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French Functional
Method for Congenital
Clubfoot:
20 years of experience
R. Elbaum* B.Noel* V.Degueldre** P.Ghyselinck***
* Department of Orthopaedic surgery, CHIREC Orthopaedic Group (Brussel)
** Department of Physiotherapy , Etterbeek Ixelles Hospital , Brussel , Belgium
*** Faculty of Medicine Free University of Brussel (ULB) Belgium
Disclosures
I, (R.Elbaum) DO NOT have a financial interest/arrangement or affiliation with one or more
organizations that could be perceived as a real or apparent conflict of interest in the context
of the subject of French Functional Method for congenital Clubfoot
Principles of conservative treatment of CCF As soon as possible!!!
Antiquity Middle Age Industrial period Modern Period Today
 Introduction
• Conservative treatment for
Congenital clubfoot (CCF),
especially the Ponseti
method, has showed the
advantage on surgery.
• Laaveg SJ, Ponseti IV. Long-term results of treatment
of congenital club foot. J Bone Joint Surg Am 1980
• Ponseti IV, Smoley EN. Congenital club foot: the
results of treatment. J Bone Joint Surg Am. 1963
 Introduction
• Another conservative method, developed
in France ,the “French”Functional Method
(FFM) is presented.
• The “Saint Vincent Protocol” describe by
Pr. Raphael Seringe (Paris)
• Méthode fonctionnelle versus Ponseti dans le traitement du pied bot
varus équin
Aim of the Study
• Results?
• Surgery and tenotomy?
• Compliance and follow-up?
• Recurrence rate ?
• Advantages and limits ?
History of
French
Functional
Method
(FFM)
• 1950 P.Masse @ Daniel
• 1970 G.Bensahel @ Guillaume
• 1973 R.Seringe @ R.Chedeville
• 1985 P.Souchet @ Delaby
• 1993 P.Wicart @MJ Clio-Assouvie
• 1994 R.Elbaum@B.Noel
Protocol
Protocol
Protocol
Protocol
*Wicart/Chotel, Rev Chir Orthop 2008
 Protocol
• Jo till 4w : 5 x  w
• 6w à 3mo: 3- 4 x  w
• >4 mo :1/w to 1/mo
• Night Splint till 5-7 Yo
www.pied-bot.fr
 Our
Serie
Retrospective study
Since 1994,175 children
(230 CCF) were treated in
our Institution.
145 children (210 CCF) were
evaluated on.
Inclusion criteria:
o Idiopathic CCF
o <3Mo
o No previous treatment
o walking age
0.3669
0.223
0.4101
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
DROITE GAUCHE BILATÉRAL
Laterality
Droite
Gauche
Bilatéral
64%
36%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
GARÇON FILLE
Gender
garçon
fille
 Our Serie
4 subgroups = 4 periods of time
corresponding to major modifications of
the protocol:
• Subgroup 1 (1996-1998): no tenotomy
• Subgroup 2 (1998-2005): progressive
onset of tenotomy.
• Subgroup 3 (2005-2014): more
pronounced derotation of splints
• Subgroup 4 (2014-2016): addition of
an anterior hull in the splints.
0
10
20
30
40
50
60
70
Subgroup 1 Subgroup 2 Subgroup 3 Subdroup A
Colonne1
 Our
Serie
0.0657
0.2879
0.4898
0.1414
0
0.1
0.2
0.3
0.4
0.5
0.6
GRADE 1 GRADE 2 GRADE 3 GRADE 4
Dimeglio Classification
grade 1
grade 2
grade 3
grade 4
Result
Ghanem I, Seringe R Rev.Chir.orthop, 1995 ; 81 :616-21
Statistical analysis:
- Descriptive study using absolute
and relative frequencies
- Chi2 test for qualitative variables
- Tests considered significant at
the 5% .
 Result
5.26
9.23
22.81
38.46
59.65
32.31
12.28
20
GARÇON FILLE
Dimeglio according Gender
Grade 1 Grade 2 Grade 3 Grade 4
Bergerault F, Fournier J, Bonnard C. Idiopathic congenital clubfoot: Initial treatment
Pediatric Orthopedics Department, Clocheville Hospital, Tours University Hospital, 37044 Tours, France
p=0,006
 Result
P=0,05
12 Hereditary Clubfoot
PALMER, R.
