Re: Locals for surgery and more DAFO stuff

[Guest guest]

,

I am no expert and you will probably get more answers from others but

I believe the 70 degree rotation is necessary to prevent relapse.

The same condition that causes clubfeet continues to cause it until

the child is 3 or 4 and if the foot is not over corrected it can end

up relapsing. I " think " the clubfoot should have a more outward

rotation at her young age then the non clubfoot (someone correct me

if I am wrong sense my daughter is bilateral).

How long do you have to wait for the braces? Is she going into a

DAFO? I hope the exercises work to help hold her over until your

braces get there. I know for us exercises wouldn't have worked

because Tori goes to daycare 9 hours a day and the daycare provider

wouldn't have been to happy about doing exercises on her feet all the

time. That might be why they usually recast until the braces are

available.

Hope you get some more answers.

Tori 1/30/04 bialteral atypical cf

PS: I was in the room when Tori had her Tenotomy under local and she

didn't seem to be in much pain. Maybe it is different for kids or

clubfooters or just different pain tolerances.

[Guest guest]

,

Probably the best place to get the technical reasons as to why the

FAB is the preferred method of post-correction bracing and why the

AFO or DAFO is not as successful as the FAB in preventing relapses is

to write to Dr. Ponseti and ask him for a technical explanation that

you can share with your doctor....or ask your doctor to discuss it

with Dr. Ponseti specifically.

Here is a quote from Dr. P's website in the information for providers

that is one of the common errors in the treatment of clubfoot:

" Failure to use shoes or molded orthotics attached to a bar in

external rotation for three months full-time and at night for two to

four years. These splints are necessary to counter the tendency of

the ligaments to tighten, causing relapses. The ankles and knees are

free to move and the leg and thigh muscles gain strenghth. "

It's brief, but essentially explains that the outward rotation is

necessary to counter-act the ligaments pulling back in. The same is

true for the Achilles tendon, which is why the shoes are mounted on

the bar with a bend so that the toes are pointed upward, keeping the

Achilles stretched.

Don't worry about discussing your personal research with your doctor-

you're not " telling " on him...it's your job as a parent to make

decisions on your daughter's behalf- and you're doing a great job of

educating yourself and understanding all that you can about this

complicated medical condition so that you can discuss your daughter's

treatment with your doctor and make decisions as a team- not just

follow blindly along with his recommendations if you don't agree with

them. If your doctor is a parent, you know that they would be doing

the exact same thing for their own children!

Please note that I've been told that just a few hours without a

cast/brace during the initial stages of correction can allow some

relapse to occur (may not be visible). So if you have a difficult

time with Ava being in a brace when you do get it, you might want to

consider having another cast re-applied to see if that might help the

situation. Perhaps your doctor will suggest this anyway based on

what he learns at the symposium!

Regards,

& (3-16-00)

left clubfoot

>

> My mother-in-law had surgery on her foot and they gave her a local,

> but they also numbed the foot before the local even. She said it

was

> very painful even with the numbing. She was a nurse & she said the

> foot is generally very tender. We had discussed this when my

> daughter had her tenotomy, and that was another reason I was glad

my

> doc did it with general anesth.

> Anyway, my daughter's foot is fully corrected, I'm pretty positive.

> I know Dr. P doesn't want the children's feet out of casts/DBB at

> any time (until they're supposed to be) but, yes, my Doc doesn't

> have her casted while we wait for the brace. He told me exercises

> I'm to do with her foot every time I change her diaper (you know,

> about 75 times a day). Again, I know Dr. P doesn't do that--so

> please, don't slam me with how awful he is & doesn't follow the

> Ponsetti method & all that!!! But her feet look COMPLETELY the

same!

> Her club foot is slightly fatter, but I think it's still a little

> swollen because it's getting better everyday. When she's relaxed or

> sleeping her feet point outwards exactly the same on each side (CF

&

> non CF) and I can turn her CF out to the same rotation or whatever

> as her non CF. Also, what felt like the " empty heel " is starting to

> feel like her other foot, with a bone in there. So I don't really

> have any worries on that score. This may sound stupid, but I've

read

> all the info (global help book, Ponseti's site, etc.) and I'm just

> wondering if someone (, probably :-) ) can tell me why the 70

> degrees is so necessary? (In English please!) I'm not doubting the

> benefits of the DBB over the DAFO, I just want all my proverbial

> ducks in a row before I call my Doctor or Dr. P. Like I said

before,

> I totally trust my doc, and I don't want to seem like I'm " telling "

> on him to Dr. Ponseti. I just want what everyone wants--what's best

> for Ava.

