Outcome of Clubfoot Correction at ‘ Walk for Life ’ Clinic of Mymensingh Medical College Hospital : A Four Year Review

Background: Every year in Bangladesh an estimated 3500 4000 children are born with a clubfoot deformity, which is approximately one of every 1000 children born in Bangladesh. Left untreated, the condition leads to lifelong deformity causing individual disability and potential unproductivity. Affected children grow up as burden to the family and ultimately leads to significant poverty. Methods: This study was conducted at the ‘Walk for Life’ (WFL) clinic Mymensingh Medical College Hospital (MMCH) during February 2011 to December 2014.The non-surgical Ponseti method was applied by the orthopaedic surgeon and physiotherapist. Follow-up for relapsed deformity in children who were treated in 2011 occurred in 2015. Results: A total of 577 children comprised of 175 (30.32%) female and 402 (69.7%) male, a gender ratio F: 2.29 M. Completions of treatment data were available for 471 children, as 106 had dropped out at different stages of the treatment cycle. Sadly, 12 children had died. In 440 (76.4%) children, the parents’ monthly income approximated Tk. 5000, and 364 (82.8%) lived in tin shed houses. The parents with lowest incomes predominated for children with clubfoot. Most parents 383(66.4%) were labourers, small business and service workerswith the lowest income. A family history of clubfoot deformity was found in 8.3%, of which 2.8% were cousins, 1.7% were an uncle.The average number of corrective plaster casts applied before the tenotomy was 3.32% in 477 children. In 73.0% of childrenthree to six casts were used for initial correction. An Achilles tenotomy was performed in 81.0% children, 18% did undergo a tenotomy and one child had multiple tenotomies.Four years following of initial treatment, 99 children were reviewed, and 98 were walking and running. Parents’ satisfaction was 96.0%. Thirteen percent children showed relapse signs. Most of the children treated at the WFL clubfoot clinic were walking normally four years after initial treatment. Conclusion: The Ponseti method is found to be very effective and especially for a developing country like Bangladesh. Poverty and housing condition may play a role in clubfoot disease. The dropout rate across the treatment cycle was 18.4%, warranting closer evaluation. The patronage of the Glencoe Foundation WFL clinics since 2009, played an important role in relieving thousands of Bangladeshi children from disability.


Introduction
Clubfoot is a complex, congenital foot deformity of the foot also known as 'congenital talipesequinovarus' (CTEV).Visually, the foot affected by clubfoot appears to be twisted inwards and downwards.The foot is shorter than a normal one and the calf muscles of the affected limb will be smaller. 1Every year in Bangladesh an estimated 3500 -4000 children are born with a clubfoot deformity, with a global incidence of 1.5 per 1000 live births. 2 Untreated, clubfoot leads to lifelongdeformity causing individual disability and unproductivity.This causes the children to grow up as burdens of the family and ultimately leads to significant poverty.
During 2009 to 2017, over 19,500 children with clubfoot were enrolled at WFL clinics across Bangladesh. 3 WFL is a charitable project of the Glencoe Foundation, with clinics appended to the Government of Bangladesh initiatives, and acknowledged by the Government as the National Clubfoot Programme in Bangladesh.The preferred treatment of congenital idiopathic talipes equinovarus (clubfoot) is the nonsurgical Ponseti method, which has revived interest in infantile clubfeet. 4,5Ponseti method of manipulation and plaster casting is very effective in correcting clubfoot deformity.It is especially important in developing countries and well-trained staff can manage the cases effectively by manipulation and cast application. 6wever, surgical treatment in the form of posteromedial release, is often undertaken after failure of conservative measures, but this should be avoided and the 'joint-sparing' Ponseti method repeated when required.8] Nonetheless, the true cause of CTEV remains unknown. 9 reported previously, treatment is generally unaffordable for the families. 10Since the inception of 'Walk for Life' at Mymensingh Medical College Hospital (MMCH) in 2011, 634 children were treated with Ponseti method, to end 2014.Ponseti method has become the 'gold standard' of care for the treatment of CTEVand has been well circulated all over the world, especially the developing world where most clubfoot children live. 11Previous reports have indicated the challenges and successes of implementing the Ponseti technique in this poor and populous country.There are records of conservative treatment dating back to 400 BC performed by Hippocrates by means of manipulations followed by immobilization. 12 the 2l st century, surgical correction of clubfeet has been firmly denounced. 13Retrospective review and prospective studies have both shown the poor outcomes, in terms of pain and function from the Posterior Medial Release (PMR) surgical procedures. 14The non-surgical Ponseti method has been extensively investigated and found to give the best clinical outcomes, and also to be a more cost effective, when compared to surgery. 15,16 t is imperative to note the mid-term results of this large-scale project, indicating its extraordinary effectiveness, with 99% of treated children now walking independently two years after treatment. 17his study was undertaken for some baseline characteristics and to evaluate the success of Ponseti method in Bangladesh, and to explore characteristics of the affected population.

