Neonatal Therapy for Congenital Clubfoot

R. LUSSKIN, M.D.


This report outlines the application principles and techniques for correction of talipes equinovarus in the immediate postnatal period by dynamic adhesive strappings.

The profound deformity known as clubfoot has challenged physicians since antiquity. Vigorous treatment programs can effect correction in many children so afflicted, yet a visit to any children's orthopedic center will reveal many cases of resistant deformities which require surgery. In central Europe, where large reservoirs of clubfoot are to be found, we have observed similar concentrations of late sequelae requiring open surgery3.

The problem cases derive from two main sources: 1) patients in whom the disorder was never fully corrected by the initial treatment program, and 2) those cases where the deformity has recurred despite successful initial treatment.

All surgeons recognize the importance of the early application of corrective forces to the deformed limbs. What may not be appreciated is the fact that "early" really means the immediate neonatal period. As the treatment of congenital hip disease has been successful in inverse proportion to the age of the child treated, so does talipes equinovarus respond better to early active treatment than to delayed attention.

Within the first weeks of life, the infant remains under the influence of the maternal relaxing hormone and can respond to corrective forces with greater ease than is the case later, when dense collagenous connective tissues have become rigid.

The potential for remodeling of the tarsal bones is realized most easily when the skeletal realignment is done early in life. Yet, it is the first three to 21 days of neonatal life that are often lost while the surgeon waits for the foot to become large enough to control, or the child is nursed at home with the feet concealed.

The neonatal period can be utilized for active therapy, despite the smallness of the foot, the sensitivity of the skin, and the problem of maintaining circulatory adequacy. The use of this critical time for active therapy can result in the complete rotation of the foot from equinovarus into calcaneovalgus within three to four weeks. The foot can then be held in the corrected position with ease and be permitted a slow return to the neutral position with due concern for potential recurrence.

Principles

  1. Treatment is started as soon as the infant's pulmonary and cardiac status has stabilized-usually three to seven days after birth.

  2. The child's knee motion is used to apply a pure eversion corrective force to the foot.

  3. Strappings are used to take up slack in the foot in the direction of correction and do not themselves force the foot into a new position.

  4. Adequate capillary circulation must be maintained.

  5. The goal of initial therapy is full "over-correction" into calcaneovalgus.

  6. Recurrence, especially into equinus, must be prevented by continued holding of the foot in the corrected position.

  7. Other methods, such as the bipedal shoe splint of the Denis Browne type, can be introduced into the treatment regimen whenever indicated.

Technique

  1. Materials

    1. Tincture of benzoin is used for preliminary skin preparation as a toughener and aid to adhesion.

    2. Moleskin adhesive. Strips 0.75 to 1 in. in width and 9 to 12 in. in length are used. This material is soft, contours to the limb, and does not produce edge-cutting.

    3. Flannel bandaging-1.5 to 2 in. in width. This bandaging covers the moleskin strapping.

    4. Standard nonwaterproof adhesive tape, preferably perforated, 0.75 to 1 in. in width, is used to hold the flannel bandage and to reinforce the initial strapping at two-day intervals.

  2. Application

    1. Paint the skin of the feet, shanks, and thighs with tincture of benzoin and permit it to dry.

    2. Apply the first moleskin strap to the metatarsal region. Start on the dorsum of the foot at the base of the fifth toe. Bring the strap across the dorsum of the foot, then around the medial aspect of the first metatarsal, and across the plantar aspect of the foot.

      The strap is brought over the instep, up the shank, and around the thigh with the foot held in maximum eversion. The strap is not used to pull the foot into eversion but takes up the slack produced by pressure on the foot from the surgeon's fingers (Fig. 1 , Series A, top). This strap may pass up the lateral or medial aspect of the shank but must cross the flexed knee to the thigh. The knee is held in 90 deg. of flexion as the straps are applied over the thigh.

    3. Apply the second moleskin strap, starting on the medial aspect of the heel. Carry the strap up the lateral aspect of the shank and around the thigh. Take up the slack while applying this strap (Fig. 1 , Series A, center).

    4. Apply the third strap to the midtarsal region (Fig. 1 , Series A, bottom).

    5. Cover the moleskin straps with flannel bandage and reinforce with plain adhesive. The initial strapping is now complete.

    6. Check for circulation at the toes. Demonstrate to the parents how this is done and instruct them to check circulation every two hours for the first day. Release the strapping if the capillary circulation is not adequate.

    7. In 48 hours reinforce the original bandaging with new, plain, adhesive straps over the first bandage. These straps are applied in the same manner as the original moleskin straps while the foot is held in as much correction as possible.

