INTRODUCTION: Effective clubfoot treatment using the Ponseti method requires standardized training and ongoing mentoring of healthcare providers. Limitations to face-to-face training courses include limited time for covering extensive theory and hands-on practice, short resident rotations, and inability to run the course where travel restrictions and social gathering limitations are in place. METHODS: Global Clubfoot Training (GCT) is a complete set of teaching resources developed in 2018 and adapted from the Africa Clubfoot Training (ACT) course materials. The following online resources were developed: (1) E-learning modules, drawing content from the Basic Course training package of the GCT curriculum, including text, illustrations, animations, and quizzes; and (2) animated models that demonstrate the anatomy of the foot (both normal and clubfoot) and the various steps of the Ponseti manipulation. These were combined with synchronous videoconferencing sessions and asynchronous practical skills exercises to complete the blended learning course. MiracleFeet and Global Clubfoot Initiative (GCI) piloted this course among 56 healthcare providers from 17 training sites (11 from the Philippines and 6 from Zimbabwe). RESULTS: Participants reported very positive experiences with all components of the course. Though participants entered the course with some knowledge and confidence, mean scores for both domains increased between baseline and follow-up. CONCLUSION: Blended learning holds great promise in enhancing the quality and accessibility of training in clubfoot management. Future steps are needed to evaluate the impact of this method of instruction on the quality of treatment outcomes.

Introduction: Experience has shown that parent and community involvement throughout the Ponseti method for clubfoot treatment are critical for successful adherence and outcomes. Clinical training has always been emphasized, but there is also a need to train community health workers, parent advisors/counselors, and non-clinical support workers in clubfoot detection and adherence. Method: The Clubfoot Early Detection and Adherence (CEDA) project was led by Hope Walks and the Global Clubfoot Initiative to develop a comprehensive and standardized set of training modules and resources that are ideally suited for low- and middle-income country (LMIC) healthcare settings. A foundational consensus was established through a set of surveys that included 280 responses from 24 countries. An Advisory Team consisting of representatives from LMICs created the Basic, Advanced, and Training of the Trainers courses and piloted them in two countries. Additionally, an Early Detection and Referral curriculum was developed to educate healthcare workers, community leaders, and the general public. Lastly, four educational videos to support the training modules were made through the collaboration of film crews in three countries. All materials were translated into six languages. Results: Preliminary results of participant assessments and program outcomes have indicated the resources increase participant confidence in supporting families, improve adherence outcomes, and increase detection education efforts. Discussion: The creation of these resources must now be paired with a wider implementation in order to reach a greater percentage of the clubfoot population in LMICs and to support families for more favorable treatment outcomes.

Background
Clubfoot relapse following Ponseti treatment in the walking child is more common than previously thought. Although the foot may appear plantigrade, radiographic evaluation may reveal reduced calcaneal pitch which improves following tendo Achilles (TA) tenotomy. The aim of the study was to measure residual hindfoot equinus in relapsed clubfoot intra-operatively with radiographic assessment of calcaneal pitch and improvement following complete TA tenotomy.

Methods
Nine patients with 11 treated feet underwent complete percutaneous TA tenotomy and tibialis anterior tendon transfer for relapsed clubfoot in the walking age child. The calcaneal pitch was measured as an axis tangential to the inferior border of the calcaneus with respect to an axis perpendicular to the shaft of the tibia. The calcaneal pitch was measured with the foot in maximum dorsiflexion before and after tenotomy.

Results
There were 11 relapsed feet (3 girls and 6 boys) originally treated with Ponseti serial casting, TA tenotomy and abduction boots and bar to age 4 years. The mean age at surgery was 7 years (range 4-12 years). The mean calcaneal pitch before tenotomy was 4.3° (range -15° to 18°) and post tenotomy was 15.2° (range 3° to 30°) with a statistically significant difference (paired t test, p=0.001).

Conclusion
Assessment of intra-operative calcaneal pitch with the foot in maximum dorsiflexion is a valuable tool to detect mild residual hindfoot equinus and improvement following TA tenotomy in early clubfoot relapse in the walking age child.

