The children who were treated successfully in 2011 were walking normally, mixing with other children, growing toward adolescence, and enjoying a rehabilitated life.

Remarkably, the mothers or fathers themselves afflicted with clubfoot deformity were found frustrated not for their own disability, but for their child. The girls with clubfoot were not being married due to this ‘clubfoot curse’, and suffered lasting despair. Untreated clubfoot causes a critical situation for people in Bangladesh, which has been effectively improved by the Glencoe Foundation, establishing 42 WFL clinics across the country. Since 2009, over 19,500 children were treated (as on May, 2017), and most were walking and would be able to live a normal life.

This study confirmed the gender ratio disparity inherent in CTEV, as did Mejabi et al. who found 38 (62.3%) male and 23 (37.7%) female with the gender ratio of 1.7 M: 1 F. Similarly, Pulak and Swamy found 80% male and 20% female with a gender ratio of 4 M: 1 F.²⁰ The precise incidence of clubfoot in Bangladesh per se is not established, but recent global data can confidently be adopted ie 1-2:1000 births. In Bangladesh, and other developing nations, females clubfoot patients are not given due attention, due to social bias and wariness favouring male children, which may also influence reported gender ratios.²¹

This study showed that three-quarters of parents had a very low monthly income, with most living in tin shed houses. The lowest incomes, poor standard housing majority also had maximum proportion of clubfoot children. Supporting this study, a previous report found that approximately half of the family incomes were between TK 5000 to 10,000.²² The very likely reason that these very low income families brought their children with clubfoot deformity to the WFL clinic is that the treatment was provided totally free of cost.

Family history of clubfoot in this study was similar to that found by Honein but lower than reported by other family-based studies.^23-24

Morcuende et al reported the average age at first cast as three months.²⁵ Similarly, Lara et al reported the average age at first cast as between 3.2 and 5.4 months.⁹ This study from MMCH returned an older average age at first cast, as WFL were being established and public awareness still growing. From many perspectives, a younger age at first cast is preferable for easier clubfoot management. It has been recommended that treatment should begin within first 15 days of life.²⁶

Herzenberg et al found the mean number of casts to be seven, another study found a mean of five corrective casts.^26-27 In contrast, this study found an average of three and six corrective casts required, including the four year review cohort. Recently, with more experience and an adopted evidence-based modification, WFL has begun changing plaster casts at shorter intervals.¹³

The tenotomy rate in this study was 80%, comparing favourably with 67% in Laara et al,⁹ 57% in Chu et al.²⁶ It should be noted that Dr Ponseti advised and performed the tenotomy in more than 90% of cases.⁹

Parents’ satisfaction is an important factor in any paediatric condition requiring their cooperation for effective intervention. In this study parent satisfaction was very high, similarly to the findings of Bor N et al, who also found that parents indicated high satisfaction with the treatment of their children with Ponseti method.²⁷ Further, Evans et al, found 97% parents were happy with their children’s improvement with treatment, where as Rahman et al, found that half of parents were highly satisfied after receiving treatment for their child’s clubfoot deformity.^10,22

The positive effect of public awareness efforts has been apparent across WFL clinics in Bangladesh, as the age of presentation of children has reduced. Most children reviewed were aged between three and six years. By contrast, Rahman et al, reviewed 90 percent of children aged less than three years.²¹ Since 2011, when the WFL clinic at MMCH began, the age of initial presentation of children with clubfoot has reduced with most now aged less than six months at the time of first casts.

This study addressed and appreciated parents’ opinions, and what becomes relevant for them as the children become older. Being able to wear their choice shoes, being able to play with other children, to squat (for play, toileting, eating), and being able to walk and run like other same-aged children were all important factors for parents and related to their reported happiness. Rahman et al also mentioned the importance for parents for their children to be able to stand, walk and do other activities like healthy babies.²²

Relapsing clubfoot deformity is not uncommon. Those found with relapse signs in this study, were all given further treatment. Rahman et al²² returned three-fold higher relapse rate of 37%, and Morcuende et al¹³ found 25% relapses. Current knowledge expresses that relapses are not always due to non-compliance with treatment, but due to underlying connective tissue ‘stiffness’.

Based on the study finding, it may be concluded the Ponseti method has been widely found to be very effective both clinically and economically, with greatest gains and advantage for developing countries like Bangladesh. Poverty, housing conditions, and nutrition may contribute to ‘clubfoot disease’ and warrant further prospective study. The Bangladesh Government can continue to support WFL clinics where Orthopaedic surgeon and Physiotherapists are available, to alleviate the burden of this correctable disability.

The research group acknowledges all WFL clinics, the significant patronage of the Glencoe Foundation (Colin MacFarlane, Founder), all WFL volunteers, and all WFL donors. In addition, WFL acknowledge the role of the late Dr Frederick R. Dietz, our respected colleague and friend.

Conflict of Interest: Authors declare no conflict of interests.