ABSTRACT
BACKGROUND: 'Walk for Life' (WFL) is the sustainable clubfoot program in Bangladesh, where there are many challenges in implementing the Ponseti technique in a poor and highly populated country. The relapsing tendency of congenital clubfoot deformity means that initial results may well differ from those of the medium and longer term. Over 10000 children with16668 clubfeet have been treated by WFL since its inception in 2009. Such a large project provides both the need to evaluate each individual child's case, and also the opportunity to evaluate the wider WFL program results. Such systematic review requires a measure that is sufficiently robust, yet contextually practical, hence the aim of this work was to develop a tool for this purpose, and to report the examiner reliability. METHODS: The Bangla clubfoot tool was largely developed from components of existing validated clubfoot assessment measures, and adapted for local use. Three areas of examination are included: parent satisfaction, gait, clinical examination of the clubfoot. A same-subject repeated measures study design was used to assess the intra-rater reliability of a local WFL physiotherapist, and a visiting WFL volunteer. The inter-rater reliability was also assessed, which is relevant for other examiners and other clubfoot projects undertaking evaluation of medium and longer term results. RESULTS: The reliability study was conducted in 37 children who had commenced treatment for congenital clubfoot deformity using Ponseti method within the previous two years. The mean age of the children was 2.6 years, with gender 28 male: 9 female. The intra-rater reliability results [ICCs (95% CI)] were: 0.87 (0.76 - 0.93) for the local WFL examiner, and 0.82 (0.64 - 0.91) for the visiting examiner. Inter-rater reliability results [ICCs (95% CI)] were: 0.92 (0.88 - 0.96). Hence the tool showed very good intra-rater and inter-rater reliability, rendering it suitable for use. CONCLUSIONS: The Bangla clubfoot tool has been developed to suit the context of the large WFL clubfoot program in Bangladesh, and shown to be a very reliable evaluation instrument.
ABSTRACT
BACKGROUND: Bangladesh is one of the most populous countries in the world at 160 million with 1/3 existing below the poverty line. With an annual birth rate of approximately 3.2 million, an estimated incidence of 1:900 live births, the country has approximately 5000 new cases of idiopathic congenital talipes equinovarus per annum. The Bangladesh sustainable clubfoot program, Walk for Life (WFL), was conceived to respond to this unmet need. METHODS: WFL started in 2009 and has rapidly grown to 35 clinics. Overseas experts initially increased local capacity by training a team of national paramedical staff. Government support enabled integration with the public hospital system and enhanced sustainability. WFL has supplied materials, educational, administrative, and clinical support throughout. All recruited cases underwent Ponseti casting. Demographic, Pirani scores, cast, tenotomy, and bracing data have been prospectively collected from all patients. Detailed review has been undertaken for 1040 patients after 12 months of treatment in 3 divisions of Bangladesh. RESULTS: Between 2009 and 2011, 6069 feet (3922 patients) were recruited to the project. Of these 1643 feet (1040 patients) have completed a minimum of 1-year follow-up. The male:female ratio was 2.7:1 with a mean age of 22 months at presentation (range, 0 to 36). Typical idiopathic congenital talipes equinovarus responded in a median of 5 casts (range, 1 to 25) with 76% undergoing tenotomy. Thirteen percent were atypical feet requiring a median of 5 casts. The percentage of patients missing at the 12-month point was 12%. Two percent of patients experienced complications. CONCLUSIONS: The Bangladesh clubfoot program demonstrates that rapid case ascertainment is possible in a developing world setting with appropriate logistical support. The use of local physiotherapists and paramedics yielded good clinical outcomes in an environment with full access to clinical review and ongoing training. A higher than expected number of atypical cases have been noted, requiring modified Ponseti treatment. Complications have been few at this early stage. LEVEL OF EVIDENCE: Level 2-therapeutic study.
