When to Rethink Clubfoot Treatment

Original Editor - Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project

Top Contributors - Naomi O'Reilly  

Introduction

Sometimes things do not go well in treating clubfeet. The foot may fail to correct, or require a large number of casts to make a small change. The deformity may get worse, or a serious complication like a pressure sore may occur. The parents may stop bringing the child for treatment and any correction in the deformity may recur, thus taking away any of the benefit of treatment. It is important to recognize problems as early as possible so that changes can be made to prevent things getting worse. Here we will look at the common warning signs that should make you talk with a senior person in the clinic or your mentor about a case. If you understand how an error is made then you are less likely to make it. Signs that should make you discuss a case with a senior colleague:[1]

Appearance

The foot does not look like a normal clubfoot, or the child has other obvious problems. This may be a secondary or syndromic clubfoot. Often they can be treated with the Ponseti Method but the degree of correction is reduced.

Slow Progress

The Pirani Score does not always change at each plaster change, but if 2 plaster changes in a row occur without any progress then the case should be reviewed. There may be a problem with the foot or there may be a problem with the manipulation or casting technique.

Skin Problems

These are usually due to problems with the cast, and can be painful. They need review by a senior person and sometimes can be helped by extra padding, or by a period resting out of cast to heal the sore area.

Cast Slipping

This may be due to using too much padding, making the cast loose, or not going sufficiently high enough in the thigh area, or having the knee too straight. If the toes slip into the cast then the POP is no longer doing its job and may be making the clubfoot worse. The plaster needs to be removed and reapplied properly.
Remember: Toe to Groin Casts
Remember: TWO People to Cast

Insufficient Dorsiflexion after Tenotomy

This is usually due to the tenotomy being done too early before the foot is ready, or because the tendon was not fully cut.
Remember: Cover Talus before Tenotomy

Patients Dropping out of Treatment

Patients dropping out of treatment is a warning sign because we know that not completing the full course of treatment including the FAB is the main cause of recurrence. This is why it is important to keep track of who is expected to attend each week - so you know when visits are missed.

“Dropout” has not really been defined but depends on the phase of treatment - for instance if a child who is in cast doesn’t attend for more than 2 weeks this could be considered a dropout, or if a patient who is on 6-monthly FAB checks doesn’t attend for 9 months this could be considered dropout.[1]

These patients may well attend later with a recurrence of deformity.

  • Dropout can occur due to poor communication, unreliable supply of braces, distance, financial difficulties, or loss of belief in the treatment or staff
  • Causes of dropout will depend on many factors that are specific to your area, so if you notice that many patients are dropping out it is worth investigating as to why!
  • Much of ensuring families comply with the full course of treatment has to do with how well we as clinicians communicate the importance of each stage, especially the FAB as that is when most drop out
  • Poorly organized clinics, long waiting times for treatment, families being charged for treatment can all be causes
  • There could be seasonal factors such as harvest time – in this case, consider delaying the start of treatment until afterwards
  • Families may be unable to attend for financial reasons (cost of transport) or because they don’t have support from their husbands, or childcare for their other children
  • Always talk about the full course of treatment, from day 1, with special emphasis on the FAB and reinforce this at each visit. Written information may help
  • Try to make the treatment, especially the bracing phase, a partnership between the clinician and the parents. In Uganda it was found that some fathers were failing to give support to mothers to attend the clinics, contributing to dropout – giving written information or encouraging fathers to attend for 1 visit with their child may help with this
  • Parent advisors have been very helpful in reducing dropout rates in some clinics – they can help educate families, work through individual problems, give education and advice, and help ensure that the clinics run smoothly and that patients know when to attend for their next appointments.
Remember: Talk to Parents from the Start, especially about Braces!
Remember: Keep Talking to Parents

References

  1. 1.0 1.1 Africa Clubfoot Training Project. Chapter 9 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.