Disability and Rehabilitation, June 2007; 29(11 – 12): 857 – 862

Club foot treatment in Malawi – a public health approach

C. B. D. LAVY, S. J. MANNION, N. C. MKANDAWIRE, A. TINDALL,

C. STEINLECHNER, S. CHIMANGENI & E. CHIPOFYA

Beit Trust Cure International Hospital, Blantyre, Malawi, Africa

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Abstract
Purpose. Malawi is a very poor country with a current population of 12 million people and very few orthopaedic surgeons or
physiotherapists. An estimated 1125 babies are born per year with club foot. If these feet are not corrected early, then severe
deformity can develop, requiring complex surgery. A task force was established to address this problem using locally available
resources.
Methods. A nationwide early manipulation programme was set up using the Ponseti technique, and a club foot clinic
established in each of Malawi’s 25 health districts. One year later the clinics were reviewed.
For personal use only.

Results. Twenty out of the 25 clinics originally established were still active, and over one year had seen a total of 342
patients. Adequate records existed for 307 patients, of whom 193 were male and 114 female (ratio 1.7:1). A total of 175
patients had bilateral club foot and 132 were unilateral (ratio 1.3:1) giving a total of 482 club feet; 327 of the 482 feet were
corrected to a plantigrade position. Most clinics had problems with supply of materials. Many patients failed to attend the full
course of treatment.
Conclusions. Overall the establishment of a nationwide club foot treatment programme was of benefit to a large number of
children with club feet and their families. In a poor country with many demands on health funding many challenges remain.
The supply of plaster of Paris and splints was inadequate, clinic staff felt isolated, and patient compliance was limited by
many factors which need further research.

Keywords: Club foot, Malawi, public health

the possibility of setting up a nationwide early

Introduction
manipulation programme.
In 1998, Malawi had a population of about 12
million and only two orthopaedic surgeons. Most
Identifying the magnitude of the problem
cases of club foot that reached these surgeons came
too late for any conservative treatment and needed The exact cause of idiopathic club foot or congenital
major surgery involving bone resection to correct talipes equinovarus is not known. The incidence in a
them. Western European population is approximately 1 in
In 1998, over 200 cases of neglected club foot were 1000 live births [1]. There was no published data on
operated on, representing a significant part of the incidence in Malawi but on reviewing all births in
elective surgery done by the two surgeons. The total Queen Elizabeth Central Hospital Blantyre over one
number of cases of neglected club foot needing year we found an incidence of 34 cases of club feet
surgery in the country was not known, nor was there in 16,877 births, equivalent to almost 1 in 500 [2],
any record of the number of children being born with which is approximately twice that in Western
club foot. There were very few sites in the country Europe. The office of National Statistics in Malawi
where club foot manipulation was taking place, there estimated 614,000 births in the country per year [3].
was no unified method of manipulation or treatment, Thus, on the assumption that the incidence in
nor was there any national policy on club foot Blantyre is similar to the rest of the country,
management. It was therefore decided to investigate approximately 1125 babies with club feet could be

Correspondence: C. B. D. Lavy, Beit Trust Cure International Hospital, PO Box 31236, Blantyre 3, Malawi, Africa. E-mail: [Link]@[Link]
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd.
DOI: 10.1080/09638280701240169
 858 C. B. D. Lavy et al.

expected per year, which is nearly six times the

Planning the programme
number that were being operated on.
A club foot task force was set up, comprising the
three orthopaedic surgeons and representatives from
Identifying the resources
the Ministry of Health, the Physiotherapy Associa-
By 2000 there was a third orthopaedic surgeon, and tion of Malawi, and the OCO training school. A
approximately 12 practising physiotherapists in the method of manipulation needed to be chosen, and
country. However most of these professional staff the Ponseti technique, developed by Ignatio Ponseti
were clustered around the two main towns, and too in the 1960s [4] was investigated. The technique
committed with other duties to be the backbone of a involves gentle staged correction of the deformities of
district level manipulation programme. Most district club foot. Weekly manipulations are performed and
hospitals have only one doctor who is busy with the foot is put into a plaster of Paris cast at the
managing the whole health district and is not free for maximum correction at the end of every manipula-
much clinical work. The clinical workload is there- tion. The cast is then removed before the next
fore handled by an experienced cadre of non-doctor manipulation and slowly the correction is increased.
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clinicians known as clinical officers. Orthopaedic In many cases full correction is prevented by a tight
clinical officers (OCOs) are a specialized sub group Achilles tendon and this is released percutaneously
of such clinicians who deal with trauma and as an outpatient procedure under local anaesthetic.
musculoskeletal pathology at the district level, and Once full correction of the club foot is achieved
are therefore the most suitable group of healthcare (Figures 3 and 4), the patient is given an abduction
professionals to oversee a club foot manipulation splint to wear full time for three months, except for
programme. washing, then at night only for 2 years (Figure 5).
The splint is changed as the child grows.
The Ponseti technique was growing in popularity in
many countries of the world and had very favourable
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reports including a 30-year follow-up of Ponseti’s own

