T.E.V. 4yo boy - to treat or not to treat?

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Morning all, a patient that I thought would warrant debate (which I believe similar have been before)

Yesterday I saw a 4 1/2 yo boy with a history of Talipes Equino Varus. He had tenotomies done at 3 months, then underwent the Ponseti method and was using Denis Browne boots (parents told me that at first he was wearing them up to 23hrs a day, and only finished wearing them at night at age 3). Then in Jun 2010 he also had muscle transfers.

He was a full term prenancy, born by normal vaginal delivery, weighing 6lbs 7oz. He bagan walking independently at 14 months, but as he was in the boots only shuffled at first. There is no family history and his old brother (aged 9) has no problems.

With regard to range and quality of motion in his joints, on standing he cannot weight bear on his heels, standing comfortably in an equinus position - if he tries to put his heels down, he falls over backwards. His talocrural joint can only achieve 90* and he can only maximally evert his STJ to neutral (no further). Gait wise he walks with a typical eqinus gait, with zero heel strike with his foot remaining in a supinated position throughout the stance phase of gait. With regards to shoe wear there is only wear on the lateral border of the midfoot and forefoot.

My issue here is that this child has zero pain or complaints. His parents are concerned about his gait (as any parent would be). This child runs and plays happily with all of his classmates with no problems. I won't dilvulge what I decided to do as I'm curious as to people's responses but - do we leave the child as he is as his body will adapt or do we cast for bespoke devices to improve his gait from the low gear that it is to a high gear type gait (before I get jumped on by all and sundry I realise that a low gear gait is not necessarily bad).

I hope this stirrs some grey cells this morning.

Cheers,

James

 

James in one word = treat

 

Michael - in one word - Why? (Come on Michael, I wanted a debate )

 

Ok this is not a tissue stress question the Child has pathological issues.

This steps outside of any tissue stress thinking on the question to treat or not to treat.

The concept of tissue stress can be used to determine the who, why´s of treatment. You could spend hours alone just looking at the compression forces and changes in direction of force alone.

I would not for 1 second consider NOT treating this patient, not just for the issues of the child mechanically there is also a psychological issue as well, family ie child and parents.

I would bet money on the fact that if you have said " the child is not in pain lets not treat and review in 6 months- you will never see them again they got to someone who will treat them, which in my option is the correct thing to do.

The child is still growing we have cast corrected foot, we have Davis and Wolfs laws at play- make them all as positive as possible by redirecting the forces of weightbearing.

 

Please elaborate on your thinkings here?

Fair point, but how much effect is this going to have now the child is 4 1/2?

The reason for this debate is that my colleague and I discussed this patient yesterday and could see pro's and con's for treating and/or not treating.

Reagrds,

James

 

1st the child has been handled in the medical field since birth, they have been told they are on a long road and working towards getting a more "normal " foot and gait etc I assume - now all of a sudden we wait and see ?? while they will be relieved that the child is happy and running around kicking the footy with his mates they will be asking themselves can we do more.

I´m a parent of 12 weeks now so no expert, but I know I will do everything in my power to help my boy be the best he can be, even if than means him hurting himself etc, but these parents will be asking themselves can we do more?

With the child be 41/2 there is a huge amount of bone remodeling going on, so if you can make this bone remodeling positive rather than negative that has to be a good thing, bone stronger and in "better" alignment will mean hopefully better joint function, better joint function "better" muscle action etc etc

 

Firstly, congratulations on becoming a parent (girl or boy?), it is the most amasing, exhilarting, tiring experience you'll ever have which you don't get paid for (I have a 20 month old son and my wife is pregnant with our 2nd).

Would this child not be a potential candidate for further surgery, potentially TA lengthening so that he can achieve a plantargrade position before any orthotic intervention?

 

Thanks Boy Oliver-

Thats for you to make up your mind on and a whole different question to which I would say a surg consultation would be a very good idea, one I would probably suggest.

ps Congratulations yourselves * 2

 

Why is it better? Because it now looks more like our "normal presentation".


So, that is Michael fighting in the Blue corner for the treating of the patient - anyone wishing to take up the mantle for the Red corner, allowing nature to take it's course (Robert, Bel...)

James

 

James I did the "" it´s all about force and the distribution of such - Talipse foot type poor distribution of such forces.

James have you ever played with a Talipse foot that was not treated in an adult?

Ps don´t ask Robert he might suggest TTO

Only for a few more days Robert I promise , should have paid Del more to keep quite

 

Yes, several, but almost all of them had no intervention as children (for whatever reasons) - result was all of them have now got casted orthoses and get great benefit from them - but the reason then they came to see me was because they were in pain.

So still playing devil's advocate - this child is not in any pain.......

 

Is there a possiblility that the toe walking (an assumption here that the child toe walks) has become habitual and that therefore there is a cycle of pathology forming, i.e, Davis's law as suggested above. If so, i would be looking to treat both behavior and pathology. I agree a surgical consultation would be beneficial but i would also be looking at a physio referal with an ultrasound scan to check for any residual scarring from previous surgery, and an update with the orthotist, wearable light weight boots would be ideal and they should be eligible for some shoes from the mobility centre (if you have one). If not there are several independent shoemakers who will make a decent pair of childrens boots for between £100 -£150, important though to take any orthotics for shoe fitting appointments.

This would mean lots of appointments for a little person, so it may be important to consider who the treatment is for, to alay parental fears or to improve long term function? You may also like to consider spacing and prioritising appointments to reduce stress on the child.

With regards to casting i would suggest that there are some excellent OTC peadiatric orthotics, check out Algeos and Talar made, remember at four and half he is liable to grow a lot in short spurts and would require regular recasting for bespoke orthotics, again all taking time and money and possibly increasing stress.

Good luck, this are just my thoughts and remember opions are like noses - everyone has one. Follow your own clinical judgement.
regards
lizzy

 

Except this guy: http://retardzone.com/2007/09/20/man-without-nose-arrested-for-kidnapping/

 

that made me choke on my tea! hilarious but in a bad way

 

Hi Lizzy, thanks for your input and your good wishes, it's greatly appreciated. That's part of my reasons for posting here - I've got a very good idea of what I will do with this patient before I posted, but as I know there are so many schools of thought I wondered what other people might do / try / suggest.

He does toe walk, but this could only be habitual as he's never had the ability to heel strike and therefore knows no different. You could treat the behaviour as much as you like, he cannot physically heel strike.

With regard to casting, there are alot of OTC devices which are very good and I've readily used, but these are made for a standard shaped foot/last which our little lad doesn't have (to make this easier, I'm seeing this lad on the NHS so there is no financial implications to the patient - he gets what he needs if I have the facilities to provide and the budget to do so).

Cheers,

James

 

Hi James,
When your ready, in your own time) let us know what you decide to do, always interested to hear what people are doing and what the outcomes are, good luck,
Lizzy

 

Hi I have been researching the Ponseti method of treating TEV for some years and now that practitioners are more experienced they are able to successfully treat adults with previuosly untreated TEV using the Ponseti method.
I think that it would be a good idea to either recast or have a tenotomy carried out and then recast. This will at least reduce the amount of surgical proceedures needed and at best provide a decent amount of dorsiflexion.
What did you do? or did I miss that bit.
Janet