treatment of congenital club foot with a modified

TREATMENT WITH

OF

CONGENITAL

A MODIFIED

DENIS

HARUYASU

From

We them

treated

91 congenital

for an average

plastic

shoe

club

of 6 years

inserts

moulded

into

four weeks to nine months. We have reviewed the other

good been

function and from well corrected. Our

Denis

Browne

described

club

foot

feet

his

for

since

then

Fripp

the splint. the

and The

correction

Shaw splint which

treatment. We have again using it at first after this modified splint operative evaluate

the

(1967)

Japan

in 59 children

using

a modified

Denis

The modified and

treatment

several

of

modifi-

19%

success

used

by

with

other

methods

of

review

our

experience

and

AND

METHODS

One child and great

also toes,

93 congenital Denis Browne had bilateral and another

H. Yamamoto, MD, Associate Professor K. Furuya, MD, Professor Department of Orthopaedic Surgery, University, 1-5-45 Ushima, Bunkyo-ku, be sent

club feet in splint after hypoplasia also had

Tokyo Tokyo

Medical 113, Japan.

to Dr H. Yamamoto.

© 1990 British Editorial Society ofBone 030l-620X/9013085 $2.00 J Bone Joint Surg [Br] 1990; 72-B : 460-3.

460

and followed

holding whose

a pair of

ages

ranged

had excellent

deformities

or

had

all

Follow-up ranged from three to I 3 years, averaging years 3 months. Our splint was first used at an average age of 3.5 months (range 4 weeks to 9 months), depending on the began

time of the first visit to our clinic. Once to walk, the splint was used at night,

inserts

by day,

up to the age of three

if the

was

maximum

performed

(as

shown

by

the

of the angle

a radiograph)

was

modified

Denis

Browne

age

ankle than

splint.

of one

was

in maximum more

than

(Yamamoto

ranged The

year

less

dorsiflexion 80

and Furuya 1988). The age at operation months to 4 years (average 2.6 years). The

child shoe

years.

af’ter

dorsiflexion

the and

6

usual

from

10

Denis

Browne splint has a crossbar between a pair of foot plates or shoes; it is difficult to hold the hindfoot and to correct

to 1985 we treated with the modified

should

in children

10#{176}, and the tibiocalcaneal

We

splint,

crossbar

in only 31 feet in 20 children. by splintage alone. All 60 feet

Operation

of a

unilateral congenital hip dislocation. Two children were excluded : one died of pneumonia and one was lost to follow-up. The 91 remaining club feet were in 45 boys and 14 girls, being bilateral in 32 and unilateral in 27.

Correspondence

required treated

Browne

has an aluminium

its use was started

to maintain

modified the Denis Browne splint, surgery. Since 1974 we have used to correct deformities by non-

PATIENTS

serial plasters. the thumbs

only

splint

assessment, equinus, adduction, varus and cavus that the modified splint can give good results.

the

sometimes

is gained

treatment. results.

From 1974 61 children

had

is now

FURUYA

Unirersitv,

cations have been reported, but the results were not very good. Bertelsen (1957) reported only 34% complete cures and Jansen (1957) had satisfactory or good results in only 43%.

SPLINT

Dental

Operation was later 60 feet in 39 children

splint ;

KOHTARO

positions,

FOOT

BROWNE

and

corrected

radiographic results show

in 1931

Medical

and 3 months.

from

congenital

YAMAMOTO,

Tokyo

CLUB

and

Joint

Surgery

and

Dental

the equinus deformity. We replaced the foot plates or shoes by plastic shoe inserts fixed to an aluminium crossbar (Fig. 1). The plastic shoe inserts are made by moulding a heated plastic sheet over a positive cast in which adduction, varus and equinus deformities have been corrected (Fig. 2). If the foot slides off this insert in forced dorsiflexion, its contour can easily be changed by reheating so that it holds the hindfoot. The shoe insert was fixed to the crossbar at an angle of from 25#{176} to 35#{176}, and

the

length

of

the

crossbar

was

the

width

of

the

patient’s shoulders. The splint is light (down to 40 g), and does not hinder kicking movements. Functional assessment. The functional results were assessed using the McKay rating system (McKay 1983), which includes 10 categories giving a maximum of 180 points. These are : ankle motion (30 points), angle of the bimalleolar plane to the longitudinal plane of the foot (20), strength of triceps surae (20) and of flexor hallucis longus (10), the position ofthe heel (10) and forefoot (10),

