Congenital Clubfoot: Fundamentals of Treatment

Objective
Congenital talipes equinovarus (CTEV), or clubfoot, is a structural malformation that develops early in gestation. Birth prevalence of clubfoot is reported to vary both between and within low- and middle-income countries (LMICs), and this information is needed to plan treatment services. This systematic review aimed to understand the birth prevalence of clubfoot in LMIC settings.

Methods
Six databases were searched for studies that reported birth prevalence of clubfoot in LMICs. Results were screened and assessed for eligibility using pre-defined criteria. Data on birth prevalence were extracted and weighted pooled estimates were calculated for different regions. Wilcoxon rank-sum test was used to examine changes in birth prevalence over time. Included studies were appraised for their methodological quality, and a narrative synthesis of findings was conducted.

Results
Forty-eight studies provided data from 13 962 989 children in 20 countries over 55 years (1960–2015). The pooled estimate for clubfoot birth prevalence in LMICs within the Africa region is 1.11 (0.96, 1.26); in the Americas 1.74 (1.69, 1.80); in South-East Asia (excluding India) 1.21 (0.73, 1.68); in India 1.19 (0.96, 1.42); in Turkey (Europe region) 2.03 (1.54, 2.53); in Eastern Mediterranean region 1.19 (0.98, 1.40); in West Pacific (excluding China) 0.94 (0.64, 1.24); and in China 0.51 (0.50, 0.53).

Conclusion
Birth prevalence of clubfoot varies between 0.51 and 2.03/1000 live births in LMICs. A standardised approach to the study of the epidemiology of clubfoot is required to better understand the variations of clubfoot birth prevalence and identify possible risk factors.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/tmi.12833

Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: a systematic review and meta-analysis.

Introduction Clubfoot is a common congenital birth defect, with an average prevalence of approximately 1 per 1000 live births, although this rate is reported to vary among different countries around the world. If it remains untreated, clubfoot causes permanent disability, limits educational and employment opportunities, and personal growth. The aim of this systematic review and meta-analysis is to estimate the global birth prevalence of congenital clubfoot. Methods and analysis Electronic databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Global Health, Latin American & Caribben Health Science Literature (LILACS), Maternity and Infant Care, Web of Science, Scopus and Google Scholar will be searched for observational studies based on predefined criteria and only in English language from inception of database in 1946 to 10 November 2017. A standard data extraction form will be used to extract relevant information from included studies. The Joanna Briggs Institute appraisal checklist will be used to assess the overall quality of studies reporting prevalence. All included studies will be assessed for risk of bias using a tool developed specifically for prevalence studies. Forest plots will be created to understand the overall random effects of pooled estimates with 95% CIs. An I2 test will be done for heterogeneity of the results (P>0.05), and to identify the source of heterogeneity across studies, subgroup or meta-regression will be used to assess the contribution of each variable to the overall heterogeneity. A funnel plot will be used to identify reporting bias, and sensitivity analysis will be used to assess the impact of methodological quality, study design, sample size and the impact of missing data. Ethics and dissemination This review will be conducted completely based on published data, so approval from an ethics committee or written consent will not be required. The results will be disseminated through a peer-reviewed publication and relevant conference presentations. PROSPERO registration number CRD42016041922.

https://bmjopen.bmj.com/content/bmjopen/8/3/e019246.full.pdf

Systematic review and meta-analysis of global birth prevalence of clubfoot: a study protocol.

