Safety and long-term effects on gait of hemiplegic patients in equinovarus foot deformity surgical correction followed by immediate rehabilitation: a prospective observational study.

BACKGROUND: Equinovarus foot deformity (EVFD) is the most common lower limb deformity in stroke patients. Immobilization following EVFD surgical correction is known to have a negative impact on muscle rearrangement with possible loss of walking ability in stroke patients. In a previous study, safe and positive effects at one-month follow-up after surgery were obtained with an early rehabilitation treatment (ERT) characterized by immediate walking and training. AIM: To determine long-term safety and efficacy of functional surgery followed by early rehabilitation (FSER). DESIGN: A 12 months prospective observational study. SETTING: Outpatients clinic, Gait and Motion Laboratory, Sol et Salus Hospital, Rimini, Italy. POPULATION: Twenty-four adult chronic stroke survivors with EVFD surgical correction followed by ERT, age 55±13 years, affected side 12L/12R, time from lesion 5±4 years. METHODS: Patients received clinical and instrumental evaluation by gait analysis (GA) before (T0), one, three and twelve months after surgery. Safety was defined as the absence of any complication consequent to FSER. Efficacy was assessed by the recovery in ankle kinematics, walking speed and space-time parameters. RESULTS: No clinical complication (thrombosis, surgical wound infection, muscle or tendon injury, muscle hematoma) arose in the sample during the follow-up year. Variables relating to ankle kinematics improved towards their normal values at one month after surgery. These were maintained at 3 and 12 months, with a significant difference between follow-ups and pre-surgical values (Durbin-Conover Test, P<0.01). Gait speed, cadence, anterior step length and stride length of the affected side showed a statistical improvement at 3 and 12 months (Wilcoxon test, P=0.012 and P=0.001, respectively). Stride width decreased at 1 month after surgery and showed a further stable reduction at 3 months (P=0.008). CONCLUSIONS: The ERT protocol with immediate rehabilitation starting on the first day after surgical correction was safe and effective in providing a long-term correction of EVFD. Ankle dorsiflexion improved both in stance and swing, allowing for a significative improvement in walking speed. CLINICAL REHABILITATION IMPACT: FSER can be considered an encouraging approach in the management of EVFD, with durable results.

Gross Motor Function at 10 Years of Age in Children With Clubfoot Following the French Physical Therapy Method and the Ponseti Technique.

PURPOSE: To evaluate gross motor skills [Bruininks-Oseretsky Test of Motor Proficiency, 2nd ed (BOT-2)] of patients with idiopathic clubfoot initially treated nonoperatively with either the French functional physical therapy (PT) method or the Ponseti technique, at age 10 years. METHODS: The BOT-2 was administered by trained physical therapists on patients with idiopathic clubfoot at age 10 years. The cohort was divided by initial treatment method (PT or Ponseti), and compared. Subsequent analyses included comparisons of: initial clubfoot severity (Dimeglio scores: ≤13 vs. >13), laterality (unilateral vs. bilateral), and surgical versus nonoperative outcome. RESULTS: Of the 183 patients tested, 172 were included. The Ponseti and PT groups did not significantly differ according to age, height, weight, body mass index, ankle dorsiflexion, sex, average initial Dimeglio score, laterality, or surgical versus nonsurgical outcome. Overall, patients with treated clubfoot had average gross motor BOT-2 scores compared with age-matched peers. Patients in the PT group scored higher on Running Speed/Agility (P=0.019), Body Coordination percentile rank (P=0.038), and Strength and Agility percentile rank (P=0.007) than patients treated by the Ponseti technique. Patients with bilateral clubfoot scored significantly lower on the Balance subtest (P<0.01), and Body Coordination percentile rank (P<0.01), than those with unilateral clubfoot. Patients who required surgery scored significantly lower on the Balance subtest (P=0.04) than those who did not require surgery. CONCLUSIONS: Clubfoot may impair balance in 10 year olds with bilateral involvement and those requiring surgery. Future research should evaluate whether components of the PT method may improve gross motor outcomes as a supplement to the Ponseti technique. LEVELS OF EVIDENCE: Level II.