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

TREATMENT

ankle

pain

sports

ability

(30),

subtalar

OF CONGENITAL

pain

(20),

shoe

wear

CLUB

FOOT

(15),

and

assessment was by of the feet taken in maximum dorsi-

flexion. The anteropostenior radiograph was taken with the beam angled at 30#{176} to the vertical, and from this the talocalcaneal and the tab-first metatarsal angles were measured. The talocalcaneal angle is that between the long

axes

index

of talus

of varus

and

calcaneus;

deformity.

The

on

this

tab-first

view

A MODIFIED

DENIS

is that between first metatarsal;

(15).

Radiological assessment. Radiological anteropostenior and lateral radiographs while standing, and a lateral view

WITH

BROWNE

the long axis it is an index

461

of the talus ofadduction

and that of the deformity.

On the lateral radiograph in maximum dorsiflexion, the tibiocalcaneal angle was measured as an index equinus deformity. From the standing lateral radiograph the vertical tab-first metatarsal angle was measured an index ofcavus deformity.

of as

RESULTS

it is an

metatarsal

SPLINT

angle

Of

the

91

feet

reviewed,

60

were

operation; surgery was required children with residual deformities. in 13 boys (29%) and seven girls them cases)

had and

operation

bilateral six had

involvement (43.8% unilateral involvement

in these

cases

in maximum lateral 21 1 .

#{176},

treated

passive

talocalcaneal and the

the average

dorsiflexion

angle average

without

for 31 feet (34%) in 20 Operation was needed (50%) (Table I); 14 of of all bilateral (22.2%). Before

tibiocalcaneal was

angle

93.7#{176}. The

in maximum anteropostenior

average

dorsiflexion was talocalcaneal

angle was 26.3#{176}.The average anteroposterior tab-first metatarsal angle was 2.3#{176} and the average lateral tabfirst metatarsal angle was 175#{176}. We evaluated 60 feet (66%) in 39 children (66. 1%) -

Fig. The modified Denis in place of foot plates

Browne splint or shoes.

which

1 uses

a pair

of moulded

shoe

were

treated

without

surgery.

rating system, 42 feet scored 175, 14 feet scored 170, and

inserts

On

this

scale

73%

were

On

the

McKay

I 80 points, two two feet scored

feet scored 165 points.

as excellent

(I 75 to 180

graded

points) and 27% were good (160 to 174). There were no fair or poor results. The average angle ofdorsiflexion was 20.8#{176} (s.d. 5. 1 The angle of the bimalleolar plane to the #{176}).

longitudinal

plane

of the

foot

(73%) and 76#{176} to 82#{176} in 16 feet the heel was in 0#{176} to 5#{176} valgus in a neutral in

three

position feet

was

in 57 feet

(5%).

No

83#{176} to 90#{176} in 44 feet

(27%), and, during standing in all feet. The forefoot was (95%)

child

and

complained

in 5#{176} adduction of

ankle

or

subtalar pain or needed special shoes. The strength of triceps surae and flexor hallucis bongus was normal in all feet. The radiographic angles are shown in Table II in comparison with our figures for normal feet. All the

Fig.

splinted feet showed angles a little greater than normal, but all were within the normal range of angles reported in the literature (Simons 1980). These radiographic

2

The shoe insert is made by moulding positive cast of the foot in which deformities have been corrected.

a heated adduction,

plastic varus

sheet over and equinus

a

assessments show cavus deformities

that equinus, adduction, were all well corrected.

varus

and

the

non-

DISCUSSION Table Denis

I. Treatment Browne splint

of 59 patients, alone or followed

using either by operation

Affected side

Modified Browne

Male

Unilateral Bilateral

19 13

2 11

Female

Unilateral Bilateral

2 5

4 3

39

20

Sex

Denis splint only

the

modified

Operation needed after failed splintage

Various

success

operative reported

treatment that 92%

and

Total

VOL.