Background Club foot is a common congenital deformity affecting 150 000–200 000 children every year. Untreated patients end up walking on the side or back of the affected foot, with severe social and economic consequences. Club foot is highly treatable by the Ponseti method, a non-invasive technique that has been described as highly suitable for use in resource-limited settings. To date, there has been no evaluation of its cost-effectiveness ratio, defined as the cost of averting one disability-adjusted life year (DALY), a composite measure of the impact of premature death and disability. In this study, we aimed to calculate the average cost-effectiveness ratio of the Ponseti method for correcting club foot in sub-Saharan Africa. Methods Using data from 12 sub-Saharan African countries provided by the international non-profit organisation CURE Clubfoot, which implements several Ponseti treatment programmes around the world, we estimated the average cost of the point-of-care treatment for club foot in these countries. We divided the cost of treatment with the average number of DALYs that can be averted by the Ponseti treatment, assuming treatment is successful in 90% of patients. Results We found the average cost of the Ponseti treatment to be US$167 per patient. The average number of DALYs averted was 7.42, yielding a cost-effectiveness ratio of US$22.46 per DALY averted. To test the robustness of our calculation different variables were used and these yielded a cost range of US$5.28–29.75. This is less than a tenth of the cost of many other treatment modalities used in resource-poor settings today. Conclusions The Ponseti method for the treatment of club foot is cost-effective and practical in a low-income country setting. These findings could be used to raise the priority for implementing Ponseti treatment in areas where patients are still lacking access to the life-changing intervention.

https://gh.bmj.com/content/bmjgh/1/1/e000023.full.pdf

Cost-effectiveness of club-foot treatment in low-income and middle-income countries by the Ponseti method

BACKGROUND Clubfoot also called as congenital tailpipes equinovarus is a complex ankle and foot deformity characterized by forefoot adduction and supination, midfoot cavus and hindfoot varus and equinus. It is estimated that more than 100,000 babies are born each year worldwide with clubfoot, and 80% are seen in developing nations. Different scoring systems are used for grading the severity of deformity or monitoring the natural history of clubfoot. The Pirani scoring system is now routinely used in most clubfoot clinics, including Cure Ethiopia, Children's Hospital. METHODS A facility based retrospective study was conducted on 278 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani system between September 2013/14 to September 2017/2018. Age at presentation, number of casts required, need for percutaneous Achilles tenotomy, casting effects were recorded. RESULTS A total of 287 clinical folders of children were retrieved (424 feet). The mean (±SD) number of casts required for correction of the deformity was 5.54 ± 1.63. The number of cast required for correction is significantly, and positively correlated with initial severity of Pirani score (r = 0.62 for right foot; r = 0.675 for left foot). There is a significant difference on the overall initial Pirani score between tenotomy and non- tenotomy group (P value < 0.001). CONCLUSION The study revealed that severity of initial Pirani score can be used to estimate the number of Ponseti cast required for correction of clubfoot deformity and the need for tenotomy. Besides, the number of Ponseti cast required may not be affected by age of a child at the commencement of treatment.

Prediction of Number of Casts and Need of Tenotomy Using Pirani Score in the Management of Clubfoot.

Background: While the congenital clubfoot deformity is a common deformity recorded in Uganda, the incidence of the condition had never been accurately determined. The objective of this study was to measure the overall incidence of congenital clubfoot deformity in a representative sample of births. Methods: A study of all babies born with foot anomalies took place from March 2006 to October 2007. The study was based at 8 Regional Hospitals with active maternity units and a functioning clubfoot clinic. All babies with foot deformities at birth at any of eight centres as detected by the delivery room staff were referred to the respective centre’s clubfoot clinic. The children were examined by clubfoot clinic orthopedic officers who diagnosed the specific deformity. Children referred to the clinic from any source and born at the maternity unit were included in the study. The denominator was all live births at the centre during the study period. Results: The total number of live births during the study period was 110,336. The maternity units of the centres identified 290 infants with a foot deformity. One hundred and thirty infants born during the study period were diagnosed in the clubfoot clinic as having a congenital clubfoot deformity. The proportion of infants with a clubfoot deformity was 1.2 per 1000 births over the 20-month period. The male to female ratio was 2.4:1. Recommendation: The rate of clubfoot deformities in the newborn can be used to estimate the numbers of children who should be treated and to estimate resource needs for the identification and management of this treatable congenital malformation. By comparing the number of those treated with the expected number of cases, the numbers of children with neglected clubfoot can be calculated. Key words: Clubfoot; incidence; gender ratio

/pdf/incidence-of-clubfoot-in-uganda-52kcli5jxa.pdf

Incidence of clubfoot in Uganda.