How Many Patients Who Have a Clubfoot Treated Using the Ponseti Method are Likely to Undergo a Tendon Transfer?

BACKGROUND: The Ponseti method has become the standard of care for the treatment of idiopathic clubfoot. A commonly reported problem encountered with this technique is a relapsed deformity that is sometimes treated in patients older than 2.5 years by an anterior tibial tendon transfer (ATTT) to the third cuneiform. Presently, there is insufficient information to properly counsel families whose infants are beginning Ponseti treatment on the probability of needing later tendon transfer surgery. METHODS: All idiopathic clubfoot patients seen at the authors' institution during the study period who met the inclusion criteria and who were followed for >2.5 years were included (N=137 patients). Kaplan-Meier Survival analysis was used to determine the probability of survival without the need for ATTT surgery. In addition, the influence of patient characteristics, socioeconomic variables, and treatment variables on need for surgery was calculated. RESULTS: On the basis of the survivorship analysis, the probability of undergoing an ATTT remained below 5% for all patients at 3 years of age, but exceeded 15% by 4 years of age, increasing steadily afterwards such that by 6 years of age, the probability of undergoing an ATTT reached 29% of all patients. Overall, controlling for all other variables in the analysis, parent-reported adherence with bracing reduced the odds of undergoing surgery by 6.88 times, compared with parent-reported nonadherence (P<0.01). CONCLUSIONS: This is the first study to report the probability of undergoing ATTT surgery as a function of age using survivorship analysis following Ponseti clubfoot treatment. Although the overall probability reached 29% at 6 years, this was significantly reduced by compliance with bracing. This information may be useful to the clinician when counseling families at the start of treatment. LEVEL OF EVIDENCE: Level III-theraputic.

Treatment of clubfoot with the modified Copenhagen method: A 10-year follow-up.

BACKGROUND: Clubfoot is one of the most frequent congenital malformations in the world. Non-operative methods follows limiting surgery to a minimum. The modified Copenhagen method has not been studied enough. STUDY DESIGN: longitudinal retrospective study. OBJECTIVES: To evaluate prognostic factors for clinical rehabilitation with the modified Copenhagen method in a 10-year follow-up period. METHODS: A retrospective study was carried out on a 10-year follow-up of 82 children diagnosed with clubfoot at birth and treated with the modified Copenhagen method. Their sex, side, severity, bilaterality, forefoot orientation, and age when the nonoperative treatment was started were registered, and a cluster analysis was performed to determine which variables were most significant for predicting whether surgical treatment was needed. RESULTS: Of the clubfeet, 13.4% were grade I, 65.9% were grade II, and 20.7% were grade III according to the Harrold and Walker classification. In total, 58 patients needed surgery at some point during the follow-up period. The severity and talo-first metatarsal angle made it possible to determine whether the patients required surgery in 68% (56/82) of the cases. CONCLUSION: The results of the study suggest the possibility of providing physicians with an algorithm which might facilitate assessing whether the children will require surgery or not, depending on the data obtained from the cluster analysis. Clinical relevance This study provides health professionals with an algorithm that might facilitate assessing whether the children will require surgery or not.

A Critical Evaluation of the Updated Evidence for Casting for Equinus Deformity in Children with Cerebral Palsy.