    8. Repeat step g. in 48 hours- this is the second reinforcement.

    9. Seven days after the initial strapping (steps a. through e.) remove the entire strapping and bandaging, and repeat the moleskin strapping-steps a. through e. (Fig. 1 , Series B).

    10. Reinforce strapping at two-day intervals (repeal steps g. and h.) (Fig. 1 , Series C, gives the approximate positions achieved).

    11. Repeat the preceding steps weekly (Fig. 2 , Series A, B, and C).

    12. When full "over-correction" has been achieved, apply short moleskin straps ending below the knee (Fig. 3 , Series A, B, and C). Cover with flannel and plain adhesive. Change at weekly intervals for three weeks, then biweekly for four weeks.

    13. If the patient tolerates this strapping well, it can be continued at two-week intervals until the fifth month. Permit the child to remain out of strapping one day between strappings. By the time this stage is reached the parents can remove the straps.

    14. Repeat the strappings while gradually increasing the intervals without straps. By the seventh month, strappings for one week in each six should be sufficient.

    15. When the child begins to walk, discontinue strapping and use a straight last or outdare shoe. Observe carefully throughout the entire growth phase. If there has been no recurrence by the age of four years, there probably will be none.

    16. Use a Denis Browne shoe splint to resist any tendency towards equinus.

    17. Cover minor skin abrasions with Telfa and continue strappings.

Case Report

Fig. 4 , Fig. 5 , Fig. 6 , Fig. 7 , Fig. 8 , and Fig. 9 show the application of this technique to a neonate (D.S.) with bilateral deformities. In this case full correction was achieved over a period of five weeks.

Discussion

The method of treatment described is not new, but it is not now generally used in the United States. Fripp and Shaw1 discussed the history of strapping and demonstrated one application technique, but did not emphasize the critical factor of the time of application. They did not achieve complete fixation of the foot with their method nor did they permit knee motion to exert a pure eversion force on the foot. Nevertheless they reported a 71 per-cent correction rate with stretchings and strapping, much higher than with the Denis Browne splint.

In Czechoslovakia early strappings have been used for many years with good results4, but this method is not used in Poland or Yugoslavia3. Harold Lusskin* described this method based on his experience with 100 cases. He emphasized the need for continued maintenance of over-correction following the active treatment phase and noted the possibility that skin irritation could cause delays which, nevertheless, could be overcome.

Certain points deserve emphasis. Clubfoot will recur after any method of correction if the foot is neglected. Neonatal therapy permits early and rapid achievement of the first goal of treatment-correction of the deformity. Early treatment will also be more apt to minimize the sequelae of calf atrophy and weakness.

The second goal is prevention of recurrence. Here the adhesive straps can be used successfully, but they must be continued far beyond the time which might be indicated by mere observation of the foot. Experience has demonstrated recurrence of equinus following too early release of the foot. Aim for a flat foot as the end result in talipes equinovarus. This dictum runs counter to some teaching but is more apt to produce a good outcome meeting the criteria of a supple foot without longitudinal deformity, no heel varus, full range of eversion. and normal dorsiflexion.

For this method to be successful in producing a corrected foot, the infant must exert forces with the affected limb. In arthrogryposis, for example, there is profound joint contracture and muscle deficiency, usually with little active movement. Dynamic treatment will not be successful here and the problem in these circumstances remains unsolved. Skeletal resections are often required to produce proper alignment of the feet in this disorder.

Conclusion

Neonatal therapy for congenital talipes equinovarus. using a method of dynamic adhesive strappings, offers an opportunity for early correction of a rather profound structural disorder. This therapy is successful because the neonate's dense collagen bundles are still pliable, presumably under the influence of the maternal relaxing hormone. Early correction can be achieved before joint and bone deformities become fixed. Due attention must be paid to the vulnerability of the neonate's circulation to external pressure and the sensitivity of the skin to shear forces. With proper prolongation of therapy to prevent recurrence, the problems of late deformity can be avoided. Early case finding and intensive initial therapy should eliminate prolonged, tedious, and often unsatisfactory treatment regimens.

New York University Medical Center New York, New York

References:

  1. Fripp, Alfred T., and Shaw, Norman E., Clubfoot. E. & S. Livingstone Ltd, Edinburgh and London, pp. 7, 48, 61-63, 1967.

  2. Lusskin, Harold, A nonrigid method of treatment for early clubfoot. J. Int. Coll. Surgeons, 14:444-447, October 1950.

  3. Lusskin, Ralph, and Fishman, Sidney, Report of a Traveling Fellowship to Poland and Yugoslavia under Exchange of Experts Program for the Maternal and Child Health Service, Public Health Service, Dept. of HEW. New York University, New York, 1970.

  4. Truchly, George, and Ort, Paul, Personal Communications.