Essential Training for Health Professionals

Around 900 babies are born with idiopathic clubfoot in the UK each year. The vast majority of these are treated using the Ponseti Method by trained practitioners.

The Ponseti Method is ideally started in the first few weeks of life. It involves gentle manipulation of the affected feet to an improved position and application of an above knee plaster cast to hold that position. The casts are changed weekly until the assessment of the foot position shows that an Achilles tendon tenotomy, which is ideally done under local anaesthetic, is performed. A final cast is applied directly after the tenotomy for 2-3 weeks. On removal of this last cast, the infant is fitted with a boots and bar orthosis to maintain correction. This is worn for 23 hours a day for the first three months and for night times and naps up until the age of 4 years, 5 if possible.

There is abundant evidence that the Ponseti Method is an effective treatment for clubfoot. There is also good evidence from countries where delayed clubfoot treatment is a significant issue that treatment started much later can still be effective.

All our practices involve older children who require casting and surgery for recurrence of the deformity. For the purposes of this paper, it is noted that these are non-urgent interventions and will be delayed as part of the national and individual hospital policies for the duration of the outbreak.

The UKCCG are a group of practitioners with considerable experience and understanding of the Ponseti Method and the nuances of treatment. They have been asked by BSCOS for guidance.

Watch our videos on clubfoot treatment during the Covid-19 pandemic

Considerations

1. Information for Families

• Information for families is in production and will be widely available through clinical and non-clinical routes.
• Anxiety is likely to be high for those facing delay and an advice line (or email address) is recommended for queries during this period.
• ‘Steps’ charity and Global Club Foot Initiative are supporting this
• Brief webinars/question and answer sessions for families are being arranged through Steps and GCI

2. Completion of first stage of treatment for infants already on the pathway

• It is likely that in the foreseeable future that there will be significant barriers to completing treatment due to the complexity of care required.
• Clubfoot management is non-urgent and we support clinicians who are required to temporarily stop their face-to face clubfoot service.
• If there is a possibility to continue treatment due consideration should be given to needs of the baby and family in the following weeks and the likely impact that the pandemic will have on services in the weeks ahead eg. Ability to perform tenotomy
• Babies of families isolating for any reason would need to discontinue treatment.

3. Changes in out-patient departments

• Where face to face appointments are considered necessary, it is vital to make families aware of any revised local processes for entry/exit and how to notify/seek advice from the service in the event they are self-isolating.
• It is expected that social distancing rules are followed for every out-patient department, including:
  Ability to keep 2m distance in waiting areas Only one family in plaster room at a time Only one carer to accompany each child
• In some departments, revised patient flows will have an impact on clinic locations and accessible facilities (eg plaster room may not be available).

4. Method of cast removal

• Soaking is the preferred method of cast removal
• Guidance on how to do this is appended to this document

5. Waste water from bathing

• To be managed with normal health and safety guidelines

6. Cast application and materials

• Plaster of Paris remains the cast of choice. Use of other materials eg. Soft cast, are not advised.

7. PPE required for health staff

• The advice from the national teams should be followed. This is a rapidly changing situation and it is important that each practitioner keeps themselves up to date with advice.

8. Location of tenotomy procedure

• Some services perform tenotomies under local anaesthesia in the theatre environment and some in the clinic. Both areas are subject to pressures depending on local activity. There may be a need to be flexible about the location for tenotomies and advice is available from the UKCCG

9. First fitting of boots and bars

• This is better done ‘face to face’ due to the individual fitting needs and requirement to ensure parents are familiar with techniques.
• If families are unable to attend for any reason, the fitting can be postponed by up to
  two weeks.
• If a tenotomy has been done, every effort should be made to fit the boots and bar orthosis and it may be appropriate to consider sites other than the usual hospital to do this
• There may be a need for remote fitting and instruction for families, ideally through video contact.

10. Surveillance of boots and bars

• Where facilities remain for face to face surveillance; families who are within the first 12 weeks of boots and bar use are the priority.

11. Use of remote consultations for pre-natal counselling

• This should be standard and depending on the due date and will need to include new advice on delay of treatment during the active phase of the pandemic.

12. Use of remote consultations for boots and bar check

• This is the preferred option during the pandemic

13. Provision of new orthoses

• This should be discussed with the local provider
• C-pro direct have offered to send boots and bars out direct to families.
• Other orthotic companies are putting similar arrangements in place to reduce the need for hospital attendance
• There is a need to have consent from families for the sharing contact details with any outside agency before arranging this
• Even when toes are protruding some way from the boot, the orthosis is still effective therefore less regular changes of boot sizes is acceptable.

14. Starting new treatments

• The advice is not to start new treatments during this period of the pandemic

15. Delay of treatment – implications

• There is good evidence that starting treatment later can still lead to good results.
• Treatment protocols for older babies and children can be more challenging. Practitioners unfamiliar with this situation are advised to seek support from local tertiary centres and to comply with the advice of the European Consensus Group.
• The UKCCG will also be providing advice as required.