BACKGROUND AND PURPOSE: Equinus deformity is common in ambulant children with cerebral palsy (CP). Although lower leg casting is frequently used, the physiological basis for casting and effects beyond range of motion (ROM) gains are unclear. This review critically evaluates the updated evidence for casting in the management of ankle equinus in children with CP. METHODS: Comprehensive searches were conducted using electronic databases AMED, MEDLINE, CINAHL, Scopus, PEDro and the Cochrane Database of Systematic Reviews, publication years 2005-2014, in order to identify literature published since an earlier comprehensive systematic review. Only studies evaluating lower leg casting for conservative management of equinus deformity in children with CP were considered. Two independent raters critically appraised studies against the hierarchy of levels of evidence and rigour of study conduct questions proposed by the American Academy of Cerebral Palsy and Developmental Medicine's methodology for systematic review. RESULTS: Four relevant systematic reviews were identified, although these largely concerned earlier literature. Five original studies were included, all demonstrating improvement in dorsiflexion ROM. Combined treatment with botulinum toxin and casting offered greater and/or more sustained ROM gains than botulinum toxin alone in three studies. Effects on gait parameters and motor function were inconsistent. Participation outcomes were not evaluated. Methodological limitations make firm conclusions difficult. CONCLUSIONS: Recent years have offered little progress in the state of evidence for casting in the management of equinus deformity. Casting appears to offer at least short-term improvement in ankle dorsiflexion, although the proposition that this improves function or avoids surgery is not well substantiated. Future research needs to ensure more robust study design and broader evaluation across domains of the International Classification of Functioning, Disability and Health to determine the functional and long-term effect of casting for equinus deformity. Greater knowledge is required of the effect of casting on muscle structure and function in spastic CP. Copyright © 2015 John Wiley & Sons, Ltd.

Initial treatment of congenital idiopathic clubfoot: Prognostic factors.

BACKGROUND: The initial treatment of congenital idiopathic clubfoot (CIC) is nonoperative. Either the French physiotherapy method or the Ponseti casting method may be used. Whether either method is superior over the other remains unclear. However, the method used initially is not the only determinant of the final outcome. OBJECTIVE: The primary objective was to identify determinants of the final outcome as evaluated based on the need for surgical treatment and on the Ghanem-Seringe score. HYPOTHESIS: Factors associated with the final outcome can be identified. METHODS: Between 2004 and 2011, 100 CICs in 79 patients were treated in two centres, 47 using the French method and 53 the Ponseti method. The Dimeglio grade was determined at baseline and the Ghanem-Seringe score at last follow-up. Surgical procedures (if any), splinting duration, and rehabilitation therapy duration were recorded. The two groups showed no statistically significant differences for Dimeglio grade distribution, time from birth to treatment initiation, or mean follow-up. RESULTS: Factors significantly associated with a poor outcome by univariate analysis were use of the Ponseti method (P=0.0027), older age at last follow-up (P=3×10-4), initial Dimeglio grade (P=7×10-5), and need for surgery (P=10-5); no significant effect was found for splinting duration, rehabilitation duration, bilateral involvement, or antenatal diagnosis. By multivariate analysis, factors independently associated with a poor prognosis were older age at last follow-up, Dimeglio grade, and need for surgery. CONCLUSION: This study confirms the major prognostic significance of initial severity (Dimeglio grade) on the final outcome. The data do not firmly establish that one method is superior over the other. Nevertheless, the need for percutaneous Achilles tenotomy with the Ponseti method leads us to prefer the French physiotherapy method. LEVEL OF EVIDENCE: IV, retrospective study.

Problems encountered by parents of infants with clubfoot treated by the Ponseti method in Madagascar: A study to inform better practice.

OBJECTIVE: Ponseti treatment for clubfoot is effective and inexpensive, improving children's social participation. Two rehabilitation centres in Madagascar piloted Ponseti treatment; however, at one centre 46% of infants failed to complete treatment. The aim of this study was to determine the causes of defaulting in order to facilitate subsequent improvements nationwide when treatment is rolled out to all centres. METHODS: Questionnaire-based interviews. PATIENTS: Twenty mothers of infants younger than 1 year were interviewed after 3 months of treatment in relation to difficulties they experienced with continuing treatment. RESULTS: Fifteen families of these had financial problems: 7 incurred debt, 2 sold possessions, 4 parents stopped work an 2 did not give any further details. All mothers experienced distress; 9 hid their child's foot, and 8 were accused of wrong-doing during pregnancy. Three families travelled more than 500 km to the treatment centre and journeys were costly and difficult. Ponseti splints were acceptable, but aftercare of the splints proved problematic. CONCLUSION: Repeated travel to the clinic resulted in financial and social burden on the families, which reduced their ability to engage in treatment. The findings of this study are similar to work from other countries, but publications on rehabilitation from Madagascar are few. Improved support for parents, information, splinting with better materials and provision of treatment more locally are needed. Financial support for parents is key to enhancing children's life chances.

