THET Africa Grants Programme 2020 – Delayed Presenting Clubfoot

© CURE International

Above: before and after treatment for delayed presenting clubfoot.

January 2024 update

September 2021 update 

Funder: Tropical Health Education Trust (THET) Africa Mother & Child Grants Programme, funded by Johnson & Johnson Foundation Scotland

Project duration:  21 months                 Project dates: 1 August 2020 – 31 March 2022 

Partners

• UK Partner: Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford (NDORMS). Prof Chris Lavy (project director) and Grace Drury (project manager)
• LMIC Partner: CURE Ethiopia Children’s Hospital.  Dr Tim Nunn (project director)

In addition we are delighted to work with:

• Global Clubfoot Initiative, 
• Black Lion Hospital, University Teaching Hospital, Addis Ababa
• CBM (Christian Blind Mission)
• Hope Walks
• Colleagues from orthopaedic training institutions in Ethiopia including St Paul’s Hospital Millennium Medical College, University of Gondar Teaching Hospital and Bahir Dar University, Tebebe Ghio Specialised Teaching Hospital.  
• CURE International UK
• A wider project stakeholders group including MiracleFeet.

 Background & need  

There are thousands of children who await clubfoot treatment in Ethiopia; including long waiting lists at CURE Ethiopia, the leading elective children’s orthopaedics centre in the country. CURE Ethiopia conducted a training needs analysis that identified potential partner institutions where there could be opportunity to scale up services providing clubfoot treatment to older children. Since an earlier project developing training materials for children 0-2years with clubfoot, we have received many requests from trainers in the sub-Saharan Africa region requesting more resources to treat older children with clubfoot who did not receive treatment as babies. We have been working with CURE Ethiopia on research studies developing the evidence base on management of older children with clubfoot.

Project Aim:

Increase the capacity of health workers (surgeons, physios, clinical officers) in surgical management of delayed presenting clubfoot in walking children, an underserved population. To do this, the project will develop and pilot a one-day training course and materials, train and mentor new trainers, and then roll-out the training course. The project aims to strengthen the workforce, improve surgical capacity, and improve both national and regional surgical training capacity for children with clubfoot and with clubfoot care for older children.

Overview

We have developed a 1-day surgical training course on management of delayed presenting clubfoot. This involved:

• A survey of the community of practice 
• Consultation with an expert panel
• Gathering a multidisciplinary technical advisory group 
• Creating technical teaching videos to cover surgical techniques and rehabilitation 
• Applying lessons learned and teaching approach from Africa Clubfoot Training project
• Piloting the course in Addis Ababa  
  
• Translation of materials to Amharic
• Mentoring of course participants and future trainers
• Support for roll-out of training nationally
• Making the course available to others in CURE and GCI network who wish to pilot in other settings.
• Monitoring and evaluation of project activities, and sharing of results and lessons learned.

 scope

We have created the training course 'Principles of Management for Delayed Presenting Clubfoot (in walking age children 2-10 years)' to focus on management of children with delayed presenting clubfoot who have received no prior treatment. The course has been designed primarily for use in Ethiopia, with potential for piloting and roll-out in other settings in Africa and by other GCI partners where DCP is commonly seen.

The course includes core topics on:

The older child with delayed presenting clubfoot
Correction of the CAVE deformity
Assessment and treatment planning for DPC
Applying casts to older children
Surgical correction
Rehabilitation and exercises
Team communication and planning family centred care
When to stop and rethink

The course comprises interactive teaching presentations, practical workshops on assessment and casting of the clubfoot and a new series of teaching videos to support the course content. The videos cover:

Physical Examination
Assessment of the PAVER Score
Assessment of the Midfoot in Making Casting Decisions
Cavus Correction Cast
Adduction Correction Cast / Rotation around the Talar Head
Caudal Block
Timeout Section of the WHO Checklist (before Skin Incision)
Relevant Anatomy while Performing an Achilles Tenotomy
Percutanous Achilles Tenotomy
Hoke Achilles Tendon Lengthening
Cast Wedge Removal
Tibialis Anterior Tendon Transfer
Abductor Hallucis Recession & Lateral Column Shortening
Physio Class During Casting
Post Cast Exercises
Post Cast Walking Clip
Patient Experience

Sustainability & Dissemination after the project

We are supporting health workers after pilot course training through onsite mentoring support and advocacy for service uplift in these units to support roll-out. We are working with training partners for roll-out of training in Addis Ababa and nationally, with potential for piloting in other settings too. 

Global Clubfoot Initiative are leading dissemination of the final course materials and coordinating support for roll-out of the training on behalf of the project partners. Please contact training@globalclubfoot.org for more information. The course materials are available in English, with Amharic translation of some components.

Publications

The results of our baseline survey of management of older children with clubfoot was published in September 2023  in IJERPH : Treating Older Children with Clubfoot: Results of a Cross-Sectional Survey of Expert Practitioners

Related Links

• THET AGP 2020 page: https://www.thet.org/our-work/grants/africa-grants-programme/
• Read more about treating older children with clubfoot at CURE Ethiopia in this article by our project director, Dr Tim Nunn
• We presented an abstract on: 'Health partnership solidarity and adapting to challenges in AMCGP management of delayed presenting clubfoot project' at the THET Annual Conference, October 2021.
• Nunn TR, Etsub M, Tilahun T, Gardner ROE, Allgar V, Wainwright AM, Lavy CBD. Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2-10. Strategies Trauma Limb Reconstr. 2018 Nov;13(3):171-177. doi: 10.1007/s11751-018-0324-z. Epub 2018 Nov 15.