That AFO Post

[Guest guest]

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

>>

>>

>>