Speaker:

Dr. Shamim Khan

HMO Unit 1, Dept of
Ponseti Orthopedic Surgery
CMCH
Management of
Clubfoot in Dr. Myen Uddin Majumdar
Dr. Jabed Akhter Tuhin
Chittagong Dr. Rajib Hasan
Dr. Moshiur Rahman
Disvision: Dr. Mamun Mustafa
Dr. O M Faisal
Experience of 1000 Hossain M Baker (Physio)
feet Mintu Chakma

1
It is the most common congenital deformity of ankle and
foot.
Some Facts about Congenital
Clubfoot…

 Clubfoot is one of the most common

congenital deformities.

 About 1 - 2 in every 1000 children is

born with clubfoot worldwide.

 A normal developing foot turns into a

Clubfoot around the 3rd month of
foetal life.

 The cause is not exactly known, but is

believed that genetic &
environmental factors are involved.

 More in boys than in girls.

 One or both feet may be involved.

The treatment should start soon after birth
Early treated Neglected
CLUBFOOT SIGNS
 Forefoot Cavus CAVE sign
 Mid foot Adductus

 Heel Varus

 Hind foot Equinus

 1st Metatarsal is more in Plantar flexion than the rest of the
Metatarsals
 Clubfoot is smaller than a normal foot.
 Calf is smaller
CLUBFOOT SIGNS (Continued)

Forefoot Cavus
- Increase in the height of
the medial arch of the foot
- the forefoot in relation to
the mid foot is in
Pronation.
CLUBFOOT SIGNS (Continued)
Midfoot
Adduction
Talus Plantar Flexed beneath Tibia

Adducted & supinated Navicular

Wedge Shaped head of talus, Lateral

part of Talar head is uncovered

Wedge shaped Navicular

Adducted and varus calcaneus

Medially displaced & adducted Cuboid

CLUBFOOT SIGNS (Continued)
 Heel in Varus
 Supination and Adduction of the Calcaneus.
 Calcaneus is locked under the Talus

 Hind foot Equinus

 Severe Plantar flexion in the ankle joint.
 High Calcaneus (not in the heel pad).
 Talus in severe Flexion.
 Clubfoot: Chittagong Division

CBR: 22.98 births/1,000 population (2011 est.), Infant mortality rate: 50.73 deaths/1,000 live births,
Clubfoot incidence: 1.5/1000 live birth
Our Fight
against Clubfoot

Started on July 2009

Started on Feb 2010

 Treat under 5 years old
children with clubfoot using
the Ponseti technique
absolutely free of cost.

 Build the capacity to detect

clubfoot by increasing

awareness.
Basic Ponseti treatment Protocol
 Manipulation & Casts
for 5-6 weeks
 Achilles tenotomy (if
needed)
 Foot abduction brace/
FAB
 3 months continuously
 Reducing use with age
 Night use to age 5-6 years
 Monitor child
 6 – 12 months
 To age 15 years
 15 July 17, 2014

Aim of Study
 The aim of this study is to evaluate the
effectiveness of the Ponseti method in children
presenting before 5 years of age with either
untreated or complex (initially treated
unsuccessfully by other conservative methods)
idiopathic clubfeet
 16 July 17, 2014

MATERIALS AND METHOD

 Type of study : Retrospective clinical study.
 Duration of study : From February 2010 to November 2011
(21months)
 Place of study : 6 ZCF clinics of Chittagong, Cox’s bazar,
Khagrachhari, Comilla, Noakhali & Chandpur.
 Study population : Patients with CTEV attended at these ZCF
clinics.
 Chittagong
 Cox's Bazar
 Khagrachhori
 Comilla
 Noakhali
 Chandpur
 Brahmanbaria
 Feni
 Lakshmipur
 Rangamati
 Bandarban
 18 July 17, 2014

MATERIALS AND METHOD (continued..)

 Age group : Within age of 5 years.
 Sex group : Both male and female
 Method : The Ponseti technique.
 Sample size : 1091 feet of 664 patient.
 Exclusion criteria:
 Clubfeet patients above 5 years of age
 Syndromic clubfoot.
FINAL OUTCOME MEASUREMENT
Score ranges: 0 - 0.5 - 1.0
Pirani scoring
6 criteria Mid
foot scores
A. Lateral border
B. Medial crease
C. Talar head coverage
Hind foot scores
D. Posterior crease
E. Rigid equinus
F. Empty heel
 20 July 17, 2014

Demographic Foot involved

Variables Bilateral Unilateral

Variables
46.20% 54.80%
No. of Patients 664
No. of Feet 1091
Bilateral
Involvement 364 (54.8%)
(no. of patients) Sex ratio
Male Female
Age range 6 days to 5 years
Male 463 (70%)
30%
Female 201 (30%)
70%
Initial mean Pirani
5.2
score per foot
 21 July 17, 2014

Clinical data
Variables
Type of Typical - Typical - Rigid Atypical
Clubfoot Flexible
No of feet 538 (49%) 389 (36%) 164 (15%)
Any Previous NO Yes - Yes - Surgery
treatment? conservative
No. of feet 609 443 39

Patients Feet
Missed out 194 319 (29%)
Full correction by 361 593 (54%)
Ponseti
Tenotomy done 271 445 (75%)
Referred for Surgery 109 179 (17%)
 22 July 17, 2014

Reason for Referral to Surgery

 Neglected clubfoot
 no treatment untill 3 years).
 Resistant clubfoot
 Midfoot score >1, and Hindfoot score >2 after 5
casts application
 Atypical clubfoot
 Repeated cast slip out.
 Appears complication.
 23 July 17, 2014

Effect of Treatment in Different

age groups
Total Full
Correction
By Ponseti By Surgery
(Final Pirani
Score <1)

Feet 772 593 77% 179 23%

Patients 470 361 77% 109 23%

0- 6m 213 206 97% 7 3.3%

6m - 1y 69 64 93% 5 7.2%
Age range
1 - 3y 121 85 70% 36 30%

3 - 5y 67 6 9% 61 91%
 24 July 17, 2014

Casting
Ima n Habi b
 28 July 17, 2014

Brace Follow up
No. of On Regular Irregular in Relapse
patients on follow up Follow up
FAB
361 227 108 26

Follow up
Regular Irregular Relapse

7%
30%
63%
 29 July 17, 2014

Take home Massage

 Treatment of congenital club foot by ponseti technique
is very effective method with excellent result for

below 1 years children.

 Brace follow up is essential for long term better
outcome.

 With proper monitoring and support, Ponseti service

can be effectively and successfully administered in a
district general hospitals.
Two years journey…
Year Patients Feet
2010 230 349
2011 477 742
How do we
find patients?
Clinical Treatment Goals
 By May 2012 - reach 1500 feet mark.
 By July 2012- get 80 babies each month.
(break even point).
 By December 2012 – get regularly all <1
month babies born in Chittagong Division.
 Build consensus that the Ponseti method
is an effective treatment for Congenital
Clubfoot
How you can help?
 Spread one message:
Clubfoot is completely curable, early Ponseti treatment is the
key.

 Help build up awareness among all Govt. health care providers.

 Refer clubfoot patients to ZCF Ponseti clinics working in your
District.