This is a retrospective study of a series of cases of clubfeet (n = 71). The review of the therapeutic outcome was carried out on 46 children born between February 2004 and January 2012 with idiopathic clubfoot. The feet were treated in a public hospital with the RD method (n1 = 34, before 2009) and the SVP method (n2 =37, from 2009). Data were taken from the medical records. The children were between 1 and 45 d old when they began treatment, and had a minimum follow-up of two years. Before starting the treatment, feet were photographed (to observe the conditions of the feet in detail and the sequential progress during the treatment, serving as support of the information obtained with the scale), evaluated and then classified according to the severity based on the Dimeglio-Bensahel scale by physicians or physiotherapists experienced with this rating system. This scale ranges from 0 to 20 points (0, 1-5, 6-10, 11-15 and 16-20, corresponding to normal, benign, moderate, severe, and very severe foot, respectively). This scale is widely used, and has proven to be reliable and re-producible in preceding intra-observer and interobserver studies[21,22]. We included children that were treated in our hospital with moderate, severe and very severe idiopathic clubfoot; those who attended the treatment sessions and complied with good observance of the protocol (these data was reflected in the clinical records through the care control sheet carried out by the physiotherapist responsible for each case), and we excluded those classified as benign or non-idiopathic, those previously treated with another method in other hospitals, and those who did not perform the sessions or did not properly comply with the protocol. The Ethics Committee of the Nuestra Señora de Candelaria University Hospital approved this study.
Trained physiotherapists with over ten years of experience working with the RD method performed the treatment. Our experience with the SVP method started in 2009 after the team received training in Paris.
The RD group was treated according to the approach proposed by Bensahel et al, and also followed by Souchet el al. We manipulated the foot daily and sequentially, and then applied elastic and nonelastic taping (closing the taping with a cohesive bandage to give greater consistency) between the sessions to maintain the correction obtained, until the pre-standing stage. When the child began to walk, a straight shoe was worn during the day and the Denis-Browne bar at nighttime. After correction of the foot was obtained, the parents continued the stretching, the splinting and exercises daily. The SVP group was treated according to the approach proposed by Seringe et al[17,18] with an additional manipulation for the correction of the cavus, as previously described. This additional manipulation consisted in slightly supinate position with the forefoot moving into its proper alignment with the hindfoot. We manipulated the foot daily and globally, applied an inextensible taping on a rigid plantar plate between the sessions, and then a splint was placed full-time to keep the foot aligned with respect to the leg. The physiotherapist shaped the splint according to the correction achieved and the growth of the child. When the child began to walk, a straight shoe was worn during the day and the short splint during naps, with an above-knee splint overnight. After correction of the foot was achieved, the parents continued the stretching, placing the taping, splinting and exercises daily.
Both interventions were similarly performed. Before starting the treatment, the team explained to the parents the procedure and the care needs. We also stressed that the adhesion of parents to the treatment is a prerequisite for success. Therefore, they were given clear instructions about the use of the splint and the importance of rigorously complying with the protocol. During the sessions, the parents were asked if they complied with the guidelines given and if they experienced any difficulty. The treatment was divided by stages, always adapted to each case: (1) Stage of deformities reduction: the first 3 mo, with physiotherapy daily; (2) Stage of maintenance: from 4th month until pre-standing, with physiotherapy two or three times a week. The parents were trained by the physiotherapist to perform daily stretching, taping, splinting and exercises; and performed these tasks in some sessions in order to check the training; (3) Stage of standing and walking: passive mobilizations, with active physiotherapy one or two times a week, adapted to the motor development of the child (some manipulations and active physiotherapy are shown in Figures 1 and 2, respectively). In those cases in which we observed a slight adduct of the forefoot when the child walked, a flexible bandage was applied to use with the footwear in order to improve the support and realign the foot with the leg.
Figure 1 Manipulations of the clubfoot.
