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J. Scott Doyle, MD, The Children's
Hospital of Alabama and the UAB Division of Orthopaedic Surgery
Non-operative treatment for the
treatment of clubfeet has historically met with inconsistent
success. The Iowa (Ponsetti) Method has the longest and most
carefully documented follow up studies in the published literature.
The success rate and functional outcome is reported to be
higher than with other non-operative and operative techniques.
The purpose of this study was to demonstrate whether the early
results were reproducible in a surgeon's early experience
with the technique. This is a report of a prospective initial
consecutive series of idiopathic clubfeet without prior treatment
that were treated by the Iowa Method by a single surgeon.
Forty-nine idiopathic clubfeet
in 31 patients were treated by a single surgeon (JSD) by the
Iowa Method. Patients who had received prior treatment and
pts with a neuromuscular disease or genetic syndrome were
excluded from this review. Patients included 10 females and
21 males. Fifty-five percent of patients had bilateral involvement.
Average follow-up is 2.3 yrs and minimal follow up is 1 yr.
All treatments were initiated before 2 months of age (range
4 days to 7 weeks). The feet were scored Moderate (32%), Severe
(56%), and Very Severe (12%) by the Dimeglio Scoring System.
No postural clubfeet were included. The foot was considered
to be initially corrected when there was no cavus, residual
adductus was Gr. 1 or less, the hindfoot was in valgus beyond
neutral and at least 10 degrees or dorsiflexion of the ankle
was obtained (without evidence of a midfoot break). The described
protocal was strictly followed.
Forty-nine of 49 feet were successfully
corrected with an average of 5.6 casts per foot (range 4 -
7). Ninety-six percent (47/49) of feet underwent a percutaneous
Achilles tenotomy under local anesthetic in conjunction with
the final manipulation and casting. Actual compliance with
the post-correction bracing was difficult to accurately document.
Twenty-two percent (11/49) of feet had a partial recurrence.
Four of eleven were treated with recasting (ave 3 casts).
Three of eleven underwent an anterior tibial tendon transfer
to the lateral cuneiform. Four feet (in 3 pts) have undergone
an open TEV release.
Our results are consistent with
the larger series out of Iowa. We conclude that with care
and diligence the technique is widely applicable and decreases
the need for the TEV release. Further follow up is needed
to accurately assess the number of patients ultimately needing
a TEV release. In this surgeon's practice, the percentage
of idiopathic clubfeet requiring open TEV release in the first
year of life has gone from 86% in the epoch preceding the
institution of the Iowa protocal to 8% after its institution.
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