Bracing in clubfoot: Do we know enough?

Abstract

Purpose The Ponseti method is widely used in clubfoot treatment. Long-term follow-up shows high patient satisfaction and excellent functional outcomes. Clubfoot tendency to relapse is a problem yet to solve. Given the importance of bracing in relapse prevention, we ought to discuss current knowledge and controversies about bracing. Methods We describe types of braces used, with its advantages and disadvantages, suggesting bracing schedules and duration. We identify bracing problems and pinpoint strategies to promote adherence to bracing. Results When treating a clubfoot by the Ponseti method, the corrected foot should be held in an abducted and dorsiflexed position, in a foot abduction brace (FAB), with two shoes connected by a bar. The brace is applied after the clubfoot has been completely corrected by manipulation, serial casting and possibly Achilles tenotomy. Bracing is recommended until four to five years of age and needs to be fitted to the individual patient, based on age, associated relapse rate and timing when correction was finished. Parental non-adherence to FAB use can affect 34% to 61% of children and results in five- to 17-fold higher odds of relapse. In patients who have recurrent adherence problems, a unilateral lower leg custom-made orthosis can be considered as a salvage option. Healthcare providers must communicate with patients regarding brace wearing, set proper expectations and ensure accurate use. Conclusion Bracing is essential for preventing clubfoot relapse. Daily duration and length of bracing required to prevent recurrence is still unknown. Prospective randomized clinical trials may bring important data that will influence clinicians’ and families’ choices regarding bracing. Level of Evidence V

The functional method: experience from the Robert Debré Hospital

“…Night immobilization with above knee semi-rigid casts and/ or Perlstein leather braces were also progressively added (after 2010) to the initial FFM concept, with the aim to limit cavus and ankle equinus by stretching the plantar aponeurosis. The literature shows that Denis-Browne splints are more effective than unilateral orthosis, but they have poor compliance (34% to 61%) (19,20). Poor compliance or increase recurrences was not found with our splinting regime.…”

“…Perlstein leather braces have been used to avoid the evolution to a fixed deformity requiring surgery but this needs further investigation in future research. Our institution recommends night splint immobilization be maintained until the patient recovers complete dynamic foot function, defined by the ability to walk on heels (active ankle dorsiflexion >10°) without dynamic supination or dynamic cavus (forefoot pronation), which is a different treatment concept compared to the PM (20,31). Persistent forefoot adduction (axial plane deformity), was related to the abductor hallucis muscle hypo-extensibility.…”

A Community Audit of 300 “Drop-Out” Instances in Children Undergoing Ponseti Clubfoot Care in Bangladesh—What Do the Parents Say?

“…It is curious as to why do some drop-out cases relapse and others do not [11,28,37,47]. Whilst it is encouraging in both this short-term audit and the previous longer-term review that the relapse rate following incomplete treatment was much lower than anticipated, it also raises questions of treatment "dosage", especially in the repeatedly fraught bracing phase [48][49][50].…”

Impact of COVID-19 pandemic on clubfoot program at tertiary care institute

“…It has been established that non-compliance to brace is an important factor for relapse of clubfoot. [15][16][17] So follow up visits are essential not only to improve compliance but also to pick cases in early relapse stage and intervene.…”