Patients for whom place of birth was missing may include babies who were abandoned, or those from orphanages, in which case there may be other social factors contributing to poor outcomes.
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Results of our study should be viewed in light of some limitations, including its retrospective nature. Our results are likely under-reporting the challenges to care in this developing nation as the clinic is situated in a large referral hospital in the capital city and may not be representative of potentially worse outcomes in smaller, unmonitored rural settings. Most of the CURE clubfoot free referral clinics are in cities or larger towns, but given the finding of prior treatment outside of this network for some patients, we acknowledge there must be treatment by varying levels of care providers, possibly in rural as well as more developed areas.
In addition, our study sample included all-comers as an evaluation of all care provided at this clubfoot referral clinic.
Ponseti method - Wikipedia
This included patients with diagnoses of idiopathic, syndromic, postural clubfoot and metatarsus adductus. Regardless of etiology and diagnosis, patients were typically serially casted and followed and were included in analysis. Given the very small effect size of diagnosis on delayed treatment or relapse, and the quite large effect size on number of casts, we did not feel the inclusion of postural clubfoot and metatarsus adductus would change the statistical conclusions, but it is possible it contributed in part to the overall low tenotomy rate in our sample.
We confirmed in a secondary analysis that inclusion of MTA and postural clubfoot patients had no statistical effect on delayed treatment and relapse analyses, and may have caused an underestimation of the strong effect of diagnosis on number of casts, thus only strengthening the finding that idiopathic clubfoot patients required significantly fewer casts than non-idiopathic. Our study may also be affected by limited follow-up, defined by either failure to reach the bracing phase, or no documented follow-up after entering a brace.
Given the risk of recurrence from noncompliance with bracing [ 51 ], it is possible our results under-report relapse and its risk factors.
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This underscores the need for clubfoot programs to emphasize long-term follow-up and address barriers to care. The study clinic already has a system for telephone calls after missed visits, but further support is warranted, particularly in situations where families must travel for extended periods of time. In addition, during the study period, new clinics have emerged in Haiti and may have altered the study population over time by further selecting for families near this urban center over those in rural areas.
We demonstrate here the establishment of a Ponseti clubfoot program in a resource-limited setting. Our results provide support for the creation of dedicated treatment centers to reduce inadequate or failed care elsewhere, ultimately delaying the onset of casting. We verify previously reported risk factors of associated abnormalities and high Pirani score with poorer outcomes, but also identify a potential gender disparity in this population with female patients at greater risk for relapse, warranting further review of the underlying cause of this novel finding.
Finally, we advocate that standardized, prospective electronic data entry should be an integral part of any future clubfoot programs in order to allow more accurate quality measures and ongoing research into clubfoot care in the developing world. We would like to acknowledge CURE Clubfoot for their dedication in the field and ongoing management of the study clinic.
We are also grateful to Dr. Kaye Wilkins for his long-standing leadership in developing pediatric orthopaedics in Haiti, and we thank Dr. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Purpose The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. Results Amongst children, age at presentation ranged from 0 days birth to 4. Conclusions Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting.
Introduction Congenital clubfoot is one of the most common musculoskeletal deformities at birth, affecting 1—2 babies per live births.
The Ponseti Method The Ponseti method has developed over the years into a widespread, minimally invasive protocol for the initial management of clubfoot deformity through its sequential phases of diagnosis case identification and referral , casting achieving correction with possible percutaneous Achilles tenotomy, and bracing maintaining correction Fig 1.
Download: PPT. Fig 1. Standard of care for clubfoot diagnosis and treatment in developed nations. Data elements We dichotomized several continuous variables and created categorical variables based on clinical relevance and frequency distribution. Results Study sample The study sample was comprised of children feet.
Table 1. Factors associated with delayed presentation On a bivariate level, the only risk factor significantly associated with delayed presentation was having prior treatment elsewhere RR 5. Factors associated with increased number of casts In multivariable analysis, children presenting with a non-idiopathic diagnosis were 2. Table 2. Factors associated with 10 or more casts needed to treat clubfoot deformity. Standard of care comparisons When comparing data from a Haitian clinic with a POSNA survey on typical clubfoot care parameters, patients in this low-resource setting presented at a later age median 4.
Fig 2. Comparison of North American orthopaedic survey data on clubfoot standard of care with current treatment patterns in Haiti. Discussion In this report, we analyze four years of experience with the Ponseti method in a low-resource setting, as applied to clubfoot care in Port-au-Prince, Haiti. Supporting information. S1 Table. Minimal data set. Dataset of final study population used for analysis. Acknowledgments We would like to acknowledge CURE Clubfoot for their dedication in the field and ongoing management of the study clinic. References 1. Multistate study of the epidemiology of clubfoot.
Descriptive epidemiology of idiopathic clubfoot. Am J Med Genet A. Clinical orthopaedics and related research. Owen RM, Kembhavi G. A critical review of interventions for clubfoot in low and middle-income countries: effectiveness and contextual influences. J Pediatr Orthop B. Penny JN. The Neglected Clubfoot. Techniques in Orthopaedics.
View Article Google Scholar 6. Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: a systematic review and meta-analysis. Trop Med Int Health. Penny A. School access: children with motor disabilities in rural Uganda: University of Victoria; Atria J.
