title: The effectiveness of botulinum A toxin as an adjunct to the treatment of clubfeet by the Ponseti method: a randomized, double blind, placebo controlled study.
abstract: BACKGROUND
  The Ponseti method has been shown to be a highly effective way to correct congenital clubfeet nonoperatively. Children treated with the technique frequently require percutaneous Achilles tenotomies, however, and until recently have experienced frequent relapses of their deformity. The purpose of this study was to see if Botulinum a A toxin (BTX-A) (manufactured by Allergan, Irvine CA) and administered before starting treatment with the Ponseti method might decrease the time in cast to correction, reduce the need for percutaneous Achilles tenotomy, and reduce the frequency of relapse.
  
  
  METHODS
  After IRB approval and informed consent, 20 newborns (age 0 to 30 d) with Dimeglio lll congenital clubfeet (N=32) were randomized into either BTX-A or placebo groups. All clubfeet underwent serial manipulation and casting according to the Ponseti technique. Outcomes measured were days in cast to correction of deformity (judged clinically and radiographically), and the need for percutaneous Achilles tenotomy to achieve correction. Recurrence requiring further treatment after initial correction was also recorded.
  
  
  RESULTS
  We were unable to demonstrate a significant difference (t test and chi2 procedures) between the BTX-a group and the placebo group in the outcomes measured.
  
  
  CONCLUSIONS
  We were not able to demonstrate that BTX-A as administered in this study speeds correction, reduces the need for percutaneous Achilles tenotomy, or decreases the chance of relapse after treatment when used as an adjunct to serial manipulation and casting for congenital clubfoot. It is possible that BTX-A could have a treatment effect that due to the power of our study would not have been detected by our study.
  
  
  METHODS
  Level 1b.
authors.affiliation: Department of Orthopaedics, Nemours Children's Clinic, Jacksonville, FL 32207, USA. jcumming@nemours.org
authors.forename: Robert Jay
authors.initials: RJ
authors.lastname: Cummings
mesh_terms: D000125:Achilles Tendon / Q000601:surgery; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002370:Casts, Surgical; D002675:Child, Preschool; D003025:Clubfoot / Q000503:physiopathology / Q000628:therapy*; D003131:Combined Modality Therapy; D004311:Double-Blind Method; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D055502:Secondary Prevention; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A