[Clubfoot associated with tibial and fibular hemimelia]. / Der Klumpfuß bei tibialer und fibularer Hemimelie.

AIM: Clubfoot is rarely associated with tibial or fibular hemimelia. Treatment is complex and in most of the cases extensive surgery is required. At present experience with Ponseti casting is limited. We describe casting and surgical treatment of 10 clubfeet associated with tibial and fibular hemimelia. MATERIAL AND METHOD: Between 1.1.2004 and 31.12.2009 398 clubfeet were treated with casting in our institution. In the same period 10 clubfeet were associated with fibular or tibial hemimelia. Treatment started in 9 clubfeet with Ponseti manipulation and casting. We used the classification of Weber for tibial hemimelia and the Kalamchi-Achterman classification and Paley classification for fibular hemimelia. Data of all patients were prospectively documented and the result of the foot deformity was evaluated before a first lengthening procedure. Documentation included patient data, associated foot pathologies, surgical procedures, functional results. Functional results were evaluated before the first lengthening procedure started. RESULTS: Three patients had tibial hemimelia, two Weber type 1, one Weber type 2, one Weber type 3. five patients had fibular hemimelia, Paley type IV or Kalamchi-Achterman Type IA. One child had bilateral fibular hemimelia. The prospective leg length discrepancy ranged from 3.2 cm to 14 cm. Four feet had initially a successful treatment with casting. In a type 2 according to Weber we performed an ankle reconstruction procedure to correct tibiofibular diastases. Four feet underwent PMR. We had four relapses. Two equinus relapses were treated with a posterior release. Two severe relapses were finally corrected with resection of the coalition and midfoot osteotomies. In a Weber type 3 case a complex reconstruction was performed using an Ilisarov and a TSF frame. Functional results showed in a mean follow-up of 42.2 months (24-72 months) a dorsiflexion between 5 and 20° (Ø 7.7°) and a plantarflexion between 10 and 40° (Ø 26.1°). CONCLUSION: Treatment of clubfoot associated with tibial or fibular hemimelia with the Ponseti technique is limited because of complex hindfoot deformities including tarsal coalitions. Nevertheless treatment after birth starts with casting. Only mild cases of hemimelia without coalition can be corrected with the Ponseti technique. In a case of tibiofibular diastasis successful casting is possible, but extensive surgery is often necessary. In more severe cases we do not recommend casting. In these cases surgical treatment, including posteromedial release, osteotomies for the hindfoot, resection of coalitions or complex osteotomies with Ilisarov or TSF frame is the treatment of choice.

[Early results of congenital clubfoot using Ponseti method]. / Wczesne wyniki leczenia stopy konsko-szpotawej wrodzonej metoda Ponsetiego.

Congenital clubfoot is one of the most common congenital skeletal defects. Its aetiology remains unclear. Due to its high incidence and social consequences, the therapy of congenital clubfoot presents an important medical issue. Non-surgical treatment methods are preferred. Many publications confirmed the efficacy of the Ponseti method. The aim of this study was to present early results of congenital clubfoot treatment using the Ponseti method in a one-year follow-up. The therapy protocol was in accordance with guidelines presented by the inventor. The necessity of surgical treatment was a criterion for negative treatment outcome. One hundred and sixteen feet of 92 children were analysed. A Dimeglio-Bensahel classification was used for the evaluation of the defect advance. Seventy-one feet (61.2%) were assessed as grade II, 43 feet as grade III (37.1%) and 2 feet as grade IV deformation. No patients with grade I deformation were included into the study. A positive treatment outcome was observed for 96 feet (82.7%), whereas a negative result for the remaining 20 feet (17.3%). Our results are therefore not consistent with the literature data. It could have resulted from the too precipitate qualification for surgery by the physician and problems with compliance. The Ponseti method is an effective and less straining treatment modality of the congenital clubfoot. In most cases it allows for avoiding extensive surgery and associated complications. A necessity of wearing an orthosis and a risk treatment failure, if not worn systematically, should be emphasised. A longer follow-up period is required for complete result analysis.

