Re: Journal of Pediatric Orthopedics Online

[Guest guest]

Thank you for this info .

We just had an appointment with Quinns ortho doc, and all is going well.

His x-ray showed not much change form 6 weeks ago, which totally perplexed

me. His foot is supple and he is now a 3 on the 0-20 Dimeglio scale. He

can achieve 25 degrees dorsiflexion, and normal (40degrees) of abduction.

His foot is not in varus. He still has a slight resting adduction of his

forefoot. His heel is going down into the fat pad, and when he stands, it

looks wonderful!!!

I was really disappointed with the x-ray, but after reading your note, I

don't think I am going to put too much into it anymore. Functionally, his

foot is wonderful.

(Drum roll please)...............Quinn is in a DBB now!! He will wear it at

naps and bedtime and continue with his splint at all other times. He will

also continue with the manipulations and taping.

The shoes are open toed, straight last high tops. When we go to therapy

today they will assess him in it and make adjustments.

He doesn't mind the shoes at all. I guess with strangers and mom playing

with his feet every day, and the taping and splinting, he is oblivious to

this new intrusion. I think the taping and thick socks will keep blisters

from forming. Plus, I put duo-derm on prominent bony areas. I am more

worried about his normal foot, which is not used to the taping and

splinting.

I am sure I will be back asking DBB questions. Any advise would be

appreciated. I will post some pics as soon as I get them.

Jody

Journal of Pediatric Orthopedics Online

> As some of you may be aware, after the POSNA convention in Vancouver

> last May 2000, Dr. Ponseti was invited to write an editorial on

> Clubfoot Management that appeared in the Nov/Dec 2000 issue of the

> Journal of Pediatric Orthopedics, a publication of the Pediatric

> Orthopedic Society of North America.

>

> In some excerpts from that editorial, Dr. Ponseti says, " No major

> congenital musculoskeletal deformity is easier to diagnose or simpler

> to treat than the clubfoot. And yet, the nature of the clubfoot

> deformity and its treatment continue to elude many orthopaedists

> despite the several available studies correcting misconceptions on

> this subject.... "

>

> " At present, many surgeons consider nonoperative measures as

> preliminary steps to facilitate the primarily surgical interventions

> needed to correct the clubfoot toward 6 months of age. Improved

> surgical techniques have yielded better short-term results, but at

> what cost? Extensive surgical approaches and dissections with

> severance of most tarsal joint capsules and ligaments have become the

> fashion. (1994) voices his concern about " the tremendous

> impact in the older child " that these operations may have. The

> consequences of ligament and joint damage inflicted by the extensive

> tarsal joint releases routinely performed in an effort to align the

> bones of a clubfoot should not be ignored.... "

>

> " ....Unfortunately, long-term results of surgery beyond adolescence

> are lacking. "

>

> The editorial also discusses some other issues relating to

> ultrasounds, how the development of a clubfoot procedes, shortfalls

> in the prevailing manipulation techniques that lead most ped orthos

> to perform sugical interventions, some historical issues, french

> physiotherapy methods and information relating specifically to the

> Ponseti method.

>

> The article is not available online that I know of.

>

> It is also interesting that the Journal of Pediatric Orthopaedics has

> just started offering an online version of the Journal that will be

> free for the Jan/Feb 2001 and Mar/Apr 2001 issues. We can also

> subscribe to it's 6 issues for $228 per year. They indicate that

> their circulation is 2,600 issues and that they also take ads.

>

> In the Jan/Feb issue, there are a number of articles on clubfoot

> including one on " Patient Based Outcomes After Clubfoot Surgery " by

> doctors at Columbia University and about 6 other hospitals in New

> York (Not including NYU)

>

> Their study included 46 patients with an average age of 8 years. The

> article references Dr. Ponseti's 1980 long term study a number of

> times and appears to agree with Dr. Ponseti's position that using x-

> ray analysis to determine outcomes (as most other outcome studies do)

> " may not be a meaningful or appropriated one. "

>

> From their article:

>

> " .... Surgical experience in correcting this deformity extends back

> over 200 years when Lorenz first perfomed a tenotomy in 1784.

> Despite this wealth of experience, there is no firm consensus with

> respect to etiology (I think etiology is how and why clubfoot occurs)

> or to the best treatment protocol. Much of the controversy arises

> from the absence of a standardized method for assessing the results

> of clubfoot surgery and a lack of focus on patient based outcomes in

> this area.... "

>

> " Historically, the literature of clubfoot outcomes has focused on

> traditional, " intermediate " end points of outcome, such as

> radiographic angles and physician-based assessments, with little

> focus on patient-based information. The utility of radiographic data

> was called into question as early as 1964, when Wynne-Davies asked

> whether " radiographic appearances bore any relation to clinical

> assessment, " but radiographic outcomes such as talocalcaneal (Kite's)

> angle remain perhaps the most commonly reported yardstick in these

> cases. All articles reviewed used radiographic criteria as an end

> point. Although 43 of 53 articles used the talocalcaneal angle ....

> this measure may not be a meaningful or appropriate one. " (J of Ped

> Ortho 2001:21:42-49) http://www.pedorthopaedics.com

>

> If you remember from Dr. Ponseti's web site, he felt that one of the

> common errors that doctors made when treating clubfoot was to feel

> that they needed to use surgery in " ... #8 Attempts to obtain a

> perfect anatomical correction. It is wrong to assume that early

> alignment of the displaced skeletal elements results in a normal

> anatomy and good long term function of the clubfoot. We found no

> correlation between the radiographic appearance of the foot and long-

> term function [3]. In severe clubfoot, complete reduction of the

> extreme medial displacement of the navicular may not be possible by

> manipulation. The medial tarsal ligaments cannot be stretched

> sufficiently to properly position the navicular in front of the head

> of the talus. Since the joint capsules and ligaments play a crucial

> role in the kinematics of the tarsal joints [7], they cannot be

> stripped away with impunity. In infants, the medial ligaments should

> be gradually stretched as much as they will yield rather than cut,

> regardless of whether a perfect anatomical reduction is obtained or

> not [11]. "

> http://www.vh.org/Providers/Textbooks/Clubfoot/Clubfoot.html

>

> I just thought that some might be interested in this information.

>

> and (3-17-99)

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