Re: relapse

[Guest guest]

,

There have been a few parents whose child's feet were relapsing

where it was possible to correct with casting without having to do

the ATTT. If not, then at 3 1/2 years old, it may be good to get

whatever is needed done sooner rather than later even if the ATTT

needs to be done. That will allow the bones and joints of the feet

to be growing in a corrected postion instead of a position that

isn't quite right. I would encourage you to contact Dr. Dietz

and/or Dr. Ponseti.

If the ATTT is not used, then I would think that the FAB/DBB would

probably be needed. If the ATTT is done, then I believe that

usually the FAB/DBB is not used.

Concerning AFO's, I beleive that Dr. Ponseti would feel that below

the knee AFO's do not have the ability to maintain the external

rotation of the foot and therefor don't really work. About 20 years

ago, while Dr. Ponseti was in retirement, the U of Iowa tried using

AFO's instead of the FAB/DBB and found that they didn't work as well

and so returned to the FAB/DBB.

As far as KAFO's or knee-ankle-foot-orthotics that extend above the

knee and therefor can help a bit in keeping the foot externally

rotated it states at the new Gobal HELP pamphlet on the Ponseti

method.

" Alternatives to foot abduction brace. Some surgeons have tried

to " improve " Ponseti management by modifying the brace protocol or

by using different braces. They think that the child will be more

comfortable without the bar and so advise use of straight last shoes

alone. This strategy always fails. The straight last shoes by

themselves do nothing. They function only as an attachment point for

the bar. Some braces are no better than the shoes by themselves and,

therefore, have no place in the bracing protocol. If well fitted,

the knee-ankle-foot braces, such as the Wheaton brace, maintain the

foot abducted and externally rotated. However, the knee-ankle-foot

braces keep the knee bent in 90 degrees of flexion. This position

causes the gastrocnemius muscle and Achilles tendon to atrophy and

shorten, leading to recurrence of the equinus deformity. This is

particularly a problem if a knee-ankle-foot brace is used during the

initial 3 months of bracing, when the braces are worn full time. In

summary, only the brace as described by Ponseti is an acceptable

brace for Ponseti management and should be worn at night until the

child is 3 to 4 years of age. " The Gobal HELP booklet can be found

at their site at http://www.global-

help.org/publications/pdfs/PonsetiBook.pdf

Stated simply, a bent leg KAFO keeps the leg bent at the knee. That

bend can be used to try to help abducted the feet outward. But in

that position, that achilles tendon is not stretched as much as if

the leg is straight and the feet held in 70 degrees of abduction and

slightly dorsiflexed. The FAB/DBB allows for much more foot, leg

and ankle motion that helps stretch out all of the ligaments and

tendons.

Here is a copy of an article written by Dr. Ponseti on the

topic of the Treatment of Relapsing Clubfoot in the Ponseti method.

It was a printed version of a Lecture delivered at the DC National

Congress of the Italian Society of Pediatric Orthopaedics and

Traumatology, in Rome, Italy at October 2001 and printed in a 2002

issue of the Iowa Orthopedic Journal.

Iowa Orthopedic Journal: Volume 22, 55-56, 2002

RELAPSING CLUBFOOT: CAUSES, PREVENTION, AND TREATMENT, Ignacio V.

Ponseti

INTRODUCTION

" Regardless of the mode of treatment, the clubfoot has a strong

tendency to relapse. Stiff, severe clubfeet and small calf sizes are

more prone to relapse than less severe feet. Clubfeet in children

with very loose ligaments tend not to relapse. Relapses are rare

after four years of age. "

" Not all components of the clubfoot tend to relapse to the same

degree. In most of our cases, forefoot correction is permanent

without metatarsus adductus. The relapse of the cavus deformity is

rare and usually mild. The most important relapses occur in the

hindfoot, first in the equinus, and then in the heel varus. In some

relapsed clubfeet, the heel varus is very severe, while in others it

is mild. Rarely, the heel in equinus may go into valgus resulting in

a calcaneovalgus deformity. This is a frequent occurrence in

surgically treated clubfeet In our experience, most relapses develop

gradually and may be difficult to recognize in the early stages. A

relapse is detected when there is an appearance of a slight equinus

and varus deformity of the heel, most often without increased

adduction and cavus in the forefoot When walking, the child tends to

put more weight on the outside of the sole of the foot. "

