Predictors of cast-related skin complications during Ponseti casting: analysis of 306 casting episodes

Cast-related skin complications remain an under-recognised challenge during Ponseti casting for congenital talipes equinovarus (CTEV). These complications - ranging from erythema and skin peeling to deep sores - can prolong treatment, increase infection risk, and reduce caregiver compliance. This study aimed to determine the prevalence and predictors of skin complications during serial casting for idiopathic CTEV. An ambispective observational cohort study was conducted at a tertiary care centre between December 2023 and June 2025. Children with idiopathic CTEV undergoing Ponseti casting were included. Cast-related skin lesions were documented at removal and categorised as erythema, skin peeling, superficial sore, or deep sore. Variables across patient, procedural, hospital, and caregiver domains were analysed using univariate and multivariate logistic regression to identify independent risk factors. A total of 306 casting episodes were analysed. The overall incidence of skin complications was 13.1%. On univariate analysis, dorsum swelling after cast removal [odds ratio (OR): 17.06, P < 0.001], patient irritability (OR: 3.17, P < 0.001), cast staining (OR: 11.56, P = 0.010), and foul odour (OR: 23.29, P = 0.008) were significantly associated with skin lesions. Multivariate analysis identified dorsum swelling as the strongest predictor [adjusted OR: 30.96, 95% confidence interval (CI): 5.26-182.13, P < 0.001]. Bilateral casting was protective compared with unilateral casting (adjusted OR: 0.19, 95% CI: 0.05-0.66, P = 0.009). Cast-related skin complications occur in over one in eight CTEV casting episodes. Postcast swelling and unilateral involvement are significant predictors. Routine inspection for swelling and risk-stratified follow-up can reduce morbidity while maintaining high correction success with the Ponseti method.