Nov Bulletin ONLINE ONLY Articles.
qxp 06/10/2011 16:48 Page 1
DOI: 10.1308/147363511X594993
R E S U LT S O F A N E F F E C T I V E H U B
AND SPOKE MODEL FOR
T R E AT M E N T O F C L U B F O O T
NA Jagodzinski Junior Orthopaedic Fellow
NE Fisher Specialist Registrar
LC Bryan Senior Physiotherapist
H Prem Consultant in Trauma and Orthopaedics
Birmingham Children’s Hospital, Birmingham, UK
The aim of this study was to assess a
‘hub and spoke’ model for a
treatment of clubfoot that involves
the casting of feet by trained
physiotherapists based at local
hospitals close to the patients’
homes. It has been demonstrated
that non-medical personnel can be
trained effectively in the Ponseti
technique in developing nations
where resources and orthopaedic
surgeons are scarce.1–5 In the UK the
British Orthopaedic Association
published the ‘blue book’ on
children’s orthopaedics in 2006,
which advises a hub and spoke
model to address the issue of a
shortage of paediatric orthopaedic
surgeons in peripheral district
general hospitals (DGHs).6 The
extent of subspecialisation among
orthopaedic surgeons and the lack
of paediatric anaesthetists have
reduced peripheral paediatric
orthopaedic surgical treatment. We
believe there is no study in the
literature to date assessing the
advantages of such a service using
existing physiotherapy facilities at
multiple centres.
Ann R Coll Surg Engl
(Suppl) 2011; 93:
Hub and spoke framework
Maternity services, GPs, physiotherapists
and orthopaedic surgeons around
Birmingham city refer patients with
clubfoot to the senior author (HP) at
Birmingham Children’s Hospital (BCH). In
those instances where the patient is
initially referred to a local specialist
physiotherapist, casting is commenced
locally by the physiotherapist who then
refers the patient to the surgeon at BCH.
When the initial referral is made directly
to the orthopaedic surgeon, these
referrals are urgently redirected by fax or
phone to the specialist physiotherapist
nearest to the patient’s home, who would
then commence casting.
Methods
All patients in this study were referred to
the senior author, an orthopaedic surgeon
with a special interest in foot and ankle
problems, based at BCH.
Four physiotherapy departments around
Birmingham were involved in the study,
including the one at BCH, which treated
patients living in the city centre. All
physiotherapists in this study had
attended at least one of the Manchester
International Clubfoot conferences (run
by the UK Ponseti User Group), which
includes training in the practical
application of the Ponseti programme.
The first physiotherapist at BCH to do
this course (co-author LCB) initially
worked alongside a paediatric
orthopaedic surgeon to gain experience
in casting. At the time this was common
practice.7,8 However, all the other
physiotherapists in the study gained their
experience by shadowing another
experienced physiotherapist as a form of
apprenticeship after attending the course.
Physiotherapists always work in pairs
when carrying out the casting.
Physiotherapists attend the orthopaedic
consultation with their first few patients
to discuss their progress and any casting
problems with the surgeon. They also
initially attend the theatre sessions to
watch the tenotomy and perform the
post-operative casting as part of their
training. Subsequently, once they are well
trained, they do not attend the central
hospital except for discussing problems
like cast slippage, non-compliance with
boots and bars or parental or social
problems. A BCH-based physiotherapist is
always present during clinic consultations
with the senior author. The former then
liaises with the respective local
physiotherapist to convey the outcome of
the consultation.
Patients are generally seen by the
surgeon within three weeks of the first
referral to him or her. Children with
associated medical problems or
syndromes are usually seen sooner. Most
patients have commenced casting by then
and the cast change for that week is
adjusted to fit the consultation date. The
local physiotherapist continues the casting
regime and intimates to the senior
author at BCH once sufficient
correction has been obtained as per the
Ponseti protocol, ie heel in valgus. A date
for the tenotomy is allotted as soon as
possible and the surgeon will not see the
patient again until the day of surgery
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BU L L E T I N
unless there are problems with deformity
correction.
