Utrilla-Rodríguez, Elia María PT; Martínez-Cañavete, María Jesús Guerrero PT; Casares, Juan Andrés Conejero MD
INTRODUCTION AND PURPOSE
Previous studies have demonstrated that when surgical treatment is considered the first treatment option in patients with idiopathic clubfoot it is frequently associated with further complications such as overcorrection, recurrence, and pain.1–5 These results have revived global interest in conservative treatment methods, mainly the French method developed in the late 1970s6–13 and the Ponseti method, developed in 1948.14–20 Another method that has comparable results to the French method is the modified Copenhagen method.21 Although these methods have similarities, they differ in such important matters as the dressing and splints used.21,22
The Copenhagen method, which originated in the Copenhagen Orthopedic Hospital, was introduced in our hospital in 1976. During the following years, modifications to the original technique transformed the procedure to the one that we use today. Our current technique, which has improved previous results, consists of flexing and manipulating the foot, using muscle stimulation and applying an immobilizing plaster cast. This treatment is performed daily from birth until the foot is corrected, which is normally achieved within 6 weeks. Subsequently, bandaging is substituted with braces until the child commences walking and the foot is periodically checked until skeletal maturity is achieved. Although this method has been used for a long time, very few data are available, which has encouraged this study of the obtained results in a long-term follow-up period.
The purpose of this study was to evaluate the efficacy of a modified Copenhagen method in reducing surgery rates for congenital idiopathic clubfoot.
Medical records of 82 patients, 57 (69%) male and 25 (31%) female with idiopathic clubfeet that were treated with the modified Copenhagen method in our hospital from 1980 to 2003, were reviewed. Altogether, 123 clubfeet were included, including 41 cases (50%) of unilateral clubfoot. The patients were younger than 2 months when treatment began. All feet were rated at the initial visit by a physician and a pediatric physical therapist with 41 years of combined experience. They rated the feet according to the Harrold and Walker scale,23 which classifies feet at 3 levels: grade I includes feet that can be brought into orthoposition, grade II clubfeet have a persistent equinus or varus component less than or equal to 20°, and grade III are those in which the equinus or varus component is greater than 20°. The modified Copenhagen method21 was performed by physical therapists with more than 20 years of experience in the children's physiotherapy unit at our hospital and reviewed by the rehabilitation physician once a month or more if considered necessary. Treatment sessions were conducted 5 days a week for approximately 30 minutes per foot; a corrective splint was maintained on weekends. Minimum time of follow-up was 3 years. All participants received the same treatment and no data were lost.
The main objectives of this method were to reduce luxated and subluxated joints (talonavicular and subtalar), to maintain the achieved reduction, to rebalance the activity of muscles acting on the foot, and to achieve a position of the bony structures closest to the true anatomical position. With this purpose, stretching and manipulating the foot using the “correction rule” was begun. This rule indicates in which order corrections must be done starting by correcting adduction, then cavus, hindfoot varus, and finally, equinus.
To correct adduction, the child is placed prone with the rearfoot held with one hand, placing the tibial epiphysis and the cuboid bone between the thumb and index finger. Forefoot adduction is corrected with the other hand by a distraction movement, placing the thumb at the first metatarsal-phalangeal joint (see Figure 1). To correct the cavus, the ankle is set by holding the thumb of one hand on the talar head, while the other hand elevated the forefoot, putting direct pressure on the dorsal face of the sole (see Figure 2). Correction of varus is achieved by placing one hand on the posterior side of the foot, holding the heel; the index finger on the same hand is placed on the talar neck, pushing it inwards, while the thumb is placed on the calcaneus, pushing it outwards. The other hand is placed on the sole at metatarsal level, pressing slightly to achieve eversion of the forefoot (see Figure 3). For equinus correction, the ankle is held by one hand, placing the index finger at the insertion of the Achilles tendon applying a gentle traction on the ankle, while progressive dorsiflexion of the foot is done with the other hand (see Figure 4). Once the manipulations are done, we stimulate the foot musculature, emphasizing the hypotonic muscles (usually peroneal) with a toothbrush applied to the lateral and anterior-lateral area of the foot (see Figure 5). To date, there is a lack of published data corroborating that the use of a toothbrush may produce a muscle response. Our experience has demonstrated that after stimulation of the lateral and anterolateral face of the foot, a muscle response can be observed as a peroneal muscle contraction. To complete the session, we apply a 5-cm wide cotton bandage and 2 strips of plaster to maintain the obtained correction (see Figure 6). Bandaging follows a distal to proximal direction up to the lower third of the thigh, maintaining the knee at a 90° angle. After several layers of bandage, the first plaster strip is placed from the talonavicular joint over the first and second cuneiforms, cuboid, and lateral border of the leg, ending on top of the thigh. The second plaster strip is placed over the head of the first metatarsal and then over the rest of the metatarsals also ending on top of the thigh. Thereafter, several layers of bandage are applied to maintain plaster strip tension and correction achieved during manipulation (see Figures 7 and 8). The bandage is not so tight as to compromise circulation, and is examined before the child leaves the physiotherapy unit. If necessary, it is removed and replaced with another bandage. The bandage is removed when the foot is completely corrected, which usually occurs within 6 weeks, approximately. At this time, a maintenance splint is applied, usually a Larsen ActiveT (see Figure 9). This correction system maintains the foot in a reduced position through 3 support points (anterior-lateral and anterior-medial border of the foot, and anterior face of the middle third of the thigh), and through a system of elastic straps that control and correct supination, adduction, and equinus.