> Sorry my posts are so long! I'm a writer at heart!

> Thanks to everyone for your replies!

>

> mommy of:

> Guinevere (no CF) on (no CF) Ava 8/4/04 (right CF)

[Guest guest]

,

We are sorry if we at this group sometimes seem a bit over zealous in

tring to encourage you and/or other newer parents regarding

the " real " Ponseti method. It is just that many of us have watched

the experiences of 500-1,000 parents on the internet over the past 5

years. Many times, we see very similar experiences by many parents

over the course of the years and are anxious to help. Please forgive

us for occasionally being a little overly " helpful " .

In his 1996 book, Dr. Ponseti talks about having a premature baby

fully relapse in one week while they were waiting for smaller shoes.

I think that the speed of relapsing was much faster than it would be

in most children. Plus he indicated that premature babies in general

relapse quicker.

Regarding your specific question, I think that when Dr. Ponseti was

developing his method in the late 1940s and 1950's, he didn't just

start out doing 70 degrees because he wouldn't have known right from

the beginning what worked better than other alternatives. I think

that he initially used less overcorrection and lower amounts of time

in the brace but saw higher rates of relapsing. In the first long

term outcome study that Dr. Ponseti did in 1963, the rate of

relapsing was almost half of the patients he treated. During the

following years, he has adjusted the method to get less risk of

relapsing.

I beleive that over a 50 year period of implementing his method and

seeing what worked better, Dr. Ponseti has indicated that using 70

degrees seems to work the best in getting a good outcome with less

risk of relapsing. From 1991 to 2001, Dr. Ponseti's rate of

relapsing for those complying with the prescribed use of the FAB/DBB

was about 10%. The 70 degrees, bend of the bar and other aspects of

the method have come from fine tuning the method over a 50 year

period.

Dr. Ponseti discusses this in an article on relapsing that he wrote

in 2001.

" 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. "

Here is a full copy of that 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 hope this information has been of help.

and (3-17-99)

>

> My mother-in-law had surgery on her foot and they gave her a local,

> but they also numbed the foot before the local even. She said it

was

> very painful even with the numbing. She was a nurse & she said the

> foot is generally very tender. We had discussed this when my

> daughter had her tenotomy, and that was another reason I was glad

my

> doc did it with general anesth.

> Anyway, my daughter's foot is fully corrected, I'm pretty positive.

> I know Dr. P doesn't want the children's feet out of casts/DBB at

> any time (until they're supposed to be) but, yes, my Doc doesn't

> have her casted while we wait for the brace. He told me exercises

> I'm to do with her foot every time I change her diaper (you know,

> about 75 times a day). Again, I know Dr. P doesn't do that--so

> please, don't slam me with how awful he is & doesn't follow the

> Ponsetti method & all that!!! But her feet look COMPLETELY the

same!

> Her club foot is slightly fatter, but I think it's still a little

> swollen because it's getting better everyday. When she's relaxed or

> sleeping her feet point outwards exactly the same on each side (CF

&

> non CF) and I can turn her CF out to the same rotation or whatever

> as her non CF. Also, what felt like the " empty heel " is starting to

> feel like her other foot, with a bone in there. So I don't really

> have any worries on that score. This may sound stupid, but I've

read

> all the info (global help book, Ponseti's site, etc.) and I'm just

> wondering if someone (, probably :-) ) can tell me why the 70

> degrees is so necessary? (In English please!) I'm not doubting the

> benefits of the DBB over the DAFO, I just want all my proverbial

> ducks in a row before I call my Doctor or Dr. P. Like I said

before,

> I totally trust my doc, and I don't want to seem like I'm " telling "

> on him to Dr. Ponseti. I just want what everyone wants--what's best

> for Ava.

> Sorry my posts are so long! I'm a writer at heart!

> Thanks to everyone for your replies!

>

> mommy of:

> Guinevere (no CF) on (no CF) Ava 8/4/04 (right CF)