Patients with multiple deformities,
associated syndromes, complex idiopathic
clubfeet or with referrals following failed
treatment elsewhere are treated only at
the hub hospital (BCH) and are evaluated
by the surgeon more frequently. For these
patients, the cast is usually applied by the
most senior physiotherapist (co-author
LCB) and the surgeon assists with the
initial cast changes.
Our hub-and-spoke protocol requires
parents to remove the long-leg plaster of
Paris casts by soaking them in the bath at
home just before leaving for the
physiotherapy appointment. This was in
order to reduce the time spent in the
physiotherapy clinic and allow the foot to
be cleaned. Some patients with non-
compliant parents are placed in moulded
plaster of Paris that is then reinforced
with 3M™ Scotchcast™, which has to be
removed by the physiotherapists. This is
to avoid the parents removing the casts
too early.
All tenotomies are performed
percutaneously using a Beaver™
(ophthalmic) blade in an operating theatre
under a short general anaesthetic as a day
case. Post-operatively, the patients remain
in a cast until it is removed in the
surgeon’s clinic three weeks later and
placed in a foot abduction orthosis
(FAO). The majority of patients received
the Markell (Yonkers, NY, US) brand of
FAO. The more expensive MD
Orthopaedics (Wayland, IA, US) FAO was
reserved for feet with pressure-related
problems with the Markell FAO.
Further follow-up appointments and the
renewal of the FAO as the child grows
are performed by the respective local
physiotherapist. The patients wear the
FAO for 23 hours a day for the first three
months and then just at night until the
age of four. Postoperatively, the surgeon
reviews the patients at three weeks, three
months and six- to twelve-monthly
thereafter. Meanwhile, the physiotherapist
reviews the patient at least once every
month, assessing for recurrence,
complications, compliance and sizing of
the FAO.
2
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We have reviewed the work of four
teams of physiotherapists (12
physiotherapists in total), all of whom
treated patients referred to the senior
author at BCH between October 2005
and March 2007. Three teams of
physiotherapists were based at separate
DGHs around Birmingham; these acted as
the ‘spokes’. Although the fourth team
was based at BCH, it also provided an
assessment and casting service that was
independent of the senior author (except
if the deformity was recalcitrant or
complex).
Patient data were collated retrospectively
from the physiotherapy and medical case
notes. We studied all patients with
structural clubfoot, including those with
associated syndromes.
Results
We included 71 clubfeet from 49
consecutive patients (22 bilateral). There
were 29 boys and 20 girls. Three patients
had first degree relatives with clubfeet
and five patients had more distant family
members affected. Patients with
coexisting syndromes or deformities are
shown in Table 1.
Thirty-four clubfeet (48%) were
diagnosed at the 20-week prenatal
ultrasonography. Two patients, however,
were initially diagnosed with unilateral
clubfoot but were then born with
TABLE 1
NUMBER OF PATIENTS WITH COEXISTING SYNDROMES
Coexisting syndrome or deformity
Arthrogryposis
Polydactyly / syndactyly / missing digits or rays
Down’s syndrome
Renal abnormalities
TABLE 2
RESPONSE TO PONSETI CASTING
Initial Pirani Number of casts
score /6 before tenotomy
Minimum 2.5 4 22
Maximum 6.0 40
Median 5.5 8 85
bilateral involvement. Twenty patients
(41%) were referred to physiotherapists
at the peripheral centres, which all have
maternity services on site. The median
age of commencement of casting in these
hospitals was four days (range: 0–11
days). BCH is a paediatric tertiary referral
centre with no maternity services on site.
Therefore, the median age at which casts
were commenced here was higher at 14
days (range: 3–87 days) to take into
account the time for referral. Fourteen
per cent of patients were casted more
than three weeks after birth. These
patients were delayed referrals owing to
concomitant medical issues or were
referred following attempted treatment
with stretching or Ponseti casting at
other centres outside the region covered
by our hub and spoke model.
The median time from first casting to the
Achilles tenotomy was 85 days (range:
36–273 days). Only two patients had their
tenotomies delayed until over five months
of age. Both of these had non-compliant
parents who did not attend clinics and
who removed casts at home.
