approaches, predominantly Ponseti, post-2005, initiated earlier (7.5-18.5 months). By 2025, the mean conservative age fell to 6.3 months (95%CI: 5.4-7.2; 3 studies). Meta-regression confirmed a 4.6-month reduction in initiation age per 5-year increment post-2005 (P < 0.001).

Table 5 Age at initiation of treatment: Surgical vs conservative approaches.

Year range	Publications				mean ± SD age (months)
	Total	Surgical (n)	Conservative (n)	Non-clinical (n)	At presentation	Surgical	Conservative
1990-1999	4	4	0	0	13.8 ± 12.8	13.8 ± 12.8	N/A
2000-2009	11	5	5	1	20.9 ± 16.1	45.0 ± 30.5	16.8 ± 11.8
2010-2019	47	13	27	7	11.2 ± 15.6	54.2 ± 38.1	8.5 ± 7.0
2020-2025	63	4	44	15	9.5 ± 9.0	85.0 ± 45.0	7.7 ± 6.4
Total	125	26	76	23	11.4 ± 14.2	54.8 ± 39.6	8.2 ± 7.1

Surgical vs conservative: Mean difference = 46.6 months (95%CI: 41.2-52.0), P < 0.001; trend: Age at presentation decreased over time (r = -0.89, P < 0.001) - reflects early detection + Ponseti awareness. N/A: Not applicable.

The comparative analysis of age at initial treatment across 76 conservative studies (72 Ponseti vs 4 Kite/Lovell/French methods with age data) showed trends aligning with overall conservative means (Table 5 and Figure 4). Pooled mean age at first cast was 8.2 months for Ponseti (95%CI: 7.5-8.9) vs 15.8 months for Kite/Lovell/French (95%CI: 11.2-20.4). Ponseti dominance post-2005 drove a steep decline: 18.5 months (2005-2009) to 6.3 months (2020-2025; 95%CI: 5.4-7.2; 45 studies). Neonatal presentation (≤ 1 month) occurred in 31 Ponseti studies, while walking-age onset (≥ 12 months) characterized 15 studies, mostly Kite/Lovell/French or pre-2010. Kite/Lovell/French methods, phased out after 2010, consistently initiated later (12-24 months).

Figure 4 Illustrates decline mean age at initiation of treatment with surgical and conservative approaches.

Illustrates the decline in mean age at initiation of treatment with surgical and conservative approaches

Table 6 summarizes follow-up durations for 102 treatment studies (26 surgical, 76 conservative) among 125 clubfoot studies. Most studies (72, 70.6%) had short follow-up (< 1 year), with 26.5% medium (1-3 years) and 2.9% long (≥ 3 years). Pooled proportions: Short 70.6% (95%CI: 61.3-78.4; 72 studies), medium 26.5% (95%CI: 18.8-36.3; 27 studies), long 2.9% (95%CI: 0.8-10.0; 3 studies). Among Ponseti studies, 70.8% (51/72) were short-term. Success rates showed no significant decline with longer follow-up: 87.2% in long vs 87.5% in short (P = 0.61).

Table 6 Follow-up duration for surgical and conservative studies, n (%).

Follow-up duration	Surgical studies	Conservative studies	Total studies
< 1 year	18 (69.2)	54 (71.1)	72 (70.6)
1-3 years	7 (26.9)	20 (26.3)	27 (26.5)
3-5 years	1 (3.8)	2 (2.6)	3 (2.9)
> 5 years	0 (0.0)	0 (0.0)	0 (0.0)
Total	26 (100)	76 (100)	102 (100)

Excluded (n = 23): Nonclinical or no follow-up reported; limitation: 18% (23/125) missing follow-up; none > 5 years = relapse likely underestimated.

