Nonsurgical Management of Idiopathic Clubfoot

Kenneth J. Noonan, MD, and B. Stephens Richards, MD

Abstract
Because nonsurgical management was thought not to yield adequate correction and a durable result, most children with idiopathic clubfoot have undergone surgery with extensive posteromedial and lateral release. However, surgical management caused residual deformity, stiffness, and pain in some children; thus, the favorable longterm results with the Ponseti and French methods of nonsurgical management have garnered interest. The Ponseti method consists of manipulation and casting of idiopathic clubfeet; the French method consists of physiotherapy, taping, and continuous passive motion. Careful evaluation of the techniques and results of these two approaches may increase their use and decrease or minimize the use of surgical management and thus the associated morbidity resulting from extensile releases. J Am Acad Orthop Surg 2003;11:392-402 method was derived from the concept of three-point pressure, such as might be used to correct a bent wire. The technique consisted of grasping and distracting the forefoot with one hand while holding the heel from the back with the other hand. After elongating the foot, a laterally placed thumb pushed the talus in a medial direction, and the medially placed index nger pushed the navicular in a lateral direction. The heel was everted as the forefoot was abducted. This manipulation was followed by application of a slipper cast with abduction of the forefoot against a fulcrum over the calcaneal cuboid joint. When the slipper cast hardened, the cast was extended to below the knee, with the foot everted with gentle external rotation. After correction of the forefoot adduction and hindfoot varus, the foot was gradually dorsiexed to correct the

The history of medicine is replete with cyclical trends of nonsurgical and surgical management approaches as well as reports of so-called new methods of treatment that were really modications of techniques used decades before. The treatment of idiopathic clubfoot is no exception. In 1939, J. Hiram Kite presented his management method of and experience with congenital clubfoot as a plea for conservative treatment.1 However, because some patients did not achieve full correction of the deformity with nonsurgical management, interest in surgical approaches increased, and nonoperative methods were largely ignored during subsequent decades. Surgical treatment predominated because it was thought to predictably obtain full and lasting correction. Some centers in Iowa and France continued using nonsurgical management, but their results were viewed with skepticism. However, long-term follow-up results of many children treated with extensive surgical release has revealed high rates of overcorrection, stiffness, and pain. As a result, contemporary interest in

treatment methods involving less extensive surgery has resurfaced. The three nonsurgical approaches for correction of idiopathic clubfoot are the Kite, Ponseti, and French methods. Effective use of the latter two in particular can alleviate the need for wide posterior, medial, and lateral release in most children with clubfeet, thus avoiding the potential for overcorrection. Patients with short, very stiff feet may still eventually require surgical treatment; however, appropriate nonsurgical treatment can initially produce at least partial correction and allow a less aggressive surgical release, even in patients with severe deformity.

Dr. Noonan is Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, University of Wisconsin, Madison, WI. Dr. Richards is Professor, Department of Orthopaedic Surgery, University of TexasSouthwestern, and Assistant Chief of Staff, Texas Scottish Rite Hospital for Children, Dallas, TX. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Noonan and Dr. Richards. Reprint requests: Dr. Richards, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. Copyright 2003 by the American Academy of Orthopaedic Surgeons.

Kite Method
Kites nonsurgical approach to managing idiopathic clubfoot, consisting of manipulation and serial casting in a prescribed manner, was developed in response to the stiffness and pain that occurred in feet treated with forceful manipulation (eg, Thomas wrench) and extensive surgical release.2 Kites

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equinus. Casts often had to be changed two times per week. After full correction, a Phelps night splint was applied to prevent relapse. In 1979, Lovell et al3 published the results of using the Kite method in 85 children between 1950 and 1956. Fortyseven of those patients (67 affected feet) were followed for 10 years or more. Good results were noted in approximately two thirds. Twelve feet were rated fair and 12, poor. Although this method was effective in most cases, treatment required an average of 20.4 months in casts.4 Thus, the practice changed and surgical management was recommended for those patients with residual deformity after 3 months of manipulation and casting.3

