Remote monitoring of clubfoot treatment with digital photographs in low resource settings: Is it accurate?

Tracey Smythe,Debra Mudariki,Tim Theologis,Laura J Clifton,Marie-Caroline Nogaro,Chris Lavy

doi:10.1371/journal.pone.0232878

Abstract

Clinical examination and functional assessment are often the first steps to assess outcome of clubfoot treatment. Clinical photographs may be an adjunct used to assess treatment outcomes in lower resourced settings where physical review by a specialist is limited. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment. In this single-centre diagnostic accuracy study, we included all children with clubfoot from a cohort treated between 2011 and 2013, in 2017. Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required. Photographic images were then taken of 79 feet. Two blinded orthopaedic surgeons assessed three sets of images of each foot (n = 237 in total) at two time points (two months apart). Treatment for each foot was rated as 'success', 'borderline' or 'failure'. Intra- and inter-observer variation for the photographic image was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the photographic image compared to the ACT score. There was perfect correlation between clinical assessment and photographic evaluation of both raters at both time-points in 38 (48%) feet. The raters demonstrated acceptable reliability with re-scoring photographs (rater 1, k = 0.55; rater 2, k = 0.88). Thirty percent (n = 71) of photographs were assessed as poor quality image or sub-optimal patient position. Sensitivity of outcome with photograph compared to ACT score was 83.3%-88.3% and specificity ranged from 57.9%-73.3%. Digital photography may help to confirm, but not exclude, success of clubfoot treatment. Future work to establish photographic parameters as an adjunct to assessing treatment outcomes, and guidance on a standardised protocol for photographs, may be beneficial in the follow up of children who have treated clubfoot in isolated communities or lower resourced settings.

Highlights

Clubfoot, or congenital talipes equinovarus (CTEV) is one of the most common musculoskeletal deformities seen at birth
We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment
Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required

Summary

Introduction

Congenital talipes equinovarus (CTEV) is one of the most common musculoskeletal deformities seen at birth. More than 95% of cases are successfully treated with the Ponseti method [3, 4] This minimally invasive technique consists of two distinct phases, the correction phase with manipulation, casting and often an Achilles tenotomy, and the maintenance phase with use of a foot abduction brace (FAB). In LMIC these cases are often managed by clinical officers and physiotherapists [5,6,7] and input from orthopaedic surgeons may be necessary to perform a percutaneous Achilles tenotomy for residual equinus deformity, or if there is recurrence of the deformity following casting. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment

Objectives

Methods

Results

Conclusion