Re: Ponseti's reply.....let's try this again!

[Guest guest]

At 07:08 PM 6/13/2006, you wrote:

>WOW!!! I got an email back from Dr. Ponseti this evening. I don't

>understand about half of the the terminology, but now I feel armed

>with information!!!

>

>This is what he said:

>Dear Mrs. Crossley:

>

>After seeing only the picture taken from above, I can say that

>iel's right foot appears to be a good deal shorter than the

>left and the heel appears to be in varus.

here's some information about heel varus:

" the foot assumes a posture of an inward tipping of the heel (heel

supination or varus). "

" Patients with heel varus have a visible portion of the heel pad

" peeking out " from the medial border of the foot "

so the heel varus is the part where you can see his heel pushing

toward the inside, unlike the left foot.

> The forefoot is severely

>adducted about 25 degrees.

his foot appears bean or kidney shaped, the forefoot (front part of

the foot) is in adduction meaning it's pointing inward. You can see

this in the picture. Adduction would be the opposite of abduction

which means the turned out (like on the FAB's).

>Without a lateral view of the foot in

>dorsiflexion, I don't know if the foot is in plantar flexion or if

>the foot has some dorsiflexion.

he wants to see a profile picture of his dorsiflexion. Probably both

one with the palm pushing as well as something like him squatting,

both from the side. I'd also send him pictures of his soles and one

each from front and back (camera on the floor) directly.

>Since he is 4 1/2 years old, I would try to correct the deformity

>without surgery. He will likely need about three or four long leg

>casts changed weekly. The correction without surgery depends on the

>amount of stiffness in the ligaments of the foot. Most can be

>stretched in children gradually with a few casts to soften them.

>The heel varus also can be corrected but it is sometimes necessary

>to transfer the anterior tibial tendon to the third cuneiform to

>prevent another relapse.

>

>If you go to the web site www.global-help.org and click on

>Publications, you can download a copy of Clubfoot: Ponseti

>Management. In the English version on pages 20-21 this tendon

>transfer surgery is outlined.

ATTT would only be done after all casting options are exhausted is

what he's saying here. Due to age, I bet he's simply preparing mama

for the possibility as well as showing her what it entails. As an

introduction to what the osteotomy entails and it's comparison to the

ATTT as stated below:

>Osteotomies to correct the adduction of the forefoot are often done

>by removing a wedge of bone from the outside, opening up the first

>cuneiform on the inner side, and placing the wedge of bone

>there. However, this surgery can easily damage the joints so I would try to

avoid it by casting first.

basically, pretend you have a pie. Take out a piece on the right

side, and open up a slit on the left side and wedge it in. Pie

closes up on the opposite side. In doing this, they hope to force

the forefoot to become straight by putting this wedge of bone in one

side and leaving the hole on the other.

>The transfer of the anterior tibial

>tendon is used to prevent the heel varus from relapsing and at the

>same time it is useful in maintaining the forefoot in proper

>alignment with the hindfoot.

so he's saying that casting would more than likely get the foot into

a corrected position. If it stays there, great. If not, he'll take

the AT tendon and transfer *it* over to the opposite side (in as

such, the tendon keeps the foot aligned) as opposed to the osteotomy

which affects the bones. Basically the degree of surgery is reduced

considerably if the osteotomy is avoided. Casting, with experienced

hands (experienced with older feet) would either correct the foot

entirely, without relapse or the casting would bring the foot close

enough to proper correction so that only the ATTT would be

needed. Scratch the osteotomy entirely :~}

hope this helps. I saw his foot, if he can get to Iowa... wow... I'd say GO!

Kori

>I.V. Ponseti, M.D.

>

>I'll keep you all posed on the progress.

>Thankagain for all the help and support.

>

>

>__________________________________________________

>

[Guest guest]

here's info about correcting adduction and heel varus with the

Ponseti Method. Sorry it's so technical, but basically this part of

the correction is done for all Ponseti Patients and likely how Dr.

