BackgroundThe management of congenital talipes equino varus (clubfoot deformity) has been transformed in the last 20 years as surgical correction has been replaced by the non-surgical Ponseti method. The Ponseti method, consists of corrective serial casting followed by maintenance bracing, and has been repeatedly demonstrated to give best results - regarded as the ‘gold standard’ treatment for paediatric clubfoot.MethodsTo develop the study protocol Level 2 evidence was used to modify the corrective casting phase of the Ponseti method in children aged up to 12 months. Using Level 4 evidence, the percutaneous Achilles tenotomy (PAT) was performed using a 19-gauge needle instead of a scalpel blade, a technique found to reduce bleeding and scarring.ResultsA total of 123 children participated in this study; 88 male, 35 female. Both feet were affected in 67 cases, left only in 22 cases, right only in 34 cases. Typical clubfeet were found in 112/123 cases, six atypical, five syndromic. The average age at first cast was 51 days (13–240 days).The average number of casts applied was five (2–10 casts). The average number of days between the first cast and brace was 37.8 days (10–122 days), including 21 days in a post-PAT cast. Hence, average time of corrective casts was 17 days.Parents preferred the reduced casting time, and were less concerned about unseen skin wounds.PAT was performed in 103/123 cases, using the needle technique. All post tenotomy casts were in situ for three weeks. Minor complications occurred in seven cases - four cases had skin lesions, three cases disrupted casting phase. At another site, 452 PAT were performed using the needle technique.ConclusionsThe ‘fast cast’ protocol Ponseti casting was successfully used in infants aged less than 8 months. Extended manual manipulation of two minutes was the essential modification. Parents preferred the faster treatment phase, and ability to closer observe the foot and skin. The treating physiotherapists preferred the ‘fast cast’ protocol, achieving better correction with less complication. The needle technique for PAT is a further improvement for the Ponseti method.

Introduction: Drop-out before treatment completion is a vexing problem for all clubfoot clinics. We and others have previously identified better engagement with parents as a crucial method of ameliorating incomplete clubfoot treatment, which increases deformity relapse. Materials and methods: The novel use of community facilitators enabled an audit of over 300 families who had dropped-out from a child’s clubfoot treatment. A questionnaire standardized the parent interviews. Parents were encouraged to present for clinical review of their child’s clubfeet. Results: When treatment was discontinued for six months, 309 families were audited. A social profile of families was developed, showing that most lived in tin houses with one working family member, indicating low affluence. Family issues, brace difficulty, travel distances, and insufficient understanding of ongoing bracing and follow-up were the main reasons for discontinuing treatment. Overt deformity relapse was found in 9% of children, while half of the children recommenced brace use after review. Conclusions: Identifying families at risk of dropping out from clubfoot care enables support to be instigated. Our findings encourage clinicians to empathize with parents of children with clubfoot deformity. The parent load indicator, in parallel with the initial clubfoot severity assessment, may help clinicians to better appreciate the demand that treatment will place on parents, the associated risk of drop-out, and the opportunity to enlist support.

Background: Completed treatment of congenital clubfoot deformity using the non-surgical Ponseti method yields very good results. However, many children do not complete the treatment course, potentiating relapse of the deformity, forever compromising independent gait and quality of life. If the factors precipitating 'drop out' from treatment can be averted, more children will complete the Ponseti method of treatment which has low rate of complication and is both economical and highly effective. Children depend on parents to bring them to the clinics, hence we aimed to identify factors obstructing parents and ultimately the children's outcomes. Once identified, barriers to completing treatment may be removed. Aim:To identify the factors obstructing completion of clubfoot treatment.Method: Two of the 32 Walk for Life (WFL) clubfoot clinics in Bangladesh were utilised for participants, who were parents and children (n=72) who had dropped out from completing the clubfoot treatment course four to six years earlier. Bootstrapping was used to improve statistical power (based on 1000 random sample). Validated outcome measures included a specific context drop out questionnaire, the Oxford Ankle Foot questionnaire, the Bangla clubfoot assessment, and the Foot Posture Index. Parent's insights, experiences and recommendations were canvassed both qualitatively and quantitatively.Result: Relapse occurred in 15/72 drop out cases, predicted by problems with the initial casting process. The main reasons for drop out were difficulty with the foot abduction brace (42%), family issues (31%), and other problems with the child's clubfoot treatment (15%). Despite problems and incompletion, the parents were generally satisfied (93%), although many felt sad or ashamed for not completing the treatment course and realizing clubfoot deformity recurrence (96%). Parents who had dropped out, were noted by WFL staff to be regretful, and especially so if their now older child's clubfoot had relapsed to obviously compromise independent gait and mobility. A lack of discernment of postural clubfeet from 'true' clubfeet was identified in some clinicians, indicating variable practice methods despite uniform training, and probably lowering the overall relapse rate with inclusion of 'postural' cases. Conclusion:Relapse was predicted by problems with casting and predicted worse foot posture and reduced physical functioning. Walk for Life adopted appointment reminders, parent support groups, cost sharing, and staff updates.

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