Guest guest Posted June 24, 2004 Report Share Posted June 24, 2004 Minus the note to . This is just what I found from the last few months of 's posts in regards to AFO's. I know, I suck. I never delete anything. I have this in both my out box and my nosurgery box. Duh! Kori >Delivered-To: frogabog@... >Delivered-To: mailing list nosurgery4clubfoot >Date: Mon, 26 Apr 2004 01:53:45 -0000 > >To: nosurgery4clubfoot > >, > >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) > > > > > > > > >>If you could get that info from her or tell me how to get the info, that >>would be great. I don't know why an AFO would be useless in maintaining >>correction...maybe the tethers are a new thing? It seems that people all >>over the net >>use them. I did find one study, although it is not the same one I found last >>week...the link is Postoperative Clubfoot Orthosis | JACPOC Library, 1988 >>, it >>is old and it really doesn't apply to me because Kaitlin is not post-op. >> I thought about the Sandals, but I've heard of some people >>getting blisters and I really can't afford to try them for $350 just for >>her to >>get another blister. Like I said, she has not had any brace on for almost 3 >>weeks b/c whenever we try to put her DBB on she starts to get sores in less >>than 2 hours...we have kind of given up on it I guess. I don't know >>exactly what >>her AFO will be like, I will see tomorrow. The orthotist said there will be >>3 sets of tethers to hold her foot externally rotated. I don't know what it >>will be like, but it has got to be better than no brace at all or sores >>on her >>foot. Maybe we will try the DBB when her foot is bigger. >> >>Thanks for your input, >> Freeman >>Kaitlin Freeman 3/9/04 LCF >> >> >> Quote Link to comment Share on other sites More sharing options...
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