Management Of Clubfoot Research Articles

Clubfoot management in the Middle East: a survey-based review.

Clubfoot is the most frequent congenital deformity involving the foot. Little is known about the management of this disease in the Middle East as sparse data is available in the literature. Through the last 5 decades, congenital clubfoot management in the Middle East went from manipulation through Kite’s technique in the late seventies, to early primary surgical intervention in the late eighties and early nineties of the previous century, and then back to manipulation with Ponseti’s technique and the French functional technique in the late nineties, with the latter falling out of favor with time. This is comparable to the evolution of management witnessed in the United States and in Europe, with 10 to 15 years of delay. The delay is getting shorter with time due to the easier access to published scientific data and the increasing number of fellows from Middle East travelling to referral centers in Europe and the USA. A survey was performed among pediatric orthopedic surgeons in the Middle East to assess their approach to clubfoot management. This is the first survey of its kind in the region. It showed a wide adoption (97.1%) of the Ponseti’s technique with serial manipulation and casting, Achilles tenotomy followed by abduction bracing. Divergent practices were found concerning the upper age limit for Ponseti treatment and the setting of the Achilles tenotomy. Nevertheless, these subjects are still a matter of debate in the literature and international conferences. All in all, pediatric orthopedic surgeons in the Middle East are offering their patients the gold standard of care. However, lot of work is to be done in raising awareness for this disease in the community, and among our colleagues as prenatal screening for clubfoot in the Middle East is practically nonexistent.

Narrative review of the management of a relapsed clubfoot.

The management of idiopathic clubfoot has transformed over the past several decades as the Ponseti method for the correction of this deformity became the standard of care, and surgical release has almost all but been abandoned. The Ponseti method has shown very high initial success rate and excellent long-term functional results. Relapse of the deformity, however, continues to be a major problem, occurring in up to 40% of patient, and there is no consensus on the definition and management of the relapsed clubfoot. This review discusses the available management options for the treatment of a relapsed clubfoot deformity following initial treatment with the Ponseti method [including repeat casting, tendo-Achilles lengthening, plantar fascia release, and tibialis anterior tendon transfer (TATT)] as well as following initial surgical treatment with posteromedial release (including casting, hemiepiphysiodesis, revised posteromedial release, osteotomies, fusion, and the use of gradual distraction with external fixators). These are discussed from the least to the most invasive. Available evidence, and limitations of the literature, for the management of relapses following both the Ponseti method and initial surgical release is reviewed along with along with the reported outcomes. Future efforts should be geared towards standardizing the definition of a relapse with objective criteria for its management.

Effectiveness of Ponseti Versus Kite Method for the Management of Club Foot- A Quasi Experimental Trial

Objective: To determine the effectiveness of ponseti versus kite method for the management of club foot among children. Methods: A quasi experimental trial was conducted to determine the most effective conservative method for managing idiopathic club foot. This study was carried out in District Head Quarter Hospital, Layyah. A total of 46 children (60 Feet) aged less than six months of both genders were included in this study using convenience sampling technique. The study sample was divided into Group A (Ponseti) and Group B (Kite). Each treatment group comprises of 30 feet. Patients were called for weekly follow up till ten weeks consecutively. At every follow-up visit, patients were assessed to check the improvement of deformity with the help of the Pirani scoring system for the foot. Pirani score difference was measured in both treatment groups from the baseline until the last follow-up interval until the 10th Week. Pirani score difference was measured in both treatment groups from the baseline until the last follow-up interval until the 10th Week. A greater negative value signified better correction. SPSS 23 was used for data entry and analysis. Results: Children's mean age in both treatment groups (A and B) was 10.83±4.59 and 10.20±4.75 weeks. At presentation mean Pirani score in both treatment groups (A and B) was 5.85±0.67 and 5.86±0.45, respectively, while at 10th follow up it was 1.42±0.39 and 2.35±0.54 for group A and group B, respectively. Conclusion: This study demonstrates that the Ponseti technique significantly improved the management of club foot as that of the Kites method. Ponseti's method is more effective in terms of rapid improvement in the involved group. Key words: Non operative Management, Idiopathic Club foot, Kites method, Ponseti method.

The foot external rotation above-knee (FERAK) brace versus the Denis Browne brace for management of idiopathic clubfoot following Ponseti casting: a randomized controlled trial.

