Outpatient taping in the treatment of idiopathic congenital talipes equinovarus

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1 CHILDREN S ORTHOPAEDICS Outpatient taping in the treatment of idiopathic congenital talipes equinovarus A. K. Singh, A. Roshan, S. Ram From Advanced Orthopaedic Centre, Patna, India The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, good ). Late relapses or failure of taping required limited posterior in 20 feet (5.2%, fair ) or posteromedial in eight feet (2.1%, poor ). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results. Cite this article: Bone Joint J 2013;95-B: A. K. Singh, MRCS, MBBS, Specialist Registrar in Orthopaedics King's College Hospital, Denmark Hill, London SE5 9RS, UK. A. Roshan, MRCS, MBBS, Specialist Registrar in Plastic Surgery Addenbrooke s Hospital, Hills Road, Cambridge CB2 0QQ, UK. S. Ram, MCh(Orth), FRCS, MBBS, Consultant Orthopaedic Surgeon Advanced Orthopaedic Centre, 160/C, Road No 3, Rajendra Nagar, Patna , India. Correspondence should be sent to Mr S. Ram; shatrughna.ram@me.com 2013 The British Editorial Society of Bone & Joint Surgery doi: / x.95b $2.00 Bone Joint J 2013;95-B: Received 9 August 2012; Accepted after revision 30 October 2012 The philosophy of the correction of clubfoot deformity has for centuries fluctuated between operative and non-operative methods. 1-2 However, growing awareness that rapid surgical correction was at the expense of future function led to an interest in developing less invasive treatments. 3-5 In the early 1900s in the United Kingdom, Robert Jones, followed by Denis Browne, advocated non-operative correction through strapping, casts and splints in preference to forcible manipulation and surgery. 3,6 Repeated gentle manipulations and stepwise maintenance in plaster casts was popularised in the United States by Joseph Kite in the 1920s. 7 From the 1940s, Ponseti developed his technique of manipulation, which follows the normal arc of the subtalar joint and maintains the correction in serial casts. 8 However, in the 1960s these methods were interrupted by improved paediatric anaesthesia, leading to the popularity of extensive posteromedial surgical s. Jones strapping continued in the United Kingdom but was hampered by the lack of a formal protocol, inadequate supervised application and frequent failure, leading to its eventual abandonment. 9 In the 1980s and 1990s, reports of superior long-term outcomes with the Ponseti method 10 re-established conservative techniques. In parallel, during the 1970s the French functional method was developed by Bensahel and Masse This intensive daily physiotherapy regime added to the belief that conservative approaches could lead to successful long-term outcomes without major surgery. The Ponseti and French taping methods are currently the most widely practiced primary treatment of clubfoot. 14,15 However, these methods have their limitations. The former involves a foot abduction brace until two to four years of age; the latter requires daily manipulations by specially trained physiotherapists; and both include percutaneous heel-cord tenotomy in up to 85% of patients. Thus, acceptance of the brace by the child in the Ponseti method and parental co-operation in the French method are considered key factors for good results. 16 It is increasingly recognised that hybrid conservative approaches to clubfoot treatment have the potential to improve on current care. 1,15 In this study, we report a modification of the VOL. 95-B, No. 2, FEBRUARY

2 272 A. K. SINGH, A. ROSHAN, S. RAM Treatment phase Maintenance phase All idiopathic previously untreated clubfeet Severity grading Pre-2000 by Harrold & Walker classification Post-2000, additionally by Pirani Score Accelerated dynamic taping regimen 1st and 2nd taping sessions - concentrate on cavus & adductus Maintain for 4 days intervals each 3rd and 4th taping sessions - concentrate on supination & varus Maintain 3rd taping for 4 days and 4th taping for 5 days 5th taping - create a valgus and pronated foot Maintain for 5 day interval 6th taping session - concentrate on equinus Leave final taping for 12 days Typical total treatment regimen = 5 weeks; 6 sessions Corrected foot Talipes splint & foot exercises Typically until 1 year of age, or start of walking Day-time talipes shoes, night-time talipes splint & foot exercises Until 3 years of age Medium-term outcome assessment at age of 3 years Normal footwear No further intervention Final outcome assessment at age > 10 years Laaveg & Ponseti scoring Fig. 1 Flowchart demonstrating salient features, timing of stages and steps during treatment. Jones dynamic taping method that reduces the intensity of treatment, includes modern principles of Ponseti manipulation, avoids heel-cord tenotomy and reduces the need for the extensive use of orthoses to maintain correction. 