Dr Ponsetis reply to Dr Frick

[Guest guest]

Thx for email – see below. I will also answer your email

L. Frick, MD

Residency Program Director

Dept. of Orthopaedic Surgery

Carolinas Medical Center

3 yo clubfoot patient

Dear Dr Ponseti, and - hope you are well and enjoying the

holiday season. I met Grace Boothe yesterday, who is now about 3 and

a half years old. She has bilat clubfoot, initially treated with

below knee casts in army system for 5 months, then by in

Chapel Hill with a few casts and right tenotomy, then by Dr Ponseti

with casts and bilateral tenotomies. She was in orthotic full time

but then was cut back because of concerns about ligamentous laxity

and overcorrection. She had a few followup visits with

Herzenberg around age 2, and mom says she was worried then about the

heels not being down but she said she was given assurance that it

was ok and would not be a problem.

She has had delayed milestones and is very short for her age- seems

to be barrel chested to me with disproportionately large head and I

wonder if she might have mild SED congenita- work up beginning now.

Her feet show bilateral rocker bottom deformity, right worse than

left, with empty heel pads and abnormal contour of the heel. She

walks with a stiff knee gait, wide abduction of limbs, and with

midfoot and forefoot contact but no heel contact with the ground.

She cannot run or jump.

I have attached copies of xrays of her feet. I would appreciate (and

her parents would also) your thoughts/ comments about her feet and

what to do now. My thoughts are that in some cases where children

have ligamentous laxity, the midfoot/forefoot ligaments give way

during casting before the tighter hindfoot ligaments and rocker

bottom develops. I have observed a few of these children after

emailing Dr Ponseti, and some have improved after beginning to walk,

with the heel dropping down into the heel pad and ankle dorsiflexion

improving (rather than only dorsifelxing through the midfoot). In a

few cases, the rockerbottom did not improve after a few months of

walking, and I have done limited posterior tibiotalar and

talocalcaneal arthrotomies with very little to no addition

lengthening of the Achilles. These few cases seem to be doing ok,

and maybe have retained some motion at the ankle/ST joint because of

their global propensity for laxity.

Should I proceed with posterior arthrotomy in Grace? Right side only

or both? Can we work on providing Ponseti method practitioners with

some guidelines for when (if ever) you believe it is appropriate to

proceed with surgery? The group (esp Internet parents) are so set

against any surgery that it is often difficult to even discuss with

them. In addition, there is a current " rage " of concern

about `whether or not my child has an atypical clubfoot " . I think of

the atypical foot as the ones that are short, broad and have

plantaris instead of only first ray cavus.

Any thoughts/ideas appreciated. Thanks.

Steve

L. Frick, MD

Residency Program Director

Dept. of Orthopaedic Surgery

Carolinas Medical Center

---------------------------------------------------------------------

-----------

This electronic message may contain information that is confidential

and/or legally privileged. It is intended only for the use of the

individual(s) and entity named as recipients in the message. If you

are not an intended recipient of this message, please notify the

sender immediately and delete the material from any computer. Do not

deliver, distribute or copy this message, and do not disclose its

contents or take any action in reliance on the information it

contains. Thank you.

---------------------------------------------------------------------

-----------

This electronic message may contain information that is confidential

and/or legally privileged. It is intended only for the use of the

individual(s) and entity named as recipients in the message. If you

are not an intended recipient of this message, please notify the

sender immediately and delete the material from any computer. Do not

deliver, distribute or copy this message, and do not disclose its

contents or take any action in reliance on the information it

contains. Thank you.

| | | | | Inbox

Get the latest updates from MSN

MSN Home | My MSN | Hotmail | Search | Shopping

| Money | People & Chat

Feedback | Help

© 2004 Microsoft Corporation. All rights reserved. TERMS OF USE

Advertise TRUSTe Approved Privacy Statement Anti-Spam Policy