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Malhotra K, Colta R, Jani P, Haldar A, Patel S, Welck M, Cullen N. Talar neck rotation angle in adults with clubfoot deformity: Observed values and intra- and inter-observer reliability using weightbearing CT. Foot Ankle Surg 2024; 30:263-267. [PMID: 38216337 DOI: 10.1016/j.fas.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Abstract
INTRODUCTION Adults presenting with symptomatic clubfoot represent a challenging cohort of patients. An appreciation of the location and degree of deformities is essential for management. Talar anatomy is often abnormal with varus within the talar neck, however, there are few reproducible methods which quantify talar neck deformity in adults. We describe a technique of assessing talar neck deformity, and report on observed values and intra- / inter-observer reliability. METHODS This was a single-centre, retrospective study including 96 feet from 56 adult patients with clubfeet (82 feet had clubfoot deformity, 14 were normal). Mean age was 34.3 ± 16.9 years and 31 (55.3%) were male. Weight-bearing CT scans captured as part of routine clinical care were analysed. Image reformats were oriented parallel to the long axis of the talus in the sagittal plane. In the corresponding axial plane two lines were drawn (on separate slices): 1) a line perpendicular to the intermalleolar axis, 2) a line connecting the midpoints of the talar head and narrowest part of the talar neck. The talar neck rotation angle (TNR angle) was the angle formed between these lines. Intraclass correlation coefficients (ICC) were performed for intra- and inter-observer reliability. RESULTS Mean TNR angle in clubfeet was 27.6 ± 12.2 degrees (95%CI = 25.0 to 30.2 degrees). Mean TNR angle in normal feet was 18.7 ± 5.1 degrees (95%CI = 16.0 to 21.4 degrees) (p < 0.001). The ICC for clubfeet was 0.944 (95%CI = 0.913 to 0.964) for intra-observer agreement, and 0.896 (95%CI = 0.837 to 0.932) for inter-observer agreement. CONCLUSION This measurement technique demonstrated excellent intra- and inter-observer agreement. It also demonstrated that compared to normal feet, clubfeet had about 9 degrees of increased varus angulation of the talar neck. This technique and data may be used for future research into clubfoot deformity and in planning treatment. LEVEL OF CLINICAL EVIDENCE 3.
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Affiliation(s)
- Karan Malhotra
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.
| | - Raul Colta
- Ortopedicum, 40-44 Banu Andronache Str, Bucharest, Romania
| | - Priyanka Jani
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK
| | - Anil Haldar
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK
| | - Shelain Patel
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK
| | - Matthew Welck
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK
| | - Nicholas Cullen
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK
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Walani SR, Penny N, Nakku D. The global challenges of surgical congenital anomalies: Evidence, models, and lessons. Semin Pediatr Surg 2023; 32:151348. [PMID: 38006693 DOI: 10.1016/j.sempedsurg.2023.151348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
The treatment of congenital anomalies (structural birth defects) is common to all the surgical sub-specialties dealing with children. Globally more than 90 % of all babies born with a congenital anomaly are born in middle-and-low-income countries where there is often limited access to needed surgical care. Challenges include lacks of early identification, registry and surveillance systems, missing referral pathways, shortage of trained surgical expertise and insufficient surgical infrastructure. Poverty, transportation logistics, financial constraints and social stigma are also serious barriers for families. There is, however, growing recognition of the priority to expand services, encouraged by the World Health Organization and other global players, and examples of successful models of care. Registry programs are growing, especially in Latin America. The Ponseti method of clubfoot care has been revolutionary on a global scale. The role of not-for-profit non-governmental-organizations has been instrumental in fundraising, training and logistical support as exemplified in the care of oro-facial clefts. Specialized "niche" hospitals are providing needed sub-specialist expertise. The way forward includes the need for effective partnerships, innovative methods to distribute care out from referral hospitals into the districts and the development of national plans embedded in national health policy.
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Affiliation(s)
| | - Norgrove Penny
- Branch for Global Surgical Care, University of British Columbia, Vancouver, Canada
| | - Doreen Nakku
- Department of Surgery, Mbarara University of Science and Technology (MUST) Mbarara, Uganda
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Zeaiter Z, Alzein H, Daher Y. An Insight on Current Clubfoot Management: A Reported Data From Lebanon. Cureus 2023; 15:e40194. [PMID: 37431334 PMCID: PMC10329864 DOI: 10.7759/cureus.40194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND/AIM Clubfoot, which has been reported in the literature since the time of Hippocrates in 400 BC, is regarded as one of the most difficult congenital orthopedic anomalies, with a high relapse incidence of 16.87 infants per 10,000 births. The Lebanese region holds limited data concerning the evolution of clubfoot management. Herein, we aim to present novel findings in the treatment of clubfoot without surgical intervention. MATERIALS AND METHODS This single-center, cross-sectional research included 300 patients with virgin idiopathic clubfoot treated at our facility from 2015 to 2020. The Pirani and DiMeglio Scores were used to determine the severity of the illness prior to treatment, and the DiMeglio Score was used to determine the severity of the disease after treatment. For data analysis, the Statistical Package for Social Sciences (SPSS, IBM-Version 26; IBM Corp., Armonk, NY) was used and results with p-value < 0.05 were considered statistically significant. RESULTS Our study included 300 patients, with 188 boys (62.7%) and 112 girls (37.3%). The mean age of the patients' onset was 32 days. We recorded an average initial Pirani score of 4.27 ± 0.65 and an average initial DiMeglio score of 11.58 ± 2.56 (62 out of 300) while the average final DiMeglio score was 2.17 ± 1.82. The mean number of casts was 5 ± 0.8, with a minimum of four and a maximum of six casts. The prevalence of relapse was 20.7%. CONCLUSIONS Clubfoot remains a challenging deformity with a high rate of treatment failure and recurrence. While the superiority of Ponseti's technique in terms of success rate could not be disputed, tailored therapy based on the patient's socioeconomic status is considered critical for compliance and treatment success.
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Affiliation(s)
- Zeinab Zeaiter
- Department of Internal Medicine, Lebanese University Faculty of Medicine, Beirut, LBN
| | - Hassan Alzein
- Department of Orthopedics and Traumatology, Lebanese University Faculty of Medicine, Beirut, LBN
| | - Youssef Daher
- Department of Orthopedics and Traumatology, Lebanese University Faculty of Medicine, Beirut, LBN
- Department of Orthopedic Surgery, Rafik Hariri University Hospital, Beirut, LBN
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Grin L, van Oorschot L, Vanwanseele B, Wijnands SDN, Kars HJJC, Besselaar AT, van der Steen MCM. Kinematic Gait Impairments in Children with Clubfeet Treated by the Ponseti Method: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050785. [PMID: 37238333 DOI: 10.3390/children10050785] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Being aware of possible gait impairments in Ponseti-treated clubfoot children might be useful for optimizing initial and additional treatment. Therefore, this systematic review and meta-analysis aimed to identify kinematic gait abnormalities in children with clubfoot treated with the Ponseti method (with and without relapse). METHODS A systematic search was conducted. Studies comparing kinematic gait parameters of Ponseti-treated clubfoot children to healthy controls were included. Meta-analyses and qualitative analyses were conducted on the extracted data. RESULTS Twenty studies were identified. Twelve of the 153 reported kinematic outcome measures could be included in the meta-analysis. Plantarflexion at push-off, maximum ankle dorsiflexion during the swing, maximal plantarflexion, and ankle range of motion was significantly lower in Ponseti-treated clubfoot children. Ponseti-treated clubfoot children showed more internal foot progression. Qualitative analysis revealed 51 parameters in which pre-treatment relapse clubfeet deviated from healthy controls. CONCLUSIONS Ponseti-treated clubfoot children showed several kinematic gait differences from healthy controls. In future studies, homogeneity in measured variables and study population and implementation of multi-segmental foot models will aid in comparing studies and understanding clubfoot complexity and treatment outcomes. The question remains as to what functional problems gait impairments lead to and whether additional treatment could address these problems.
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Affiliation(s)
- Lianne Grin
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
- Department of Movement Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
| | - Lisa van Oorschot
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
| | - Benedicte Vanwanseele
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
- Department of Movement Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
| | - Saskia D N Wijnands
- Department of Movement Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, 5600 PD Eindhoven, The Netherlands
| | - H J J Cojanne Kars
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
| | - Arnold T Besselaar
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, 5600 PD Eindhoven, The Netherlands
| | - M C Marieke van der Steen
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, 5600 PD Eindhoven, The Netherlands
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, 5602 ZA Eindhoven, The Netherlands
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Janatová K, Nováková T, Lopot F. The Incidence of Clubfoot in the Czech Republic: A Nationwide Epidemiological Study from 2000 to 2014. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040714. [PMID: 37189962 DOI: 10.3390/children10040714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
Clubfoot is one of the most common musculoskeletal birth deformities worldwide. The prevalence varies among individual countries and populations. There is a lack of nationwide incidence studies in Central Europe. We analyzed the incidence of clubfoot in the Czech Republic over 14 years. Patients born with clubfoot in the Czech Republic were identified using The National Registry of Congenital Anomalies. Demographic data were included. Data from 2000 to 2014 were collected and analyzed regarding gender and regional distribution. The study's chosen time frame was grounded on the condition of the Czech industry. Following extensive transformations in 1989, the industry eliminated highly non-ecological operations with significant environmental impact and related health risks. The incidence of clubfoot during the study period was 1.9 (95% CI 1.8-2.0) per 1000 births; males comprised the majority (59%). The incidence significantly differed among individual regions of the Czech Republic (p < 0.001). The incidence in the Czech Republic was higher than in previous European studies. We found significant regional differences in incidence, which could indicate that there may be exogenous pathogenic factors. For this reason, we plan to follow up our work with an up-to-date study.
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Affiliation(s)
- Klára Janatová
- Sport Sciences-Biomedical Department, Faculty of Physical Education and Sport, Charles University, Jose Martiho 31, 16200 Prague, Czech Republic
| | - Tereza Nováková
- Department of Physiotherapy, Faculty of Physical Education and Sport, Charles University, Jose Martiho 31, 16200 Prague, Czech Republic
| | - František Lopot
- Sport Sciences-Biomedical Department, Faculty of Physical Education and Sport, Charles University, Jose Martiho 31, 16200 Prague, Czech Republic
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Patel Y, Barik S, Agarwal A. What exactly is "foot abduction" during management of idiopathic clubfoot in clinical practice? INTERNATIONAL ORTHOPAEDICS 2023; 47:1109-1114. [PMID: 36715714 DOI: 10.1007/s00264-023-05703-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/14/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE There is however gross ambiguity regarding the use of term "foot abduction" in clubfoot treatment. We measured below defined angles at different stages of clubfoot treatment to decipher their precise interpretation. METHODS In a prospective evaluation of 25 unilateral clubfeet in infants' age less than six months treated with Ponseti technique, clinical leg foot and thigh foot angle were measured at talar head reduction (LHT0), pre-tenotomy, and post-tenotomy stage. A "normal" reference was available in the form of measurements of contralateral limb. RESULTS Talar head (LHT0) was reduced at mean leg foot angle of 26 degrees. The corresponding pre- and post-tenotomy angles were 42.6 and 50.0 degrees, respectively. The reference leg foot angles for contralateral limb were 49.8 degrees. The thigh foot angle for LHT0, pre-tenotomy, post-tenotomy, and contralateral side were, respectively, 39.2, 56, 68, and 65.6 degrees. There was an additional tibial external rotation component of mean 13.4 degrees (SD 4.5) in the thigh foot angle when compared to the leg foot angle at tenotomy. This increased to 18 degrees (SD 3.4) post-tenotomy. CONCLUSIONS The study suggested that the foot abduction described in the "Ponseti Manual" probably intends thigh foot rather than leg foot angles. There was a significant difference in the angles when talar head reduced and tenotomy was decided. The foot abduction is an ambiguous term which should be replaced by the more specific leg or thigh foot abduction angle.
