Treatments

1 - Various treatments 2 - Characteristics of the method used at"Saint Vincent de Paul" hospital (Paris) 3 - Clubfoot protocol chronology of the functional physiotherapic processing at "Saint Vincent de Paul" hospital (Paris)   Various treatments There are many means to correct a clubfoot, they vary according to orthopedic, surgical and ancillary medical teams. Each clubfoot is a particular case, the process must be adapted according to the child. Functional process. In general it associates physiotherapy and retentions (systems of maintenance between the physiotherapy meetings). According to the results, the surgery will intervene during the first two years and even throughout the growth. Physiotherapy. It should be as early as possible, daily at the beginning, with a calm baby, slackened. The purpose of the soft mobilizations is to restore mobility gradually. No hypercorrection should be practised. Plasters process. Successive correct plasters can be made from the very start of the treatment by the orthopaedic surgeon : thigh, leg and foot plaster or leg and foot plaster. They are renewed each week. Three possibilities, plasters for one month, plasters during several months, punctual plasters (holidays, repetitions). In the Ponsetti method there are eight plasters during eight weeks then a surgical gesture on the Achilles tendon and night splints during four years; in France physiotherapy is associated to the treatment. Bindings process. There are some teams who favour bindings or the installation of elastic adhesive plaster. This light mode of application is necessary to preserve the assets of the physiotherapy meeting. Plates process. Fixed under the plantar voute by non-elastic adhesive plaster, plates maintain and even prolonguer the correction of the feet, apart from the physiotherapy meetings. They adapt to the various splints to obtain the rectification of the foot compared to the leg. Splints process. The splints of Dennis Browne solidarize the two feet by a bar. The posterior thigh-leg-foot thermoformable resin splint is changed very regularly to follow the growth of the child and the profits acquired at the time of the meetings of physiotherapy. They are remade every week, then every fifteen days, every month etc... The articulated splint releases the knee. When the correction is satisfactory in the course of the day, the posterior thigh-leg-foot thermoformable resin splint is replaced by a short splint or boot which releases the knee. Apparatus of mobilization process. This apparatus is efficace because the foot solidarized by a plate with the arthromotor, is mobilized every night. The startup is delicate and requires a parents training in hospital. Characteristics of the method used at "Saint Vincent de Paul hospital (Paris)" Our room of physiotherapy is an opened place of meeting between physiotherapists, doctors and the concerned parents. This friendly atmosphere encourages the families to talk together, which is very conforting, cheering and reassuring them up. The functional method associates the physiotherapy and the means of retention in place between the meetings. The rigorous treatment is composed overall of three successive stages adapted to the psychomotor development of the child. During the first period, or "reduction phase", the meetings are daily and the applications are permanent. Several handlings will be practised on a child slackened or even asleep, (Postures, stretching & muscular stimulations) 1- The derotation of the block calcaneum and foot corrects the total adduction of the foot compared to the ankle bone and the leg which constitutes "the unit behind-foot-tibia-fibula". This first operation is a manner of "contact" making it possible to test overall the retractions, the facility of relaxation of the child, and the amount of correction not to exceed. 2- The decoaptation of the scaphoid bone compared to the tibia, prolonged by the decoaptation of the scaphoid bone compared to the talus, will lead gradually to the realignment of the internal arch. 3- The correction of equine is achieved by various grasps of stretching of the Achilles tendon. Exclusive traction of the calcaneum will prohibit all false sagittal correction in the median-tarsus. 4 -Finally, the plantar voute objectifies the correction of the adduction of the articulation median-tarsus and a possible associated hollow. According to the results, these handlings combine the ones with the others , lead to the restoration of the ankle bone. To preserve the benefit of the manual corrections and to prolong the physiotherapic epic, the foot is installed on a plate with none-extensible and hypoallergenic tapes of adhesive plaster (Plates setup). It is essential to protect the skin by various means, a plane plate is used for this period. Two tapes put on the internal edge of the foot exert an opposite bipolar traction of the internal arch. The first tape tractor draws before foot forwards, the second fixes before foot tractor drawn on the plate. The third tape stretches the back foot backwards, the fourth one hangs the large tuberosity of the calcaneum and folds back without traction plate on both sides. The vertical fifth one maintains the calcaneum on the plate, and the calcaneum should absolutely never fall apart of the plate. The sixth tape called as a Spartan is stuck under the median-tarsus, each side chief fixes the large tuberosity of the calcaneum and is folded back on both sides on the plate. The vertical seventh tape of calcaneum ensures a good fixing. Finally the eighth elastic tape of adhesive plaster completes the whole. The colouring of the foot must