Research Award Details

Institution:

Hospital for Sick Children, Toronto

Additional Information:

Summary of project:
On April 23, 2019, the non-profit organization Mobility Outreach International (MOI)
collaborated with local surgeons to provide a one-day Ponseti method clubfoot course in
Hanoi, Vietnam. The organizers included Dr. Maryse Bouchard (Toronto, ON), Dr. Rob
Veith (Seattle, WA), Vietnamese pediatric orthopedic surgeons Huynh Manh Nhi (Ho
Chi Minh City) and Minh Duc Thanh (Da Nang), and our MOI’s Hanoi-based staff.

Background:
The prevalence of clubfoot in Vietnam is estimated at 1 in 1000 live births.12 The Ponseti
method was introduced in Vietnam in 2003 by the International Committee of the Red
Cross (ICRC) and other smaller organizations and individuals from North America,
Australia and Europe.12, 20 When formal Ponseti courses were initiated by MOI (then
Prosthetics Outreach Foundation) and the ICRC in 2006 and 2007, respectively, the
number of patients in Vietnam treated with the method increased significantly.20, 21 Since
then, the Ponseti technique is increasingly practiced and the numbers of babies treated
with casting over surgery continues to grow.20, 21
Many barriers continue to prevent widespread access to Ponseti treatment and parents’
ability to adhere to all components of the method. The literature on clubfoot care in
Vietnam, as well as other low- and middle-income countries, confirm a major barrier is
the inadequate availability of skilled providers and insufficient continuing education for
Ponseti practitioners.1, 2, 3, 4 Other commonly reported barriers include financial
constraints, lack of transportation for patient and family, difficulties with brace and cast
care, and scant physical resources to provide Ponseti care.2, 3, 4, 13, 14, 15, 16 Access to
Ponseti training is therefore critical and has been shown to improve the practitioner’s
confidence and in turn increase the volume of patients they treat.6, 11 The most recent
Ponseti courses in Vietnam were in 2009 in Hanoi and in Danang in 2015.

Methods:
A one-day didactic and hands-on Ponseti course was held in Hanoi, Vietnam on April 23,
2019. The course was taught in English and translated into Vietnamese, remaining
sensitive to local resources, culture and needs. Ponseti casting was conducted on models
and live patients. Surgeons, physicians, cast technicians, physical therapists and nurses
from across the country were invited. A survey to assess attendee satisfaction of the
course and their experience with the Ponseti method was distributed at the end of the day.
A second survey to evaluate the attendees’ current clubfoot practice and the impacts of
the course on their care delivery was emailed to participants one year after the course.
The survey questions were translated from English to Vietnamese by MOI staff, as were
the responses from Vietnamese to English. The grant applicant tabulated the survey
results and prepared the written report. This person was also blinded to the respondents’
names, as each attendee was given a random identification number to keep their
responses confidential.

Outcomes and results:
There were 30 attendees. Twenty-nine completed the first survey on the day of the
course. Most respondents were medical doctors (41%), and cast technicians (28%).
There were only 5 orthopaedic surgeons (18%), three of whom were pediatric
orthopaedists (7%). There were two nurses, one physical therapist, and one general
surgeon. Most attendees were from Hanoi (9; 31%). There were 5 attendees from
southern Vietnam (18%), with 3 from the capital Ho Chi Minh City. The remaining
attendees were from Northern and Central Vietnam. Eighty-six percent worked in public
hospitals. Twenty-six of 29 respondents said they currently practiced the Ponseti Method
(90%).

All respondents selected agree or strongly agree to statements that the course was well
organized and valuable, translation was adequate, and they would implement what they
learned in their practice. All answered they would want to attend another course within a
year. Eighty-seven percent of attendees felt the length of the course and distribution of
lectures to hands-on learning was appropriate, however 27.6% wanted more hands-on
time.

When asked what learning points they expected to implement in their practice after the
course, 41% responded specific Ponseti casting techniques, 31% the Ponseti method,
14% tenotomy technique, and 10% tips on education for families. Most did not respond
when asked how the course could be improved (41%), while almost half (48%) said they
had no suggestions for improvement.