9,14 Patients and Methods In this retrospective cohort study we included all infants under the age of three months with idiopathic unilateral or bilateral talipes equinovarus who were treated at our hospital between September 1991 and August We excluded those with positional talipes or calcaneovalgus, metatarsus adductus, vertical talus, or who had any previous treatment. Before 2001, severity was assessed by the Harrold and Walker 17 clinical grades of mild (the foot can be held at or beyond neutral with firm pressure insufficient to cause pain), moderate (fixed equinus or varus < 20 ) or severe (fixed deformity of equinus or varus 20 ). After 2001, the Pirani score 18 was also recorded as an additional measure of deformity. This score is based on six features: three hindfoot contracture elements (posterior crease, empty heel, rigid equinus) and three midfoot elements (curvature of the lateral border, medial crease and reducibility of the lateral head of the talus), each scoring 0, 0.5 or Technique. The taping regime can be considered in two phases: treatment and maintenance. During the treatment phase typically six outpatient sessions over a five-week period a series of manipulations and tapings are carried out (Fig. 1). All sessions were performed and monitored by the same orthopaedic surgeon (SR). Before each, the child is fed, given oral paracetamol (15 mg/kg) and ibuprofen (10 mg/kg), and the skin cleansed with alcoholic spirit. Repetitive manipulations are performed with increasing force as tolerated in five to ten cycles, then held in position for five seconds. Manipulation in the first and second sessions consists of correcting the cavus and adductus by elevating the medial forefoot and abducting the foot using the head of the talus as a fulcrum. The foot is then painted with tincture of benzoin to enhance the adhesion to the strapping. No padding is used, as an extra layer would provide a plane for loss of dynamic reduction. A two-inch wide elasticated adhesive strapping is applied from the middle of the dorsum of the foot, curved along the medial side to the sole of the foot and then stretched taking care not to compromise the circulation. While maintaining this position, the knee is flexed to 110 and the tape stretched over the lower thigh (Fig. 2a), thereby allowing further dynamic correction when the knee is extended (Fig. 2b). A second overlayer is applied to enhance the correction and protect the first. The third and fourth taping sessions aim to correct varus and supination, and to some degree the equinus. This is done with the middle finger pushing the navicular bone into alignment with the talar head, while supporting the heel in the operator s palm. Taping at these sessions is similar to the above. The fifth session concentrates on creating a valgus and pronated foot, erring on gentle overcorrection. The sixth and final session concentrates on correcting equinus by an additional tape applied on the medial aspect of the foot (Fig. 3). As this is a dynamic correction, it is not possible to correct each part of the deformity separately. Whereas each session concentrates on a particular aspect, all deformities are corrected to varying extents simultaneously. The child is observed for 30 to 60 minutes after strapping to make sure the taping is not too tight, and the carers are taught passive exercises to stretch the toe flexors. The first and second tapings are maintained for four days, the third to fifth for five days, and the sixth for 12 days. Following this regime an additional one or two sessions may occasionally be needed to achieve a plantigrade foot. Conversely, in some infants only four or five sessions may be needed. During the maintenance phase, the plantigrade position is maintained by a 90 passive thermoplastic splint with a tape bolster attached to the outer side (Fig. 3c). This is tightened to achieve up to 20 of dorsiflexion. The carers are taught to perform dorsiflexion and valgus manipulations for 30 minutes four times daily. The splint is worn full-time, except when the foot is being exercised. From the THE BONE & JOINT JOURNAL

3 OUTPATIENT TAPING IN THE TREATMENT OF IDIOPATHIC CONGENITAL TALIPES EQUINOVARUS 273 Fig. 2a Fig. 2b Diagrams showing the technique of dynamic taping. The two-inch elasticated strapping is applied directly to the skin after preparation with alcoholic spirit and tincture of benzoin (a). After appropriate manipulation, the tape is applied from the middle of the dorsum of the foot, curved along the medial side of the sole of the foot to the outer aspect of the foot, and anchored to the thigh with the knee at 90. Knee extension leads to further reduction of the ankle deformity (b). time of walking, a talipes shoe incorporating an 8 mm lateral wedge to maintain mild valgus is worn during the day and a thermoplastic splint with bolster at night. The exercises and splintage are continued until three years of age, when normal shoes may be worn without restriction. During the maintenance phase the patients were followed every four to six weeks until six months of age, then three monthly until two years of age, six monthly until three years of age and then annually. Outcome measures. As reported elsewhere, at a three-year medium-term follow-up a clinically good outcome was defined as an unoperated plantigrade foot, a fair outcome as a plantigrade foot that had a limited posterior and a poor outcome as one requiring a posteromedial. 