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Affiliation(s)
- Yogesh Patel
- Department of Pediatric Orthopedics, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Sitanshu Barik
- Department of Orthopedics, All India Institute of Medical Sciences, Deoghar, India
| | - Anil Agarwal
- Department of Pediatric Orthopedics, Chacha Nehru Bal Chikitsalaya, New Delhi, India.
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Chen Y, Cao S, Wang C, Ma X, Wang X. Use of Ankle Dorsiflexion and the Dimeglio and Pirani Scores in Predicting Relapse of Clubfoot Treated With the Ponseti Method. J Foot Ankle Surg 2023; 62:218-221. [PMID: 35868981 DOI: 10.1053/j.jfas.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 02/03/2023]
Abstract
Although Dimeglio and Pirani scores are frequently employed to rate the severities of clubfoot and to evaluate treatment outcomes, it is unclear if these scores predict relapse after treatment. Ankle dorsiflexion has been suggested in recent years to be a promising predictor of relapse. The aim of this study was to investigate ankle dorsiflexion and Dimeglio and Pirani scores in predicting the relapse of clubfoot after treatment with the Ponseti method. We included patients with clubfoot previously treated by the Ponseti method, and retrospectively analyzed their initial ankle dorsiflexion, Pirani and Dimeglio scores, number of castings, and the occurrence of relapse. We analyzed 218 feet of 176 infants with clubfoot who showed an incidence of relapse of 17.0% (30/176). The mean initial Pirani and Dimeglio scores of the feet showing recurrence were significantly higher than individuals with non-recurrence (p < .001 each). We observed a robust association between Pirani and Dimeglio scores and the recurrence of clubfoot at the last follow-up (γ = 0.53, p = .001). In contrast, ankle dorsiflexion was negatively correlated with recurrence of clubfoot (γ = -0.21, p = .001). Dimeglio scores significantly predicted the recurrence of clubfoot (p = .014). Receiver operating characteristic curve analysis exhibited slightly better performance regarding the Dimeglio score relative to the Pirani score and ankle dorsiflexion in predicting recurrence. Ankle dorsiflexion and Pirani and Dimeglio scores were related to recurrence in patients with clubfoot. However, the Dimeglio score reflected superior accuracy in predicting the prognosis of clubfoot treated with the Ponseti method.
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Affiliation(s)
- Yungu Chen
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shengxuan Cao
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China.
| | - Xin Ma
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Wang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
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Özdemir MA, Topak D, Turgut C, Telek M, Doğar F. Evaluation of depression, anxiety, and stress status in parents of patient with congenital clubfoot treated with Ponseti method: A prospective study. Medicine (Baltimore) 2022; 101:e31654. [PMID: 36343081 PMCID: PMC9646646 DOI: 10.1097/md.0000000000031654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Congenital diseases have been reported to increase the incidence of depression, anxiety, and stress among parents. In this study, we aimed to investigate the depression, anxiety, and stress status in parents of patients with congenital clubfoot before and after treatment with the Ponseti method. A total of 20 patients diagnosed with congenital clubfoot at our clinic and treated with the Ponseti method were included in this study. The Depression Anxiety Stress Scale-21 (DASS-21) was used to evaluate the depression, anxiety, and stress status of the parents before and after treatment. We considered the following parameters to investigate the effects of these on the parents: the educational level of the parents; economic status of the family; gender; birth order of the child in the family; time of diagnosis (prenatal or postnatal). The mean DASS and subdomain scores after treatment were significantly lower than those before treatment (P < .05). Moreover, there was a significant difference in the pre- and posttreatment mean DASS and depression scores of the participants in terms of the education level (P < .05). The pre- and posttreatment DASS and depression scores of the participants with an education level of primary school and below were lower than those of the participants with an education level of secondary and high school. Parents may be less concerned during this process if they are fully informed by the orthopedic surgeons about the treatment protocol and the near-perfect results of the Ponseti method as well as are counseled by healthcare professionals.
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Affiliation(s)
- Mustafa Abdullah Özdemir
- Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Orthopaedic and Traumatology, 46040, Kahramanmaras, Turkey
- *Correspondence: Mustafa Abdullah Özdemir, Kahramanmaraş Sütçü İmam Üniversitesi Tip Fakültesi Avşar Mahallesi Bati Çevreyolu Blv. No:251\A, 46040-Onikişubat\Kahramanmaraş, Türkiye (e-mail: )
| | - Duran Topak
- Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Orthopaedic and Traumatology, 46040, Kahramanmaras, Turkey
| | - Celaleddin Turgut
- Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Psychiatry, 46040, Kahramanmaras, Turkey
| | - Mikail Telek
- Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Orthopaedic and Traumatology, 46040, Kahramanmaras, Turkey
| | - Fatih Doğar
- Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Orthopaedic and Traumatology, 46040, Kahramanmaras, Turkey
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Alosaimi MA, Jawhari AM, Amin OA, Alzahrani ES, Alomar MO, Nouri MT, Altalhi MJ, Marzogi AA. Community Awareness of Congenital Talipes Equinovarus (Clubfoot) in Makkah Region, Saudi Arabia: A Cross-Sectional Study. Cureus 2022; 14:e30602. [PMID: 36420226 PMCID: PMC9680592 DOI: 10.7759/cureus.30602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Congenital talipes equinovarus (CTEV) or clubfoot is known as a deformity characterized by excessively turned-in feet and high medial longitudinal arches. It is one of the most common musculoskeletal abnormalities. It is estimated that approximately 20% of CTEV cases are caused by another congenital disease or syndromic condition. OBJECTIVES The aim of this study was to assess the knowledge about CTEV among the general population in the Makkah region of the kingdom. Methods: This study was a community-based cross-sectional descriptive study carried on by an online questionnaire, previously validated in published studies, among residents in the Makkah region of Saudi Arabia who successfully fulfilled the inclusion and exclusion criteria. Results: Out of the total number of respondents (n=1,987), gender was found to be significantly associated with awareness about CTEV (p-value=0.007) as females tend to have higher awareness levels than males. Having a child with CTEV was found to be significantly associated with awareness level (p-value˂0.001). In addition, university and secondary levels of education are more aware of CTEV than other levels of education (p-value=0.023). CONCLUSION According to the results, the lack of awareness campaigns may contribute to the low public awareness of CTEV. It is recommended that social media platforms and public campaigns be utilized to increase awareness of CTEV in key locations such as malls. These initiatives may motivate people to seek treatment for their disease as early as possible. In addition, early management of CTEV is less invasive and leads to better patient outcomes when followed up regularly.
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Affiliation(s)
| | | | - Omar A Amin
- Orthopedic Surgery, Alnoor Specialist Hospital, Makkah, SAU
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How to Cope with the Ponseti Method for Clubfoot: The Families’ Standpoint. CHILDREN 2022; 9:children9081134. [PMID: 36010025 PMCID: PMC9406557 DOI: 10.3390/children9081134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/17/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022]
Abstract
(1) Background: The Ponseti Method is the gold standard for the treatment of congenital clubfoot. It is a low-cost treatment consisting in a series of plaster casts, a percutaneous Achilles’ tenotomy and a Mitchell Ponseti brace to wear with a definite protocol. This treatment allows children to be with their families instead of being hospitalized. This advantage is also a challenge for the families that have to follow the protocol at home. This paper aims to analyze the perception, the difficulties and the overcomes of the families during the treatment. (2) Methods: We used a 41 questions questionnaire by Nogueira and Morquende. Questions were answered by families who had already finished the treatment or were still following it. (3) Results: We interviewed 92 families. The worst handling phase appeared to be the cast phase, while the brace seemed more bearable. In total, 57 families overrated tenotomy; (4) Conclusions: Families perceived the Ponseti Method as a quality treatment. The anxiety about the diagnosis played a strong role, but none of the difficulties encountered decreased the treatment outcomes or affected families’ adherence to the protocol. The open-ended answers highlighted that the positive relationship with doctors played a key role in the everyday compliance and the achievement of good results.
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Eight-year Review of a Clubfoot Treatment Program in Pakistan With Assessment of Outcomes Using the Ponseti Technique: A Retrospective Study of 988 Patients (1,458 Clubfeet) Aged 0 to 5 Years at Enrollment. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00019. [PMID: 35467578 PMCID: PMC9042583 DOI: 10.5435/jaaosglobal-d-22-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/19/2022] [Indexed: 11/18/2022]
Abstract
To conduct an 8-year retrospective review of a clubfoot treatment program using the Ponseti technique with close monitoring of outcomes.
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Cinthuja P, Wijesinghe PCI, Silva P. Use of external fixators in developing countries: a short socioeconomic analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:14. [PMID: 35351146 PMCID: PMC8961085 DOI: 10.1186/s12962-022-00353-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/11/2022] [Indexed: 11/10/2022] Open
Abstract
The use of external fixators (EFs) dates back to 377 BC Hippocrates’ time, and it has a wide range of orthopaedic applications. External fixator has expanded its use in the management of fractures and other musculoskeletal conditions. It is widely used all over the world to manage complex musculoskeletal injuries. It has many advantages as compared to internal fixation in some trauma scenarios. However, the cost of the external fixators presents a dilemma to the healthcare system in developing countries. The goals of this review article are to explain the importance of EFs in developing countries in managing fractures, to determine the problems encountered at present during external fixation by developing countries, to identify solutions that could be used to address these issues, expand the use of external fixation into other domains of treatment, the impact of COVID-19 pandemic on fracture management based on existing literature. In conclusion, EFs are very expensive, researches have been conducted to overcome these barriers in developing countries. However, there are limitations in implementing in developing countries. It is important to have affordable and clinically acceptable EFs available in developing countries.
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Novotny T, Eckhardt A, Doubkova M, Knitlova J, Vondrasek D, Vanaskova E, Ostadal M, Uhlik J, Bacakova L, Musilkova J. The possible role of hypoxia in the affected tissue of relapsed clubfoot. Sci Rep 2022; 12:4462. [PMID: 35292718 PMCID: PMC8924187 DOI: 10.1038/s41598-022-08519-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 03/07/2022] [Indexed: 02/07/2023] Open
Abstract
Our aim was to study the expression of hypoxia-related proteins as a possible regulatory pathway in the contracted side tissue of relapsed clubfoot. We compared the expression of hypoxia-related proteins in the tissue of the contracted (medial) side of relapsed clubfoot, and in the tissue of the non-contracted (lateral) side of relapsed clubfoot. Tissue samples from ten patients were analyzed by immunohistochemistry and image analysis, Real-time PCR and Mass Spectrometry to evaluate the differences in protein composition and gene expression. We found a significant increase in the levels of smooth muscle actin, transforming growth factor-beta, hypoxia-inducible factor 1 alpha, lysyl oxidase, lysyl oxidase-like 2, tenascin C, matrix metalloproteinase-2, matrix metalloproteinase-9, fibronectin, collagen types III and VI, hemoglobin subunit alpha and hemoglobin subunit beta, and an overexpression of ACTA2, FN1, TGFB1, HIF1A and MMP2 genes in the contracted medial side tissue of clubfoot. In the affected tissue, we have identified an increase in the level of hypoxia-related proteins, together with an overexpression of corresponding genes. Our results suggest that the hypoxia-associated pathway is potentially a factor contributing to the etiology of clubfoot relapses, as it stimulates both angioproliferation and fibroproliferation, which are considered to be key factors in the progression and development of relapses.
