Tratamiento del pie metatarso aducto con el método de vendajes funcionales correctores: estudio retrospectivo

Title: Corrective bandage for conservative treatment of metatarsus adductus: A retrospective study. Running title: Corrective bandage for metatarsus adductus AUTHORS: Elia Utrilla Rodríguez (Utrilla-Rodríguez E) Physiotherapist. Paediatric Rehabilitation Service, University Hospitale “Virgen de Macarena”, Seville (Spain). Address: Avd. Dr. Fedriani, 3, 41071 Sevilla. Phone: +34 955 00 80 00 E-mail: [email protected] María Jesús Guerrero Martínez-Cañavete (Guerrero-Martínez-Cañavete MJ) Physiotherapist. Paediatric Rehabilitation Service, University Hospitale “Virgen de Macarena”, Seville (Spain). Address: Avd. Dr. Fedriani, 3, 41071 Sevilla. Phone: +34 955 00 80 00 E-mail: [email protected] Manuel Albornoz Cabello, Ph.D (Albornoz-Cabello M) Lecturer at the Department of Physiotherapy, University of Seville. Address: Departamento de Fisioterapia. Calle Avicena, s/n. 41009 Seville (Spain) Phone: +34 954486528 E-mail: [email protected] Pedro V. Munuera, Ph.D (Munuera PV) CORRESPONDING AUTHOR Lecturer at the Department of Podiatry, University of Seville. Address: Departamento de Podología. Calle Avicena, s/n. 41009 Seville (Spain) Phone: +34 954482170 E-mail: pmunuer[email protected] TITLE: Corrective bandage for conservative treatment of metatarsus adductus: A retrospective study. Running title: Corrective bandage for metatarsus adductus Keywords: Newborn; Metatarsus adductus; Bandage; Splints ABSTRACT Background: Metatarsus adductus is the most common congenital foot deformity observed in children. Objectives: To analyze the evolution of a corrective bandage of the semi-rigid metatarsus adductus (MA) foot in newborn and to recommend the age interval at which to start treatment of MA with corrective bandage alone, without the need of splints. Study Design: An observational, clinical study was performed at the University Hospital “Virgen Macarena,” in Seville, Spain. Children born with semi-rigid metatarsus adductus feet at the Virgen Macarena University Hospital in Seville during the years 2010-2011 were included. Corrective bandaging was applied to all children until clinical correction of the deformity. Sex, laterality of the deformity, weight and length of the newborn, age at the start of treatment, antecedents related to the pregnancy and birth, type of treatment (bandaging, splints) and correction or no correction with bandaging alone were recorded. Age differences at the start of the bandaging treatment between patients whose deformity was corrected with and without the need of splints were examined. The ROC curve method was applied to analyze the predictive ability of the age at the start of bandaging treatment relative to whether the deformity was corrected or not corrected with bandaging alone. Results: The bandage achieved complete correction in 68.1% of the metatarsus adductus patients and corrected the deformity more frequently in girls compared to boys (p=0.017). Of the 56 patients who began the treatment within the first month of life, 92.8% were corrected with the corrective bandaging alone. Conclusion: Corrective bandages showed high effectiveness, particularly in girls, and overall when started within the first month of life. INTRODUCTION Metatarsus adductus is the most common congenital foot deformity observed in children, and its frequency has increased in recent years (1 to 3 per 1000 newborns)1-3. It is a complex deformity that requires knowledge of its causal components prior to correct treatment4,5, as treatment and expected outcomes will differ accordingly. There is a disorder of the alignment of the forefoot, with varying degrees of adduction and supination (Figure 1). Moreover, the outer side edge of the foot is convex, with a lateral and dorsal prominence at the base of the fifth metatarsal and cuboid bone. Although the calcaneus is in a valgus position, there is no equinus deformity, in contrast to a clubfoot. In some cases, the deformity improves or corrects itself spontaneously. However, if these outcomes do not occur and the deformity is also not treated, then the child will have an altered