Clubfoot, Management and Barriers to treatment in underdeveloped countries.

Original and Lead Editors - Abdul Basit Top Contributors -

About Clubfoot[edit | edit source]

Clubfoot also known as CTEV (Congenital Talipes Equino Varus) is a congenital physical deformity in which a newborn’s baby foot are internally rotated at the ankle, soles of the feet face each other while the toes are twisted downward and inwards. In 50% of cases, both feet are affected. Male babies are two times more likely to get this deformity. According to National Institute of Health every 1.2 in 1000 babies are born with clubfoot.[1][2] It has been estimated that every year at least 150,000 are born with clubfoot.[3] It may occur alone or in combination with multiple neuromuscular pathologies. Exact cause of clubfoot is still to be found but studies have shown many possible risk factors which may contribute to clubfoot.[4] See...Ponseti method” is considered the Gold standard for the treatment of clubfoot. For information on Clubfoot management, See...

Barriers to Clubfoot Treatment in Underdeveloped Countries[edit | edit source]

Beliefs and Lack of Awareness[edit | edit source]

According to some studies smoking by mother during pregnancy may be one the most possible causes of clubfoot.[5] It is also believed that if one parent is having this deformity, the newborn baby have the risk of getting it. The risk is even higher if both parents are affected.[6] Many researches have been take place and still on going in developed countries but in underdeveloped countries, many false perceptions and beliefs are found. In many underdeveloped countries of the world, clubfoot and such physical deformities are still linked with solar and lunar eclipses.[7] while some people claim it punishment of God to the parents. Many false perceptions and beliefs are still present about clubfoot and generally all physical deformities. Parents don’t have any awareness about this deformity; they don’t know when is the most appropriate time to start treatment.[8]

Lack of Knowledge and Skilled Clinicians[edit | edit source]

In underdeveloped countries many clinicians are unqualified, inexperienced and untrained in Ponseti method. Some clinician who do not know anything about this deformity, advised parents to keep away from any treatment as it will get better as the child grows up. Some calls it a deficiency of vitamins. Some parents seek religious healers. Some seek for surgery. And many think that just exercises and massage can correct it. Many children are left untreated as it is believed that it can’t be treated. In short, there is still too much work to be done about this deformity. We need to know what this deformity is. How and when it can be treated? And if not treated what complications can occur in the future?

The most widely accepted method being used for clubfoot treatment is the “Ponseti Method”, developed by Ignacio Ponseti (1942-2009). It includes Manipulations by an expert physiotherapist, several serial castings and a minor surgical operation in which the Achilles tendon is released. If applied correctly and in time, individuals with clubfoot can recover up to 90% of normal foot alignment with minor differences when compared to normal foot.[9] In developed countries a lot of researches, annual conferences and training sessions are arranged to educate people about this deformity, and to train medical professionals for successful treatment of clubfoot. But in underdeveloped countries there is no such a system. Many medical professionals and clinicians do not know about clubfoot, many don’t have the idea of treating it with a method of most accurate outcome. If there are any hospitals or facilities available to treat clubfoot, they don’t have any qualified or expert medical professionals. As seen in general practice, such children are brought for medical treatment when the deformity has worsened.

Affordability and Availability of Treatment[edit | edit source]

Generally at Government hospitals there is a dearth of medical professionals who can perform Ponseti method. In rare situations that it is available in private clinics, cost of treatment is high. Many parents don’t have enough money to continue the treatment for many sessions as in most cases correction cannot be gained in a single or two sessions. As seen in many cases, even if there is a free Ponsetti treatment available, it does not achieve full correction through serial castings; thus surgical interventions are needed.

Refusal of Surgical Intervention[edit | edit source]

As suggested by some studies, 80% of cases requires a minor surgical operation to release the rigid equinous.[10] But often seen in underdeveloped countries due to lack of awareness, many parents refuse to perform surgery, which causes a hurdle in complete recovery of the equinous deformity. Their refusal are most times due to their inherent beliefs and sometimes as a result of financial constraint.

Preventive braces are not used correctly[edit | edit source]

It has been noted that after serial castings when Abduction foot brace shoes and other corrective braces are applied, many parents don’t know how to fit them properly; Which is also a hurdle in gaining proper correction of the deformity. Some parent due their ignorance do not adherE to the continued use of AFAB for up to four years of age[11]

No proper follow up[edit | edit source]

Many parents never visit the clinics in proper time after correction as proper follow up is a basic part of clubfoot treatment. Many children are brought to clinic so late for follow up, as the deformity has already recurred.

“Ponseti method” as a Gold standard for the treatment of clubfoot can be implemented accurately in underdeveloped countries only if the barriers are removed.

References

  1. Disease condition, Clubfoot. Available from: http://orthoinfo.aaos.org/topic.cfm?topic=A00255 (accessed 22 August 2019)
  2. Wang H, Barisic I, Loane M, Addor MC, Bailey LM, Gatt M, et al. Congenital clubfoot in Europe: A population-based study. Am J Med Genet A. 2019; 179 (4):595-601. 
  3. Global Clubfoot Initiative. Clubfoot. Available from: https://globalclubfoot.com/clubfoot/ (accessed 22 August 2019)
  4. Parker SE, Mai CT, Strickland MJ, Olney RS, Rickard R, Marengo L, et al. Multistate study of the epidemiology of clubfoot. Birth Defects Res A Clin Mol Teratol. 2009; 85(11):897-904
  5. Dickinson KC, Meyer RE, Kotch J. Maternal smoking and the risk for clubfoot in infants. Birth Defects Res A Clin Mol Teratol. 2008;82(2):86-91.
  6. Maranho DAC, Volpon JB. Congenital Clubfoot. 2011;19(3):163-9.
  7. Burfat A, Mohammad S, Siddiqui O, Samad L, Mansor AK, Amin CM. Understanding the knowledge and perception about clubfoot in Karachi, Pakistan.Iowa Orthop J. 2013; 33: 149–152.
  8. Africa Clubfoot Training Project. Chapter 2 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
  9. Segev E, Keret D, Lokiec F, Yavor A, Wientroub S, Ezra E, et al. Early experience with the Ponseti method for the treatment of congenital idiopathic clubfoot. Isr Med Assoc J. 2005;7:307–10. 
  10. Bridgens J, Kiely N. Current management of clubfoot (congenital talipes equinovarus). BMJ. 2010; 340(7741):c355. DOI: 10.1136/bmj.c355.
  11. Göksan SB1, Bilgili F, Eren I, Bursali A, Koç E. Factors affecting adherence with foot abduction orthosis following Ponseti method. Acta Orthop Traumatol Turc. 2015;49(6):620-6. doi: 10.3944/AOTT.2015.14.0348.