Ponseti Method
In the early 1940s, Ignacio Ponseti developed a nonsurgical approach for the management of clubfoot.4 Like Kite, he wanted to investigate a less aggressive method of correction that would decrease the high rates of complications, stiffness, and overcorrection seen with surgery. Careful anatomic dissections of the idiopathic clubfeet in stillborn babies were critical for Ponseti to be able to dene the pertinent pathoanatomy and to rationalize a mechanism for correction. In addition, detailed investigations into the biology of collagen were fundamental to support the method of gradual correction. His procedure of weekly manipulations and cast application to hold correction allowed for relaxation of the collagen and atraumatic remodeling of joint surfaces without the brosis and scarring resulting from surgical release.

varus, and equinus (CAVE). The forefoot deformity is the result of medial displacement of the navicular, which articulates with the medial aspect of the head of the talus. The cuboid also is adducted in front of the calcaneus along with the metatarsals, which are further adducted on the midfoot. The hindfoot deformity is caused by malposition of the calcaneus in adduction and inversion under the talus. Although the entire foot is supinated, the forefoot pronation relative to the hindfoot causes the cavus (ie, high arch) deformity. The muscles and tendons of the gastrocnemius-soleus complex, the posterior tibialis muscle, and long toe exors are shortened. The posterior and medial ligaments of the ankle and tarsal joints are thicker and shorter than in normal feet.5

Pathoanatomy At birth, the idiopathic clubfoot is severely supinated, but the forefoot is still adducted and pronated relative to the hindfoot, which is in varus and in equinus. The four basic clubfoot deformities are cavus, adductus,

Management Protocol In general, the ability to obtain full correction with the Ponseti approach is enhanced when treatment is instituted within the rst month of life. Posteromedial and lateral release is avoided in almost 95% of affected children when treatment commences early.5 Although the success rate in infants aged 7 to 10 months is less than that in newborns, there is some merit in attempting to obtain as much nonsurgical correction as possible before using surgical release. Successful management of clubfoot depends on both an appreciation of the pathoanatomy and an understanding that correction requires an organized, sequential methodology. For instance, a common error in the initial treatment is to immediately orient the foot in a corrected position that includes maximal dorsiexion. Although reduction of forefoot adduction and cavus may thus be possible, lasting hindfoot correction is blocked. Initiation of treatment with maximal dorsiexion leaves the calcaneus adducted and inverted under the talus, thereby blocking correction of varus and equinus. The acronym

CAVE is helpful because it not only describes the clinical position of the clubfoot but also outlines the general order of deformity correction via the Ponseti method. To stretch the ligaments and gradually correct the deformity, the foot is manipulated for 1 to 3 minutes. The correction is maintained for 5 to 7 days with a plaster cast extending from the toes to the upper third of the thigh with the knee at 90 of exion. Five or six cast changes are sufficient to correct most clubfeet. Casting is usually timed to coincide with routine feedings; after manipulation, the baby is fed a bottle, which tends to relax the infant, allowing easier cast application. The rst management goal is correction of the cavus deformity by forefoot supination relative to the hindfoot. This manipulation seems counterintuitive because it tends to exaggerate the appearance of overall foot inversion. Elevation of the rst metatarsal and supination of the forefoot is in contradistinction to other methods of manipulation that propose correction of the cavus by pronation of the rst metatarsal. At the rst session, the forefoot is simultaneously supinated and abducted. The cavus is almost always corrected with the rst cast. At successive manipulation and casting sessions, metatarsus adductus and hindfoot varus are simultaneously corrected by abducting the foot while applying counterpressure laterally. The calcaneus, navicular, and cuboid are gradually displaced laterally (Fig. 1, A and B). This key maneuver corrects most of the clubfoot deformity and must be done at each session with attention to three points. First, forefoot abduction should be done with the foot in slight supination. Doing so preserves correction of the cavus deformity and maintains colinearity of the metatarsals, thereby producing an efficient lever arm for abduction. Second, the heel should not be constrained by premature dor-

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Figure 1 A, Dorsal view of Ponseti method. Note the medial deviation of the navicular and cuboid on the head of the talus and the distal end of the calcaneus, respectively. Manipulation by the Ponseti approach involves abduction of the forefoot (curved arrow) against counterpressure applied at the talar head (thick arrow). B, With the manipulation, the Chopart joint is reduced and the metatarsus adductus is corrected. Open circle = lateral aspect of the talar head; solid circle = lateral aspect of the navicular. C, Posteroanterior view of an unreduced deformity. The calcaneus is adducted and inverted underneath the body of the talus. The hindfoot is therefore in varus. D, After abduction of the forefoot (as in panels A and B), the hindfoot is abducted and everted into a neutral to slight valgus position. The dark vertical lines indicate the longitudinal axis of the calcaneus.