Accurate placement of pedicle screws in the subaxial cervical spine requires precise understanding of vertebra anatomy. Little is known about the morphometric characteristics of the subaxial cervical pedicle in the Ugandan population. The objective of the study was to determine the morphometric dimensions of pedicles in the subaxial cervical spine among the adult Ugandan population.We conducted a cross-sectional study from March to November 2019 among adult Ugandans with a normal cervical CT scan at Nsambya hospital in Kampala. Eligible participants were consecutively recruited into the study. Data on baseline characteristics and pedicle dimensions from the CT scan finding was collected using a structured questionnaire. Data was analysed using Stata 13.0. Pedicle dimensions for the different levels of subaxial cervical vertebrae were summarised as means and standard deviations, the Mann-Whitney test was used to compare pedicle dimensions for the different vertebra levels among females and males on both right and left sides, and the level of significance was set at 0.05.A total of 700 subaxial cervical pedicles (C3-C7) from 49 males and 21 female participants were studied. Pedicle width diameter showed cephalocaudal gradual increment from C3 1.65(0.63) mm to 3.46(0.75) mm at C7. Pedicle height also showed an increase caudally with smallest diameter at C3 (1.98(0.76) mm) and largest at C5 in females (3.67(6.42) mm) and at C7 in males (3.83(0.76) mm). The pedicle height was wider than the pedicle width at all levels. The pedicle chord length gradually increased caudally in both sexes ranging from 29.08(1.35) mm at C3 to 32.53(3.19) mm at C7. The axial angles were oriented medially and showed no consistent trend ranging between 50° and 53°. The sagittal angles decreased as one moved from C3 to C7. The dimensions of females were significantly smaller than in males.Pedicle endosteal width was smaller than pedicle height dimensions at all levels. Pedicle cord length increased caudally. The pedicle dimensions, except angulations, were smaller in females than in males. 

Pedicle Morphometry of Subaxial Cervical Spine Using Computed Tomography Scans among Adult Ugandan Subpopulation

Purpose: Supracondylar fractures (SCF) of the humerus is one of the commonest global health concerns among children and need a rigorous management process to obtain satisfactory outcomes. It is of paramount importance to use systematic guidelines to aid abate bad fracture outcomes. The study primarily sought to determine the functional and radiological management outcomes of SCF of the humerus in children at Mulago National Referral Hospital (MNRH) and associated factors to the outcomes. Methods: We conducted a hospital-based, cross-sectional study among children managed for SCF of the humerus at MNRH. Using Flynn’s criteria, current flexion and extension at the elbow joints, humeroulnar angle and the neurology were assessed and compared to the contralateral limb to get the functional outcomes. The pre-management digital radiographs of the elbow joint were compared with the current radiographs to assess radiological outcomes. Bivariate and multivariate analyses were used to determine the associated factors. Results: Of the 77 children, 46 (60%) were male with a mean age of 7.86±2.30 years. Gartland type I fracture constituted 55.8% (43), type II was 29.9% (23) and type III was 14.3% (11). About 88.3% of the patients were managed non-operatively and 11.7% were managed operatively. The overall satisfactory functional outcome was 46.7%, while 81.8% of the patients had a satisfactory radiological outcome at 6 months after the intervention. Delay in seeking treatment, type 1 fracture, and prolonged duration of immobilization were significantly associated with unsatisfactory functional management outcome. Type II fracture and prolonged duration of immobilization were significantly associated with unsatisfactory radiological management of SCF of the humerus. Conclusion: The short-term functional outcome was unsatisfactory, while a satisfactory radiological outcome was found in most of the patients. Duration of immobilization, type of fracture, and seeking late medical care had a negative impact on the outcome of these fractures.

