Abstract
In the developing world, neglected clubfoot often results in a permanent and disabling deformity with subsequent social implications. Data from the four organizations that manage clubfoot in Zambia were collected using clinic and operating room registries and analyzed using Fisher exact test. In the central hospitals in the capital city 65% (204/313 feet) of clubfeet were suitable for treatment by the Ponseti method compared with only 23% (38/166 feet) in the peripheral hospitals (P < 0.001, two-tailed Fisher's exact test). In the central hospitals only 14% (42/313 feet) of clubfeet required extensive surgery for neglected clubfeet compared with 29% (49/116 feet) in peripheral hospitals (P < 0.015, two-tailed Fisher's exact test). Patients from outside the capital have a higher percentage of neglected clubfeet that are no longer suitable for conservative management and require extensive, complex and costly surgical treatment. By allowing earlier access to less invasive procedures the burden of disability may be reduced.
Clubfoot, or congenital talipes equinovarus, is a complex congenital deformity which, if left untreated, may result in a permanent, painful disability with corresponding educational, social and medical implications. Identification and treatment of clubfoot with the Ponseti method early in life can correct the deformity and produce a functional foot and ankle. Neglected clubfoot requires complex surgical treatment which is associated with a worse functional outcome. The Ponseti treatment involves repeated passive stretching of the tight contracted soft tissues by careful specific manipulation and casting and it is a low-cost method that has had considerable success in the developing world. 1,2 The purpose of this study was to survey the current treatment of clubfoot in Zambia, which is representative of many resource-poor developing countries.
Four organizations manage patients with clubfoot in Zambia and three of these are in the capital city: The University Teaching Hospital (UTH); the Zambian Italian Orthopaedic Hospital (ZIOH); and the Beit CURE Hospital (BCH). The fourth organization, FlySpec, is an initiative that provides an outreach service to government and mission hospitals outside the capital. Data was collected from clinic and operating room registries from all four organizations.
In Zambia an average of 479 clubfeet were treated per annum. Of these, 313 (65%) were treated in the capital (UTH, ZIOH and BCH) and 166 (35%) in peripheral hospitals (FlySpec). There are statistically significant differences between patients presenting in the capital and peripheral hospitals and this is reflected in the type of treatment they were suitable to receive for their clubfeet (Table 1). In the central hospitals more of the clubfeet (65%, 204/313 feet) were suitable for treatment by the Ponseti method (with or without percutaneous tenotomies) compared to the peripheral hospitals where the percentage fell to 23% (38/166 feet; P < 0.001, two-tailed Fisher's exact test). Twenty-one percent (67/313 feet) of the clubfeet that presented from patients in the central hospitals were suitable for soft-tissue release surgery but no longer suitable for the Ponseti treatment. This was considerably higher in the peripheral hospitals where 48% (79/166 feet) were suitable for soft-tissue release surgery (P < 0.001, two-tailed Fisher's exact test). The same was true for the neglected clubfeet for which the only option was bone removing surgery. In the central hospitals only 14% (42/313 feet) required this surgery but in the peripheral hospitals 29% (49/116 feet) required this extensive surgery (P < 0.015, two-tailed Fisher's exact test).
The results of the survey and statistical analysis
The data demonstrated that patients outside the capital city have a higher percentage of clubfeet presenting late that are no longer suitable for Ponseti treatment. Such patients have to undergo complex and costly surgical treatment, both soft-tissue releases and bone procedures in order to correct the clubfoot deformity. One likely reason could be that rural patients are not able to access treatment within the time period normally required for successful Ponseti treatment (in practice this is during the first year in Zambia). This may be due to lack of awareness about the treatment available for clubfeet or a lack of locally available treatment programmes.
Considerable effort has been made in some countries such as Malawi 3 and Kenya 4 to develop rural clubfoot clinics that are accessible to the majority of the population. These clinics are run by a non-medically qualified technician who has been trained in the Ponseti technique. These clinics have logistical support from a national co-ordinator and there is often specific donor funding to allow these clinics to run. Whilst these clinics have been successful in treating hundreds of children with clubfeet, there are difficulties: reliable sources of plaster and undercast padding; appropriately trained personnel; adequate supplies of post-cast splintage; and non-compliant patients (treatment may be disturbed by the planting or harvest season). The challenge, therefore, is to instigate a system of clubfoot management in Zambia and similar sub-Saharan countries that will allow patients outside the capital city early access to treatment that will be less complex and less expensive with better functional outcomes. Such a management system must be robust and sustainable in order to reduce the burden of disability created by the clubfoot deformity.
Footnotes
Acknowledgements
The authors would like to thank the participating hospitals and organizations that made this survey possible: in particular Professor John Jellis of Flyspec for allowing the survey of his data and allowing the authors to fly with him to rural areas in order to see clubfeet treated. Thanks are also to Dr Yacob Mulla of the Zambian Italian Orthopaedic Hospital, Dr James Munthali of the University Teaching Hospital and Dr Malcolm Swann of the Beit Cure Hospital.