Re: The 3rd International Congress on Clubfoot

February 1, 2003

When looking over some past posts, I had noticed an important item

that son had mentioned about the 3rd International

Congress on Clubfoot meeting in San Diego. is a pediatric

orthopedic doctor who treats clubfeet and occasionlly shares insights

here with out group. was also at the 3rd International

Congress on Clubfoot meeting along with a number of other Ponseti

method doctors.

The meeting was over a 2 day period in August 2002, and much of the

afternoon of the first day was on the Ponseti method related papers.

The effect of so many Ponseti method papers from different places and

different doctors reporting great non-surgical success was very

powerful in the meeting. I think that a number of the doctors were

astonished by what was presented and discussed. So much so that in

the second days meeting, a number of surgical method related

presenters asked to withdraw their papers before they had to present

them (either 2 or 3 papers).

Also, son reported on the concluding statements of Dr.

Duhaime who was one of the co-chairs of the meeting. said in

her message here from August 2002, " It was a truly inspiring meeting.

I have a few points to add. Dr. Duhaime, in his closing remarks

clearly stated that one of the striking conclusions arising from the

research and discussion presented was that non-surgical means

(Ponseti and the Physiotherapy methods) were superior to surgery and

should be attempted in preference to surgery. The point was also made

by several well-respected surgeons that the Ponseti method must be

learned and performed properly and that those seeking to use it

should receive proper instruction and ensure that they are truly

following the correct protocol. "

http://groups.yahoo.com/group/nosurgery4clubfoot/message/12472

I thought that this was an interesting item that has not been

highlighted here.

and (3-17-99)

> This past Tuesday and Wednesday, August 27 - 28th was the 3rd

> International Congress on Clubfoot at the San Diego Convention

> Center. It was a part of the The International Society of

> Orthopaedic Surgery and Traumatology Convention (SICOT/SIROT).

SICOT

> describes itself as the worlds Orthopedic Organization whereas the

> AAOS is limited mostly to American orthopedists.

> http://www.sicot2002.com/

> The chairmen of the meeting were Dr. Bensahel (Paris), Dr. Kuo

> (Chicago) and Dr. Duhaime (Canada)

>

> In February, Dr. Morcuende of the U of Iowa and I decided to try to

> write and submit a paper to the meeting about the influence of the

> internet in helping parents have information on clubfoot and

> treatment alternatives. Our paper was accepted and I got the

> opportunity to present it at the meeting in San Diego. Allyson,

> Charity and were also able to attend some of the meetings.

>

> I will try to report here on some of the information that I learned

> from the meeting. It is possible that I may have misunderstood

> someones position or statements and may not remember things

exactly,

> but these are my recollections of what I heard. If anyone feels

that

> I have missed something or misinterpreted it, please let me know

and

> I will try to correct it.

>

> There were 70 papers presented from 20 different countries. The

> countries from which papers were presented were: USA (27), Canada

> (6), France (6), Swiss (4), Brazil (3), Uganda (3), China (2),

India

> (2), Poland (2), Russia (2), Turkey (2), Australia, Argentina,

Korea,

> Japan, Pakistan, Sweden, Thailand and Venezuela. There were also

> doctors there that were from Norway, Germany, UK, Nigeria, S.

Africa,

> Mexico and probably a few other countries that I didn't know about.

>

> The papers were sorted and presented by the following topics:

> Anatomy and Pathophysiology (6), Epidemiolgy and Community (4),

> Classification (2), Outcome & Evaluation (4), Gait after Surgery

(5),

> Ultrasound (4), Ponseti (8 directly, 15 related to the Ponseti

> method), French Method (4), Orthosis (2), Clubfoot Release (11),

> Additional Procedures (ATTT, Ilizarov)(7), Complications (7) and

Misc

> (Arthrogryposis)(4). Three of the papers were also related to the

> Uganda Clubfoot project and one of Dr. Norgrove Penny's papers on

> Uganda was the lead story in the next days " Convention Newspaper " .

