|Year : 2016 | Volume
| Issue : 1 | Page : 27-30
Manipulation and orthosis in the management of congenital talipes equinovarus
Asem Rangita Chanu, Naorem Bimol, Bijendra Rai, Kunjabashi Wangjam, Nongmaithem Romi Singh
Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||5-Feb-2016|
Asem Rangita Chanu
Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Background: There have been controversies regarding the ideal treatment method for congenital talipes equinovarus (CTEV). It is now accepted that conservative management is the first line of management. Aims: To find out if manipulation and maintenance of the correction achieved with a dynamic CTEV orthosis can correct CTEV deformities. Study Settings: Department of Physical Medicine and Rehabilitation in a tertiary care teaching institute, Imphal. Study Design: Intervention study without comparison group. Materials and Methods: Fifteen patients (twenty-one CTEV feet) were enrolled in the study. Manipulation with the head of talus as fulcrum was performed without any attempt to separately correct cavus and other deformities from the beginning. This procedure was repeated ten times for a minimum of three sittings daily. Correction so achieved was maintained with a dynamic CTEV orthosis manufactured with polypropylene plastic. The CTEV orthosis was worn throughout the day except during manipulations and bathing. Roentgenography was performed before the start and at the end of the treatment to assess improvement. Statistical Analysis: Wilcoxon signed-rank test was used to assess the improvement in the radiological angles from baseline to the last follow-up. Results: The differences in the paired X-ray angles [talocalcaneal angle-lateral (TCA-LAT), tibiocalcaneal angle-lateral (TibCA), talocalcaneal angle-anteroposterior (TCA-AP), talo-first metatarsal angle-anteroposterior (TMT)] between the baseline and the sixth follow-up were statistically significant (P < 0.001). Conclusion: Proper daily manipulation by a caregiver and maintenance of correction with appropriately designed dynamic ankle-foot orthosis is a practical and effective means of correcting CTEV deformity.
Keywords: Congenital talipes equinovarus (CTEV), manipulation, orthosis, talocalcaneal angle, talo-first metatarsal angle, tibiocalcaneal angle
|How to cite this article:|
Chanu AR, Bimol N, Rai B, Wangjam K, Singh NR. Manipulation and orthosis in the management of congenital talipes equinovarus. J Med Soc 2016;30:27-30
|How to cite this URL:|
Chanu AR, Bimol N, Rai B, Wangjam K, Singh NR. Manipulation and orthosis in the management of congenital talipes equinovarus. J Med Soc [serial online] 2016 [cited 2019 Aug 19];30:27-30. Available from: http://www.jmedsoc.org/text.asp?2016/30/1/27/175800
| Introduction|| |
Congenital talipes equinovarus (CTEV) is defined as fixation of the foot in cavus, adduction, varus, and equinus (i.e. inclined inwards, axially rotated inwards, and pointing downwards) with concomitant soft tissue abnormalities.  There have been debates amongst the experts regarding the ideal treatment method for its deformities. It is now accepted that conservative method is the first line of management with Ponseti technique as the standard. But Ponseti technique has its own drawbacks as follows: High rate of tendo-achilles tenotomy, poor compliance of parents reporting every week for remanipulation and casting, problems of the cast slipping off, skin irritation, poor compliance of wearing Denis Browne splint, etc.
This study was conducted to find out if manipulation exercise several times a day and maintenance of the correction achieved with a dynamic CTEV orthosis can correct the deformities of CTEV.
| Materials and Methods|| |
A total of 21 clinically diagnosed CTEV feet who reported during the study period to our tertiary care teaching institute in Imphal with an age of less than 6 months at the time of presentation were included in the study. Operated cases of CTEV, cases of grade IV severity in Dimeglio scoring system, or those associated with other congenital deformities were excluded from the study. Ethical approval was taken from the Institutional Ethics Committee. Written informed consent was taken from the parents of the participants.
As soon as a clinically diagnosed case of CTEV fulfilling the inclusion criteria was enrolled into the study, an intervention in the form of manipulation and use of CTEV orthosis was started.
In the same manipulation exercise, different deformity corrections of CTEV were done. At first, forefoot adduction correction was attempted by applying firm manual pressure while bringing the first ray in line with the hind foot. Then, while maintaining the pressure, adduction and varus correction were attempted with the head of talus as the fulcrum, not calcaneocuboid joint. The pressure was then redirected to correct equinus at a later stage. The position was maintained for 10 s and released for 5 s. This procedure was repeated ten times for a minimum of three such sittings daily. The technique was demonstrated to the mother or any other suitable person [Figure 1] to follow as home program and the compliance was checked and assessed in each follow-up at two weekly intervals for a total of six follow-ups.
