Rather A1, Drabu N2, Kant S3, Parvez Z4, Lukkarinen S5, Saggurthi P1, Barth C1
1International Committee of the Red Cross (ICRC), Physical Rehabilitation Program (PRP), J&K, India, 2JLNM Hospital, Orthopedic Surgeon, J&K, India, 3JLNM Hospital, Orthopedics, J&K, India, 4Cure International India, J&K, India, 5International Committee of the Red Cross (ICRC), PRP, J&K, India

Background: Around the world 150,000 - 200,000 babies are born with clubfoot each year. In India, a baby with clubfoot is born every 10 minutes, with 1.2/1000 live births. Initial treatment of clubfoot is recommended immediately after birth. Yet, due to poverty, lack of awareness and/or lack of appropriate medical resources, often the treatment is either not initiated or performed incompletely/with delay. Neglected clubfoot can have various effects including limitation in mobility, stigma and social exclusion.
Today classic surgical correction of clubfoot has been minimized due to unsatisfactory results (painful with limited success rates) and surgical treatment has been replaced by the Ponseti method. Yet, the upper age limit of usefulness of the Ponseti technique is still unclear and being studied, therefore, there is a need of further evidence to support its effectiveness.
The Clubfoot programme has been one of the International Committee of the Red Cross's (ICRC) activities in many countries which are carried out alongside its Physical Rehabilitation Programme. The ICRC has a vast experience in successfully treating clubfoot with the Ponseti method all over the world.

Purpose: To elucidate the Ponseti treatment response in a 17 year old girl, Sara, presented with neglected idiopathic unilateral clubfoot.

Methods: A multidisciplinary team evaluation using the 'Pirani score' was applied, whereby initial midfoot score was 3 and the decision was taken to apply serial casts. Twenty serial casts were applied over a period of 25 weeks to correct the cavus, adductus and varus deformities i.e. Pirani score for midfoot at the end was recorded as zero. After serial casting, tenotomy was performed and the outcome of the tenotomy did not correct the equinus; as a result, tendoachellis lengthening with capsulotomy was performed to correct the equinus. This correction was maintained for 6 weeks in a cast and the patient was allowed to bear weight thereafter.

Results: The neglected clubfoot of adolescent patient responded well to the serial casting. The patient is able to walk on the plantar surface, dynamic foot movements are observed and range of motion has significantly improved. There were no major complications during the procedures. Sara and her parents, expressed their satisfaction about the treatment and worries about Sara's future due to her disability have considerably reduced.

Conclusion(s): As expected, the treatment process was longer for this adolescent case than for an ideal age child. This intervention not only corrected Sara's deformity but also nullified the need of extensive surgery. Foot abduction brace was not fitted due to unavailability of the size and no evidence supporting FAB for such an age group. Related to treatment of adolescent cases, further studies would be required to support the effectiveness of Ponseti and use of AFOs to maintain the correction.

Implications: Extensive surgical interventions can be limited when applying the Ponseti method of treatment. As experience with the Ponseti technique has grown, its applicability to treating late presenting or neglected clubfeet should be considered. Physiotherapists should also be equipped with adequate clinical knowledge of clubfoot management using the Ponseti method.

Keywords: Pirani Score, Ponseti Method, Neglected clubfoot

Funding acknowledgements: None

Topic: Musculoskeletal: lower limb; Service delivery/emerging roles; Disability & rehabilitation

Ethics approval required: No
Institution: Jawaharlal Nehru Memorial Hospital (JLNM Hospital)
Ethics committee: N/A for institution and Ethics Committee,
Reason not required: Ethical approval could not be received as no ethical committee is available in the hospital. Keeping in view the impact of the Ponseti on an adolescent patient (otherwise applied upto 2-3 years of age), the hospital is keen to propogate this case study in international fora. The hospital has provided a formal certificate stipulating its importance and no need of an ethics approval. Informed consent of the patient was also received.

All authors, affiliations and abstracts have been published as submitted.

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