>

> Dr.'s that I knew who were in attendance who were Ponseti method

> doctors included: Dr's Ponseti & Morcuende (Iowa), Pirani

> (Vancouver), Penny & Steenbeek (Uganda), Frick (S. Carolina),

Lehman

> (NYU), Mosca (Seattle), Dobbs (St. Louis), son

> (Ontario), Dale Jarka (Kansas City), Dalia Sepulvida (Chile),

> Alvarez (Ponseti/Botox - Vancouver), s &

> (French/Ponseti, Dallas), (Cleveland), Lourenco (Brazil)

and

> del Campo (Mexico) and one from UCSD (San Diego). I assume that

> there were also other Ponseti method doctors there but that I

didn't

> know who they were.

>

> Dr.'s there that were French method doctors included Dr's Bensahel

> (France), s & (French/Ponseti, Dallas), Exner

> (Swiss). I assume that there were also others there who use the

> French methods, but I didn't know who they were.

>

> There were also a number of surgical method doctors including

Gennari

> (France), Synder (Poland), Singh (India), Lara (Brazil), Ozeki

> (Japan), Fernandez (Venezuela), (Shriners, Chicago), Aroojis

> (India) and about 15 others who presented surgically related

papers.

> There were probably also other surgically related doctors who I

> didn't know who their names as well as some who may use

combinations

> of different methods.

>

> There were 15 papers presented during the meetings that were

>

> Can the Internet Spare Children from Clubfoot Surgery? The effect

of

> web-based information and parent support-groups on parent treatment

> choices for clubfoot. Egbert M, Morcuende JA, Ponseti IV (USA)

>

> Community Based Rehabilitation (CBR) in the Management of Clubfoot

> Deformity in Africa. Penny JN, Steenbeek M (Uganda) This paper

> became the subject for the lead story in the next days Convention

> Newspaper.

>

> A Reliable Method of Assessing the Amount of Deformity in the

> Congenital Clubfoot Deformity. Pirani S, Hodges D, Sekeramayi F

> (Canada)

>

> MRI Study of Congenital Clubfeet Treated with the Ponseti Method.

> Pirani S (Canada)

>

> A Single Surgeon's Experience with the Ponseti Method for the

> Treatment of Idiopathic Clubfoot Deformity. Dobbs MB (USA)

>

> Ponseti Treatment of the Congenital Clubfoot: The New Westminster

> Experience. Pirani S (Canada)

>

> Efficacy of the Ponseti Method in the Treatment of Idiopathic

Clubfoot

> Morcuende JA, Dolan LA, Ponseti IV (USA)

>

> A Technical Note on the Ponseti Method: The Importance of the

> Supination of the Forefoot in the Initial Cast to Reduce Cavus

> Deformity. Frick S (USA)

>

> Method for Evaluating the Effectiveness of the Iowa (Ponseti)

> Clubfoot Technique. Lehman WB, Scher DM, Feldman DS, Bazzi J,

> Mohaideen A, Madan S, van Bosse HJP, Iannacone MR (USA)

>

> Botulinum A Toxin in the Treatment of Clubfeet: A Preliminary

Report

> of a Pilot Study. Alvarez CM, Tredwell SJ, Sawatzky BJ, Beauchamp

> RD, Choit R (Canada) This method is the Ponseti method except for

> the use of BOTOX instead of a tenotomy.

>

> Ponseti Method Treatment of Congenital Clubfoot in Older (4 Months)

> Children Who Have Failed Prior Non-Ponseti Cast Treatment. Frick SL

> (USA)

>

> Conservative Treatment of Clubfoot After Walking Age. Lourenco AF,

> Prata SD, Sodre H, Milani C (Brasil)

>

> The Steenbeek Foot Abduction Brace (SFAB): Preventing Recurrence

of

> Deformity in Developing Nations During Treatment of Congenital

> Clubfoot by the Ponseti Method. Steenbeek HM (Uganda)

>

> Initial Results of the Ponseti Method in Patients with Clubfoot

> Associated with Arthrogryposis. Morcuende JA, Dolan LA, Ponseti IV

> (USA)

>

> I will put the outline and titles of all of the papers in the files

> section of the Ponseti method parents support group site which can

be

> located at http://groups.yahoo.com/group/nosurgery4clubfoot/

>

> I was able to spend a few hours on monday with Dr.'s Ponseti,

> Morcuende, Frick, Mubarak and Wenger at the UCSD Children's

> hospital. Charity and Trenton were there as well as some other S.

