letter between Dr H. and Dr Frick

January 12, 2005

See below

L. Frick, MD

Residency Program Director

Dept. of Orthopaedic Surgery

Carolinas Medical Center

Re: 3 yo clubfoot patient

Hello Steve:

Regarding Grace Booth. The lateral x-ray of the right looks OK but

the

left is lacking DF. Is this a true stress x-ray? I think it would be

worth repeating the film with MD supervision to insure that it was

made

with a DF stress. You are describing a patient with a weak push off,

and

in this case, I would be loath to lengthen the Achilles again. If the

stress film shows true lack of DF, then I would consider two options:

Gradual distraction with Ilizarov or TSF versus posterior release and

capsulotomy. If I did the capsulotomy, I would keep her in cast for a

minimum amount of time to avoid getting stiff.(3-4 weeks only). The

ilizarov treatment might appeal to the internet parent who is open

surgery phobic....Ilizarov is a " Super cast " ..

Hope this is helpful.

Herzenberg, MD

>>> " Frick, " .Frick@...> 12/1/2004

10:03:03 AM >>>

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

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January 12, 2005

At 09:48 AM 1/12/2005, you wrote:

> The

>ilizarov treatment might appeal to the internet parent who is open

>surgery phobic....Ilizarov is a " Super cast " ..

That has rods poked into the child's foot and leg... ugh!

I don't understand this statement at all. I know it can work but

jeez... like one is *that* much better than the other. I would want to

know why and how and how long the Ilizarov device (it's not a cast, it's a

huge metal thing with metal rings around the leg and foot with rods poking

into the leg and foot and you adjust it to correct the CF, or something

like that - their are pictures online, search *Ilizarov*) would be used as

opposed to the capsulectomy (sp? is it an *ectomy?) which he says would be

a 3-4w cast. What are they going to do in the ankle capsule and why? What

does the Ilizarov device do instead and how is that better?

I'm also kinda weirded out about the reference to the *internet parent who

is open surgery phobic*. What does that say for us and how are we

different than any other parent who doesn't want surgery? More informed

about it I'm sure but why the distinction of an internet parent?

hummm...

Kori

January 12, 2005

One person I know likened the internet to a big bathroom wall, full of graffiti.

This was years ago, but the same holds true today. Some stuff just isn't that

accurate. The doctor was probably referring to that tendency.

Re: letter between Dr H. and Dr Frick