What is a good result after clubfoot treatment? A Delphi-based consensus on success by regional clubfoot trainers from across Africa

Abstract

Background: Congenital talipes equino-varus (CTEV), also known as clubfoot, is one of the most common congenital musculoskeletal malformations. Despite this, considerable variation exists in the measurement of deformity correction and outcome evaluation. This study aims to determine the criteria for successful clubfoot correction using the Ponseti technique in low resource settings through Africa.

Methods: Using the Delphi method, 18 experienced clubfoot practitioners and trainers from ten countries in Africa ranked the importance of 22 criteria to define an 'acceptable or good clubfoot correction' at the end of bracing with the Ponseti technique. A 10cm visual analogue scale was used. They repeated the rating with the results of the mean scores and standard deviation of the first test provided. The consistency among trainers was determined with the intra-class correlation coefficient (ICC). From the original 22 criteria, ten criteria with a mean score >7 and SD <2 were identified and were rated through a second Delphi round by 17 different clubfoot treatment trainers from 11 countries in Africa. The final definition consisted of all statements that achieved strong agreement, a mean score of >9 and SD<1.5.

Results: The consensus definition of a successfully treated clubfoot includes: (1) a plantigrade foot, (2) the ability to wear a normal shoe, (3) no pain, and (4) the parent is satisfied. Participants demonstrated good consistency in rating these final criteria (ICC 0.88; 0.74,0.97).

Conclusions: The consistency of Ponseti technique trainers from Africa in rating criteria for a successful outcome of clubfoot management was good. The consensus definition includes basic physical assessment, footwear use, pain and parent satisfaction.

Fig 1. Flow chart of criteria selection.

Definitions of abbreviations: SD = standard deviation, ICC = intra-class correlation, VAS = visual analogue scale).

Fig 2. Ratings for successful clubfoot correction after bracing (10 criteria in the order asked on the questionnaire).

Box and whisker plot of the final ten criteria. The middle 50% of the VAS ratings are shown as the box. The horizontal line in the box represents the median value. The upper and lower quartiles are indicated by the whiskers and outliers are indicated by a circle. (Definitions of abbreviations: DF = dorsiflexion, abd = abduction).