Ponseti would approach this relapse assuming no cavus is present (pic

doesn't really show this aspect). Incidentally, this phase of the

treatment happens after the cavus correction, and after the adduction

and varus is corrected, they then approach correction of equinus

(bring toes/foot up, attain dorsiflexion). Not knowing how good his

dorsiflexion is at the moment, it is unclear whether he'll even need

equinus correction but I would hazard a guess that by the time the

varus is corrected properly it'll show more accurately how much

dorsiflexion he's got (dorsiflexion meaning how far past " L " or

neutral, plantarflexion being negative degrees or equinus - pointing

toes, heel up off ground) and whether some stretching with casts only

will be adequate.

For information about the whole correction process please click on

the link, only the adduction and heel varus portion is quoted here.

http://www.wheelessonline.com/ortho/casting_for_club_foot

- correction of adduction and heel varus:

- goal is to abduct the supinated foot under the talus;

- again, forceful pronation of the foot is avoided

since it increases the cavus deformity, causes mid foot

break down and does not address the varus heel deformity;

- talus is rotated laterally so that the foot abducts

underneath the talus which is fixed in the ankle mortice;

- this causes lateral rotation of navicular, together

w/ cuboid & anterior aspect of calcaneus, w/o pronation of foot;

- to correct the varus and adduction, the foot in supination

is abducted while counterpressure is applied with

the thumb against the head of the talus;

- foot is abducted in flexion and slight supination to

stretch the medial tarsal ligaments, while counter pressure applied on the

lateral aspect of the head of the talus;

- this allows the calcaneus to abduct under the

talus which correction of the heel varus;

- heel must not be touched during this manipulation;

- calcaneus abducts by rotating and sliding under the talus;

- noted that the calcaneus can evert only when it is

abducted (laterally rotated) under the talus.

- as the calcaneus abducts it simultaneously extends

and everts which corrects the heel varus;

- note that the calcaneus cannot evert unless it is abducted;

- casting involves a toe-to-groin plaster cast w/ knee

flexed 90 degrees and the foot in maximum external rotation;

- maintenance of correction of varus deformity of hind

part of foot which requires external rotation of foot distal to talus;

- radiographs may be taken at this point inorder to confirm

that the talonavicular joint is reduced, prior to managing equinus;

- cautions:

- avoid forced external rotation of the foot to

correct adduction while the calcaneus is in varus;

- this causes a posterior displacement of the

lateral malleolus by externally rotating the talus in the ankle mortice.

- avoid abducting the foot against pressure at the

calcaneocuboid joint the abduction of the calcaneus is blocked, thereby

interfering with correction of the heel varus

At 10:18 PM 6/13/2006, you wrote:

>At 07:08 PM 6/13/2006, you wrote:

>

> >WOW!!! I got an email back from Dr. Ponseti this evening. I don't

> >understand about half of the the terminology, but now I feel armed

> >with information!!!

> >

> >This is what he said:

> >Dear Mrs. Crossley:

> >

> >After seeing only the picture taken from above, I can say that

> >iel's right foot appears to be a good deal shorter than the

> >left and the heel appears to be in varus.

>

>here's some information about heel varus:

>

> " the foot assumes a posture of an inward tipping of the heel (heel

>supination or varus). "

> " Patients with heel varus have a visible portion of the heel pad

> " peeking out " from the medial border of the foot "

>

>so the heel varus is the part where you can see his heel pushing

>toward the inside, unlike the left foot.

>

> > The forefoot is severely

> >adducted about 25 degrees.

>

>his foot appears bean or kidney shaped, the forefoot (front part of

>the foot) is in adduction meaning it's pointing inward. You can see

>this in the picture. Adduction would be the opposite of abduction

>which means the turned out (like on the FAB's).

>

> >Without a lateral view of the foot in

> >dorsiflexion, I don't know if the foot is in plantar flexion or if

> >the foot has some dorsiflexion.

