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Some Frequently Asked Questions....Page 4

36. How soon should treatment begin after a child is born?

Treatment should begin optimally within the first 10 days of life. Each case needs to be reviewed by a physician, especially for older children who tend to lose the flexibility that a newborn has which may make their feet harder to successfully treat.

37. How are casts removed?

Casts are usually soaked off at the beginning of the appointment in a tub of warm water and vinegar, then cut away with a small blade or scissors when they are soft. Some physicians prefer to use a cast saw.

38. How many hands does it take to cast a baby?

It takes a few people to help with the casting of the child. Usually the doctor will hold the foot in position, one assistant or parent will help hold the leg still, and another assistant will wrap the padding and then the plaster on the leg.

39. Do manipulation and casting sessions hurt the child?

No. Depending on the child, they may cry because they're irritated with people holding their leg, or they're scared, but some kids don't cry at all. It helps to bring a bottle for the baby to feed during casting sessions to draw their attention away from the casting process, also it may help the baby to relax when the doctor is physically examining the foot/feet. For older children, bring a few toys or give them a small flashlight to help distract them during the process.

40. How long does a child typically wear the DBB/FAB?

The brace is typically prescribed for 23 hours/day (one hour for bathing, stretching, playing etc) for 2-3 months and then 2-3 years of 12-14 hours/day. Each case is different, so a physician will determine the amount of time required in the brace at each check-up. In some rare cases, babies with clubfeet will also have loose ligaments. This cannot be diagnosed until the child is 8-10 months old. For these cases, the clubfoot can be overcorrected. The DBB/FAB should be discarded when the child starts to walk.

41. Are there long-term studies on patients treated with the Ponseti Method?

Yes, the Ponseti method has been in use since about 1950 at the University of Iowa. There have been long term results studies done on patients about every ten years since 1963 (1963, 1972,1980, 1993). They have over 40 years of good outcomes as shown in 4 longer-term studies. There are no studies that directly compare surgical corrections versus corrections obtained using the Ponseti method, there are also no studies of the outcomes of surgical treatment methods that extend longer than about 16 years of age. The Ponseti method studies focused on patient satisfaction and painless functional performance of the foot into adult life. As a side note, the longer term studies on the Ponseti method excluded the mild cases of clubfoot that were corrected in four cast changes or less, and only focused on the severe cases. There is not a universally accepted rating system for assessment of results, so comparisons between studies of different methods are difficult. A well corrected clubfoot should look and function as that of a normal person.

42. Is the Ponseti Method really "non-surgical" since tenotomies are often used?

A tenotomy is considered a non-operative procedure by the medical community. Perhaps a better term for the general public would be "less-invasive" surgery as compared to a full surgical release.

43. What is the significance of below the knee versus toe-to-groin casts?

In his book, Congenital Clubfoot, Fundamentals of treatment, on pages 70-71, Dr. Ponseti states; "The foot can be maintained in external rotation only if the talus, the ankle and the leg are stabilized by a toe-to-groin (to upper thigh) plaster cast while the knee is in 90-degree flexion. In order to maintain a strong external rotation of the foot under the talus while the talus is firmly immobilized against rotation in the ankle mortise, a toe-to-groin plaster cast is mandatory The talar head will continue to stretch the tight plantar calcaneonavicular ligament as well as just the tibionavicular part of the deltoid ligament, and the posterior tibial tendon just as we stretch them with manipulation. A cast extending to just below the knee cannot immobilize the foot in firm external rotation under the talus. The reason is that since the leg of a baby is round and the anterior crest of the tibia is covered with baby fat the casts cannot be well molded and therefore will rotate inwardly with the foot. As a result, the stretch of the tarsal ligaments and posterior tibial tendon obtained by manipulations is lost and the varus and adduction of the tarsus are left uncorrected. To insist on using short-leg cats in the treatment of clubfeet is to ignore the basic role that the leg and talus rotation have on the kinematics of the subtalar joint, the midfoot and the forefoot. Furthermore, short-leg casts tend to slip off the foot. To prevent this, the orthopaedists often apply the casts too tightly around the calf and the malleoli, causing sores. Below-the-knee casts are not only useless but detrimental."

