The hybrid method for the treatment of congenital talipes equinovarus: preliminary results on 92 consecutive feet

Comparison of kinematics and pedobarography findings between the unaffected foot of patients with unilateral clubfoot and controls

PURPOSE

Idiopathic clubfoot (ICF) involves structural abnormalities in the lower extremities. Approximately half of patients have unilateral ICF, which could be due to differences in limb formation. The contralateral unaffected foot may have subclinical ICF. The objectives were to compare ankle and foot kinematics and pedobarography findings between the unaffected foot of patients with unilateral ICF and controls.

METHODS

Eleven children with unilateral ICF (11 unaffected feet, 11.7 ± 3.8 years) and 15 age-matched controls (30 control feet, 11.1 ± 3.0 years) were enroled. Five complete gait trials were performed. Data were collected using ten cameras and a two m long Footscan system and compared between groups using the Wilcoxon rank sum test.

RESULTS

All children with ICF underwent the selective soft tissue release procedure. The unaffected feet showed limited ranges in inversion-eversion and dorsiflexion-plantar flexion on kinematic analysis. There was a delay in landing time in all regions of the foot during heel rise and propulsion. The peak time was achieved significantly later in the unaffected feet compared to the controls. Although plantar pressure parameters were comparable, unaffected feet showed a larger contact area in the midfoot region.

CONCLUSIONS

Gait data on the unaffected foot in unilateral ICF patients do not correspond to those of controls despite an indistinguishable clinical appearance. This could be due to the effect of treatment, the process of foot development, or a combination. The relationship between genetics and gait deviation in patients with unilateral ICF needs further evaluation. The unaffected foot should receive similar attention during follow-up.

Manipulation of a clubfoot prior to a Ponseti method decreases the need for tenotomy!

The combination of the Ponseti method with functional treatment produces better results and may reduce the need for surgery. The objective of this study was to assess the impact of manipulation of a congenital equinovarus clubfoot performed before correction by the Ponseti method. This was a cohort study of children <5 years treated with the Ponseti method followed over a minimum period of 1 year. Each foot was treated according to the Ponseti method. The study parameters were as follows: age, gender, concept of previous treatment, previous treatment with manipulation, the degree of deformation according to the Pirani score, the laterality of the deformation, the number of casts required and the time needed for correction, the evolution of the Pirani score before each correction by plaster, the use or not of tenotomy and the Pirani score at the end of the correction session, the evolution of the Pirani score when wearing an abduction boot. The series comprised a total of 68 feet. The average age of the children was 15.5 months. Regarding the deformity, 29 children presented a severe or very severe deformity. Before the treatment, 16 children received regular handling massage. Feet that had received manipulation prior to correction were the least exposed to tenotomy (P = .009). For the children who did not require a tenotomy, all the feet had a Pirani score of zero after the fourth week of wearing the splint. We noted a rapidly decreasing in the Pirani score of the feet, which did not require an tenotomy compared with other feet (Kolmogorov-Smirnov test: D = 0.61; P = .01). The combination of functional treatment with the Ponseti method reduces the need for tenotomy.

The effectiveness of three-phase physiotherapy program in children with clubfoot after Ponseti treatment

BACKGROUNDS

Clubfoot is a foot disorder frequently seen. Although, there are several studies about the efficiency of physiotherapy in the treatment of clubfoot, physiotherapy programs may be more efficient if the treatment apply step by step similar to the logic of the serial casting progression of the involved foot. Therefore, the aim of this study was to determine the effectiveness of three-phase physiotherapy program in children with clubfoot.

METHODS

Fifty-seven patients (37 males, 20 females; 7.26 ± 1.27 years) with clubfoot which had Ponseti treatment before were included. The ankle dorsiflexion (DF) and plantar flexion (PF) ranges of motion (ROM), one-leg standing time, sit-to-stand test, The Oxford Ankle Foot Questionnaire (OxAFQ) and treatment satisfaction were evaluated before and after treatment. A three-phase physiotherapy program was applied for 3 months.

RESULTS

DF, PF, one-leg standing time, sit-to-stand test, treatment satisfaction and all parameters of OxAFQ except 'Emotional' parameter of OxAFQ-Children significantly improved after treatment (p < 0.05).

CONCLUSIONS

The three-phase physiotherapy program increased the ankle range of motion, improved functional status and treatment satisfaction in children with clubfoot. The three-phase physiotherapy might be a reasonable treatment for clubfoot. Although, there is a need for long-term studies to understand its effects on preventing relapse.

The 'Hybrid method' for the treatment of congenital clubfoot

Background

The hybrid method combines the advantages of the Ponseti technique and of the French Physical Therapy method. The main goal of this study is to present our results on 139 consecutive newborns with clubfoot (n=212 feet) treated at our Institution with the hybrid method.

