unsure of next step-a little confused

[Guest guest]

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