19 From this cohort, a subset of patients with potential tenyear outcomes was identified. They were invited for evaluation using the 100-point Laaveg Ponseti scale, 10 as radiographs and gait analysis were not practicable. This scale combines three patient-reported features (satisfaction, 20 points; function, 20 points; pain, 30 points) and three clinical features (position of the heel when standing, 10 points; passive motion, 10 points; gait, 10 points). The scores were classified as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points) and poor (< 70 points). 10,20 Statistical analysis. All continuous data are expressed as a mean and standard deviation. For medium-term outcome data, Fisher s exact test for contingency tables was used to compare the distribution of proportions between groups, using outcomes from published data with the same rating system. 19,21-26 Long-term data were similarly compared with reports using the Laaveg Ponseti grading system to assess outcome after Ponseti 10,27-29 and surgical treatment. 20 A two-tailed p-value was determined with a level of significance < Direct comparison with the French method was not possible, as different outcome measures were used to incorporate radiological and gait analyses. Results A total of 235 patients (159 male and 76 female) were included. There were 167 bilateral cases, resulting in a total of 402 clubfeet (Fig. 4). Their mean age at presentation was 19 days (0 to 90). A total of 185 feet were graded before 2001 using the Harrold and Walker system 17 : the grade was mild in 11 feet (5.9%), moderate in 57 (30.8%) and severe in 117 (63.2%). After 2001, the remaining 217 feet were graded similarly as mild in 13 (6.0%), moderate in 46 (21.2%) and severe in 158 (72.8%). This latter group of 217 feet were also graded using the Pirani score, the mean value of which was 4.97 (2 to 6). The Pirani score was < 3 points in 11 feet (5.0%), between 3 and 5 points in 42 (19.3%) and 5 points in 164 (75.6%). The progress of the patients is summarised in Figure 4. At the end of the initial five-week treatment, 396 feet (98.5%) were plantigrade and six (1.5%) had incompletely corrected equinus deformity. Of the 396 plantigrade feet, 83 (21.0%) relapsed within six months and underwent between one and three additional taping sessions. Of these 83 feet and the six that had originally failed to reach plantigrade at the end of five weeks, the additional treatment was successful in 68 feet (76.4%), but the remaining 21 (23.6%) required operative treatment. Along with these were a further seven feet that had relapsed between six to 16 months after initial treatment. Of the 28 feet requiring surgery, 20 underwent limited posterior (tendo Achillis lengthening with posterior ankle capsulotomy) and eight required a full posteromedial. The operations were performed at around one year of age and no tendon transfers were required. VOL. 95-B, No. 2, FEBRUARY 2013

4 274 A. K. SINGH, A. ROSHAN, S. RAM Fig. 3a Fig. 3b Fig. 3c Clinical photographs showing the taping progression, with a) typical fourth taping episode with a single tape predominantly correcting the varus deformity, b) typical final taping addressing equinus, with taping to both medial and lateral aspects of the lower limb, and c) simple talipes splint with lateral bolster. After the initial taping 12 patients (17 feet) were lost to follow-up, three patients (four feet) within six months and nine patients (13 feet) between six months and the threeyear medium-term evaluation. There were three minor complications (skin blisters) and one major complication, a tibial fracture as a result of overzealous parental massaging, all of which were managed by interrupting treatment until spontaneous healing occurred. There was no adverse effect from this delay. A total of 223 patients with 385 treated feet (95.8%) were seen at the medium-term follow-up of three years, when normal footwear was permitted. Of these, 357 feet (92.7%) had a good response to treatment (plantigrade foot without surgery), 20 (5.2%) a fair response (plantigrade foot following limited posterior ) and eight feet (2.1%) a poor response (plantigrade foot following full posteromedial ). No rocker-bottom deformity was observed. We compared our results with published data using the outcome criteria of Richards et al 19 (Table I) Our three-year results are similar to the two-year follow-up of the largest cohort in the literature (p = 0.6). 22 However, highly statistically significant differences were seen when our results were compared with those of Richards et al, 19 who investigated both the Ponseti method and French taping in a large dataset: the results of the current study were found to be superior (both p < 0.001). 19 Of the 185 eligible feet (125 patients) treated up until 2001, only 44 (23.8%, 31 patients) returned for long-term THE BONE & JOINT JOURNAL

