Question: For infants who have had surgical correction of clubfoot,
is continuous passive motion (CPM) more effective than standard immobilization
in a cast?
Design: Randomized allocation
concealed*, blinded
(outcome assessor), controlled trial with 48-month follow-up.
Information provided by author.
Setting: A university clinic in Heidelberg, Germany.
Patients: 38 infants (71% boys; mean age, 8 months; 50 affected
feet) who had Dimeglio grade-3 deformities treated with manipulation and
immobilization in a cast for 6 months (which did not correct the deformity).
Follow-up was 97% (37 infants, 37 feet).
Intervention: 38 feet were randomly allocated.
All infants had posterolateral medial release of the contracted capsule of
the talocalcaneal and tibiotalar joints; lengthening of the tendo Achillis by
Z-plasty; lengthening of the tendons of tibialis posterior, flexor hallucis
longus, and flexor digitorum longus; and open reduction of the talonavicular
joint. After surgery, the feet were allocated to CPM (n = 19) or
immobilization in a cast (n = 18). The CPM group had a cast applied for 10
days followed by computer-assisted three-dimensional CPM therapy with a
Kinetec 5090 ankle CPM machine (S and U Medizintechnik, Partenheim, Germany).
Standardized protocols were used to move the joints through a specified range
of movement. CPM was begun in the hospital, and each foot was prescribed =4
hours of treatment daily. The cast group had standard immobilization in a cast
for 6 weeks. After 6 weeks, each foot wore a brace at night, and physiotherapy
was continued for 6 more months in each group.
Main outcome measure: Dimeglio clubfoot score (range, 4 to 16 [worst
score]) at 6, 12, 18, and 48 months after surgery.
Main results: Infants in the CPM group had greater improvement than
the cast group at up to 1 year after surgery
(Table). Groups did not differ
at 18 or 48 months (Table). At
48 months, 5 feet in each group had residual deformity.
Conclusion: In infants with surgically corrected clubfoot,
continuous passive motion led to greater improvement in the short term, but
the result did not differ at 4 years from standard cast immobilization.
Source of funding: No external funding.
While recent clubfoot literature focuses on nonoperative treatment, some
feet still require surgery. This novel study by Zeifang and colleagues
randomly allocated children who had clubfoot release and 10 days of cast
immobilization to either CPM or further casting.
CPM has been used by Dimeglio as part of the French physical therapy
technique, which emphasizes daily manipulation and taping. CPM machines have
been specially fabricated to hold and move the infant's foot gently in
prescribed directions. Babies must lie supine quietly when using the machine.
In our experience with nonoperative treatment, compliance by the babies is
unpredictable. In this study, CPM was initiated in the hospital. One assumes
the subsequent 4.5 weeks of CPM was done at home. How the babies tolerated CPM
and whether compliance was monitored were not mentioned.
The authors' premise was that CPM would lessen postoperative stiffness, a
well-documented problem in operatively treated club-feet. Although reporting
Dimeglio scores as a measure of passive flexibility, the authors did not study
gait or function. It would be interesting to see how the two groups of feet
"work" in addition to how they feel.
Improved correction by Dimeglio scores was seen for up to 18 months with
CPM compared with casting, but the improvement was not maintained.
Furthermore, 10 of 50 feet had residual deformity only 4 years after surgery,
and 2 more underwent reoperation. Most importantly, recurrence was seen
regardless of the postoperative regimen in equal numbers of patients.
Because infant CPM is not readily available and parent compliance is
unknown, and because intermediate-term results are equivalent, casting should
remain an acceptable treatment following clubfoot release.