In between the manipulations, the correction achieved was maintained in a dynamic CTEV orthosis manufactured with 5-mm-thick polypropylene plastic sheet by cutting a pattern to fit the foot and the leg as shown in [Figure 2]. The ankle of the orthosis was kept at a desired angle by molding the sheet in a plastic furnace. Three fixation straps made of velcro were attached to the sheet viz., pretibial, ankle, and forefoot. An additional lateral velcro strap was attached to the lateral aspect of the upper leg portion of the CTEV orthosis. This lateral velcro strap can be adjusted when connected to the lateral aspect of foot portion of the orthosis as required. The CTEV orthosis was worn throughout the day except during the manipulations and bathing.
|Figure 2: CTEV baby wearing dynamic CTEV orthosis to maintain the correction achieved after manipulation. (a) Adjustable lateral velcro strap to correct equinus, (b) Pretibial velcro strap, (c) Ankle velcro strap, (d) Forefoot velcro strap, (e) Polypropylene sheet that has foot and leg portions|
Click here to view
Roentgenography was performed before the start and at the end of treatment to measure the following angles: Talocalcaneal angle-lateral (TCA-LAT), tibiocalcaneal angle-lateral (TibCA), talocalcaneal angle-anteroposterior (TCA-AP), and talo-first metatarsal angle-anteroposterior (TMT) [Figure 3].
|Figure 3: Radiological angles. (a) Talocalcaneal angle-lateral (TCA-LAT), (b) Tibiocalcaneal angle-lateral (TibCA), (c) Talo-first metatarsal angle-anteroposterior (TMT), (d) Talocalcaneal angleanteroposterior (TCA-AP)|
Click here to view
Wilcoxon signed-rank test was used to assess the significance of the changes in the radiological angles from baseline to the last follow-up after the intervention. Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS Inc., Chicago, Illinois, USA) was used for the analyses.
| Results|| |
A total of 15 patients (twenty-one feet) were finally enrolled in the study. Fifteen feet presented in the first 2 months; four at 2-4 months and two at 4-6 months of age.
Out of the 16 patients, 9 (60%) were males and 6 (40%) were females. Six patients (40%) had bilateral feet involvement, four (26.7%) had only right foot affection, and five (33.3%) had affection of left foot only. Radiological angular measurements assessed at the baseline and at sixth follow-up are shown in [Table 1]. The differences in the paired X-ray angles (TCA-LAT, TibCA, TCA-AP, and TMT) between the baseline and sixth follow-up were statistically significant (P < 0.001) on Wilcoxon signed-rank test.
|Table 1: Radiological angular measurements at the baseline and sixth follow-up|
Click here to view
| Discussion|| |
Several radiographic techniques have been used as indices for clubfoot correction. In the present study, radiological method similar to that described by Simons  was used. Simons measured the following angles: TCA-AP and TCA-LAT. We used two additional angles over and above to that described by Simons viz., TibCA and TMT, to evaluate and assess the correction of clubfoot after the intervention.
Beatson et al. found that TCA-AP in clubfeet ranged from 0°-55° (normal, 10°-50°), and TCA-LAT from -5°-40° (normal, 15°-55°). So, there was a large overlap in the two angles between normal and clubfeet. They found a talocalcaneal index of 40° as a convenient dividing line between the normal and clubfeet. In our study, we found that before the intervention, TCA-AP ranged 15°-60° and TCA-LAT, 10°-35°. At the end of the last follow-up after the intervention, the corresponding values were 25°-50° and 20°-40°, respectively. We, thus, found a similar result to that of Beatson et al. in that there was a large overlap in the two angles between the normal and clubfeet. Hence, it might not be surprising that the TCA did not correlate well with the clinical results in some other studies.  The study by Joseph et al. showed that the TCAs could assess the subtalar relationship and give some indications of the deformity at the ankle. However, they could not give any insight into the extent of forefoot adduction and forefoot equinus (cavus), all of which have a pivotal role on the final outcome of the clubfoot correction. It is, therefore, inappropriate to rely on the TCAs alone to assess the overall correction of a clubfoot. TMT reflects the relative position between the hindfoot and the forefoot. Abulsaad et al. found a significant correlation between TMT and clinical results of clubfoot correction. In our present study, TMT improved from 0°-6° at the baseline to 2°-10° at last the follow-up after the intervention.