gait, i.e., he or she will walk with the toes pointed toward the midline ("in-toeing") and may experience recurrent tripping, that could moreover have a significant impact on both the child and parents6. This dysfunction results in an increased number of falls due to the child's consequent psychomotor retardation7,8. Furthermore, in the long-term, the pressure exerted by the shoe may be a predisposing factor for the development of hallux valgus3,9. The classification used for years at Hospital Universitario Virgen Macarena de Sevilla for this deformity, is the following9: Grade 1, when there is adduction of the forefoot without inversion, being able to perform abduction passively or by means of stimulation of the peroneal musculature; Grade 2, when the foot is slightly shortened, the forefoot is in adduction and inversion, the external border of the foot is convex (with prominent base of the fifth metatarsal), and the internal border concave, with normal longitudinal arc, and that can be partially corrected; Grade 3, which corresponds to feet with more structured deformity, because we have to add kidney-shaped form to the features reported above, with transversal sulci in the medial region of the foot, increased internal longitudinal arc, marked longitudinal shortening of the foot and passive correction of the forefoot is not possible. Cases of grade 3 deformity require surgery whilst grade 1 and 2 cases can be corrected traditionally9. Treatment of the metatarsus adductus foot varies depending on the degree of misalignment, ranging from observation and conservative (observation and monitoring) in mild cases, to the placement of serial casts, thermoplastic splints, and even surgery in the most severe cases10, 11. Most authors agree that the best therapeutic option will be dependent on the initial flexibility of the foot, which ranges from a waiting attitude in mild cases to surgery for the stiffest feet2, 4, 7, 9, 12-15. There is a general consensus that, in the most flexible cases (grade 1 feet, according to the classification of the Virgen Macarena Hospital9), a vigilant attitude should be adopted or parents should be taught foot flexibility exercises to be performed regularly at home. However, to the best of our knowledge, there is little scientific literature supporting successful treatments of more severe cases of MA. Thus, determining the most appropriate treatment remains controversial. Most studies of semi-rigid or second-grade metatarsus adductus have shown that treatment with serial casts below the knee is the most common therapy1, 4, 10, 16-18. This treatment is followed in frequency by the placement of position-correcting splints and parental control of the child's sitting and sleeping postures4, 12, 16, 19. Although this is a rather aggressive treatment, in the authors’ opinion, more simple and costeffective new techniques could be developed, i.e. by means of corrective bandages. To the best of our knowledge, only a few studies have recommended treatment with corrective bandaging as the primary conservative treatment option 9, 13, 14. This technique has the advantage of allowing daily manipulation and correction of the foot, as well as reducing treatment time and cost. The main aim of this study was to ascertain the effectiveness of a corrective bandaging treatment of the semi-rigid (or second-grade 2) metatarsus adductus foot in newborns at the Virgen Macarena Hospital in Seville. Another aim was to establish the most recommended age interval at which to commence start this treatment in order to achieve correction of the deformity with bandaging alone, without applying splints. STUDY DESIGN A retrospective study was designed with children born with semi-rigid or second-grade MA feet during the years 2010-2011 who were treated with corrective bandaging. The study was performed at the Virgen Macarena Hospital in Seville, Spain, and was approved by the Hospital’s Ethics Committee. Participants The inclusion criteria for participants included having been diagnosed with secondgrade MA foot according to the classification of the Hospital Virgen Macarena9, and having received no prior treatment. The exclusion criteria