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Common Errors in the Management of Idiopathic Clubfeet Using the Ponseti Method: A Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010152. [PMID: 36670703 PMCID: PMC9856779 DOI: 10.3390/children10010152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
Congenital talipes equinovarus is one of the most prevalent birth defects, affecting approximately 0.6 to 1.5 children per 1000 live births. Currently, the Ponseti method is the gold-standard treatment for idiopathic clubfeet, with good results reported globally. This literature review focuses on common errors encountered during different stages of the management of idiopathic clubfeet, namely diagnosis, manipulation, serial casting, Achilles tenotomy, and bracing. The purpose is to update clinicians and provide broad guidelines that can be followed to avoid and manage these errors to optimize short- and long-term outcomes of treatment of idiopathic clubfeet using the Ponseti method. A literature search was performed using the following keywords: "Idiopathic Clubfoot" (All Fields) AND "Management" OR "Outcomes" (All Fields). Databases searched included PubMed, EMBASE, Cochrane Library, Google Scholar, and SCOPUS (age range: 0-12 months). A full-text review of these articles was then performed looking for "complications" or "errors" reported during the treatment process. A total of 61 articles were included in the final review: 28 from PubMed, 8 from EMBASE, 17 from Google Scholar, 2 from Cochrane Library, and 6 from SCOPUS. We then grouped the errors encountered during the treatment process under the different stages of the treatment protocol (diagnosis, manipulation and casting, tenotomy, and bracing) to facilitate discussion and highlight solutions. While the Ponseti method is currently the gold standard in clubfoot treatment, its precise and intensive nature can present clinicians, health care providers, and patients with potential problems if proper diligence and attention to detail is lacking. The purpose of this paper is to highlight common mistakes made throughout the Ponseti treatment protocol from diagnosis to bracing to optimize care for these patients.
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Pigeolet M, Vital A, Daoud HA, Mita C, Corlew DS, Alkire BC. The impact of socio-economic factors on parental non-adherence to the Ponseti protocol for clubfoot treatment in low- and middle-income countries: A scoping review. EClinicalMedicine 2022; 48:101448. [PMID: 35706498 PMCID: PMC9112092 DOI: 10.1016/j.eclinm.2022.101448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Ponseti treatment is considered the gold standard for clubfoot globally, but requires strong engagement from parents. The aim of this review is to assess the impact of socio-economic factors on the presence of drop-out, relapse or non-compliance during Ponseti treatment in low and middle-income countries (LMICs). METHODS This scoping review includes all articles available from inception until 4.4.2022. All articles describing an association between one or more socio-economic factors and one or more adverse outcomes during the Ponseti treatment in an LMICs were considered for inclusion. Studies were identified by searching Medline/PubMed, Embase, Global Health and Global Index Medicus. Data extraction was done using Covidence extraction 2.0 by two independent reviewers. FINDINGS A total of 281 unique references were retrieved from the database searches, 59 abstracts were retained for full-text review, of which 19 studies were included in the final review. We grouped the identified socio-economic factors into 4 larger themes: poverty and physical accessibility of clubfoot clinics, presence of support systems, educational level of the parents, and household-level factors and cultural norms. Reduced access to care for girls was considered an important risk factor in South Asia and the Caribbean. Lack of family and community support was an issue raised more often in studies from Eastern Africa. The extreme heterogeneity among collected variables within a small sample of papers made it not possible to perform a meta-analysis. INTERPRETATION The identified factors are very similar to the socio-economic factors identified in studies looking at the barriers parents and children face when seeking care initially. Poverty was identified as a cross-cutting risk factor in all 4 domains and the most important socio-economic risk factor based on this review, reconfirming poverty eradication as the challenge for the 21st century. FUNDING None.
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Affiliation(s)
- Manon Pigeolet
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
- Université Libre de Bruxelles, Faculty of Medicine, Avenue de Lennik 808, 1070 Brussels, Belgium
- Corresponding author.
| | - Anchelo Vital
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
- State University of Haiti, Faculte de Medecine et de Pharmacie, 10 Imp. Ambroise, Port-au-Prince, Haïti
| | - Hassan Ali Daoud
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
- Amoud University, Somaliland Amoud University College of Health Sciences, Borama, Somalia
| | - Carol Mita
- Countway Library, Harvard Medical School, Harvard University Libraries, 10 Shattuck St, Boston, MA 02115, United States
| | - Daniel Scott Corlew
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
| | - Blake Christian Alkire
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
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Eight-year Review of a Clubfoot Treatment Program in Pakistan With Assessment of Outcomes Using the Ponseti Technique: A Retrospective Study of 988 Patients (1,458 Clubfeet) Aged 0 to 5 Years at Enrollment. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00019. [PMID: 35467578 PMCID: PMC9042583 DOI: 10.5435/jaaosglobal-d-22-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/19/2022] [Indexed: 11/18/2022]
Abstract
To conduct an 8-year retrospective review of a clubfoot treatment program using the Ponseti technique with close monitoring of outcomes.