>

>he wants to see a profile picture of his dorsiflexion. Probably both

>one with the palm pushing as well as something like him squatting,

>both from the side. I'd also send him pictures of his soles and one

>each from front and back (camera on the floor) directly.

>

> >Since he is 4 1/2 years old, I would try to correct the deformity

> >without surgery. He will likely need about three or four long leg

> >casts changed weekly. The correction without surgery depends on the

> >amount of stiffness in the ligaments of the foot. Most can be

> >stretched in children gradually with a few casts to soften them.

> >The heel varus also can be corrected but it is sometimes necessary

> >to transfer the anterior tibial tendon to the third cuneiform to

> >prevent another relapse.

> >

> >If you go to the web site www.global-help.org and click on

> >Publications, you can download a copy of Clubfoot: Ponseti

> >Management. In the English version on pages 20-21 this tendon

> >transfer surgery is outlined.

>

>ATTT would only be done after all casting options are exhausted is

>what he's saying here. Due to age, I bet he's simply preparing mama

>for the possibility as well as showing her what it entails. As an

>introduction to what the osteotomy entails and it's comparison to the

>ATTT as stated below:

>

> >Osteotomies to correct the adduction of the forefoot are often done

> >by removing a wedge of bone from the outside, opening up the first

> >cuneiform on the inner side, and placing the wedge of bone

> >there. However, this surgery can easily damage the joints so I would try to

>avoid it by casting first.

>

>basically, pretend you have a pie. Take out a piece on the right

>side, and open up a slit on the left side and wedge it in. Pie

>closes up on the opposite side. In doing this, they hope to force

>the forefoot to become straight by putting this wedge of bone in one

>side and leaving the hole on the other.

>

> >The transfer of the anterior tibial

> >tendon is used to prevent the heel varus from relapsing and at the

> >same time it is useful in maintaining the forefoot in proper

> >alignment with the hindfoot.

>

>so he's saying that casting would more than likely get the foot into

>a corrected position. If it stays there, great. If not, he'll take

>the AT tendon and transfer *it* over to the opposite side (in as

>such, the tendon keeps the foot aligned) as opposed to the osteotomy

>which affects the bones. Basically the degree of surgery is reduced

>considerably if the osteotomy is avoided. Casting, with experienced

>hands (experienced with older feet) would either correct the foot

>entirely, without relapse or the casting would bring the foot close

>enough to proper correction so that only the ATTT would be

>needed. Scratch the osteotomy entirely :~}

>

>hope this helps. I saw his foot, if he can get to Iowa... wow... I'd say GO!

>

>Kori

>

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

> >

> >I'll keep you all posed on the progress.

> >Thankagain for all the help and support.

> >

> >

> >__________________________________________________

> >

[Guest guest]

ah heck, have her look at this page. Apparently they got the

Physician's section back up at the U of Iowa Clubfoot website

whoohoo!!! (hummmm.... I do remember emailing them a couple of

months ago asking where it had gone and could we please have it back?).

There is a nice picture of heel varus (skeletal pic), and it's

correction on the figure's pages (pictures) which are linked in the

text describing the correction process. (figures 10 & 11) Forefoot

adduction pictures start at figure 6. Heel varus, corrects with the

positioning of the calcaneous under the talus in the figures prior to

6, I believe it would be corrected with the second and/or third casts

actually.

http://www.uihealthcare.com/topics/medicaldepartments/orthopaedics/clubfeet/forp\

roviders/index.html

Kori

At 12:18 AM 6/14/2006, you wrote:

>here's info about correcting adduction and heel varus with the

>Ponseti Method. Sorry it's so technical, but basically this part of

>the correction is done for all Ponseti Patients and likely how Dr.

