The 2nd South African Ponseti Seminar for Clubfoot Care was hosted in Johannesburg by STEPS Charity, in conjunction with the Division of Orthopaedics at Wits Medical School.

STEPS Charity provides support for South African babies and children with lower limb disorders. A primary goal is to make available sustainable, universal, effective, efficient, and safe treatment of the congenital clubfoot deformity in South Africa by promoting use of the Ponseti technique. The 1st Ponseti seminar in South Africa was on 27&28 July 2006.

Endorsed by Dr Ignacio Ponseti (Professor Emeritus, University of Iowa Hospital) and Dr Jose Morcuende, President of the Ponseti International Association.

"Congratulations on your work in organizing the second South African seminar on clubfoot treatment. I am sure it will be a great success especially if the Steenbeek brace will be available. I have tested this brace here on several patients and they work very well." - I.V. Ponseti, Iowa

SEMINAR GOALS

• Practical techniques for running an effective Ponseti clinic
  
• National Consensus on clubfoot care
  
• For Sustainability within the Public Health system - Steenbeek FAB manufacture

THE FACULTY

International:

STEPS hosted 5 international speakers and trainers from the USCCP (Uganda Sustainable Clubfoot Care Project):

Ponseti technique - Theory and Casting (Johannesburg Hospital)

Dr Shafique Pirani (Canada), Diirisa Kitemagwa (Uganda), Henry Musoke (Uganda

Steenbeek Brace manufacture (Chris Hani Baragwanath Hospital)

Michiel Steenbeek (Holland), David Okello (Uganda)

South African:

Dr Mark Eltringham, Dr Anthony Robertson, Dr Kobus Smit. Special guest: Prof Arnold Christianson (Human Geneticist, NHLS Wits University)

THE DELEGATES

The majority were from public health hospitals and clinics. Geographic spread was 7 of South Africa's 9 provinces: Western Province, Gauteng, Limpopo, Mpumalanga, Free State, Eastern Cape, North West Province

Paediatric Orthopaedic Surgeon/Registrar 23
Orthotist 2
Prosthetist/Shoemaker 11

THE PROGRAMME

The seminar consisted of two programmes run concurrently at two venues:

Programme A - Johannesburg Hospital (2 days)

Day 1: Ponseti theory, assessment and treatment of patients, technique practice on models and trouble-shooting.

6 patients of varying ages examined: casts applied to 2 infants, a tenotomy on 1 toddler in front of the faculty, 2 older children had assessments of possible relapse after Ponseti treatment (3 year old from early brace release, 4 year old from problems with brace compliance), a 4 year old with relapse after PMR surgery.

This was the first tenotomy performed without general anaesthetic at the Johannesburg Hospital. It demonstrated how simply the procedure could be done without the need to use up theatre time which is at a premium in public hospitals, and without the associated risks of general anaesthetic for young babies.

The faculty split into 3 groups and practiced the technique on rubber leg models with guidance from the 3 trainers from the USCCP.

Day 2: Uganda clubfoot project, status in South Africa, achieving consensus, the clubfoot care programme for the future in South Africa and neighbouring countries.

Dr Pirani presented the Ugandan programme with their results and showed the Uganda DVD. Professor Christianson discussed the way ahead for a National Clubfoot Programme within public health based on his experiences in programmes for other birth defects. Three South African doctors presented results and experiences with running a clubfoot clinic using the Ponseti technique (1 from private health sector, 2 from public health sector).

The ensuing discussion established that clinics which had implemented the Ponseti technique had reduced surgery rates over 95%. The technique had proven very successful in correcting clubfoot in private health care, but in public health care facilities follow-up figures showed that some parents did not bring their babies to complete treatment, lowering the percentage success rate. Reasons were socio-economic, lack of effective braces, late referrals from smaller clinics and possibly HIV/Aids affecting families who would then be unable to bring their babies for further treatment.

South African manufacture of the Steenbeek brace would help relieve the problem. However, there was a need for a unified National Clubfoot Programme to streamline procurement of plaster and braces and training of allied health professionals to diagnose the clubfoot earlier at primary health care level.

Programme B - Chris Hani Baragwanath Hospital Orthopaedic Workshop (2 days)

Practical training in manufacture of the Steenbeek brace in hospital workshops. The 11 shoemakers and prosthetists came from hospital workshops covering 6 of the 9 provinces: Gauteng, Limpopo, Mpumalanga, Free State, Eastern Cape, North West Province. Each delegate had hands-on training in brace making and received hand-outs with patterns for all the shoe sizes.

