O3275: The Effect of Transportation Barriers on the Risk of Relapse for Idiopathic Clubfoot

Background: Clubfoot is one of the most common orthopedic birth defects, with significant risk factors for deformity relapse including noncompliance with brace wear and increased number of casts. However, given that the Ponseti method requires active and consistent engagement from the parents, psychosocial factors such as the physical accessibility of clubfoot clinics can be equally influential in predicting a patient’s outcomes. The primary aim of this study was to evaluate the impact of transportation barriers on the risk of relapse in patients undergoing treatment for idiopathic clubfoot.

Methods: Patients diagnosed with idiopathic clubfoot were enrolled in a prospective registry at a single tertiary care center between May 2019 and August 2022. A prospective survey was administered regarding demographics and transportation. A chart review was conducted to collect outcomes such number of casts, relapse, and surgical procedures. Zip codes were also used to query a Los Angeles health needs assessment spatial database to identify the percentages of households without vehicles and those below the federal poverty level.

Results: 97 patients met inclusion criteria and underwent the Ponseti treatment method with a median of 8 serial casts. Eighty (83.3%) patients underwent a tenotomy procedure. Fourty-six (47.4%) patients experienced a relapse and 27 (27.8%) patients experienced multiple relapses. For the first episode of relapse, 27/46 (58.7%) patients underwent repeat casting, 15/46 (32.6%) underwent a surgical procedure, and 4/46 (8.7%) underwent both repeat casting and a surgical procedure. Across the subsequent episodes of relapse, 18/46 (39.1%) patients underwent repeat serial casting alone, 13/46 (28.2%) patients underwent a surgical procedure alone, and 15/46 (32.6%) underwent both. Of the 13 patients who underwent a surgical procedure for relapse without repeat serial casting, 11 (84.6%) completed a gait study prior to surgical discussion.
Patients with a relapse had a longer commute time to the clinic, median 38.0 (IQR 29) vs. 52.5 (IQR 42.5) minutes (p=0.031). Additionally, patients who experienced relapse lived in areas with a higher percentage of households without vehicles (p=0.008). Patients from areas with more households below the federal poverty level were significantly more likely to experience relapse (p=0.037). However, patients from areas with a higher unhoused population were not significantly more likely to experience relapse (p=0.084) (Table 1). Insurance status was not associated with relapse (p=0.273).

Conclusion: Transportation barriers correlate with higher relapse rates in clubfoot patients. These findings underscore the importance of addressing social determinants of health, particularly transportation access, to optimize treatment outcomes and reduce the burden of relapse for this population.