>Ponseti would approach this relapse assuming no cavus is present (pic

>doesn't really show this aspect). Incidentally, this phase of the

>treatment happens after the cavus correction, and after the adduction

>and varus is corrected, they then approach correction of equinus

>(bring toes/foot up, attain dorsiflexion). Not knowing how good his

>dorsiflexion is at the moment, it is unclear whether he'll even need

>equinus correction but I would hazard a guess that by the time the

>varus is corrected properly it'll show more accurately how much

>dorsiflexion he's got (dorsiflexion meaning how far past " L " or

>neutral, plantarflexion being negative degrees or equinus - pointing

>toes, heel up off ground) and whether some stretching with casts only

>will be adequate.

>

>For information about the whole correction process please click on

>the link, only the adduction and heel varus portion is quoted here.

>

><http://www.wheelessonline.com/ortho/casting_for_club_foot>http://www.wheelesso\

nline.com/ortho/casting_for_club_foot

>- correction of adduction and heel varus:

>- goal is to abduct the supinated foot under the talus;

>- again, forceful pronation of the foot is avoided

>since it increases the cavus deformity, causes mid foot

>break down and does not address the varus heel deformity;

>- talus is rotated laterally so that the foot abducts

>underneath the talus which is fixed in the ankle mortice;

>- this causes lateral rotation of navicular, together

>w/ cuboid & anterior aspect of calcaneus, w/o pronation of foot;

>- to correct the varus and adduction, the foot in supination

>is abducted while counterpressure is applied with

>the thumb against the head of the talus;

>- foot is abducted in flexion and slight supination to

>stretch the medial tarsal ligaments, while counter pressure applied on the

>lateral aspect of the head of the talus;

>- this allows the calcaneus to abduct under the

>talus which correction of the heel varus;

>- heel must not be touched during this manipulation;

>- calcaneus abducts by rotating and sliding under the talus;

>- noted that the calcaneus can evert only when it is

>abducted (laterally rotated) under the talus.

>- as the calcaneus abducts it simultaneously extends

>and everts which corrects the heel varus;

>- note that the calcaneus cannot evert unless it is abducted;

>- casting involves a toe-to-groin plaster cast w/ knee

>flexed 90 degrees and the foot in maximum external rotation;

>- maintenance of correction of varus deformity of hind

>part of foot which requires external rotation of foot distal to talus;

>- radiographs may be taken at this point inorder to confirm

>that the talonavicular joint is reduced, prior to managing equinus;

>- cautions:

>- avoid forced external rotation of the foot to

>correct adduction while the calcaneus is in varus;

>- this causes a posterior displacement of the

>lateral malleolus by externally rotating the talus in the ankle mortice.

>- avoid abducting the foot against pressure at the

>calcaneocuboid joint the abduction of the calcaneus is blocked, thereby

>interfering with correction of the heel varus

>

>At 10:18 PM 6/13/2006, you wrote:

>

> >At 07:08 PM 6/13/2006, you wrote:

> >

> > >WOW!!! I got an email back from Dr. Ponseti this evening. I don't

> > >understand about half of the the terminology, but now I feel armed

> > >with information!!!

> > >

> > >This is what he said:

> > >Dear Mrs. Crossley:

> > >

> > >After seeing only the picture taken from above, I can say that

> > >iel's right foot appears to be a good deal shorter than the

> > >left and the heel appears to be in varus.

> >

> >here's some information about heel varus:

> >

> > " the foot assumes a posture of an inward tipping of the heel (heel

> >supination or varus). "

> > " Patients with heel varus have a visible portion of the heel pad

> > " peeking out " from the medial border of the foot "

> >

> >so the heel varus is the part where you can see his heel pushing

> >toward the inside, unlike the left foot.

> >

> > > The forefoot is severely

> > >adducted about 25 degrees.

> >

> >his foot appears bean or kidney shaped, the forefoot (front part of

> >the foot) is in adduction meaning it's pointing inward. You can see

> >this in the picture. Adduction would be the opposite of abduction

> >which means the turned out (like on the FAB's).