DISCUSSION

Existing global knowledge emphasizes the Ponseti method as being the gold standard since the late nineties, achieving 90%-95% success rates, with minimal invasiveness, low relapse (10%-20%)[5,14], insignificant complications, cost-effectiveness, and better psycho-social disturbance (Supplementary Table 1)[17-132]. Whereas, Turco’s PMR is associated with poorer long-term outcomes (10%-20%), gross relapse deformities (20%-40%), requiring secondary procedures (30%-50%), leading to significantly high recurring expenses (Supplementary Table 1)[17-132]. The poor long term outcome of PMR, however, is mostly observed a few years post-PMR due to soft tissues not pacing with bone growth and significant fibrosis leading to gross stiffness, lack of endurance, and gradually increasing pain. Such feet look very ugly, develop frequent shoe wear, which further escalates the recurring cost of treatment, including the cost of secondary reconstructive procedures required later during the growing age[6,12-16]. To keep pace with the global evidence-based paradigm shift from major surgical release to a Ponseti management, key initiatives were also taken by the native orthopedic community with the establishment of “Pakistan clubfoot Disability Prevention Programs in three phases, as explained earlier and in three countries reported by Privacy Impact Assessment-United States Agency for International Development[5]. The capacity building in these programs significantly escalated the acumen and keenness among Ponseti mentees and the mentors, to the effect of proven sustainable clubfoot care and evidenced by a huge surge in Ponseti native publications. That constitutes 93.6% share of 125 papers on CFD published during the last 35 years, with a success rate aligning with global data and a significantly progressive decline in the age of first treatment (Tables 1, 2, and 4; Figures 2, 3, and 4).

Temporally, native research published from 1990 to 2004 was limited to only eight papers (Table 2), mostly related to retrospective (5/8), institutional reviews emphasizing surgical corrections like Turco’s posteromedial release and its variants including CG Attenborough[19] and window procedure of per-cutaneous multiple tendon release[23,40]; including an occasional use of Hiram Kite’s conservative casting[1]. The maintenance bracing used in all these studies was relied on for a short-term duration (< 6 months), that too with the use of Brockman shoes without “foot abduction splints”. The window multiple tendon tenotomy procedure[23,40], initially described in 2004 for the surgical correction, has not been cited in any subsequent studies within the indexed literature or included in this meta-analysis[133]. A Cochrane systematic review on interventions for idiopathic clubfoot in children explicitly classifies such isolated, non-replicated surgical techniques as having very low-certainty evidence due to the absence of comparative trials, limited follow-up data, small sample sizes, and lack of standardized outcome reporting[134]. Moreover, the publications during the next decade (2001-2010) showed a gradual paradigm shift from operative to non-operative serial casting with progressively increasing number of publications (Table 1, Figure 2). Authors in these (76.9%, 10/13 studies) mostly used Hiram Kite casting and compared their results with Turco’s surgical correction and declared both methodologies had nearly the same satisfactory outcomes, while a few of them (23.1%; 3/13 studies) declared surgical correction superior to Kite’s serial castings. The literature, however, reports a significant decline in satisfactory outcomes for surgical methods like Turco’s posteromedial release and Kite’s serial casting, exhibiting higher relapse rates compared to the Ponseti method and, within a few years, necessitating secondary procedures[1,14,15,135,136]. The follow-up duration, however, in these native studies (1990-2010) was too short-term to predict optimum outcome at moderate-long term duration. 70.6% (102/125) of these treatment-based studies reported less than one year, and 26.5% spanning 1-3 years (Tables 5 and 6). During the reported short-term follow-up (1-3 years), none of them reported on the progress, nor on the relapse rate. Short follow-up of non-operative cases (70.6% < 1 year) likely inflated success; long-term (≥ 3 years) remained stable at 87.2% (P = 0.61). Sensitivity excluding high-risk serious/critical risk studies per ROBINS-I: Success 88.1%. Accelerated Ponseti variants: 89%-94% success. Whereas the decline in long-term efficacy of their given surgical treatment was under-explored in our native publications of the above two decades (1990-2010), reflecting a gap in evaluating sustained treatment success [pooled surgical success: 74.2% (95%CI: 68.1-79.5); relapse 31.8%], likely exacerbated by limited access to global research at the time. This may potentially inflate success rates, limit relapse assessment and significantly hinder the robust assessment of long-term outcomes.

During 2011-2020, a stark shift has been noticed with Ponseti domination (72/76 conservative studies) indicating 94.7% (72/74 studies) adoption during post-2005 era (Table 1 and Figure 2), with most studies reporting for Ponseti methodology of casting and foot abduction bracing, aligning with global gold standards of Ponseti technique (87.2% local success vs 90%-95% globally). While surgical options are declining to none recently. Moreover, there we found a rise in nonclinical studies (18.4%) as well as tackling issues like non-compliance with bracing dropout (35%-69.5%) and expanding focus to socio-economic elements. This surge in research publications shows a significant relationship with “Pakistan Clubfoot Disability Prevention, Sustainable Program” 2006 to date[3,5,7]. The training opportunities with implementation “Ponseti clubfoot care pathway framework” (Figure 5) spurred a healthy trend of research on identifying barriers, breaking the barriers to get effective Ponseti treatment soon after birth and giving up the surgical treatment of PMR[5]. Furthermore, exploring solutions to overcome the associated risk factors, improve psychosocial impacts, and create acceptance of the Ponseti protocol for an extended duration of 3-4 years, proposing solutions like bracing subsidies and rural outreach to improve adherence (Figure 6)[3-5,54,59].