Materials and Methods
This study was conducted as a retrospective and cross-sectional reviewof the WFL clinicat MMCH between 2011 and 2015.Ethical approval was taken from Ethical Review Committee of Mymensingh Medical College.MMCH is a tertiary referral teaching hospital in greater Mymensingh area in the north east to the capital of Bangladesh, covering almost 25 million people.All children treated at WFL at MMCH during February 2011 to December 2014 were included.All children were aged from birth to three years.
Relevant demographic and clinical information were documented for this study.Family history, housing condition, clubfoot severity score (Pirani method), need for tenotomy, number of casts to get correction and complications were recorded.
Children with clubfoot and an associated syndrome, and those who had had previous surgery for clubfoot, were excluded from this study.The standard Ponseti method was applied, with follow up by the Orthopaedic surgeon and Physiotherapist.
Follow up for relapses for those children treated in 2011 occurred when the parents brought their children to the clinic periodically.Ultimately, all children who had commenced treatment in 2011 were contacted for review in 2015.
For the follow-up reviews, WFL made phone calls to all the children's parents over mobile (cell) phone, requesting them to bring their child to the clinic.WFL covered the transport costs.At the review appointments, information was collected by face to face interview with parents and someolder children could also answer questions.
Children's physical ability to squat, walk, run, and use stairs were assessed by asking their parents and seeing the children's movements.A previously developed assessment tool was used for this purpose-The Bangla Clubfoot assessment tool. 12ta were entered on an electronic spreadsheet using both Microsoft Excel and SPSS software for analyses.
Descriptive and frequency statistics were used for demographic data, including both whole scores and percentage.Mean scores were reported at follow-up.

Results
Clubfoot has from long been an unsolved clinical challenge for the Orthopaedic surgeons.The problem is more serious in developing countries on account of late presentation, higher rate of drop outs from treatment and superstitious beliefs attached to this congenital problem. 18 this study, a total of 577 clubfoot children reported to WFL clinic MMCH from 2011 to 2014.Of the total 577 patients 175 (30.32%) were female and 402 (69.7%) were male.Gender ratio was 1 F: 2.29 M.
There was no inherent family history of clubfoot in 91.7% of affected children, and only 8.3% had family history, of which 2.8% cousins, 1.7% uncle (table II).The average age at the time of first cast was 1.75 (0.96) years with approximately half of children (54.5%) less than three months, and three-quarters (78%) up to one year of age (table III).Parents' occupation were predominately day labourers, and small business and were least income peoplewere 383 (66.4%).
For the 99 children reviewed from 2011, the average number of casts was between three and six 73% (72/99).One child had 17 casts, 16 children had between seven to 11 casts and 10 had only one to two casts (table IV).Overallfor the 471 children, the average number of casts applied was 3.32 (1.1%) before the tenotomy, and up to six casts were required in 147/471 children.
Parents' satisfaction was observed in this study and it was found that 435 (91.2%) were satisfied with the overall treatment of their children.A total of 30 (6.2%) parents were not completely satisfied with their child's treatment.The four-year review of 99 children found a similar result, with 96% parents satisfied.
Most of the children reviewed after four years, 38 (38.4%) were aged between four and five years, 25 (25.3%) were a year older, and 22 (22.2%) a year younger.
Parents'opinion of their child's physical abilityfour years after treatment returned the following: 80/99 could weartheir chosenshoes, 8/99 could not wear their chosen shoes, 11/99 parents did not know, and could not afford shoes for their child.Regarding activity, 97/99 children played, 84/99 could fully squat, 98/99 children walked and ran.Overall, 97/99 parents were happy on the management and treatment of the clinic (table V).Not all children were available for the four-year review.Of the 151 contacted, 48 could not be located, two children had sincedied, 103 reported of which 4 children had syndromic foot and were excluded from this study.Of the 99 included children, 13 (13.1%)had developed relapse signs and were managed accordingly, with repeated Ponseti method, and minor surgery if indicated.