> >

> > >Without a lateral view of the foot in

> > >dorsiflexion, I don't know if the foot is in plantar flexion or if

> > >the foot has some dorsiflexion.

> >

> >he wants to see a profile picture of his dorsiflexion. Probably both

> >one with the palm pushing as well as something like him squatting,

> >both from the side. I'd also send him pictures of his soles and one

> >each from front and back (camera on the floor) directly.

> >

> > >Since he is 4 1/2 years old, I would try to correct the deformity

> > >without surgery. He will likely need about three or four long leg

> > >casts changed weekly. The correction without surgery depends on the

> > >amount of stiffness in the ligaments of the foot. Most can be

> > >stretched in children gradually with a few casts to soften them.

> > >The heel varus also can be corrected but it is sometimes necessary

> > >to transfer the anterior tibial tendon to the third cuneiform to

> > >prevent another relapse.

> > >

> > >If you go to the web site www.global-help.org and click on

> > >Publications, you can download a copy of Clubfoot: Ponseti

> > >Management. In the English version on pages 20-21 this tendon

> > >transfer surgery is outlined.

> >

> >ATTT would only be done after all casting options are exhausted is

> >what he's saying here. Due to age, I bet he's simply preparing mama

> >for the possibility as well as showing her what it entails. As an

> >introduction to what the osteotomy entails and it's comparison to the

> >ATTT as stated below:

> >

> > >Osteotomies to correct the adduction of the forefoot are often done

> > >by removing a wedge of bone from the outside, opening up the first

> > >cuneiform on the inner side, and placing the wedge of bone

> > >there. However, this surgery can easily damage the joints so I

> would try to

> >avoid it by casting first.

> >

> >basically, pretend you have a pie. Take out a piece on the right

> >side, and open up a slit on the left side and wedge it in. Pie

> >closes up on the opposite side. In doing this, they hope to force

> >the forefoot to become straight by putting this wedge of bone in one

> >side and leaving the hole on the other.

> >

> > >The transfer of the anterior tibial

> > >tendon is used to prevent the heel varus from relapsing and at the

> > >same time it is useful in maintaining the forefoot in proper

> > >alignment with the hindfoot.

> >

> >so he's saying that casting would more than likely get the foot into

> >a corrected position. If it stays there, great. If not, he'll take

> >the AT tendon and transfer *it* over to the opposite side (in as

> >such, the tendon keeps the foot aligned) as opposed to the osteotomy

> >which affects the bones. Basically the degree of surgery is reduced

> >considerably if the osteotomy is avoided. Casting, with experienced

> >hands (experienced with older feet) would either correct the foot

> >entirely, without relapse or the casting would bring the foot close

> >enough to proper correction so that only the ATTT would be

> >needed. Scratch the osteotomy entirely :~}

> >

> >hope this helps. I saw his foot, if he can get to Iowa... wow... I'd say GO!

> >

> >Kori

> >

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

> > >

> > >I'll keep you all posed on the progress.

> > >Thankagain for all the help and support.

> > >

> > >

> > >__________________________________________________

> > >

[Guest guest]

Thanks Kori!!! You're the best!!! I have forwarded your messages to

the clubfootcanada board and I am sure that this will help

tremendously!

& Grace

> >

> > >WOW!!! I got an email back from Dr. Ponseti this evening. I don't

> > >understand about half of the the terminology, but now I feel

armed

> > >with information!!!

> > >

> > >This is what he said:

> > >Dear Mrs. Crossley:

> > >

> > >After seeing only the picture taken from above, I can say that

> > >iel's right foot appears to be a good deal shorter than the

> > >left and the heel appears to be in varus.

> >

> >here's some information about heel varus:

> >

> > " the foot assumes a posture of an inward tipping of the heel (heel

> >supination or varus). "

> > " Patients with heel varus have a visible portion of the heel pad

> > " peeking out " from the medial border of the foot "

> >

> >so the heel varus is the part where you can see his heel pushing

> >toward the inside, unlike the left foot.