72-B, No. 3. MAY

1990

wedging

rates

continued

reported that Price feet treated by Kite

have

been

of congenital of 922 patients for some

reported

for

club foot. Kite (1964) were corrected by casts years.

Meehan

(1982)

and Lovell had reviewed 32 of 121 between 1950 and 1956 and reported

that 21 feet (65.6%) had good results at an average followup of 23.6 years. Blockey and Smith (1966) treated 186 feet by manipulation and splintage; acceptable results

H. YAMAMOTO,

462

were obtained 27.6% at five

in 34.9% years. Fnipp

at a 3-year and Shaw

K. FURUYA

assessment and in (1967) reviewed 221

patients with a follow-up of two to 1 2 years and reported that only 19% of 105 patients treated in Denis Browne splints had successful results, while 71% of 96 patients were effectively treated by stretching and strapping and none casts.

of 20 Turco

patients (1981)

treated from non-operatively.

birth

had successful results with serial reviewed at seven years, patients

; only Harrold

35% were and Walker

successfully treated (1983) treated 103

feet with serial plasters; 53.4% responded success depended on the severity of the birth. These varying results may reflect

satisfactorily, deformities

at

methods

of

treatment, but are much influenced by the severity of the abnormalities, the method of assessment and the length of follow-up. Our patients all had equinus, adductus, varus and cavus deformities which had resisted correction to neutral

position

by manipulation,

and

averaged 6 years and 3 months. Of9l feet, to treatment with the modified Denis showed

good

radiological

or good on the McKay ison is very difficult,

alignments

our

Fig.

follow-up A baby wearing the of repeated kicking.

66% responded Browne splint,

and

were

deformity pointed inheritance continuum the

with probably

other anomalies did reflect the influence

comparto that

of

abnormal

genes

to have

respond. These of the severity of

threshold. A clinical deformity more abnormal genes were appears to be sex-related, with males than in females. affected, and females genes

exceeds

would present. a lower

a

be more This boundary

certain

severe if threshold level in

Thus males are more commonly require a higher number

to manifest

the

deformity,

Table II. treatment

Lateral

forced

splint,

to show

the

mode

of inheritance

effect

thus

a more

severe

deformity.

The

maintain either partial or total correction after manipulation had given the foot a normal range of movement and position of rest. Thomson (1942) modified this approach, believing that the principle should be to allow the infant The Denis

to correct Browne

the deformities splint is now

by its own kicking. commonly used after

initial correction, but we believe that in the manner suggested by Thomson. incessantly from the age of three influence asymmetric

of

tending

crossed

Radiological angles in degrees by Denis Browne splint alone

View

Browne

of congenital club foot in Japan is also polygenic (Yamamoto 1979) and the sex ratio is 1 female to 2 males. Our results are compatible with Coleman’s explanation. The mechanism ofaction ofthe Denis Browne splint has been discussed. Browne, in 1931, used his splint to

on the success of treatment. Coleman (1983) out that congenital club foot has a polygenic pattern with a threshold effect. There is a of multiple gene loci : deformity occurs when

number

abnormal

not

Denis

excellent

rating system. Although our success rate is similar

reported for Kite (Meehan 1982). Our success rate for girls (50%) was lower than that for boys (71%); as was that for bilateral involvement (56%) as compared with unilateral (78%). The two children results

modified

3

Angle

Deformity

Tibiocalcaneal

Equinus

of

the neck

primitive reflex,

the

reflex

(Fig.

extension

(mean

± s.e.m.)

