Serial Casting Before Relapse Surgery: Investigating the Challenges of Relapsed Clubfoot Care

BACKGROUND: Clubfoot is a common congenital condition typically treated in infancy using the Ponseti method. Despite successful initial treatment, relapse occurs in up to 40% of cases and often requires surgical management. While serial casting is widely used for initial correction, its utility before surgical relapse management remains unclear. This study evaluates whether presurgical casting is associated with a reduction in the number and complexity of surgical procedures for relapsed clubfoot in children under the age of 16 years. METHODS: A retrospective cohort audit conducted at a tertiary treatment center reviewed children treated surgically for relapsed clubfoot between 2015 and 2024 following initial Ponseti management. Data were extracted from medical records, and participants were stratified into 2 groups: those who received presurgical casting and those who did not. Primary outcomes included the number and complexity of procedures. RESULTS: Sixty-five participants were included: 14 (21.5%) received presurgical casting. The casting group demonstrated a 40.0% reduction in surgical complexity from waitlist to surgery, while the noncasting group showed only a 1.9% reduction (P=0.001). High-complexity surgeries were less common in the casting group (53.3% compared with the noncasting group, 80.6%, P=0.004). Noncompliance with orthosis use was common, and Indigenous children were overrepresented in the relapse cohort. CONCLUSION: Presurgical casting may reduce the surgical burden in relapsed clubfoot. LEVEL OF EVIDENCE: The retrospective comparative study provides a comparison between presurgical casting and noncasting, providing evidence to guide clubfoot service development.