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.

Keywords: Ponseti method; bracing; clubfoot; family adherence; relapse prevention.

Fig. 1

A three-year-old boy with a left clubfoot, treated by Ponseti method, and using a foot abduction brace. The external rotation on the left affected is to 60° to 70° and on the right unaffected foot is 30° to 40°.

Fig. 2

The Steenbeek brace, developed in Uganda, is made with local tools, being quite affordable and matching all the requirements for bracing following Ponseti casting.

Fig. 3

The Mitchell Brace is very comfortable and became popular between patients and healthcare providers, being widely distributed in developed countries.

Fig. 4

Skin injuries are one of the problems which can interfere with family and child adherence to bracing. Education of parents is quite important, so that they can dress the child’s feet with adequate socks and properly position the foot in the brace. This two-month-old boy was brought to clinic after two weeks of bracing. The skin injury was due to inadequate socks and difficulties in foot positioning within the brace.