After bandage removal, parents learn splint placement and exercises to do 5 times a day at home. For this reason, it is essential for them to understand the extent of the problem, and earn their trust and involvement in treatment to attain good results with this method.24–26 At 7 or 8 months of age, the child will be progressively released from the splint during the day, using prewalking boots with an inverted internal border or separating form, until the active splint is only used at night. At this phase it is very important that physiotherapy treatment be intensified, meaning that stimulation and manipulation exercises should be carried out more frequently by the parents. In a similar way, physical therapist's reassessments and modifications should be done more frequently to assure that the foot maintains the corrected position and that evolution is favorable. When the child begins standing on both feet, prewalking boots will be replaced by a shoe with tongue and laces and good heel support. Standing and walking must be carefully controlled from this point on (see Figures 10 and 11).
Correction criteria used to evaluate the Copenhagen method results for bilateral clubfeet were the following: achievement of at least 15° dorsiflexion in 1 ankle; achievement of 1 mobile and plantigrade foot with the heel in normal position or slight valgus; and forefoot aligned, with radiographic correction of talocalcaneal joint position (sum of talocalcaneus, anteroposterior and lateral angles > 50°). If unilateral, the main objective was that the treated foot appeared as similar as possible to a normal foot. Evaluation of the feet and follow-up control were done by foot print pedometry, inclinometry, manual muscle testing, and radiography.
After 3 years of follow-up, 67 feet (54%) did not need any surgery, meeting all correction criteria. Two feet (2%) required percutaneous tenotomy of the Achilles, and 54 feet (44%) needed posterior release. Following Harrold and Walter classification, initially 10% of feet were grade I, 67% grade II, and 23% grade III. Examining each category separately, we were able to affirm that 77% of grade I feet, 59% of grade II, and 32% of grade III feet did not need any type of surgery. Eight percent of grade I feet and 1% of grade II feet needed percutaneous tenotomy of the Achilles tendon. Z-plasty and capsulotomy were done on 15% of grade I feet, 40% grade II, and 68% grade III feet (Table 1). One postsurgical case (2 feet) of avascular necrosis of the talus was observed, and 2 children (3 feet) required a second surgery.
Long-term follow-up was performed on 38 of the original 82 patients (60 feet) all of whom were monitored for 10 years. Twenty-one feet (35%) did not need any surgery while 39 feet (65%) required Z-plasty and capsulotomy. Of these, 100% of grade I feet, 38% grade II feet, and 5% grade III feet did not need surgery. On the contrary, 62% of grade II feet and 95% of grade III feet needed Z-plasty and capsulotomy (Table 1). During this time we observed 1 case (2 feet) of avascular necrosis of the talus and 2 patients (4 feet) required a second surgery.
Conservative methods to treat clubfoot have have been used successfully to achieve maximum anatomical correction and obtain good mobility and foot function without pain during bipedal stance and walking. To this end, some methods employ dressings and others, plaster casts, but all conservative methods resort to surgery only when strictly necessary to attain better results. In light of the latest long-term studies done on the effect of surgical treatment on clubfoot, the need to limit and delay surgery has acquired greater importance, lending major relevance to nonsurgical intervention obtained with each treatment method.1–5 In relation to the French method,9,10,25,27 daily manipulations, stimulation of musculature, bandaging and passive movement machines13 are used to reach clubfoot correction. Diverse results were noted in the absence of surgery. Bensahel et al6,7 reported that no type of surgical intervention was needed in 48% of feet examined in their study Van Campenhout et al28 reported that only the 25% of the total cases in their research did not undergo surgery. Later, Karol et al4 and Richards et al25 in their respective studies reported that 48% and 45% of clubfeet did not require surgery to obtain good results.4 Using the Ponseti method of successive casts to obtain maximum clubfoot correction, Herzenberg et al14 reported good results, but 91% of the clubfeet in their study required percutaneous tenotomy of the Achilles tendon. Morcuende et al29 noted reduction of surgery in clubfeet using the Ponseti method, reporting that 98% of corrected feet did not need surgical treatment, although 86% of these required an Achilles tenotomy to achieve the stated correction.
Avascular necrosis derives from an increase in the astragalum pressure due to either a rapid growth rate of the foot or an incorrect understanding of the indicated exercises by the parents. This complication has also been observed in other studies.19,30,31
The main limitation of the cited reports was that none was carried out with a follow-up period of more than 3 years. The results obtained in this study show that in a 3-year monitoring period, more than half of clubfeet treated with the modified Copenhagen method did not require surgery and met preestablished correction criteria. This confirms this technique as an appropriate option for conservative treatment of idiopathic clubfeet.
In a 10-year follow-up period, the percentage of patients not requiring surgery dropped to 35%. This may be due to the natural development of the foot and to the fact that the prescribed exercises were not carried out with the recommended frequency. In any case, the need for surgery will depend on clinical and/or radiological results that are not stable until growth is complete. For this reason, the most precise data on the need for surgical treatment will not be established until the foot no longer experiences growth-related changes.
Further research is needed to evaluate surgery rates when the children's growth is complete. Futures studies of the modified Copenhagen method should include parent satisfaction and gait variables.
In our opinion, the modified Copenhagen method provides very good anatomical and functional results when it is applied by adequately trained professionals (physicians, physical therapists, and orthopedic technicians) and with appropriate revisions. To achieve these good results, absolute cooperation of the patient as well as the family and strict compliance with the prescribed treatment are essential. If all these conditions are met, the proportion of patients requiring surgery could be considerably reduced.
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casts/plaster; clubfoot/therapy; female; infant; male; manipulation/orthopedic; nonoperative treatment; orthoses; physical therapy/methods; severity of illness index
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