Discussion
The children who were treated successfully in 2011 were walking normally, mixing with other children, growing toward adolescence, and enjoying are habilitated life.
Remarkably, the mothers or fathersthemselves afflicted with clubfoot deformitywere found frustrated not for their own disability, but for their child.The girls with clubfoot were not being married due to this 'clubfoot curse', and suffered lasting despair.Untreated clubfoot causes a critical situation for people in Bangladesh, which has been effectively improved by the Glencoe Foundation, establishing 42 WFL clinics across the country.Since 2009, over 19,500 children were treated (as onMay, 2017), and most were walking and would be able to live a normal life.
This study confirmed the gender ratio disparity inherent in CTEV, as did Mejabi et al. who found 38 (62.3%) male and 23 (37.7%) female with the gender ratio of 1.7 M:1 F. Similarly, Pulak and Swamy found 80% male and 20% female with a gender ratio of 4 M:1F. 20The precise incidence of clubfoot in Bangladesh per se is not established, but recent global data can confidently be adopted ie 1-2:1000 births.In Bangladesh, and other developing nations, females clubfoot patients are not given due attention, due to social bias and wariness favouring male children, which may also influence reported gender ratios. 21is study showed thatthree-quarters of parents had a very low monthly income, with most living in tin shed houses.The lowest incomes, poor standard housing majority also had maximum proportion of clubfoot children.Supporting this study, a previous report found that approximately half of the family incomes were between TK 5000 to 10,000. 22The very likely reason that these very low income families brought their children with clubfoot deformity to the WFL clinic is that the treatment was provided totally free of cost.
Morcuende et al reported the average age at first cast as three months. 25Similarly, Lara et al reported the average age at first cast as between 3.2 and 5.4 months. 9This study from MMCH returned an older average age at first cast, as WFL were being established and public awareness still growing.From many perspectives, a younger age at first cast is preferable for easier clubfoot management.It has been recommended that treatment should begin within first 15 days of life. 267] In contrast, this study foundan average of three and six corrective casts required, including the four year review cohort.Recently, with more experience and an adopted evidencebased modification, WFL has begun changing plaster casts at shorter intervals. 13e tenotomy rate in this study was 80%, comparing favourably with 67% in Laara et al, 9 57% in Chu et al. 26 It should be noted that Dr Ponsetiadvised and performed the tenotomy in more than 90% of cases. 9rents' satisfaction is an important factor in any paediatric condition requiring their cooperation for effective intervention.In this study parent satisfaction was very high, similarly to the findings of Bor N et al, who also found that parents indicated high satisfaction with the treatment of their children with Ponseti method. 27Further, Evans et al, found 97% parents were happy with their children's improvement with treatment, where as Rahman et al, found that half of parents were highly satisfied after receiving treatment for their child's clubfoot deformity. 10,22e positive effect of public awareness effortshas been apparent across WFL clinics in Bangladesh, as the age of presentation of children has reduced.Most children reviewed were aged between three and six years.By contrast, Rahman et al, reviewed 90 percent ofchildren aged less than three years. 21ince 2011, when the WFL clinic at MMCH began, the age of initial presentation of children with clubfoot has reduced withmost now aged less than six months at the time of first casts.
This study addressed and appreciated parents' opinions, and what becomes relevant for them as the children become older.Being able to wear their choice shoes, being able to play with other children, to squat (for play, toileting, eating), and being able to walk and run like other same-aged children were all important factors for parents and related to their reported happiness.Rahman et al also mentioned the importance for parentsfor their children to be able to stand, walk and do other activities like healthy babies. 22lapsing clubfoot deformity is not uncommon.Those found with relapse signs in this study, were all given further treatment.Rahmanet al 22 returned three-fold higher relapse rate of 37%, and Morcuende et al 13 found 25% relapses.Current knowledgeexpresses that relapses are not always due to non-compliance with treatment, but due to underlying connective tissue 'stiffness'.

Conclusion
Based on the study findings , it may be found to be very effective both clinically and economically, with greatest gains and advantage for developing countries like Bangladesh.Poverty, housing conditions, and nutrition may contribute to'clubfoot disease' and warrant further prospective study.The Bangladesh Government can continue to support WFL clinics where Orthopaedic surgeon and Physiotherapists are available, to alleviate the burden of this correctable disability.concluded that the Ponseti method has been widely

Table II :
Inherent Family History of Club Foot (n = 577)

Table III :
Children by age at 1 st cast (n = 471)

Table I :
Distribution of Children by condition of Housing and

Table IV :
Number of casts applied before Tenotomy (n = 471)

Table V :
Parents' Observation on their child Progress (n= 99)