Information on FAB/DBB in Gobal HELP Booklet

[Guest guest]

The Group Global HELP has published a 32 page booklet on the Ponseti

method that discusses all aspects of treatment. Here is their

information on FAB/DBB Bracing.

Bracing Bracing protocol.

" 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 . In

bilateral cases, it is set at 70 degrees of external rotation on

each side. The bar should be of sufficient 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 finds 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 dorsiflexion [D].The brace should be

worn full time (day and night) for the first 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. "

Types of braces

" 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 fixed. 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]. "

Rationale for bracing.

" 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 final cast is left in place for 3 weeks. Ponsetiʼs

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 dorsiflex.

This helps maintain the stretch on the gastrocnemius muscle and

Achilles tendon [D]. "

Importance of bracing

" 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.). "

Alternatives to foot abduction brace.

" 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 fitted, 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 flexion. 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 knee-ankle-

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. "

Strategies to increase compliance to bracing protocol.

" 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 office

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. 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. "

" 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 first few days and have them leave the

brace off for brief periods of time during these few days to allow

the childʼs feet to get accustomed to the shoes. Teach the parents

to exercise the childʼs knees together as a unit (flex 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 firm but patient hand. There should

be no " negotiations " with the child. Schedule the first return visit

in 10 to 14 days. The main purpose if 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 sufficient 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 office visits. All families are encouraged to

call us if they hit a period of difficulty with bracing,

so that we can work through the issues. In the beginning, for

example, children may kick off the shoes if they arenʼt tightened

correctly. Gluing a small pad at the upper rim of the heel counter

can help keep the feet captured in the shoes . "

When to stop bracing

" 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 scientific 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 nightʼs 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. "

http://www.global-help.org/publications/pdfs/PonsetiBook.pdf