One year later, a follow up survey was emailed to the same 29 participants. Thirteen
(44.8%) responses were received. All thirteen indicated they actively treated clubfoot
with the Ponseti method. In their initial survey responses, twelve of the 13 indicated they
used Ponseti method already while the thirteenth did not respond to the question.
The demographics of the second, or post-survey, respondents were similar to the first.
Most respondents were medical doctors (38.5%) and cast technicians (23.1%), two
pediatric orthopaedic surgeons (15.4%), one general surgeon and one physical therapist.
The majority practiced in Hanoi (23.1%) and Ho Chi Minh City (15.4%), while the others
lived throughout the country. Eighty-five percent practiced in public hospitals.

When asked how many clubfoot patients they saw per month, 6/29 (20.6%) of the initial
cohort selected 1-3 patients. Four (13.8%) saw 4-6 patients per month, while three
responded over 8 patients (10.3%) and another three over 15 patients. Ten did not answer
the question. In the second survey, all 13 answered this question with 69.2% seeing 4-6
patients per month, 23.1% seeing 1-3 patients and one person seeing 11-14 patients per
month. Interestingly, 5 respondents reported a lower number of patients seen per month
on the second survey, one person was seeing more patients and three reported the same
number.

Regarding the average number of casts performed on each child, the initial cohort
responded most commonly between 5 and 6 casts (34.5%), followed by 3 to 4 casts
(20.6%) and 7 to 8 casts (17.2%). Three selected 1-2 casts and 5 attendees did not
respond. Of the thirteen attendees who completed the post-survey, 69.2% selected 7 to 8
casts and the remaining 30.8% chose 5 to 6 casts. Of the 11 of 13 that completed this
question on the initial survey, 46.2% had reported they performed 4 or fewer casts on
average. One person reported the same average number of casts on both surveys,
however all others selected a higher range on the second survey.

Twenty of 29 respondents reported their tenotomy rate on the initial survey. The most
common rates were 81-90% and 41-50% (6 respondents, 20.6%, each). Two attendees
reported a rate of 91-100%, and three less than 40%. In the post-survey all 13 responded
to the question with the majority reporting a tenotomy rate under 10% (53.8%). Three
reported 11-50% and another three selected 51-80%.

This discrepancy may be due to the addition of two follow up questions in the second
survey.

Do you perform the tenotomy?
If not, who?
[Orthopedic surgeon, other surgeon, other doctor, other practitioner]

Over half (7/13) reported they did not perform tenotomies themselves, though still 2/6
who did still reported a tenotomy rate of 1-10%. While one might think this low
tenotomy rate is due to over half of the cohort not being a surgeon, the same group
reported tenotomy rates over 50% on the first survey. Misunderstanding of the question
or poor translation may also contribute to these findings.

When asked if tenotomies were performed with local in the clinic or under general
anesthesia in the operating room, 34.5% of 29 responded on the initial survey for local
and 31% for the OR. Nine of 29 did not respond to the question. Of the 13 who
completed the post-survey, 6 (46.2%) performed the tenotomies under local and 7
(53.8%) under general. These answers were consistent with their initial survey responses.

In the post-survey, attendees were asked what they had changed about their practice since
the course. Six of 13 (46.2%) responded the number of Ponseti casts applied increased
which is reflected in their responses on average cast number. Interestingly, 5 of 13 (38.5)
said their tenotomy rate increased. This is notably inconsistent with their responses
specifically regarding tenotomy rates discussed above. One attendee mentioned they now
incorporated use of x-rays for decision making in some cases.

Impact and future directions:
Based on these survey results, we conclude our course addressed a well-documented need
for continuing education of clubfoot providers. Satisfaction with the course was high
based on the initial surveys and 6 of 13 attendees who completed the post-survey had
amended their practice based on the course. There was a clear desire from attendees for
more hands-on training and coaching on how to educate families.

