Project Proposal by Dr.
Monica Nogueria:
Conservative
Treatment of Clubfoot with Ponseti technique –
Training Orthopaedic
Surgeons in Brazil
Brazilian Paediatric Orthopaedic
Society (SBOP), affiliated to the Brazilian Orthopaedic and Traumatology
Society (SBOT)
It is estimated that more than 100,000 babies are born
worldwide each year with congenital clubfoot. Eighty percent of the
cases occur in developing nations. Most are untreated or poorly treated.
Neglected clubfoot causes crushing physical, social, psychological, and
financial burdens on the patients, their families, and the society.
Globally, neglected clubfoot is the most serious cause of physical
disability among congenital musculoskeletal defects.
In our country,
Brazil, we have 2,53 births per 1000 and a clubfoot incidence of 2 in
each 1000 children born: we have about 7300 Brazilian children born with
clubfeet every year.
Treatment is economical and easy on babies. If well
implemented, it will greatly decrease the number of clubfoot cripples.
The child with
neglected clubfoot is condemned to the downward spiral of deformity,
disability, dependency, demoralization, depression, and despair.
Digging, ploughing, harvesting, and carrying firewood and water are
unmanageable tasks for children whose limbs are maimed by heredity,
accident, or disease. These children are intellectually capable of
integrating into the normal school system but never have the opportunity
because their needs are not a high priority. Fewer than 2% of children
with disabilities attend school in developing countries. The more
difficulty the children experience in locomotion, the less likely they
are to attend school.
In agrarian societies,
physical disability is a major cause of poverty and ill health.
Afflicted individuals are socially and economically disadvantaged, with
reduced educational and employment opportunities. The burden of care of
the disabled child falls on the mother, who has less time for other
children and for domestic, agricultural, and economic activities. Ill
health is the most frequent cause and consequence of poverty.
The neglected clubfoot
deformity results in disability for the individual, a reduced standard
of living for the entire family, and a burden to the community.
Clubfoot in an
otherwise normal child can be corrected in 2 months or less with Ponseti
method of manipulations and plaster cast applications, with minimal or
no surgery. This was proven by the results of 35-year follow-up study
and confirmed in many clinics around the world.
The technique is easy
to learn but requires correct training and attention to detail. A
well-organized health system is needed to ensure that parents follow the
instructions for use of the foot abduction brace to prevent relapses.
Medical education
projects with the Ponseti technique represent the most efficient way to
reduce the incidence of neglected clubfoot and correct the deformities
in the newborn babies. Examples where this “recipe” worked well are the
Uganda Clubfoot Project (Dr Shafique Pirani and Dr Norgrove Penny,
British Columbia, Canada) and the project in Nepal (Dr David Spiegel,
Philadelphia, USA), both presented in the second conference in birth
defects in developing countries, in Beijing, China (September 11th
and 14th, 2005). These projects have been successful even in
problematic situations, such as lack of orthopaedic surgeons/medical
personnel or political instability, what is fortunately not the case in
Brazil.
The Brazilian
paediatric orthopaedic society aims to offer Ponseti clubfoot treatment
to every state in Brazil, to reach the child in the most remote village,
away from the big cities. To do this, the society will train orthopaedic
surgeons from each regional orthopaedic society.
This project has the
support from Iowa University, especially from the just created Clubfoot
International Study Group, located in Iowa and from Dr José Morcuende,
Dr Ponseti representative in Latin America. It is also supported by Dr
James Hanson (NIH) and Dr Jaime Frias (CDC).
Brazil is the country
in South America where Ponseti technique has had the best acceptance and
Brazilian doctors have been able to reproduce the good results. This was
shown in the second Brazilian symposium on Ponseti technique in May
2005. Dr Jose Morcuende was an invited guest here in Brazil, together
with Shafique Pirani, from British Columbia, Canada, Anna Ey, from
Barcelona, and Cristina Alves from Madeira, Portugal. Among the 15
different hospitals presenting preliminary results with Ponseti
technique (in 4 different states, São Paulo, Minas Gerais, Maceió and
Rio Grande do Sul), 1293 feet were treated in 853 children, with
correction of deformity in 94% of feet .
The project
This project consists
in training 20 to 30 Brazilian orthopaedic surgeons in every regional
branch of Brazilian Orthopaedic Society, covering all states, including
the cities: Manaus, Belém, Cuiabá, Campo Grande, Brasília, São Luis,
Teresina, Fortaleza, Natal, Recife, Maceió, Aracaju, Salvador, Belo
Horizonte, Rio de Janeiro, Vitória, Marília, Curitiba, Florianópolis and
Porto Alegre.
The training includes
a 2 day course, Friday with lectures and a workshop with practical
explanation with clubfoot models and casting, and Saturday morning with
discussion of clinical cases selected by local orthopaedic surgeons, and
explanations about the foot abduction brace production. The symposium
will be organized by the orthopaedic surgeons responsible for teaching
activities, together with the local orthopaedic surgeons.
Click here to see photos of the first
training course held in Mato Grosso
Training Program:
Held by 3 orthopaedic
surgeons, trained in Ponseti technique:
Friday morning
- Clubfoot treatment
with the Ponseti technique – History
- Technical
considerations
- Scoring and follow
up – use of the abduction brace
- How to recognize
and treat the recurrences
- Data collection
protocol – Ponseti study group
Friday afternoon
- Workshop with
clubfoot models
- Hands on - plastic
model casting
Saturday morning
- Case discussion
- How to produce the
braces
Total Cost of Project: USD$47,500
1. Textbook to be
distributed.