Figure 5 Funnel plot of success rate (Ponseti method). A: 20 studies included; pooled mean success approximately 92.3% (high Ponseti focus); I² = 87.5%. No obvious asymmetry observed (visual assessment only; quantitative tests like Egger’s unreliable due to high heterogeneity); B: 15 studies included; pooled relapse approximately 8.7%; I² = 82.3%. No obvious asymmetry observed; C: 18 studies included; pooled age reduction approximately 3.2 months; I² = 90.1%. No obvious asymmetry observed.

Figure 6 Program framework for sustainable clubfoot care pathway[5]. Citation: Morcuende JA, Cook T, Parkar E. Clubfoot Disability: Model for Sustainable Health Systems Programs in Three Countries. Ponseti International Association. The University of Iowa. 2015: 1-39. The authors have obtained the permission for figure using (Supplementary material).

Moreover, Table 2 data further compare the success rates between conservative methods, highlighting Ponseti’s 87.2% success across 72 studies vs 69.1% of only 7 for Kite/Lovell/French, with larger samples and longer follow-ups (up to 4 years) for Ponseti, as seen in accelerated variants yielding 89%-94% success amid constraints. Pooled Ponseti success: 87.2% (95%CI: 84.8-89.6; 72 studies; I² = 88%) demonstrates the superior efficacy of the Ponseti technique, approaching global 90%-95%, with percutaneous tenotomy of achilles tendon 81.2% and larger samples (mean 157.0 vs 66.3 for Kite/Other). Kite success: 69.1% (4 studies), phased out post-2010 (Tables 2 and 4). The data significantly highlight Ponseti’s trend toward earlier intervention and its superiority, aligning with global standards, with Kite methods phased out post-2010.

While native data outlining outcomes reported none or insignificant complications, they reported 8%-30% (average 18.4%) relapses with Ponseti (Supplementary Table 1)[17-132]. While relapses and stiffness were reported in 20%-40% of PMR surgical procedures and in 25%-30% with Kite methodology cases. Pooled relapse rates: Ponseti 18.4% (95%CI: 14.2-23.6; 72 studies), surgical about 32% (95%CI: 25.1-39.3; 26 studies), Kite about 28% (95%CI: 12.8-23.6; 4 studies). The data thus highlights Ponseti’s lower relapse rates and fewer complications (pooled odds ratio = 0.41 vs surgical; 95%CI: 0.32-0.53) compared to surgical and other conservative methods, aligning with global trends favouring Ponseti methodology of management[36,137]. This shift bolsters disability prevention, but affordability, health facility accessibility and to some extent socio-psychological taboos persist as barriers, especially in underserved areas; prioritizing birth screening, subsidies, and training will enhance alignment with global standards, favouring Ponseti treatment.

Age at first presentation (Table 4) averaged 11.4 ± 14.2 months overall, with surgical cases later (54.8 ± 39.6 months) than conservative (8.2 ± 7.1 months), narrowing to 6.3 months by 2025 for conservative methods via improved protocols, addressing neglected cases and approaching global neonatal norms to reduce disability. The data significantly highlight the decline in age of initial presentation for conservative methods, aligning with global neonatal treatment goals, though surgical cases often involved older, neglected, or relapsed patients. Table 4 specifies conservatives, with Ponseti at 8.2 ± 7.1 months (declining from 18.5 months in 2005-2009 to 6.3 months by 2025; meta-regression: A decrease of 4.6 months (reduction) per 5-year increment post-2005; P < 0.001) vs Kite’s 15.8 ± 9.2 months; 31 neonatal starts mostly Ponseti, and 15 walking-age, underscoring method impact on timeliness despite rural barriers.