While only 30% post-survey respondents reporting a change in their practice of clubfoot
treatment as a result of the course may seem low, all already practiced Ponseti method
prior to the training. While a small number of similar studies on clubfoot training
programs showed closer to 90-100% of attendees reporting a change in their management
of clubfoot after a course, these papers studied groups who until the course were
previously performing surgical releases. Additionally, their response rates to the post
surveys were significantly lower than ours. 17, 18

Nearly half the attendees who completed a post-survey a year after the initial training
reported performing a higher average number of casts per patient (7 to 8) after the course.
This is consistent with the mean of 5-9 casts reported by clubfoot programs in low- and
middle-income counties.7, 8, 17, 18 The overall increase in number of casts performed by
these 13 attendees may mean their criteria for tenotomy were better understood and
additional correction was achieved prior to the procedure. On the contrary, less than half
of the post-survey respondents performed tenotomies themselves. They may be
performing more casts if they do not have access to tenotomy or need to wait for a
surgeon to be available to perform the procedure.

The reason for the significant drop in reported tenotomy rates is unclear. Since most
respondents do not perform tenotomies themselves they may have misinterpreted the
question and responded based on how many tenotomies they perform personally instead
of indicating how many babies in their practice undergo a tenotomy. Average tenotomy
rates reported in the literature for clubfoot programs based in low- and middle income
countries range from 76% to 81%.7, 8, 17

One of the main limitations of this course and study was the need to translate lectures and
surveys from English to Vietnamese, and in addition, to translate survey responses back
into English. Our local MOI staff completed the translations of written documents, and
local Vietnamese orthopedic surgeons performed live interpretation of the course. None
were certified interpreters or translators. As the course instructors are long-standing
Ponseti practitioners, it is unlikely the course content was relayed incorrectly, however
the need to translate did limit ability for discussion and spontaneous teaching moments.

The written documents had a much higher likelihood of misinterpretation. The high rate
of incomplete questions and contradicting responses could support this. Our response rate
for the initial survey was high as it was distributed prior to the meal at the conclusion of
the course. The post-survey was emailed only once to participants and only in Word
format. Response rate was low at 44.8%, though higher than in prior studies. Reasons for
a low response rate may have included survey emails being directed to junk mail, or
attendees feeling overburdened by an additional task. An online survey through a tool
like Survey Monkey or repeated attempts to email the survey may have increased the
response rate.

Additional ongoing education for clubfoot providers in Vietnam is wanting. Based on our
results and suggestions in prior literature, local options could include providing advanced
Ponseti courses with hands-on labs for casting techniques for complex feet and
tenotomies, and additional time spent on parent education and bracing.5, 6, 17 Training
non-surgeons to perform tenotomies may also address a large gap in care as availability
of surgeons to perform tenotomies is considered a significant barrier to performing the
Ponseti method in Vietnam.9, 10, 13, 21 In a prior study by Evans, at 12-24 months after a 3-
day Ponseti training course in Ho Chi Minh City in 2008, most attendees were continuing
to use the Ponseti method, however ability to perform tenotomies, availability of
abduction braces and parent compliance were the major barriers to proper Ponseti care
delivery.21

As previously described in a report by Wu et al., an online community for clubfoot
practitioners in Vietnam may facilitate discussion and peer support with challenging
cases, sharing of educational resources.20 This platform could also be used to encourage
mentorship and organize webinars. E-learning modules for clubfoot have shown good
retention and comprehension.19 Mini-fellowships with local experts and more formal
international observerships or fellowships in other countries could be promoted. The
POGO international scholars program would be an excellent opportunity for further
training of Vietnamese orthopaedic surgeons.

This report is currently being edited for submission for publication in a pediatric
orthopaedic or global surgery journal, and we plan submit it as an abstract for the
POSNA and COA annual meetings in 2021.

We extend sincere thanks to the POSNA Micro Grants committee for awarding us this
grant in 2019. The final expense report for the project is attached, with the initial and
secondary surveys. The details of the expenditures on the invoice are not itemized,
however costs included casting materials, audio-visual equipment and conference room
rentals, and food for attendees. Honoraria for the speakers, travel costs and
accommodations for attendees were not supported with this grant.


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