Determining Reasons Affecting Late Presentation of Neglected CTEV

in Saiful Anwar General Hospital

Qualitative research
Devi.LK*, Sananta P.**, Harianti T.***

*Resident Orthopaedic and Traumatology, Faculty of Medicine Brawijaya University

Dr. Saiful Anwar General Hospital, Malang, Indonesia.
**Lecturer of Orthopedic and Traumatology, Faculty of Medicine Brawijaya University
Dr. Saiful Anwar General Hospital, Malang, Indonesia.
***Lecturer of Public Health, Faculty of Medicine Brawijaya University
Dr. Saiful Anwar General Hospital, Malang, Indonesia

ABSTRACT

Background: Many CTEV patients got delayed treatment even they have a clearly striking
deformity. Most orthopaedic surgeons agree that the initial treatment should be non-surgical
and started soon after birth. In developing countries, late presentation of neglected CTEV to
Orthopaedic clinic is fairly common. A delayed treatment case is difficult to treat and has
poorer outcome than early treatment case at Saiful Anwar General Hospital. This study
investigates the reason why these patients came to Saiful Anwar General Hospital with delayed
presentation using qualitative research.

Objective: To know the determining factors affecting late presentation of CTEV patients in
Saiful Anwar General Hospital with qualitative research

Method: This is a qualitative research with phenomenology approach at our hospital. We

interviewed thoroughly 6 parents of patients with CTEV who came to our clinic and
investigated about why there were delay in obtaining medical treatment.

Result: Our study revealed the reason they came with late presentation is socioeconomic
problems that are low income, low education and lack of knowledge, rural areas or irregular
residence. Medical-related problems is furtherly complicating, that are focus on treating other
accompanying disease (cerebral palsy, congenital heart disease), child psychological trauma
following Ponseti treatment, intentionally delaying or refusing treatment, and seeking
alternative medical options. Most of them also got wrong information from previous physician,
stating that CTEV is the least attention needed problem. Thus, they didn’t come immediately
to orthopaedic clinic.
Conclusion: In developing countries, patient with CTEV occasionally came late to seek
medical treatment. Those 6 patients didn’t immediately come to the orthopaedic clinic because
they got wrong information from previous physician and lack of knowledge and attention
regarding their child foot problem, even if they have clearly striking deformity. CTEV
treatment can be delayed is what their parents thought. A delayed case is harder to treat and
have poorer outcome. Raising awareness to general population is important in improving
outcome of CTEV treatment.

Keywords: neglected CTEV, delayed treatment, wrong information, Qualitative research,

Phenomenology.
Introduction

Neglected clubfeet are those resulting from failure to detect the deformity at birth or in
early infancy and failure to provide adequate treatment during infancy and early childhood.
The neglected clubfoot / CTEV deformity is a problem in poorer developing country. It is the
most common congenital problem leading to locomotor disability. Approximately 80% of
children born with a clubfoot deformity are born in the developing world, and the large majority
of these do not have access to appropriate medical care. The obstacles of poverty, lack of
awareness, lack of appropriate medical resources, scarcity of materials, and ethnocultural belief
in accessible locations mean that treatment is either not initiated or incompletely performed.1,2
Neglected clubfoot surgery is among the most difficult ones. However, it often is
performed in an environment of limited resources. Children with a neglected clubfoot
deformity can walk without the use of crutches or walking aids. However, these children have
pain in the skin and subcutaneous tissues on the dorsum of the foot, and they do have difficulty
with locomotion over longer distances. There is an inability to wear normal shoes, which
aggravates all of the previously stated problems. Recurrent skin breakdown with infections is
not uncommon, and recurrent infections can lead to amputations during adulthood. 2
Qualitative study was presented as a way to learn and identify steps to enhance health
care quality and outcomes for heterogenous patient populations and conditions. The advantage
of qualitative study lie in their ability to make difficult-to-study phenomena become more clear.
In the past two decades, many researchers admitting the need for qualitative study in medicine,
because it is designed to learn about social context of the underlying health prognosis.
Qualitative research often build hypotheses which will then evaluated by quantitative
approaches. The reason why qualitative study prioritized aside from quantitative study for
health research is to understand improving barriers to treatment adherence for patients and to
gain insights into disparate health care3
A delayed treatment case is difficult to treat and has poorer outcome than early
treatment case at Saiful Anwar General Hospital. This study investigates the reason why these
patients came to Saiful Anwar General Hospital with delayed presentation of CTEV using
qualitative research.

Method

We did a qualitative research with phenomenology approach at our hospital. There are
6 patients with neglected CTEV who came to our clinic. All of them are living in rural areas.
We interviewed their parents thoroughly and analyzed about why there were delay in obtaining
medical treatment.

Results

There are 6 patients who came to our clinic with CTEV. Their mean age were 1,8 ± 0,3.
There were 3 male patients and 3 female patients. All of their parents work as labor most of
their educational background were elementary school graduates (n=5), and only one was a high
school graduates.

Our study revealed the reason they came with late presentation is socioeconomic
problems that are low income, low education and lack of knowledge, rural areas or irregular
residence. Other accompanying disease (cerebral palsy, congenital heart disease), child
psychological trauma following Ponseti treatment, intentionally delaying or refusing treatment,
and seeking alternative medical options were also delaying their visit to our clinic. Most of
them also got wrong information from previous physician, stating that CTEV is the least
attention needed problem.

Discussion

Congenital equinovarus (CTEV) or clubfoot is the commonest congenital anomaly

which presents to a paediatric orthopaedic surgeon, and is the commonest congenital condition
resulting in loco motor disability [3]. Clubfoot is a complex foot deformity which requires
dedicated efforts from both the parents (of younger patients) and the surgeon to achieve
correction.
Most of the parent’s education and socioeconomic status is low,most of them are labor.
In rural areas, where the ethnocultural belief is strong, most of the population prefer alternative
treatments to modern medical interventions. These are correlated with lack of knowledge and
lack of awareness.

Conclusion

In developing countries, patient with CTEV occasionally came late to seek medical
treatment. Those 6 patients didn’t immediately come to the orthopaedic clinic because they got
wrong information from previous physician and lack of knowledge and attention regarding
their child foot problem, even if they have clearly striking deformity. CTEV treatment can be
delayed is what their parents thought. A delayed case is harder to treat and have poorer
outcome. Raising awareness to general population is important in improving outcome of CTEV
treatment.

1. Penny JN. The neglected clubfoot. Tech Orthop. 2005;20(2):153–66.

2. Dimeglio A, Cavanese F. Orthopaedic challenges in Asia: Management of Resistant,

Relapsed, and Neglected Clubfoot. Curr Orthop Pract. 2013;24(1):4.

3. Maragh-Bass AC, Appelson JR, Changoor NR, Davis WA, Haider AH, Morris MA. Prioritizing
qualitative research in surgery: A synthesis and analysis of publication trends. Surgery. 2016;
160(6): 1447-1455.