Clinical Orthopaedics and Related Research: 1964 - Volume 33
Dorsal flexion evolution
-30
-20
-10
0
10
20
30
40
Time
Dorsal
flexion
(°)
Ponseti
Functional
Calcaneopedal bloc derotation evolution
-40
-20
0
20
40
60
80
Time
Derotation
(°)
Ponseti
Functional
Comparaison of 2 methods of treatment
for clubfeet: functional and Ponseti method
R.Elbaum, MD ,B. Noel, P-L Docquier, MD, PhD EPOS 2011
 Prospective study
 42 clubfeet (in 28 newborns)
 19 boys and 9 girls
 Two groups
– Functional treatment (French
method according to Seringe-
Chedeville): 22 feet
– Ponseti method: 20 feet
 Clinical evaluation of the feet
according to the Dimeglio scoring
for clubfeet: Day 0, Weeks 2, 4
and 6, Months 4
 Radiographic evaluation : 4
months
Souad El Batti, Federico Solla,Virginie Rampal, Méthode fonctionnelle versus Ponseti dans le traitement
du pied bot varus équin. RCOVolume 100, Issue 7, Supplement, November 2014,
 Result
• El Batti S, Solla F, Clément JL et al. Initial treatment of
congenital idiopathic clubfoot: Prognostic factors. Orthop
Traumatol Surg Res. 2016 Dec;102(8):1081-1085.
 Result
Grade 2
Grade 3
Grade 4
0
10
20
30
40
50
60
70
80
Very Good
Good
Fair
Poor
Result without grade 1
Grade 2 Grade 3 Grade 4
 Result
according
subgroup
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sous groupe 1 Sous groupe 2 Sous groupe 3 Sous groupe 4
60
11.32
86.77 83.33
30
81.13
8.82 16.67
10 1.89
1.47
0
0
5.66 2.94 0
Excellents Trés bons Moyens Mauvais
p = 0,00001
Need for
Surgery
Comparison of different conservative treatments for
idiopathic clubfoot: Ponseti's versus non-Ponseti's
methods.
J Int Med Res. 2017 Jun;45(3): Epub 2017 May 28.
He JP, Shao JF1, Hao Y
 Need for
Surgery
 Result :
Role of
Tenotomy
Gait lab analysis
The effect of tenotomy on kinematics, kinetics and pressure parameters in
children with idiopathic clubfoot
R. Elbaum3,4, C. Mahieu1,7, C. Concessa1, F. Adam6, B. Noel7, B. Beyer1, F.
S. Van sint jan1, V. Feipel5, 1 , P. Salvia1, 2
 Result:
Compliance
Rate
COMPLIANCE FOLLOW UP
(Mo)
SUBGROUP 1 90% 55
SUBGROUP 2 88% 37
SUBGROUP 3 83% 61
SUBGROUP 4 70% 50
TOTAL 86% 48
Compliance rate in the litterature
Compliance
related to
mother age
Result according
compliance
P=0,023
Result: Recurence rate
 Recurence
according
compliance
73.33
92.31
26.67
7.69
0
10
20
30
40
50
60
70
80
90
100
1 2 3
Pas de récidive
Récidive
Non compliant compliant
p = 0,023
 Recurence
rate in the
littérature
+/- 30%!
Relapse of Clubfoot after Treatment with the Ponseti Method and the Function of the Foot Abduction Orthosis
Dahang Zhao, MD, Jianlin Liu, MD, Li Zhao, MD,corresponding author and Zhenkai Wu, MD
Dobbs MB, Rudzki JR, Purcell DB, 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(1)
Thacker MM, Scher DM, Sala DA, van Bosse HJ, Feldman DS, Lehman WB. Use of the foot abduction orthosis
following Ponseti casts: is it essential? J Pediatr Orthop 2005
Chen RC, Gordon JE, Luhmann SJ, Schoenecker PL, Dobbs MB. A new dynamic foot abduction orthosis for
clubfoot treatment. J Pediatr Orthop 2007
Avilucea FR, Szalay EA, Bosch PP, Sweet KR, Schwend RM. Effect of cultural factors on outcome of Ponseti
treatment of clubfeet in rural America. J Bone Joint Surg Am 2009
Ramirez N, Flynn JM, Fernandez S, Seda W, Macchiavelli RE. Orthosis noncompliance after the Ponseti method
for the treatment of idiopathic clubfeet: a relevant problem that needs reevaluation. J Pediatr Orthop 2011
Haft GF, Walker CG, Crawford HA. Early clubfoot recurrence after use of the Ponseti method in a New Zealand
population. J Bone Joint Surg Am 2007
Ponseti IV. Relapsing clubfoot: causes, prevention, and treatment. Iowa Orthop J 2002;22:55–56.
FFM an
alternative to
Ponseti
Method in
developping
country ?
 CONCLUSION
FFM is an interesting approach for treating clubfeet, especially
concerning rigourous and modularity of splinting system.
