I have no disclosures TALIPES EQUINOVARUS PONSETI METHOD CLUBFOOT: NON-ORTHOPAEDIC SURGEON HEALTHCARE PROVIDERS ARE A VALUABLE TOOL IN TREATMENT

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CLUBFOOT: NON-ORTHOPAEDIC SURGEON HEALTHCARE PROVIDERS ARE A VALUABLE TOOL IN TREATMENT I have no disclosures KATIE FREEMAN, MD ELIANA DELGADO, MD AMANDA WHITAKER, MD UNIVERSITY OF CALIFORNIA SAN

Abbott Society Scientific Program May 10 th, 2013 TALIPES EQUINOVARUS a condition causing a child s foot to have a characteristic deformity Midfoot cavus Forefoot adductus and supination Hindfoot

1 CLUBFOOT: NON-ORTHOPAEDIC SURGEON HEALTHCARE PROVIDERS ARE A VALUABLE TOOL IN TREATMENT I have no disclosures KATIE FREEMAN, MD ELIANA DELGADO, MD AMANDA WHITAKER, MD UNIVERSITY OF CALIFORNIA SAN FRANCISCO 58 th Annual LeRoy C. Abbott Society Scientific Program May 10 th, 2013 TALIPES EQUINOVARUS a condition causing a child s foot to have a characteristic deformity Midfoot cavus Forefoot adductus and supination Hindfoot varus Equinus estimated incidence of 1:1,000 births estimated 100,000 children are born with clubfoot worldwide, and of those, 80% are born in developing nations Neglected clubfoot is common in developing countries There is a large need for effective clubfoot treatment in underprivileged areas of the world Neglected Clubfoot in Uganda 18 Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital clubfoot. J Bone Joint Surg Am. 1980;62(1):23-31 PONSETI METHOD gold standard treatment with success rates reported between %. method involving: manipulation serial casting bracing heel cord release can be taught to non-orthopaedic surgeon health professionals to help meet the great demand for clubfoot treatment Dr. Ignacio V. Ponseti 1

brace is worn full time for 2-3 months then at night only for 3-4 years Casting begins

countries have implemented programs to treat clubfoot with the Ponseti method often

this study was to conduct a meta-analysis evaluating the effectiveness of clubfoot

identify barriers which make clubfoot treatment difficult, especially in countries

2 brace is worn full time for 2-3 months then at night only for 3-4 years Casting begins in the first 1-2 weeks of life Casts applied weekly for ~5-7 weeks PONSETI METHOD Many countries have implemented programs to treat clubfoot with the Ponseti method often involve treatment by a wide range of healthcare providers OBJECTIVES The purpose of this study was to conduct a meta-analysis evaluating the effectiveness of clubfoot treatment by nonorthopaedic surgeon healthcare providers secondary objectives: identify barriers which make clubfoot treatment difficult, especially in countries where nationwide treatment programs have been established Identify important traits of a successful program 2

METHODS Studies included in this report: the Ponseti method was followed as previously described treatment was administered by a healthcare professional other than a board certified orthopaedic

3 METHODS Studies included in this report: the Ponseti method was followed as previously described treatment was administered by a healthcare professional other than a board certified orthopaedic surgeon success rates defined as correction of the deformity were reported An additional literature review conducted to identify both barriers in implementing these programs as well as aspects that make a clubfoot treatment program successful Nine studies in five different countries have implemented a program in which non-orthopaedic surgeon healthcare providers treated clubfoot using the Ponseti method. Malawi, Vietnam, Uganda, Canada, United Kingdom Success rates in these studies ranged from %. Country # feet treated # successful Percent successfully treated Malawi Malawi (completed treatment) Vietnam 85 Uganda 80 Canada UK Eight studies in nine countries identified barriers and successful aspects in the use of the Ponseti method in these clubfoot treatment programs Malawi Paupa New Guinea Uganda Guatemala Peru Chile India China United States Barriers: - Lack of adequate supplies - Poverty - length of travel - Compliance with full treatment course - Lack of sufficient training in some providers - Unique cultural issues (ex. China s one-child policy) - Lack of public awareness about the importance of early intervention - Lack of support from family members, specifically paternal support 3

Successful Aspects: - Well trained healthcare professionals - Adequate resources and financial support from governments, agencies, or charities - Adequate counseling and moral support from providers

Under the supervision, guidance, and training of orthopaedic surgeons, teaching healthcare providers the Ponseti method is an effective way to treat the thousands of children around the world without

Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital clubfoot. J Bone Joint Surg Am. 1980;62(1):23-31 2. Ponseti IV. Treatment of congenital clubfoot. J Bone Joint Surg Am. 1992;74(3):448-454 3.