In our study, the male:female ratio was 3:2 (M:F = 9:6). Gupta  reported a similar sex distribution of 4.3:1 (M:F = 78:18). But Alves et al. reported a male:female ratio of 14:4 (M:F = 33:17). Doobs  explained this male preponderance to clubfoot by suggesting that females might require a greater genetic load than males in order to inherit the disorder to produce a clubfoot deformity.
In the present study, bilateral involvement was found in 40% of the cases. This is at par with the current literature. Sanghvi  reported a 34.3%, while Alves et al. reported a 46% bilateral involvement.
In this study, the mean age of the patients at presentation was 51.90 ± 47.13 days (median, 32 days; range 6-162 days). This observation is similar to that of Sanghvi et al.,  where the mean age at the presentation was 26 days (1 day to 33 weeks). However, Agrawal et al. reported a mean age of 3 months (1 day to 22 months), Willis et al. reported a median age of 2 weeks (range, 1-52 weeks), and Halanski et al. also reported a mean age of 21 days at the time of first visit.
There were no major complications of our technique, but one foot developed blisters and erythema due to which only manipulation exercises were given withdrawing the use of orthosis for 2-3 days. No infection, skin necrosis, neurovascular compromise, or swelling of feet were observed.
This study was conducted with an attempt to see if serial manipulation exercise and donning and doffing of CTEV orthosis taught to an educated caregiver is effective in the treatment of CTEV. However, it is not free from its own limitations. The sample size of the study was small, and the duration of the follow-up was short. Another issue could be that the actual manipulation imparted by the caregivers at home could not be directly observed. Further prospective studies in a large clinical setup are suggested.
| Conclusion|| |
Daily manipulation by the caregiver with maintenance of correction achieved by an appropriately designed dynamic ankle foot orthosis is a practical, easy, economical, safe, and effective means of correcting CTEV deformity. But there is still much to learn about idiopathic CTEV and longer term follow-up will be required to see whether the technique lives up to the expectation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
The authors declare that there is no conflict of interest.
| References|| |
Barker S, Chesney D, Miedzybrodzka Z, Mafulli N. Genetics and epidemiology of idiopathic congenital talipes equinovarus. J Pediatr Orthop 2003;23:265-72.
Simons GW. A standardized method for the radiographic evaluation of clubfeet. Clin Orthop Relat Res 1978;107-18.
Beatson TR, Pearson JR. A method of assessing correction in club feet. J Bone Joint Surg Br 1966;48:40-50.
Laavage SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am 1980;62:23-31.
Joseph B, Bhatia M, Nair NS. Talo-calcaneal relationship in clubfoot. J Pediatr Orthop 2001;21:60-4.
Abulsaad M, Abdelgaber N. Correlation between clinical outcome of surgically treated clubfeet and different radiological parameters. Acta Orthop Belg 2008;74:489-95.
Gupta A, Singh S, Patel P, Patel J, Varshney MK. Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nation. Int Orthop 2008;32:75-9.
Alves C, Escalda C, Fernandes P, Tavares D, Neves MC. Ponseti method: Does age at the beginning of treatment make a difference? Clin Orthop Relat Res 2009;467:1271-7.
Dobbs MB, Rudzki JR, Purcell BD, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of Idiopathic clubfeet. J Bone Joint Surg Am 2004;86-A:22-7.
Sanghvi AV, Mittal VK. Conservative management of idiopathic clubfoot: Kite versus Ponseti method. J Orthop Surg (Hong Kong) 2009;17:67-71.
Agrawal RA, Suresh MS, Agrawal R. Treatment of congenital club foot with Ponseti method. Indian J Orthop 2005;39:244-7.
Willis RB, Al-Hunaishel M, Guerra L, Kontio K. What proportion of patients need extensive surgery after failure of the Ponseti Technique for Clubfoot? Clin Orthop Relat Res 2009;467:1294-7.
Halanski MA, Huang JC, Walsh SJ, Crawford HA. Resource utilization in Clubfoot management. Clin Orthop Relat Res 2009;467:1171-9.
[Figure 1], [Figure 2], [Figure 3]