remain remain normal from the beginning to the end of the setting. To correct the foot compared to the leg a femur-leg-foot splint in hardware thermoformable is made and adapted according to the clinical data, it of is never hypercorrected (Back splint setup). The second period is a "maintenance phase" even of functional improvement of the result previously obtained, which continues until the verticalization of the child. Kinesitherapy is practised three times per week, the carried out mobilisations are the same as previously. One adds to it the mobilization in dorsal inflection and plantar of the articulation tibia-tarsus in order to supervise the setting of a possible retraction of the "anterior-tibial muscle" harmful inflection because making a "varus". The active work of the fibulars muscles by cutaneous stimulations on the external edge of the foot can then be undertaken. The reinforcement length fibular muscle will ensure a good anterior support and intern support when walking. The implication of the families in the process, allows a little flexibility with respect to them. Concerning the applications, a curved plate with plantar concavity is used. It enables a better stretching of the Achilles tendon while protecting the median-tarsus articulation in the sagittal plan, thus avoiding the deformation in convex foot. In the course of the day a short splint is sufficient, it gives more autonomy to the child who will able to sit crawl afterwards. The long splint is always required during night. The third period is the verticalization and walking. Plate and short splint are not obstacles to its acquisitions. The more verticalized the child is, the more it is released from the retention in the course of the day. Bare-foot walking is recommended and allows us to appreciate the residual defects in order to be able to correct them by the physiotherapy and the means of night retention. The appointements of physiotherapy are more and more spaced out until it becomes a simple monitoring in order to detect any risk of repetition. Night small splints are preserved if the result is good (correct orientation of the foot; positive back inflection; peroneal muscles very strong) if not, it will be necessary to carry on wearing the femur-leg-foot splints. In 80% of the cases the results are good and the children will not need any operation. Rarely (10% of the cases) a percutaneous tenotomy of the Achilles tendon (which requires only one local anaesthesia) followed by a femur-leg-foot plaster during three weeks can be suggested for a baby who is between four and six months. This movement with minima makes the physiotherapic treatment easier. When a more invasive surgery is necessary (10% of the cases) the indication can be put on as soon as the child verticalise, then at any moment if the result degrades. A clubfoot can never be considered as totaly cured before the end of the growth. In ant case, well treated, a clubfoot should not be regarded as a handicap anymore. The child must be fitted normally; sports and outside activities are highly encouraged. Clubfoot protocol chronology of the functional physiotherapic processing at "Saint Vincent de Paul" hospital (Paris) Initial phase, or period of reduction of the deformations: birth at the 8th week. Apart from the pure technique, it is the period when the families should be reassured. The room of physiotherapy is a place of dialogue, exchange and meeting. Physiotherapy 5 or 3 times per week according to the context and the severity of the attack. Contentions: As of the dédut of the processing, plate with traction of the internal arch and traction calcanéenne poses to prolong the act kinesitherapic. Cruropédieuse splint. Passive manipulations: Derotation of the calcaneum-foot block. Decoaptation of the scaphoid. Stretching of the internal arch. Correction of the median-tarsus adduction.Stretching of the Achilles tendon Contentions: Dès le dédut du traitement, pose de plaquette avec traction de l'arche interne et traction calcanéenne pour prolonger l'acte kinésithérapique. Attelle cruropédieuse.   Second phase, or period of maintenance, the 8 2nd week at the station upright. Improvement then maintenance of the result. It is for this period that the team implies the families with some simple mobilizations, stretching of the Achilles tendon, work of peroneal muscle and with the plates and back splint setup (autonomsation of the families). The frequency of the physiotherapy meetings decreases. Same passive mobilizations + the tibiotalar joint stretching in plantar and dorsal inflection. Active work of the peroneal muscles. Plates with higher convexity for better stretching the Achilles tendon of Achilles and with rectilinear board. Short thermoformable resin splint (leg-foot ) for the day as soon as the child spontaneously holds his foot in good position. Posterior thight-leg-foot thermoformable resin splint for the nap and the night. Phase of verticalisation with pre-support and support and walking. The put on one's shoes is normal. Leisures and sports activities are encouraged. The frequency of the physiotherapy meetings decrease. Passive stretching of maintenance. Active work (ludic-therapy). Walk with plate. Monitoring and vigilance of the tibiotarsal joint dorsal inflection and walking on the external edge of the foot. Short or thight-leg-foot night splint according to the functional result.   The success of the functional treatment depend of the good observance of these rules: 1- perseverance 2- familie's close co-operation when looking after the work made by the doctor, the hospital, the physiotherapist and the liberal physiotherapist.