In the treatment of idiopathic clubfoot deformity, two nonoperative methods (the Ponseti method and the French functional method) have been successful for reducing the need for surgery. Initial correction of the clubfoot deformity can be achieved in 95% of patients with use of either method. Complete correction of the deformity is imperative in order to maximize tolerance for the subsequent use of braces (shoes and bar). Relapses will occur in some patients, necessitating repeated efforts to regain correction.
Ponseti Method
The Ponseti method involves the use of serial manipulations of the foot, followed by casting, to achieve gradual correction of the clubfoot. The major deformities of the foot that require correction include cavus, adductus, varus, and equinus (Figs. 1-A and 1-B). These deformities must be sequentially corrected, in the order in which they are listed, in order to achieve a successful outcome. At each session, the foot is manipulated for approximately one to three minutes to sequentially correct these deformities. The correction is then maintained in an above-the-knee plaster cast with the knee bent to 90° until the next session, five to seven days later.
The first goal of treatment is to correct the cavus deformity, which is accomplished by elevating the first metatarsal and supinating the forefoot in relation to the hindfoot (Figs. 2 and 3). This maneuver usually corrects the cavus at the first session. It is important to perform the manipulations while the infant is relaxed. As such, combining treatments with feedings is often helpful.
At successive manipulation and casting sessions, the metatarsus adductus and hindfoot varus are simultaneously corrected. The foot is abducted with the fingers while counter-pressure is applied laterally over the talar head with the thumb (Fig. 4). At each manipulation, three key points must be followed. First, forefoot abduction should be performed with the foot in slight supination. This maintains the correction of the cavus deformity that was previously obtained and provides an efficient lever arm for abduction. Second, correction of forefoot adduction and hindfoot varus must be completed with the foot in equinus. Premature dorsiflexion of the foot blocks the calcaneus from everting and rotating under the talus to a neutral position. Forceful dorsiflexion can also create a rocker-bottom deformity if varus has not been fully corrected (Figs. 5 and 6). Finally, care must be taken to locate the fulcrum for lateral counter-pressure at the talar head (Figs. 4, 7, 8-A, and 8-B). This allows the forefoot to be displaced as a unit. If pressure is applied to the lateral column of the foot or to the calcaneocuboid joint, correction of hindfoot varus and calcaneal inversion will be hindered. With each cast application, forefoot supination is gradually decreased to correct the inversion of the tarsal bones while the foot is further abducted under the talus. The foot is never pronated. When these steps are followed, the calcaneus, navicular, and cuboid are gradually displaced laterally, which corrects most of the clubfoot deformity. This usually requires three or four sessions of manipulation and casting (Fig. 4). Typically, Ponseti casting should be able to achieve correction in five to eight weeks with five casts.
Finally, correction of the equinus component of the clubfoot deformity is undertaken. This should only be attempted once the hindfoot varus has been corrected to neutral or slight valgus and the foot is abducted to 70° relative to the leg. Correction of the equinus is achieved by applying pressure under the entire sole of the foot, and not just under the metatarsal heads, in order to avoid creating a rocker-bottom deformity. Correction may be achieved with gradual stretching, but more commonly it also requires a percutaneous heel cord tenotomy. One should expect to perform a tenotomy in approximately 75% of patients. During this procedure, the entire Achilles tendon is transected. In an infant who is less than three months of age, the tenotomy can be done in the clinic under sterile conditions. The skin overlying the Achilles tendon is anesthetized with use of transcutaneous lidocaine or topical anesthetic cream. We prefer the cream as it avoids distention of the soft tissues, as may occur with lidocaine. If the soft tissues (skin and subcutaneous fat) are distended, palpation of the tendon may be obscured. The foot is held by an assistant in mild to moderate dorsiflexion, and the tendon is palpated. A cataract blade is introduced along the medial border of the tendon, 0.5 to 1.0 cm proximal to its insertion (Figs. 9 and 10). The blade is then rotated underneath the tendon and counter-pressure with the opposite index finger pushes the tendon onto the blade, thus preventing unnecessary skin laceration. A palpable "pop" of the tendon is experienced, and dorsiflexion of the ankle increases. Sterile cast padding is then applied, followed by the final above-the-knee cast with the foot in maximum dorsiflexion and 70° of abduction.
