Introduction: Congenital clubfoot is a very common deformity in developing countries which leads to secondary socioeconomic problems. Clubfoot programs using the Ponseti method have been initiated in many third world countries in the last years. However, many treatment related, logistic, and structural problems are encountered during these efforts. We report our two-year experience with a clubfoot program in Mali.

Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006. Further visits for advanced teaching, documentation, follow-up and implementation of a clinical structure were scheduled approximately every three months. Parallel to the Ponseti program a program to operate neglected or resistant clubfeet was initiated. Regular meetings with the government at different levels were attained and efforts were made to include the clubfoot program into the national RBC program.

Results: During workshops in October 2006 and January and March 2007 seven health care workers have been intensively trained in the Ponseti method. A review of our documentation showed that up to now 235 patients had been seen and treated. Out of 105 children with idiopatic clubfoot who presented younger than one year of age 52 were available for follow-up after the end of Ponseti treatment. The outcome was “good” or “medium” in 40 patients (77%) and “poor” in 12 children (23 %). The late age at presentation, the low compliance and the rare use of the abduction orthosis are ongoing problems which could not have been solved yet. Additionally, the structural improvements in our treatment center as well as the direct government support are still insufficient.

Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world. Nevertheless, many obstacles have to be overcome to implement a sustainable project, most of which are not so much treatment associated but of structural, organizational and political nature.

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.

Introduction: Congenital tarsal coalition is one of the most prevalent (1–6%) anomalies of the hindfoot and midfoot. Its etiology is unknown. By definition there are boney, cartilaginous or fibrous brigdes between 2 bones of the hindfoot and midfoot, which are classified by their localization; the most common coalitions are calcaneonavicular (53%) and talocalcaneal (37%).

Patients and Methods: From 2001 to 2007 28 patients with 37 coalitions had surgery at the Orthopedic Hospital Vienna-Speising.

32 calcaneonavicular coalitions were surgically excised and an autogenous free fat graft was interponed to prevent a relapse. 1 calcaneonavicluar coalition also had an interposition of the extensor digitorum brevis after resection, while 1 calcaneonavicular coalition had lengthening of the short peroneal tendon in addition to excision and autogenous free fat graft. 1 calcaneonavicular coalition had to have an arthrodesis of the talocalcaneal joint.

From 2 talocalcaneal coalitions 1 had excision the other 1 talocalcaneal arthrodesis.

Both of the coalitions that had arthrodesis had short-leg plastercasts for 12 to 13 weeks.

For patients with bilateral coalition pedobarography was performed and the foot that had been treated compared to the untreated contralateral side. For these patients the AOFAS ankle and hind foot score and pain according to the VAS were evaluated.

Results: 22 coalitions that had had surgery were uncomplaining after intervention, including 1 patient who had had arthrodesis. 3 calcaneonavicular coalitions that had had excision and autogenous free fat graft had a relapse within 2 to 3 years. 2 of them had a revision and second-look excision of the bridge.

1 patient showed a suspicious relapse in MRI after excision of a calcaneonavicular coalition. 1 talocalcaneal coaltion that had had excision continued to have pain after surgery. Both patients did not want a revision.

1 patient who was treated by an arthrodesis of the subtalar joint had a fracture of the tibial head, where autogenous bone graft had been taken. Osteosynthesis of the tibia was performed.

4 patients had pain after excision of a calcaneonavicular coalition but could be relieved by conservative treatment.

For 5 patients adequate follow up is still pending due to short interval to surgery.

Pedobarography showed tendecies of improved pressure distribution of the treated feet that were not significant.

Conclusion: Excision and autogenous free fat graft should be first approach to surgery of symptomatical congenital tarsal coalitions for whom conservative treatment was not satisfying. When resected sufficiently the rate of relapse of the boney, cartilaginous or fibrous bridge is 7%. Depending on the patients age, the size of the affected area of the joint (50%) and secondary arthrotic changes of the joint an arthrodesis of the talo-calcaneal joint should be performed.