> California internet parents who we had met at Dr. Colburns 1 1/2

> years ago.

>

> I thought that the meetings on Tuesday and Wednesday were very

> informative and that the Ponseti method was recieved very well by

> those who were there. After our paper on the internet, there were

a

> number of doctors that asked about the internet groups. I had told

> them that Clarrisa had assembled what I think is the greatest

library

> of internet information on clubfoot in the world on Parentsplace

that

> had links to sites on all subjects. One doctor said that most of

> what is on the internet shouldn't be trusted and that we should be

> censoring which sites get placed into our library. I indicated

that

> we didn't see it as our role to censor the information, but to make

> all the information we could find available so that parents could

be

> aware and that different subjects and questions could be

discussed.

> Our own Dr. son stood up and defended our efforts to

> provide information on all clubfoot related topics to parents.

>

> There was a lot of new information in the different Ponseti method

> papers. I will try to summarize some of the new information.

>

> Dr. Dobbs (St. Louis, Shriners) report was on 55 consecutive

patients

> with 95 clubfeet. There were 33 males and 22 females. Thirty three

> patients had been treated by others before going to see him with an

> average of 10 casts, (range of 3 to 20 casts by prior doctors).

> Treatment was begun at his institution at an average of 14 weeks of

> age, (range 2-64 weeks). Six feet were corrected with serial casts

> alone. The remaining 89 feet were fully corrected after casting

plus

> a percutaneous heel cord tenotomy. Two patients required a

posterior

> ankle release after having been non-compliant with brace wear.

>

> Dr. Dobbs report included a study on non-compliance with the use of

> the FAB brace. Similar to the prior U of Iowa studies, most but

not

> all of the relapses they had were related to non-compliance with

the

> use of the FAB. They did a study on factors that seemed to

correlate

> with non-compliance and then used those to identify patients most

> likely to have non-compliance problems. Then from the time of

> initial casting they were able establish a method of reducing the

> number affected by non-compliance and relapsing.

>

> The issue of the potential difficulty of getting parents to use the

> FAB was often a topic of questions of the doctors relating to the

> Ponseti method.

>

> Dr. Frick's paper was on what he called the " Magic Move " of the

> Ponseti method. He mentioned that a number of doctors he had

talked

> to said that they were trying the " Ponseti " method but that it

wasn't

> working as it was supposed to. He said that upon further

questioning

> of their method, he was able to find what he felt was a common

error

> in the way some doctors try to do the initial Ponseti method cast

> that makes it much for difficult for them to have success. (It is

> also listed as one of Dr. Ponseti's common errors at his site as

#1,2

> Pronating instead of Supinating the foot)

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

>

> Dr. Frick said that once he and other doctor get that initial

> manipulaion move to supinate instead of pronate the foot in the

first

> casting that it sets up the balance of the foot correction in later

> casts to flow smoothly.

>

> Dr. Lehman said how they at NYU used to treat most of the children

> they saw surgically, but that now they almost never do. He said

that

> almost all of the clubfoot surgery he is now doing is treating

> relapsed feet that were previously surgically treated.

>

> An extremely interesting Ponseti and Physiotherapy paper was by a

Dr.

> Lourenco of Brazil about conservative treatment of clubfoot after

> walking age. He indicated that in Brazil, that there are

tremendous

> treatment resources for those who are wealthy but that the poor

often

> get no care. Over the past few years, he has been trying to treat

> older poor children who have had no prior treatment. He said that

> the financial resources have not existed for him to be able to do

> surgery so that he has tried a physiotherapy/Ponseti-like casting

> method for children from 5 to 8 years of age with very bad

previously

> untreated feet. Although it is not as good as it would have been

if

> treatment had been when they were little it is working and it is

> currently those children's only alternative. I think all of the

> Ponseti method doctors including Dr. Pirani, Penny, Steenbeek of

the

> Uganda clubfoot project were very amazed and feeling inspired by

that

> paper.