A: Reduction of the talo-navicular joint subluxation; B: Derotation of the calcaneo-forefoot block; C: Achilles tendon stretching; D: Achilles tendon stretching with midtarsal protection; E: Stretch the median groove and plantar fascia; F: Passive mobilizations in plantar flexion and dorsiflexion.
Figure 2 Physiotherapy adapted to motor development of the child.
A: Strengthening of the fibularis muscles; B: Squat for active stretching of the Achilles tendon; C: Incline support to stretch the triceps surae; D: Support by four points to stretch the entire posterior muscle chain; E: Propiocepción on an air cushion; F: Sitting down in a toy car to stimulate support and propulsion; G: Going up and down stairs; H: Squat at four points to stretch the Achilles tendon with feet abduction.
The manipulations were performed daily with gentle joint tractions with the child stress-free, each session lasted 30 min per foot and was done by the same ph-ysiotherapist. In each bimonthly consultation, the feet were rated again using the Dimeglio-Bensahel scale in order to objectify the improvement achieved (also, a series of photographs of the feet were taken); a score ≤ 5 was considered good enough, and > 5 not good enough. If at 8 mo of age the treatment was no longer effective, the evolution was considered stabilized and two surgeons evaluated the need for surgery and the optimal time to perform it. In our hospital, it was generally between 10-11 mo old; the surgeon considered that upon re-initiation of ph-ysiotherapy post-surgery, the child would be prepared to stand up, and this contributed to maintaining the correction of the equine of the calcaneus. According to the clinical assessment, we estimated that for the feet that did not exceed 90 degrees ankle dorsiflexion, a percutaneous heel-cord tenotomy was scheduled. When the calcaneus remained elevated with contracture of the posterior soft tissues without reaching 90 degrees of dorsiflexion of the ankle, a limited release was scheduled (Achilles tendon lengthening, with subtalar and tibiotalar capsulotomy). In specific cases, limited surgery could be supplemented with release of the adductor hallucis, and/or plantar fascia through a mini-incision; these were noted as nonrelease surgeries). When the foot was not corrected, and kept triple deformation and stiffness, a complete release (extensive posteromedial release) would be indicated. The surgery was a complementary intervention and was tailored to the specific needs of each case, with an intent to be as conservative as possible. The feet were not X-rayed at the time of revision.
The immobilization was performed with long plaster in knee flexion at 90 degrees for 4-6 wk. At 3 wk, the cast was changed in the operating room under anesthesia to check the correctness achieved, the skin and the scar. The physiotherapy post-surgery was immediately provided to stabilize the correction achieved, including in cases of surgery for recurrence. When the child walked properly, the treatment was considered complete. Then the child was discharged and was controlled each month, then eventually every 3-6 mo, and throughout the growth to detect any functional impairment. If there was any deterioration, it was again referred to physiotherapy. We recommended using the splints up to 4-5 years old, according to severity and evolution.
We could not complete the data for three patients (four feet) because they did not follow the treatment properly for various reasons: three feet in the RD group (two of which developed an allergy to the taping and had to stop the treatment, and one of a child who was changed to another hospital) and one foot in the SVP group also due to a change of residence. Therefore, we did not get considered for the results.
Assessment of outcome
The primary outcome measure was the rate of the severity of deformity by the Dimeglio-Bensahel scale. To get this scoring, the degrees of reducibility of the internal rotation of the calcaneo-forefoot block, the adduction of forefoot relative to hindfoot, the equinus and the varus of the hindfoot were measured using a small goniometer and the charts. These four components can add a maximum of 16 points. It was also taken into account whether the foot presented medial and posterior creases, cavus, and the poor muscle condition (hypertonic, contracture, amyotrophic). Each of these conditions adds one more point. A second outcome measure was the need of complementary surgery to achieve a plantigrade foot. Other data recorded were the affected laterality, gender, and date of birth. To achieve a plantigrade foot, patient outcome were defined as: (1) Very good, when obtained only by phy-siotherapy; (2) Good, complemented by percutaneous heel-cord tenotomy; (3) Fair, complemented by limited release; and (4) Poor, complemented by complete release.