FW: From Dr. Ponseti

February 13, 2006

Hello,

This is the e-mail that I received back from Dr. Ponseti regarding the

pictures of Keira's foot that I e-mailed him. I sent the same pictures to

Dr. Morcuende who said that her foot looked nicely corrected so now I am

somewhat confused! I will e-mail Dr. Ponseti back with this question but

does it sound like she needs more casting, or casting with a different

doctor (I would be willing to take her to Vancouver to see Dr. Pirani), or

just a different brace?

Maybe some of you veterans could help me figure this out. Meanwhile, I will

e-mail Dr. Ponseti to ask the same thing.

Thanks so much!

Halley

Btw, I tried to send pictures to the CFPics group but they are too large.

How do you shrink them again?

_____

From: Roller, Joyce

Sent: February 13, 2006 8:25 AM

To: Halley Prestage

Subject: From Dr. Ponseti

February 13, 2006

The pictures show the forefoot is hyperabducted and the big toe is short.

The transverse crease that seems to extend over 2/3 of the sole of the foot

I suspect was present even at birth. This type of foot often has a deep

crease on the back of the foot above the heel, but I don't see that Keira

has one. I wonder if the equinus is fully corrected. In the picture where

you are pushing up with your hand, the foot only goes to a right angle with

the leg. The other pictures show the heel is in slight valgus. It looks

like this was a complex atypical clubfoot which your doctor treated with

excessive abduction of the forefoot, which is a common error in the

correction of this type of clubfoot.

This type of clubfoot does poorly with the Markell open toe lace up shoes.

Keira will be more comfortable and her feet will be held securely in the

three strap sandal type shoes made by Mr. . See his web site

mdorthopaedics.com E-mail mdortho@...

The shoes should be in 20-30 degrees of outward rotation on the bar so the

forefoot can develop in proper alignment with the hindfoot. The

shoes

also appear helpful in stretching the heelcord. The shoes do not need to go

into 70 degrees of abduction since the hindfoot varus is corrected.

I.V. Ponseti, M.D.

would you mind looking at Keira's foot?

Good Afternoon Dr. Ponseti,

I had e-mailed you a few months ago after we found out via ultrasound about

our daughter's clubfoot. We had considered coming to see you in Iowa but

because we have two other children under three years old, it would have been

quite difficult to arrange.

My daughter, Keira, was born on December 4 2005 with a right club foot. She

was casted at 10 days old with Dr. at the Children's Hospital

in Calgary, Canada. I did ask him all of the qualifying questions before we

began casting to ensure that he was adhering to the Ponseti Method of

treatment. We chose him because out of all of the doctors here in Calgary,

he was described as the " Ponseti-purist " by the head of orthopedics.

She received 6 casts including her tentomy cast. She started as a 6/6 on the

Pirani scale and Dr. scored her every week. She went into her shoes

and bar (Markells) on Wednesday and when Dr. evaluated her, she was

0/6 on the Pirani scale so he said that her feet are fully corrected.

Would you please take a look at the attached photos and give me your opinion

of her foot? I was concerned about a crease on the bottom of her foot on the

outside. It was present on Wednesday and Dr. didn't seem to think it

was a problem. My husband thinks it's just because they overcorrect the foot

to 70 degrees.

I would be so thankful if you would take a look at the attached photos to

give me your opinion/evaluation of her foot and if it seems to be fully

corrected.

By the way, like so many others, I really appreciate all that you do for

these little babies and how you've pioneered this technique to help them

without surgery. You are a blessing to all.

Thanks so much,

Halley Prestage

February 14, 2006

Hello,

Here is the second e-mail I received from Dr. Ponseti regarding Keira's

foot. I am going to send him some pics of her foot at birth tonight plus

some additional shots of her foot and see what he says.

From his e-mail it sounds as if the brace on a different angle

setting might be all that is needed.

I am quite hopeful that Dr. corrected her foot properly, particularly

as it relates to the relationship between the talus and the calcaneous. I

asked him to show me that the bones were in the proper position and we went

through the tenotomy check list (I think pg 13 of Global Help Booklet)

before he did the tenotomy. I asked him specifically about the calcaneous

and the talus and he showed he the calcaneous must come out from underneath

the head of the talus (or whatever it says in the Global health book and

also in Dr. Dobbs article in Biomechanics- I can't find my Global Health

book to reference but I did take it to the appointment).

Anyway, I think that Dr. will be open to consulting with Dr. Ponseti.

We see him next week so I'll discuss this with him then. Hopefully he

doesn't feel threatened or defensive that I sent Ponseti the pictures. Any

ideas of how to approach it in a non-threatening way?

Meanwhile, the impression kit is on it's way! Yeah!

Thanks all of you for your help and feedback!

Halley

_____

From: Roller, Joyce

Sent: February 13, 2006 4:13 PM

To: Halley Prestage

Subject: RE: From Dr. Ponseti

February 13, 006

Yes, I would like to see photos of Keira's foot at birth. In the atypical

clubfoot at birth there is involvement mostly in the calf muscle and the

deep plantar intrinsic muscles of the foot. Only about 3-4% of all clubfeet

are atypical. Possibly your doctor has never treated one before. The

turning in of the foot and ankle tends to correct fairly easily but then the

forefoot goes into excessive abduction because the metatarsals are bent

downwards and the ligaments and joints in the middle of the foot are loose.

The tendo Achilles is tight and this was probably corrected with the

tenotomy performed by your doctor. If there is persistent tightness of this

tendon, it usually improves with time and the foot hyperabduction also

improves in time with the use of the brace.

We have written a paper outlining the proper treatment for the atypical

clubfoot which we hope will be published in Clinical Orthopaedics and

Related Research.

Last year when I talked to Dr. Pirani about this, he had not yet been called

upon to treat one. I think you should see Dr. . When you get the

shoes, the right shoe should be turned out 20-30 degrees but no

more. The foot will be nearly straight on the bar so the metatarsus

adductus will improve. The left shoe should be in about 30 degrees of

abduction as well. It would be best not to apply another cast until you see

how the foot responds to the brace.

Please encourage Dr. to contact me by phone (319 356-3469) or

e-mail if he would like to discuss Keira's treatment.