Professional Documents
Culture Documents
Ford Powell 2013
Ford Powell 2013
RESULTS
Between 2009 and 2011, a total of 3922 patients
have entered the project. Of these, 3358 patients were
in WFL and LAMB clinics. A full data set is available
for 3249 patients. Partner clinics initiated by “Zero
Clubfoot” (Chittagong Lions Foundation and Pedrollo
Welfare Foundation) covering around 20% of the Ban- FIGURE 2. Male:female ratio across first 14 clinics after 12
gladesh population in the Chittagong division provided a months.
Children progressing to
braces within 10 casts
Children progressing to
braces within 25 casts
Missing
incomplete data
Strengths Challenges
Case ascertainment Overcrowded clinics
Functional assessments and outcomes Maintaining quality under pressure
Time and case management Consistent location of head of talus
Consistent Pirani scoring Manipulation time decreased
Competent Ponseti technique Management of pressure sores
High level of satisfactory outcomes Access to timely tenotomise with
reduced tenotomy rates
Spacious, well ventilated clinical Sterile techniques for tenotomy,
environments
Interdisciplinary team work Recognising and dealing with atypical
feet
MoU with Government – national Ergonomic difficulties
ownership of programme
Robust data collection Lack of hand washing facilities
increased the sustainability of the project and reduced correction rate remained consistently high, showing the
dependence on visiting experts. efficacy of the Ponseti method as staffed in this project.
Most significantly, in the author’s view, an NGO/ Pirani score mapping nationally showed that staff fol-
government equal partnership has produced a sustainable lowed the Ponseti treatment protocol well with limited
system that has meaningful national ownership. Relation- complications. Despite the poor infrastructure and pov-
ships with all levels of management, from the local civil erty of the country, compliance to the lengthy treatment
servants in each hospital through to the Minister of Health, was considered satisfactory with only 12% lost to follow-
have grounded the future success of the project. Without up after 2 years.
this level of local investment in a project, the long-term Program issues differed from area to area depending
sustainability would be at risk. Many partnership projects upon the number of trained staff, skill levels, and the
exist within Bangladesh, but few have secured an MOU working environment. Some shared issues were common
with the government, defining a partnership based on re- throughout the program. Clinic overcrowding, decreased
lationships that produce an entirely equal responsibility for manipulation time due to pressure of work, and poor
the provision of care. recognition of atypical feet were highlighted as the main
The majority of referrals have come from the medical issues. Complications were noted in 2% of cases and re-
profession, indicating that the MOU with the government, flected slipped casts or poor recognition of the talar ful-
aiming to increase the credibility of the treatment, has crum. Often these could be attributed to misdiagnosis of
generated the necessary awareness amongst local clinicians. atypical feet or pressure of case numbers within the
The high proportion of parent-to-parent referral is taken to clinics. The range of casts required for correction ranged
be an encouraging surrogate measure of parental sat- from 1 to 25. The reasons recorded for using over 10 casts
isfaction. Further clinics are scheduled to open that should included: atypical clubfeet, an older “neglected” case, cast
further enhance case ascertainment. breakage, and complications (eg, pressure sores requiring
time without casts).
Project Outcomes Each clinic has been organized with 2 staffs in a
Overall, correction of clubfeet using the Ponseti limited space, resulting in a recommended maximum of
method through the WFL project was good, with over 20 patients per clinic. Demand has exceeded initial pro-
80% wearing boots and bars at the 12-month review. vision in most clinics with deleterious effect on clinical
Loss to follow-up is concerning and raises the possibility practice such as rushed treatment resulting in poor tech-
of selection bias in the cohort under review as those nique, lengthened treatment, and pressure sores. Pirani
missing may include unknown complications. Each clinic score mapping demonstrated that although the treatment
was able to account for each patient treated while still protocol was followed, the correction of the adductus
within the program; however, some loss was incurred took longer than expected in many cases, suggesting
transferring data from regions to the central office, re- manipulation was not adequate before cast application.
flecting the problems of data collection within a resource- This may reflect the limited time available for each pa-
limited setting. However, the database and mapping from tient, contributing to increased treatment time before te-
all the clinics provided an ideal opportunity to study notomy after the cavus correction. WFL have responded
outcome measures, demographic implications, public to the high demand by increasing the number of clinics.
health implications, and disease trends. A higher than expected incidence of atypical club-
Although all the clinics were led by a trained foot was noted (13%). Across the clinics, early recognition
therapist, they often relied on assistants, with limited or of atypical clubfeet was poor. Although the number of
no training, as the second practitioner. Nevertheless, the reported atypical feet on the database was high, during the
audit visits many more atypical clubfeet were seen that ACKNOWLEDGMENTS
had not been diagnosed. Hence, for these infants the The authors thank Colin Macfarlane, founder of
necessarily modified Ponseti method had not been used, Walk for Life, Partner clinics at LAMB Hospital,
resulting in increased complications (eg, slipped casts, Dinajpur; Zero Clubfoot project, Chittagong, CRP, Dhaka;
edema, and pressure sores) being seen when compared Government of Bangladesh with special thanks to Professor
with the typical group. This reflected the emphasis during A.F.M. Ruhal Haque, MP, FRCS (Edin) Hon’ble Minister
initial training for the new Ponseti practitioners to be of health and Family Welfare; Dr Kh. Abdul Awal Rizvi,
competent in the standard treatment process. Mis- Director of National institute of Trauma & Orthopedic
diagnosis of atypical feet can lead to complications during Rehabilitation (NITOR); all orthopaedic surgeons in
the casting process, an increase in symptoms, and deteri- participating clinics; and volunteer overseas visiting. The
oration in treatment outcome.9 Given the deficit in train- authors also thank Ponseti trainers especially Dr Paul
ing and the apparent high incidence of atypical feet, WFL Wade, Podiatric Surgeon, Adelaide, SA, Australia;
has carried out a second wave of advanced training to Professor Shafique Pirani, Orthopedic Surgeon, Vancouver;
address this need. A further review is necessary to evaluate Denise Watson Physiotherapist, London, UK; Kate Lock,
the gain from this training. Hospital Hdministrator, Dorset UK; Steve Mannion,
Limitations of the current study include the un- Orthopedic Surgeon, Blackpool, UK and “Walk for life”
certain incidence of ICTEV in Bangladesh, limiting the team in Bangladesh, specifically Jahangir Alam (Country
reliability of population statistics. This is a common Director) and Dr Abdur Rouf (Honorary Medical Advisor).
problem in developing countries. The data are weakened
by loss to follow-up (12%) and incomplete data sheets
(7%) raising the concern of selection bias in this cohort. REFERENCES
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