Full programme is at http://www.steps.org.za/ponseti-seminar-2007.htm

RESULTS AND RESPONSE

Practical techniques for running an effective Ponseti clinic:

• Based on the doctors' seminar presentations and feedback from other delegates, the estimated number of South African children to have avoided clubfoot surgery in the past 3 years was well into the hundreds. This was because of the increased use of the Ponseti method at most major state hospitals and many private hospitals.
  
  
• Establishing a national clubfoot care programme in all state hospitals and clinics would increase the number of patients treated with the Ponseti method. The ultimate goal is every 1 of the 2,200 (based on estimated live birth statistics) children born every year in South Africa with clubfoot having access to timely diagnosis, the correct materials and the best treatment (in line with the Iowa Declaration).
  
  
• There was a need for better communication: between the treatment centres, setting up an accurate database of patients, and sending results to Iowa for accreditation.
  
  
• A Ponseti User group would share information via email; a list was drawn up of interested doctors at the seminar. This would also assist in compiling clubfoot statistics for South Africa to present papers at future international conferences.

Consensus was reached by the delegates on the Ponseti method as the standard for clubfoot care throughout South Africa. It was agreed that:

• STEPS, as a registered NPO would, with guidance from Professor Christianson, apply to international donors for assistance in the South African Sustainable Clubfoot Care project.
  
  

• A Clubfoot Focus Group would be formed to help implement the SASCCP throughout South Africa. Members to include Government, NGO, Academics, Public Health Administrators, Public and Private Doctors, Rural Doctors and Geneticists.

• The SASCCP three year programme would include training of allied professionals; nurses, midwives, immunisation centres and primary health care clinics to assist with diagnosis and counselling of parents.

• There is an immediate need for localised training in the Ponseti technique at all state hospitals and clinics. The training and referral system would be similar to Uganda with 3 levels of Hospitals/Clinics; Central (Level 3), Regional (Level 2) and District (Level 1).

• Research programmes should be established to better understand South African conditions: demographic studies of clubfoot incidence, treatment success, relapse rates and follow-ups.

For Sustainability within the Public Health system - Steenbeek FAB manufacture:

• Following the success of the Steenbeek training, there was a need for follow-up training of shoemakers at all state hospital / clinic orthopaedic workshops. Delegates who attended the 2007 Steenbeek FAB training session could assist in future training sessions at Chris Hani Baragwanath's orthopaedic workshop.
  
  
• As only 15% of the South African population is covered by private medical aid schemes, the majority of infants born in South Africa would benefit from the cost-effective Steenbeek brace being manufactured and readily available to the clubfoot clinics. The resulting improved brace compliance would help to increase successful treatment and avoid potential relapse.

FOLLOW UP PLANS

The South African Ponseti seminar is an annual event. The 2008 seminar will include practical workshops for all allied health professionals with a strong focus on public health systems, rural areas and primary health care training. There will be a session for parents' support groups. Delegates will be invited from neighbouring countries Lesotho, Zimbabwe, Mozambique, Angola, as well as Central and East Africa, Mauritius, Seychelles and other developing countries to share results, experiences and establish more training programmes.

ACKNOWLEDGEMENT AND THANKS

We are extremely grateful to our sponsors and supporters who helped to make the 2nd Ponseti seminar a success: SAVRALA, Rotary Club of Burnaby, Professor Shafique Pirani and the USCCP, BSN Medical, Avis Point to Point, Eventfull Productions and Mtshali Moss Projects Africa.

Special thanks to Professor Mkhululi Lukhele and Dr Anthony Robertson; the Division of Orthopaedics at Wits Medical School, Johannesburg Hospital and Chris Hani Baragwanath Hospital for providing the venues; materials and support staff; Mr Daniel Mashaba for helping to co-ordinate the Steenbeek Workshop and sourcing all the materials; Juju Lethoba for facilitating the conference room at Chris Hani Baragwanath; Mathaba and Innocent Tele at Johannesburg Hospital and Wits Medical School for facilitating the Orthopaedic Seminar Room and use of the lunch venue.
STEPS greatly appreciates the generosity of the International and Local Speakers who contributed their time and expertise. Thank you to the STEPS Board of Trustees for their ongoing input and efforts; and to all the 2007 Ponseti Seminar Delegates for their valued support.

A special message of gratitude to Dr Ignacio V. Ponseti and the team in Iowa whose dedication and support is a continuing inspiration.

Karen Moss, CEO STEPS Charity
14 November 2007
Johannesburg, South Africa
karen@steps.org.za