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Affiliation(s)
- Tomas Novotny
- Department of Orthopaedics, University J.E. Purkinje and Masaryk Hospital, Usti nad Labem, Czech Republic.,Department of Histology and Embryology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adam Eckhardt
- Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic.
| | - Martina Doubkova
- Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic. .,Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Jarmila Knitlova
- Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - David Vondrasek
- Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic.,Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - Eliska Vanaskova
- Department of Orthopaedics, University J.E. Purkinje and Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Martin Ostadal
- Department of Orthopaedics, University Hospital Bulovka, Charles University, Prague, Czech Republic
| | - Jiri Uhlik
- Department of Histology and Embryology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lucie Bacakova
- Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - Jana Musilkova
- Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic
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14
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Kumar P, Baburaj V, Bist O, Belludi PS, Sudesh P. Does the use of ultrasound guidance during percutaneous Achilles tendon tenotomy improve outcomes of clubfoot management? A randomized controlled trial. J Pediatr Orthop B 2022; 31:e190-e194. [PMID: 34751177 DOI: 10.1097/bpb.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Achilles tenotomy is a crucial aspect in the non-operative management of clubfoot as per Ponseti's casting protocol. Achilles tenotomy is routinely carried out percutaneously in a blind manner without any image guidance. This study aimed to determine the role of ultrasound-guided percutaneous Achilles tenotomy (PAT) in improving outcomes in clubfoot management. There are no previous studies that have explored the role of image guidance in PAT. This prospective, single-center randomized control trial included 50 clubfoot cases (74 feet) planned for PAT at a mean age of 30.2 months. A single experienced senior surgeon performed tenotomies. Patients were randomized to two groups, with the tenotomies performed under ultrasound guidance in one group (test group) and PAT carried out without image guidance in the other (control) group. Outcome measures assessed included rate of complications, immediate postoperative FLACC score for pain severity and Pirani score at a minimum follow-up of 12 months. There were no significant differences in the complication rates between the test and control groups regarding bleeding, nerve injury and incomplete tenotomies. The mean pain FLACC score was significantly higher in the control group (PAT without image guidance) (P = 0.03), suggesting that the child would better tolerate the ultrasound-guided procedure. All patients in both groups had a Pirani score of zero and plantigrade feet at final follow up, with no relapses. Ultrasound-guided PAT does not have any added advantage over PAT with clinical examination without image guidance in terms of long-term outcomes. Level of evidence: Therapeutic level II.
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Affiliation(s)
- Pardeep Kumar
- Department of Orthopaedics, Civil Hospital, Jind, Haryana
| | - Vishnu Baburaj
- Department of Orthopaedics, AIIMS Bilaspur, Himachal Pradesh, India
| | - Omkar Bist
- Department of Orthopaedics, Nisarga Hospital, Dhangadhi, Nepal
| | | | - Pebam Sudesh
- Department of Orthopaedics, PGIMER Chandigarh, India
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15
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Radler C. The Treatment of Recurrent Congenital Clubfoot. Foot Ankle Clin 2021; 26:619-637. [PMID: 34752231 DOI: 10.1016/j.fcl.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The Ponseti method for treatment of congenital clubfoot is well established and has been introduced in most pediatric orthopedic centers worldwide. However, reported rates of recurrence are largely variable and open joint surgery is still performed frequently, even in the age group younger than 6 years of age. Preventing recurrence and residual deformity can be achieved by strict adherence to the Ponseti method, ensuring and enforcing brace compliance, frequent follow-up, and early treatment of recurrence. This review discusses reasons for clubfoot recurrence, prevention of clubfoot recurrence, and the treatment of recurrent congenital clubfoot within the realm of the Ponseti method.
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Affiliation(s)
- Christof Radler
- Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Orthopaedic Hospital Speising GmbH, Speisinger Strasse 109, Vienna A-1130, Austria.
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16
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Hemo Y, Yavor A, Kalish M, Segev E, Wientroub S. Ponseti treated idiopathic clubfoot - outcome predictive factors in the test of time: analysis of 500 feet followed for five to 20 years. J Child Orthop 2021; 15:426-432. [PMID: 34858528 PMCID: PMC8582614 DOI: 10.1302/1863-2548.15.210156] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/07/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To investigate a set of risk factors on the outcome of Ponseti treated idiopathic clubfeet (ICF). METHODS This study was approved by the institutional review board. A retrospective analysis of prospectively gathered data over a 20-year period, at a single dedicated clubfoot clinic. Records of 333 consecutive infants with 500 ICF were analyzed. Initial Pirani score, number of casts, need for tenotomy, foot abduction brace compliance and functional score had been documented. The need for surgery after initial correction was the outcome measure. All children were followed by the same team throughout the study period. Descriptive statistics, chi-squared and multivariate analysis were performed. RESULTS In total, 82 children (24%) with 119 feet (23.8%) were operated on, with 95.1% of feet being operated up to the age of nine years. There was a significant correlation between the Pirani score at presentation and the number of surgical procedures (chi-squared = 79.32; p < 0.001). Achilles tenotomy was done in 94.8% of patients. Pirani score of > 4.5 before casting was strongly associated with increased surgical risk (odds ratio = 1.95). When six to eight cast changes were needed, surgical prospect was 2.9 more, increasing to 11.9 when nine or more casts were needed. CONCLUSION Foot severity and number of cast changes were the strongest predictors for future surgery. Estimation of the risk of deformity recurrence after initial correction may help in tailoring a cost-effective personal treatment and follow-up protocol. Personalized focused protocol will help patients and caregivers and will reduce expenses. LEVEL OF EVIDENCE Level II - prognostic study.
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Affiliation(s)
- Yoram Hemo
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Correspondence should be sent to Yoram Hemo, MD, Senior Paediatric Orthopaedic Surgeon, Department of Paediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel.
| | - Ariella Yavor
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meirav Kalish
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eitan Segev
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Wientroub
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Grin L, van der Steen MC, Wijnands SDN, van Oorschot L, Besselaar AT, Vanwanseele B. Forefoot adduction and forefoot supination as kinematic indicators of relapse clubfoot. Gait Posture 2021; 90:415-421. [PMID: 34583148 DOI: 10.1016/j.gaitpost.2021.09.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/07/2021] [Accepted: 09/16/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Understanding the kinematic characteristics of relapse clubfoot compared to successfully treated clubfoot could aid early identification of a relapse and improve treatment planning. The usage of a multi segment foot model is essential in order to grasp the full complexity of the multi-planar and multi-joint deformity of the clubfoot. RESEARCH QUESTION The purpose of this study was to identify differences in foot kinematics, using a multi-segment foot model, during gait between patients with Ponseti treated clubfoot with and without a relapse and age-matched healthy controls. METHODS A cross-sectional study was carried out including 11 patients with relapse clubfoot, 11 patients with clubfoot and 15 controls. Gait analysis was performed using an extended Helen Hayes model combined with the Oxford Foot Model. Statistical analysis included statistical parametric mapping and discrete analysis of kinematic gait parameters of the pelvis, hip, knee, ankle, hindfoot and forefoot in the sagittal, frontal and transversal plane. RESULTS The relapse group showed significantly increased forefoot adduction in relation with the hindfoot and the tibia. Furthermore, this group showed increased forefoot supination in relation with the tibia during stance, whereas during swing increased forefoot supination in relation with the hindfoot was found in patients with relapse clubfoot compared with non-relapse clubfoot. SIGNIFICANCE Forefoot adduction and forefoot supination could be kinematic indicators of relapse clubfoot, which might be useful in early identification of a relapse clubfoot. Subsequently, this could aid the optimization of clinical decision making and treatment planning for children with clubfoot.
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Affiliation(s)
- L Grin
- KU Leuven, Department of Movement Sciences, Tervuursevest 101, 3001, Heverlee, Belgium; Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN, Eindhoven, the Netherlands.
| | - M C van der Steen
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Postbus 90052, 5600 PD, Eindhoven, the Netherlands; Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA, Eindhoven, the Netherlands
| | - S D N Wijnands
- KU Leuven, Department of Movement Sciences, Tervuursevest 101, 3001, Heverlee, Belgium; Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Postbus 90052, 5600 PD, Eindhoven, the Netherlands
| | - L van Oorschot
- Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN, Eindhoven, the Netherlands
| | - A T Besselaar
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Postbus 90052, 5600 PD, Eindhoven, the Netherlands; Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA, Eindhoven, the Netherlands
| | - B Vanwanseele
- KU Leuven, Department of Movement Sciences, Tervuursevest 101, 3001, Heverlee, Belgium; Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN, Eindhoven, the Netherlands
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18
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Tonkovich N, Baskar D, Frick S. The Impact of the Digital Age and Social Media on Connecting the Clubfoot Community. Cureus 2021; 13:e16780. [PMID: 34513387 PMCID: PMC8405383 DOI: 10.7759/cureus.16780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2021] [Indexed: 11/30/2022] Open
Abstract
Background Internet chat rooms played an important role in the late 1990s promoting the Ponseti method as the preferred initial treatment for congenital clubfoot. The social media boom has created multiple new methods for caregivers to seek support from a global community using a variety of platforms that are now easily available. This study assesses the reach of information shared across social media platforms about congenital clubfoot and analyzes topics most commonly discussed among members in these groups. Methodology Posts and pages across Facebook, Instagram, Twitter, and TikTok were evaluated to identify the top clubfoot-related hashtags and accounts. In addition, content themes were analyzed for posts across all platforms. Results There were 122 clubfoot-focused Facebook groups for parent support, and the five Facebook groups with the highest number of posts during the study period were found to frequently discuss the following topics: successful treatment stories, questions about casting, bracing, relapse, and commercial items compatible with clubfoot treatment. Twitter pages contained information about live webinars, educational resources for parents and providers, and the impact of the coronavirus disease 2019 pandemic on clubfoot treatment. A search across visual platforms using “#clubfoot” yielded over 59,000 cumulative posts on Instagram and over 34.7 million total views on TikTok. Conclusions Parents of clubfoot patients are increasingly connecting through digital social media platforms, relying on them for information on clubfoot, and utilizing them as a network for social support. Clubfoot physicians should be aware of this content on social media to promote education and discussion that addresses parent concerns, provides accurate information, and guides expectations.
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Affiliation(s)
| | | | - Steve Frick
- Orthopaedics, Stanford University, Stanford, USA
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19
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Ghanem I, Rizkallah M. Clubfoot management in the Middle East: a survey-based review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1106. [PMID: 34423018 PMCID: PMC8339851 DOI: 10.21037/atm-21-33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/04/2021] [Indexed: 11/23/2022]
Abstract
Clubfoot is the most frequent congenital deformity involving the foot. Little is known about the management of this disease in the Middle East as sparse data is available in the literature. Through the last 5 decades, congenital clubfoot management in the Middle East went from manipulation through Kite’s technique in the late seventies, to early primary surgical intervention in the late eighties and early nineties of the previous century, and then back to manipulation with Ponseti’s technique and the French functional technique in the late nineties, with the latter falling out of favor with time. This is comparable to the evolution of management witnessed in the United States and in Europe, with 10 to 15 years of delay. The delay is getting shorter with time due to the easier access to published scientific data and the increasing number of fellows from Middle East travelling to referral centers in Europe and the USA. A survey was performed among pediatric orthopedic surgeons in the Middle East to assess their approach to clubfoot management. This is the first survey of its kind in the region. It showed a wide adoption (97.1%) of the Ponseti’s technique with serial manipulation and casting, Achilles tenotomy followed by abduction bracing. Divergent practices were found concerning the upper age limit for Ponseti treatment and the setting of the Achilles tenotomy. Nevertheless, these subjects are still a matter of debate in the literature and international conferences. All in all, pediatric orthopedic surgeons in the Middle East are offering their patients the gold standard of care. However, lot of work is to be done in raising awareness for this disease in the community, and among our colleagues as prenatal screening for clubfoot in the Middle East is practically nonexistent.