Functional midterm outcome in 131 consecutive cases of surgical clubfoot treatment.

INTRODUCTION: Since introduction and widespread use of the Ponseti method in the last decade, the need for surgical treatment of clubfeet is nowadays limited to resistant cases. In the time before, surgery via dorsomedial release was a very common treatment option. METHOD: Very few long-term follow-up studies cover the outcome of surgical methods, which is particularly interesting, as clinical results rather worsen with time. In the present study, 98 children (131 clubfeet), who underwent surgical correction using the Imhauser method at the age of 4.5 months were included. Follow-up time was 8.2 years (0-11.8 years) at average. RESULTS: Data could be retrieved from 46 patients (71 feet), only 5 patients (7 feet) were lost to follow-up. The rate of relapses was high, as 47 patients (53 feet) needed surgical revision for recurrence, while clinical scores showed a good result in the Laaveg and Ponseti Score and the Foot-Function-Index. Isokinetic testing and clinical data indicated a significant weakness of the treated foot, when compared to the healthy side in 12 patients with unilateral deformity. The presented study supports like others the issue that the clinical outcome of a surgical, posteromedial release in terms of relapses is disappointing. This fact is apparently not sufficiently reflected in the current clinical scores, which showed rather good results. CONCLUSION: As the question of evaluation methods for results of clubfoot treatment remains controversial, isokinetic testing is an easy to use alternative that provides detailed information about functional limitations and may help in reducing the need for repeated radiographic examinations.

Patient-reported outcome at 62 to 67 years of age in 83 patients treated for congenital clubfoot.

The outcome in 83 patients with congenital clubfoot was evaluated at a mean age of 64 years using three validated questionnaires assessing both quality of life (short-form (SF)-36 and EQ-5D) and foot and ankle function (American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle questionnaire). In SF-36, male patients scored significantly better than male norms in seven of the eight domains, whereas female patients scored significantly worse than female norms in two of the eight. Male patients scored better than male norms in both the EQ-5D index (p = 0.027) and visual analogue scale (VAS) (p = 0.013), whereas female patients scored worse than female norms in the VAS (p < 0.001). Both male and female patients had a significantly worse outcome on the AAOS Core Scale than did norms. There was a significant correlation for both genders between the SF-36 Physical Component Summary Score and the AAOS Core Scale. The influence on activities of daily life was limited to foot and ankle problems in all patients, and in females there was an adverse effect in physical aspects of quality of life.

Gait changes after tendon functional surgery for equinovarus foot in patients with stroke: assessment of temporo-spatial, kinetic, and kinematic parameters in 177 patients.

OBJECTIVE: In patients with hemiplegic stroke, equinovarus foot is one of the most frequent deformities. Outcome evidence for surgical correction of equinovarus foot is scarce, and results are usually assessed only clinically. Moreover, concerns about possible loss of function after elongation of the plantar flexor muscles are still at issue. The objective of this study was to verify if surgical correction of equinovarus foot can improve gait speed and function. DESIGN: We used a retrospective, nonrandomized design. One hundred seventy-seven chronic hemiplegic patients who underwent surgical correction of equinovarus foot were evaluated before and 1 yr after surgery. Outcome measures were walking handicap score, temporal-spatial parameters, gait kinematics and kinetics, and paretic propulsion. RESULTS: After surgery, walking handicap and temporal-spatial parameters significantly improved, as did ankle kinematic data and gait kinetic data. Patients' gait at follow-up was faster, with a more normal base of support and with better foot advancement. Paretic propulsion increased significantly after surgery, even if ankle power at push-off was reduced. We also observed a low complication rate. CONCLUSIONS: Surgical correction of equinovarus foot deformity in patients with stroke is a safe and effective procedure. Even if the power generation at the ankle decreased, overall gait function and parameters improved after surgery.