To compare the foot external rotation above-knee (FERAK) brace and the Denis Browne boot (DBB) brace in terms of relapse prevention and parents' compliance after successful correction with Ponseti casting. A single-centre, randomized controlled study was conducted between 2016 and 2020. A total of 60 feet in 38 patients with idiopathic clubfoot initially corrected with the Ponseti method were included. They were randomized into two equal groups: the FERAK group and the DBB group. The primary outcome was the efficacy in maintaining correction measured by the Pirani score. The secondary outcomes were parents' compliance and complications (e.g., relapses, skin complications). The follow-up period was 24months for each patient. The mean final Pirani score was 0.42 ± 0.76 in the FERAK group and 0.57 ± 0.82 in the DBB group. This difference was statistically insignificant (p-value = 0.411). Regarding parents' compliance in the FERAK group, 86.7% of parents had good and intermediate compliance while 13.3% had bad compliance. In the DBB group, 66.7% had good and intermediate compliance while 33.3% had bad compliance. This difference was also statistically insignificant (p-value = 0.118). Both braces achieved good comparable outcomes after Ponseti casting. However, the FERAK brace yielded slightly better parents' compliance with a less recurrence rate.

Development of a core outcome set for idiopathic clubfoot management.

AimsThis study aims to define a set of core outcomes (COS) to allow consistent reporting in order to compare results and assist in treatment decisions for idiopathic clubfoot.MethodsA list of outcomes will be obtained in a three-stage process from the literature and from key stakeholders (patients, parents, surgeons, and healthcare professionals). Important outcomes for patients and parents will be collected from a group of children with idiopathic clubfoot and their parents through questionnaires and interviews. The outcomes identified during this process will be combined with the list of outcomes previously obtained from a systematic review, with each outcome assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). This stage will be followed by a two round Delphi survey aimed at key stakeholders in the management of idiopathic clubfoot. The final outcomes list obtained will then be discussed in a consensus meeting of representative key stakeholders.ConclusionThe inconsistency in outcomes reporting in studies investigating idiopathic clubfoot has made it difficult to define the success rate of treatments and to compare findings between studies. The development of a COS seeks to define a minimum standard set of outcomes to collect in all future clinical trials for this condition, to facilitate comparisons between studies and to aid decisions in treatment.Cite this article: Bone Jt Open 2021;2(4):255–260.

A COMPARATIVE STUDY TO EVALUATE THE OUTCOME OF PONSETI'S TECHNIQUE AND ACCELERATED PONSETI'S TECHNIQUE FOR CORRECTION OF CLUBFOOT

Introduction: Clubfoot is a common congenital deformity with incidence of1-6.8/1000 live births. Ponseti method is currently the gold standard for treatment of clubfoot which conventionally involves weekly plaster changes. A prospective comparative study was carried out at our hospital where we compared one group with weekly plaster change to other group with twice weekly plaster change, using the classical Ponseti protocol of manipulation. A total 50 feet (36 children ), divided into two Methods: groups, were randomly allocated to either Group 1 – 25 feet(accelerated Ponseti) or Group 2 – 25 feet (standard Ponseti). Group 2 underwent serial manipulations and casting once a week and Group 1 received manipulations and castings twice a week. Pirani score was documented at the time of presentation, after each cast, and at the time of removalof nal cast to assess the success of treatment ( Pirani score ≤1). A tota Results: l 43 feet (29 patients) underwent the entire course of treatment, while 7 patients discontinued the treatment during the course of the study. 14 patients, i.e, 21 feet were treated with Accelerated Ponseti Protocol (APP),i.e Group -1, and 15 patients, i.e, 22 feet were treated with Standard Ponseti Protocol (SPP), i.e Group-2. Mean duration of treatment from the rst cast to tenotomy in the accelerated ponseti protocol group was 20.57 ± 4.5 days (ranging from 12 to 29 days), and in standard ponseti protocol group was 39.66 ± 6.9 days (ranging from 29 to 51 days). Conclusion: Both the methods proved to be equally efcacious for the management of clubfoot in our study. However, the accelerated method had an overall shorter treatment duration making it convenient for the parents. As the patient is under direct observation of surgeons, complications, in any, are detected early and easily. Overall, the accelerated technique is more practical, benecial, and equally efcacious as standard ponseti technique, providing a more rapid correction of the deformity.