Figure 1. Late presenting neglected club feet in a 14-year-old boy,

viewed from behind.

Figure 3. A club foot in a newborn child before manipulation.

Figure 2. Late presenting bilateral club foot in a 16-year-old boy

viewed from the front. The left foot has already had corrective Figure 4. The foot after six manipulations and Achilles tenotomy
surgery in the form of a triple arthrodesis. The right is about to be to correct the deformity. Note that the child is able to actively
operated on. dorsiflex the ankle.
 Club foot treatment in Malawi 859

attendants. A public awareness campaign was also run

on radio TV and in newspapers.

Review after one year

One year after setting up the club foot clinics, a
nationwide review was organized. This was done by
two surgeons who travelled round the entire country
visiting every clinic and reviewing the records of all
Figure 5. An abduction splint (designed in Uganda by Michiel children who attended clinics in 2003. Their findings
Steenbeek).
are outlined below:

cases [5]. It was decided to run a pilot study of the

(a) Existence of clinics
technique in the two major cities Blantyre and
Lilongwe for one year before making a decision to It was found that out of the 25 clinics set up, only 20
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recommend it for the whole country. After this year it were actually functioning. In three of the five districts
was reported that all those using the technique found where there was no clinic, the organizers said there
it worked well, and in Blantyre it had dramatically was no need as the patients were going elsewhere,
reduced the number of cases that were referred for presumably to a neighbouring clinic. In the other
surgery [6]. It was therefore decided to make the two, the organizers could not be found and it ap-
Ponseti technique the country standard for the peared that no clinic had been set up.
conservative treatment of clubfoot.
(b) Patients seen
Setting up the programme
Of the 1125 patients with club foot expected, 342 were
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A three-day ‘training of trainers’ course was ar- recorded as having attended the clinics. This repre-
ranged, which aimed to instruct a faculty of eight sents 30% of the number expected. (See Figure 6).
trainers in the Ponseti method. The faculty then The true number of patients seen may of course
toured the country, training staff in each of Malawi’s have greater than the recorded number of 342. The
25 health districts. The key personnel were OCOs standard of record-keeping varied from excellent to
but the course also trained nurses and medical almost non-existent. Of the 342 records reviewed,
assistants so that there would be a team of at least only 307 were adequate with any meaningful in-
three people in each district. The estimated birth rate formation about the club foot.
for each district was known so it was possible to
estimate the number of children with club feet who
(c) Patient characteristics
would be born in that district.
Each district clinic was provided with a set of club Of the 307 patients with club foot who had adequate
foot splints, and arrangements were made with a records there were 193 boys and 114 girls, giving a
national disability organization to make new splints as ratio of 1.7:1. The mean age at presentation was 2.8
required. Provision of plaster of Paris and undercast months (range 0 – 20, SD 3.8); 175 children had
padding was left to the Ministry of Health as clinics bilateral club feet and 132 unilateral, (a ratio of
were held at district hospitals. Each centre was asked 1.3:1), giving a total of 482 club feet. The Columbia
to decide on a day in the week when it would run the Club Foot Score (CCFC) has a grading system of
clinic and thus a database was built up for the country 0 – 6 where zero is a normal foot and six is the most
with details of when each district clinic would occur, severe deformity; 0.5 is thus a very mild club foot.
how many patients they might expect over a year, and Scoring is done in half point intervals. Details of
who was in charge, with contact details. Every club the scoring system are outlined in Reference [7].
foot clinic was also given a file and pre-printed record Figure 7 shows the distribution of severity among the
sheets for every patient seen. The Ponseti method 482 club feet.
does not have any scoring system for severity, but a
scoring system had been developed by Professor
(d) Treatment and compliance
Pirani in British Columbia, Canada, known as the
Columbia Club Foot Score (CCFS). This has proven Of the 482 club feet with adequate records, 327
inter and intra-observer reliability [7]. It was decided (68%) were reported as having been corrected to the
to use this scoring system for the national programme. plantigrade position or better (Plantigrade being
Recruitment to the clinics was by word of mouth, defined as being able to have the sole of the foot flat
through maternity departments and traditional birth on the floor when standing). A total of 120 of the 327
 860 C. B. D. Lavy et al.
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Figure 6. Expected babies (n ¼ 1125) versus clinic attendees (n ¼ 342). The babies with club foot expected (lighter columns) and those
actually seen (darker columns) for all district clinics.
For personal use only.

