Dr.

[Guest guest]

Hi ,

Did you recieve your package?

I have a few questions...Do you put the foot at 20degrees of

dorsiflexion in the cast after the percutaneous tenotomy? and when

you say the hindfoot correction is less then you would like do you

mean Equinous or varus? How do you determine the heel being in place

X-ray or palpatation. I am so tempted to give a little pull to the

calcaneous (if timing for the PAT is delayed) if the forefoot to

hindfoot is fully corrected but that is a no-no with Ponseti and I am

not sure if just the molding real well over the posterior crease (not

allways superior to the calcaneous) is enough. Feed back please.

Beth~~The Cast Lady PS did you see the article on Dr. Aadalen on the

shriners web site? See post 6999

> Hello,

>

> I hate to throw myself into the middle of the fray here, but I felt

> that I must comment on the above. It is generally accepted that

> surgical lengthening weakens a tendon/muscle group. I am sure that

> there is not good data specifically on infant heel cord tenotomies

> because (until recently) this was used in few places. It may be

that

> this is an insignificant difference when performed in very young

> babies with great healing potiential.

>

> Theoretically, a non-surgical lengthening avoids this risk and

> is " better " however I use the word advisedly as it is not better if

> in an attempt to get lengthening too much force is put across the

> joints and damage is caused (say to the blood supply or the joint

> surface at the top of the talus).

>

> A tendon that is cut and then heals may be scarred and retract more

> if not held out to length. This may be very different in the

Ponseti

> tenotomies due to the young age of the patient and the lack of

trauma

> to surrounding tissues.

>

> What am I saying here? I think that it is a bit of a fruitless

> debate. Both methods are good and have their place for different

> feet, different children and different skill sets (I'm speaking of

> surgeons and therapists as a whole here). I'm beginning to believe

> that I must have both techniques available to me in order to

acheive

> my goal of as little surgery as possible and as anatomic and

flexible

> feet as possible.

>

> While my early results with the Ponseti technique are good, I have

> one patient with a very severe foot that I am not happy with. Even

> after tenotomy her hindfoot is not corrected. Now, I suppose that

I

> may have incompletely released the tendon, however my hunch is that

> she is so tight elsewhere (skin, joint capsules) that this is

> preventing the heel from coming down. I have taken her out of

casts

> at this point and am working on a physio type protocol. It took

her

> about 10 days to desensitize her feet, but now she rests quietly or

> sleeps during mobilization (my physio doesn't like the term

> manipulation) and taping. Her hind foot is a bit more supple over

> the past 2.5 weeks. I don't know where we'll get to with her but

I'm

> pleased to have a variety of ideas and possibilities.

>

> A few years ago I looked after a nice little baby who turned out to

> have an inherited condition called Beall's syndrome. We originally

> didn't know what he had (other than peculiar feet and long finger

Dad

> has it too and has never had much problem over the long term). The

> point of my story is that I had never quite seen feet like his

before

> and we worked on them with manipulations, casts and tape for 8

> months. About 5 or 6 months into this treatment I began to despair

> as things didn't seem to be progressing, but I really didn't want

to

> operate on him. Anyway by 8 months his feet were (not

normal,but..)

> really quite good and he has done well into toddlerhood. I learned

a

> lot from that baby and I think that informed persistence is

important

> in the conservative treatment of clubfeet. One method is likely

not

> right for every one.

>

> Anyway, that's my soapbox speech for the day.

>

>