Compliance rate is very high comparing to PM
Achilleus tenotomy is less systematic in our series and is indicated
after 4 month of age
Long term follow up and result encourages us to continue on this
way.
However, it requires a well-trained physical therapist team and a
good collaboration of the parents.
The
Future
TODA RABA

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French Functional Method for Congenital Clubfoot: 20 years of experience

  • 1. French Functional Method for Congenital Clubfoot: 20 years of experience R. Elbaum* B.Noel* V.Degueldre** P.Ghyselinck*** * Department of Orthopaedic surgery, CHIREC Orthopaedic Group (Brussel) ** Department of Physiotherapy , Etterbeek Ixelles Hospital , Brussel , Belgium *** Faculty of Medicine Free University of Brussel (ULB) Belgium
  • 2. Disclosures I, (R.Elbaum) DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of French Functional Method for congenital Clubfoot
  • 3. Principles of conservative treatment of CCF As soon as possible!!! Antiquity Middle Age Industrial period Modern Period Today
  • 4.  Introduction • Conservative treatment for Congenital clubfoot (CCF), especially the Ponseti method, has showed the advantage on surgery. • Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am 1980 • Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. J Bone Joint Surg Am. 1963
  • 5.  Introduction • Another conservative method, developed in France ,the “French”Functional Method (FFM) is presented. • The “Saint Vincent Protocol” describe by Pr. Raphael Seringe (Paris) • Méthode fonctionnelle versus Ponseti dans le traitement du pied bot varus équin
  • 6.
  • 7. Aim of the Study • Results? • Surgery and tenotomy? • Compliance and follow-up? • Recurrence rate ? • Advantages and limits ?
  • 8. History of French Functional Method (FFM) • 1950 P.Masse @ Daniel • 1970 G.Bensahel @ Guillaume • 1973 R.Seringe @ R.Chedeville • 1985 P.Souchet @ Delaby • 1993 P.Wicart @MJ Clio-Assouvie • 1994 R.Elbaum@B.Noel
  • 13.  Protocol • Jo till 4w : 5 x w • 6w à 3mo: 3- 4 x w • >4 mo :1/w to 1/mo • Night Splint till 5-7 Yo www.pied-bot.fr
  • 14.  Our Serie Retrospective study Since 1994,175 children (230 CCF) were treated in our Institution. 145 children (210 CCF) were evaluated on. Inclusion criteria: o Idiopathic CCF o <3Mo o No previous treatment o walking age 0.3669 0.223 0.4101 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 DROITE GAUCHE BILATÉRAL Laterality Droite Gauche Bilatéral 64% 36% 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 GARÇON FILLE Gender garçon fille
  • 15.  Our Serie 4 subgroups = 4 periods of time corresponding to major modifications of the protocol: • Subgroup 1 (1996-1998): no tenotomy • Subgroup 2 (1998-2005): progressive onset of tenotomy. • Subgroup 3 (2005-2014): more pronounced derotation of splints • Subgroup 4 (2014-2016): addition of an anterior hull in the splints. 0 10 20 30 40 50 60 70 Subgroup 1 Subgroup 2 Subgroup 3 Subdroup A Colonne1
  • 16.  Our Serie 0.0657 0.2879 0.4898 0.1414 0 0.1 0.2 0.3 0.4 0.5 0.6 GRADE 1 GRADE 2 GRADE 3 GRADE 4 Dimeglio Classification grade 1 grade 2 grade 3 grade 4
  • 17. Result Ghanem I, Seringe R Rev.Chir.orthop, 1995 ; 81 :616-21 Statistical analysis: - Descriptive study using absolute and relative frequencies - Chi2 test for qualitative variables - Tests considered significant at the 5% .
  • 18.  Result 5.26 9.23 22.81 38.46 59.65 32.31 12.28 20 GARÇON FILLE Dimeglio according Gender Grade 1 Grade 2 Grade 3 Grade 4 Bergerault F, Fournier J, Bonnard C. Idiopathic congenital clubfoot: Initial treatment Pediatric Orthopedics Department, Clocheville Hospital, Tours University Hospital, 37044 Tours, France p=0,006
  • 19.  Result P=0,05 12 Hereditary Clubfoot PALMER, R. Clinical Orthopaedics and Related Research: 1964 - Volume 33
  • 20. Dorsal flexion evolution -30 -20 -10 0 10 20 30 40 Time Dorsal flexion (°) Ponseti Functional Calcaneopedal bloc derotation evolution -40 -20 0 20 40 60 80 Time Derotation (°) Ponseti Functional Comparaison of 2 methods of treatment for clubfeet: functional and Ponseti method R.Elbaum, MD ,B. Noel, P-L Docquier, MD, PhD EPOS 2011  Prospective study  42 clubfeet (in 28 newborns)  19 boys and 9 girls  Two groups – Functional treatment (French method according to Seringe- Chedeville): 22 feet – Ponseti method: 20 feet  Clinical evaluation of the feet according to the Dimeglio scoring for clubfeet: Day 0, Weeks 2, 4 and 6, Months 4  Radiographic evaluation : 4 months Souad El Batti, Federico Solla,Virginie Rampal, Méthode fonctionnelle versus Ponseti dans le traitement du pied bot varus équin. RCOVolume 100, Issue 7, Supplement, November 2014,
  • 21.  Result • El Batti S, Solla F, Clément JL et al. Initial treatment of congenital idiopathic clubfoot: Prognostic factors. Orthop Traumatol Surg Res. 2016 Dec;102(8):1081-1085.