Methods

From May 2010 until August 2020, 139 consecutive newborns with congenital clubfoot (66 unilateral; 73 bilateral) were treated by the hybrid method protocol and were retrospectively reviewed. All patients were admitted via the maternity ward with their family and personal history records, i.e., parental age, parity, gender, birth weight, involved side and presence/absence of associated medical conditions. At birth, all clubfeet were graded in ascending order of severity according to Dimeglio et al.’s classification system. AP and lateral radiographs of each foot are taken every 5 to 6 months from age 6 months to 2 years, then once a year until age 4 years, to assess divergence between talus and calcaneus on both projections

Results

The cohort counted a total of 100 boys (71.9%) and 39 girls (28.1%). Clubfoot was unilateral in 66 patients (47.5%) and bilateral in 73 (52.5%). All but 10 patients had idiopathic clubfoot deformity (92.8%). Mean number of casts per patient was 8 (range: 4–11). One hundred and thirty patients out of 139 underwent percutaneous Achilles tenotomy under general anesthesia (93.5%). Overall, tibialis anterior transfer was performed in 6/212 feet (2.8%), posterior release in 9/212 (4.2%) and medial release in 1/212 foot (0.05%).

Conclusions

Our experience with the hybrid method has allowed us to constantly reduce the number of patients requiring surgery over the years, as well as the extent of surgical release. These results are encouraging, but larger cohorts of patients from different institutions and with longer follow up are needed to confirm our findings.

The functional method: experience from the Robert Debré Hospital

Background

In the 1970s a conservative treatment for clubfoot (CF) deformity based on daily physiotherapy combining specific sequences was developed: the French functional method (FFM). Over time, the FFM technique has improved and additional measures have been introduced. The aim of this study was to report mid-term and long-term results of clubfeet treated conservatively by the FFM at birth.

Methods

All patients consecutively treated for clubfoot by the FFM between 1993 and 2010 were prospectively included. Initial severity was assessed by the Dimeglio classification. All patients were followed up by the same treating surgeon until skeletal maturity. Final assessment was performed using the International Clubfoot Study Group evaluation system (ICFSG).

Results

A total of 779 feet were included. Surgery was required in 41% of cases (mean age 2.0±0.1 years). The incidence of surgery significantly decreased after the introduction of percutaneous Achilles tenotomy (PAT) in 2000 (63.4% vs. 29.6%). At latest evaluation (mean follow-up 12±0.2 years), 86% of patients had excellent or good outcomes (mean ICFSG was 1.83±0.1). Mean ankle dorsiflexion was 10° in non-idiopathic CF and 12.1° in idiopathic CF. Eleven percent of the idiopathic clubfeet exhibited decreased ankle function (0–10°). There were no cases of overcorrection into excess ankle dorsiflexion or rocker bottom foot deformities.

Conclusions

Current team was the funding institution of the FFM and several modifications were proposed over times to improve outcomes. Eighty-six percent of feet had excellent to good outcomes according to the ICFSG score, with minimal residual deformities (ankle dorsiflexion between 0° and 10°, calcaneal-thigh angle between 10° and 20°) or insufficient radiological correction (defined by talo-calcaneal angle between 10° and 20°) at latest follow-up.

Clinical examination and classification systems of congenital clubfoot: a narrative review

Clinical examination of the newborn's foot is a complex exercise that requires a lot of sensitivity, practice and deep understanding of normal and pathological anatomy, and the clinical assessment of a child with congenital talipes equinovarus, or congenital clubfoot, must be complete and it should not be limited to a simple orthopedic evaluation of the foot; the search for a cause is a pressing concern. This narrative review article aims to provide the key information about clinical examination of children with congenital clubfoot; classification systems are also described. Clinical examination of children with congenital clubfoot is essential. In particular, it is important to evaluate the mental age of the child (developmental milestones), to rule out the presence of a spinal dysraphism, to eliminate a mild form of neurological disease (congenital myopathy or arthrogryposis), as well as to carefully examine the face and hands of the patient. The examination of the foot and the classification of the clubfoot deformity complete the clinical evaluation. In the end, the pediatric orthopedic surgeon must not underestimate any clinical signs, and must act as a pediatrician. This narrative review summarizes the key points in taking a history and performing a comprehensive clinical examination for patients with congenital clubfoot; the review also briefly describes the normal foot anatomy and growth as to give the reader the opportunity to better understand the morphological and functional modifications secondary to congenital clubfoot.