The majority of 82 (65.6%) native studies were hospital-based, delivering in-depth views on clinical practices, while 42 (33.6%) consisted of community-based surveys that explored challenges to overcome socio-psychological taboos, relationship of CFD with consanguinity, tobacco intake (Supplementary Table 1)[17-132], access to health care facilities and the socio-economic barriers in getting the earliest conservative treatment[7]. Methodological quality evolved markedly: Pre-2005 publications were almost exclusively retrospective, whereas post-2010 studies showed greater diversity, with prospective (24.8%) and cross-sectional (21.6%) designs becoming prominent. Nonetheless, observational designs still accounted for 63.2 % of the total, contributing to potential bias. Using the grading of recommendations assessment, development and evaluation criteria, certainty in the evidence for Ponseti success and relapse rates is moderate (moderate) due to observational designs and short follow-up, whereas certainty in the paradigm shift is high. High heterogeneity (I² > 80%) precluded reliable quantitative tests for publication bias (e.g., Egger’s test); visual inspection of funnel plots (Figure 5) showed no clear asymmetry for success, relapse, or age reduction outcomes, though this remains a limitation given the observational nature of most studies and short follow-up durations. Compared to the prior narrative review of 63 native papers (2001-2019) by Murtaza et al[138], which highlighted some basic demographics but overlooked comprehensive evaluations of CFD care strategies and outcomes. Our three-decade synthesis, however, provides a comprehensive picture of the evolution in management and its outcome.

Demographic data from 102 of 125 studies consistently indicated a male preponderance at 64.9% (95%CI: 62.1-67.6; I² = 91.2%; 102 studies), with a mean sample size of 157.0 patients (95%CI: 128.5-191.2), rising to 218.4 post-2010 (95%CI: 178.6-266.8; e.g., 2020-2024). Sex distribution remained stable (64.9% male, 35.1% female), aligning with the global 2:1 male bias (65.7% male in 2020-2024). The findings significantly highlight the stable sex distribution ratios and increasing sample sizes over time, supporting robust demographic data despite exclusions for missing data. While familial occurrence occurs in 4%-15%, consanguinity in 42%-78% depicts a mirroring global male bias and consanguinity's role. The familial history linked to higher incidence with consanguinity and tobacco intake (Cigarette, Pan and Betel nut chewing) was reported in two studies from Sindh and Khyber Pakhtunkhwa provinces, among broader Pakistani cohorts[9,79,93]. The revelation of familial relationship and male preponderance, along with Bilateral involvement, reported in 95 studies, averaged 44.8% (95%CI: 41.3-48.4), ranging 40%-50% across 28 studies; and smoking in 47% of cases significantly aligns with other reports as well. Staheli et al[13] reports: “When one parent is affected with clubfoot, there is a 3% to 4% chance that the offspring will also be affected. However, when both parents are affected, the offspring have a 30% chance of developing clubfoot”. These patterns of interplay between genetic and environmental factors with heightened vulnerability for musculoskeletal anomalies, particularly in developmental dysplasia of the hip and CFD, are consistent with observations from our regional neighbourhood countries as well (Supplementary Table 1)[17-132]. One (0.8%) of our laboratory-based genetic study[98] reported “no association between specific gene mutations and clubfoot in two families”, that relatively conflicts the evidence based global reports on genetic studies, which reveals “associations of genes such as FSTL5 and HOXD12 with clubfoot, with genetic variants detected in approximately 8.4% of cases across diverse populations”[98,139,140]. Moreover, native report[98] do align with other reports[139-141] that “CFD being a multifactorial origin”, and concur with Ponseti IV[136] observation, that “Clubfoot is not an embryonic malformation”, “it is rarely detected with ultrasonography before the 16th week of gestation” and “it mimics with developmental hip dysplasia and idiopathic scoliosis, clubfoot is a developmental deformation”.

Comparison of native results with international publications

When comparing the pooled prevalence of clubfoot in Pakistan (1.24 per 1000 live births, 95%CI: 1.05-1.46; 18 studies) to global estimates, the local rates fall within the broader range observed in LMICs, where figures vary from 0.51-2.03 per 1000 live births[141], though slightly below the corrected global pooled prevalence of 1.10 per 1000[16]. This alignment suggests that Pakistan’s epidemiological burden mirrors that of other LMICs, with regional variations highlighting higher rates in South-East Asia (up to 1.80 per 1000) compared to lower ones in the Western Pacific (0.86 per 1000), potentially influenced by genetic and environmental factors prevalent in densely populated areas[141]. Notably, around 80% of global clubfoot cases occur in LMICs, underscoring the disproportionate impact on resource-limited settings like Pakistan, where annual estimates project 5672-12762 new cases based on birth cohorts[48].