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VAN SCHELVEN H, MOERMAN S, VAN DER STEEN M, BESSELAAR AT, GREVE C. Prognostic factors for recurrent idiopathic clubfoot deformity: a systematic literature review and meta-analysis. Acta Orthop 2022; 93:11-28. [PMID: 34607499 PMCID: PMC8815420 DOI: 10.1080/17453674.2021.1982576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods - PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results - 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30-2,190), brace non-compliance (OR = 10, CI 5-21), no additional stretching (OR = 31, CI 10-101), more casts (OR = 3.5, CI 1.6-7.8), lower education level of parents (OR = 1.8, CI 1.2-2.6), non-marital status of parents (OR = 1.8, CI 1.1-3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2-3.3) were associated with higher recurrence rates. Interpretation - Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.
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Affiliation(s)
- Heleen VAN SCHELVEN
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen
| | - Sophie MOERMAN
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen
| | - Marieke VAN DER STEEN
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven,Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Arnold T BESSELAAR
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Christian GREVE
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen,Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Agarwal A, Rastogi A, Rastogi P. Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis. J Clin Orthop Trauma 2021; 18:199-204. [PMID: 34026487 PMCID: PMC8122108 DOI: 10.1016/j.jcot.2021.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children. METHODS A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1st January 2001 to 15th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients. RESULTS There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA). CONCLUSIONS Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.
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Affiliation(s)
- Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India,Corresponding author. Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India.
| | - Anuj Rastogi
- Department of Orthopaedics, Integral Institute of Medical Sciences and Research, Integral University, Lucknow, Uttar Pradesh, India
| | - Prateek Rastogi
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 31, India
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Thomas HM, Sangiorgio SN, Ebramzadeh E, Zionts LE. Relapse Rates in Patients with Clubfoot Treated Using the Ponseti Method Increase with Time: A Systematic Review. JBJS Rev 2020; 7:e6. [PMID: 31116129 DOI: 10.2106/jbjs.rvw.18.00124] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Ponseti method is the preferred technique to manage idiopathic clubfoot deformity; however, there is no consensus on the expected relapse rate or the percentage of patients who will ultimately require a corrective surgical procedure. The objective of the present systematic review was to determine how reported rates of relapsed deformity and rates of a secondary surgical procedure are influenced by each study's length of follow-up. METHODS A comprehensive literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed to identify relevant articles. The definition of relapse, the percentage of patients who relapsed, the percentage of feet that required a surgical procedure, and the mean duration of follow-up of each study were extracted. Pearson correlations were performed to determine associations among the following variables: mean follow-up duration, percentage of patients who relapsed, percentage of feet that required a joint-sparing surgical procedure, and percentage of feet that required a joint-invasive surgical procedure. Logarithmic curve fit regressions were used to model the relapse rate, the rate of joint-sparing surgical procedures, and the rate of joint-invasive surgical procedures as a function of follow-up time. RESULTS Forty-six studies met the inclusion criteria. Four distinct definitions of relapse were identified. The reported relapse rates varied from 3.7% to 67.3% of patients. The mean duration of follow-up was strongly correlated with the relapse rate (Pearson correlation coefficient = 0.44; p < 0.01) and the percentage of feet that required a joint-sparing surgical procedure (Pearson correlation coefficient = 0.59; p < 0.01). Studies with longer follow-up showed significantly larger percentages of relapse and joint-sparing surgical procedures than studies with shorter follow-up (p < 0.05). CONCLUSIONS Relapses have been reported to occur at as late as 10 years of age; however, very few studies follow patients for at least 8 years. Notwithstanding that, the results indicated that the rate of relapse and percentage of feet requiring a joint-sparing surgical procedure increased as the duration of follow-up increased. Longer-term follow-up studies are required to accurately predict the ultimate risk of relapsed deformity. Patients and their parents should be aware of the possibility of relapse during middle and late childhood, and, thus, follow-up of these patients until skeletal maturity may be warranted. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hannah M Thomas
- Orthopaedic Institute for Children, The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Los Angeles, California
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Qudsi RA, Selzer F, Hill SC, Lerner A, Hippolyte JW, Jacques E, Alexis F, May CJ, Cady RB, Losina E. Clinical outcomes and risk-factor analysis of the Ponseti Method in a low-resource setting: Clubfoot care in Haiti. PLoS One 2019; 14:e0213382. [PMID: 30870447 PMCID: PMC6417735 DOI: 10.1371/journal.pone.0213382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/19/2019] [Indexed: 12/21/2022] Open
Abstract
Purpose The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti. Methods We conducted a records review of patients presenting from 2011–2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse. Results Amongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18–12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08–4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17–6.64). Female sex (RR 1.54, 95% CI 1.01–2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00–1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6–18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%). Conclusions Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.
