Effectiveness of bracing in preventing relapse in patients with clubfoot: a systematic review

Congenital clubfoot affects approximately 1–2 per 1,000 live births. The Ponseti method achieves initial correction in over 95% of cases, but preventing relapse through maintenance bracing remains the central challenge, with reported relapse rates of 6% to 47%. To synthesize evidence on the effectiveness of foot abduction bracing in preventing clubfoot relapse after Ponseti correction, and to identify determinants of adherence and success across brace types, wearing schedules, and healthcare settings, including low- and middle-income countries (LMICs). MEDLINE (PubMed), Embase, and Scopus were searched from inception to December 31, 2024. Twenty-five studies (at least 2,317 patients and 2,927 clubfeet in the primary studies) were included: 19 primary studies and 6 contextual sources. Quality was assessed with design-specific tools (Cochrane RoB 2, Newcastle–Ottawa Scale, AMSTAR-2, SANRA, AGREE II, CROSS; see Supplementary File). Given substantial heterogeneity, findings were synthesized narratively without meta-analysis. Relapse rates in primary studies ranged from 0% to 48% (mean follow-up 42 months). Non-adherence was the strongest predictor of relapse (odds ratios 5–11). The lowest relapse rates (8–12.1%) followed full-time bracing for 3 months, then nighttime use until age 4–5 years. Higher baseline Pirani score, evertor weakness, and prolonged casting predicted inferior outcomes. Dynamic and unilateral designs showed better adherence (81–88%) than Denis-Browne splints (47–67%), though biomechanical equivalence with fixed orthoses is unestablished. Sensor-based studies showed that parent-reported adherence overestimates actual wear. Socioeconomic and health-system barriers limited adherence, particularly in LMICs. Adherence is the dominant determinant of relapse prevention, outweighing brace design. Fixed abduction orthoses remain the evidence-based first-line option. Successful programs need active, family-centered support, including structured counseling, protocolized follow-up, and reduction of socioeconomic barriers, especially in LMICs. Long-term multicenter randomized trials with objective adherence monitoring are the research priority.