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Affiliation(s)
- Ismat Ghanem
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.,Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
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20
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Bernasconi A, Iorio P, Lintz F, Ray R, Sadile F. Tibiotalar Incongruency in Clubfoot Treated Operatively Is a Predictor of Worse Outcome at a Mean of 26 Years. J Foot Ankle Surg 2021; 60:655-662. [PMID: 33744065 DOI: 10.1053/j.jfas.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 02/01/2020] [Accepted: 02/27/2020] [Indexed: 02/03/2023]
Abstract
The traditional approach to congenital talipes equinovarus (CTEV) has relied on stepwise manipulations, followed by surgery in severe or recurrent cases. The 3 aims of this study were: (1) to report long-term results of clubfoot treated by posterior capsulectomy and selective release (PCSR); (2) to determine the reliability of a visual scale in the assessment of intraoperative tibiotalar incongruency (TTI); and, (3) to assess the role of TTI as a prognostic factor. We reviewed data regarding 95 CTEV (65 patients) treated by PCSR at a minimum follow-up of 20 years. Patients underwent a physical and radiographic examination, and were assessed through multiple clinical scores. The inter- and intraobserver reliability for TTI evaluation was calculated on clinical photographs. Based on TTI, 52 CTEV were divided in 2 groups (30 congruent vs 22 incongruent) and compared. At a mean follow-up of 26.8 (from 24 to 31) years, 52 CTEV (38 patients) were available for the analysis. Functional results were globally satisfactory. The inter- (κ = 0.748) and intraobserver analysis (κ = 0.688) for the TTI visual assessment showed substantial agreement. In patients with incongruency, patient reported outcomes were significantly worse, with also a greater development of subtalar (p = .02), talonavicular and calcaneocuboid arthritis (p < .001 for both). In treating severe CTEV, the surgical PCSR performed in the first year of life obtains satisfactory clinical and patient-recorded outcomes at over 25 years of follow-up. The visual assessment of TTI is reproducible and potentially represents a long-term prognostic factor.
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Affiliation(s)
- Alessio Bernasconi
- Orthopaedic Surgeon, Department of Public Health, Orthopaedic and Traumatology Unit, University of Napoli "Federico II", Napoli, Italy.
| | - Paolino Iorio
- Orthopaedic Surgeon, Department of Public Health, Orthopaedic and Traumatology Unit, University of Napoli "Federico II", Napoli, Italy
| | - François Lintz
- Orthopaedic Surgeon, Foot and Ankle Surgery Center, Clinique de l'Union, Saint-Jean, France
| | - Robbie Ray
- Orthopaedic Surgeon, Department of Trauma and Orthopaedics, PRUH, King's College Hospital, London, United Kingdom
| | - Francesco Sadile
- Professor of Orthopaedics, Department of Public Health, Orthopaedic and Traumatology Unit, University of Napoli "Federico II", Napoli, Italy
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21
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Tahririan MA, Ardakani MP, Kheiri S. Can clubfoot scoring systems predict the number of casts and future recurrences in patients undergoing Ponseti method? J Orthop Surg Res 2021; 16:238. [PMID: 33820564 PMCID: PMC8020540 DOI: 10.1186/s13018-021-02261-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 01/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background Congenital clubfoot is one of the common congenital orthopaedic deformities. Pirani and Dimeglio scoring systems are two classification systems for measuring the severity of the clubfoot. However, the relation between the initial amount of each of these scores and the treatment parameters is controversial. Methods Patients with severe and very severe idiopathic clubfoot undergoing Ponseti treatment were entered. Their initial Pirani and Dimeglio scores, the number of castings as a short-term treatment parameter, and the recurrences as a long-term parameter until the age of three were prospectively documented. Results One hundred patients (143 feet) with mean age of 9.51 ± 2.3 days including 68 males and 32 females and the mean initial Pirani score of 5.5 ± 0.5 and the mean initial Dimeglio score of 17.1 ± 1.6 were studied. The incidence of relapse was 8.4 %( n = 12). The mean initial Pirani score (P < 0.001) and the mean initial Dimeglio score (P < 0.003) of the feet with recurrence were significantly more than the non-recurrence feet. The mean number of casts in the recurrence group (7 ± 0.9) was significantly more than the feet without recurrences (6.01 ± 1.04) (P = 0.002). The ROC curve suggested the Pirani score of 5.75 and the Dimeglio score of 17.5 as the cut-off points of these scores for recurrence prediction. Conclusion In our study, Pirani and Dimeglio scores are markedly related with more number of casts and recurrence in patients with severe and very severe clubfoot. Also, we have introduced new cut-off points for both classification systems for prediction of recurrence. To the best of our knowledge, this finding has not been introduced into the English literature.
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Affiliation(s)
- Mohammad Ali Tahririan
- Department of Orthopaedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Sara Kheiri
- Department of Orthopaedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran.
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22
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Abstract
BACKGROUND Clubfoot deformity (pes equinovarus) is one of the most common birth defects, and its etiology is still unknown. Initial clubfoot treatment is based on the Ponseti method throughout most of the world. Despite the effectiveness of this therapy, clubfoot may relapse. Recent studies confirm the theory of active fibrotic remodeling processes in the extracellular matrix of the affected tissue. The aim of this study was to clarify whether relapses in clubfoot therapy are associated with altered angiogenesis and to suggest possible regulatory pathways of this pathologic process. METHODS We compared microvessel density, arteriole density, and concentration of angioproliferative-related proteins found between tissues in the contracted, that is, the medial side (M-side), and noncontracted, that is, the lateral side (L-side) of the relapsed clubfeet. Tissue samples from 10 patients were analyzed. Histopathologic analysis consisted of immunohistochemistry and image analysis. Real-time polymerase chain reaction was used to study mRNA expression. RESULTS An increase in microvessel and arteriole density was noted in contracted, relapsed clubfoot tissue. This was accompanied by a significant increase in the levels of the vascular endothelial growth factor, vascular endothelial growth factor receptor 2, β catenin and active β catenin. Vascular endothelial growth factor, vascular endothelial growth factor receptor 2, and CD31 overexpression was also seen with mRNA analysis. CONCLUSIONS Increased microvessel and arteriole density in the contracted side of the relapsed clubfoot was noted. These processes are mediated by specific proangiogenic proteins that are overexpressed in the contracted tissue. These findings contribute to the etiology and the development of relapses in the treatment of clubfoot. LEVEL OF EVIDENCE Level II-analytical and prospective.
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23
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Sheik-Ali S, Navarro SM, Shaikh H, Keil EJ, Johnson W, Lavy C. The Health Determinants of Accessibility to Clubfoot Treatment in LMICs: A Global Exploration of Barriers and Solutions. Int J MCH AIDS 2021; 10:241-250. [PMID: 34900392 PMCID: PMC8647193 DOI: 10.21106/ijma.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Clubfoot or Congenital Talipes Equinovarus (CTEV) treatment in newborn infants involves simple, non-invasive manipulation and is primarily managed non-surgically if identified early. In low- and middle-income countries (LMICs), less than 15% of patients with CTEV access treatment. This cross-sectional questionnaire study conducted descriptive and regression analysis of institutional reasons for CTEV management in LMICs. METHODS A cross-sectional study was undertaken of 1,489 medical institutions in 62 LMICs. Data were evaluated from the "World Health Organization Situation Analysis tool" database. We analyzed characteristics of institutions that manage and did not manage CTEV. With the use of a multivariate linear regression model, we identified a set of factors linked to referral for non-management of CTEV. RESULTS A total of 72.7% (1,083/1,395) of institutions surveyed did not manage CTEV. The most common reason cited for not managing CTEV was a lack of sufficient skills, 92.1% (668/725, P<0.001). A total of 39.4% (286/725) of institutions also cited a lack of functioning equipment as a reason. Multivariate linear regression analysis showed lack of training, lack of supplies, and lack of functioning equipment were most closely related to non-management of CTEV. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS We identified that failure to manage CTEV may result from a lack of skills and medical equipment. Increasing the capacity of sustainable training programs may reduce the presently available skill deficit in treating CTEV in LMICs and provide improved health outcomes for those with CTEV. While considerable progress has been made in building capacity for the treatment and management of CTEV in LMICs, structured training programs that support conservative manipulative methods to manage CTEV should be initiated globally.
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Affiliation(s)
- Sharaf Sheik-Ali
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
| | - Sergio M Navarro
- Department of Surgery, The University of Minnesota, Minneapolis, Minnesota, USA
| | - Hashim Shaikh
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
| | - Evan J Keil
- Department of Surgery, The University of Minnesota, Minneapolis, Minnesota, USA
| | - Walter Johnson
- Organisation Mondiale de la Sante, Global Initiative for Emergency & Essential Surgical Care Geneva, Switzerland
| | - Chris Lavy
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford Nuffield Orthopedic Center Oxford, UK
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24
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Sucu M, Demir SC. The relationship between isolated pes equinovarus and aneuploidies and perinatal outcomes: Results of a tertiary center. Turk J Obstet Gynecol 2020; 17:270-277. [PMID: 33343973 PMCID: PMC7731604 DOI: 10.4274/tjod.galenos.2020.60669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 01/08/2023] Open
Abstract
Objective Congenital pes equinovarus (PEV) is the most common congenital deformity of the foot, characterized by plantar flexion with a frequency of 0.2-0.3%. It can be diagnosed from the 12th week of pregnancy. Non-isolated cases tend to be syndromic and complex. We aimed to evaluate the results of perinatally diagnosed isolated PEV. Materials and Methods This was a retrospective cohort study conducted between March 2015-March 2020. Women who presented for fetal anomaly screening or were referred due to any suspected fetal anomaly were subjected to detailed fetal anomaly scans and checked for the presence of PEV. Karyotype analysis was discussed for patients with PEV. Pregnancy termination was recommended for those with chromosomal/life-threatening anomalies. The diagnosis was confirmed by postnatal examination/autopsy. Postnatal diagnosis was accepted as false-positive in those with no PEV. Results One-hundred thirty-eight patients were found to have PEV, 41 (29.7%) of which were isolated. In the isolated group, the false-positive rate in the first trimester was significantly higher compared with the second trimester, 50%/15.3%, respectively (p<0.05). Chromosomal anomalies were detected in 2 (4.8%) patients in the isolated group. Termination was performed to 1 (2.4%) patients due to trisomy 21. In the non-isolated group, chromosomal anomalies were detected in 13 (13.4%) patients, and termination was recommended. Termination was also recommended to 18 (18.5%) patients due to anomalies incompatible with life. In the postnatal evaluation, the surgical treatment rate in the isolated/non-isolated groups was 6%/39.7% (p<0.05). Conclusion When PEV is diagnosed, detailed fetal anomaly screening must be performed, patients should be informed about the chromosomal anomaly risk. High false-positive rates in the first trimester should be kept in mind for diagnosis. Karyotype analysis should be recommended also to isolated cases. It should be remembered that some neuromuscular/skeletal system anomalies may occur for the first time in the postnatal period in isolated cases.