Figure 7. Numbers of club feet in each scoring group on presentation.

(37%) had undergone percutaneous tenotomy. For feet that had no record of having reached planti-
the 327 feet that reached a plantigrade corrected grade, 12 were recorded as having been referred for
position the mean number of weekly manipulations surgery because of failed manipulation, and the rest
was plotted against the initial severity score (Figure 8), were lost to follow-up for unrecorded reasons.
showing that the worse the initial foot deformity, the
higher the number of manipulations that were needed
(e) Issues identified by clinic staff
to correct it.
Of the 327 feet that were corrected to plantigrade, All clinics were asked to fill in a proforma indicating
145 (44%) were given abduction splints. Of the 155 the strengths and weaknesses of their clinics over the
 Club foot treatment in Malawi 861
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Figure 8. Mean time to correction of club foot against initial severity of club foot.

year. All felt that the Ponseti method was an effective possibly due to absence of or lack of planning on the
For personal use only.

way of correcting club foot, and all felt that the part of the local organizer. Similarly, record-keeping
setting up of the district clinic system had resulted in problems were probably due to lack of interest or
a better service for club foot than before. All clinics diligence by the local organizer.
felt that the training had been adequate and that they The mean age at presentation was 2.8 months
were comfortable with the technique. The following which is well before the child is starting to walk and
were identified as major weaknesses by almost all it is thus encouraging that those mothers who do
clinics: attend the clinic do so early, when the feet are more
supple and have a better chance of manipulative
. Shortage of plaster of Paris; correction.
. Shortage of undercast padding; The sex ratio and unilateral to bilateral ratio
. Difficulty in getting replacement splints; are similar to published figures for club feet in
. Mothers’ complaints that they could not afford Western populations, with more males than females
transport to the clinics; and marginally more bilateral than unilateral cases
. Mothers’ lack of compliance with the manip- [8].
ulations and the long period of splinting; The most common CCFS score on presentation
. Not all patients with club feet were presenting was 6 (Figure 7) which is the most severe possible.
to the clinics. This may be because Malawi has particularly severe
club feet, but may also be because mild cases were
less likely to present. The CCFS is relatively new and
Discussion
at present there are no club foot cohorts from other
This paper describes a first attempt to cover an countries with which to compare these figures. The
under-resourced country’s need for a district level mean time to correct club foot deformity using the
club foot manipulation service. It appears that the Ponseti technique was longer with more severe initial
training given was adequate; indeed at the end of deformities (Figure 8), which is what might have
the training all course attendees were examined in been expected. This graph also shows that the
the technique and found to be competent. However majority of cases of correctable deformity can reach
cultural politeness may have caused any complaints plantigrade within 7 weeks.
about the course to be held back. In another paper A total of 327 out of 482 club feet are reported to
[9] we have looked at the first 100 cases manipu- have reached a plantigrade position and only 120 of
lated by OCOs and found that their results were these 327 (37%) had an Achilles tenotomy. Ponseti
satisfactory. himself recommends a tenotomy in most cases [4],
Some of the clinics just did not happen, perhaps with the aim of over-correcting the equinus of the
because the patients preferred to go elsewhere but club foot to at least 10 degrees dorsiflexion at the
 862 C. B. D. Lavy et al.

