Comment on “Are early antero-posterior and lateral radiographs predictive of clubfoot relapse requiring surgical intervention in children treated by Ponseti method?”

We read with great interest the article by Li et al. entitled “Are early antero-posterior and lateral radiographs predictive of clubfoot relapse requiring surgical intervention in children treated by Ponseti method?.” ¹ We congratulate the authors on their retrospective analysis study to evaluate the role of radiographs in predicting relapse following clubfoot correction by Ponseti’s method. We had an extensive discussion on this article in our institutional journal club, which yielded the following observations and requires clarification on the following concerns:

1. The authors have included patients for which antero-posterior and lateral radiographs have been obtained within 3 months after Achilles tenotomy. However, they have not mentioned the indication for ordering the said radiographs. Ponseti et al. do not recommend routine radiographs for follow-up of patients managed using their protocol. ² Were those radiographs taken if the treating surgeon had a suspicion of under-correction or possibility of recurrence?

2. Children that were noncompliant with the bracing protocol were excluded. Since poor brace compliance is generally considered to be the prime reason for relapse, how do the authors explain the very high incidence of relapse in their study population (23.1%) and the reason these relapsed cases presented very late (Mean age of 6.07 ± 1.85 years at relapse)?

3. All the cases in the relapsed group were managed surgically by the authors. Did the authors include only those relapses that were managed surgically or was surgery done for all cases of relapsed feet?

4. The authors have not given any details with regard to their relapses, that is, which specific deformity relapsed most commonly. Was it equinus or forefoot adduction or heel varus?

5. The shape of the immature tarsal bone in an infant would appear to be highly variable on plain radiographs (ossified part), thereby the angles that were measured will be likely to be subjective.

6. The authors have mentioned that radiographs were taken after complete correction and Achilles tenotomy. However, the radiographs that were included in the images do not represent corrected clubfeet. In fact the image shown in Figure 1 (c)–(e) represents a midfoot break in an uncorrected clubfeet.