CAUSES

" It is wrongly assumed that relapses occur because the deformity has

not been completely corrected. Actually, relapses are caused by the

same pathology that initiated the deformity. Therefore, when we

understand the pathogenesis of the clubfoot, the causes of the

relapse will become clear. "

" The clubfoot in otherwise normal children is a developmental anomaly

originating after the third month of intrauterine life. It is induced

by an unknown dysfunction in the posterior and medial aspects of the

lower leg, ankle and foot. There is a slight decrease in size of the

muscles, and an excess of colagen synthesis with retracting fibrosis

in the medial and posterior tarsal ligaments, in the deep fascia, the

tendo Achilles, and the posterior tibial tendon. These changes induce

severe equinus, medial displacement of the navicular, heel varus and

foot adduction. "

" The period of dysfunction causing the deformity starting in the

middle third of pregnancy lasts to the third or fourth year of life.

In mild cases, it may start in late fetal life, and remain active for

only a few months after birth. In all cases, the resulting fibrosis

is most pronounced from. a few weeks preceding birth, to a few months

after birth. This is the period when collagen accretion is greatest

in tendons and ligaments of normal mammals and presumably also of

man. The speed of growth of the foot decreases after the first year

of life, diminishing greatly after five years. "

" Relapses appear to be related to the intensity of collagen synthesis

as the foot grows. Thus, relapses occur swiftly in premature infants

and more slowly in older infants. Relapses are less common and less

severe in mild club feet with little fibrosis and in children with

loose ligaments. They occur because the factors inducing the

deformity are still active. Relapses are rare after four years of

age, regardless of whether the deformity is fully or partially

corrected. "

" The clubfoot is no different from other non-embryonic human

deformities such as torticoris, scoliosis, or Dupuytren's

contracture, in that it develops in normal individuals, and

progresses for a limited time before becoming inactive. Torticollis

usually develops within days after birth and increases for a few

weeks. Idiopathic scoliosis starts in late childhood and increases

throughout adolescence. Dupuytren's contracture develops at maturity

and may be active for a few years. Clubfoot develops in the middle of

pregnancy and is active during the first to fourth years of life. In

torticollis, Dupuytren's contracture, and presumably in clubfoot, a

localized temporary increase of collagen synthesis is a common

pathologic feature. "

" With our technique, most congenital clubfeet in infants are

corrected within four to six weeks. However, splinting for several

months or years is indispensable to help prevent relapses. Since the

main corrective force of the varus and adduction of the clubfoot is

abduction (external rotation) of the foot under the talus, a splint

is needed to maintain the foot in the same degree of abduction as it

was in the last plaster cast. This is best accomplished with the feet

in well-fitted, open-toed high top shoes with a well-molded heel

attached in 70 degrees external rotation to a bar of about the length

between the baby's shoulders. Unless the feet are sprinted in firm

external rotation, the pull of the retracting fibrosis in the

ligaments of the medial aspect of the ankle and of the tibialis

posterior and toe flexors is strong enough to cause a recurrence of

the deformity in most feet. "

" The splints are worn full time for two to three months, and

thereafter at night and naps for two to four years. The splint should

maintain the foot in 70 degrees of abduction to prevent relapse of

the varus deformity of the heel of the adduction of the foot and the

in-toeing. The ankle should be in dorsiflexion to prevent relapse of

the equinus. This is accomplished by bending the splint with the

convexity of the bar distally directed. A splint or strapping that

cannot firmly maintain the foot in marked abduction without pronation

is ineffectual. The added advantage of shoes attached to a bar, as

opposed to a fixed splint, is that it allows motion of the feet,

ankles and knees. Most babies feel uncomfortable for the first two to

three days when trying to kick their legs alternatively. Parents can

easily teach their babies to kick both legs simultaneously. The

splints are then well accepted. "

" In the first 20 years of my practice, relapses occurred in about

half of the patients at ages ranging from ten months to five years,

averaging two-and-one-half years. Usually, relapses were observed

from two to four months after the splints were prematurely discarded

at the families' own initiative, believing that the correction was

stable. More recently, relapses have been less frequent because, for

one thing, I have further overcorrected the deformity in the last

plaster and to be certain that the calcaneus is fully abducted and

its anterior joint surface is well under the head of the talus.