siexion. It is important that abduction be accomplished with the foot in equinus, which allows the calcaneus to abduct freely under the talus and evert to a neutral position (without pressure on the heel). It also is important to avoid forceful dorsiexion before correction of hindfoot varus because a rocker-bottom deformity could develop. Finally, care must be taken to locate the fulcrum for counterpressure on the lateral head of the talus. Correction of hindfoot varus and calcaneal inversion would be hindered if counterpressure were applied to the lateral column of the foot or at the calcaneal cuboid joint rather than to the talar head.6 Three to four weekly manipulation and casting sessions are generally required to loosen the medial ligamentous structures of the tarsus and partially mold the joints. After each cast, foot supination is gradually decreased to correct the inversion of the tarsal bones while the foot is further abducted under the talus (Fig. 1, C and D). Equinus is corrected last and should be attempted when the hindfoot is in neutral to slight valgus and

the foot is abducted 70 relative to the leg. This degree of abduction may seem excessive, but it is needed to prevent recurrence of deformity. Equinus may be corrected by progressively dorsiexing the foot after the varus and adduction have been corrected. The foot is dorsiexed by applying pressure under the entire sole of the foot, not just under the metatarsal heads, to avoid a rocker-bottom deformity. Equinus may be completely corrected through further progressive stretching and casting. However, to facilitate more rapid correction, a subcutaneous heel cord tenotomy is done in 70% to 75% of patients.5 Heel cord tenotomy, a procedure in which the entire Achilles tendon is transected, has been done in children as old as 1 year without incidence of overlengthening or weakness (Fig. 2). Tenotomy may be done in a surgical suite with a thin cataract knife or in the clinic under sterile technique after application of lidocaine/prilocaine anesthetic cream. Although performed in the clinic in most patients, in children older than 5 months, tenotomy probably should be done in the operating

room to provide better anesthesia and analgesia. In addition, it is easier in the operating room to apply a better cast without the resistance encountered in older, stronger infants.

Percutaneous Tenotomy After standard sterile preparation, an assistant holds the foot and applies mild to moderate dorsiex-

Figure 2 Intraoperative posterior view of the Achilles tendon in an 18-month-old boy who underwent open heel cord lengthening because of recurrent posterior deformity. Excellent tendon morphology and minimal scarring are present despite heel cord sectioning at 3 months.

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ion pressure. Excessive pressure may tighten the skin and hinder the ability to palpate the tendon well. The blade enters the skin along the medial border of the Achilles tendon. Because the calcaneus is usually elevated in the fat pad, it is important to cut the tendon 0.5 to 1.0 cm proximal to its insertion, where it tends to fan out onto the tuberosity of the calcaneus. After insertion, the blade is pushed medial to the tendon and rotated underneath the tendon. Counterpressure with the opposite index nger pushes the tendon onto the blade and prevents inadvertent and unnecessary skin laceration. Successful tenotomy is heralded by a palpable pop and immediate ability for further dorsiexion of approximately 15 to 20 (Fig. 3). No stitches are needed, and sterile cotton cast padding is applied, followed by application of a long leg cast in maximal dorsiexion with abduction to 70. Most infants require immobilization for 3 weeks, but 4 weeks is reasonable in children older than 6 months.

agement. Benzoin is not applied to the skin, and berglass is not used because of its poor molding characteristics. Long leg casts are necessary to maintain the foot in abduction and external rotation and to improve results. The casts are carefully molded to prevent pressure spots over the heel and malleoli. The plaster on top of the toes is trimmed off, but a platform of plaster is left under the toes to favor stretching of the toe exors. Cast application while feeding distracts the infant and facilitates optimal tting.