Occasionally, the tenotomy was delayed
by lack of theatre availability or
postponed for anaesthetic reasons.
The severity of clubfoot was graded using
Pirani scores. The improvement in Pirani
scores with serial Ponseti casting in our
study can be seen in Table 2. If there was
Patients
2
5
1
1
Days from first Pre-tenotomy Pirani
cast to tenotomy score /6
0.5
319 4.0
1.5
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BU L L E T I N
a delay in theatre availability, the final foot
position was maintained in casts that
were intermittently changed to check the
underlying skin condition. Therefore, a
moderately high number of casts does
not always reflect a foot resistant to
treatment. However, such delay was
exceptional and usually occurred only
over the holiday seasons when elective
theatres were closed for maintenance.
Four patients had a severe equinus with
associated severe cavus, a transverse
midfoot crease, a short foot and clawing
of the hallux. They were resistant to
initial casting and the heel tilt did not go
into valgus in spite of forefoot abduction.
The senior author felt that a tenotomy at
this stage would unlock the calcaneum
and allow it to correct into valgus with
further serial casting for three to four
weeks.9 The normal protocol for FAO
was then followed as previously outlined.
The only reported complications of
casting were minor. Initial slippage of casts
occurred in six feet, two of which had
arthrogryposis. The physiotherapists
therefore applied hip spicas instead of
long-leg casts and these proved
successful. The senior author came across
this method of treating unusually shaped
feet with hip spicas during discussions at
one of the Manchester International
Clubfoot conferences. The position of the
hips was not important and the
‘extension’ around the abdomen only
acted as a corset, preventing slippage of
the long-leg casts.
A BCH plaster technician specifically
trained in this technique applied the
3M™ Soft Cast spica extension after the
physiotherapists applied the long-leg
plaster of Paris casts. This technique was
used belatedly, although successfully, in a
patient who underwent 40 castings
before a tenotomy for clubfeet. This
patient had very small feet with two
missing outer rays, webbing of the
remaining toes and large thighs, making it
impossible to prevent slippage, in spite of
flexing the knee beyond a right angle.
The physiotherapists reported other
complications on 13 feet. These included
mild redness, bruising and swelling over
pressure areas such as the hallux, the
06/10/2011 16:48 Page 3
lateral talar head and the thigh around
the proximal end of the cast. There was
also one blister reported on a hallux. All
such complications were treated
successfully by extra padding and
DuoDERM® dressings, without any
cessation of casting. No patients in the
study suffered any serious complication
from casting requiring cessation of
treatment.
Three feet (in two patients) in the study
achieved dorsiflexion with casting alone
and did not require a tenotomy. They
both obtained Pirani scores of 0, with
adequate dorsiflexion and abduction to fit
into the FAO and continue with this
aspect of the treatment.
Eight feet required repeat Achilles
tenotomies within the first year, including
the four feet of the patients with
arthrogryposis. One patient with bilateral
clubfeet had non-compliant parents.
However, another two patients with
bilateral clubfeet and compliant parents
required repeat tenotomies on only one
side. Three patients required a third
tenotomy for a persistent equinus
deformity including the two patients with
arthrogryposis and the patient with the
non-compliant family.
All patients in the study received a
minimum of 27 months’ follow-up after
the tenotomy (range: 27–49 months;
median: 40 months) with a median age at
follow-up of 44 months (range: 29–54
months). Within this follow-up period, no
feet required open surgical release for
persistent deformities or recurrence of
equinus.
All feet retained a Pirani score of 0 at
their last follow-up appointment.
However, two feet have had a tibialis
anterior tendon lateral transfer in this
period: one patient was aged 34 months
and the other 38 months. Both children
had simple idiopathic clubfeet, initially
treated successfully with an average
number of casts before the tenotomy and
excellent dorsiflexion post-operatively.
Neither set of families had issues with
compliance.
Seventeen of the clubfeet were of
children who reached four years of age
during our study and these children had
therefore discontinued the use of
nocturnal FAO by the end of our study
period. We found that compliance with
the FAO usually maintains an excellent
foot position over the three to four years
of its use. In our study, there is a median
change of 0º from the tenotomy to
current follow-up. Non-compliance usually
led to a marked negative change and
occasional recurrence of equinus.