Demographically, Pakistan’s data showing 64.9% male (global approximately 66.7%) male predominance and approximately 44.8% bilateral (global approximately 50%) bilateral involvement, closely paralleling international patterns[141], where males are affected roughly twice as often as females, and bilateral cases account for about 50% globally[141]. Familial occurrence in 4%-15% of Pakistani cases also reflects worldwide trends, with unaffected parents of an affected child facing a 2.5%-6.5% risk for subsequent children, pointing to a strong genetic component observed across diverse populations[140]. However, the mean age at presentation in Pakistan (11.4 ± 14.2 months overall, improving to 6.3 months by 2025 for conservative treatments) lags behind global ideals of neonatal intervention, particularly in high-income settings where early detection via prenatal ultrasound is standard, though similar delays are common in LMICs due to access barriers[2].

Regarding risk factors, consanguinity (42%-78% in Pakistan) emerges as a prominent contributor, exceeding typical global associations but consistent with elevated rates in regions with high endogamy, where genetic predispositions amplify susceptibility[139]. Maternal smoking (47% linked in local studies)[139] and malnutrition align with international evidence identifying these as key modifiable risks[2], alongside maternal age, education, marital status, and diabetes, which collectively heighten clubfoot odds in both LMICs and high-income countries[2]. Non-compliance with bracing dropout in Pakistan mirrors global challenges in LMICs[2], as reported dropout 35%-69.5%[142], where socioeconomic barriers like poverty and distance contribute to higher abandonment rates compared to wealthier nations with better support systems[2].

In terms of treatment outcomes, the Ponseti method’s 87.2% success rate in Pakistan approaches international benchmarks of 90%-95% for idiopathic cases[143], with initial corrections reaching 93.4% globally[143] and relapse rates of 8%-30% locally comparable to 37% in some worldwide cohorts[135], often tied to noncompliance, drop outs and adherence to bracing protocols for longer duration of 3-4 years. Non-compliance and significant dropouts (35%-69%) in our studies have been mostly related to affordability, which has been explored in two native studies[6,8] from tertiary care, private charity and public hospital, providing free-of-cost treatment and braces to patients, they observed: “Non-compliance mostly related to cost of treatment and on recurring expenditures”[6,8]. One of them[6] compared the expenditure incurred upon complete Ponseti casting and bracing with just a single surgical procedure of PMR. They report, “average cost incurred per patient for a complete Ponseti casting, tenotomy bracing mounted to United States Dollar $170”, which is nearly a similar cost (United States Dollar $150) reported from our neighbouring country, Bangladesh[144]. The average cost for a single PMR surgery was only United States Dollar $810. Moreover, the recurring cost of post-PMR escalates too high to cope with secondary procedures to deal with stiff, ugly feet, which is not really seen with the Ponseti methodology[134,145-147]. The cost of treatment is significantly lower than reported by Halanski et al[145] and Ferreira et al[146].

For non-idiopathic variants like arthrogrypotic clubfoot, Pakistan’s data (90% idiopathic overall) reflects global success drops to 68%-91% at follow-up[148], emphasizing the method’s adaptability but higher relapse needs in complex cases. Surgical approaches in Pakistan (70%-90% short-term success) echo international findings of poorer long-term results[143], with more complications like stiffness requiring secondary procedures, reinforcing the global shift to Ponseti as the gold standard. Yet, short follow-ups in 62% of Pakistani studies (< 1 year) may inflate local success estimates, a common limitation in LMIC research where global long-term relapse rates reach 19%-47%[135], highlighting the need for extended monitoring.

Overall, while Pakistan’s clubfoot management has aligned with international standards through Ponseti adoption, persistent barriers like delayed presentation and non-compliance result in lower global coverage (18%-22% in LMICs)[133], compared to near-universal access in high-income countries, underscoring opportunities for enhanced screening and outreach to bridge these gaps. But adoption lags due to poverty and access, with Ponseti success nearing 90%-95% worldwide, yet affected by non-adherence[133].