20 years of functional treatment for clubfoot: advantages and limitations compared with the Ponseti method.

Currently, the Ponseti method has become the most popular technique for the management of congenital clubfoot. Besides this treatment, the functional method or the 'French method' (FFM) represents another treatment option. Throughout our study, we will describe this method, based on the 'Saint Vincent de Paul' protocol with some modifications that we bring progressively. Carried out over the last 20 years at our institution. In total 145 children (210 clubfeet) were treated using FFM. Our technique is based on the 'Saint Vincent de Paul' protocol from Paris. This method consists of daily manipulations of the feet by specialised physiotherapists associated with thermoformable orthotics devices. An evaluation of the patient at 5 year of age is performed. Gait analysis was introduced in 2011 as a complementary assessment tool. Less than 15% of the feet underwent a surgical procedure at walking age. Compliance to treatment was significantly higher than with the Ponseti method. At the last follow-up, 80% of the children had good to excellent results without major residual deformity. Totally 7% of the children required a later intervention either for recurrence or for major residual deformity. FFM is an alternative approach in the management of clubfoot that has proven to be successful due to the precision and modularity of its splinting system. Good compliance and low recurrence rate are other elements to consider. However, it requires a well-trained physical therapist. The main disadvantages of this method are the high cost compared to the Ponseti method and the difficulty of applying this method in developing countries.

Evaluation of effectiveness of Ponseti's method in the clubfoot management under 1-year children: a prospective study

<p class="abstract"><strong>Background:</strong> Congenital talipes equino Varus is common congenital orthopedic foot deformity in children characterized by hindfootequinus, hind foot varus, midfoot cavus, and forefoot adduction deformities. There is a necessity to analyze the number of casts employed in the treatment, compliance of bracing, relapse pattern and percentages of surgical referral under 1 year of age for clear understanding and better practice to achieve successful outcomes. This study aimed to judge the effectiveness of Ponseti in the treatment of clubfoot under 1-year old children. </p><p class="abstract"><strong>Methods:</strong> The patients were selected in the OPD and evaluated for virgin idiopathic clubfoot under 1-year age. Serial casting done weekly by Ponseti method after assessing Pirani and Demeglio score before every cast.</p><p class="abstract"><strong>Results:</strong> In our study all 29 clubfeet that were treated by Ponseti method showed complete correction. Minimum cast being 5 and maximum being 10 casts. Corrected feet were supple, plantigrade and painless of which 1 foot had relapse<3weeks due to ill-fitting shoes. Which was subsequently corrected with repeat tenotomy and cast application.</p><p class="abstract"><strong>Conclusions:</strong> The Ponseti method is a safe, effective, cheap and reproducible method for correction of CTEV which significantly reduces the rate of extensive corrective surgeries for correction of clubfoot under 1-year age. For successful outcome and to prevent relapse, this technique must be applied strictly in accordance to the protocol and parents must be taught the importance of full compliance with bracing. Our series has a short follow up. Longer follow-up is needed for further evaluation of effectiveness of Ponseti method. </p>

A Study of orthopaedic management of club foot at tertiary health care centre

A Study of orthopaedic management of club foot at tertiary health care centre

A survey on idiopathic congenital talipes equinovarus (ICTEV) managed by the Ponseti technique at Mulago Hospital - Uganda.