5 OUTPATIENT TAPING IN THE TREATMENT OF IDIOPATHIC CONGENITAL TALIPES EQUINOVARUS 275 Treatment phase 5 weeks 396 Plantigrade feet 402 clubfeet 6 Residual equinus Early observation and maintenance phase 4 Lost to follow-up 83 Early relapse (< 6 months) Salvage additional taping if age < 6 months 1 to 3 sessions according to degree 68 Plantigrade feet 21 Residual equinus 6 months Late observation and maintenance phase 13 Lost to follow-up 289 No relapse 68 Rescued relapses 7 Late relapse (6 to 16 months) 20 Limited posterior Surgery 8 Posteromedial 3 years > 10 years 357 (92.7%) Good Medium-term (3 year) follow-up Outcomes grading; 385/402 patients (95.8%) 20 (5.2%) Fair 8 (2.1%) Poor Long-term (> 10 year, mean 14.3 year) follow-up Laaveg & Ponseti patient rating; 23.8% follow-up (44 of 185 eligible feet) 23 (52.3%) Excellent 17 (38.6%) Good Fig. 4 3 (6.8%) Fair 1 (2.3%) Poor Number of patients at each step of treatment and outcome summary at medium-term and longterm follow-up. (> ten years) follow-up. Their mean follow-up was 14.3 years (11 to 20). A total of 23 feet (52.3%) were rated on the Laaveg-Ponseti score as excellent, 17 (38.6%) good, three (6.8%) fair and one (2.2%) poor. We found five other reports using the Laaveg Ponseti grading system for long-term evaluation of different methods of treatment for clubfoot (Table II). 10,20,27-29 Our dynamic taping method was significantly better than any of these methods (all p 0.023). We found no long-term studies that used the Laaveg Ponseti scale to evaluate the French method. Discussion The long-term objective of treatment in clubfoot is a painless, supple plantigrade foot and a normal range of movement without extensive use of cumbersome orthoses. Additionally the technique should be simple, easily reproducible, generally applicable and cost-effective. The French taping method has not been widely adopted outside France because of the intensive training requirements and the daily nature of initial treatment. 19 The Ponseti method has led to issues concerning compliance and recurrence involving the two- to four-year use of orthoses following correction. 30,31 These obstacles do not hinder our method. Although the technique described here was originally inspired by the Jones method, there are important differences. 3,9,32 Our manipulation is similar to the Ponseti method, with the same five principles of simultaneous correction of deformity (except equinus), initial correction of cavus and adductus, followed by foot abduction under the talus, final correction of equinus, and no pronation in the initial stages. 14,33 The taping, unlike the original Jones strapping, extends above the knee to allow passive correction with knee extension. 3 Modified versions of the Jones method, as described by Fripp and Shaw 32 and Fixsen and Lloyd-Roberts, 9 remain ineffective, as they included a thick VOL. 95-B, No. 2, FEBRUARY 2013

6 276 A. K. SINGH, A. ROSHAN, S. RAM Table I. Medium-term (approximately three years) outcome comparison. A good result is defined as a plantigrade foot without surgery, fair as a plantigrade foot following limited posterior, and poor as a plantigrade foot following full posteromedial 19 Number of feet Mean follow-up (yrs) Good (%) Fair (%) Poor (%) p-value * Current study Ponseti method Morcuende et al Richards et al < Haft et al < Colburn and Williams French taping Diméglio et al ? < Richards et al < Richards et al < Van Campenhout et al 26 (CPM alone) < * comparison with results of current study (Fisher s exact test) CPM, continuous passive movement Table II. Long-term (> ten years) outcome comparison. Grading according to Laaveg Ponseti method, 10 with excellent > 90 points; good 81 to 90 points; fair 71 to 80 points; and poor 70 points Method of treatment Feet (n) Mean follow-up (yrs) Excellent (%) Good (%) Fair (%) Poor (%) p-value * Current study Dynamic taping Laaveg and Ponseti 10 Ponseti Cooper and Dietz 27 Ponseti (fair and poor) Ippolito et al 28 Serial cast limited Serial cast posteromedial Edmondson et al 29 Serial taping posteromedial Dobbs et al 20 Extensive softtissue < * comparison with results of current study (Fisher s exact test) felt pad and were performed by multiple physiotherapists in the absence of a strict protocol. Our method combines manipulation based on scientific principles with an effective dynamic taping regime. Although our adhesive bandage was applied directly to the skin there were only three minor blistering complications. We believe this is partly because non-caucasian skin is relatively resistant to shear forces, and the correct tension was applied. No taping had to be removed or slackened because of distal vascular compromise, despite firm application and close initial observation for up to an hour afterwards. The taping also dramatically reduces the need for Achilles tenotomy, which we believe is as a result of a combination of passive continuous stretching of the tendo Achillis during manipulation, maintenance of position during taping, and active stretching through knee extension. The stress-relaxation in the tendo Achillis was sufficient to maintain a plantigrade foot in 357 of 385 feet (92.7%) three years after treatment. We found the Harrold and Walker classification 17 simple and easy to apply, and along with a high mean Pirani score of 4.97 after 2001, it indicated that our referral population tends towards severe deformity. The initial correction in the Ponseti and French methods has been reported to be in the range of 90% to 100%, similar to our 98.5% response. 