Accessibility and relevance of education for children with disabilities in Uganda. Ponseti I. Congenital Clubfoot: Fundamentals of Treatment. Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti method: a realistic alternative for the developing world? Journal of pediatric orthopedics. Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre. Journal of orthopaedic science: official journal of the Japanese Orthopaedic Association.
Cost-effectiveness of the Ponseti method for treatment of clubfoot in Pakistan. World journal of surgery. Ponseti method for untreated idiopathic clubfeet in Nepalese patients from 1 to 6 years of age. The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age.
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Bone Joint J. Barriers experienced by service providers and caregivers in clubfoot management in Kenya. Tropical doctor. Agarwal A, Gupta N. Does initial Pirani score and age influence number of Ponseti casts in children?
Int Orthop. Cady R. Update on clubfoot: etiology and treatment. Chalayon O, Dobbs MB.
The Ponseti Technique for Treating Clubfoot. Orthopaedic Knowledge Online Journal. View Article Google Scholar Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am. Staheli L, Ponseti I. Ponseti method treatment of neglected idiopathic clubfoot: Preliminary results of a multi-center study in Nigeria. World journal of orthopedics. Ayana B, Klungsoyr PJ. Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia.
A prospective study of 22 children 32 feet from 2 to 10 years of age. Acta orthopaedica. Modified Ponseti method of treatment for correction of neglected clubfoot in older children and adolescents—a preliminary report. Khan SA, Kumar A. Correction of neglected idiopathic club foot by the Ponseti method. J Bone Joint Surg Br. Modified Ponseti technique for management of neglected clubfeet. Evaluation of Ponseti method in neglected clubfoot. Indian journal of orthopaedics. Ponseti management of clubfoot after walking age.
Pediatrics international: official journal of the Japan Pediatric Society. The classic: congenital club foot: the results of treatment. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Effect of cast removal timing in the correction of idiopathic clubfoot by the Ponseti method. Of the 92 feet, 77 The overall male-to-female ratio was5. The highest discrepancy was found in RE scores. Means of TS were identical. Kvalues for the observations made were 0.
The statistical inter-observer reliability for all components was rated as substantial to moderate agreement except RE and TS that were rated as fair agreement Table The Kvalues calculated for the first 15 feet that were assessed in the month of November and December, , were 0. The Kvalues calculated for the remaining 76 feet assessed in were 0.
Discussion Initially the focus of treatment was towards finding a better surgical technique rather than looking for a better functional outcome. This focus shifted after long-term follow-ups became available. Currently the Ponseti approach is being recognised all over the world as the most efficient and affordable treatment method regarding the correction of clubfoot. Patients who were treated surgically had stiffer feet and often became arthritic in adulthood.
This interest in cast treatment further increased with better understanding of the pathology of the disease and consistent treatment. Our findings were similar to a study conducted in Sudan 14 which utilised a trained physician and a trained nurse having three-year diploma and additional experience as a physiotherapist assistant. However, in our study, comparison was made between an orthopaedic surgeon and a lower level allied health worker, i.
The inter-observer reliability that our study showed was found to be fair to substantial whereas the Sudanese study showed moderate to substantial inter-observer reliability between the two types of raters. The only difference was that the raters were both physicians of comparable skills. To see if training could make a difference, we divided our analysis into two parts — the first 15 observations when the experience of assessment would have been less, and the second part for the remaining period of assessment.
We found that kappa interpretations were suggestive of an increase in agreement as experience increased. In the first part, the agreement was erratic from a whole range of agreement ranging from less-than-chance to substantial. However, with increased experience, four of the eight assessment points had substantial agreement; three out of eight had moderate; and only one had fair agreement.
The result accentuates the fact that the skills of the second rater improved with experience. Pirani scoring is thus a reliable method for clubfoot assessment by lesser skilled assessors provided he is given adequate training and sufficient hands-on experience. Pirani scoring agreement improved with time reflecting increased experience. Other than training, professional supervision in the early phase is also vital. We recommend the use of Pirani score by trained allied health workers for clubfoot assessment so that the burden on orthopaedic surgeons may be relieved, especially in areas where there is scarcity of orthopaedic surgeons.
Secondly, we recommend the training of plaster technicians in Ponseti method for the application of casts so that they may be able to do independent treatment of clubfoot in areas where no physicians are available. Such models have been adopted in underdeveloped countries like Uganda and Malawi. It is easy to learn and use. Louis, Mo. Tachdjian MO. Pediatric orthopedics. J Bone Joint Surg Br ; Dyer PJ, Davis N. The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone Joint Surg Br. Classification of clubfoot. J Pediatr Orthop B. Evaluation of the treatment of clubfeet with the Dimeglio score.
J Pediatr Orthop. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am ; Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am. Staheli L. Clubfoot: Ponseti Management 3rd edition. Ponseti versus traditional methods of casting for idiopathic clubfoot.
J Pediatr Orthop ; Interobserver reliability in Pirani clubfoot severity scoring between a paediatricorthopaedic surgeon and a physiotherapy assistant. J Pediatr Orthop B ; An independent assessment of two clubfoot-classification systems. Clin Orthop Relat Res. Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees:.