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Ponseti Management of Clubfoot in Chittagong Disvision: Experience of 1000 feet

Dr. Myen Uddin MajumdarDr. Jabed Akhter TuhinDr. Rajib HasanDr. Moshiur RahmanDr. Mamun MustafaDr. O M FaisalHossain M Baker (Physio)Mintu Chakma

Speaker:

Dr. Shamim KhanHMO Unit 1, Dept of Orthopedic SurgeryCMCH

Clubfoot / CTEV

It is the most common congenital deformity of ankle and foot.

Some Facts about Congenital Clubfoot…

Clubfoot is one of the most common congenital deformities.

About 1 - 2 in every 1000 children is born with clubfoot worldwide.

A normal developing foot turns into a Clubfoot around the 3rd month of foetal life.

The cause is not exactly known, but is believed that genetic & environmental factors are involved.

More in boys than in girls.

One or both feet may be involved.

New born baby with Clubfoot

The treatment should start soon after birth

Early treated

Neglected

CLUBFOOT SIGNS

Forefoot Cavus

Mid foot Adductus

Heel Varus

Hind foot Equinus 1st Metatarsal is more in Plantar flexion than the

rest of the Metatarsals Clubfoot is smaller than a normal foot. Calf is smaller

CAVE sign

CLUBFOOT SIGNS (Continued)

Forefoot Cavus

- Increase in the height of the medial arch of the foot

- the forefoot in relation to the mid foot is in Pronation.

CLUBFOOT SIGNS (Continued)

Talus Plantar Flexed beneath Tibia

Adducted & supinated Navicular

Wedge Shaped head of talus, Lateral part of Talar head is uncovered

Wedge shaped Navicular

Adducted and varus calcaneus

Medially displaced & adducted Cuboid

MidfootAdduction

CLUBFOOT SIGNS (Continued) Heel in Varus

Supination and Adduction of the Calcaneus. Calcaneus is locked under the Talus

Hind foot Equinus Severe Plantar flexion in the ankle joint. High Calcaneus (not in the heel pad). Talus in severe Flexion.

Clubfoot : Bangladesh Picture Every year, at least

5000 children are born with a clubfoot deformity in Bangladesh.

Around 1000 children born with clubfoot in CHITTAGONG division each year.

…..That is 2 - 3 babies every day!!!

Clubfoot: Chittagong Division

CBR: 22.98 births/1,000 population (2011 est.), Infant mortality rate: 50.73 deaths/1,000 live births, Clubfoot incidence: 1.5/1000 live birth 

Our Fight against Clubfoot

Started on July 2009

Started on Feb 2010

Treat under 5 years old

children with clubfoot

using the Ponseti

technique absolutely

free of cost.

Build the capacity to

detect clubfoot by

increasing awareness.

What we do?

Basic Ponseti treatment Protocol

Manipulation & Casts for 5-6 weeks

Achilles tenotomy (if needed)

Foot abduction brace/ FAB 3 months continuously Reducing use with age Night use to age 5-6

years Monitor child

6 – 12 months To age 15 years

April 11, 202315

Aim of Study

The aim of this study is to evaluate the

effectiveness of the Ponseti method in

children presenting before 5 years of age

with either untreated or complex (initially

treated unsuccessfully by other

conservative methods) idiopathic

clubfeet

April 11, 202316

MATERIALS AND METHOD

Type of study : Retrospective clinical study.

Duration of study : From February 2010 to November

2011 (21months)

Place of study : 6 ZCF clinics of Chittagong, Cox’s bazar,

Khagrachhari, Comilla, Noakhali & Chandpur.

Study population : Patients with CTEV attended at these

ZCF clinics.

Chittagong Cox's Bazar  Khagrachhori Comilla Noakhali Chandpur Brahmanbaria Feni Lakshmipur Rangamati Bandarban

Ponseti Clinics

April 11, 202318

MATERIALS AND METHOD (continued..)

Age group : Within age of 5 years.

Sex group : Both male and female

Method : The Ponseti technique.

Sample size : 1091 feet of 664

patient.

Exclusion criteria: Clubfeet patients above 5 years of age

Syndromic clubfoot.

FINAL OUTCOME MEASUREMENT

Pirani scoring 6 criteriaMid foot scores

A. Lateral borderB. Medial creaseC. Talar head coverage

Hind foot scoresD. Posterior creaseE. Rigid equinusF. Empty heel

Score ranges: 0 - 0.5 - 1.0

April 11, 202320

Demographic Variables

Variables

No. of Patients 664

No. of Feet 1091

Bilateral Involvement(no. of patients)

364 (54.8%)

Age range 6 days to 5 years

Male 463 (70%)Female 201 (30%)

Initial mean Pirani score per foot 5.2

54.80%46.20%

Foot involvedBilateral Unilateral

70%

30%

Sex ratioMale Female

April 11, 202321

Clinical dataVariables

Type of Clubfoot

Typical - Flexible

Typical - Rigid

Atypical

No of feet 538 (49%) 389 (36%) 164 (15%)

Any Previous treatment?

NO Yes - conservative

Yes - Surgery

No. of feet 609 443 39

Patients Feet

Missed out 194 319 (29%)

Full correction by Ponseti

361 593 (54%)

Tenotomy done 271 445 (75%)

Referred for Surgery

109 179 (17%)

April 11, 202322

Reason for Referral to Surgery Neglected clubfoot

no treatment untill 3 years). Resistant clubfoot

Midfoot score >1, and Hindfoot score >2 after 5 casts application

Atypical clubfoot Repeated cast slip out. Appears complication.

April 11, 202323

Effect of Treatment in Different age groups

Total Full Correction (Final Pirani Score <1)

By Ponseti By Surgery

Feet 772 593 77% 179 23%

Patients 470 361 77% 109 23%

Age range

0 - 6 m 213 206 97% 7 3.3%

6m - 1y 69 64 93% 5 7.2%

1 - 3y 121 85 70% 36 30%

3 - 5y 67 6 9% 61 91%

April 11, 202324

Casting

Im

an

Ha

bib

Follow up …

Brace..

April 11, 202328

Brace Follow upNo. of patients on FAB

On Regular follow up

Irregular in Follow up

Relapse

361 227 108 26

63%

30%

7%

Follow up

Regular Irregular Relapse

April 11, 202329

Take home Massage Treatment of congenital club foot by ponseti

technique is very effective method with

excellent result for below 1 years children.

Brace follow up is essential for long term better

outcome.

With proper monitoring and support, Ponseti

service can be effectively and successfully

administered in a district general hospitals.

Two years journey…Year Patients Feet

2010 230 349

2011 477 742

How do we find patients?

Clinical Treatment GoalsBy May 2012 - reach 1500 feet mark. By July 2012- get 80 babies each

month. (break even point).By December 2012 – get regularly

all <1 month babies born in Chittagong Division.

Build consensus that the Ponseti method is an effective treatment for Congenital Clubfoot

How you can help? Spread one message:

Clubfoot is completely curable, early Ponseti treatment

is the key.

Help build up awareness among all Govt. health care

providers.

Refer clubfoot patients to ZCF Ponseti clinics working in

your District.