19,31 In our series, 76.4% of partial responders and early relapses were rescued by further taping if the patient was under the age of six months. These initial partial responses often had a residual equinus, indicating that the tendo Achillis required further stretching, but responded well to additional taping sessions. We did not find that over-activity of the tibialis anterior was unresponsive to correction by taping, presumably owing to similar stress-relaxation. This led to an overall 7% failure of conservative management requiring operative treatment. The need for tendon transfer or limited or complete posteromedial has been reported to be between 5% and 28% with the Ponseti method and 25% to 67% with the French method, with wide variation between THE BONE & JOINT JOURNAL

7 OUTPATIENT TAPING IN THE TREATMENT OF IDIOPATHIC CONGENITAL TALIPES EQUINOVARUS 277 groups. 19,24-26 However, it should be noted that the Ponseti and French methods include subcutaneous heel-cord tenotomy in their standard protocol. 16 During the taping period we could not predict who would require surgery. We used the Laaveg Ponseti system 10 for long-term evaluation as it is the only published score that can be measured clinically without radiographs, gait analysis or plantar pressure assessments. Traditional radiological endpoints often do not reflect patient-based outcomes after clubfoot correction, and their use has been cautioned. 34,35 Some studies have criticised the Laaveg Ponseti system for its bias towards patient-weighted components. 27,36,37 High scores may be achieved despite a reduced range of movement, and in our population the ability to squat is a key determinant of satisfaction. Also, its widespread use in the long-term evaluation of the Ponseti method allows direct comparison with this technique. Gait analysis in treated clubfeet demonstrates good rates of normal kinematic ankle movement in the Ponseti and French methods compared to aggressive surgical, although residual differences have been noted in the plantar pressures of toddlers treated with French taping It would be interesting to compare MRI changes in bone and joint alignment in our cohort with those seen after the Ponseti and French methods 41,42 but we do not have the resources for such a detailed study. A weakness of our study is the low long-term follow-up rate of 23.8%, despite a high three-year follow-up rate. The former is similar to other long-term cohorts from Iowa 10,27 and reflects the geographically mobile nature of young adults through education and work, making it difficult to obtain high return rates. We believe that our method provides advantages in its simplicity and good long-term results to justify its trial and uptake by other centres, especially where resources are limited. The authors would like to thank Professor L. Klenerman for his support and for reviewing this manuscript. The authors would also like it to be stated that both A. K. Singh and A. Roshan are to be attributed as first authors. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References 1. Carroll NC. Clubfoot in the twentieth century: where we were and where we may be going in the twenty-first century. J Pediatr Orthop B 2012;21: Brockman EP. Historical survey of the literature. In: Brockman EP, Chir M, eds. Congenital club-foot (talipes equinovarus). Bristol: John Wright & Sons Ltd, 1930: Jones R, Lovett RW. Club-foot. In: Orthopaedic surgery. Second ed. 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8 278 A. K. SINGH, A. ROSHAN, S. RAM 37. van Mulken J, Bulstra S, Hoefnagels N. Evaluation of the treatment of clubfeet with the Diméglio Score. J Pediatr Orthop 2001;21: El-Hawary R, Karol LA, Jeans KA, Richards BS. Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique. J Bone Joint Surg [Am] 2008;90-A: Karol LA, O Brien SE, Wilson H, Johnston CE, Richards BS. Gait analysis in children with severe clubfeet: early results of physiotherapy versus surgical. J Pediatr Orthop 2005;25: Jeans KA, Karol LA. Plantar pressures following Ponseti and French physiotherapy methods for clubfoot. J Pediatr Orthop 2010;30: Richards BS, Dempsey M. Magnetic resonance imaging of the congenital clubfoot treated with the French functional (physical therapy) method. J Pediatr Orthop 2007;27: Pirani S, Zeznik L, Hodges D. Magnetic resonance imaging study of the congenital clubfoot treated with the Ponseti method. J Pediatr Orthop 2001;21: THE BONE & JOINT JOURNAL