The Ponseti Method for Clubfoot Correction

Addressing Barriers to the Ponseti
Method of Clubfoot Treatment
in Guatemala
Developing an Educational Solution
By Rhonda Endecott
MHIRT Intern Summer 2010
Project Overview
At Home…
◦ Project Advisors: Dr. Jose Morcuende and Dr.
Laurence Fuortes
On Location…
◦ Quetzaltenango, Guatemala
 2 Wks at San Juan de Dios Hospital
 Preceptor: Dr. Jorge Escalante
◦ Guatemala City, Guatemala
 8 Wks at IGSS Hospital
 Preceptor: Dr. Ana Zambrano
What do these people
have in common?
Young Bangladeshi girl
Mia Hamm
Troy Aikman
What is Clubfoot?
Talipes Equinovarus: the most
common birth deformity of the
lower limbs1
◦ Occurs, on average, 1.1 in every
1000 live births2
The foot is turned inward and
◦ One or both feet affected3
◦ Presents en utero at week 16-18 of
the pregnancy4
◦ Most cases are Idiopathic (the cause
is unknown)3
◦ Genetics play a role in some cases5
Every 3 minutes a child
with clubfoot is born.
Incidence in the
Developing World
The Cost
Abortion7 or abandonment8,9
Physical disability3
Social stigma  Marginalization4,6
Limited future prospects…
 Education, Jobs, and Marriage10
Family/Community: high financial burden4,6
Results of Treatment:
Ponseti Method
The Ponseti Method of
Clubfoot Treatment11
The Problem…
• Untreated clubfoot poses significant
• Traditional surgical treatments are…
1 to 8 clubfoot cases
• High Cost unattainable for many
• Low success rate undesirable for
per 1000 live births
nearly ALL
• Gold Standard: Ponseti Method
• Over 90% success rate
• Non-invasive
450 Guatemalan children • Collaboration with caregivers is key to
born with clubfoot yearly
• Poor compliance in bracing is the
most common cause for relapse.
• When given additional support,
including educational materials,
they were more likely to comply
with the treatment.15
The Project…
Goal 1 Enhance the
educational support materials
available to caregivers of
children with clubfoot
undergoing the Ponseti
method of treatment.
Goal 2 Enhance the
educational materials available
to referral and treatment
healthcare providers on
clubfoot and the non-invasive
Ponseti method of treatment.
Goal 3 Implement a public awareness poster campaign on
clubfoot and the non-invasive Ponseti method of treatment.
Summer 2010…
target audiences were provided with the following
developed education and awareness materials.
Education Module
Awareness Poster
Healthcare Provider
For 10 Weeks at 2 Clinics…
Caregivers were…
◦ Walked through the information step-by-step.
◦ Given Q & A time.
◦ Provided with a hardcopy to take home.
Caregiver Education Module
They were encouraged to share the
information with the child’s other
They were informally asked about...
• Any commentary on the materials.
• Their treatment compliance.
• Their self-efficacy regarding sharing treatment
Provider Tri-fold
Presentation on
clubfoot and the
Ponseti method
◦ Given to the heads of
nursing department at
◦ Informational Tri-folds
handed out
Copies given to
preceptors and
posted at each clinic
◦ Also including San Juan
de Dios at the capital.
Both: Dr. Ana Zambrano distributed copies at her
presentation to local pediatric doctors.
Lessons Learned
For proper referral…
A list of treatment sites and/or providers needs
to be included the tri-fold and posters.
For better understanding in a low literacy
Even more of the text in the caregiver
information could be pictorially represented.
For greater tailoring…
Pictures in the materials could be altered to
those in traditional dress, and text to include
local jargon.
Future Direction
Revise the materials to tailor to this population.
Keep it general enough to implement on a broad
Increase accessibility to scientific literature on the
topic to help build clinician advocates.
Move the poster campaign beyond the clinic
setting and into the community.
Give the healthcare provider information out to a
broader range of professionals (including
At the Hospital…
Off the
Special Thanks to…
Project Advisors and
Site Preceptors
 Medical staff at each
 MHIRT staff
 Host families
Kromber, J., Jenkins, T., (1982) Common Birth Defects in South African Blacks. South African Medical Journal 16;62 (17) 599-602.
Barker, S., Chesney, D., Miedzynbrodzka, Z., Mafulli, N., (2003) Genetics and Epidemiology of Idiopathic Congential Talipes
Equinovarus. Journal of Pediatric Orthopedics 23:265-227.
Ponseti I., Congenital Clubfoot: Fundamentals of Treatment (1996) Oxford University Press Inc., New York.
Pirani, S., Naddumba, E., Mathias, R., Konde-Lule, J., Norgrove, P. J., Beyeza, T., et al. (2009). Towards Effective Ponseti Clubfoot
Care: The Uganda Sustainable Clubfoot Care Project. Clinical Orthopaedics and Related Research , 467 (5), 1154-1163.
Deitz, F., (2002). The Genetics of Idiopathic Clubfoot. Clinical Orthopaedics & Related Research. 401:39-48.
E.A. Mayo, A. J. (2007). Creating a Countrywide Program Model for Implementation of a Ponseti Method Clubfoot Treatment Program in
Developing Countries. Retrieved from CURE International:
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Dobbs MB, Nunley R, Schoenecker PL. (2006). Long-term follow-up of patients with clubfeet treated with extensive soft-tissue
release. J Bone Joint Surg Am. (88). 986-96.
Scher, David M. (2006) The Ponseti Method for Treatment of Congenital Clubfoot, Current Opinion in Pediatrics, 18(1):22-25,
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