> >

> > > The forefoot is severely

> > >adducted about 25 degrees.

> >

> >his foot appears bean or kidney shaped, the forefoot (front part of

> >the foot) is in adduction meaning it's pointing inward. You can see

> >this in the picture. Adduction would be the opposite of abduction

> >which means the turned out (like on the FAB's).

> >

> > >Without a lateral view of the foot in

> > >dorsiflexion, I don't know if the foot is in plantar flexion or

if

> > >the foot has some dorsiflexion.

> >

> >he wants to see a profile picture of his dorsiflexion. Probably

both

> >one with the palm pushing as well as something like him squatting,

> >both from the side. I'd also send him pictures of his soles and one

> >each from front and back (camera on the floor) directly.

> >

> > >Since he is 4 1/2 years old, I would try to correct the deformity

> > >without surgery. He will likely need about three or four long leg

> > >casts changed weekly. The correction without surgery depends on

the

> > >amount of stiffness in the ligaments of the foot. Most can be

> > >stretched in children gradually with a few casts to soften them.

> > >The heel varus also can be corrected but it is sometimes

necessary

> > >to transfer the anterior tibial tendon to the third cuneiform to

> > >prevent another relapse.

> > >

> > >If you go to the web site www.global-help.org and click on

> > >Publications, you can download a copy of Clubfoot: Ponseti

> > >Management. In the English version on pages 20-21 this tendon

> > >transfer surgery is outlined.

> >

> >ATTT would only be done after all casting options are exhausted is

> >what he's saying here. Due to age, I bet he's simply preparing mama

> >for the possibility as well as showing her what it entails. As an

> >introduction to what the osteotomy entails and it's comparison to

the

> >ATTT as stated below:

> >

> > >Osteotomies to correct the adduction of the forefoot are often

done

> > >by removing a wedge of bone from the outside, opening up the

first

> > >cuneiform on the inner side, and placing the wedge of bone

> > >there. However, this surgery can easily damage the joints so I

would try to

> >avoid it by casting first.

> >

> >basically, pretend you have a pie. Take out a piece on the right

> >side, and open up a slit on the left side and wedge it in. Pie

> >closes up on the opposite side. In doing this, they hope to force

> >the forefoot to become straight by putting this wedge of bone in

one

> >side and leaving the hole on the other.

> >

> > >The transfer of the anterior tibial

> > >tendon is used to prevent the heel varus from relapsing and at

the

> > >same time it is useful in maintaining the forefoot in proper

> > >alignment with the hindfoot.

> >

> >so he's saying that casting would more than likely get the foot

into

> >a corrected position. If it stays there, great. If not, he'll take

> >the AT tendon and transfer *it* over to the opposite side (in as

> >such, the tendon keeps the foot aligned) as opposed to the

osteotomy

> >which affects the bones. Basically the degree of surgery is reduced

> >considerably if the osteotomy is avoided. Casting, with experienced

> >hands (experienced with older feet) would either correct the foot

> >entirely, without relapse or the casting would bring the foot close

> >enough to proper correction so that only the ATTT would be

> >needed. Scratch the osteotomy entirely :~}

> >

> >hope this helps. I saw his foot, if he can get to Iowa... wow...

I'd say GO!

> >

> >Kori

> >

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

> > >

> > >I'll keep you all posed on the progress.

> > >Thankagain for all the help and support.

> > >

> > >

> > >__________________________________________________

> > >

[Guest guest]

I think the description of heel varus is kind of confusing (not

specifically what you said Kori, but in general) -- in purely

layperson terms, heel varus means that the heel bone tilts side to

side, when looking at it straight on from the back. The bottom of the

bone points towards the left foot (in a right foot heel varus), and

the top of the bone is pointing away from the other foot, sort of like

/ .

This website is really good for describing the various anatomical

terms of the foot:

http://www.footmaxx.com/clinicians/anatomic.html

Hope this helps,

>

>

> >WOW!!! I got an email back from Dr. Ponseti this evening. I don't

> >understand about half of the the terminology, but now I feel armed

> >with information!!!

