Evaluation of a surgical treatment algorithm for neglected clubfoot in low-resource settings

Purpose
Idiopathic clubfoot affects approximately 1/1000 alive-born infants, of whom 80–91% are born in low- or middle-income countries (LMICs). This retrospective study aimed to evaluate the morphological, functional, and social outcomes in patients with neglected clubfoot in rural Bangladesh, after receiving surgical treatment.

Methods
Patients received a posteromedial release (PMR) with or without an additional soft tissue intervention (group 1), a PMR with an additional bony intervention (group 2), or a triple arthrodesis (group 3) according to our surgical algorithm. Patients were followed until two year post-intervention. Evaluation was done using a modified International Clubfoot Study Group Outcome evaluation score and the Laaveg-Ponseti score.

Results
Twenty-two patients with 32 neglected clubfeet (ages 2–24 years) received surgical treatment. Nineteen patients with 29 clubfeet attended follow-up. At two year follow-up an excellent, good, or fair Laaveg-Ponseti score was obtained in 81% (group 1), 80% (group 2), and 0% (group 3) of the patients (p value 0.0038). Age at intervention is inversely correlated with the Laaveg-Ponseti score at two year follow-up (p < 0.0001). All patients attended school or work and were able to wear normal shoes.

Conclusion
Our treatment algorithm is in line with other surgical algorithms used in LMICs. Our data reconfirms that excellent results can be obtained with a PMR regardless of age. Our algorithm follows a pragmatic approach that takes into account the reality on the ground in many LMICs. Good functional outcomes can be achieved with PMR for neglected clubfoot. Further research is needed to investigate the possible role of triple arthrodesis.

Resuming elective surgeries in Corona pandemic from the perspective of a developing country

Since the COVID-19 pandemic, healthcare facilities have entered into a “crisis mode”. One of the measures used to allow hospitals to surge their capacity and serve the patient population with COVID-19 infection was the suspension of elective activity, most importantly elective surgery and other procedures. Now as the infection is fading, efforts are being made to resume elective surgical services keeping in mind the safety of the patient and health care workers. Resuming surgical services in developing countries is an uphill task.

Building neurosurgical capacity in low and middle income countries

Neurosurgery capacity in low- and middle-income countries is far from adequate; yet burden of neurological diseases, especially neuro-trauma, is projected to increase exponentially. Previous efforts to build neurosurgical capacity have typically been individual projects and short termmissions. Recognizing the dual needs of addressing disease burden and building sustainable, long-term neurosurgical care capacity, we describe in this paper an ongoing collaboration between the Mulago Hospital Department of Neurosurgery (Kampala, Uganda) and Duke University Medical Center (Durham, NC, USA) as a replicable model to meet the dual needs. The collaboration employs a threefold approach to building capacity: technology, twinning, and training performed together in a top-down approach. Also described are lessons learned to date by Duke Global Neurosurgery and Neurosciences (DGNN) and applicability beyond Kampala.