>

> I believe that it was Dr. Lourenco who told me that he had been

doing

> the surgical method in Brazil for his regular patients up until

about

> 2 years ago. He said that he had gotten a call from a fellow

doctor

> whose own child had just been born with clubfoot. This fellow

doctor

> said, " I want you to do all that you can to avoid the surgery. "

Dr.

> Lourenco had recently heard something about the Ponseti method,

> investigated it further and used it for the other doctors child.

He

> said that since then he had treated 55 children with the Ponseti

> method.

>

> Dr. Penny had said that 3 years ago, when the Uganda Clubfoot

project

> first got started that they felt that 6 months was about as late as

> they could start a child in the Ponseti method in Africa and so

they

> usually kind of just planned on the surgery if they were older than

> that. As they had been using the method, they had slowly been

trying

> it for children who came who were older and over 1 and been able to

> make it work, but had not considered that there was still a chance

to

> try to make it work out to 5 to 8 years of age in untreated feet.

>

> Mr. Steenbeek also presented a paper on his Ugandan FAB for use in

> developing countries where the cost of a US made FAB would be too

> expensive.

>

> Dr. Morcuende also presented some information about the U of Iowa's

> experience with using the Ponseti method in the treatment of

> Arthrogryposis. They indicated that from 1992 to 2001 that they

had

> been about 50% successful in avoiding posterior release types of

> surgery. They indicated that although surgery may be necessary, it

> is less extensive. Dr. Gotfried from Lubbock, Texas had also

> reported on his encouraging experience with the use of the Ponseti

> method for a few arthrogryposis children in his poster presented at

> the May 2002 POSNA meeting.

>

> The effect of having the 8 Ponseti method papers all one after

> another and all from different doctors and hospital groups and all

> essentially saying the same thing was very powerful. One doctor at

> the end said in a general question from the floor microphone, can

> anyone think of a reason not to try using the Ponseti method first

> before considering going toward a surgery.

>

> Also it appeared that there were a number there who had never

before

> heard of the Ponseti method. The main group of Ponseti method

papers

> were presented on Wednesday morning and at the end of the

conference

> that day, a number of doctors gathered in different parts of the

room

> around Dr. Ponseti, Dr. Pirani, Dr. Penny, Dr. Morcuende, Mr.

> Steenbeek to try to learn the specific manipulation and casting

> technique and to get copies of the CD's that were available that

had

> the Ponseti method video and Uganda Clubfoot Project information.

I

> told Dr. Morcuende, Pirani, Penny, Steenbeek that I thought that

they

> were all going to be very busy trying to help get information to

> people who were interested.

>

> Dr. Morcuende said that the Costa Rica Ponseti method project was

> going well and that he had been invited to go to a clinic in

> Columbia. The head of the Nigerian pediatric orthopedics was very

> interested in the Uganda Clubfoot Project. A doctor from Bombay

> India said that what he had learned was going to have a big impact

on

> what they did in the future.

>

> There was also one doctor I met during the 3 days there who

indicated

> to a group of doctors with me that his surgical skills were too

> valuable to be used in trying to conservatively cast a child's

feet.

> That if the casting techs couldn't learn how to do the Ponseti

method

> well enough that his time couldn't be spent doing it. He indicated

> that the money generated for hospitals that were already

financially

> strapped was in highly skilled ped ortho surgeons in doing

surgery.

> That they should be utilized in their most financially valuable

role

> and the role that they were trained for which was surgery. He also

> felt that the Ponseti method took too much time to spend on

> manipulation and casting. I thought that it was a fairly

surprising

> statement. I thought later that I should have mentioned that since

> most children were already being casted for 3-4 months prior to a

> surgery as well as 3 months post surgery anyway, that it might also

> be more economical to just cast for 2 months with the Ponseti

method

> and save the hospital some money by not having to cast as much.

>

> It was a great meeting and I was very grateful to be able to be

there

> and learn from all of the information presented. To try to go over

> all of the other papers will be much too long. If anyone has any

> specific questions about a paper from the title in the files

section

> please ask.

>

> and (3-17-99)

February 1, 2003