IntroductionPonseti technique is the treatment of choice for idiopathic congential talipes equino varus (ICTEV) since 1950s with excellent treatment outcomes reported worldwide. However, despite the popularity of this technique, Uganda adapted it as a treatment modality for ICTEV in May 2005. Since then, the effectiveness of delivered Ponseti care to children with this very common orthopaedic deformity under the supervision of an orthopaedic surgeon was unknown. The implication of this undertaking was that, satisfactory outcomes would then support the Ministry of Health (MOH)-Uganda´s decision to embrace this mode of treatment and if the outcomes were unsatisfactory, MOH would then consider a policy revision in this regard. To assess the midterm treatment outcomes of children with ICTEV who had been enrolled for treatment at Mulago National Referral Hospital in the period of 2006-2009.Methodsin November/December 2013, a cross-sectional study was conducted to assess the treatment outcomes of 68 feet of 45 children using the designed questionnaire and the PBS score; a pilot study of 10 neonates was performed prior to research. A good treatment outcome meant having a foot or feet that did not require any major or minor surgery.Resultsforty-five (45) children with 68 ICTEV feet were evaluated; males 29 (64.4%) and 16 (35.6%) females with a mean age of 73.22 months (SD 11.364, range 48-96 months). Among the feet assessed, 46 (68%) had good to excellent outcomes while 22 (32%) had a relapse of moderate and severe deformity. Good functionality was seen in 61.8% out of which, 69% and 55.9% had no limitation in walking or running respectively.ConclusionPonseti treatment technique in children with ICTEV under the care of predominantly orthopaedic officers with some supervision from orthopaedic surgeons had fair to good midterm outcomes even in low resource settings like Uganda. Public health approach should be embraced in the management of clubfoot in Uganda by enhancing adequate comprehensive support supervision and establishment of reliable institutionalized systems for patient follow up which will lead to early detection and treatment of relapsed ICTEV cases or neglected clubfeet in the communities.

Ponseti Method versus Posteromedial Soft Tissue Release for the Management of Clubfoot: A Prospective Interventional Study

Ponseti Method versus Posteromedial Soft Tissue Release for the Management of Clubfoot: A Prospective Interventional Study

Correction of clubfoot by ponseti method - Our experience

Background: Congenital idiopathic clubfoot is a complex deformity which occurs in an otherwise normal child. The Ponseti method of clubfoot management has been shown to be effective, producing better results and fewer complications than traditional surgical methods. Weekly manipulation and plaster casting reduce the deformity. Most feet also require a percutaneous Achilles tenotomy. The correction is maintained by a foot abduction brace (Dennis Browne splint). Recent studies suggest that the Ponseti method can be successful in up to 98% of feet. Objective: The purpose of this study was to assess the results of correction of idiopathic clubfoot by Ponseti method and its complications in children below 2 years of age. Methodology: It is a prospective study in 37 children below 2years of age with idiopathic clubfoot treated by Ponseti method. The study was conducted from august 2016 to august 2018 in Yashoda Superspeciality Hospital, Hyderabad. Observation and Analysis: The mean age of the patient’s was 35 weeks (0-120). Of 37 patients, 25 children presented between 0-6 months, 6 between 6 to 12 months and 6 between 1- 2 years. Among 37 children, 29 were male and 8 were female. Most children had grade III and grade IV (Dimeglio et al. grading) deformity. The average number of casts was 5.1, 5.5 and 7.4 for the age groups 0-6 months, 6 months to 1 year and 1-2 years respectively. The mean number of casts required was 5.76 (4 to 10). Tenotomy was required in 51 feet (100%). The scores for the entire group ranged from 4.0 to 7.0 (of 10) and 4 to 19 (of 20) in the Dimeglio classification. Pirani scores for the age group 0- 6 months were 4.46, 6 months to 1 year were 5.36 and 1-2 years were 5.75 respectively. The results were excellent in 88.3% and good in 11.7%.The mean of initial and final Pirani score is 3.52083 with a ‘ p’ value is 0.000 which is less than 0.01 hence they are statistically significant. Conclusion: Congenital talipes equinovarus (C.T.E.V) is the commonest of all the foot deformities being commoner in male children and bilateral in 66% of cases, idiopathic type being the commonest form. We conclude that the Ponseti method is safe and effective treatment for congenital idiopathic clubfoot in children up to 6 years of age.

Tratamiento del pie equino varo asociado a síndromes. Revisión de conceptos actuales

Congenital clubfoot secondary to syndromes that produce contractures such as spina bifida and arthrogryposis are challenging, because the rigidity of the deformity and the high percentage of recurrences. In the literature there are multiple treatment strategies, most of them with invasive methods and extensive surgeries that can generate multiple alterations in the shape and mobility of the foot.The Ponseti method has positioned as the gold standard treatment for the management of idiopathic clubfoot. In recent years, multiple studies have shown the application of the method in foot deformities associated with syndromes.The overall purpose of the review is to highlight the current PEVC approach associated with syndromes, focusing on what points should be considered before starting treatment and how to apply the Ponseti method in this group of patients.Evidence Level: IV.