4 Successful Aspects: - Well trained healthcare professionals - Adequate resources and financial support from governments, agencies, or charities - Adequate counseling and moral support from providers - Family education about the importance of following through with the entire treatment including bracing - Access to information about clubfoot including pamphlets and internet resources CONCLUSIONS Under the supervision, guidance, and training of orthopaedic surgeons, teaching healthcare providers the Ponseti method is an effective way to treat the thousands of children around the world without access to orthopaedic care. There is a need to train more non-orthopaedic physicians and non-physicians the correct application of the Ponseti method in order to treat clubfoot. 1. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital clubfoot. J Bone Joint Surg Am. 1980;62(1): Ponseti IV. Treatment of congenital clubfoot. J Bone Joint Surg Am. 1992;74(3): Ponseti IV. Clubfoot management. J Pediatr Orthop. 2000;20(6): Ponseti IV. Congenital club foot: fundamentals of treatment. 1st ed. New York:Oxford University Press; Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-upnote. J Bone Joint Surg Am. 1995;77: Abdelgawad AA, Lehman WB, van Bosse HJ, Scher DM, Sala DA. Treatment ofidiopathic clubfoot using the Ponseti method: minimum 2-year follow- up. J PediatrOrthop B. 2007;16: Colburn M, Williams M. Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method. J Foot Ankle Surg. 2003;42: Lehman WB, Mohaideen A, Madan S, Scher DM, Van Bosse HJ, Iannacone M,Bazzi JS, Feldman DS. A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot. J Pediatr Orthop B. 2003;12: Ponseti IV, Smoley EN. Congenital clubfoot: the results of treatment. J Bone Joint Surg [Am]. 1963;45:

5 10. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV (2004) Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 113(2); Jowett C R, Morceunde J A, Ramachandran M, et al. Management of congenital talipes equinovarus using the Ponseti method. J Bone Joint Surg Br. 2011;93: Scher, D M. The Ponseti method for treatment of congenital clubfoot. Curr Opin Pediatr. 2006;18: Van Bosse H J P. Ponseti treatment for clubfeet: an international prespective. Curr Opin Pediatr. 2011;23: Lavy, C B D, Mannion J, Mkandawire N C, et al. Club foot treatment in Malawi- a public health approach. Disability and Rehabilitation. 2007;29(11-12): Tindall, A J, Steinlechner C W, Lavy C B D, et al. Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti method. A realistic alternative for the developing world? J Pediatr Orthop. 2005;25(5): Gupta A, Singh S, Patel P, et al. Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nation. International Orthopaedics. 2008;32: Pirani S, Naddumba E, Mathias R, et al. Towards effective Ponseti clubfoot care. The Uganda sustainable clubfoot care project. Clin Orthop Relat Res. 2009;467: McElroy T, Konde-Lule J, Neema S, et al. Understanding the barriers to clubfoot treatment adherence in Uganda: A rapid ethnographic study. Disability and Rehabilitation. 2007;29(11-12): Kampa R, Binks K, Dunkley M, et al. Multidisciplinary management of clubfeet using the Ponseti method in a district general hospital setting. J ChildOrthop. 2008;2: Evans A M, Van Thanh D. A review of the Ponseti method and development of an infant clubfoot program in Vietnam. J Am Podiatr Med Assoc. 2009;99: Janicki, J A, Narayanan U G, Harvey B J, et al. Comparison of surgeon and physiotherapistdirected Ponseti treatment of idiopathic clubfoot. J Bone Joint Surg Am. 2009;9(1): Shack N, Eastwood D M. Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congetital talipes equinovarsu foot deformity. J Bone Joint Surg [Br]. 2006;88-B: Docker C, Lewthwaite S, Kiely N. Ponseti treatment in the management of clubfoot deformity-a continuing role for paediatric orthopaedic services in secondary care centres. Ann R Coll Surg Engl. 2007;89: Lu N, Zhao L, Du Q, et al. From cutting to casting: impact and initial barriers to the Ponseti method of clubfoot treatment in China. Iowa Orthop J. 2010;30: Culverwell, A D and Tapping C R. Congenital talipes equinovarus in Papua New Guinea: a difficult yet potentially manageable situation. International Orthopaedics. 2009;33: Avilucea F R, Szalay E A, Bosch P P, et al. Effect of cultural factors on outcome of Ponseti treatment of clubfeet in rural America. J Bone Joint Surg Am. 2009;9(1): Jayawardena A, Boardman A, Cook T, et al. Diffusion of innovation: enhancing the dissemination of the Ponseti method in Latin America through virtual forums. Iowa Orthop J.2011;31:

Modified Ponseti method of management of neonatal club feet

Acta Orthop. Belg., 2012, 78, 210-215 ORIGINAL STUDY Modified Ponseti method of management of neonatal club feet Malhar N. KuMAR, Chethan GOpAlAKRISHNA From HOSMAT Hospital, Bangalore, India The aim of