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: Congenital clubfoot deformity can cause significant disability, and if left untreated, may further impoverish those in developing countries, like Bangladesh. The Ponseti method has been strategically introduced in Bangladesh by a nongovernment organization, Walk For Life (WFL). WFL has provided free treatment for over 8000 Bangladeshi children with clubfeet, sustained by local ownership, and international support. This audit assesses the 2-year results in children for whom treatment began before the age of 3 years. METHODS: The 10 largest WFL clinics, of the 24 across Bangladesh, were pragmatically accessed in this audit availing 1442 subjects meeting the study criteria, from which 400 children were randomly selected and examined. A specific assessment tool was developed and validated. RESULTS: Results for 400 cases were returned: 269 males, 131 females. Typical clubfeet comprised 79% of cases, and 55% were bilateral. A tenotomy rate of 79%, and brace use after 2 years of 85%, were notable findings. Functionally, most children could walk independently (99.0%), run (95.5%), squat (93.3%), and manage steps unassisted (93.0%). The ability to squat was the most indicative outcome measure, correlating with: less corrective casts, good and continued brace use, nonvarus heel position, good ankle range of motion, good Bangla clubfoot scores, and the ability to walk. Relapsing deformity was suspected with heel varus (18.0% left; 21.5% right). Parental satisfaction was very high, but cost of 3000 Taka ($US 38.48) was deemed unaffordable by 59%. CONCLUSIONS: The outcomes in young children after 2 years of Ponseti treatment for clubfoot deformity showed that 99% were able to walk independently. The assessment tool developed for this study avails ongoing monitoring. Without the patronage of WFL, most of these children would not have had access to treatment, and be unable to walk. LEVEL OF EVIDENCE: Level II-lesser-quality prospective study.