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Affiliation(s)
- Mete Sucu
- Çukurova University Faculty of Medicine, Department of Obstetrics and Gynecology, Adana, Turkey
| | - Süleyman Cansun Demir
- Çukurova University Faculty of Medicine, Department of Obstetrics and Gynecology, Adana, Turkey
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25
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Implementation of a Ponseti Clubfoot Program Decreases Major Surgery: A Quality Improvement Initiative. Pediatr Qual Saf 2020; 5:e362. [PMID: 33575522 PMCID: PMC7870159 DOI: 10.1097/pq9.0000000000000362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/12/2020] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. Clubfoot describes a congenital condition. If untreated, clubfoot can cause long-term functional issues. The Ponseti method is the gold-standard treatment; it emphasizes casting over surgery. We identified a high rate of major recurrence in patients with isolated clubfoot at our institution. We implemented a quality improvement intervention to address the recurrences.
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26
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Clubfoot treatment with Ponseti method-parental distress during plaster casting. J Orthop Surg Res 2020; 15:271. [PMID: 32680553 PMCID: PMC7368756 DOI: 10.1186/s13018-020-01782-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/02/2020] [Indexed: 11/23/2022] Open
Abstract
Background Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot. Therefore, we want to determinate first, how pronounced the parents’ worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents’ mental resilience in relation to the therapy of the child as a global distress parameter. Methods To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T0) and at the end (TE) of the treatment with plaster casting. Results High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63), and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. Spearman correlation coefficient between Pirani score (T0) and mental resilience (T0) is 0.21, so the initial hypothesis had to be rejected. Conclusion The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.
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Sheik-Ali S, Navarro SM, Keil E, Lavy C. The role of clubfoot training programmes in low- and middle-income countries: a systematic review. Trop Doct 2020; 50:291-299. [PMID: 32571163 PMCID: PMC7539599 DOI: 10.1177/0049475520931343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
While adoption of the Ponseti method has continued gradually, its use to manage patients with congenital talipes equinovarus (CTEV) has been limited in low- and middle-income countries (LMICs) for a number of reasons including a lack of clinical training on technique and lack of appropriate clinical equipment. There are a frequent number of emerging studies that report on the role of clubfoot training programmes; however, little is known in regard to cumulative benefits. A systematic review was undertaken through Medline, the Cochrane Library and Web of Science for studies analysing clubfoot training programmes. There were no limitations on time, up until the review was commenced on January 2020. The systematic review was registered with PROSPERO as 165657. Ten articles complied with the inclusion criteria and were deemed fit for analysis. Training programmes lasted an average of 2–3 days. There was a reported increase in knowledge of applying the Ponseti method in managing clubfoot by participants (four studies P < 0.05). Skill retention was examined by multiple choice (MCQ) examination style questions before and after the training programme in two studies; both showed an improvement (MCQ answers improved from 59% to 73%). All studies showed an improvement in participants' self-reported understanding of the Ponseti method and confidence in its use in future practice (P < 0.05). There were improved benefits of knowledge and clinical application of the Ponseti method by participants in the programmes in all studies examined. However, there was a significant lack of follow-up and exploration of long-term effects of these programmes. Implementing training programmes based on perceived benefits rather than actual long-term benefits may have a negative impact on healthcare delivery and patient management in LMICs.
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Affiliation(s)
- Sharaf Sheik-Ali
- Academic Foundation Doctor, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - Sergio M Navarro
- Surgical Trainee, Department of Surgery, Baylor College of Medicine, Houston, USA.,Surgical Trainee, Said Business School, University of Oxford, Oxford, UK
| | - Evan Keil
- Medical Student, Department of Surgery, 5635University of Minnesota, Minneapolis, USA
| | - Chris Lavy
- Professor, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
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Harris M, Skopec M, Issa H. Authors' reply to Hunter. BMJ 2020; 368:m36. [PMID: 31924661 DOI: 10.1136/bmj.m36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Matthew Harris
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Mark Skopec
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Hamdi Issa
- Institute of Global Health Innovation, Imperial College London
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Dibello D, Colin G, Galimberti AMC, Di Carlo V. Ten year challenge with Ponseti method for clubfoot: our experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:127-130. [PMID: 31821296 PMCID: PMC7233724 DOI: 10.23750/abm.v90i12-s.8831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/22/2019] [Indexed: 12/04/2022]
Abstract
Equino-varus-adducted-supinated, also known as clubfoot, is the most frequent congenital malformation of the foot. Scientific evidences of the last decades has definitively confirmed the efficacy of the non-invasive Ponseti Technique, which is based on manipulation, plaster casts, percutaneous achillean tenotomy and stabilization of the foot using a brace. The aim of the article is to describe the experience of our third level hospital in treating clubfoot with Ponseti Method. Our data are similar to the ones in literature, confirming the effectiveness and good reproducibility of the Method. (www.actabiomedica.it)
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Affiliation(s)
- Daniela Dibello
- Orthopedic Pediatric Department Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste.
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Affiliation(s)
- Mark Skopec
- Department of Primary Care and Public Health, Imperial College London
| | - Hamdi Issa
- Institute of Global Health Innovation, Imperial College London
| | - Matthew Harris
- Department of Primary Care and Public Health, Imperial College London
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Hemo Y, Yavor A, Gigi R, Wientroub S. The significance of foot length at the initiation of the Ponseti method: a prospective study. J Child Orthop 2019; 13:252-257. [PMID: 31312264 PMCID: PMC6598042 DOI: 10.1302/1863-2548.13.190075] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES We sought to evaluate foot length (FL) and forefoot circumference (FC) and their impact on the severity of idiopathic clubfoot (CF) and results of treatment. We hypothesized that a smaller foot size at birth that represents a lesser than term newborn may affect the response of the CF to the treatment. METHODS We conducted a prospective study documenting FL and FC of all neonates presented with idiopathic CF. Additional demographic information was collected. Outcome measures were number of casts needed for correction, need for recasting, additional surgery and functional score. RESULTS In all, 52 children with 73 CF with a minimum mean follow-up of two years (2.0 to 5.6; sd 1.08) were evaluated. Mean gestational age was 38.63 weeks and mean birth weight (BW) was 3184 g. The mean FL at presentation was 74 mm (5.70 to 9.00), initial Pirani score was 5.5 (2.5 to 6.0) while number of casts was 6.9 (4.0 to 11.0). The FL was significantly correlated both to initial Pirani score (r = -0.35; p < 0.01) and number of casts (r = -0.33; p < 0.05). Positive correlation was found between the number of casts to Pirani score and number of additional procedures (r = 0.39; r = 0.36; p < 0.01, respectively). A foot size of up to 8 cm, needed 7.3 casts (4 to 7) compared with a FL of 8 cm or longer who needed 4.7 casts (4 to 6; t = 7.11; p < 0.001). CONCLUSION FL is a simple approach to identify preterm babies. It can be used as part of the initial evaluation of CF and help in predicting the course of treatment. We recommend adding FL to the existing classification. LEVEL OF EVIDENCE I - Prognostic study.
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Affiliation(s)
- Y. Hemo
- Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Correspondence should be sent to Yoram Hemo, MD, Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. E-mail:
| | - A. Yavor
- Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R. Gigi
- Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S. Wientroub
- Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Smythe T, Mudariki D, Gova M, Foster A, Lavy C. Evaluation of a simple tool to assess the results of Ponseti treatment for use by clubfoot therapists: a diagnostic accuracy study. J Foot Ankle Res 2019; 12:14. [PMID: 30867682 PMCID: PMC6399889 DOI: 10.1186/s13047-019-0323-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background We aimed to develop and evaluate a tool for clubfoot therapists in low resource settings to assess the results of Ponseti treatment of congenital talipes equinovarus, or clubfoot, in children of walking age. Method A literature review and a Delphi process based on the opinions of 35 Ponseti trainers in Africa were used to develop the Assessing Clubfoot Treatment (ACT) tool and score. We followed up children with clubfoot from a cohort treated between 2011 and 2013, in 2017. A full clinical assessment was conducted to decide if treatment was successful or if further treatment was required. The ACT score was then calculated for each child. Inter-observer variation for the ACT tool was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the ACT score compared to full clinical assessment (gold standard). Predictors of a successful outcome were explored. Results The follow up rate was 31.2% (68 children). The ACT tool consisted of 4 questions; each scored from 0 to 3, giving a total from 0 to 12 where 12 is the ideal result. The 4 questions included one physical assessment and three parent reported outcome measures. It took 5 min to administer and had excellent inter-observer agreement. An ACT score of 8 or less demonstrated 79% sensitivity and 100% specificity in identifying children that required further intervention, with a positive predictive value of 100% and negative predictive value of 90%. Children who completed two or more years of bracing were four times more likely to achieve an ACT score of 9 or more compared to those who did not (OR: 4.08, 95% CI: 1.31–12.65, p = 0.02). Conclusions The ACT tool is simple to administer, had excellent observer agreement, and good sensitivity and specificity in identifying children who need further intervention. The score can be used to identify those children who definitely need referral and further treatment (score 8 or less) and those with a definite successful outcome (score 11 or more), however further discrimination is needed to decide how to manage children with a borderline ACT score of 9 or 10. Level of evidence Level II, Diagnostic Study. Electronic supplementary material The online version of this article (10.1186/s13047-019-0323-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tracey Smythe
- 1International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E7HT UK
| | - Debra Mudariki
- 2University of Witwatersrand, 1 Jan Smuts Avenue, Braamfontein, Johannesburg, 2000 South Africa
| | - Maxman Gova
- 3Department of Surgery, Parirenyatwa Hospital & University of Zimbabwe, Harare, Zimbabwe
| | - Allen Foster
- 1International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E7HT UK
| | - Christopher Lavy
- 4Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Windmill Road, Headington, Oxford, OX3 7HE UK
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Smythe T, Gova M, Muzarurwi R, Foster A, Lavy C. A comparison of outcome measures used to report clubfoot treatment with the Ponseti method: results from a cohort in Harare, Zimbabwe. BMC Musculoskelet Disord 2018; 19:450. [PMID: 30579347 PMCID: PMC6303847 DOI: 10.1186/s12891-018-2365-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 11/30/2018] [Indexed: 11/20/2022] Open
Abstract
Background There are various established scoring systems to assess the outcome of clubfoot treatment after correction with the Ponseti method. We used five measures to compare the results in a cohort of children followed up for between 3.5 to 5 years. Methods In January 2017 two experienced physiotherapists assessed children who had started treatment between 2011 and 2013 in one clinic in Harare, Zimbabwe. The length of time in treatment was documented. The Roye score, Bangla clubfoot assessment tool, the Assessing Clubfoot Treatment (ACT) tool, proportion of relapsed and of plantigrade feet were used to assess the outcome of treatment in the cohort. Inter-observer variation was calculated for the two physiotherapists. A comparative analysis of the entire cohort, the children who had completed casting and the children who completed more than two years of bracing was undertaken. Diagnostic accuracy was calculated for the five measures and compared to full clinical assessment (gold standard) and whether referral for further intervention was required for re-casting or surgical review. Results 31% (68/218) of the cohort attended for examination and were assessed. Of the children who were assessed, 24 (35%) had attended clinic reviews for 4–5 years, and 30 (44%) for less than 2 years. There was good inter-observer agreement between the two expert physiotherapists on all assessment tools. Overall success of treatment varied between 56 and 93% using the different outcome measures. The relapse assessment had the highest unnecessary referrals (19.1%), and the Roye score the highest proportion of missed referrals (22.7%). The ACT and Bangla score missed the fewest number of referrals (7.4%). The Bangla score demonstrated 79.2% (95%CI: 57.8–92.9%) sensitivity and 79.5% (95%CI: 64.7–90.2%) specificity and the ACT score had 79.2% (95%CI: 57.8–92.9%) sensitivity and 100% (95%CI: 92–100%) specificity in predicting the need for referral. Conclusion At three to five years of follow up, the Ponseti method has a good success rate that improves if the child has completed casting and at least two years of bracing. The ACT score demonstrates good diagnostic accuracy for the need for referral for further intervention (specialist opinion or further casting). All tools demonstrated good reliability. Electronic supplementary material The online version of this article (10.1186/s12891-018-2365-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tracey Smythe
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E7HT, UK.
