From cutting to casting: impact and initial barriers to the Ponseti method of clubfoot treatment in China.
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In 2005, a nationwide clubfoot treatment program focused on the Ponseti method -an effective, affordable and minimally-invasive method- was initiated in China. The purpose of this study was to evaluate and identify barriers to the program. A qualitative study (rapid ethnographic study) was conducted using semi-structured interviews of 44 physicians who attended four of the 10 Ponseti training workshops, focus groups with parents of children with clubfoot, and observation. Several barriers to the Ponseti method are quite unique due to China's size, socio-economics, culture, politics, and healthcare systems. The barriers were classified into seven themes: (i) physician education, (ii) caregiver compliance, (iii) culture, (iv) public awareness, (v) poverty, (vi) financial constraints for physicians/hospitals, and (vii) challenges of the treatment process. A number of suggestions that could be helpful in reducing or eliminating the effects of these barriers were also identified: (i) pamphlets explaining clubfoot and treatment for caregivers, (ii) directories of Ponseti providers, (iii) funding/financial support, and (iv) improving public awareness. The information from this study provides healthcare planners with knowledge to assist in meeting the needs of the population and continued implementation of effective and culturally appropriate awareness and treatment programs for clubfoot throughout China. (+info)
Ponseti clubfoot management: changing surgical trends in Nigeria.
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BACKGROUND: Congenital clubfoot treatment continues to be controversial particularly in a resource-constrained country. Comparative evaluation of clubfoot surgery with Ponseti methods has not been reported in West Africa. OBJECTIVES: To determine the effects of Ponseti techniques on clubfoot surgery frequency and patterns in Nigeria. METHODS: This was a prospective hospital-based intention-to-treat comparative study of clubfoot managed with Ponseti methods (PCG) and extensive soft tissue surgery (NPCG). The first step was a nonselective double-blind randomization of clubfoot patients into two groups using Excel software in a university teaching hospital setting. The control group was the NPCG patients. The patients' parents gave informed consent, and the medical research and ethics board approved the study protocol. Biodata was gathered, clubfoot patterns were analyzed, Dimeglio-Bensahel scoring was done, the number of casts applied was tallied, and patterns of surgeries were documented. The cost of care, recurrence and outcomes were evaluated. Kruskal-Wallis analysis and Mann-Whitney U technique were used, and an alpha error of < 0.05 at a CI of 95% were taken to be significant. RESULTS: We randomized 153 clubfeet (in 105 clubfoot patients) into two treatment groups. Fifty NPCG patients (36.2%) underwent manipulation and extensive soft tissue surgery and 55 PCG patients (39.9%) were treated with Ponseti methods. Fifty-two patients of the Ponseti group had no form of surgery (94.5% vs. 32%, p<0.000). Extensive soft tissue surgery was indicated in 17 (34.0%) of the NPCG group, representing 8.9% of the total of 191 major orthopaedic surgeries within the study period. Thirty-five patients (70.0%) from the NPCG group required more than six casts compared to thirteen patients (23.6%) of the PCG (p<0.000). The mean care cost was high within the NPCG when compared to the Ponseti group (48% vs. 14.5%, p<0.000). The Ponseti-treated group had fewer treatment complications (p<0.003), a lower recurrence rate (p<0.000) and satisfactory early outcome (p<0.000). CONCLUSION: Major clubfoot surgery was not commonly indicated among patients treated with the Ponseti method. The Ponseti clubfoot technique has reduced total care costs, cast utilization, clubfoot surgery frequency and has also changed the patterns of surgery performed for clubfoot in Nigeria. (+info)
Peroneal nerve dysfunction in patients with complex clubfeet.
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Complex clubfeet represent a subset of clubfeet with unique features. Their correction requires a modification of the Ponseti casting technique and good short term results have been reported. However, these clubfeet are very difficult to treat and there is a higher chance for potential complications. We reviewed the database of patients with clubfeet treated from January 2001 to December 2009. There were 837 patients (1376 feet) with 111 (182 feet) (13%) having complex deformity. Of these, 8 patients (10 complex clubfeet) (0.7%) experienced a peroneal nerve dysfunction. Severity of the dysfunction varied from no active dorsiflexion (2 patients) to weakness for active dorsiflexion or foot eversion (6 patients). Deformity correction required an average of 5 casts (range, 1 to 8). Two patients required an Achilles tenotomy and the average ankle dorsiflexion at last follow up was 14 degrees (range: 5 to 25). No surgical releases have been required. Two patients required an ankle foot orthosis to improve gait. There were three relapses (37%) that responded to casting and 1 patient required a tibialis anterior tendon transfer. Only 3 feet have recovered the nerve dysfunction. In conclusion, repeated neurological evaluations and very careful cast placement should be performed during the treatment of complex clubfeet. The modified Ponseti technique, if applied properly, is successful in correcting these feet and avoids extensive surgical releases. (+info)