STARTING A CLUBFOOT PROGRAM IN A DEVELOPING COUNTRY

Abstract

Introduction: In many developing countries clubfeet are not recognized at birth and usually remain untreated due to limited medical and financial recourses. With high births rates of up to 50 births per 1000 population in the poorest countries like Mali, Uganda or Niger the clubfoot deformity has become a socioeconomic problem.

Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. During the project design and planning members from an already established Ponseti program, the Uganda Sustainable Clubfoot Care Project, gave valuable advice and guidance for the planning of the Mali program. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006.

Results: During workshops in October 06 and January and March 07 a total of 31 health care workers have been trained using the Ponseti method. Documentation as of March 07 shows that 124 clubfeet in 80 Patients have been treated. There were 54 male and 26 female patients which resembles the male to female ratio described in literature. The mean age at presentation was 12.1 months (range: 9 days to 37 months). The Pirani score was evaluated at presentation in 93 of 124 feet and was 4.23 at the average. In March 07 follow-up for patients in whom treatment was initiated from October to January was available for 25 patients with 38 clubfeet. A medium result (plantigrade foot, DF at least neutral) was seen in 11 feet, a good result (plantigrade foot, DF possible) in 23 feet, an early recurrence with need for re-casting in 4 feet. A release operation was performed in 2 feet (2 patients), and 11 feet (7 patients) are awaiting operation. These patients presented at a mean age of 22 months (12–36 months) and included 3 patients with secondary clubfeet.

Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world and gives these infants in the poorest countries the rare opportunity to receive the same state-of-the-art treatment as infants in the richest countries around the world. Nevertheless, many obstacles have to be overcome to implement a sustainable project. The lack of doctors and especially orthopaedic surgeons can only partly be compensated by highly motivated health care workers. The lack of documentation and follow-up impedes quality control and evaluation needed for funding. Awareness programs to ensure treatment within the first months of live are most important to increase the success-rate but imply fully operable Ponseti clinics which are able to take care of the increasing patient flow.