title: Early ultrasonographic evaluation of idiopathic clubfeet treated with manipulations, casts, and Botox(®): a double-blind randomized control trial.
abstract: BACKGROUND
  The manipulations, casts, and Botox(®) method for treating idiopathic clubfoot is an alternative non-surgical treatment method. Botox(®)-induced reversible muscle paralysis of the gastrocsoleus enables a physician to manipulate and cast the clubfoot in greater dorsiflexion. Ultrasound is incorporated during the early treatment stages to monitor the underlying physiology of the muscle-tendon unit following Botox(®).
  
  
  METHODS
  Ultrasonographic evaluation was performed parallel to a double-blind randomized control trial administering Botox(®) or placebo to correct clubfoot. Patients underwent two-dimensional ultrasound to monitor the length changes to the gastrocsoleus and Achilles tendon unit at two time points: pre-injection (baseline) and 6 weeks post-blinded injection. Gastrocsoleus and Achilles tendon length measurements were analyzed among placebo, Botox(®) and contralateral controls using repeated measures ANOVA.
  
  
  RESULTS
  The baseline gastrocsoleus length of the clubfoot (322.4 pixels) before blinded injection appears shorter than controls (337.5 pixels), but fails to reach significance (p = 0.05). The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks. The complex-tendon ratio and muscle-tendon ratio of the Botox(®) treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively). Briefly, when expressed as a proportion, an increase in Achilles tendon length and decrease in gastrocsoleus is observed when clubfeet are treated with Botox(®).
  
  
  CONCLUSIONS
  Only in the Botox(®) treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex-tendon ratio and muscle-tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.
authors.affiliation: Department of Orthopaedics, British Columbia's Children's Hospital, 1D18-4480 Oak Street, Vancouver, BC V6H 3V4, Canada, ahowren@cw.bc.ca.
authors.forename: Alyssa M
authors.initials: AM
authors.lastname: Howren
authors.forename: Douglas H
authors.initials: DH
authors.lastname: Jamieson
authors.forename: Christine M
authors.initials: CM
authors.lastname: Alvarez