Two patients with complex idiopathic
clubfeet had a residual cavus deformity
but no equinus after bilateral tenotomies.
These patients were referred to another
surgeon in Manchester after their
tenotomy for a modified casting
technique published by Ponseti et al in
2006.10
Discussion
The UK currently faces a problem related
to high subspecialisation among
orthopaedic surgeons. Many DGHs have
sufficient numbers of orthopaedic
surgeons for adult practice but not for a
paediatric orthopaedic service. This is in
sharp contrast to those in developing
countries where there is a severe lack of
general orthopaedic surgical expertise in
rural areas. However, if all patients with
clubfoot were referred to a specialist
centre for paediatric orthopaedics, then
surgical services would be overwhelmed
and delays to casting would be inevitable.
Early referral from maternity services to
specially trained physiotherapists working
on the same site shortens the time to
application of the patient’s first Ponseti
cast.
All assessments and casts are performed
and applied by the same physiotherapist,
offering continuity of care and an overall
holistic approach to the patient. This
generally increases compliance with
treatment, which is particularly hard to
achieve with the FAO as it requires daily
removal and reapplication by the parents
for four years.8,11–14 It is thought that non-
compliance is the highest risk factor for
recurrence of deformity.15,16 Parents
need to be well informed, encouraged
and frequently reminded of the risks
of recurrence. This is more effective if
a rapport is built with a single
practitioner.8
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BU L L E T I N
Previous studies have shown that Achilles
tenotomies can be performed under local
anaesthetic either by topical application
or by infiltration.8 However, we
performed all tenotomies under a general
anaesthetic, which has two primary
benefits. Firstly, it permits the use of the
‘Bulgarian Pull-Down Technique’ and,
secondly, it allows teaching of the
technique to trainees. Dr Zhivkov (of
Varna, Bulgaria) first described the
technique in 2003 for patients with
severe equinus.17 The technique involves
plantar traction on the calcaneal
tuberosity with a claw retractor for
additional correction following the
tenotomy. It stretches the contracted
deep posterior tissues like the capsule
and ligaments and it was used successfully
in our series for the four patients with
severe equinus. This technique avoids
causing a rocker bottom deformity of the
foot.
Radiographs were used in our institution
only if there were doubts about
alignment. The senior author has used
x-ray in cases outside of this study
group where lateral radiographs were
made in maximum dorsiflexion in a
cast to confirm that there was true
hindfoot dorsiflexion rather than a
midfoot rocker.
Dynamic supination is a well recognised
problem that can develop in clubfeet
despite compliance with the Ponseti
regimen.18 Two patients in our study
underwent a lateral transfer of the tibialis
anterior tendon, which successfully
corrected this deformity.
We can conclude that it is safe for a
limited number of physiotherapists to
practise the Ponseti technique provided
that a strict protocol is followed. Training
courses should be combined with a
period of apprenticeship with an
experienced physiotherapist and regular
monitoring of their progress should be
carried out by an orthopaedic surgeon.
All casting should be done by a team of
two physiotherapists as both the person
holding the foot and the person applying
the cast should be familiar with the
technique. Regular audit meetings need to
16:48 Page 4
be held with the team to evaluate
complications related to the skin, cast
slippage and recurrences. These meetings
are held every three to four months at
BCH.
No feet in our study required open
surgical release and there were no
complications that required cessation of
casting. We feel that our high success rate
is attributable to us adopting several
innovative factors like the application of a
spica cast for cast slippage, pre-emptive
tenotomies with follow-up casting in
cases with severe locked equinus, the use
of the Bulgarian pull-down technique, the
immediate application of the new
technique published by Ponseti et al10 and
early identification of non-compliance. We
are aware that, with longer term follow-
up, some patients with complex clubfeet
may have a recurrence needing open
surgery.
We feel that the incidence of non-
compliance was reduced by
physiotherapists having more time
dedicated to building a family rapport
than most UK surgeons have during their
consultations. Families have direct access
to physiotherapists, which allows pressure
problems from ill-fitting casts and FAOs
to be corrected urgently, thereby
improving compliance.