| | - Maxman Gova
- Department of Surgery, Parirenyatwa Group of Hospitals, Harare, Zimbabwe
| | - Rumbidzai Muzarurwi
- Rehabilitation Department, Parirenyatwa Group of Hospitals, Harare, Zimbabwe
| | - Allen Foster
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E7HT, UK
| | - Christopher Lavy
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
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Tuinsma ABM, Vanwanseele B, van Oorschot L, Kars HJJ, Grin L, Reijman M, Besselaar AT, van der Steen MC. Gait kinetics in children with clubfeet treated surgically or with the Ponseti method: A meta-analysis. Gait Posture 2018; 66:94-100. [PMID: 30170140 DOI: 10.1016/j.gaitpost.2018.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/26/2018] [Accepted: 08/09/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Currently, the Ponseti method is the gold standard for treatment of clubfeet. For long-term functional evaluation of this method, gait analysis can be performed. Previous studies have assessed gait differences between Ponseti treated clubfeet and healthy controls. RESEARCH QUESTION/PURPOSE The aims of this systematic review were to compare the gait kinetics of Ponseti treated clubfeet with healthy controls and to compare the gait kinetics between clubfoot patients treated with the Ponseti method or surgically. METHODS A systematic search was performed in Embase, Medline Ovid, Web of Science, Scopus, Cochrane, Cinahl ebsco, and Google scholar, for studies reporting on gait kinetics in children with clubfeet treated with the Ponseti method. Studies were excluded if they only used EMG or pedobarography. Data were extracted and a risk of bias was assessed. Meta-analyses and qualitative analyses were performed. RESULTS Nine studies were included, of which five were included in the meta-analyses. The meta-analyses showed that ankle plantarflexor moment (95% CI -0.25 to -0.19) and ankle power (95% CI -0.89 to -0.60, were significantly lower in the Ponseti treated clubfeet compared to the healthy controls. No significant difference was found in ankle dorsiflexor and plantarflexor moment, and ankle power between clubfeet treated with surgery compared to the Ponseti method. SIGNIFICANCE Differences in gait kinetics are present when comparing Ponseti treated clubfeet with healthy controls. However, there is no significant difference between surgically and Ponseti treated clubfeet. These results give more insight in the possibilities of improving the gait pattern of patients treated for clubfeet.
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Affiliation(s)
- A B M Tuinsma
- Department of Orthopaedic Surgery, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA, Eindhoven, The Netherlands
| | - B Vanwanseele
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Theodor Fliednerstraat 2, 5361 BN, Eindhoven, The Netherlands; Department of Kinesiology, KU Leuven, Tervuursevest 101, 3001, Heverlee, Belgium
| | - L van Oorschot
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Theodor Fliednerstraat 2, 5361 BN, Eindhoven, The Netherlands
| | - H J J Kars
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Theodor Fliednerstraat 2, 5361 BN, Eindhoven, The Netherlands
| | - L Grin
- Department of Health Innovation and Technology, Fontys University of Applied Sciences, Ds Theodor Fliednerstraat 2, 5361 BN, Eindhoven, The Netherlands
| | - M Reijman
- Orthopaedic Center Máxima, Máxima Medical Center, Postbus 90052, 5600 PD, Eindhoven, The Netherlands; Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - A T Besselaar
- Department of Orthopaedic Surgery, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA, Eindhoven, The Netherlands; Orthopaedic Center Máxima, Máxima Medical Center, Postbus 90052, 5600 PD, Eindhoven, The Netherlands
| | - M C van der Steen
- Department of Orthopaedic Surgery, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA, Eindhoven, The Netherlands.
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Owen RM, Capper B, Lavy C. Clubfoot treatment in 2015: a global perspective. BMJ Glob Health 2018; 3:e000852. [PMID: 30233830 PMCID: PMC6135438 DOI: 10.1136/bmjgh-2018-000852] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 02/06/2023] Open
Abstract
Introduction Clubfoot affects around 174 000 children born annually, with approximately 90% of these in low-income and middle-income countries (LMIC). Untreated clubfoot causes life-long impairment, affecting individuals’ ability to walk and participate in society. The minimally invasive Ponseti treatment is highly effective and has grown in acceptance globally. The objective of this cross-sectional study is to quantify the numbers of countries providing services for clubfoot and children accessing these. Method In 2015–2016, expected cases of clubfoot were calculated for all countries, using an incidence rate of 1.24/1000 births. Informants were sought from all LMIC, and participants completed a standardised survey about services for clubfoot in their countries in 2015. Data collected were analysed using simple numerical analysis, country coverage levels, trends over time and by income group. Qualitative data were analysed thematically. Results Responses were received from 55 countries, in which 79% of all expected cases of clubfoot were born. More than 24 000 children with clubfoot were enrolled for Ponseti treatment in 2015. Coverage was less than 25% in the majority of countries. There were higher levels of response and coverage within the lowest income country group. 31 countries reported a national programme for clubfoot, with the majority provided through public–private partnerships. Conclusion This is the first study to describe global provision of, and access to, treatment services for children with clubfoot. The numbers of children accessing Ponseti treatment for clubfoot in LMIC has risen steadily since 2005. However, coverage remains low, and we estimate that less than 15% of children born with clubfoot in LMIC start treatment. More action to promote the rollout of national clubfoot programmes, build capacity for treatment and enable access and adherence to treatment in order to radically increase coverage and effectiveness is essential and urgent in order to prevent permanent disability caused by clubfoot.
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Affiliation(s)
| | | | - Christopher Lavy
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Smythe T, Mudariki D, Foster A, Lavy C. Indicators to assess the functionality of clubfoot clinics in low-resource settings: a Delphi consensus approach and pilot study. Int Health 2018; 10:340-348. [PMID: 29788430 PMCID: PMC6104708 DOI: 10.1093/inthealth/ihy033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/11/2018] [Indexed: 12/14/2022] Open
Abstract
Background This study aims to determine the indicators for assessing the functionality of clubfoot clinics in a low-resource setting. Methods The Delphi method was employed with experienced clubfoot practitioners in Africa to rate the importance of indicators of a good clubfoot clinic. The consistency among the participants was determined with the intraclass correlation coefficient. Indicators that achieved strong agreement (mean≥9 [SD <1.5]) were included in the final consensus definition. Based on the final consensus definition, a set of questions was developed to form the Functionality Assessment Clubfoot Clinic Tool (FACT). The FACT was used between February and July 2017 to assess the functionality of clinics in the Zimbabwe clubfoot programme. Results A set of 10 indicators that includes components of five of the six building blocks of a health system-leadership, human resources, essential medical equipment, health information systems and service delivery-was produced. The most common needs identified in Zimbabwe clubfoot clinics were a standard treatment protocol, a process for surgical referrals and a process to monitor dropout of patients. Conclusions Practitioners had good consistency in rating indicators. The consensus definition includes components of the World Health Organization building blocks of health systems. Useful information was obtained on how to improve the services in the Zimbabwe clubfoot programme.
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Affiliation(s)
- Tracey Smythe
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Debra Mudariki
- Witswatersrand University, 1 Jan Smuts Avenue, Braamfontein 2000, Johannesburg, South Africa
| | - Allen Foster
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Christopher Lavy
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Windmill Road, Headington, Oxford, UK
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Pavone V, Chisari E, Vescio A, Lucenti L, Sessa G, Testa G. The etiology of idiopathic congenital talipes equinovarus: a systematic review. J Orthop Surg Res 2018; 13:206. [PMID: 30134936 PMCID: PMC6104023 DOI: 10.1186/s13018-018-0913-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/15/2018] [Indexed: 12/19/2022] Open
Abstract
Background Also known as clubfoot, idiopathic congenital talipes equinovarus (ICTEV) is the most common pediatric deformity and occurs in 1 in every 1000 live births. Even though it has been widely researched, the etiology of ICTEV remains poorly understood and is often described as being based on a multifactorial genesis. Genetic and environmental factors seem to have a major role in the development of this disease. Thus, the aim of this review is to analyze the available literature to document the current evidence on ICTEV etiology. Methods The literature on ICTEV etiology was systematically reviewed using the following inclusion criteria: studies of any level of evidence, reporting clinical or preclinical results, published in the last 20 years (1998–2018), and dealing with the etiology of ICTEV. Results A total of 48 articles were included. ICTEV etiology is still controversial. Several hypotheses have been researched, but none of them are decisive. Emerging evidence suggests a role of several pathways and gene families associated with limb development (HOX family; PITX1-TBX4), the apoptotic pathway (caspases), and muscle contractile protein (troponin and tropomyosin), but a major candidate gene has still not been identified. Strong recent evidence emerging from twin studies confirmed major roles of genetics and the environment in the disease pathogenesis. Conclusions The available literature on the etiology of ICTEV presents major limitations in terms of great heterogeneity and a lack of high-profile studies. Although many studies focus on the genetic background of the disease, there is lack of consensus on one or multiple targets. Genetics and smoking seem to be strongly associated with ICTEV etiology, but more studies are needed to understand the complex and multifactorial genesis of this common congenital lower-limb disease.
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Affiliation(s)
- Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Via Plebiscito, 628, 95124, Catania, Italy
| | - Emanuele Chisari
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Via Plebiscito, 628, 95124, Catania, Italy
| | - Andrea Vescio
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Via Plebiscito, 628, 95124, Catania, Italy
| | - Ludovico Lucenti
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Via Plebiscito, 628, 95124, Catania, Italy
| | - Giuseppe Sessa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Via Plebiscito, 628, 95124, Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Via Plebiscito, 628, 95124, Catania, Italy.
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Smythe T, Le G, Owen R, Ayana B, Hansen L, Lavy C. The development of a training course for clubfoot treatment in Africa: learning points for course development. BMC MEDICAL EDUCATION 2018; 18:163. [PMID: 30005662 PMCID: PMC6044045 DOI: 10.1186/s12909-018-1269-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 06/26/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Clubfoot is a common congenital musculoskeletal disorder that causes mobility impairment. There is a lack of trained mid-level personnel to provide clubfoot treatment in Africa and there is no standard training course. This prospective study describes the collaborative and participatory approach to the development of a training course for the treatment of clubfoot in children in resource constrained settings. METHODS We used a systems approach to evaluate the development of the training course. Inputs: The research strategy included a review of context and available training materials, and the collection of data on current training practices. Semi-structured interviews were conducted with seven expert clubfoot trainers. A survey of 32 international and regional trainers was undertaken to inform practical issues. The data were used to develop a framework for training with advice from two technical groups, consisting of regional and international stakeholders and experts. PROCESS A consensus approach was undertaken during workshops, meetings and the sharing of documents. The design process for the training materials took twenty-four months and was iterative. The training materials were piloted nine times between September 2015 and February 2017. Processes and materials were reviewed and adapted according to feedback after each pilot. RESULTS Fifty-one regional trainers from Africa (18 countries), 21 international experts (11 countries), 113 local providers of clubfoot treatment (Ethiopia, Rwanda and Kenya) and local organising teams were involved in developing the curriculum and pilot testing. The diversity of the two technical advisory groups allowed a wide range of contributions to the collaboration. Output: The resulting curriculum and content comprised a two day basic training and a two day advanced course. The basic course utilised adult learning techniques for training novice providers in the treatment of idiopathic clubfoot in children under two years old. The advanced course builds on these principles. CONCLUSION Formative research that included mixed methods (both qualitative and quantitative) was important in the development of an appropriate training course. The process documentation from this study provides useful information to assist planning of medical training programmes and may serve as a model for the development of other courses.