> >

> >This is what he said:

> >Dear Mrs. Crossley:

> >

> >After seeing only the picture taken from above, I can say that

> >iel's right foot appears to be a good deal shorter than the

> >left and the heel appears to be in varus.

>

> here's some information about heel varus:

>

> " the foot assumes a posture of an inward tipping of the heel (heel

> supination or varus). "

> " Patients with heel varus have a visible portion of the heel pad

> " peeking out " from the medial border of the foot "

>

> so the heel varus is the part where you can see his heel pushing

> toward the inside, unlike the left foot.

>

> > The forefoot is severely

> >adducted about 25 degrees.

>

> his foot appears bean or kidney shaped, the forefoot (front part of

> the foot) is in adduction meaning it's pointing inward. You can see

> this in the picture. Adduction would be the opposite of abduction

> which means the turned out (like on the FAB's).

>

> >Without a lateral view of the foot in

> >dorsiflexion, I don't know if the foot is in plantar flexion or if

> >the foot has some dorsiflexion.

>

> he wants to see a profile picture of his dorsiflexion. Probably both

> one with the palm pushing as well as something like him squatting,

> both from the side. I'd also send him pictures of his soles and one

> each from front and back (camera on the floor) directly.

>

>

> >Since he is 4 1/2 years old, I would try to correct the deformity

> >without surgery. He will likely need about three or four long leg

> >casts changed weekly. The correction without surgery depends on the

> >amount of stiffness in the ligaments of the foot. Most can be

> >stretched in children gradually with a few casts to soften them.

> >The heel varus also can be corrected but it is sometimes necessary

> >to transfer the anterior tibial tendon to the third cuneiform to

> >prevent another relapse.

> >

> >If you go to the web site www.global-help.org and click on

> >Publications, you can download a copy of Clubfoot: Ponseti

> >Management. In the English version on pages 20-21 this tendon

> >transfer surgery is outlined.

>

> ATTT would only be done after all casting options are exhausted is

> what he's saying here. Due to age, I bet he's simply preparing mama

> for the possibility as well as showing her what it entails. As an

> introduction to what the osteotomy entails and it's comparison to the

> ATTT as stated below:

>

> >Osteotomies to correct the adduction of the forefoot are often done

> >by removing a wedge of bone from the outside, opening up the first

> >cuneiform on the inner side, and placing the wedge of bone

> >there. However, this surgery can easily damage the joints so I

would try to

> avoid it by casting first.

>

>

> basically, pretend you have a pie. Take out a piece on the right

> side, and open up a slit on the left side and wedge it in. Pie

> closes up on the opposite side. In doing this, they hope to force

> the forefoot to become straight by putting this wedge of bone in one

> side and leaving the hole on the other.

>

> >The transfer of the anterior tibial

> >tendon is used to prevent the heel varus from relapsing and at the

> >same time it is useful in maintaining the forefoot in proper

> >alignment with the hindfoot.

>

> so he's saying that casting would more than likely get the foot into

> a corrected position. If it stays there, great. If not, he'll take

> the AT tendon and transfer *it* over to the opposite side (in as

> such, the tendon keeps the foot aligned) as opposed to the osteotomy

> which affects the bones. Basically the degree of surgery is reduced

> considerably if the osteotomy is avoided. Casting, with experienced

> hands (experienced with older feet) would either correct the foot

> entirely, without relapse or the casting would bring the foot close

> enough to proper correction so that only the ATTT would be

> needed. Scratch the osteotomy entirely :~}

>

>

> hope this helps. I saw his foot, if he can get to Iowa... wow...

I'd say GO!

>

> Kori

>

>

>

>

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

> >

> >I'll keep you all posed on the progress.

> >Thankagain for all the help and support.

> >

> >

> >__________________________________________________

> >