B.S. Richards, S. Faulks, K.E. Rathjen, and L.A. Karol reply:
We thank Ms. Issler-Wüthrich and her colleagues for their interest in our paper. We share many similar perspectives with them regarding the approach to the nonoperative treatment of clubfoot.
Beginning in 1996, Frédérique Bonnet and Alain Dimeglio were instrumental in teaching the physical therapists at our institution the correct methods of the French technique. Like Ms. Issler-Wüthrich, our physical therapists have gained a tremendous amount of experience and expertise with this method. In a similar fashion, in 1999, our medical staff learned directly from Professor Ponseti how to properly utilize his method. It is based on these solid foundations of learning that we have gained our institutional experience in both treatment techniques.
We want to respond to several points made by Ms. Issler-Wüthrich and her colleagues.Measurement. We agree that functional dynamic assessments of clubfeet will provide optimal information on the outcomes. As such, we have used gait analysis studies to determine functional results accurately and objectively. This information is published in another recent study from our institution1. There were no significant differences in cadence parameters between patients treated by the Ponseti method and those treated by the French functional method. More of the children treated with the French method walked with knee hyperextension, a mild equinus gait, and mild footdrop. In contrast, more of the patients in the Ponseti group demonstrated mildly increased stance-phase dorsiflexion and a mild calcaneus gait. These measurements will be repeated when the children are older, and will likely serve as the future gold standard for functional assessment. In addition, our physical therapy department is performing functional assessments (with use of the Peabody Developmental Motor Scales2) in patients between 4.5 and 5.5 years of age, and we will likely repeat this assessment when they are ten years of age.Sample selection. We agree with Ms. Issler-Wüthrich and her colleagues that the best outcomes are obtained when treatment is begun at a very early age, preferably within the first two weeks of life. Either method has a high degree of success—we did not demonstrate a preference for one over the other.Treatment procedures. We agree that professional expertise and experience is essential for good outcomes when the French method is used. We limit this treatment method to several experienced physical therapists in order to maximize good outcomes. This study only included children with idiopathic clubfeet. The patients found to have other disabilities were excluded from the study, but they have been treated in a similar fashion, particularly in light of the fact that their disabilities may not have been evident early in their treatment program.Surgical interventions. Several years ago, our Montpellier colleague, Professor Alain Dimeglio, began performing lengthening of the gastrocnemius-soleus complex more frequently than he had previously, as he noted a persistence of equinus in too many feet. This persistent equinus may not be appreciated as well on the clinical assessment as it is on the radiographic assessment. Professor Dimeglio has not yet published his recent experience with lengthening of the gastrocnemius-soleus, but it has become a routine part of his French treatment program, as it has in ours.
Measurement. We agree that functional dynamic assessments of clubfeet will provide optimal information on the outcomes. As such, we have used gait analysis studies to determine functional results accurately and objectively. This information is published in another recent study from our institution1. There were no significant differences in cadence parameters between patients treated by the Ponseti method and those treated by the French functional method. More of the children treated with the French method walked with knee hyperextension, a mild equinus gait, and mild footdrop. In contrast, more of the patients in the Ponseti group demonstrated mildly increased stance-phase dorsiflexion and a mild calcaneus gait. These measurements will be repeated when the children are older, and will likely serve as the future gold standard for functional assessment. In addition, our physical therapy department is performing functional assessments (with use of the Peabody Developmental Motor Scales2) in patients between 4.5 and 5.5 years of age, and we will likely repeat this assessment when they are ten years of age.
Sample selection. We agree with Ms. Issler-Wüthrich and her colleagues that the best outcomes are obtained when treatment is begun at a very early age, preferably within the first two weeks of life. Either method has a high degree of success—we did not demonstrate a preference for one over the other.
Treatment procedures. We agree that professional expertise and experience is essential for good outcomes when the French method is used. We limit this treatment method to several experienced physical therapists in order to maximize good outcomes. This study only included children with idiopathic clubfeet. The patients found to have other disabilities were excluded from the study, but they have been treated in a similar fashion, particularly in light of the fact that their disabilities may not have been evident early in their treatment program.
Surgical interventions. Several years ago, our Montpellier colleague, Professor Alain Dimeglio, began performing lengthening of the gastrocnemius-soleus complex more frequently than he had previously, as he noted a persistence of equinus in too many feet. This persistent equinus may not be appreciated as well on the clinical assessment as it is on the radiographic assessment. Professor Dimeglio has not yet published his recent experience with lengthening of the gastrocnemius-soleus, but it has become a routine part of his French treatment program, as it has in ours.
In conclusion, either treatment method, when performed properly, can provide good clinical outcomes. For some patients, optimal outcomes can only be achieved when certain aspects of both methods are combined. We look forward to seeing the results in future studies from the Universitätskinderklinik in Zurich and the Institut Saint Pierre in Montpellier.
These letters originally appeared, in slightly different form, on . They are still available on the web site in conjunction with the article to which they refer.