Background: Merely 130 orthopedic surgeons serve Tanzania’s 50 million residents, resulting in the majority of the country’s 2,600 annual clubfoot births being treated by a paramedical workforce. We studied treatment outcomes to determine the efficacy of this task-shifting. Methods: We conducted a retrospective chart review of patients treated for idiopathic clubfoot since 2015, and of training participation records. Outcomes of interest included number of casting visits, tenotomy rates, and number of new treatment providers. Results: Of the 6168 records analyzed at 40 clinics, patients achieved correction — a plantigrade foot — with an average of 4.3 casting visits and a 94.6% tenotomy rate. These metrics meet or exceed global standards. Using a standardized curriculum accredited by the Royal College of Surgeons, 220 healthcare providers were trained, of which 176 were paramedical staff (103 physiotherapists, 73 of other professions); 66 of this staff also provide parent education and follow-up support. Discussion: A shortage of orthopedic surgeons resulted in a network of paramedical treatment providers, formed under the leadership of two orthopedic surgeons. Casting and follow-up care are now performed primarily by physiotherapists, while medical doctors and orthopedic surgeons perform training, clinical supervision, and tenotomies. These providers achieved global standards for clinical outcomes, making a strong case for continuing case for task-shifting in resources-constrained settings. Conclusion: In Tanzania, clubfoot treatment by paramedical staff, especially physiotherapists, has demonstrated that the necessary task-shifting due to under-resourcing of specialists can achieve optimal outcomes.

Treatment of syndromic clubfoot has always posed a challenge. The range of syndromes associated with clubfoot is vast, some are associated with laxity of soft tissue while others are associated with contractures. There is an increasing need to understand how these feet respond to treatment. We present our experience in treating syndromic clubfoot at a tertiary government hospital. Method: Children with established syndromic clubfoot between 2010 to 2019 were included in the study. On initial presentation, patients were assessed using the Pirani score and the Ponseti casting protocol initiated. Resistant or relapsed clubfoot underwent surgical intervention. The collected data was analysed to assess the management and outcomes. Results: We had 129 patients with syndromic clubfoot with an average follow-up of 2 years. 51.1% of these children had arthrogyposis and 9.3% children had Larsen’s Syndrome. Other children had various other syndromes such as Amniotic band syndrome, Wieacker syndrome, various Limb Deficiency syndromes etc. Average age at presentation was 7.8 months and mean Pirani score was 5.5. Initial correction was achieved in 93 children and the average number of casts required to achieve correction was 13 ±7 which was contrary to many published data and a TA tenotomy was performed in all patients. 19.3% had significant relapse and 36 failed to respond to the ponseti method, they were subsequently managed surgically. Conclusions: Each syndromic clubfoot behaves differently and treatment cannot be generalized. Ponseti method is effective but often require greater number of casts, have higher rate of failure and recurrence.

The Ponseti method effectively treats idiopathic clubfoot, but its effectiveness in treating the stiffer clubfoot associated with arthrogryposis is less clear. The purpose of this study was to assess the comparative effectiveness of the Ponseti method in children with clubfoot and arthrogryposis.
Methods: A metanalysis was conducted of observational studies selected through a systematic review of articles included in electronic databases (Pubmed, Embase, SCOPUS e WOS). until August 2020. A pooling analysis of proportions with 95% confidence intervals (CIs) and a publication bias assessment were performed as routine. Estimates of success and recurrence,rates were weighted and pooled using the random effects model. Results: Five studies, including 102 feet diagnosed with congenital clubfoot in children with arthrogryposis were included for analysis. The rate of satisfactory outcomes found via a cluster metanalysis of proportions using the random effects model was 73% (95% CI = 0.81–0.83, p = 0.25), relative to the total analysed. The recurrence rate was 30% (95% CI = 0.14–0.52, p < 0.01). Conclusion: Application of the Ponseti method in children with congenital clubfoot and arthrogryposis leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications.