Idiopathic clubfoot treatment and heterogeneity of current therapeutic strategies: The Ponseti method versus the French functional method (a systematic review)

BACKGROUND

Since Hippocrates, the treatment of idiopathic clubfoot has undergone many changes, with surgical techniques and conservative approaches evolving over the centuries. Today, a wide variety of practices exist in France and throughout the world; consequently, the treatment of idiopathic clubfoot remains controversial, but the Ponseti method and the functional method seem to stand out. Nevertheless, has one of them demonstrated superiority?

METHODS

The purpose of this review is to compare these two methods. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 recommendations, this research was conducted on Pubmed, Web of Science, and 1Findr. Only articles concerning patients with moderate or severe idiopathic clubfoot (10-17 on the Dimeglio scale) treated early using the Ponseti method or the functional method were eligible.

RESULTS

After reviewing 49 studies, seven published between 2008 and 2018 were selected: five prospective cohort studies, one retrospective cohort study, and one meta-analysis. Each method, according to morphological and kinetic criteria, seems to have advantages that the other does not have.

CONCLUSIONS

Although the Ponseti method is becoming the gold standard and appears more appropriate in poor countries, it is impossible to affirm its superiority over the functional method. Therefore, the combination of their advantages deserves attention: a hybrid method could be an appealing prospect for the future.

The "Gastrocnemius-Achilles Tendon-Calcaneus Complex": Different Responses after Percutaneous versus Vulpius Achilles Tendon Lengthening in New Zealand White Rabbits

BACKGROUND

This study aimed to describe the clinical, radiological, biomechanical, electromyographic, and histoenzymologic modifications in the "Gastrocnemius-Achilles Tendon-Calcaneus complex" caused by percutaneous Achilles tendon lengthening (PATL) versus Vulpius Achilles tendon lengthening (VATL) in New Zealand White (NZW) rabbits.

MATERIALS AND METHODS

Eight female NZW rabbits were used at 7 months of age. Two rabbits were euthanized before surgery for anatomical dissection, three underwent PATL (two bilateral and one unilateral), and the three others underwent VATL (two bilateral and one unilateral). Clinical examination, biomechanics, electromyography, standard radiographs and magnetic resonance imaging (MRI), and histology and histoenzymology were assessed after surgery.

RESULTS

At the end of the experiment, the subjects showed good clinical status but different functional outcomes of surgery: rabbits submitted to PATL developed permanent limp and lost their capacity to jump compared to rabbits submitted to VATL which remained able to ambulate and jump normally. Standard radiographs and MRI showed that PATL led to significantly greater increase in dorsal or anterior flexion of the tibiotarsal angle (TT angle) compared to VATL, whereas electromyographic and histoenzymologic observations of muscle unit showed little or no variation between the two groups of operated rabbits.

CONCLUSIONS

Although PATL leads to greater improvement in dorsal or anterior flexion (TT angle) of the rabbit ankle compared to VATL, it has negative effects on functional outcome as it reduces the contractile capacity of the rabbit muscle unit, ultimately impairing the ability to ambulate and jump.

Gross Motor Function at 10 Years of Age in Children With Clubfoot Following the French Physical Therapy Method and the Ponseti Technique

PURPOSE

To evaluate gross motor skills [Bruininks-Oseretsky Test of Motor Proficiency, 2nd ed (BOT-2)] of patients with idiopathic clubfoot initially treated nonoperatively with either the French functional physical therapy (PT) method or the Ponseti technique, at age 10 years.

METHODS

The BOT-2 was administered by trained physical therapists on patients with idiopathic clubfoot at age 10 years. The cohort was divided by initial treatment method (PT or Ponseti), and compared. Subsequent analyses included comparisons of: initial clubfoot severity (Dimeglio scores: ≤13 vs. >13), laterality (unilateral vs. bilateral), and surgical versus nonoperative outcome.

RESULTS

Of the 183 patients tested, 172 were included. The Ponseti and PT groups did not significantly differ according to age, height, weight, body mass index, ankle dorsiflexion, sex, average initial Dimeglio score, laterality, or surgical versus nonsurgical outcome. Overall, patients with treated clubfoot had average gross motor BOT-2 scores compared with age-matched peers. Patients in the PT group scored higher on Running Speed/Agility (P=0.019), Body Coordination percentile rank (P=0.038), and Strength and Agility percentile rank (P=0.007) than patients treated by the Ponseti technique. Patients with bilateral clubfoot scored significantly lower on the Balance subtest (P<0.01), and Body Coordination percentile rank (P<0.01), than those with unilateral clubfoot. Patients who required surgery scored significantly lower on the Balance subtest (P=0.04) than those who did not require surgery.

CONCLUSIONS

Clubfoot may impair balance in 10 year olds with bilateral involvement and those requiring surgery. Future research should evaluate whether components of the PT method may improve gross motor outcomes as a supplement to the Ponseti technique.

LEVELS OF EVIDENCE

Level II.