  • 22.  Result Grade 2 Grade 3 Grade 4 0 10 20 30 40 50 60 70 80 Very Good Good Fair Poor Result without grade 1 Grade 2 Grade 3 Grade 4
  • 23.  Result according subgroup 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sous groupe 1 Sous groupe 2 Sous groupe 3 Sous groupe 4 60 11.32 86.77 83.33 30 81.13 8.82 16.67 10 1.89 1.47 0 0 5.66 2.94 0 Excellents Trés bons Moyens Mauvais p = 0,00001
  • 24. Need for Surgery Comparison of different conservative treatments for idiopathic clubfoot: Ponseti's versus non-Ponseti's methods. J Int Med Res. 2017 Jun;45(3): Epub 2017 May 28. He JP, Shao JF1, Hao Y
  • 26.  Result : Role of Tenotomy
  • 27. Gait lab analysis The effect of tenotomy on kinematics, kinetics and pressure parameters in children with idiopathic clubfoot R. Elbaum3,4, C. Mahieu1,7, C. Concessa1, F. Adam6, B. Noel7, B. Beyer1, F. S. Van sint jan1, V. Feipel5, 1 , P. Salvia1, 2
  • 28.  Result: Compliance Rate COMPLIANCE FOLLOW UP (Mo) SUBGROUP 1 90% 55 SUBGROUP 2 88% 37 SUBGROUP 3 83% 61 SUBGROUP 4 70% 50 TOTAL 86% 48
  • 29. Compliance rate in the litterature
  • 33.  Recurence according compliance 73.33 92.31 26.67 7.69 0 10 20 30 40 50 60 70 80 90 100 1 2 3 Pas de récidive Récidive Non compliant compliant p = 0,023
  • 34.  Recurence rate in the littérature +/- 30%! Relapse of Clubfoot after Treatment with the Ponseti Method and the Function of the Foot Abduction Orthosis Dahang Zhao, MD, Jianlin Liu, MD, Li Zhao, MD,corresponding author and Zhenkai Wu, MD Dobbs MB, Rudzki JR, Purcell DB, 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(1) Thacker MM, Scher DM, Sala DA, van Bosse HJ, Feldman DS, Lehman WB. Use of the foot abduction orthosis following Ponseti casts: is it essential? J Pediatr Orthop 2005 Chen RC, Gordon JE, Luhmann SJ, Schoenecker PL, Dobbs MB. A new dynamic foot abduction orthosis for clubfoot treatment. J Pediatr Orthop 2007 Avilucea FR, Szalay EA, Bosch PP, Sweet KR, Schwend RM. Effect of cultural factors on outcome of Ponseti treatment of clubfeet in rural America. J Bone Joint Surg Am 2009 Ramirez N, Flynn JM, Fernandez S, Seda W, Macchiavelli RE. Orthosis noncompliance after the Ponseti method for the treatment of idiopathic clubfeet: a relevant problem that needs reevaluation. J Pediatr Orthop 2011 Haft GF, Walker CG, Crawford HA. Early clubfoot recurrence after use of the Ponseti method in a New Zealand population. J Bone Joint Surg Am 2007 Ponseti IV. Relapsing clubfoot: causes, prevention, and treatment. Iowa Orthop J 2002;22:55–56.
  • 35. FFM an alternative to Ponseti Method in developping country ?
  • 36.
  • 37.
  • 38.  CONCLUSION FFM is an interesting approach for treating clubfeet, especially concerning rigourous and modularity of splinting system. Compliance rate is very high comparing to PM Achilleus tenotomy is less systematic in our series and is indicated after 4 month of age Long term follow up and result encourages us to continue on this way. However, it requires a well-trained physical therapist team and a good collaboration of the parents.