French Functional Method in the treatment of Clubfoot 20 years of Experience: Advantages and Limits

Introduction: Clubfoot treatment has evolved over the last 30 years.
Conservative treatment, especially the Ponseti method, has showned the advantage on surgery concerning the immediate correction and the long term follow up.
Another conservative method, developed in France since 1950, the Functional Method (FFM) is presented. The purpose of the authors was to present the result of this conservative treatment of clubfoot after 20years of experience.

Methods: Since 1993,175 children (230 clubfeet) were treated with the FFM in our Institution
210 clubfeet (149 children) were evaluated and reviewed. Only idiopathic clubfeet were included.
There were 66% male and 34% female. Bilaterality was present in 40% of the cases.
All feet were assessed according to the Dimeglio score.
FFM used in our department is based on the “Saint Vincent de Paul” protocol from Paris. (R. Seringe and R. Chedeville).
It consists in daily manipulations associated with a system of strapping and plates, the lower limb maintained by thermo formable splints (X-Lite). A night ankle foot orthosis is placed until the age of 5 years.
An evaluation at walking age is proposed.
After the age of 5, another evaluation is performed according to Ghanem and Seringe score .
From 2011, we use Gait analysis to assess long term results.

Results: Less than 15% of the feet, underwent a posteromedial release at walking age ( most were type 3 and 4 ).
Compliance was excellent ( up to 90% ).
At the last follow up, 70% of the children had good to very good result without major residual deformity. Less than 5% of the children required a later surgery either for recurrence, or for major residual deformity.

Conclusion: FFM is an interesting approach for treating clubfeet, especially concerning rigourous and modularity of splinting system. However, it requires a well-trained physical therapist team and a good collaboration of the parents.

Achilleus tenotomy is less systematic in our series and is indicated at 4 month of age when X-ray show the persistence of a high calcaneus with a tibio calcaneal angle superior to 80°.

Long term evaluation encourages us to continue on this way.

Significance: FFM represents an alternative method to the Ponseti method for conservative treatment of clubfoot. However comparative study needs to be done, especially regarding the compliance and the cost of those two methods.