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Affiliation(s)
- Rameez A. Qudsi
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Policy and Innovation Evaluation in Orthopedic Treatments Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Faith Selzer
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Policy and Innovation Evaluation in Orthopedic Treatments Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stephen C. Hill
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Ariel Lerner
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | | | | | - Francel Alexis
- Department of Orthopaedic Surgery, Adventist Hospital, Diquini, Haiti
| | - Collin J. May
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Robert B. Cady
- Departments of Orthopaedics and Pediatrics, Upstate Medical University, Syracuse, New York, United States of America
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Policy and Innovation Evaluation in Orthopedic Treatments Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Munambah N, Chiwaridzo M, Mapingure T. A cross-sectional study investigating impressions and opinions of medical rehabilitation professionals on the effectiveness of the Ponseti method for treatment of clubfoot in Harare, Zimbabwe. Arch Physiother 2016; 6:7. [PMID: 29340189 PMCID: PMC5759920 DOI: 10.1186/s40945-016-0021-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/27/2016] [Indexed: 12/25/2022] Open
Abstract
Background The Ponseti method of managing clubfoot was introduced in Zimbabwe in 2011. This followed massive training of health workers such as medical rehabilitation practitioners through a programme called the Zimbabwe Sustainable Clubfoot Programme. Today, the Ponseti method is the technique of choice for managing clubfoot in hospitals. However, since then, there is no published evidence documenting the efficacy and the relevance of the technique especially comparing to previously used methods. This is a significant shortcoming if sustainability issues are to be considered. Therefore, this study was designed to investigate the impressions and opinions of medical rehabilitation practitioners on the method in terms of its effectiveness, perceived challenges and possible recommendations for improvement of the technique application in their setting. Methods A descriptive cross-sectional study was conducted targeting medical rehabilitation practitioners previously trained on the method and working in public or private clinics that offer clubfoot management in Harare. A questionnaire was self-administered to 41 participants who volunteered to participate in the study. Data from open-ended questions was analysed thematically. Statistica version 12 was used for analysis for quantitative data. Results The Ponseti method was perceived as an effective method in the treatment of children with clubfoot by all the participants. All the participants 41 (100 %) felt that the method was relevant because of better clinical outcomes. Amongst challenges faced when using Ponseti method, 25 (61 %) participants agreed that caregivers to the children with clubfoot were not compliant to treatment. A total of 22 (54 %) participants felt that lack of adequate insight by the caregivers of this new method was a challenge which hinder progress in treating clubfoot. Conclusions The medical rehabilitation professionals in Harare, Zimbabwe trained to use the Ponseti technique for the management of clubfoot, perceived the method as an effective method resulting in better clinical outcome than previous methods. This probably highlights the need to continue training medical rehabilitation professionals so that there is widespread use of the technique in the country. However, there is need to increase awareness of the method among caregivers to improve compliance, which is key to successful rehabilitation of the clubfoot.
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Affiliation(s)
- N Munambah
- Department of Rehabilitation, University of Zimbabwe, College of Health Sciences, P.O Box A178, Avondale, Harare Zimbabwe
| | - M Chiwaridzo
- Department of Rehabilitation, University of Zimbabwe, College of Health Sciences, P.O Box A178, Avondale, Harare Zimbabwe
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Sharma S, Butt MF, Dev B. Comment on Mootha et al.: Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre. J Orthop Sci 2011; 16:836-7; author reply 838. [PMID: 21997639 DOI: 10.1007/s00776-011-0161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 08/30/2011] [Indexed: 10/16/2022]
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