were patients with skeletal dysplasia, neuromuscular pathology, or other abnormalities of the foot, and children whose medical records were incomplete or who had not completed treatment. The final number of patients who met the selection criteria was 94. Tests and measures The variables recorded were: gender (male or female), laterality of the deformity (unilateral right or left, or bilateral), weight (grams) and length (centimeters) of the newborn, age (days) at the start of the treatment, antecedents related to the pregnancy and birth (normal vaginal, Cesarean section, vacuum suction or forceps), type of treatment (bandaging, splints) and its duration (days), and whether the deformity was corrected with bandaging alone. Two experienced physiotherapists treated all of the children in the same manner (EUR: 22 years as a physiotherapist, 18 years of experience as a pediatric physiotherapist; and MJGMC: 40 years as a physiotherapist, 37 years of experience as a pediatric physiotherapist). Procedure Treatment with corrective bandaging was performed by physical therapists with more than 20 years of experience in the children’s physiotherapy unit at our hospital. Treatment sessions were conducted five5 days a week for approximately 15 minutes per foot and consisted of a first phase of flexing the retracted structures of the foot with corrective manipulation and stimulation of the peroneal muscles with a toothbrush. Subsequently, corrective bandaging was applied using cotton bandages and strips of adhesive dressings placed from the base of the first metatarsal to the top of the leg. Bandaging followed a distal to proximal direction. After several layers of cotton bandage, the strip was placed over the head of the first metatarsal and then on the plantar surface of the remaining metatarsals ending on top of the leg, under the knee (Figure 2). Thereafter, several layers of bandage were applied to maintain plaster strip tension and correction achieved during manipulation. The bandage was not so tight as to compromise circulation, and was examined before the child left the physiotherapy unit. If necessary, it was removed and replaced with another bandage. The bandaging was renewed every other day until the deformity was clinically corrected. Correction criteria included complete correction of the external convexity of the foot, absence under palpation of the prominence of the fifth metatarsal base, and balance in the musculature of the foot8. Patients were followed up at two years after treatment initiation. Data analysis The data were analyzed using IBM SPSS statistics v. 20 (SPSS Science, Chicago, USA). The analysis included a general descriptive analysis with a determination of the means and standard deviations of the quantitative variables measured, and absolute and relative frequencies (as percentages) of the qualitative variables. Next, the potential associations of the variables laterality, sex, and type of birth with the effectiveness of the bandaging treatment were evaluated using the chi-squared or Fisher's exact tests in the case of 2×2 contingency tables. Age differences at the start of the bandaging treatment between patients whose deformity was corrected without splints and those who needed splints were examined using the Mann-Whitney U-test. A subsequent test of potential age differences was performed by binning the ages at the start of treatment into four intervals and comparing the cases that did or did not require splints using the chi-squared test. Finally, the ROC curve method was applied to analyze the predictive ability of age at the start of the bandaging treatment relative to whether the deformity was corrected with bandaging alone or whether splints would be required. Values of the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined. In all of the analyses, α significance level was established at 0.05, or confidence level = 0.95. Also, β value (type II error) was a priori established at 0.2, or power (1 - β) = 0.8. patients who began treatment within the first month of life, 92.8% were corrected with the corrective bandaging alone. REFERENCES 1. Jackson JF, Stricker SJ. Pediatric foot notes: A review of common congenital foot deformities. Int Pediatr. 