Managing clubfoot with Ponseti method: Our experience with children upto 3 years of age

Introduction: Ponseti method has become the mainstay of congenital clubfoot treatment in children presenting at early age. The initial efficacy rate of Ponseti method reaches almost 100%. The Ponseti method is also effective in older children with varied degree of success and preventing open joint surgery in almost every case. The Pirani method of evaluating the deformity and treatment outcome is easy and fairly reproducible and corresponds to the functional outcome of the treated feet. Aim: The present study aims at elucidating the efficacy of Ponseti method of clubfoot correction in an inexperienced hand and evaluating the feasibility and worth of Pirani severity scoring system in deformity and treatment evaluation. Materials and Methods: This is a prospective study carried out ii our institution Shri Guru Ram Rain Medical College Dehradun, India over a period of 2 ½ years from June 2015 to December 2017 and includes 44 idiopathic Clubfeet corrective cast application at weekly interval as per Ponseti protocol and were assessed with Pirani scoring system. The cases were followed up regularly at least for 6 months. Results: Following Ponseti protocol, we were able to achieve success rate of 95.45%. We experienced only a few minor complications such as plaster sores and overcrowding of toes that too in initial phase of study. Conclusion: Ponseti method is truly the gold standard of clubfoot management. Using Ponseti method, one can expect to achieve almost 100% success rate. It is also fairly effective in older children though with varied outcome or can at least prevent open joint surgery in them. The Pirani scoring system is clinical based, easy to apply and is in sync with Ponseti method. Keywords: Clubfoot, Ponseti method, Pirani score.

Implementation of a Ponseti Clubfoot Program Decreases Major Surgery: A Quality Improvement Initiative.

We established a clubfoot program that aimed to (1) develop a standardized treatment pathway; (2) improve care team education; (3) improve coordination of care with families; and (4) improve documentation. The purpose of this study was to outline our quality improvement intervention and evaluate its success. Data were retrospectively collected from isolated clubfeet before (2003-2007, phase I) and after (2012-2014, phase II) implementation of the clubfoot program. We compared the differences in treatment and major recurrence between the 2 phases using generalized logistic or linear mixed models. Modified Poisson regression models were used to evaluate the association between provider nonadherence and recurrence. The pre- (phase I) and post- (phase II) implementation groups included 91 patients (131 feet) and 68 patients (101 feet), respectively. The incidence of major recurrence (odds ratio: 59.5, 95% confidence interval: 7.8-454.4, P < 0.0001) was lower during phase II compared to phase I. Nonadherence with the care pathway was associated with an increased risk of recurrence (risk ratio: 4.1, 95% confidence interval: 1.2-14.3, P = 0.0274). The implementation of a clubfoot program was associated with a decrease in major clubfoot surgery and improved adherence to established guidelines for clubfoot management.

Changes in the Management of Clubfoot Cases During COVID-19 Pandemic-A Survey Among Orthopaedic Specialists.

PurposeThe on-going COVID-19 pandemic has curtailed the established practice norms of many ailments including clubfoot. We conducted a survey to study the changes in the clubfoot treatment practices, Achilles tenotomy methods, and the role along with the possible impact of teleconsultation during this pandemic.MethodsA web-based survey was conducted using a questionnaire prepared on Google forms. The link for this questionnaire was sent to Indian Orthopaedic specialists with a special interest in clubfoot management via a social messaging platform.Results127 eligible responses were analysed. Of them, 67% respondents were in practice for more than 10 years. During the study period, 30.7% of doctors did not perform any casting; 66.9% performed casting in 1–5 cases per week and only 2.4% performed casting in more than five cases per week. A statistically significant difference was noted in the number of doctors who performed casting in less than five cases per week and the doctors who performed casting in more than five cases per week, before and during the COVID-19 pandemic. 30.7% of doctors deferred doing Achilles tenotomy during the study period, and among those who performed one, a significant number of them avoided tenotomy under general anaesthesia.ConclusionThe COVID-19 pandemic has significantly impacted clubfoot treatment practices during the lockdown period in India. Significant reductions in the number of cases, and a reduction with changes in Achilles tenotomy practices were noted too. However, whether this had any adverse influence on the eventual outcome in these feet is yet to be determined.Electronic supplementary materialThe online version of this article (10.1007/s43465-020-00277-2) contains supplementary material, which is available to authorized users.

