Towards Effective Ponseti Clubfoot Care: The Uganda Sustainable Clubfoot Care Project

Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada.
Clinical Orthopaedics and Related Research (Impact Factor: 2.88). 06/2009; 467(5):1154-63. DOI: 10.1007/s11999-009-0759-0
Source: PubMed

ABSTRACT Neglected clubfoot is common, disabling, and contributes to poverty in developing nations. The Ponseti clubfoot treatment has high efficacy in correcting the clubfoot deformity in ideal conditions but is demanding on parents and on developing nations' healthcare systems. Its effectiveness and the best method of care delivery remain unknown in this context. The 6-year Uganda Sustainable Clubfoot Care Project (USCCP) aims to build the Ugandan healthcare system's capacity to treat children with the Ponseti method and assess its effectiveness. We describe the Project and its achievements to date (March 2008). The Ugandan Ministry of Health has approved the Ponseti method as the preferred treatment for congenital clubfoot in all its hospitals. USCCP has trained 798 healthcare professionals to identify and treat foot deformities at birth. Ponseti clubfoot care is now available in 21 hospitals; in 2006-2007, 872 children with clubfeet were seen. USCCP-designed teaching modules on clubfoot and the Ponseti method are in use at two medical and three paramedical schools. 1152 students in various health disciplines have benefited. USCCP surveys have (1) determined the incidence of clubfoot in Uganda as 1.2 per 1000 live births, (2) gained knowledge surrounding attitudes, beliefs, and practices about clubfoot across different regions, and (3) identified barriers to adherence to Ponseti treatment protocols. USCCP is now following a cohort of treated children to evaluate its effectiveness in the Ugandan context. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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    ABSTRACT: Introduction Globally, traumatic injuries are amongst the 10 leading causes of morbidity and mortality in children and adolescents, with most of the burden borne by low-and middle-income countries (LMICs), in particular in Africa, South-East Asia, and the Western Pacific Region. 1 Furthermore, for every injury-related death, an estimated four or five children with severe injury-related disabilities are a significant drain to their families and health systems troubled by already low resources. 2 Traumatic injury is estimated to get worse over time, in particular in the developing world, largely due to the increasing prevalence of road traffic injuries, especially in Africa. 3 Most posttraumatic disabilities are due to injuries to the upper or lower extremities or to the spine. 4,5 For the sheer volume of musculoskeletal injuries seen everywhere in Africa, rural or urban, any hospital accepting all types of emergencies would require significant orthopaedic surgical services. 6 Furthermore, with more than 50% of the population under the age of 15 years in most developing countries, a specific familiarity with paediatric orthopaedic traumatic injuries would be required. In most LMICs, very few orthopaedic surgeons are available to deal with these many surgical problems, and even fewer are formally trained paediatric orthopaedic surgeons. As such, most orthopaedic surgical services throughout Africa have been provided by general surgeons or orthopaedic clinical officers with some surgical training. 7 With the literature on the efficacy of African traditional bonesetters being limited, and in general negative, 8–10 it is likely that generalist surgeons and nonphysician clinical officers will continue to provide the vast majority of orthopaedic surgery in Africa for the foreseeable future. Apart from the traumatic orthopaedic problems African children must endure are the additional surgical problems of congenital deformities, infections, and other conditions affecting the musculoskeletal system. Figure 120.1 presents data from Rwanda from what is probably the first national, population-based survey done in sub-Saharan Africa examining the extent of musculoskeletal impairment and treatment needs in children. 11 Beyond the sizeable burden of the acute traumatic issues already mentioned, data extrapolation from the results of this study estimates that 50,000 children in Rwanda are in need of orthopaedic surgery for old traumatic problems, neurological impairments, nontraumatic angular deformities (e.g., rickets), congenital anomalies (e.g., clubfoot), and bony infections. The purpose of this chapter is to introduce newer, evidence-based approaches to some old and persistent orthopaedic surgical problems, not only in sub-Saharan Africa but also throughout the developing world. Bach 7 argues the traditional orthopaedic mantra of "Never close an open fracture nor open a closed one" in African centres, given improvements in sterilisation equipment, orthopaedic implants, availability of antibiotics, and so forth. Furthermore, failures of conservative orthopaedic care can result in significant disability. Utilisation of a public health, evidence-based approach to musculoskeletal surgical problems may reduce the sizeable morbidity of orthopaedic problems in African children. Specific problems discussed will include clubfoot, an approach to open fractures to reduce posttraumatic chronic osteomyelitis, and evidence to support an open surgical approach to supracondylar fractures of the paediatric elbow. Also addressed are angular deformities related to polio and nutritional rickets. Figure 120.1: The musculoskeletal problems that exist beyond the acute orthopaedic trauma needs for children in Rwanda. A major part of a public health–oriented, evidence-based approach to surgical problems is the need for accurate data to plan health services. Source: Atijosan O, Simms V, Kuper H, Rischewski D, Lavy C. The orthopedic needs of children in Rwanda: results from a national survey and orthopaedic service implications. J Pediatri Orthop 2009; 29:948–951.
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    ABSTRACT: In 2005, a nationwide clubfoot treatment program focused on the Ponseti method -an effective, affordable and minimally-invasive method- was initiated in China. The purpose of this study was to evaluate and identify barriers to the program. A qualitative study (rapid ethnographic study) was conducted using semi-structured interviews of 44 physicians who attended four of the 10 Ponseti training workshops, focus groups with parents of children with clubfoot, and observation. Several barriers to the Ponseti method are quite unique due to China's size, socio-economics, culture, politics, and healthcare systems. The barriers were classified into seven themes: (i) physician education, (ii) caregiver compliance, (iii) culture, (iv) public awareness, (v) poverty, (vi) financial constraints for physicians/hospitals, and (vii) challenges of the treatment process. A number of suggestions that could be helpful in reducing or eliminating the effects of these barriers were also identified: (i) pamphlets explaining clubfoot and treatment for caregivers, (ii) directories of Ponseti providers, (iii) funding/financial support, and (iv) improving public awareness. The information from this study provides healthcare planners with knowledge to assist in meeting the needs of the population and continued implementation of effective and culturally appropriate awareness and treatment programs for clubfoot throughout China.
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    ABSTRACT: The Ponseti method has become accepted worldwide as the treatment of choice for nonoperative management of clubfoot. However, there has been no research on whether casting should begin in the newborn period (< or = 30 days old) or later (> 30 days but < 1 year old) or on whether the length of the foot at the beginning of casting is predictive of the outcome of therapy. Therefore, we conducted an investigation to compare outcomes in patients started on casting therapy in the newborn period or later. Outcomes were based on Pirani and Diméglio scores. The study population was comprised of 40 clubfeet in 29 consecutive infants with no associated neuromuscular disease, who underwent Ponseti treatment. The median follow-up was 34 months (range, 20-47 months). Casting began in the newborn period on 26 feet of 18 patients (newborn group), and after 1 month of age on 14 feet of 11 patients (older infant group). Final Diméglio scores were significantly worse for the patients whose casts were applied in the newborn period, compared with those who had the first cast applied at a time >30 days postpartum (P = .04). Infants with feet > or =8 cm in length at the start of cast treatment had better final Diméglio scores than those with feet <8 cm. Our findings suggest that casting according to the Ponseti method should begin in infants older than 1 month of age, or with an involved foot > or =8 cm in length.
    The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons 09/2010; 49(5):426-31. DOI:10.1053/j.jfas.2010.06.010 · 0.98 Impact Factor
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