Casting Technique Well-molded long leg plaster casts are applied over a thin layer of cotton padding at all steps during man-

Prevention of Recurrence After removal of the last cast, a foot abduction orthosis (ie, Denis Browne bar) is prescribed to prevent recurrence of the deformity, to favor remodeling of the joints with the bones in proper alignment, and to increase leg and foot muscle strength (Fig. 4). The orthosis consists of two straight last open-toe shoes connected by a bar that allows the shoes to be placed at shoulder width. The bar should hold the shoes at 70 of external rotation and 10 of dorsiexion. In unilateral cases, the normal foot should be in 40 of outward rotation. Maintaining the feet at shoulder width facilitates foot abduction. The orthosis is worn

Figure 4 A 3-month-old infant wearing an abduction orthosis (Denis Browne bar and shoes), which holds the feet at shoulder width. The affected feet are externally rotated 70.

full time for at least 2 to 3 months, after which it is worn during naps and overnight for 2 to 4 years.5 Infants are often irritated when transitioned from the casts into the shoes because their feet are not used to being touched. Because poorly tting shoes can cause blisters, the shoes should be removed and the feet examined several times a day for the rst week. In infants younger than 6 months, the t of the shoes can be improved with application of a lightweight foam heel counter and tongue liner. It is necessary to reassure parents that the initial sensitivity soon resolves and to emphasize the need for compliance; without proper use of this orthosis, recurrence of clubfoot deformity is inevitable.

Figure 3 A, Lateral radiograph showing forced dorsiexion in a 7-week-old infant before heel cord tenotomy. B, Lateral radiograph showing forced dorsiexion of the same foot 3 weeks later, after the last cast was removed. Improvement is seen in the tibiocalcaneal angle.

Management of Recurrence Partial recurrence of clubfoot deformity occurs in approximately one third of feet.7 Early recurrence of deformity (within the rst year) is usually a result of residual equinus contracture and forefoot adduction. It often is a result of poor compliance with the abduction orthosis or de-

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layed initiation of management. In such cases, repeat manipulation and application of casts will stretch and correct residual deformity. It can be difficult to apply casts to infants older than 12 months; however, marked correction of residual deformity can be obtained and subsequently maintained with the abduction orthosis. Surgical intervention is indicated when recurrence of deformity does not respond to repeat casting. However, extensive posteromedial and lateral release is usually not needed in such cases. An extensive release at this juncture could lead to overcorrection because some elements of the deformity would have been corrected from the initial treatment. Therefore, the surgical release should include only those extrinsic tendons and joints that produce deformity theposteriorsubtalar, ankle, and talonavicular joints.8 In most cases, the medial subtalar joint and interosseous ligament do not require release. In patients older than 12 to 18 months, a dynamic swing phase supination deformity may develop as a result of medial overpull of the anterior tibialis tendon. Incomplete reduction of the navicular onto the head of the talus results in changing the anterior tibialis muscle from predominately a strong dorsiexing to a strong supinating force. If uncorrected, this can lead to recurrence of hindfoot varus. In these patients, transfer of the anterior tibialis tendon to the third cuneiform is done at the age of 2.5 years or older (after 4 to 6 weeks of repeat casting).7 To prevent bowstringing, the tendon should be left under the anterior retinaculum of the ankle. It is important to assess for recurrent equinus deformity, which may require Achilles tendon Z-lengthening at the time of anterior tibialis transfer.

Results Results depend to a great extent on the outcome variables used as well as on length of follow-up. For instance, some studies judge nonsurgical re-

sults based on the eventual need for subsequent extensive surgical release. This method is fundamentally awed because of the inability to reproducibly quantify deformity and the variable and subjective criteria used to dene failed management. However, despite these limitations, the rate of posteromedial and lateral release is <5% when treatment is started within 1 month of birth.5 Another factor used to assess results is the rate of deformity recurrence and need for secondary surgery. The differences in long-term foot function between feet treated nonsurgically and those treated with extensive surgical release are unknown. No prospective randomized studies have compared these two groups. It is also important to note that, as part of this management, one third of patients eventually require tendon transfer, tendon lengthening, or selective release.5 Therefore, it is inaccurate to compare only those feet that did not require surgery with those that failed other nonsurgical methods and required posteromedial and lateral release. However, it seems intuitive that feet treated with less surgery would have better long-term function with less pain and greater strength, mobility, and function than those treated surgically. In 1995, Cooper and Dietz7 published a retrospective review of 45 patients with 71 clubfeet who were evaluated at an average age of 34 years. Thirty-eight of the 71 feet required anterior tibialis tendon transfer. Sixtytwo percent of patients (28) had an excellent result; 16% (7), good; and 22% (10), poor. Physical examination showed very good strength and decreased foot motion compared with those whose contralateral foot was normal. Subjective evaluation was based on age-matched controls and failed to show any differences in functional outcome. Only with long-term follow-up of patients with extensive surgical release will comparison be possible.