Following each weekly manipulation of the foot, a well-molded above-the-knee cast is applied over a thin layer of cotton padding (Fig. 11). A few key points can aid in the casting technique. The patient should be placed at the end of the examining table with the physician positioned on the lateral side of the leg, holding the leg in the desired position. An assistant at the foot of the table then rolls the cotton padding from the toes to the knee. Then, the plaster is rolled in a similar fashion to create the below-the-knee portion of the cast. The physician then sits at the foot of the table to mold the cast while the assistant holds the knee of the patient immobile. The cast must be carefully molded to prevent pressure points over the heel and malleoli. The plaster on the top of the toes may be trimmed but is left longer under the toes to aid in stretching the toe flexors. Once the mold is complete on the foot, the cast is extended up the thigh to complete the above-the-knee cast (Figs. 12 through 16).
When the final correction has been achieved, it is maintained with the use of an abduction orthosis. This orthosis consists of two straight-last open-toe shoes connected by a removable bar. The shoes are placed shoulder-width apart and at 70° of external rotation and 10° of dorsiflexion (Fig. 17). In cases of unilateral involvement, the uninvolved foot can be placed at 40° of external rotation. The orthosis is worn full time for two to three months and then at night and during naps for two to four years. At the initiation of bracing, the shoes should be removed several times each day to check the skin for irritation, and periodic adjustments will need to be made to accommodate growth. The importance of brace wear must be emphasized to prevent recurrence.
French Functional Method
The developers of the French functional method believed that the clubfoot deformity resulted from a contracted posterior tibialis tendon with fibrotic tissues, deviated midtarsal joints, and weakened peroneus longus and peroneus brevis muscles. Consequently, the treatment has been focused on stretching of the tight medial structures, passive reduction of the talonavicular joint, sequential correction of forefoot adduction, hindfoot varus and equinus of the calcaneus, and strengthening and stimulation of the muscles. Daily corrective manipulations of the clubfoot are performed by an experienced physical therapist, and the correction is held with elastic taping and splints until the next day's session. Family participation is integral to the success of this treatment program as the family must be able to bring the infant to therapy during the week for one to three months, depending on the severity of the deformity. Initially, the infant is seen by the therapist as many as five times each week. Eventually, the parents perform the exercises and taping daily at home and the frequency of visits to the therapist decreases.
As with the Ponseti method, the infant must be relaxed in order to achieve the best results. Each session lasts approximately thirty minutes per foot, and manipulations are performed in a progressive gentle pattern. A session consists of the therapist exercising the foot for ten to fifteen minutes, taping it, and then, if necessary, fabricating an ankle-foot orthosis to maintain the correction that is obtained as a result of the exercises. There are two phases of treatment: correction and maintenance. The correction phase begins with derotation of the calcaneopedal block and correction of forefoot adduction. This is facilitated with massage of the Achilles tendon and the gastrocnemius muscle (Figs. 18 and 19). Next, the medial soft tissues are stretched to allow the navicular to move away from the medial malleolus and its medial position on the head of the talus (Figs. 20 and 21). Distraction of the forefoot and midfoot helps to loosen the tightened structures, and derotation of the foot (Fig. 22) facilitates reduction of the talus. To maintain the gain achieved in passive range of motion, the toe extensors and peroneals are recruited by stimulating (tickling) the lateral border of the foot and leg and the tops of the toes. The presence of active toe extension confirms that the muscles are being stimulated (Fig. 23).
Once the talonavicular joint has been reduced, attention is directed toward the correction of varus and equinus. With the valgus maneuver (Fig. 24), the calcaneus gradually moves to a neutral and eventually valgus position. The ankle is externally rotated at the same time that the calcaneus is being mobilized into valgus. The knee should be kept at 90° during these maneuvers. Finally, equinus is corrected with gradual dorsiflexion of the foot (Fig. 25). The thumb must be in the arch of the foot and not under the metatarsal heads in order to prevent creating midfoot break. As with Ponseti casting, correction of equinus can be augmented with a percutaneous heel cord tenotomy.
After each manipulation, the improvement in the foot position is maintained by taping. Supplies needed for taping include No-Sting Skin-Prep (Smith and Nephew, Largo, Florida), M Wrap (thin foam underwrap) (Mueller Sports Medicine, Prairie du Sac, Wisconsin), Tensoplast (elastic 1-in [2.54-cm] tape) (BSN Medical, Charlotte, North Carolina), and Hypafix (BSN Medical, Hull, England) (Fig. 26). First, a single layer of M Wrap is rolled over the calf to the toes to protect the skin from tape-induced irritation. Hypafix tape is then placed at the proximal end to hold the M Wrap in place (the Hypafix slightly overlaps the skin). This is the only tape in contact with the skin, and it serves to provide an anchor for the Tensoplast (Figs. 27,28, and 29). Next, four pieces of Tensoplast tape are used to hold the foot in position. The first piece promotes derotation of the foot, the second piece supports the arch and holds the foot derotated, the third piece maintains dorsiflexion, and the fourth piece supports the arch (Figs. 30 through 33). Because these four pieces of tape are elastic, parents can continue to exercise the foot while it is taped. The therapist then creates an Aquaplast (WFR/Aquaplast, Wyckoff, New Jersey) ankle-foot orthosis, which is worn over the tape at least twenty-two hours per day until walking age (Fig. 34). The ankle-foot orthoses are refabricated, as needed, to accommodate new correction and/or growth. Over the weekends, the taped foot position is maintained with a soft-cast overwrap (Scotchcast Soft Cast; 3M, St. Paul, Minnesota) until the parents are independent in performing the taping at home.