Printed material,
translated in Portuguese, produced by Iowa University. This material can
be downloaded for free from the non profit organization Global-Help
website:
www.global-help.org . Printed samples were donated by the Iowa
Paediatric Orthopaedic William C Hanson Foundation, from Iowa
University, Iowa City. Printing
cost: USD$3000
2. Clubfoot plastic
models
20 Clubfoot models to
teach manipulation – USD$200/model
Cost: USD$4,000
20 Clubfoot models to
be casted – USD$365/model
Cost: USD$7,300
Total models
cost– USD$11,300
3. Rental of
projector for presentation
USD$100/day x 20
cities = cost:
USD$2,000
4. Plane tickets for 3 orthopaedic surgeons trained in
Ponseti technique, and hotel stay, from Thursday to Saturday in 20
cities:
Tickets:
USD$400/person
USD$8,000/orthopaedic surgeon (for 20 cities) x 3 =
USD$24,000
Hotels: USD$120
for 2 nights
USD$2400 /person (for 20 cities) x 3 = USD$7200
Total cost for hotel
stay and tickets for this project with 20 cities:
USD$31,700
Possible expansion
of the project:
-
Central database with multicentric studies
- Possibility of
recycling the used braces to be used in other children - “Brace Bank”,
reducing costs of the treatment
- Project evaluation:
by orthopaedic surgeon,. by public heath personnel, by the Brazilian
government and by international institutions. (As an example:
International Ponseti Study Group)
Monica Paschoal
Nogueira, MD
Paediatric
Orthopaedic Surgeon
Beneficência
Portuguesa Hospital
São Paulo SP
Brazil
Edilson Forlin, MD
President -
Brazilian Paediatric Orthopaedic Society (SBOP)
Curitiba – PR
Brazil
References
1963
Ponseti IV, Smoley EN. “Congenital Clubfoot: The Results of
Treatment.” Journal of Bone & Joint Surgery 45A(2):2261–2275.
1966
Ponseti IV, Becker JR. “Congenital Metatarsus Adductus: The Results
of Treatment.” Journal of Bone & Joint Surgery 43A(4):702–711.
1972 Campos J,
Ponseti IV.
“Observations on
Pathogenesis and Treatment of Congenital Clubfoot.” Clinical
Orthopaedics and Related Research 84:50–60.
1974
Ionasescu V, Maynard JA, Ponseti IV, Zellweger H. “The Role of
Collagen in the Pathogenesis of Idiopathic Clubfoot: Biochemical and
Electron Microscopic Correlations.”
Helvetica Paediatrica
Acta
29(4):305–314.
1980
Ippolito E, Ponseti IV. “Congenital Clubfoot in the Human Fetus: A
Histological Study.” Journal of Bone & Joint Surgery 62A(1):8–22.
1980 Laaveg SJ,
Ponseti IV. “Long-term Results of Treatment of Congenital Clubfoot.”
Journal of Bone & Joint Surgery 62A(1):23–31.
1981 Brand RA,
Laaveg SJ, Crowninshield RD, Ponseti IV. “The Center of Pressure Path in
Treated Clubfoot.” Clinical Orthopaedics and Related Research 160:43–47.
1981 Ponseti IV, El-Khoury
GY, Ippolito E, Weinstein SL. “A Radiographic Study of Skeletal
Deformities in Treated Clubfoot.” Clinical Orthopaedics and Related
Research 160:30–42.
1992 Ponseti IV.
“Treatment of Congenital Clubfoot.” [Review, 72 refs] Journal of Bone &
Joint Surgery 74A(3):448–454.
1994 Ponseti IV.
“The Treatment of Congenital Clubfoot.” [Editorial] Journal of
Orthopaedic & Sports Physical Therapy 20(1):1.
1994 Farsetti P,
Weinstein SL, Ponseti IV. “The Long-term Functional and Radiographic
Outcomes of Untreated and Non-Operatively Treated Metatarsus Adductus.”
Journal of Bone & Joint Surgery 76(2):257–265.
1995 Cooper DM,
Dietz FR. “Treatment of Idiopathic Clubfoot: A Thirty-Year Follow-up
Note.” Journal of Bone & Joint Surgery 77(10):1477–1489.
1996 Ponseti IV.
Congenital Clubfoot: Fundamentals of Treatment. Oxford University Press.
1997 Ponseti IV.
“Common Errors in the Treatment of Congenital Clubfoot.” International
Orthopaedics 21(2):137–141.
1998 Ponseti IV.
“Correction of the Talar Neck Angle in Congenital Clubfoot with
Sequential Manipulation and Casting.” Iowa Orthopaedic Journal 18:74–75.
2000 Ponseti IV.
“Clubfoot Management.” [Editorial] Journal of Pediatric Orthpedics
20(6):699–700.
2001 Pirani S,
Zeznik L, Hodges D. “Magnetic Resonance Imaging Study of the Congenital
Clubfoot Treated with the Ponseti Method.” Journal of Pediatric
Orthpedics 21(6):719–726.
2003 Ippolito E,
Farsetti P, Caterini R, Tudisco C. “Long-term Comparative Results in
Patients with Congenital Clubfoot Treated with Two Different Protocols.”
Journal of Bone & Joint Surgery 85A(7):1286–1294.
2003 Morcuende JA,
Egbert M, Ponseti IV. The effect of the internet in the treatment of
congenital idiopathic clubfoot. Iowa Orthop J 23:83-86.
2004 Morcuende JA,
Dolan L, Dietz F, Ponseti IV. Radical reduction in the rate of extensive
corrective surgery for clubfoot using the Ponseti method. Pediatrics
113:376-380.
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