ankle. It is likely that a reluctance to perform a further training session with all clinic staff looking
the minor surgery by the clinic staff or the parents at the results of this study and seeing what lessons
led to the low rate of tenotomy and probable accep- can be learned. There are many areas where further
tance of a simple plantigrade position rather than research is needed, for example, comparing inci-
an over-corrected position. It is possible that this dence in different areas of the country, looking at
acceptance of less than over-correction may lead to a mothers’ attitudes to the condition of club foot, and
higher risk of recurrence in future. looking in detail at reasons for non-attendance and
Of the 327 feet that were reported to have reached discontinuing treatment. Further research into
a plantigrade position, only 145 (44%) were whether mothers continue with splinting the feet
recorded as having been given abduction splints. after they appear corrected, and long-term studies of
This is disappointing as it is believed [4] that long- outcome following manipulative correction are also
term splinting in the corrected position is funda- needed.
mental to avoiding recurrence of the deformity. It is Despite the disappointments in supplies, record-
not clear why splints were not given. The most likely keeping, patient compliance and follow-up, we
reason is a lack of splints of that size on that day. believe that a national club foot manipulation
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Another possibility is that mothers are so happy to programme is the most appropriate method in a
see the foot looking normal that they feel they don’t country like Malawi, of both treating club feet, and
need any further treatment. preventing major reconstructive surgery. Even
Every clinic had supply problems with plaster of though there were many setbacks, 327 feet in one
Paris, undercast padding and splints. Much of this is year were reported as having been corrected to
due to general supply problems in Malawi’s health plantigrade and it is hoped that this number will
service, and is not localized to the club foot clinic. increase as the programme continues.
For example, the lack of plaster of Paris is affecting
not only this programme but also treatment of
Acknowledgements
fractures.
For personal use only.

Attendance problems by mothers were found in all The authors would like to express their thanks to the
clinics. Even in the 482 feet that had adequate initial Rotary clubs of Limbe Malawi and San Diego, USA,
records there is a loss to follow-up of 155 feet (32%). for funding the project, and to Shafiq Pirani, Michiel
It is likely that the loss to follow-up overall was signi- Steenbeek, and Norgrove Penny from Uganda for
ficantly higher than this as patients who attended visiting Malawi to teach the Ponseti technique.
were probably more likely to have adequate records
than those who did not. Several individual clinics in
the North of Malawi which were visited regularly by References
one of the authors were noted to have loss to follow- 1. Barker S, Chesney D, Miedzynbrodzka Z, Mafulli N. Genetics
up rates of over 50% [10]. There was no attempt in and epidemiology of idiopathic congenital Talipes Equino-
this study to look at reasons for poor attendance and varus. J Pediatric Orthopedics 2003;23:265 – 227.
2. Mkandawire NC, Kaunda E. Incidence and patterns of
high drop out rates, but likely reasons were cost of
congenital talipes equinovarus (clubfoot) deformity at Queen
travel and cultural factors. In some parts of Malawi it Elizabeth Central Hospital. East and Central African J Surg
is believed that congenital abnormalities are caused 2004;2:2 – 31.
by evil spells. Deformities and congenital anomalies 3. The office of National Statistics in Malawi. Accessed at: http://
are also commonly accepted as ‘fate’, and medical [Link]/
4. Ponseti IV. Congenital clubfoot. Fundamentals of treatment.
help, even if it is known about, is not sought. Other
Oxford/New York: Oxford University Press; 1996.
reasons may have been poor understanding of the 5. Cooper DM, Deitz FR. Treatment of idiopathic clubfoot. A
nature of the treatment, and dissatisfaction when the 30-year follow-up. J Bone Joint Surg (Am) 1995;77:1477.
child was not cured at the first appointment. Lack of 6. Mkandawire NC, Chipofya E, Likoleche G, Phiri M, Katete
materials such as plaster of Paris and undercast L. Ponseti technique of correcting idiopathic clubfoot de-
formity. Malawi Med J 2003;15(3):99 – 101.
padding may also have deterred mothers from
7. Pirani S. AU2 The Columbia Clubfoot Scoring System.
coming back to clinics. Clubfoot: Ponseti Management. Global-HELP 2003.
In conclusion, setting up a national club foot Accessed at: [Link]
programme is not a single or one-off intervention. 8. Kite JH. The Clubfoot. New York: Grune and Stratton; 1964.
The programme needs regular audit to identify 9. Tindall AJ, Steinlechner CWB, Lavy CBD, Mannion SJ,
Mkandawire N. Results of manipulation of idiopathic club
weaknesses, and continued support both in the areas
foot deformity in Malawi by orthopaedic clinical officers using
of human resources and supplies. There is need for the Ponseti method. A realistic alternative for the developing
accurate recording of attendances and progress world. J Pediatric Orthopaedics 2005;25(5):627 – 629.
during treatment, and it would be beneficial to have 10. Mannion S. Personal communication; 2004.