RE: Re: unsure of next step-a little confused

[Guest guest]

Hi Jescie,

Thanks so much for the e-mail. I wanted to ask you if you thought Sierra's

foot looked fine before you saw Dr. Ponseti? Could you tell it was

overabducted?

How many casts did Dr. Ponseti do to correct this and how long did you have

to stay in Iowa?

I am definitely considering the trip though I think I will take Keira to see

her current Dr. to discuss Dr. Ponseti's recent e-mail and see if he is

willing to collaborate with him on her treatment.

If I end up going to Iowa, I am hoping it would be a brief trip. Wouldn't it

be great if Dr. Ponseti's practice was in say....Hawaii? I think Keira's

dorsiflexion seems good so I doubt another tenotomy would be needed.

What led to Sierra having a second tenotomy and what made her Dr. think she

was atypical?

I always thought that atypical feet had to be quite short and chubby so I

didn't even consider the possibility that Keira's may be.

I am so glad to her that Sierra is doing so well! It must feel great to get

that " seal of approval " from Dr. Ponseti himself to know that her foot is

fine. Was he doing a lecture on atypical feet? Is that what he wanted Sierra

to be there for?

Thanks for the info...I'd write more but Keira is crying in her crib.

Usually she naps in the swing in the evening and then comes to bed with us

but the motor on the swing quit working today. She is having a crash course

in sleeping in her crib!

Halley

Re: unsure of next step-a little confused

Hi Halley,

I just wanted to make some general comments/hopeful reassurance

regarding atypical feet and the degree of abduction in the brace.

Since the atypical population is small, I thought I should put our

personal experience/two cents in.

Our daughter has/had bilateral atypical cf (currently 8 months old),

and was severely overabducted by her original Ponseti certified

doctor - unknown to us. Since her 2nd tenotomy (when our doctor

mentioned she may have atypical cf) we've been seeing Dr. Ponseti.

Once he was done casting her back to a neutral position - the

's were set at 30 degrees. After reading everybody's posts

here about how important it is to have the brace set at 70 degrees, I

e-mailed him about it, wondering if we should gradually change them

to 35, 40, 45.and he said no, keep them at 30 because her hind foot

is corrected. Then I got a call from him 2 weeks ago, asking us to

bring her in so he could take pictures of her feet for a talk he gave

on the 2nd of March. Of course we were honored to bring her in (I'm

VERY proud she's able to contribute to the science and teaching of

the Ponseti method). Dr. Ponseti was so excited that she was doing

so well (Dr. Mercuende had a look at her too), and within the week he

e-mailed to tell me to move her brace to 20 degrees. From what I

understand, atypical feet should be as straight as possible

(perpendicular to the leg) - maybe others know different. If you have

the time/means to go to Iowa to see Ponseti and get his personal

opinion - I definitely would.

Hope things go well,

Jescie and Sierra

> >

> > Hello,

> >

> > I posted a few weeks ago about how I had e-mailed both Dr.

> Morcuende and Dr.

> > Ponseti pictures of Keira's foot. Dr. Morcuende said they

> looked " nicely

> > corrected " while Dr. Ponseti said that he thinks that they may be

> atypical

> > and that he believes that her forefoot is too hyperabducted. He

> couldn't

> > confirm if they were atypical as I didn't have a picture of the

> sole of her

> > foot prior to treatment for his reference. He recommended

getting

> the

> > brace (we just ordered this) and reducing degree of

> abduction to no

> > more than 30 degrees.

> >

> > I send him a follow up e-mail to ask about the impact of reducing

> abduction

> > as it relates to maintaining a full range of motion as well as

> allowing for

> > some natural regression of the foot. I will post the last two

> replies from

> > Dr. Ponseti below. I don't know if it's just me, but they seem a

> bit

> > contradictory with the first saying that no casting should be

done

> until we

> > see how she responds to brace and the next one saying one or two

> more casts

> > needed before the brace. I know it's hard for Dr. Ponseti to see

> what is

> > going on with a foot via pictures over the internet especially

> since I'm not

> > a great photographer. I will also post the e-mail from Keira's

> doctor, Dr.