As our hub and spoke Ponseti service
uses existing local physiotherapy services,
the cost to the National Health Service
and the burden on overstretched
paediatric orthopaedic surgeons is
significantly reduced.
Conclusions
The hub and spoke model is a safe and
effective method of treating clubfoot in
countries where there are relatively few
specialist paediatric orthopaedic surgeons
spread geographically. Developing
countries where orthopaedic
practitioners are scarce in rural locations
may also benefit from this model.
References
1. Culverwell AD, Tapping CR. Congenital talipes
equinovarus in Papua New Guinea: a difficult yet
potentially manageable situation. Int Orthop 2009; 33:
521–26.
2. Gupta A, Singh S, Patel P et al. Evaluation of the utility
of the Ponseti method of correction of clubfoot
deformity in a developing nation. Int Orthop 2008; 32:
75–79.
3. Lavy CB, Mannion SJ, Mkandawire NC et al. Club foot
treatment in Malawi – a public health approach. Disabil
Rehabil 2007; 29: 857–62.
4. McElroy T, Konde-Lule J, Neema S, Gitta S.
Understanding the barriers to clubfoot treatment
adherence in Uganda: a rapid ethnographic study.
Disabil Rehabil 2007; 29: 845–55.
5. Tindall AJ, Steinlechner CW, Lavy CB et al. Results of
manipulation of idiopathic clubfoot deformity in Malawi
by orthopaedic clinical officers using the Ponseti
method: a realistic alternative for the developing
world? J Pediatr Orthop 2005; 25: 627–29.
6. British Orthopaedic Association, British Society for
Children’s Orthopaedic Surgery. Children’s Orthopaedics
and Fracture Care. London: BOA; 2006.
7. Docker CE, Lewthwaite S, Kiely NT. Ponseti treatment
in the management of clubfoot deformity – a
continuing role for paediatric orthopaedic services in
secondary care centres. Ann R Coll Surg Engl 2007; 89:
510–12.
8. Shack N, Eastwood DM. Early results of a
physiotherapist-delivered Ponseti service for the
management of idiopathic congenital talipes
equinovarus foot deformity. J Bone Joint Surg Br 2006;
88: 1,085–89.
9. Zhivkov M. Treatment of most severe clubfoot cases: is a
modification of Ponseti’s method able to improve the
prognosis? Presented at: Manchester International
Clubfoot Conference; November 2003; Manchester.
10.Ponseti IV, Zhivkov M, Davis N et al. Treatment of the
complex idiopathic clubfoot. Clin Orthop Relat Res 2006;
451: 171–76.
11.Bradford WD, Kaste LM, Nietert PJ. Continuity of
medical care, health insurance, and nonmedical advice
in the first 3 years of life. Med Care 2004; 42: 91–98.
12.Parchman ML, Pugh JA, Noël PH, Larme AC. Continuity
of care, self-management behaviors, and glucose
control in patients with type 2 diabetes. Med Care
2002; 40: 137–44.
13.Spath P. Continuity of care means better instruction on
meds. Hosp Peer Rev 2000; 25: 53–55.
14.Thom DH, Ribisl KM, Stewart AL, Luke DA. Further
validation and reliability testing of the Trust in
Physician Scale. The Stanford Trust Study Physicians.
Med Care 1999; 37: 510–17.
15.Dobbs MB, Rudzki JR, Purcell DB et al. Factors
predictive of outcome after use of the Ponseti method
for the treatment of idiopathic clubfeet. J Bone Joint
Surg Am 2004; 86: 22–27.
16.Haft GF, Walker CG, Crawford HA. Early clubfoot
recurrence after use of the Ponseti method in a New
Zealand population. J Bone Joint Surg Am 2007; 89:
487–93.
17.Zhivkov M. Making it work in the difficult patient.
Presented at: Manchester International Clubfoot
Conference; November 2003; Manchester.
18.Heilig MR, Matern RV, Rosenzweig SD, Bennett JT.
Current management of idiopathic clubfoot
questionnaire: a multicentric study. J Pediatr Orthop
2003; 23: 780–87.