Clubfoot, Management and Barriers to treatment in underdeveloped countries.

CLUBFOOT, MANAGEMENT AND BARRIERS TO TREATMENT IN UNDERDEVELOPED COUNTRIES Clubfoot also known as CTEV (Congenital Talipes Equino Varus) is a congenital physical deformity in which a newborn’s baby foot are internally rotated at the ankle. The soles of the feet face each other while the toes are twisted downward and inwards. In 50% of cases both feet are affected. Male babies are two times more likely to get this deformity. According to National Institute of Health every 1 in 1000 babies are born with clubfoot.(1) It has been estimated that every year at least 150,000 are born with clubfoot. It may occur alone or in combination with multiple neuromuscular pathologies. Exact cause of clubfoot is still to be found but studies have shown many possible risk factors which may contribute to clubfoot. According to some studies smoking by mother during pregnancy may be one the most possible causes of clubfoot. It is also believed that if one parent is having this deformity, the newborn baby have the risk of getting it. The risk is even higher if both parents are affected. Many researches have been take place and still going on in developed countries but in underdeveloped countries many false perceptions and beliefs are found. In many countries of the world and backward areas clubfoot and such physical deformities are still linked with solar and lunar eclipses.(2) some people claim it punishment of God to the parents. In underdeveloped countries many clinicians who do not know anything about this deformity, advised parents to keep away from any treatment as it will get better as the child grows up. Some calls it a deficiency of vitamins. Some parents seek to religious healers. Some seek for surgery. And many think that just exercises and massage can correct it. Many children are left untreated as it is believed that it can’t be treated. In short, there is still too much work to be done about this deformity. We need to know what this deformity is. How and when it can be treated? And if not treated what complications can occur in the future? The most prominent method being carried out for clubfoot treatment is the “Ponseti Method”, developed by Ignacio Ponseti (1942-2009). It includes Manipulations by an expert physiotherapist, several serial castings and a minor surgical operation in which the Achilles tendon is released. If applied correctly and in time, individuals with clubfoot can be recovered up to 80%, except minor differences compared to normal foot. In developed countries a lot of researches, annual conferences and training sessions are arranged to educate people about this deformity, and to train medical professionals for successful treatment of clubfoot. But in underdeveloped countries there Is not such a system. Many false perceptions and believes are still present about clubfoot and generally all physical deformities. Many medical professionals and clinicians do not know about clubfoot, many don’t have the idea of treating it with a method of most accurate outcome. If there are any hospitals or facilities available to treat clubfoot, they don’t have any qualified or expert medical professionals. Parents don’t have any awareness about this deformity. They don’t know what the most appropriate time to start treatment is. As seen in general practice such children are brought for medical treatment when the deformity has been developed and is in worst condition. Generally at Government hospitals there are no any medical professionals who can perform Ponseti method, in rare situations it is available in private clinics which is too much expensive, roundabout 50 $ per session. Many parents don’t have enough money to continue the treatment for many sessions as in most cases correction cannot be gained in a single or two sessions. As seen in many cases if there is a free treatment available for Ponseti, it is not necessary to gain 100% correction through serial castings. As suggested by some studies in 80% of cases a minor surgical operation is required to release the rigid equinous. But often seen in underdeveloped countries due to lack of awareness, many parents refuse to perform surgery, which causes a hurdle in complete recovery of the equinous deformity. It has been noted that after serial castings when DB shoes and other corrective braces are applied, many parents don’t know how to fit them properly. Which is also a hurdle in gaining proper correction of the deformity? Many parents never visit the clinics in proper time, as proper follow up is a basic part of clubfoot treatment. Many children are brought to clinic so late for follow up, as the deformity is recurred. “Ponseti method” as it is considered as Gold standard for the treatment of clubfoot can be implemented accurately in underdeveloped countries only if the barriers are removed. The barriers can be summarized like:  Lack of awareness about clubfoot  Unqualified, inexperienced and untrained Ponseti method performers  No government hospital is providing Ponseti Method of treatment  Ponseti Method of treatment is very expensive in underdeveloped countries  Many parents are not ready to perform corrective surgery  Preventive braces are not used correctively  No proper follow up

References 1. .(http://orthoinfo.aaos.org/topic.cfm?topic=A00255) 2. Aziza Burfat, Shama Mohammad, Osama Siddiqui, Lubna samad, Understanding the knowledge and perception about clubfoot in Karachi, Pakistan.