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Affiliation(s)
- Tracey Smythe
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E7HT UK
| | - Grace Le
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | | | - Linda Hansen
- CURE International, Beit CURE Hospital, Lusaka, Zambia
| | - Christopher Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Drew S, Gooberman-Hill R, Lavy C. What factors impact on the implementation of clubfoot treatment services in low and middle-income countries?: a narrative synthesis of existing qualitative studies. BMC Musculoskelet Disord 2018; 19:72. [PMID: 29499667 PMCID: PMC5834880 DOI: 10.1186/s12891-018-1984-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 02/22/2018] [Indexed: 11/21/2022] Open
Abstract
Background Around 100,000 children are born annually with clubfoot worldwide and 80% live in low and middle-income counties (LMICs). Clubfoot is a condition in which children are born with one or both feet twisted inwards and if untreated it can limit participation in everyday life. Clubfoot can be corrected through staged manipulation of the limbs using the Ponseti method. Despite its efficacy and apparent availability, previous research has identified a number of challenges to service implementation. The aim of this study was to synthesise these findings to explore factors that impact on the implementation of clubfoot services in LMICs and strategies to address them. Understanding these may help practitioners in other settings develop more effective services. Methods Five databases were searched and articles screened using six criteria. Articles were appraised using the Critical Appraisal Skills Programme (CASP) checklist. 11 studies were identified for inclusion. A thematic analysis was conducted. Results Thematic analysis of the included studies showed that a lack of access to resources was a challenge including a lack of casting materials and abduction braces. Difficulties within the working environment included limited space and a need to share treatment space with other clinics. A shortage of healthcare professionals was a concern and participants thought that there was a lack of time to deliver treatment. This was exacerbated by the competing demands on clinicians. Lack of training was seen to impact on standards, including the nurses and midwives attending to the child at birth that were failing to diagnose the condition. Financial constraints were seen to underlie many of these problems. Some participants identified failures in communication and cooperation within the healthcare system such as a lack of awareness of clinics. Strategies to address these issues included means of increasing resource availability and the delivery of targeted training. The use of non-governmental organisations to provide financial support and methods to disseminate best practice were discussed. Conclusions This study identified factors that impact on the implementation of clubfoot services in LMIC settings.Findings may be used to improve service delivery.
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Affiliation(s)
- Sarah Drew
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK.
| | - Rachael Gooberman-Hill
- School of Clinical Sciences, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Christopher Lavy
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
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Ganesan B, Luximon A, Al-Jumaily AA, Yip J, Gibbons PJ, Chivers A. Developing a Three-Dimensional (3D) Assessment Method for Clubfoot-A Study Protocol. Front Physiol 2018; 8:1098. [PMID: 29354068 PMCID: PMC5758584 DOI: 10.3389/fphys.2017.01098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background: Congenital talipes equinovarus (CTEV) or clubfoot is a common pediatric congenital foot deformity that occurs 1 in 1,000 live births. Clubfoot is characterized by four types of foot deformities: hindfoot equinus; midfoot cavus; forefoot adductus; and hindfoot varus. A structured assessment method for clubfoot is essential for quantifying the initial severity of clubfoot deformity and recording the progress of clubfoot intervention. Aim: This study aims to develop a three-dimensional (3D) assessment method to evaluate the initial severity of the clubfoot and monitor the structural changes of the clubfoot after each casting intervention. In addition, this study explores the relationship between the thermophysiological changes in the clubfoot at each stage of the casting intervention and in the normal foot. Methods: In this study, a total of 10 clubfoot children who are <2 years old will be recruited. Also, the data of the unaffected feet of a total of 10 children with unilateral clubfoot will be obtained as a reference for normal feet. A Kinect 3D scanner will be used to collect the 3D images of the clubfoot and normal foot, and an Infrared thermography camera (IRT camera) will be used to collect the thermal images of the clubfoot. Three-dimensional scanning and IR imaging will be performed on the foot once a week before casting. In total, 6–8 scanning sessions will be performed for each child participant. The following parameters will be calculated as outcome measures to predict, monitor, and quantify the severity of the clubfoot: Angles cross section parameters, such as length, width, and the radial distance; distance between selected anatomical landmarks, and skin temperature of the clubfoot and normal foot. The skin temperature will be collected on selected areas (forefoot, mid foot, and hindfoot) to find out the relationship between the thermophysiological changes in the clubfoot at each stage of the casting treatment and in the normal foot. Ethics: The study has been reviewed and approved on 17 August 2016 by the Sydney Children's Hospitals Network Human Research Ethics Committee (SCHN HREC), Sydney, Australia. The Human Research Ethics Committee (HREC) registration number for this study is: HREC/16/SCHN/163.
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Affiliation(s)
- Balasankar Ganesan
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Kowloon, Hong Kong.,Department of FEIT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Ameersing Luximon
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Adel A Al-Jumaily
- Department of FEIT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Joanne Yip
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Paul J Gibbons
- University of Sydney and Department of Orthopaedic Surgery, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Alison Chivers
- Department of Physiotherapy, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Smythe T, Wainwright A, Foster A, Lavy C. What is a good result after clubfoot treatment? A Delphi-based consensus on success by regional clubfoot trainers from across Africa. PLoS One 2017; 12:e0190056. [PMID: 29267350 PMCID: PMC5739468 DOI: 10.1371/journal.pone.0190056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 12/07/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Congenital talipes equino-varus (CTEV), also known as clubfoot, is one of the most common congenital musculoskeletal malformations. Despite this, considerable variation exists in the measurement of deformity correction and outcome evaluation. This study aims to determine the criteria for successful clubfoot correction using the Ponseti technique in low resource settings through Africa. METHODS Using the Delphi method, 18 experienced clubfoot practitioners and trainers from ten countries in Africa ranked the importance of 22 criteria to define an 'acceptable or good clubfoot correction' at the end of bracing with the Ponseti technique. A 10cm visual analogue scale was used. They repeated the rating with the results of the mean scores and standard deviation of the first test provided. The consistency among trainers was determined with the intra-class correlation coefficient (ICC). From the original 22 criteria, ten criteria with a mean score >7 and SD <2 were identified and were rated through a second Delphi round by 17 different clubfoot treatment trainers from 11 countries in Africa. The final definition consisted of all statements that achieved strong agreement, a mean score of >9 and SD<1.5. RESULTS The consensus definition of a successfully treated clubfoot includes: (1) a plantigrade foot, (2) the ability to wear a normal shoe, (3) no pain, and (4) the parent is satisfied. Participants demonstrated good consistency in rating these final criteria (ICC 0.88; 0.74,0.97). CONCLUSIONS The consistency of Ponseti technique trainers from Africa in rating criteria for a successful outcome of clubfoot management was good. The consensus definition includes basic physical assessment, footwear use, pain and parent satisfaction.
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Affiliation(s)
- Tracey Smythe
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew Wainwright
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Headington, United Kingdom
| | - Allen Foster
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christopher Lavy
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Science, University of Oxford, Headington, United Kingdom
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Fan H, Liu Y, Zhao L, Chu C, An Y, Wang T, Li W. The Correlation of Pirani and Dimeglio Scoring Systems for Ponseti Management at Different Levels of Deformity Severity. Sci Rep 2017; 7:14578. [PMID: 29109415 PMCID: PMC5674063 DOI: 10.1038/s41598-017-14977-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 10/19/2017] [Indexed: 01/05/2023] Open
Abstract
The Pirani and Dimeglio scoring systems both have excellent inter-observer and intra-observer reliability, but no research has been conducted to determine their inter-observer reliability and their relationship at different levels of deformity. A total of 173 idiopathic clubfoot cases were reviewed using Pirani and Dimeglio scoring systems, and the number of casts needed was also recorded. For clubfeet with a cast number equal to 2 or 7 and 8, the inter-observer reliability of the two scoring systems was poor or moderate, and there was no correlation between the two scoring systems. There was also no correlation between the Dimeglio scoring score with the number of casts for grade II or IV clubfeet. A binary regression of the number of casts on initial Pirani or Dimeglio scores showed that there was a Quadratic or Cubic relation between the scores and the cast numbers. In conclusion, in the case of mild and very severe clubfoot deformity, the interobserver reliability and its ability to predict the number of casts needed for clubfoot deformity correction was poor. A more objective evaluation system may be required.
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Affiliation(s)
- Hua Fan
- Department of Radiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Yubin Liu
- Department of Pediatric Orthopaedics Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China.,Department of Orthopaedics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, China
| | - Li Zhao
- Department of Pediatric Orthopaedics Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China.
| | - Caiting Chu
- Department of Radiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Yongyu An
- Department of Radiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Tingting Wang
- Department of Radiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Wenhua Li
- Department of Radiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China.
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The Ponseti Method for Clubfoot Treatment in Low and Middle-Income Countries: A Systematic Review of Barriers and Solutions to Service Delivery. J Pediatr Orthop 2017; 37:e134-e139. [PMID: 26919713 DOI: 10.1097/bpo.0000000000000723] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Use of the minimally invasive Ponseti method has been increasing in low and middle-income countries, where most of the world's children with clubfoot are born. This method requires a system of service delivery involving screening, serial casting with or without a tenotomy to achieve correction, and long-term use of an orthosis to maintain correction. The goal of this systematic review is to evaluate the barriers to service delivery and the solutions that have been proposed or implemented to address these barriers. METHODS A literature search of Medline, Embase, and SCOPUS produced 3251 results. Twenty-four papers were selected for final review. Barriers and their attempted solutions were organized into a previously described health barrier model. We reported on high-impact, sustainable solutions that are feasible for organizations to implement, as opposed to solutions that require major policy or country-wide infrastructure changes. RESULTS Common barriers found to have the most impact on patient care included financial constraints, transportation, difficulties with brace and cast care, self-perceived health status, lack of physical resources, and provider's lack of knowledge and skill. The most common solutions detailed were education of the provider or patient and financial assistance for patients. CONCLUSIONS Recognizing that contextually relevant solutions to the challenges of setting up a system for clubfoot service delivery are required, several common barriers have emerged within this systematic review of papers from multiple countries, including spatial accessibility, affordability, and availability. Programs can best prepare for challenges by placing clinics close to population centers and/or allocating funds to subsidize transportation, ensuring that an adequate supply of materials are available for the casting and tenotomy, and enhancing the education of families and health providers. Strengthening communication and establishing partnerships between individuals and organizations promoting the Ponseti method will improve systems for service delivery. LEVEL OF EVIDENCE Level IV-prognostic study.