After correction of the deformity has been achieved, the emphasis of the French method changes to the maintenance of correction. Fewer visits to the therapist are needed as the parents assume the daily treatment exercises and taping. Periodic follow-up is needed to monitor the range of motion of the foot and the development of the infant and to fabricate new splints. Once the patient is walking, taping is discontinued and a resting ankle-foot orthosis is used during nighttime and naps until the age of two years. Throughout this treatment program, the patient visits the physician every two to three months for evaluation of the foot.
INDICATIONS:
Clubfoot deformities in infants should be treated with either one of these two methods. Parents are given the choice of method following a thorough description of each option. The Ponseti method is more practical for families who live far from the facility or whose schedules cannot accommodate the daily visits required for the French method treatments.
CONTRAINDICATIONS:
Ponseti method. Patients with severe teratologic clubfeet with insensate skin are not good candidates because of potential pressure areas on the skin under the casts.French functional method. Families who are unable to attend daily treatment sessions will not be able to utilize this method.
Ponseti method. Patients with severe teratologic clubfeet with insensate skin are not good candidates because of potential pressure areas on the skin under the casts.
French functional method. Families who are unable to attend daily treatment sessions will not be able to utilize this method.
PEARLS:
Patients must be relaxed. When possible, treatment should coincide with feedings.With both methods, best results are achieved when treatment is initiated in the first month of life.Crossover treatment between these two methods may salvage a foot that appears to be failing to respond to nonoperative treatment. For example, some feet that are successfully treated with the Ponseti method may not tolerate the shoes and bars because of skin blistering or persistent irritability. With use of the techniques of the French method, taping the foot in which initial correction was achieved through casting may prevent relapses and preserve a good outcome. In addition, casting for large babies with cylindrically shaped thighs may be unsuccessful because the casts slide down the leg, thus losing the correction. Taping the extremity to maintain the correction may salvage a successful nonoperative approach.Conversely, some babies who are managed with the French method cannot achieve sufficient dorsiflexion. Performing a percutaneous tendoachilles lengthening followed by Ponseti cast immobilization may achieve a plantigrade foot and allow resumption of the taping protocol to maintain correction. It is very important for the parents to have a close relationship with the therapist so that feet that are not responding well to one method can be addressed with the other.
Patients must be relaxed. When possible, treatment should coincide with feedings.
With both methods, best results are achieved when treatment is initiated in the first month of life.
Crossover treatment between these two methods may salvage a foot that appears to be failing to respond to nonoperative treatment. For example, some feet that are successfully treated with the Ponseti method may not tolerate the shoes and bars because of skin blistering or persistent irritability. With use of the techniques of the French method, taping the foot in which initial correction was achieved through casting may prevent relapses and preserve a good outcome. In addition, casting for large babies with cylindrically shaped thighs may be unsuccessful because the casts slide down the leg, thus losing the correction. Taping the extremity to maintain the correction may salvage a successful nonoperative approach.
Conversely, some babies who are managed with the French method cannot achieve sufficient dorsiflexion. Performing a percutaneous tendoachilles lengthening followed by Ponseti cast immobilization may achieve a plantigrade foot and allow resumption of the taping protocol to maintain correction. It is very important for the parents to have a close relationship with the therapist so that feet that are not responding well to one method can be addressed with the other.
PITFALLS:
Attempting to correct equinus too early can result in a "midfoot break," leading to a rocker-bottom deformity.Brace wear intolerance will lead to relapses.Parent participation in the maintenance of correction, through brace wear, is essential for a successful outcome.
Attempting to correct equinus too early can result in a "midfoot break," leading to a rocker-bottom deformity.
Brace wear intolerance will lead to relapses.
Parent participation in the maintenance of correction, through brace wear, is essential for a successful outcome.