French Method
The French method for nonsurgical correction of clubfoot was developed in the 1970s by Masse9 and Bensahel et al.10 Also known as the functional method, it consisted of daily manipulation of the newborns clubfoot, stimulation of the muscles around the foot (particularly the peroneal muscles) to maintain the reduction achieved by the passive manipulation, and temporary immobilization of the foot with nonelastic adhesive strapping. The daily treatments were continued for approximately 2 months and then were progressively reduced to three sessions per week for an additional 6 months, after which taping was continued until the children became ambulatory. Nighttime splinting was used for an additional 2 to 3 years. Intermediate-term results of patients treated between 1974 and 1978 were rst reported in the Englishlanguage medical literature in 1990.10 Outcome was good in nearly 50% of the infants with clubfoot deformity treated with this functional method.11 The feet were well aligned both clinically and radiographically; plantar pressure patterns were normal in intensity and distribution; range of motion, gait, and shoe wear patterns were all normal. For those who still required surgery, the procedures were usually limited to posterior structures only. Although results were encouraging, this method raised some concerns.12,13 It required considerable time and expertise, with success dependent on the skills of the physical therapist.10,11,14 Cooperation and availability of families were essential for this program to be effective; successful outcomes were less likely when the family lived far from the treatment center. In addition, economic concerns were a factor because the daily specialized care was not covered by all health care systems.13 A new comprehensive French classication system for clubfoot was developed by Dimglio et al15 and

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published in 1995. Their system established objective reproducible parameters that are easy to measure, even for those with limited experience with clubfoot; dened a reproducible 20-point value and severity scale; and made clinical assessment simple by providing a complete, strict checklist accompanied with drawings to avoid approximate examinations. This classication system has become assimilated into the French method of treatment (Fig. 5). In the early 1990s, continuous passive motion (CPM) developed specifically for use in the infant clubfoot was introduced in France.13,16 The CPM machine was intended to further mobilize the infants foot during sleep. After the daily manipulations and strapping by the physical therapist, the foot was taped to a at plate that, in turn, was connected to the machine. The addition of CPM resulted in fewer patients needing surgery and less extensive release for those who did require surgery.13 Although the French method of clubfoot treatment was introduced in North America in 1996, the CPM machine did not become available in the United States until 2000.

Pathoanatomy Bensahel and colleagues17,18 reported slightly different clubfoot pathoanatomy than was described by Ponseti. They thought that retraction of the posterior tibialis muscle and weak peroneal muscles were the primary factors responsible for clubfoot.17,18 This combination leads to a tight brous zone in the medial aspect of the midfoot, as well as hindfoot varus, medial deviation of the navicular bone, and subluxation of the talonavicular joint. Management The surgeon evaluates the newborn, grades the severity of the foot using the Dimglio classication system, and explains the concept of this method to the family. The need for
Figure 5 Classication of clubfoot according to Dimglio. Each major component of the clubfoot (eg, equinus, heel varus, medial rotation of the calcaneopedal block, forefoot adduction) is graded clinically from I (benign) to IV (very severe). Additional points are added for deep posterior and medial creases, cavus, and poor muscle condition. The total score is categorized into one of four groups: grade I (benign), grade II (moderate), grade III (severe), grade IV (very severe). (Adapted with permission from Dimglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F: Classication of clubfoot. J Pediatr Orthop B 1995;4:129.)

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family attendance at the daily sessions must be emphasized and clearly understood. Because of the time required for this technique, the orthopaedic surgeon typically does not perform the daily manipulations. Instead, the surgeon works closely with a physical therapist experienced with the technique. Specialized training and experience are needed for successful outcome. Decisions regarding the frequency of physical therapy visits, use of the CPM machine, and need for splinting are made primarily by the therapist. Physician follow-up is undertaken every other month to monitor improvement in the foot and determine whether surgery will be necessary. The focus of the French method is to relax the posterior tibialis muscle and medial brous zone through a combination of progressive passive