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Evans AM, Chowdhury MMH, Kabir MH, Rahman MF. Walk for life - the National Clubfoot Project of Bangladesh: the four-year outcomes of 150 congenital clubfoot cases following Ponseti method. J Foot Ankle Res 2016; 9:42. [PMID: 27833661 PMCID: PMC5103456 DOI: 10.1186/s13047-016-0175-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/02/2016] [Indexed: 11/23/2022] Open
Abstract
Background Congenital clubfoot deformity can cause significant disability, and if left untreated, may further impoverish those in developing countries, like Bangladesh. The Ponseti method has been strategically introduced in Bangladesh by a non-government organisation, Walk For Life (WFL). WFL has provided free treatment for over 17,500 Bangladeshi children with clubfeet since 2009, sustained by local ownership, and international support. This study assesses the 4-year results in children for whom treatment began before the age of 3 years. Methods A centrally located WFL clinic at Mymensingh Medical College Hospital (MMCH), representative of the larger WFL clinics, which treats >100 cases annually, was reviewed. In 2015, 99 of the 147 eligible subjects who had begun treatment in 2011 were available for follow up. Specific assessment tools enabled evaluation of parent satisfaction, gait function, and relapse cases. Results Results for 99/147 cases were returned after four years: 72 males, 27 females. Typical clubfeet comprised 98/99 of cases, and 55/99 were bilateral. The tenotomy rate was 80 %. Brace use after 3 months was 90 %, at 12 months was 65 %, and at 4 years post treatment was 40 %. Functionally, 98/99 of children could walk and run (99 %). Relapsing deformity was found in 13 %. Relapse severity varied: eight were flexible and partial, five were rigid. Half of the children lost to follow were due to changed phone numbers. While parents were very happy with their child’s feet (97 %), a materials cost of 3000 Taka ($US40) was deemed unaffordable by 60 %. Conclusions The 4-year outcomes after Ponseti treatment for clubfoot deformity, showed that 99 % of children available for follow up, were walking independently. The relapse rate was low. Parent satisfaction was high, but those whose children required further treatment were less satisfied.
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Affiliation(s)
- Angela Margaret Evans
- Department of Podiatry, Lower Extremity and Gait Studies (LEGS) Research Program, La Trobe University, Bundoora, Melbourne, 3086 Australia ; Walk For Life, Road No 15, House 4, Ground Floor, Block D, Banani, Dhaka, 1213 Bangladesh
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Liu Y, Zhao D, Zhao L, Li H, Yang X. Congenital Clubfoot: Early Recognition and Conservative Management for Preventing Late Disabilities. Indian J Pediatr 2016; 83:1266-1274. [PMID: 26341712 DOI: 10.1007/s12098-015-1860-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/22/2015] [Indexed: 12/11/2022]
Abstract
Congenital clubfoot is one of the most common musculoskeletal deformities presenting at birth. Many high risk factors have been associated with clubfoot such as male gender, primiparous mothers and maternal smoking. Accurate understanding of clubfoot pathoanatomy is supposed to be the basis for deformity correction. Prenatal ultrasonography is of reference value in recognizing clubfoot during pregnancy. Neglected clubfoot can eventually cause a noticeable disability and severely influence the quality life in adulthood. Early recognition and treatment are presumed to be the key for prevention of late disabilities. Nowadays, Ponseti method, as one of the conservative treatment regimen, has been widely accepted because of the reported good results of long-term follow-up. However, special attention should be paid to the details in clinical practice for achieving even better correction and a lower rate of relapse. After the complete correction, brace wearing is critical for preventing deformity relapse. Non-compliance or non-adherence with the brace protocol has been considered as the predominant risk factor predisposing to the relapse of clubfoot, which is still a challenging problem. This paper was prepared to give a general introduction about clubfoot, in terms of the importance of early recognition and conservative management, especially Ponseti method, for preventing late disabilities.
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Affiliation(s)
- Yubin Liu
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Dahang Zhao
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China.,The Third Department of Orthopedics, The First Affiliated Hospital of Harbin Medical University, No. 23 Youzheng Street, Harbin, 150001, Heilongjiang Province, China
| | - Li Zhao
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China.
| | - Hai Li
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Xuan Yang
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China
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Azarpira MR, Emami MJ, Vosoughi AR, Rahbari K. Factors associated with recurrence of clubfoot treated by the Ponseti method. World J Clin Cases 2016; 4:318-322. [PMID: 27803913 PMCID: PMC5067494 DOI: 10.12998/wjcc.v4.i10.318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/26/2016] [Accepted: 08/08/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To assess several associated factors on the recurrence of clubfoot after successful correction by the Ponseti method.
METHODS A total of 115 children with 196 clubfeet deformities, treated by the Ponseti method, were evaluated. Demographic data, family history of clubfoot in first-degree relatives, maternal educational level and brace compliance were enquired. Based on their medical files, the characteristics of the patients at the time of presentation such as age, possible associated neuromuscular disease or especial syndrome, severity of the deformity according to the Dimeglio grade and Pirani score, residual deformity after previous Ponseti method and number of casts needed for the correction were recorded.
RESULTS There were 83 boys (72.2%) and 32 girls (27.8%) with a male to female ratio of 2.6. The mean age at the initiation of treatment was 5.4 d (range: 1 to 60 d). The average number of casts applied to achieve complete correction of all clubfoot deformities was 4.2. Follow-up range was 11 to 60 mo. In total, 39 feet had recurrence with a minimum Dimeglio grade of 1 or Pirani score of 0.5 at the follow-up visit. More recurrence was observed in non-idiopathic clubfoot deformities (P = 0.001), non-compliance to wear braces (P < 0.001), low educational level of mother (P = 0.033), increased number of casts (P < 0.001), and more follow-up periods (P < 0.001). No increase in the possibility of recurrence was observed when the previous unsuccessful casting was further treated using the Ponseti method (P = 0.091). Also, no significant correlation was found for variables of age (P = 0.763), Dimeglio grade (P = 0.875), and Pirani score (P = 0.624) obtaining at the beginning of the serial casting.
CONCLUSION Using the Ponseti method, non-idiopathic clubfoot, non-compliance to wear braces, low educational level of mother, increased number of casts and more follow-up periods had more association to possible increase in recurrence rate after correction of clubfoot deformity.
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Abstract
Idiopathic clubfoot has a tremendous worldwide prevalence. If left untreated, the deformity has severely disabling effects on mobility and quality of life. Given its prevalence and significance, numerous studies are published on this condition every year. In this article, we attempt to highlight important themes and findings of studies published on idiopathic clubfoot over the past 3 years.
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Affiliation(s)
- Ryan M O'Shea
- San Francisco Orthopaedic Residency Program, 450 Stanyan Street, San Francisco, CA, 94117, USA
| | - Coleen S Sabatini
- UCSF Benioff Children's Hospital Oakland, 747 52nd Street, OPC 1st Floor, Oakland, CA, 94609, USA.
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Munambah N, Chiwaridzo M, Mapingure T. A cross-sectional study investigating impressions and opinions of medical rehabilitation professionals on the effectiveness of the Ponseti method for treatment of clubfoot in Harare, Zimbabwe. Arch Physiother 2016; 6:7. [PMID: 29340189 PMCID: PMC5759920 DOI: 10.1186/s40945-016-0021-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/27/2016] [Indexed: 12/25/2022] Open
Abstract
Background The Ponseti method of managing clubfoot was introduced in Zimbabwe in 2011. This followed massive training of health workers such as medical rehabilitation practitioners through a programme called the Zimbabwe Sustainable Clubfoot Programme. Today, the Ponseti method is the technique of choice for managing clubfoot in hospitals. However, since then, there is no published evidence documenting the efficacy and the relevance of the technique especially comparing to previously used methods. This is a significant shortcoming if sustainability issues are to be considered. Therefore, this study was designed to investigate the impressions and opinions of medical rehabilitation practitioners on the method in terms of its effectiveness, perceived challenges and possible recommendations for improvement of the technique application in their setting. Methods A descriptive cross-sectional study was conducted targeting medical rehabilitation practitioners previously trained on the method and working in public or private clinics that offer clubfoot management in Harare. A questionnaire was self-administered to 41 participants who volunteered to participate in the study. Data from open-ended questions was analysed thematically. Statistica version 12 was used for analysis for quantitative data. Results The Ponseti method was perceived as an effective method in the treatment of children with clubfoot by all the participants. All the participants 41 (100 %) felt that the method was relevant because of better clinical outcomes. Amongst challenges faced when using Ponseti method, 25 (61 %) participants agreed that caregivers to the children with clubfoot were not compliant to treatment. A total of 22 (54 %) participants felt that lack of adequate insight by the caregivers of this new method was a challenge which hinder progress in treating clubfoot. Conclusions The medical rehabilitation professionals in Harare, Zimbabwe trained to use the Ponseti technique for the management of clubfoot, perceived the method as an effective method resulting in better clinical outcome than previous methods. This probably highlights the need to continue training medical rehabilitation professionals so that there is widespread use of the technique in the country. However, there is need to increase awareness of the method among caregivers to improve compliance, which is key to successful rehabilitation of the clubfoot.
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Affiliation(s)
- N Munambah
- Department of Rehabilitation, University of Zimbabwe, College of Health Sciences, P.O Box A178, Avondale, Harare Zimbabwe
| | - M Chiwaridzo
- Department of Rehabilitation, University of Zimbabwe, College of Health Sciences, P.O Box A178, Avondale, Harare Zimbabwe
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Grimes CE, Holmer H, Maraka J, Ayana B, Hansen L, Lavy CBD. Cost-effectiveness of club-foot treatment in low-income and middle-income countries by the Ponseti method. BMJ Glob Health 2016; 1:e000023. [PMID: 28588918 PMCID: PMC5321308 DOI: 10.1136/bmjgh-2015-000023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/03/2016] [Accepted: 02/26/2016] [Indexed: 11/04/2022] Open
Abstract
Background Club foot is a common congenital deformity affecting 150 000–200 000 children every year. Untreated patients end up walking on the side or back of the affected foot, with severe social and economic consequences. Club foot is highly treatable by the Ponseti method, a non-invasive technique that has been described as highly suitable for use in resource-limited settings. To date, there has been no evaluation of its cost-effectiveness ratio, defined as the cost of averting one disability-adjusted life year (DALY), a composite measure of the impact of premature death and disability. In this study, we aimed to calculate the average cost-effectiveness ratio of the Ponseti method for correcting club foot in sub-Saharan Africa. Methods Using data from 12 sub-Saharan African countries provided by the international non-profit organisation CURE Clubfoot, which implements several Ponseti treatment programmes around the world, we estimated the average cost of the point-of-care treatment for club foot in these countries. We divided the cost of treatment with the average number of DALYs that can be averted by the Ponseti treatment, assuming treatment is successful in 90% of patients. Results We found the average cost of the Ponseti treatment to be US$167 per patient. The average number of DALYs averted was 7.42, yielding a cost-effectiveness ratio of US$22.46 per DALY averted. To test the robustness of our calculation different variables were used and these yielded a cost range of US$5.28–29.75. This is less than a tenth of the cost of many other treatment modalities used in resource-poor settings today. Conclusions The Ponseti method for the treatment of club foot is cost-effective and practical in a low-income country setting. These findings could be used to raise the priority for implementing Ponseti treatment in areas where patients are still lacking access to the life-changing intervention.
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Affiliation(s)
- Caris E Grimes
- Kings Centre for Global Health and Kings Health Partners, Kings College London, London, UK
| | - Hampus Holmer
- Department of Clinical Sciences, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Lund, Sweden
| | | | | | | | - Christopher B D Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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