Functional Implications of the Flat-Topped Talus Following Treatment of Idiopathic Clubfoot Deformity

Category:Hindfoot; OtherIntroduction/Purpose:The flat-top talar dome is a well-known potential consequence of both operative and non-operative clubfoot management. While it is assumed that patients with a flat-top talus will have greater problems with daily activity, the functional impact of this deformity has not been characterized in the literature. The purpose of this study is to analyze the relationship between talar dome morphology and ankle function at skeletal maturity in patients treated for idiopathic clubfoot deformity during infancy.Methods:33 skeletally mature patients (average age 17.9 years, SD 1.6 years) with 52 idiopathic clubfeet were identified from our institution’s clubfoot registry. Plain weight bearing lateral foot films, gait analysis and patient reported outcomes (PRO) using the Pediatric Orthopaedic Data Collection Instrument (PODCI) were obtained in all patients. Radius of curvature (ROC) of the talar dome and tibial plafond were measured along with numerous other parameters of talar and calcaneal morphology. Other measurements included talar dome radius to talar length (R/L) ratio, opening angle of the talar dome (alpha-angle), and talar dome to tibial plafond ROC (TD/TP) ratio. All measurements were correlated to PODCI scores and gait analysis data.Results:Patients demonstrated variability in talar dome ROC (mean 33.1mm, SD 19.6mm), R/L ratio (mean 0.60, SD 0.39), alpha- angle (mean 88.7°, SD 29.5°) and TD/TP ratio (mean 1.17, SD 0.44). Increased TD/TP ratio correlated negatively with maximal plantarflexion (r=0.404, p=0.005), ankle range of motion (ROM) (r=0.383, p=0.008) and maximum power generation during step off (r=0.381, p=0.008). Higher alpha-angle correlated positively with plantarflexion (r=0.404, p=0.005), ankle ROM (r=0.383, p=0.008) and maximum ankle power generation (r=0.381, p=0.008). Lower talar dome ROC correlated with increased maximum power generation (r=0.326, p=0.025). Increased R/L and TD/TP ratios correlated negatively with PODCI happiness domain scores (r=-0.353, p=0.044; r=-0.377, p=0.025, respectively). Talar length correlated with higher happiness and global function scores (r=0.393, p=0.024; r=0.360, p=0.040, respectively) and lower pain scores (r=0.354, p=0.043).Conclusion:While flatness of talar dome correlates significantly with altered gait mechanics, the effects on patient reported function are more modest during the second decade of life. Further study is required to assess the longer-term effects of the flat top talus on function and joint health.

Treatment evaluation of clubfoot condition by Ponseti method prevalence and clinical outcomes of spinal tuberculosis with multi drug resistance

Introduction: Dr. Ponseti developed a method of clubfoot correction that is effective, inexpensive. Many long-term follow-up studies reveal that foot treated by Ponseti technique are strong, flexible, and pain‑free. The correction achieved has been reported as being long lasting with some patients followed up to their fourth or fifth decade. Hence the present study was to assess the efficacy of Ponseti method in the management of Idiopathic Clubfoot. Materials & Methods: As per the criteria, a total of 72 clubfoot diagnosed with the condition of iditopathic clubfoot were included in the study. In all the included babies the Pirani scoring was done to assess the severity of the condition. The deformity of the cavus was corrected first by supinating the forefoot to bring in the alignment with the hindfoot. Results: When the treatment was completed the post treatment Pirani score was found to be decreased in all the age group patients. In the resent study around 52 feet did required to undergo tenotomy. Results clearly states that more severity in deformity or late presentation of condition for treatment, more will be the visit required with increase number of casting. Conclusion: The Ponseti method of clubfoot treatment is an excellent method as per our study. The follow-up of patients treated with this method has been over 40 years in some of the previous studies. Results of the clubfoot treatment by Ponseti technique in our study have been good and rewarding and now all the clubfeet are treated in our institution by this technique only.

Higher Rates of Achilles Tenotomy after a Didactic Session on Ponseti Method.

We have conducted a retrospective study to know the impact of a didactic sitting on the Ponseti method of clubfoot management. We have compared the outcome of patients managed by orthopaedic residents who attended such a session with that of patients treated by residents who didn’t get this additional training. The results revealed that the frequency of PTA tenotomy was significantly higher in the additionally-trained group compared to the classically-trained group, which emphasises the role of regular such meetings.

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

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.