4 th year of specialization in orthopedic surgery
Management and outcome of clubfoot treatment in disadvantaged populations in lower middle-income countries
Pediatric surgery department, The Indus Hospital, Karachi, Pakistan
Through study 1, we aim to compare the clinical outcomes and complication rate in
children receiving either a blade or a needle percutaneous tenotomy.
Hypothesis: 1) Percutaneous needle tenotomy has a better clinical outcome compared to the use of a percutaneous blade tenotomy when comparing the patient’s Pirani scores and dorsiflexion rate. 2)Percutaneous needle tenotomy has a lower complication rate compared to a percutaneous blade tenotomy.
Objectives: Through study 2 we aim to evaluate the clinical outcome of extensive surgery for neglected clubfoot in children above walking age in a low-resource setting Hypothesis: 1) Participation in activities of daily life will increase and pain will decrease after surgery, 2) Surgical care and surgical follow-up can be provided in a safe, appropriate and sustainable way through collaboration between local and international surgeons
Objectives: With study 3, we would like to get an insight in the socio-economic risk factors associated with lack of compliance to the prescribed treatment, dropout from the clubfoot program and relapse of clubfoot. Based on the findings of this study strategies can be developed to address specific issues that contribute to poor outcomes.
Hypothesis: 1) Compliance to the prescribed Ponseti treatment protocol, dropout Ponseti treatment protocol and relapse of clubfoot in children treated by the Ponseti treatment in a low-resource setting is associated with certain household level socio-economic factors.
2) Presence of one of the aforementioned adverse events, increases the risk of presenting with an additional adverse event.
3) Presentation of an adverse event earlier in the treatment program correlates with worse outcomes Objectives: Through study 4 we aim to identify functional aspects of the Pehlza Qadam program that are reproducible abroad as well as remaining barriers and modifiable obstacles among vulnerable sub-populations when accessing clubfoot care for their children. Hypothesis: to be determined based on outcomes of the three aforementioned studies
Idiopathic clubfoot is the most common musculoskeletal congenital malformation needing
intensive orthopedic treatment. It affects 1/1000 alive born infants, of whom 80% are born in low or
middle income countries and face difficulty accessing treatment. Ponseti casting remains the preferred
treatment, however rigid or recurrent clubfeet will need surgical treatment. Access to Ponseti treatment or surgical care is limited throughout low and middle income countries, with little research on long term outcomes of treatment in vulnerable populations in resource poor settings.
Through 4 different studies both clinical and public health aspects of clubfoot treatment in low and middle income countries will be examined. In the clinical part both the outcomes of the conservative Ponseti treatment as well as the outcomes of surgical treatment will be examined. Two different countries, Pakistan and Bangladesh, have been selected with a similar cultural and socio economic setup to execute these studies.
Main hypothesis: Providing culturally sensitive, appropriate and qualitative clubfoot care for vulnerable populations in low and middle income countries is feasible by adaptation of treatment protocols and follow up schemes to correlate better with specific patient’s needs in low resource settings.
The treatment coverage of the Ponseti treatment is estimated at less than 15% worldwide.
A serious investment into training of local health care providers, awareness creation among parents and guardians and program development around the world is needed to achieve universal access to Ponseti treatment around the globe. By evaluating clinical and programmatic aspects of Ponseti clubfoot care in vulnerable populations, this PhD project could contribute to a sustainable upscale of clubfoot care in low and middle income countries in the future.