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The Bangladesh Clubfoot Project: The First 5000 Feet

Ford-Powell, Vikki A. BSc*; Barker, Simon MD; Khan, Md Shariful I. BSc; Evans, Angela M. PhD§,∥; Deitz, Fredrick R. MD

Journal of Pediatric Orthopaedics: June 2013 - Volume 33 - Issue 4 - p e40–e44
doi: 10.1097/BPO.0b013e318279c61d

Background: Bangladesh is one of the most populous countries in the world at 160 million with 1/3 existing below the poverty line. With an annual birth rate of approximately 3.2 million, an estimated incidence of 1:900 live births, the country has approximately 5000 new cases of idiopathic congenital talipes equinovarus per annum. The Bangladesh sustainable clubfoot program, Walk for Life (WFL), was conceived to respond to this unmet need.

Methods: WFL started in 2009 and has rapidly grown to 35 clinics. Overseas experts initially increased local capacity by training a team of national paramedical staff. Government support enabled integration with the public hospital system and enhanced sustainability. WFL has supplied materials, educational, administrative, and clinical support throughout. All recruited cases underwent Ponseti casting. Demographic, Pirani scores, cast, tenotomy, and bracing data have been prospectively collected from all patients. Detailed review has been undertaken for 1040 patients after 12 months of treatment in 3 divisions of Bangladesh.

Results: Between 2009 and 2011, 6069 feet (3922 patients) were recruited to the project. Of these 1643 feet (1040 patients) have completed a minimum of 1-year follow-up. The male:female ratio was 2.7:1 with a mean age of 22 months at presentation (range, 0 to 36). Typical idiopathic congenital talipes equinovarus responded in a median of 5 casts (range, 1 to 25) with 76% undergoing tenotomy. Thirteen percent were atypical feet requiring a median of 5 casts. The percentage of patients missing at the 12-month point was 12%. Two percent of patients experienced complications.

Conclusions: The Bangladesh clubfoot program demonstrates that rapid case ascertainment is possible in a developing world setting with appropriate logistical support. The use of local physiotherapists and paramedics yielded good clinical outcomes in an environment with full access to clinical review and ongoing training. A higher than expected number of atypical cases have been noted, requiring modified Ponseti treatment. Complications have been few at this early stage.

Level of Evidence: Level 2—therapeutic study.

*Walk For Life Ponseti, LAMB Project, Dinajpur

Clinical Services, Walk For Life, Dhaka, Bangladesh

Department Paediatric Orthopaedic Surgery, Royal Aberdeen Childrens Hospital, Aberdeen, UK

§Walk For Life, AUT University, Auckland, New Zealand

Walk For Life, University of South Australia, Adelaide, SA, Australia

Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA

Project sponsorship and leadership from Colin Macfarlane and the Glencoe Foundation. None of the authors received payment for this article.

Md.S.I.K. is employed by The Glencoe Foundation. A.M.E. has a consultancy with Australian Health Professional Regulatory Agency, a small project grant with Medicine Today journal and receives payments for lecture, royalties and travel costs outside of the submitted work. The remaining authors declare no conflict of interest.

Reprints: Vikki A. Ford-Powell, BSc, Walk For Life Ponseti, LAMB Project, Rajabashor, Parbatipur, Dinajpur 5250, Bangladesh. E-mail:

© 2013 by Lippincott Williams & Wilkins