Impact of congenital talipes equinovarus etiology on treatment outcomes.

Although congenital talipes equinovarus (CTEV) is often idiopathic, additional birth defects occur in some patients that may have an impact on the treatment of this disorder. The purpose of this study was to determine the prevalence of associated malformations, chromosomal abnormalities, or known genetic syndromes, and to compare treatment outcomes of children with idiopathic CTEV with children with non-idiopathic CTEV. Of 357 children evaluated, 273 (76%) had idiopathic CTEV (179 males, 94 females; mean age 2 y 1 mo [SD 1 y 2 mo], range 0-18 y) and 84 (24%) had non-idiopathic CETV (51 males, 33 females; mean age 2 y 5 mo [SD 2 y], range 0-16 y). Disorders affecting the nervous system were found in 46 (54%) children with non-idiopathic CTEV. In a subgroup of patients treated entirely at our institution (n=196), children with non-idiopathic CTEV (n=47) required more casts for correction than those with idiopathic CTEV (n=149; 5.3 vs 4.6; p=0.016). There was also a greater risk of recurrence in non-idiopathic CTEV (14.9% vs 4%; p=0.009), but no significant difference in the need for extensive surgery (2.7% vs 8.5%; p=0.096). Treatment was initiated at a mean age of 13 weeks (range 1 wk to 2 y 6 mo) for both idiopathic and non-idiopathic patients, and treatment was assessed during a minimum 2-year follow-up. Non-idiopathic CTEV can be successfully treated with the Ponseti method of serial casting, with low recurrence rates or need for surgery.

Achilles lengthening/posterior tibial tenotomy with immediate weightbearing for patients with significant comorbidities.

BACKGROUND: Fixed equinovarus deformities can be challenging to treat especially in medically debilitated patients. The purpose of this study was to evaluate Achilles lengthening with posterior tibial tenotomy and immediate weightbearing in this difficult group of patients. MATERIALS AND METHODS: Thirteen extremities in 10 patients underwent Achilles lengthening and posterior tibial tenotomy for fixed equinovarus deformities with significant medical comorbidities. Pre- and postoperative ambulatory status and deformities were noted. RESULTS: Average age at the time of surgery was 65 with an average duration of deformity 6.3 years. The average equinus corrected from 26 degrees to 1.2 degrees and the average varus deformity improved from -8.5 degrees to 2.7 degrees. All patients except one who was wheelchair-bound had a significant improvement in ambulatory status. CONCLUSION: Achilles lengthening with posterior tibial tenotomy allowed for immediate postoperative weightbearing with improvement in deformity and ambulatory status in this complicated patient group.

[Surgery of congenital clubfoot in Don Orione, Health Center for physical handicaps of Ivory Coast (About 554 feet)]. / Chirurgie du pied-bot varus équin congénital au centre pour handicapés physiques Don Orione de Côte-d'Ivoire (A propos de 554 pieds).