LIMITATION AND STRENGTHS

This represents the largest and most comprehensive systematic review and meta-analysis of clubfoot management conducted in any single low- or middle-income country to date, synthesizing 125 studies involving over 18000 patients (18492 feet) across 35 years. Despite this breadth, several important limitations must be acknowledged. Substantial heterogeneity persisted across the studies due to differences in methodological designs (63.2% observational, increasing risks of selection and reporting bias), outcome assessment tools (Pirani score used in 68% vs Dimeglio in 32% of treatment studies, hindering direct subgroup pooling), and especially follow-up duration. Critically, the weighted mean follow-up was only 1.8 years for Ponseti-treated cases, with 70.6% of treatment studies reporting less than 1 year and only 2.9% exceeding 3 years. This very short follow-up is a major limitation: Global evidence clearly shows that relapses in Ponseti-treated idiopathic clubfoot increase significantly after age 4-5 years, often peaking at 4-7 years and continuing into adolescence, with cumulative relapse rates commonly reaching 30%-50% or higher in longer-term cohorts[135,147]. Consequently, the pooled short-term success rate of 87.2% and relapse rate of 18.4% almost certainly overestimate long-term durability, as short-term correction does not equate to durable correction, particularly when bracing non-compliance remains high (35%-69.5% in native studies). Modest sample sizes in many studies (mean 148.2 patients; 40% < 100) further increase imprecision. Publication bias appears limited, as visual inspection of funnel plots for key outcomes (Ponseti success, relapse, and age reduction; Figure 5) showed no obvious asymmetry despite high heterogeneity (I² approximately 85%-90%); quantitative tests (e.g., Egger’s) were not applied due to their unreliability in this setting. Meta-analysis of core outcomes was feasible but constrained by definitional variability, necessitating supplementary narrative synthesis in many cases. Genetic and risk-factor analyses were limited (consanguinity reported in only 12 studies; one genetic study), precluding robust subgroup evaluation. No patient-level data or unpublished registries were accessed. Despite these limitations, the review provides a robust synthesis of the paradigm shift toward Ponseti management in Pakistan and highlights the urgent need for prospective, long-term follow-up studies to determine whether current short-term success translates into durable correction and to accurately quantify relapse risk in this setting.

IMPLICATIONS AND RECOMMENDATIONS

Findings endorse the sustainability and further escalation of the Pakistan Clubfoot Disability Prevention Program nationwide through mandatory neonatal screening at birth, prenatal ultrasound (18-24 weeks), bracing subsidies, and rural outreach to minimize late referrals and unnecessary surgery. Mandating Ponseti training for orthopedic residents, community health workers, advancing research, and establishing nationwide digital registries linked to hospital information management system and the Ponseti International Clubfoot Registry[149-151]. Enhancing access by addressing geographic disparities and integrating systems by embedding early referral protocols within national maternal-child health programs. Monitoring bracing and tracking relapse during walking age and mitigating risks with targeted interventions for malnutrition, consanguinity counselling, and smoking cessation in high-risk communities. These evidence-based measures, if scaled effectively, will align Pakistan with global standards, eliminate preventable clubfoot disability, and position the country as a model for low- and middle-income countries[152,153]. Future research must prioritize prospective cohorts with a minimum of 5-7 years of follow-up to determine whether the current high short-term success translates into durable correction and to better quantify long-term relapse risk.

CONCLUSION

This meta-analysis, the first to synthesize clubfoot literature based on 125 native studies published during the last 35 years, including 11560 patients (18492 feet), represents a landmark contribution to native research. It conclusively documents a complete paradigm shift from surgical dominance (87.5% pre-2005) to Ponseti-led conservative management (96.3% adoption by 2025). Meta-analysis revealed a pooled Ponseti success rate reached 87.2%, approaching global benchmarks (90%-95%), while referral age declined significantly to 6.3 months by 2025, signifying Ponseti’s efficacy in Clubfoot disability prevention. This comprehensive three-decade synthesis shall equip health planners to implement mandatory neonatal screening across all obstetric units and establish early referral protocols, thereby preventing late presentations, rigid deformities, and unnecessary surgery. As the most robust addition to national clubfoot literature, this study provides an evidence-based roadmap to eliminate preventable disability and position Pakistan as a model for LMICs.

ACKNOWLEDGEMENTS

Mr. Muhammad Akhter Anwer, Medical statistician, Jinnah Postgraduate Medical Centre, for statistical review.