2003;18:133-40. 2. Sankar WN, Weiss J, Skaggs DL. Orthopaedic conditions in the newborn. J Am Acad Orthop Surg. 2009;17:112-22. 3. Dawoodi AIS, Perera A. Radiological assessment of metatarsus adductus. Foot Ankle Surg. 2012;18:1-8. 4. Ponseti IV, Becker JR. Congenital metatarsus adductus: The results of treatment. J Bone Joint Surg (Am). 1966;48:702-11. 5. Farsetti P, Weinstein SL, Ponseti IV. The long-term functional and radiographic outcomes of untreated and nonoperatively treated metatarsus adductus. J Bone Joint Surg (Am). 1994;76:257-65. 6. Redmond AC. The Effectiveness of Gait Plates in Controlling In-Toeing Symptoms in Young Children. J Am Podiatr Med Assoc. 2000; 90(2): 70-76. 7. Peabody CW, Muro F. Congenital metatarsus varus. J Bone Joint Surg. 1933;15:171-89. 8. Kite JH. Congenital metatarsus varus. J Bone Joint Surg (Am). 1967;49:388-97. 9. Martos-Mora C, Gentil-Fernández J, Conejero-Casares JA, Ramos-Moreno R. Congenital metatarsus adductus: A clinical classification and therapeutic attitude. Rehabilitacion. 2012;46:127-34. 10. Wan SC. Metatarsus adductus and skewfoot deformity. Clin Podiatr Med Surg. 2006;23:23-40. 11. Hutchinson B. Pediatric metatarsus adductus and skewfoot deformity. Clin Podiatr Med Surg. 2010;27:93-104. 12. Williams CM, James AM, Tran T. Metatarsus adductus: Development of a nonsurgical treatment pathway. J Paediatr Child Health. 2013;49(9):E428-33. doi: 10.1111/jpc.12219. 13. Sirbu AB, Collof B. Early treatment of metatarsus varus (adductus). Pediatrics. 1949;4:810,"819, illust". 14. Reimann I, Werner HH. Congenital metatarsus varus. on the advantages of early treatment. Acta Orthop Scand. 1975;46:857-63. 15. Sorensen MD, Hyer CF. Metatarsus primus varus correction: The osteotomies. Clin Podiatr Med Surg. 2009;26:409-25. 16. Bohne W. Metatarsus adductus. Bulletin of the New York Academy of Medicine: J Urban Health. 1987;63:835-8. 17. Katz K, David R, Soudry M. Below-knee plaster cast for the treatment of metatarsus adductus. J Pediatr Orthop. 1999;19:49-50. 18. Ferrari J, Malone-Lee J. A radiographic study of the relationship between metatarsus adductus and hallux valgus. 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Percutaneous correction of persistent severe metatarsus adductus in children. J Pediatr Orthop. 2013 Nov 21. [Epub ahead of print]. doi: 10.1097/BPO.0000000000000122 TABLE 1 Mean Median Standard deviation Minimum Maximum Total Age from birth at start of treatment (days) 50.29 24 56.148 3 300 94 Number of bandages applied 7.74 8 3.114 1 14 94 Weight at birth (g) 3373.53 3307.50 456.805 2060 4500 94 Length at birth (cm) 49.606 49.500 1.9768 43 54 94 Table 1: Descriptive statistics of the quantitative variables used in the study. TABLE 2 Age at which treatment was started (days) (n = 94) Was a splint needed? No Yes Up to two weeks (n = 28) 26 2 40.6% 6.7% Between two weeks and one month (n = 28) 26 2 40.6% 6.7% Between one month and three months (n = 26) 12 14 18.8% 46.7% More than three months (n = 12) 0 12 0% 40% Table 2: Distribution of patients who needed and who did not need half-cast plaster splints, by intervals of age at the start of the bandaging treatment. TABLE 3 Splint needed? Age at which treatment was started Age ≤ 27 days (N) Age ≥ 28 days (N) Total (N) No 46 (true negatives) 18 (false positives) 64 Yes 2 (false negatives) 28 (true positives) 30 N = 48 N = 46 N = 94 95 % IC Likelihood ratio 35.78 7.71 - 165.99 Likelihood ratio + 3.32 2.22 - 4.97 Likelihood ratio - 0.09 0.02 - 0.36 Table 3: Prediction of the need for plaster half-cast splints for the treatment of metatarsus adductus, taking as lower cut-off point 27.5 days in age at the time of starting the bandaging treatment (Sensitivity 93.3%; specificity 71.9%) and Odds Ratios derived from those data. FIGURE LEGENDS Figure 1. One-day-old child with metatarsus adductus. Figure 2. Cotton bandage and end of the strip of adhesive tape, below the knee. Figure 3. ROC graphic. 1-Specificity is represented instead of Specificity so that correct diagnosed cases can stay under the curve. In that way, false positives and false negatives would stay above the curve.