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 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. 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.

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

2. It is the most common congenital deformity of ankle and
foot.

3. 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.

4. The treatment should start soon after birth

5. Early treated Neglected

6. CLUBFOOT SIGNS
 Forefoot Cavus
 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
CAVE sign

7. 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.

8. CLUBFOOT SIGNS (Continued)
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
Midfoot
Adduction

9. 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.

11. 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

12. Our Fight
against Clubfoot
Started on July 2009
Started on Feb 2010

13.  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.

14. 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. 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
July 17, 201415

16. MATERIALS AND METHOD
July 17, 201416
 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.

17.  Chittagong
 Cox's Bazar
 Khagrachhori
 Comilla
 Noakhali
 Chandpur
 Brahmanbaria
 Feni
 Lakshmipur
 Rangamati
 Bandarban

18. 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.
July 17, 201418

19. FINAL OUTCOME MEASUREMENT
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
Score ranges: 0 - 0.5 - 1.0

20. Demographic
Variables
Variables
No. of Patients 664
No. of Feet 1091
Bilateral
Involvement
(no. of patients)
364 (54.8%)
Age range 6 days to 5 years
Male 463 (70%)
Female 201 (30%)
Initial mean Pirani
score per foot
5.2
July 17, 201420
54.80%46.20%
Foot involved
Bilateral Unilateral
70%
30%
Sex ratio
Male Female

21. Clinical data
Variables
Type of
Clubfoot
Typical -
Flexible
Typical - Rigid Atypical
No of feet 538 (49%) 389 (36%) 164 (15%)
Any Previous
treatment?
NO Yes -
conservative
Yes - Surgery
No. of feet 609 443 39
July 17, 201421
Patients Feet
Missed out 194 319 (29%)
Full correction by
Ponseti
361 593 (54%)
Tenotomy done 271 445 (75%)
Referred for Surgery 109 179 (17%)

22. 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.
July 17, 201422

23. Effect of Treatment in Different
age groups
Total Full
Correction
(Final Pirani
Score <1)
By Ponseti By Surgery
Feet 772 593 77% 179 23%
Patients 470 361 77% 109 23%
Age range
0 - 6 m 213 206 97% 7 3.3%
6m - 1y 69 64 93% 5 7.2%
1 - 3y 121 85 70% 36 30%
3 - 5y 67 6 9% 61 91%
July 17, 201423

24. Casting
July 17, 201424

25. ImanHabib

28. Brace Follow up
No. of
patients on
FAB
On Regular
follow up
Irregular in
Follow up
Relapse
361 227 108 26
July 17, 201428
63%
30%
7%
Follow up
Regular Irregular Relapse

29. Take home Massage
July 17, 201429
 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.

30. Two years journey…
Year Patients Feet
2010 230 349
2011 477 742

31. How do we
find patients?

32. 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

33. 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.