44. How do I know if my physician is using the Ponseti method correctly?

The Ponseti method relies heavily on an intimate knowledge of the components of the foot, and how to manipulate them in a certain way to obtain correction. It is a method that requires a certain "finesse" and not all physicians easily pick up on how to properly manipulate the foot. Some have called it an "art". Physicians also need to see an adequate number of cases of clubfoot so that they stay well-practiced in this "art" of manipulation. Some physicians try to implement the Ponseti method based on reading textbooks. This may be enough for some doctors to obtain good results, but not others. The surest way to check your physician is to find out how many casts they typically need to correct a clubfoot and what their success rate of treatment without surgery is. You may also want to ask if they were trained in the method, and who they were trained by. Don't be afraid to do your research on your physician and to ask for references and proof of results. Since the age of the child is significant to the ease of correction, you won't want to potentially waste time if you are not confident in the abilities of your physician. One of the biggest hurdles that I've seen as a parent bystander is helping families who are falsely lead to believe that their physician was practicing the Ponseti method. The results are commonly not satisfactory because the physician was either improperly applying the method, or only using "parts" of the method adapted to their own procedure. Physicians who claim to be practicing the Ponseti method but are not following the method as prescribed, cause confusion when their success rates are not as high as those who are properly following the method. In normal cases, you should see results within a few casting sessions, and normally no more than 9 casts are needed to obtain correction. Contact the University of Iowa for specific questions about your physician's methods or training.

45. What are the risks of relapse?

With this method of treatment, relapses are mainly related to early discarding of the foot abduction brace. However, even in the most compliant families a relapse can occur. Doctor Ponseti's experience in the past six years indicates that a relapse in a clubfoot that has been well treated is about 5%.

46. Are other genetic problems linked to clubfoot?

Usually, there are no other birth defects for a child born with clubfoot. However, there is an association of higher incidences of clubfoot for children born with some other birth defects, such as spina bifida. For example: the rates of clubfoot are higher in children with spina bifida, conversely, there is not a higher rate of spina bifida in children born with just clubfoot. Those interested in additional research may want to check out the U of Iowa's Virtual Hospital's clinical genetics study guide at http://www.vh.org/Providers/Textbooks/ClinicalGenetics/Contents.html

It has an overview of patterns of inheritance and also includes a short discussion about multifactorial inheritance as well as where a prior family history does not exist.

http://www.vh.org/Providers/Textbooks/ClinicalGenetics/Lesson2/AnalyzingFamHis.html

The site says about these items:

Polygenic Multifactorial Inheritance

"Many disorders that occur in families are known to have a genetic component but do not follow clear Mendelian patterns of inheritance. These disorders, as discussed in Lesson 1, are referred to as polygenic or multifactorial disorders because they are believed to be caused by the interaction between a variety of genes as well as environmental factors."

"Examples of multifactorial disorders include cleft lip and palate, neural tube defects and pyloric stenosis. Individuals who have a first or second degree relative with such a disorder should be referred for counseling, given that their risk of having an affected child is increased above the general population risk. The recurrence risk to sibs or the offspring of an affected individual is approximately 3 to 5%. The recurrence risk increases, however, when more family members are affected or the parents are related."

Figure 2.6 shows a pedigree suggestive of a polygenic or multifactorial pattern of inheritance.

http://www.vh.org/Providers/Textbooks/ClinicalGenetics/Lesson2/Fig2.6.html

Sporadic Cases

"In most cases, analysis of a patient's family history will reveal that he or she is the only affected member in the family. However, when dealing with sporadic cases it is not safe to assume that the disease is not genetic. As you know, sporadic disorders can be caused by de novo chromosome abnormalities, new dominant mutations, autosomal recessive genes, uniparental disomy, germline mosaicism or

exposure to a teratogenic agent. In such cases, further investigation of the patient's medical and developmental history may reveal clues to the etiology of his or her disease. A history of delayed physical

or cognitive development, major or minor malformations or exposure to a known teratogenic agent are all appropriate reasons for referral, especially if the family has questions about why a particular problem

occurred."