Task sharing clubfoot treatment in Latin America: a cross-sectional survey of expert opinions

Abstract

9While the Ponseti method has quickly become the mainstay of clubfoot treatment in most 10 parts of the world, its dissemination and successful implementation in Latin America has been 11 more limited. The additional shortage of orthopedic surgeons in this region makes task sharing a 12 practical approach to address gaps in service provision. We designed an online survey to assess 13 needs, perceptions, and willingness to task share the delivery of the Ponseti method by Ponseti-14 method-trained physicians across Latin America. Multiple-response questions were summarized 15 and an applied thematic analysis approach was used to analyze free-response questions. We 16 achieved a 66% response rate (31 of 47 experts responded). Our findings illustrate that most 17 physicians feel the need for disseminating and improving Ponseti training, as well as having 18 additional support for clubfoot treatment. While physicians who treat clubfoot have mixed 19 opinions on the role of nonphysicians treating clubfoot, most report logistical concerns and 20 insufficient training as barriers to their inclusion. Given this and the need for improved, more 21 accessible clubfoot care across Latin America, future clubfoot treatment efforts may benefit from 22 incorporating task sharing between orthopedic surgeons and non-physician personnel. 23 24 25Clubfoot, defined as the downward-and inward-turning of the foot, is one of the most 26 common musculoskeletal birth deformities in the world (1). When left untreated, clubfoot may 27 cause lifelong physical impairment, social isolation, and economic deprivation. The global 28 paradigm for management of clubfoot has shifted from the provision of extensive surgical 2 29 correction to implementation of a minimally-invasive, conservative correction that is both low-30 cost and highly-effective; this technique is called the Ponseti method (2). 31The Ponseti method, created by Dr. Ignacio Ponseti, involves a correction and a 32 maintenance phase (3). The correction phase comprises serial manipulations with simultaneous 33 correction of the four components of the deformity: cavus, adductus, varus, and equinus. A series 34 of long-leg plaster of Paris casts hold the corrected foot position, usually followed by an 35 outpatient Achilles tenotomy. Immediately after the removal of the final cast, the corrected foot 36 is placed in a foot abduction brace (FAB) with the aim of preventing recurrence. The FAB 37 should be worn 23 hours a day for the first three months and then only at night until the age of 38 four years; the FAB itself is changed as the child's foot grows. Both the maintenance and 39 correction phases are equally important for success of clubfoot management. Although success 40 rates of the Ponseti method vary based on when treatment is initiated, patient adherence, and 41 provider experience, complete correction can be achieved in the majority of patients with success 42 rates as high as 95% (4). 43While the Ponseti method has quickly become the mainstay of clubfoot treatment in m...