> > in response to the first e-mail 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.

> >

> > I.V. Ponseti, M.D.

> >

> > March 1, 2006

> >

> > The picture shows this is an atypical clubfoot. These feet have

> very tight,

> > shortened plantar intrinsic muscles which cause the crease on the

> sole of

> > the foot and they also have a tight heelcord. The muscles on the

> inner side

> > of the leg, the posterior tib and flexors of the toes, are easily

> stretched

> > so the foot should not be overabducted. The hindfoot is already

> in 10

> > degrees of valgus. The child needs another cast or two in 20

> degrees of

> > abduction and dorsiflexing all of the metatarsals with both

thumbs

> with

> > counterpressure applied by firmly holding the knee in 90 degrees

> of flexion.

> > The foot should be dorsiflexed simultaneously both at the midfoot

> (Lisfranc

> > line) and at the heel to correct the cavus and equinus. A

> heelcord tenotomy

> > may be necessary before the last cast is applied dorsiflexion is

> limited to

> > less than 10 degrees. These feet tend to improve with time and

> the calf

> > muscles become more relaxed when the child begins walking in the

>

> > brace. The shoes should be in about 20 (and not more than 30)

> degrees of

> > outward rotation and the bar should be straight, not bent up at

> the ends.

> > The child should be encouraged to stand in the brace.

> >

> > If you put the foot at 70 degrees of abduction, the crease on the

> outside

> > border of the foot will not go away. This crease indicates the

> metatarsals

> > are overabducted at the Lisfranc line. This is why the shoes

> should only be

> > at 20-30 degrees of outward rotatiion.

> >

> > I.V. Ponseti

> >

> > Hi Ms Prestage

> >

> > Thanks for your email. I am always interested to hear comments

> from others,

> > especially Dr. Ponseti.

> >

> > I believe Keira's foot is well corrected now a Pirani 0 versus 6

> when we

> > started. As well it is very flexible and achieves ankle flexion

> towards the

> > leg of about 15 - 20 degrees (dorsiflexion) after the heel cord

> tenotomy

> > which I am happy with. It is sometimes difficult to get a full

> appreciation

> > of the foot from non-standardized pictures over email.

> >

> > As for the comments regarding too much outward rotation of the

> foot, I would

> > not be against decreasing the outward rotation somewhat as per

Dr.

> Ponseti's

> > suggestion. I am also happy for you to choose the shoes

as

> > mentioned. We at the Alberta Children's Hospital have had great

> success with

> > the shoes as you have now but it can be your choice.

> >

> > Just as an aside, Dr. Ponseti would be happy to know I trained

> with one of

> > his former fellows, Dr. Haemish Crawford, who performs his

> technique

> > exactly. I also try to do this.

> >

> > Try not to worry. The foot is well corrected and we should have

> good results

> > in the long term if we stick with the foot abduction orthosis. If

> you would

> > like, I could see you sooner than our scheduled appointment to

> discuss the

> > shoes.

> >

> > Yours sincerely,

> >

> >

> >

> >

> >

> >

> > So, I was thinking of forwarding the last e-mail from Dr. Ponseti

> to Dr.

> > to see what he thinks of this. Dr. seems to think

> her foot

> > looks great but then maybe he hasn't dealt with an atypical foot

> before.

> > Speaking of atypical, I am not sure anyone knows if Keira's foot

> was

> > atypical or not..even Dr. Ponseti said that he would need to see

> pictures of

> > the plantar surface of her foot to determine this.

> >

> >

> > Sorry this is so long..but I am sort of vexed by all of this.

> Maybe I should

> > just go to Iowa and call it a day! Should I let Dr. have

> another go?

> > Ultimately, I'd like Dr. to phone/e-mail Dr. Ponseti but I

> don't want

> > to appear to impugn his expertise in this either kwim?

> >

> > Anyway, I would love to hear some feedback if you have time to

> read this

> > long e-mail!

> >

> > Thanks!

> >

> > Halley

> >

> >

> >

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