PurposeThe Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti.MethodsWe conducted a records review of patients presenting from 2011–2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse.ResultsAmongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18–12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08–4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17–6.64). Female sex (RR 1.54, 95% CI 1.01–2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00–1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6–18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%).ConclusionsHigher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.

Objectives: The aims of this study were to evaluate the reliability, sensitivity, and specificity of the Squat and Smile (S&S) test, a clinical photographic follow-up, in determination of fracture healing and to assess the extent of continued fracture healing beyond one-year post-operation. Design: Retrospective review of the SIGN database. Setting: The S&S test is utilized in low-resource settings where the SIGN intramedullary nail is used due to unavailability of intraoperative fluoroscopy. Patients/Participants: 150 patients undergoing fracture fixation utilizing SIGN intramedullary nails with data available at least one year (9-16 months) post-surgery. Intervention: None Main Outcome Measurements: We extracted clinical data and calculated scores for the S&S photographs and radiographs at the one-year (9-16 months post-operative) follow-up and last follow-up available beyond that. We analyzed the sensitivity of S&S scoring, using radiograph assessment as the gold standard for fracture union. Results: Of the 126 patients analyzed, 21% were found to have incomplete healing at one year, whereas 17% of the 64 patients with further follow-up past one year had incomplete healing. We found that both S&S and radiographic fracture healing scores had good inter-rater reliability (k=0.73-0.78 for S&S and 0.94 for radiographs). The S&S test had poor sensitivity (0.11) and specificity (0.85) in determining fracture healing at the one-year follow-up. Conclusions: The S&S scoring method was reliable but neither sensitive nor specific for determining fracture healing at one year. Fractures deemed incompletely healed by radiographic evaluation at one year following SIGN implant may still have the potential to heal over time.

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