manipulation, active muscle work, taping, and splinting.10,18,19 Bensahel believed that use of plaster cast immobilization after reduction of this deformity (by any means of forced stretching) was detrimental and that forced stretching of muscles in a child (even under anesthesia) would lead to a defense reaction, with resulting contraction of the stretched muscles.10 Sessions last approximately 30 minutes per foot. The infant must be relaxed because resistance makes this technique more difficult. Although the process is no more demanding than any other form of nonsurgical treatment, it must be well assimilated because the steps are detailed and precise, including nger placement, hand position, and sensing of the infants response. Manipulation is done gently and smoothly, and reduction of the deformities must be progres-

sive. The rst few weeks of life provide the optimal chance of success and therefore is the best time to initiate functional treatment. The management goals are to reduce the talonavicular joint, stretch the medial tissues, then sequentially correct forefoot adduction, hindfoot varus, and equinus of the calcaneus (Fig. 6). First, the navicular bone is progressively released from the medial malleolus and from its medial position on the head of the talus. This relaxation will be incomplete early on because the talus retains its pathologic position, but gradually this improves. The medial tissues are stretched throughout this maneuver. Second, forefoot adduction is corrected by stabilizing the global adduction of the calcaneopedal block. This maneuver progressively stretches all of the joints of the medial ray of the foot (ie, navic-

Figure 6 The French manipulation technique. A, Correction of the forefoot adduction and heel varus. B, Reduction of talonavicular displacement. C, Derotation of calcaneopedal block. D, Manipulation of heel varus. The calcaneus then is rotated medially away from the bula while the forefoot is externally rotated. E, Manipulation of equinus. (Reprinted with permission from Herring JA [ed]: Tachdjians Pediatric Orthopaedics, ed 3. Philadelphia, PA: WB Saunders, 2001, pp 933-934.)

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ulocuneiform, cuneiform-metatarsal, metatarsophalangeal). While this is done, and after all joints of the foot have been loosened, forefoot adduction is further decreased by continuing to stretch the medial skin crease. To maintain the new passive range of motion, the toe extensors and peroneals must be strengthened. To do this, the therapist elicits cutaneous reexes by tickling the fth ray and along the lateral border of the foot. The third step consists of progressive reduction of hindfoot varus, which begins after the talonavicular joint has been reduced and can be done in conjunction with correction of the forefoot adduction. The calcaneus gradually moves to a neutral position and eventually into valgus. The ankle is externally rotated at the same time

that the calcaneus is being mobilized into valgus. The knee is kept exed to 90 during these maneuvers. The nal step corrects the equinus of the calcaneus. This is often difficult because contracture of the posterior soft tissues may not be easily elongated by manipulation. The calcaneus is progressively brought from plantarexion to dorsiexion while the knee is kept in exion, and the knee is then very cautiously extended. This maneuver is done repeatedly. The lateral arch is carefully supported in an effort to protect the midfoot from being stretched and causing a midfoot break. These phases of the manipulation sessions must be done by the physical therapist in the order described.18 Once the manipulation is completed,

taping is applied to maintain the passive range of motion achieved during the session (Fig. 7). A very thin layer of foam underwrap is applied to protect the leg from the adhesive. An elastic tape holds the foot in position but, because it stretches, allows for exercises of the taped foot. Eightinch lengths of such tape are specifically applied to maintain the correction. Dressing retention tape keeps the proximal edges of the foam underwrap and elastic tape from sliding distally. The CPM machine is used during the rst 12 weeks of treatment while the foot is small and the infant can easily tolerate its application (Fig. 8). The machine supplies continuous motion to the functional axes of the hindfoot and has a safety system that stops and reverses motion as soon as

Figure 7 Taping is used to maintain the passive range of motion achieved during the manipulation sessions. A through C, The rst piece of tape prevents the forefoot from turning in. D and E, The second piece supports the arch and holds the foot everted. F through J, The nal two pieces maintain dorsiexion and eversion.

