We appreciate the interest of Dr.Goyal and colleagues in our recent article (1). They have raised two valid points that we will address. Their first point was the importance of having an accurate preoperative classification system to document the severity of the clubfoot deformity. We agree that this would be the ideal situation. However, the patients in this study were initially seen and evaluated a minimum of 25 years ago, and no uniform classification system was being used at that time. All patients in this study were treated with extensive soft-tissue release surgery, which gives some indication to the severity of the initial deformity.

Their second point was that the poor long-term results may not be due to the surgical technique alone; the duration of cast immobilization and the bracing protocol may have contributed to the poor outcomes. Unfortunately, we have no way to anaylze how much each of these factors contributed to the end result. We tried to emphasize in our discussion that we were reporting the results of a treatment method for clubfoot that was being widely used at the time in North America. It included preoperative casting, the described extensive soft-tissue release operation, and postoperative bracing. We also discussed the importance of future studies assessing the long-term results of clubfeet treated with more modern surgical techniques, which include less lengthy postoperative immobilization as well.

It should be noted that presently, there are very few treatment centers anywhere that offer a chance to study long-term outcomes (greater than twenty-five years) with sufficient numbers of patients and follow-up examinations. We have had the opportunity to see these patients and compare them with clubfoot patients treated with modern surgical techniques. We sense that our more modern surgical techniques lead to better short-term outcomes and will lead to better long-term outcomes when compared to patients treated with the protocol described in the current study(1), but to date, we have not formally completed this analysis.

1. Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006;88:986-996.

To The Editor:

In the paper “Long-Term Follow-Up of Patients with Clubfoot Treated with Extensive Soft-Tissue Release”(1) the authors have reviewed the long term outcome in which an aggressive surgical release was undertaken following failed conservative management. Neonatal and /or pre -operative clubfoot classification is important in order to identify those feet that may have a poor prognosis with conservative treatment(2). Non iatrogenic constitutional stiffness of the foot may functionally deteriorate in the long term, independent of the treatment modality employed. The poor results reported may be due in part to the conservative approach utilised. The Kite method(3) has been criticized by Ponseti(4) as resulting in a spurious correction (Kite’s error). Plaster casts (4 months) and orthotics (2-4years) were used for an extensive period of time following surgical release in the current paper. This long- term immobilisation has the potential to stiffen the joint secondary to the fibrosis that occurs following surgery.

The combination of a lack of an accurate assessment of the pre- operative severity of the clubfoot, a suboptimum method of conservative treatment and long-term post operative immobilization makes it difficult to attribute the poor results purely to the surgical approach.

References:

1. Dobbs MB, Nunley R, Schoenecker P. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006; 88A:986-995.

2. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. Pediatr Orthop B. 1995;4(2):129-36.

3 . Kite JH. Conservative treatment of the resistant recurrent clubfoot. Clin Orthop Relat Res. 1970 May-Jun;70:93-110.

4. Ponseti IV. Treatment of Clubfoot. http://www.uihealthcare.com/topics/medicaldepartments/orthopaedics/clubfeet/forproviders/index.html