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: 2.77). 06/2009; 467(5):1154-63. DOI: 10.1007/s11999-009-0759-0
Source: PubMed


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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Available from: Richard G Mathias, Feb 17, 2014
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    • "Walk for Life (WFL – is the sustainable clubfoot program in Bangladesh, and previous reports have indicated the challenges and successes of implementing the Ponseti technique in this poor and populous country [1]. Whilst many of the conditions faced in Bangladesh are similar to those in other parts of the developing world [2-4], there are also recognised factors that are peculiar to this cultural context and clinical setting viz. a public health system with overcrowded clinics, difficult transport for the lengthy treatment process, poor infrastructure, lack of basic facilities eg hand-washing, adequate lighting [1]. When preparing to evaluate the results of WFL in children two years after treatment commencement, it was recognised that existing assessment tools were not fully commensurate with the WFL database and clinical methods. "
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    ABSTRACT: 'Walk for Life' (WFL) is the sustainable clubfoot program in Bangladesh, where there are many challenges in implementing the Ponseti technique in a poor and highly populated country. The relapsing tendency of congenital clubfoot deformity means that initial results may well differ from those of the medium and longer term. Over 10000 children with16668 clubfeet have been treated by WFL since its inception in 2009. Such a large project provides both the need to evaluate each individual child's case, and also the opportunity to evaluate the wider WFL program results. Such systematic review requires a measure that is sufficiently robust, yet contextually practical, hence the aim of this work was to develop a tool for this purpose, and to report the examiner reliability. The Bangla clubfoot tool was largely developed from components of existing validated clubfoot assessment measures, and adapted for local use. Three areas of examination are included: parent satisfaction, gait, clinical examination of the clubfoot. A same-subject repeated measures study design was used to assess the intra-rater reliability of a local WFL physiotherapist, and a visiting WFL volunteer. The inter-rater reliability was also assessed, which is relevant for other examiners and other clubfoot projects undertaking evaluation of medium and longer term results. The reliability study was conducted in 37 children who had commenced treatment for congenital clubfoot deformity using Ponseti method within the previous two years. The mean age of the children was 2.6 years, with gender 28 male: 9 female. The intra-rater reliability results [ICCs (95% CI)] were: 0.87 (0.76 - 0.93) for the local WFL examiner, and 0.82 (0.64 - 0.91) for the visiting examiner. Inter-rater reliability results [ICCs (95% CI)] were: 0.92 (0.88 - 0.96). Hence the tool showed very good intra-rater and inter-rater reliability, rendering it suitable for use. The Bangla clubfoot tool has been developed to suit the context of the large WFL clubfoot program in Bangladesh, and shown to be a very reliable evaluation instrument.
    Full-text · Article · May 2014 · Journal of Foot and Ankle Research
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    • "In our study, nonoperative procedures took usually 5–8 weeks which is a similar period to Ponseti standards and that what other author report [11, 12]. For the treatment performed at our clinic, tenotomy of the Achilles tendom was crucial for the completion of a successful correction of the foot. "
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    ABSTRACT: The purpose of this study was to evaluate the early results of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot in patients treated in Children's Orthopaedic Clinic and Rehabilitation Department Medical University of Lublin between the years 2007-2011. Thirty-five patients with 47 idiopathic clubfeet were followed prospectively while being managed with the Ponseti method. Clubfoot severity was graded with use of the Dimeglio system. The initial correction was achieved, and early results were measured by using Pirani scoring method.
    Full-text · Article · Jul 2012 · European Journal of Orthopaedic Surgery & Traumatology
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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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