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Ponseti
Management of
Clubfoot in
Chittagong
Disvision:
Experience of 1000
feet
Dr. Myen Uddin Majumdar
Dr. Jabed Akhter T...
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 ...
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 f...
CLUBFOOT SIGNS (Continued)
Forefoot Cavus
- Increase in the height of
the medial arch of the foot
- the forefoot in relati...
CLUBFOOT SIGNS (Continued)
Talus Plantar Flexed beneath Tibia
Adducted & supinated Navicular
Wedge Shaped head of talus, L...
CLUBFOOT SIGNS (Continued)
 Heel in Varus
 Supination and Adduction of the Calcaneus.
 Calcaneus is locked under the Ta...
Clubfoot: Chittagong Division
CBR: 22.98 births/1,000 population (2011 est.), Infant mortality rate: 50.73 deaths/1,000 li...
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...
Basic Ponseti treatment Protocol
 Manipulation & Casts
for 5-6 weeks
 Achilles tenotomy (if
needed)
 Foot abduction bra...
Aim of Study
 The aim of this study is to evaluate the
effectiveness of the Ponseti method in children
presenting before ...
MATERIALS AND METHOD
July 17, 201416
 Type of study : Retrospective clinical study.
 Duration of study : From February 2...
 Chittagong
 Cox's Bazar
 Khagrachhori
 Comilla
 Noakhali
 Chandpur
 Brahmanbaria
 Feni
 Lakshmipur
 Rangamati
...
MATERIALS AND METHOD (continued..)
 Age group : Within age of 5 years.
 Sex group : Both male and female
 Method : The ...
FINAL OUTCOME MEASUREMENT
Pirani scoring
 6 criteria
Mid foot scores
A. Lateral border
B. Medial crease
C. Talar head cov...
Demographic
Variables
Variables
No. of Patients 664
No. of Feet 1091
Bilateral
Involvement
(no. of patients)
364 (54.8%)
A...
Clinical data
Variables
Type of
Clubfoot
Typical -
Flexible
Typical - Rigid Atypical
No of feet 538 (49%) 389 (36%) 164 (1...
Reason for Referral to Surgery
 Neglected clubfoot
 no treatment untill 3 years).
 Resistant clubfoot
 Midfoot score >...
Effect of Treatment in Different
age groups
Total Full
Correction
(Final Pirani
Score <1)
By Ponseti By Surgery
Feet 772 5...
Casting
July 17, 201424
ImanHabib
Brace Follow up
No. of
patients on
FAB
On Regular
follow up
Irregular in
Follow up
Relapse
361 227 108 26
July 17, 201428
...
Take home Massage
July 17, 201429
 Treatment of congenital club foot by ponseti technique
is very effective method with e...
Two years journey…
Year Patients Feet
2010 230 349
2011 477 742
How do we
find patients?
Clinical Treatment Goals
 By May 2012 - reach 1500 feet mark.
 By July 2012- get 80 babies each month.
(break even point...
How you can help?
 Spread one message:
Clubfoot is completely curable, early Ponseti treatment is the
key.
 Help build u...
Ponseti Management of Clubfoot in Chittagong Division: Experience of 1000 Clubfeet
Ponseti Management of Clubfoot in Chittagong Division: Experience of 1000 Clubfeet
Ponseti Management of Clubfoot in Chittagong Division: Experience of 1000 Clubfeet
Ponseti Management of Clubfoot in Chittagong Division: Experience of 1000 Clubfeet
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Ponseti Management of Clubfoot in Chittagong Division: Experience of 1000 Clubfeet

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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
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.
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.

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Ponseti Management of Clubfoot in Chittagong Division: Experience of 1000 Clubfeet

  1. 1. Ponseti Management of Clubfoot in Chittagong Disvision: Experience of 1000 feet Dr. Myen Uddin Majumdar Dr. Jabed Akhter Tuhin Dr. Rajib Hasan Dr. Moshiur Rahman Dr. Mamun Mustafa Dr. O M Faisal Hossain M Baker (Physio) Mintu Chakma Speaker: Dr. Shamim Khan HMO Unit 1, Dept of Orthopedic Surgery CMCH 1
  2. 2. It is the most common congenital deformity of ankle and foot.
  3. 3. 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.
  4. 4. The treatment should start soon after birth
  5. 5. Early treated Neglected
  6. 6. 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
  7. 7. 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.
  8. 8. 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 Midfoot Adduction
  9. 9. 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.
  10. 10. 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
  11. 11. Our Fight against Clubfoot Started on July 2009 Started on Feb 2010
  12. 12.  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.
  13. 13. 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
  14. 14. 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 July 17, 201415
  15. 15. MATERIALS AND METHOD July 17, 201416  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.
  16. 16.  Chittagong  Cox's Bazar  Khagrachhori  Comilla  Noakhali  Chandpur  Brahmanbaria  Feni  Lakshmipur  Rangamati  Bandarban
  17. 17. 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. July 17, 201418
  18. 18. FINAL OUTCOME MEASUREMENT Pirani scoring  6 criteria Mid foot scores A. Lateral border B. Medial crease C. Talar head coverage Hind foot scores D. Posterior crease E. Rigid equinus F. Empty heel Score ranges: 0 - 0.5 - 1.0
  19. 19. 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 July 17, 201420 54.80%46.20% Foot involved Bilateral Unilateral 70% 30% Sex ratio Male Female
  20. 20. Clinical data Variables 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 July 17, 201421 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%)
  21. 21. 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. July 17, 201422
  22. 22. 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% July 17, 201423
  23. 23. Casting July 17, 201424
  24. 24. ImanHabib
  25. 25. Brace Follow up No. of patients on FAB On Regular follow up Irregular in Follow up Relapse 361 227 108 26 July 17, 201428 63% 30% 7% Follow up Regular Irregular Relapse
  26. 26. Take home Massage July 17, 201429  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.
  27. 27. Two years journey… Year Patients Feet 2010 230 349 2011 477 742
  28. 28. How do we find patients?
  29. 29. Clinical Treatment Goals  By 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
  30. 30. 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.

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