Secondly, there has been greater awareness on the part of the Parents

regarding the importance of maintaining the night splints after

correction for three to four years. "

" In recent years, I have treated 90 patients - 52 of them initially

seen from birth to three months of age, and 38 from three Months to

one year of age. Seventy Percent of the patients had plaster casts or

physical therapy elsewhere. Forty patients had been previously

indicated for surgery by the initial treating Physician. To my

surprise, it was possible to successfully correct all these feet with

manipulations, and four or five plaster casts, changed every five

days. I performed percutaneous Achilles tenotomy in 84 percent of the

patients. Eighty-eight percent of the patients were compliant with

the use of the foot abduction splint. There were 14 relapses. The

rate of relapse was seven percent in compliant patients, compared to

78 Percent in non-compliant patients. Relapses were unrelated to age

at presentation or to the number of casts required for correction. "

TREATMENT

" In general the original correction may be recovered in four to six

weeks with manipulations and plaster casts changed every 14 days,

holding the foot in marked abduction and as much dorsiflexion as

possible at the ankle in the last cast. This treatment is followed by

lengthening the tendo Achilles when dorsiflexion of the ankle is less

than 15 degrees. A percutaneous tenotomy can be performed until one

year of age. [More recently, Dr. Ponseti mentioned tenotomies done

later than one year, up to at least 18 months of age] The last

plaster cast is left on for three to four weeks. When the cast is

removed, shoes attached in external rotation to a bar are worn at

night and with naps, until the child is about four years old. "

" To prevent further relapses, the tendon of the tibialis anterior

muscle is transferred to the third cuneiform in children over two-and

one-half years of age, if this muscle tends to strongly supinate the

foot. Often this supination takes place when the medial naviculare

displacement is not fully corrected and the AP talocalcaneal angle is

under 20 degrees. Transfer of the tibiaiis anterior tendon averts

further relapses, maintains the correction of the heel varus,

improves the anteroposterior talocalcaneal angle, and thus greatly

reduces the need for medial release operations. The tibialis anterior

tendon transfer is an easy operation and much less damaging to the

foot than the release of the tarsal joints. Joint releases are needed

when the deformity recurs in spite Of the tibialis anterior transfer.

The tibialis anterior tendon should never be split so as to not lose

its eversion power, nor should it be transferred to the fifth

metatarsal or to the cuboid, since this would excessively evert the

foot, causing severe foot pronation and heel valgus. "

CONCLUSION

" Since I developed this method of treating clubfoot 50 years ago,

only an occasional posterior release operation of the ankle and

subtalar joints has been necessary. In the 90 patients I treated in

recent years, four patients required surgery: one posterior release

of the ankle, and three anterior tibialis tendon transfers to the

third cuneiform combined with a lengthening of the tendo Achilles. "

Lecture delivered at the DC National Congress of the Italian Society

of Pediatric Orthopaedics and Traumatology, in Rome, Italy, October

2001.

Department of Orthopaedic Surgery University of Iowa Iowa City, Iowa,

U.S.A

I thought that many might be interested in this information.

and (3-17-99)

> Hi, All,

>

> My son was a bilateral clubfoot baby and was treated with the

> Ponsetti method, wore the dbb until age 2 and is now 3 1/2.

> Unfortunately we were advised that he could leave the brace behind

at

> age 2 and now he is experiencing a mild relapse. Our dr. says the

in-

> toing will likely continue to get worse and he will likely be a

> candidate for the ATT surgery in the next couple of years. My

> question to those who have gone before us is this: are there ANY

> interventions out there that we could try at this point? He is

not

> yet at surgery status, and I can not stand to just sit back and

wait

> without trying something. If we could just maintain his feet as

> they are now (slightly pigeon-toed) we would be very very

> satisfied. I am taking him for a physical therapy evaluation

> tomorrow, but our dr. does not think this will be effective.

Neither

> does he think trying to get him to wear the dbb again would be an

> effective intervention. Any input would be most appreciated.

>

> Thank you.

>