Orr_a_370357 235..245

Background: Low back pain is the leading global cause of years lost to disability. The study aimed to assess the health-related quality of life in patients with low back pain attending an outpatient clinic at a national referral hospital in Uganda 
Methods: This was a hospital based cross-sectional study that involved 250 adult patients with low back pain. Data were collected using the modified short form-36 Health Survey questionnaire. Data were summarised using descriptive statistics. Analysis of Variance, the F-test and linear regression analysis were used for inferential statistics. 
Result: Majority of participants were female (66.4%) with a mean age of 60 years (SD 12.9, range 20- 87) and 44.6% were manual labourers. 70% of participants had had low back pain for more than one year and 74% had neuropathic symptoms. The total quality of life of participants was poor with a mean score of 31.9 (SD 15.6). The factors that significantly influenced quality of Llife included performing manual work (p=0.01), being unemployed (p=0.027) and weakness in the lower limbs (p=0.01). 
Conclusion: Patients with low back pain had a poor quality of life that was significantly influenced by being unemployed, doing manual work and clinical features of nerve compression. 
Keywords: Low back pain; Quality of life; Health-related.

/pdf/health-related-quality-of-life-in-patients-with-low-back-2a4ubvdg.pdf

Health-related quality of life in patients with low back pain in a low resource setting: a cross-sectional study at a tertiary hospital in Uganda

Purpose Supracondylar fractures (SCF) of the humerus is one of the commonest global health concerns among children and need a rigorous management process to obtain satisfactory outcomes. It is of paramount importance to use systematic guidelines to aid abate bad fracture outcomes. The study primarily sought to determine the functional and radiological management outcomes of SCF of the humerus in children at Mulago National Referral Hospital (MNRH) and associated factors to the outcomes. Methods We conducted a hospital-based, cross-sectional study among children managed for SCF of the humerus at MNRH. Using Flynn’s criteria, current flexion and extension at the elbow joints, humeroulnar angle and the neurology were assessed and compared to the contralateral limb to get the functional outcomes. The pre-management digital radiographs of the elbow joint were compared with the current radiographs to assess radiological outcomes. Bivariate and multivariate analyses were used to determine the associated factors. Results Of the 77 children, 46 (60%) were male with a mean age of 7.86±2.30 years. Gartland type I fracture constituted 55.8% (43), type II was 29.9% (23) and type III was 14.3% (11). About 88.3% of the patients were managed non-operatively and 11.7% were managed operatively. The overall satisfactory functional outcome was 46.7%, while 81.8% of the patients had a satisfactory radiological outcome at 6 months after the intervention. Delay in seeking treatment, type 1 fracture, and prolonged duration of immobilization were significantly associated with unsatisfactory functional management outcome. Type II fracture and prolonged duration of immobilization were significantly associated with unsatisfactory radiological management of SCF of the humerus. Conclusion The short-term functional outcome was unsatisfactory, while a satisfactory radiological outcome was found in most of the patients. Duration of immobilization, type of fracture, and seeking late medical care had a negative impact on the outcome of these fractures.

https://www.dovepress.com/getfile.php?fileID=82195

Short-Term Management Outcomes of Supracondylar Fractures of the Humerus and Their Associated Factors in Children Managed at Mulago National Referral Hospital

Gonzaga Waiswa

Papers

Incidence of clubfoot in Uganda.

Pedicle Morphometry of Subaxial Cervical Spine Using Computed Tomography Scans among Adult Ugandan Subpopulation

Orr_a_370357 235..245

Health-related quality of life in patients with low back pain in a low resource setting: a cross-sectional study at a tertiary hospital in Uganda

Short-Term Management Outcomes of Supracondylar Fractures of the Humerus and Their Associated Factors in Children Managed at Mulago National Referral Hospital