Normal

feet

in

60

feet

reflexes, tonic 3). The

the

splint can act Babies do kick weeks under the

which include neck reflex and splint

is thus

the the very

after

After treatment by splint alone

40.5 ± 4.8

62.8 ± 6.8

37.5 ± 6.3

33.4 ± 6.1

28.6±5.0

26.6±6.8

dorsiflexion

Lateral

Talocalcaneal

Anteroposterior

Talocalcaneal

Varus

Anteroposterior

Tab-first metatarsal

Adduction

Lateralstanding

Tab-first metatarsal

Cavus

-

12.5±2.3

180.2±0.5

10.0±9.6

-

180.3±4.8

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

TREATMENT

useful reflexes

up to the decrease. In

congenital

dislocation position

age

of club

of the

six

OF CONGENITAL

months

foot

tabonavicular

of the calcaneus

and

CLUB

after

which

there

is

subluxation

joint

and

changes

the

navicular

with

FOOT

side

is forced

into

When Browne

one leg extends splint, the foot

dorsiflexion,

abduction

DENIS

or in the respect

Bertelsen A. Treatment 1957; 39-B :599. Blockey

NJ,

Joint

Smith

Surg

Coleman

58.

Fnpp

are

made

in full

can act during kicking both to correct adduction of the forefoot and the displacement ofthe navicular. Our study has shown that congenital club feet can be corrected by the use ofa No benefits commercial article.

VOL.

modified in any party

Denis

form have been related directly

72-B. No. 3. MAY

1990

Browne

Irani

AT,

Shaw

RN, Joint

Jansen

received or will be received or indirectly to the subject

from a of this

J Bone

Joint

ofcongenital

club

Surg fxt.

[Br] J Bone

defor,nities

in children.

Philadelphia

: Lea

&

NE,

eds.

C/uh/oot.

London

: F & S Livingstone,

Sherman MS. The pathological Surg [AmJ I 963 : 45-A :45-52.

K. Treatment

of congenital

anatomy

club

foot.

1967.

in congenital ofcluh

J Bone

club

ltx)t.

Joint

J Bone

Surg

[Br]

1957; 39-B :599. The c!ub/oot.

McKay

DW.

section

Settle

GW.

Simons

New

New

York

concept

of

III evaluation

The

dissected

and Instr

anatomy

specimens.

GW.

The

inclubfeet.

VJ.

Yamamoto club

& Stratton.

approach

results.

diagnosis

and

Joint

talipes Surg

treatment

I 964. clubfoot

Ort/top

management St. Louis.

of congenital J Bone

to

J Pt’diatr

nonoperative Course Lect.

ClinOrthop

C!uh/#{243}ot. New

: Grune and

and

treatment: 1983;

ofthe etc. : (‘V

3:141-8. congenital Moshy Co

equinovarus:

[Am]

I 963

;

of deformity

sixteen

45-A

: I 34 1 -54.

combinations

1980: 150:229-44.

Thomson SA. Treatment of modification of the Denis Surg 1942; 24:29 1-8. Turco

splint.

treatment

foot.

Harrold AJ, Walker CJ. Treatment and prognosis foot. J Bone Joint Surg [BrJ I 983 ; 65-B :8- 1 1.

eversion.

correction

club

1983.

Meehan PL. Anatomy clubfoot. AAOS 1982; 31 :252-6.

which

The

Comp!e.vfoot

Febiger,

off; the forefoot is forced to dorsiflex and the foot develops a rocker bottom deformity as a result of kicking. The angle at which the shoe insert is attached to the crossbar is important. As this is increased, the calcaneus is inserts

463

I966; 48-B :660-5.

Kite JH.

and

SPLINT

of congenital

MGH.

[Br]

Our carefully moulded shoe inserts are able to hold the hindfoot firmly to produce this effect. Foot plates or shoes which do not grip the calcaneus allow it to slide

abducted,

BROWNE

REFERENCES

and the other on the flexed and

A MODIFIED

these

to the talus. The calcaneus inverts under the talus, showing adduction, varus and equinus deformities (Irani and Sherman 1963; Settle 1963). The navicular also displaces medially from the head of the talus and the forefoot is adducted. flexes in the Denis

WITH

York,

congenital Browne

talipes equinovarus with a method and splint. J Botu’ Joint

etc : Churchill

H. A clinical, genetic and epidemiologic foot. JpnJ iluntan G’,tet 1979; 24:37-44.

Yamamoto H, Furuya K. One-stage posteromedial clubfoot. JPediatrOrthop 1988: 8:590-5.

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release

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