Introduction: Globally around 174,000 children are born with clubfoot each year. These children often face a lifetime of disability when not treated. The Ponseti method has been demonstrated to be an effective method of correcting congenital clubfoot. It was officially introduced in Rwanda in 2009 by Hope Walks in partnership with the Ministry of Health. Aim: To evaluate the Ponseti treatment appropriateness and long-term outcomes for the cohort of children who had begun the treatment in 2014 at Gahini clinic in Rwanda. Method: A descriptive qualitative approach and a census method of sampling were used. 60 patient records for every child enrolled in 2014 were audited retrospectively using the Hope Walks clinic audit checklist. The individual assessment was also performed to identify the long-term outcomes using the ACT (Africa Clubfoot Training) tool. Data has been recorded and analysed using excel. Results: 60/60 patient records were audited. The tenotomy was done on 82% with 18% of feet having a total Pirani score of less or equal to 0.5 before 1st brace. relapse was found in 27%. Additionally, 53/60 were physically evaluated by the ACT tool:11% were scored less than 8 (need further treatment), 38 % were scored between 9 and 10 (borderline) and 51% were scored between 11 and 12 (Successful outcome). Conclusion: The audit revealed that there is a need to improve the quality of Ponseti treatment at Gahini clinic thus recommended that same audits could be done in other clinics to evaluate the treatment effectiveness.

This study aims to provide a comprehensive assessment of Ponseti treatment availability, access and coverage globally. This analysis updates the last published work in this area, which assessed global coverage in 2015. Service disruption due to the Covid-19 pandemic in 2020 was also identified. Clubfoot treatment providers in LMIC were contacted, having been identified through service coordinator contact databases and a literature review. Respondents completed a standardised survey detailing provision of clubfoot services within their countries between 1/1/19 – 31/12/19. 32,250 children (20.7% of all those born with the condition within LMIC) were enrolled in treatment services in 2019, a rise from 31,803 children in 2017 and 24,436 children in 2015. Of those children who were enrolled, 81% started treatment within the first year of life. Whilst the number of children enrolled increased by 30.0% between 2015 and 2017, the increase in enrolment numbers slowed to 1.4% between 2017 and 2019. During weeks of treatment that were disrupted by the 2020 pandemic, services were reduced by 65% on average. Improvements in service provision have slowed substantially in the past two years and are now largely confined to South Asia. An estimated 23% of children born in LMIC accessing Ponseti treatment in 2019, up from the estimated 15% in 2015 and 20% in 2017. Further improvements in service provision will be contingent on sustainable supplies of quality braces, the strengthening of early detection and referral systems for clubfoot and the inclusion of clubfoot treatment training in LMIC domestic national health strategies.

Arthrogrypotic equinovarus feet offer a challenge to the orthopedist, due to their rigidity, higher incidence of complex feet, higher rate of recurrences and associated deformities. Patients and Methods:All children consecutively with arthrogrypotic clubfoot followed in two services were included.
Results of twenty-three patients (43 feet) with arthrogriposis were followed prospectively in two services, treated by the same professional. Fourteen out of 39 (36%) had previous treatment, presenting with incomplete or recurring corrections. Age ranged from 4 days to 5 years at the beginning of treatment, averaging 1 year. 5 patients had amyoplasia, and distal arthrogryposis 5 patients. The others are associated with syndromes with varying severity. The average number of plasters was 4, ranging from 2 to 8 plasters. Complete and percutaneous Achillis tenotomy was performed in 100% of the patients. All used the abduction brace protocol for 3 months, and then until the age of 4 at night. Two patients underwent anterior tibial transfer. All but 1 child were corrected 95% initially. The child who did not correct started treatment at 1 year and 4 months, had 5 relapses and was operated (posteromedial release) bilaterally, with mild relapse and good functionality at the time. One child died from severe seizures (association with Sd West).Conclusion
The Ponseti Method is effective in correcting arthrogrypotic equinovarus feet and should be an indication of initial treatment in these patients. Relapses are more frequent in these patients.