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Figure 8 The footplate (A) and CPM machine (B). (Reprinted with permission from Herring JA [ed]: Tachdjians Pediatric Orthopaedics, ed 3. Philadelphia, PA: WB Saunders, 2001, pp 933-934.)

it senses abnormal resistance. It requires a relaxed infant, and its use is recommended for 10 hours daily (up to 18 h/day during the rst month). The machine is rst adjusted in the horizontal plane, without affecting the equinus. Once derotation of the calcaneopedal block has been achieved, the machine can be adjusted to allow motion in the sagittal plane. The machines range of motion is directly patterned on the reducibility of the deformity; the foot is rst tested by hand, and the programming of the machine is tailored to the foots exibility. The purpose of using CPM is to soften the tissues in preparation for the physical therapy manipulations. A secondary gain may be further improvement in range of motion each day without forcing the foot. To maintain the increase in range of motion, splints are always used over the tape when the CPM machine is not in use. Although patient safety concerns about the CPM machine have been raised (eg, pressure sores, ankle strains, torquing of the tibia, falls from the crib), no complications from its use have been reported. With the functional method and accompanying use of CPM, most of the improvement in clubfoot occurs during the rst 3 months. After that, only modest amounts of further im-

provement should be expected. The stretching, taping, and splinting program is continued on a daily basis by the parents, and visits to the physical therapist decrease in frequency. If successful, this program continues until the child is walking, then is discontinued when the correction is stable (at age 2 to 3 years). Follow-up continues through adolescence. If the program is not successful, surgery may be needed. Percutaneous heel cord tenotomy may be done in the rst several months. Physiotherapy is started again after the plaster cast is removed. If further surgery is anticipated, such as a posteromedial release, it is delayed until approximately age 9 months.

Results In 1990, Bensahel et al10 reported good results using the functional method (without CPM) in 162 of 338 clubfeet (48%) (Fig. 9). When complementary surgery was performed in the remaining patients, the overall good outcomes increased to 291 of 338 clubfeet (86%). In a more recent report, good results with exclusively nonsurgical treatment had increased to 63% of 350 clubfeet (mean followup, 10 years).14 Seringe and Atia11 also reported that use of the functional method without CPM resulted in

good nonsurgical outcomes in nearly 50% of 269 clubfeet (mean followup, 6 years 2 months). In all of these reports, emphasis was placed on the importance of using experienced, well-trained physical therapists. A difference in outcome occurred depending on their degree of training and experience. With the addition of CPM to the functional method, the rate of successful nonsurgical outcomes has improved further.13,16 Dimeglio16 reported that 74% of 201 feet treated with this combination from 1991 to 1997 did not require any surgery. As experience in using CPM with the functional method grew, so did the successful nonsurgical outcomes; by 1997, only 12% of patients treated required any surgical intervention.16 In North America, a short-term (mean follow-up, 22 months) study without CPM indicated that 30 clubfeet (53.6%) required no surgery, 10 (17.9%) required limited posterior or percutaneous heel cord release, and 16 (28.6%) required posteromedial surgical release.20 With the recent addition of CPM, outcome was excellent in 30 of 50 clubfeet (60%), fair in 10 (20%), and poor in 10 (20%).21 The costs of the functional method have been investigated in a study of 25 patients with a mean of 60 phys-

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Figure 9 A, One-month-old male infant with clubfoot of the right foot. Weight bearing (B and C) and forced dorsiexion (D) at age 23 months, after successful management with the French method.

ical therapy visits.22 Total billed charges for the therapy averaged $5,035, insurance reimbursement averaged $2,977, Medicaid reimbursement averaged $448, and out-of-pocket expenses averaged $503.22 These costs are slightly higher than those assessed with the Ponseti method. Our data indicate average rst-year costs of physician visits, casting, and tenotomy of $1,600. Williams et al22 reported that all parents thought that the treatment was worthwhile although 50% stated that the treatment interfered with employment responsibilities

and 38% stated that the monetary cost of treatment was a problem for their family.

Summary
The Ponseti and the French methods of nonsurgical management of idiopathic clubfoot are in stark contrast to the extensive surgical releases that have been more commonly used. These methods may seem laborious, especially for physicians who are used to correcting deformity in one surgi-

cal setting. However, these techniques have the potential to decrease not only the rates of surgical intervention but also the extent of surgery required. Although no long-term randomized studies exist that compare extensive surgical release with either of these methods, initial results suggest that better foot function is inevitable with less surgical management. Acknowledgment: The authors would like to thank Dr. Charles Price for his review of the Kite method of clubfoot correction.

