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| Patient's
Information |
| Clubfoot |
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| BRACING |
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| BRACING PROTOCOL |
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| The brace is applied immediately
after the last cast is removed, 3 weeks after tenotomy.
The brace consists of open toe high-top straight last
shoes attached to a bar [A]. For unilateral cases, the
brace is set at 75 degrees of external rotation on the
clubfoot side and 45 degrees of external rotation on the
normal side [B]. In bilateral cases, it is set at 70 degrees
of external rotation on each side. The bar should be of
suf.cient length so that the heels of the shoes are at
shoulder width. A common error is to prescribe too short
a bar, which the child .nds uncomfortable [C]. A narrow
brace is a common reason for a lack of compliance. The
bar should be bent 5 to 10 degrees with the convexity
away from the child, to hold the feet in dorsi.exion [D].
The brace should be worn full time (day and night) for
the .rst 3 months after the tenotomy cast is removed.
After that, the child should wear the brace for 12 hours
at night and 2 to 4 hours in the middle of the day for
a total of 14 to16 hours during each 24-hour period. This
protocol continues until the child is 3 to 4 years of
age. |
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| TYPES OF BRACES |
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| Several types of commercially
made braces are available. With some designs, the bar
is permanently attached to the bottoms of the shoes. With
other designs, it is removable. With some designs, the
bar length is adjustable, and with others, it is .xed.
Most braces cost approximately US $100. In Uganda, Steenbeek
designed a brace, which is made at a cost of approximately
US $12 (see p. 24). Parents should be given a prescription
for a brace at the time of the tenotomy. This gives them
3 weeks to organize themselves. In the United States,
the Markell shoe and brace is most commonly used, but
other countries have different options [E]. |
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| RATIONALE FOR
BRACING |
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At the end of casting, the foot
is abducted [A] to an exaggerated amount, which should
measure 75 degrees (thigh-foot axis). After the tenotomy,
the .nal cast is left in place for 3 weeks. Ponseti.s
protocol then calls for a brace to maintain the
abduction. This is a bar attached to straight last open
toe shoes. This degree of foot abduction is required to
maintain the abduction of the calcaneus and forefoot and
prevent recurrence. The foot will gradually turn back
inward, to a point typically of 10 degrees of external
rotation. The medial soft tissues stay stretched out only
if the brace is used after the casting. In the brace,
the knees are left free, so the child can kick them "straight"
to stretch the gastrosoleus tendon. The abduction of the
feet in the brace, combined with the slight bend (convexity
away from the child), causes the feet to dorsi.ex. This
helps maintain the stretch on the gastrocnemius muscle
and Achilles tendon [D]. |
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| IMPORTANCE
OF BRACING |
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The Ponseti
manipulations combined with the percutaneous tenotomy
regularly achieve an excellent result. However, without
a diligent follow-up bracing program, recurrence and
relapse occur in more than 80% of cases. This is in
contrast to a relapse rate of only 6% in compliant families
(Morcuende et al.). |
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| ALTERNATIVES
TO FOOT ABDUCTION BRACE |
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| Some surgeons have tried to "improve"
Ponseti management by modifying the brace protocol or
by using different braces. They think that the child will
be more comfortable without the bar and so advise use
of straight last shoes alone. This strategy always fails.
The straight last shoes by themselves do nothing. They
function only as an attachment point for the bar. Some
braces are no better than the shoes by themselves and,
therefore, have no place in the bracing protocol. If well
.tted, the knee-ankle-foot braces, such as the Wheaton
brace, maintain the foot abducted and externally rotated.
However, the knee-ankle-foot braces keep the knee bent
in 90 degrees of .exion. This position causes the gastrocnemius
muscle and Achilles tendon to atrophy and shorten, leading
to recurrence of the equinus deformity. This is particularly
a problem if a kneeankle- foot brace is used during the
initial 3 months of bracing, when the braces are worn
full time. In summary, only the brace as described by
Ponseti is an acceptable brace for Ponseti management
and should be worn at night until the child is 3 to 4
years of age. |
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| STRATEGIES
TO INCREASE COMPLIANCE TO BRACING PROTOCOL |
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| The families who are the most
compliant to the bracing protocol are those who have read
about the Ponseti method of clubfoot management on the
Internet and have chosen that method. They come to the
of.ce educated and motivated. The least compliant parents
are often from families who did no background research
on the Ponseti method and need to be "sold"
on it. The best strategy to ensure compliance is to educate
the parents and indoctrinate them into the Ponseti culture.
It helps to see the Ponseti method of management as a
lifestyle that demands certain behavior. |
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| Take advantage of the face-to-face
time that occurs during the weekly casting to talk to
the parents and emphasize the importance of bracing. Tell
them that the Ponseti management method has two phases:
the initial casting phase, during which the doctor does
all the work, and the bracing phase, during which the
parents do all the work. On the day that the last cast
comes off after the tenotomy, "pass the baton"
of responsibility to the parents. |
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| During the initial instructions,
teach the parents how to apply the brace. Suggest they
practice putting it on and taking it off several times
during the .rst few days and have them leave the brace
off for brief periods of time during these few days to
allow the child.s feet to get accustomed to the shoes.
Teach the parents to exercise the child.s knees together
as a unit (.ex and extend) in the brace, so that the children
get accustomed to moving two legs simultaneously. (If
the child tries to kick one leg at a time, the brace bar
interferes, and the child may get frustrated). Warn the
parents that there may be a few rough nights until the
child gets accustomed to the brace [A]. Suggest the analogy
of "saddle training" a horse: it requires a
.rm but patient hand. There should be no "negotiations"
with the child. Schedule the .rst return visit in 10 to
14 days. The main purpose of that visit is to monitor
compliance. If all is well, then the next scheduled visit
is in 3 months, when the child advances to the nighttime
only protocol (or "nights and naps"). It is
useful to approach brace compliance as a public health
issue, similar to tuberculosis treatment. It is not suf.cient
to prescribe anti-tuberculosis medications; you must also
monitor compliance through a public health nurse. We monitor
compliance by frequently calling the families of our patients,
who are in the brace phase, between of.ce visits. All
families are encouraged to call us if they hit a period
of dif.culty with bracing, so that we can work through
the issues. In the beginning, for example, children may
kick off the shoes if they aren.t tightened correctly.
Gluing a small pad at the upper rim of the heel counter
can help keep the feet captured in the shoes [B]. |
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| WHEN TO STOP
BRACING |
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| Occasionally, a child will develop
excessive heel valgus and external tibial torsion while
using the brace. In such instances, the physician should
dial the external rotation of the shoes on the bar from
approximately 70 degrees to 40 degrees. How long should
the nighttime bracing protocol continue? There is no scienti.c
answer to this question. Severe feet should be braced
until age 4 years, and mild feet can be braced until age
2 years [C]. It is not always easy to distinguish which
foot is mild and which is severe, especially when observing
them at age 2 years. Therefore, it is recommended that
even the mild feet should be braced for up to 3 to 4 years,
provided the child still tolerates the nighttime bracing.
Most children get used to the bracing, and it becomes
part of their life style. However, if compliance becomes
very problematic after age 2 years, it may become necessary
to discontinue the bracing to ensure that the child and
parents get a good night.s sleep. This leniency is not
tolerable in the younger age groups. Below age 2 years,
the children and their families must be encouraged to
comply with the bracing protocol at all costs. |
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