JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
E. Ippolito, P. Farsetti, R. Caterini, and C. Tudisco
Long-Term Comparative Results in Patients with Congenital Clubfoot Treated with Two Different Protocols
J Bone Joint Surg Am 2003; 85: 1286-1294 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr. Ippolito responds to Dr. Altchek
Ernesto Ippolito, Pasquale Farsetti, Roberto Caterini, Cosimo Tudisco   (17 November 2003)
[Read Letter to the Editor] Non Operative Treatment of Club Foot Deformity
Martin Altchek   (16 October 2003)

Dr. Ippolito responds to Dr. Altchek 17 November 2003
Previous Letter to the Editor Top
Ernesto Ippolito,
ortopaedic surgeon
Univ ersity of Tor Vergata Rome,
Pasquale Farsetti, Roberto Caterini, Cosimo Tudisco

Send letter to journal:
Re: Dr. Ippolito responds to Dr. Altchek

ippolito{at}uniroma2.it Ernesto Ippolito, et al.

Dear Dr. Altcheck,

Thank you very much for your comment. We fully agree with your statement that extensive surgery should be avoided in congenital clubfoot treatment and that conservative treatment provides very good long-term functional results. However, according to previous pathological studies, medial subluxation of both the talo-navicular and the calcaneo-cuboid joints is a nearly constant finding in congenital clubfoot. On the contrary, medial and plantar deviation of the neck of the talus is not a constant deformity according to Waisbrod(1).

We also know that severe deformities of the neck of the talus are found in most severe cases of congenital club-foot. However a proper manipulation may correct the talar neck deformity as recently demonstrated by Pirani et al.(2).

Best regards.

(1)Waisbrod H.: Congenital clubfoot. An anatomical study. J.Bone Joint Surg (Br)1973; 55:796-801.

(2) Pirani S., Zeznik L., Hodges D.: Magnetic resonance imaging study of the congenital clubfoot treated with the Ponseti method. J.Pediatr Orthop 2001,21(6):719-726.
Non Operative Treatment of Club Foot Deformity 16 October 2003
Next Letter to the Editor Top
Martin Altchek,
orthopaedic surgeon
Martin Altchek, M.D., P.C.

Send letter to journal:
Re: Non Operative Treatment of Club Foot Deformity

hnick{at}frontiernet.net Martin Altchek

To The Editor:

I am a general orthopedic surgeon in private practice. Since 1956, I have treated every child with congenital club foot solely with cast correction. In my opinion, the reason that correcting club foot is difficult is because the basic deformity is in the structure of the talus. The head and neck of the talus are medially and plantarly directed and the plantar surface of the talus is also deformed in inversion and equinus.(1,2). Practically all contemporary papers that address correction of club feet fail to recognize that the primary deformity is in the talus. Instead, they state that the deformity is caused by subluxation of bones about a normal talus. If this were the case, club feet would be much easier to treat, and they would not recur so often.

Surgical correction creates a second deformity that attempts to compensate for the first. When recurrence occurs, scar that has formed about the talus makes the deformity increasingly difficult to correct. As this article(3) demonstrates, the more surgery that is performed on the foot, the worse the result.

In my opinion, the correct treatment of club foot requires frequent accurate cast changes over a prolonged period of time(4,5,6). Even if one cannot completely accomplish the goal of remodeling the talus, one can stretch the surrounding soft tissues without causing the scarring that follows surgery.

1 Irani RN, Sherman MS: Pathological anatomy of clubfoot, Journal of Bone and Joint Surgery, 45A:45, 1963.

2 Settle GW, Anatomy of Congenital Talipes Equinus Varus, Journal of Bone and Joint Surgery, 45A:1341, 1963.

3.Long Term Comparative Results in Patients with Congenital Club Feet Treated with Two Different Protocols, Journal of Bone and Joint Surgery, Vol 85A:1286-1294, July 2003.

4. Altchek MA, Molding of the Talus: A Method of Treating Club Feet, Clinical Orthopedics, May 1972.

5. Altchek MA, Treatment of Club Feet by Molding the Talus, Orthopaedic Review, May 1974.

6. Altchek MA, published letters and discussions:

a. Comments and Response on the treatment of club feet in the September 1974 issue of Orthopaedic Review.

b. Discussion of congenital club feet in Clinical Orthopaedics January/February 1978.

c. Letter concerning complete subtalar release in club feet: part one of a preliminary report in The Journal of Bone and Joint Surgery, Volume 68A.

d. Correspondence regarding non-operative treatment of idiopathic club feet in The Journal of Bone and Joint Surgery, October 1996.