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: Purpose Reported outcomes of neonatal surgery in low-income countries (LICs) are poor. We examined epidemiology, outcomes, and met and unmet need of neonatal surgical diseases in Uganda. Methods Pediatric general surgical admissions and consults from January 1, 2012, to December 31, 2012, at a national referral center in Uganda were analyzed using a prospective database. Outcomes were compared with high-income countries (HICs), and met and unmet need was estimated using burden of disease metrics (disability-adjusted life years or DALYs). Results 23% (167/724) of patients were neonates, and 68% of these survived. Median age of presentation was 5 days, and 53% underwent surgery. 88% survived postoperatively, while 55% died without surgery (p < 0.001). Gastroschisis carried the highest mortality (100%) and the greatest mortality disparity with HICs. An estimated 5072 DALYs were averted by neonatal surgery in Uganda (met need), with 140,154 potentially avertable (unmet need). Approximately 3.5% of the need for neonatal surgery is met by the health system. Conclusions More than two thirds of surgical neonates survived despite late presentation and lack of critical care. Epidemiology and outcomes differ greatly with HICs. A high burden of hidden mortality exists, and only a negligible fraction of the population need for neonatal surgery is met by health services.
    Journal of Pediatric Surgery 12/2014; 49(12). DOI:10.1016/j.jpedsurg.2014.09.031 · 1.31 Impact Factor
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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: Background and purpose - Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti's technique in neglected clubfoot in children in a rural setting in Ethiopia. Patients and methods - A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2-10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years. Results - A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot. Interpretation - This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.
    Acta Orthopaedica 09/2014; DOI:10.3109/17453674.2014.957085 · 2.45 Impact Factor

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