OBJECTIVES: Treatment of congenital clubfoot improved in occidental country. We have studied the epidemiology, clinical and therapeutic aspects of this malformation in the context of Africa. PATIENTS AND METHODS: This was a retrospective study. Two thousand five hundred and sixty-two patients were hospitalised and operated during 12 years, 362 of them were diagnosed with congenital clubfoot. This represented 14,1% of the surgical diseases, with an incidence of 30,2 cases per year. The male to female ratio was 1,6:1, and ages ranged from 4 months to 38 years old, 59% of which were less than 15 years old. Two hundred and four (56,3%) patients had bilateral disease, 93 (25,7%) had right side disease and 65 (18%) had left sided disease. Considering the classification types we noted in our patient population 82% type III, 5% type II, 3% type I and 10% were undefined. RESULTS: Posteromedial approach describe by Codivilla was used in 45,5% of cases. Codivilla approach associated with lateral access to the foot in 44,4% of cases, with dorsal access in 2,3%. Few patients (7,8%) have had another approach. One hundred and seventeen patients received physiotherapy prior, but all the patients operated have postoperative physiotherapy while wearing orthopaedic shoes. Results obtained were: good in 510 cases (92%), quite good in 35 cases (6,3%), fairly good in 7 cases (1,3%) and mediocre in 2 cases (0,4%). CONCLUSION: The surgical aspect is still only a fraction of the entire treatment. It is imperative that physiotherapy is started immediately and orthopaedic shoes be worn postoperatively.

Club foot treatment in Malawi - a public health approach.

UNLABELLED: PURPOSE. Malawi is a very poor country with a current population of 12 million people and very few orthopaedic surgeons or physiotherapists. An estimated 1125 babies are born per year with club foot. If these feet are not corrected early, then severe deformity can develop, requiring complex surgery. A task force was established to address this problem using locally available resources. METHODS: A nationwide early manipulation programme was set up using the Ponseti technique, and a club foot clinic established in each of Malawi's 25 health districts. One year later the clinics were reviewed. RESULTS: Twenty out of the 25 clinics originally established were still active, and over one year had seen a total of 342 patients. Adequate records existed for 307 patients, of whom 193 were male and 114 female (ratio 1.7:1). A total of 175 patients had bilateral club foot and 132 were unilateral (ratio 1.3:1) giving a total of 482 club feet; 327 of the 482 feet were corrected to a plantigrade position. Most clinics had problems with supply of materials. Many patients failed to attend the full course of treatment. CONCLUSIONS: Overall the establishment of a nationwide club foot treatment programme was of benefit to a large number of children with club feet and their families. In a poor country with many demands on health funding many challenges remain. The supply of plaster of Paris and splints was inadequate, clinic staff felt isolated, and patient compliance was limited by many factors which need further research.

Effect of postoperative early ankle motion exercise using hinged ankle-foot orthoses in clubfoot.

The authors proposed early application of hinged ankle-foot orthoses for improving postoperative range of ankle motion after the complete subtalar release operation for clubfoot. Forty-eight patients (74 feet) with clubfoot were divided into two groups: group A patients (20 feet) were immobilized in plaster casts for 6 weeks after surgery, followed by non-hinged ankle-foot orthoses, and group B patients (54 feet) were immobilized in plaster casts for 4 weeks after surgery, followed by hinged ankle-foot orthoses. The range of ankle plantarflexion in group B showed a significant improvement compared with group A at 3 months and 1, 2, and 3 years after surgery. There was no statistical difference between the groups in the range of dorsiflexion except at 3 months of follow-up. The postoperative talo-calcaneal index was well maintained in both groups. Early range-of-motion exercises using the hinged ankle-foot orthoses achieved good ankle function, especially in plantarflexion, with no loss of radiologic correction.

Nonoperative clubfoot treatment using the French physical therapy method.

Ninety-eight patients (142 clubfeet) treated nonoperatively by the French physical therapy method were reviewed to determine the effectiveness of this technique. All were 3 months old or less when treatment began and were rated for initial clubfoot severity using the Dimeglio scale (moderate, severe, very severe). Follow-up averaged 35 months (range 20-62 months). Forty-two percent of the feet needed no surgery to achieve a plantigrade position, 9% needed heelcord tenotomies, 29% needed posterior releases, and 20% needed comprehensive posteromedial releases. The Dimeglio scale was prognostic for outcomes, with moderate feet having the best results and very severe feet having the worst results. The French physical therapy method significantly reduced the need for operative intervention at the authors' institution.