References
1. Kite JH: Principles involved in the treatment of congenital club-foot. J Bone Joint Surg 1939;21:595-606. Kite JH: Nonoperative treatment of congenital clubfoot. Clin Orthop 1972; 84:29-38. Lovell WW, Bailey T, Price CT, Purvis JM: The nonoperative management of the congenital clubfoot. Orthop Rev 1979;8:113-115. Lovell W, Price CT, Meehan PL: The foot, in Lovell W, Winter RB (eds): Pediatric Orthopaedics, ed 2. Philadelphia, PA: Lippincott, 1986, pp 895-978. Ponseti IV (ed): Congenital Clubfoot: Fundamentals of Treatment. Oxford, England: Oxford University Press, 1996. Ponseti IV: Common errors in the treatment of congenital clubfoot. Int Orthop 1997;21:137-141. Cooper DM, Dietz FR: Treatment of idiopathic clubfoot: A thirty-year followup note. J Bone Joint Surg Am 1995;77: 1477-1489. 8. Bensahel H, Csukonyi Z, Desgrippes Y, Chaumien JP: Surgery in residual clubfoot: One-stage medioposterior release la carte. J Pediatr Orthop 1987;7: 145-148. 9. Masse P: Le traitement du pied bot par la methode fonctionnelle, in Cahier denseignement de la SOFCOT. Paris, France: Expansion Scientic 1977;3:51-56. 10. Bensahel H, Guillaume A, Czukonyi Z, Desgrippes Y: Results of physical therapy for idiopathic clubfoot: A longterm follow-up study. J Pediatr Orthop 1990;10:189-192. 11. Seringe R, Atia R: Idiopathic congenital club foot: Results of functional treatment 7. 12. (269 feet) [French]. Rev Chir Orthop Reparatrice Appar Mot 1990;76:490-501. Bensahel H, Catterall A, Dimeglio A: Practical applications in idiopathic clubfoot: A retrospective multicentric study in EPOS. J Pediatr Orthop 1990;10:186-188. Dimglio A, Bonnet F, Mazeau P, De Rosa V: Orthopaedic treatment and passive motion machine: Consequences for the surgical treatment of clubfoot. J Pediatr Orthop B 1996;5:173-180. Bensahel H, Souchet Ph, Mazda K, Desgrippes Y, Thmar-Noel C, Penneot GF: Abstract: The early physiotherapic treatment in clubfoot: Results at 10 years follow up. Pediatric Orthopaedic Society of North America 2000 Annual Meeting. Rosemont, IL: Pediatric Orthopaedic Society of North America, 2000, p 46. Dimglio A, Bensahel H, Souchet P,

2.

3.

13.

4.

14.

5.

6.

15.

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16.

17.

18.

Mazeau P, Bonnet F: Classication of clubfoot. J Pediatr Orthop B 1995;4: 129-136. Dimeglio A: Abstract: Orthopaedic treatment and passive motion machine in clubfoot. Pediatric Orthopaedic Society of North America 2000 Annual Meeting. Rosemont, IL: Pediatric Orthopaedic Society of North America, 2000, p 47. Bensahel H, Huguenin P, Themar-Noel C: The functional anatomy of clubfoot. J Pediatr Orthop 1983;3:191-195. Bensahel H, Guillaume A, Csukonyi Z, Themar-Noel C: The intimacy of clubfoot: The ways of functional treatment.

J Pediatr Orthop B 1994;3:155-160. Dimglio A, Bonnet F: Rehabilitation of the clubfoot [French], in Encycl Med Chir: Kinesithrapie-Mdecine physiqueReadaptation. Paris, France: Elsevier, 1997, 26-428-B-10, 12. 20. Richards BS, Wilson H, Johnston CE, Waanders N, Karol L: Abstract: Nonoperative clubfoot treatment using the French method: Comparing clinical outcome with radiographs. Pediatric Orthopaedic Society of North America 2001 Annual Meeting. Rosemont, IL: Pediatric Orthopaedic Society of North America, 2001, p 142. 19.

21.

22.

Richards BS, Wilson H: Abstract: Effect of continuous passive motion in the nonoperative treatment of clubfeet: Early results. Pediatric Orthopaedic Society of North America 2002 Annual Meeting. Rosemont, IL: Pediatric Orthopaedic Society of North America, 2002, p 66. Williams JJ, Shapiro J, Kahn A, Panozzo S: Abstract: Treatment outcomes and cost analysis of using the French taping technique for severe clubfeet. Pediatric Orthopaedic Society of North America 2001 Annual Meeting. Rosemont, IL: Pediatric Orthopaedic Society of North America, 2001, p 54.

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