The clubfoot brace
Following the final cast, the next phase of treatment is a brace which consists of two shoes attached to a bar at a specific angle. The clubfoot brace sometimes called an AFO, (Ankle Foot Orthosis) is an extremely important part of the Ponseti method. It holds the position of the foot and helps to prevent recurrence.
Once the clubfoot is corrected to 70 degrees external rotation (abduction), your baby’s feet will be measured to ensure that the correct size shoes are fitted once out of the final cast. These shoes are always attached to a bar that holds them at the correct angle to maintain the final casted position. Even if the child has one clubfoot, the bar must still be worn.
There are a few clubfoot brace products available. They are all based on the same principle of holding the feet at a specific angle fitted to a bar that is a comfortable width. Some braces have closed boots and others are open toed leather boots, or sandals. All of them should have a hole on the side of the heel to check that it is well set down inside the shoes.
The Ponseti AFO Brace (also known as the Mitchell brace) made by MD Orthopaedics has been available since 2005. Dr Ponseti was involved in the design of the Ponseti AFO/Mitchell brace and it is especially recommended for children with very small feet or complex clubfoot. This can be worn with either a Ponseti bar, or a Dobbs spring-assisted bar for Mitchell boots.
The setup of bars and shoes is according to Dr Ponseti’s protocol and should not be altered, unless the clubfoot is atypical or complex. It’s essential that the foot is corrected 100% before starting in the shoes and also that the person fitting the shoes is competent in the Ponseti method and knows how to set them up correctly.
For standard setup, the shoes are set at 60 degrees abduction (i.e. just short of a 90 degrees outward angle from neutral position of the foot in order to hold the outward correction) and at 15 degrees dorsiflexion (i.e. the toes will be 15 degrees higher than the heel – the necessary angle to hold the stretch of the Achilles tendon). In cases where the baby has only one (unilateral) clubfoot, the non-clubfoot will be held at 30 degrees abduction.
The space between the heels of the shoes should be the same as the width of the baby’s shoulders. This is why the bar is adjustable in length. It can be widened as the baby grows.
For children with loose ligaments it may be necessary to reduce the 60 degrees to 40-50 degrees. This is usually decided by doctors if at about two years of age, the foot is still in the over-corrected position, i.e. even after six months or more of walking.
For the first three months after the foot is corrected, the baby should wear the clubfoot brace for 23 hours a day. It can be removed for an hour at bath time. After that, it’s usually worn while the baby is sleeping (night and daytime naps), for between 12-18 hours up until the age of four years, gradually reducing and depending on the individual case.
There are many styles of braces available worldwide. As long as the shoes are at the correct angle and are comfortable to wear, they all work the same way.
There are mass-produced braces entering the market; the Iowa Brace, which is marketed by Clubfoot Solutions launches in North America and Europe end 2016. The miraclefeet brace is currently not for sale, but is donated to some partner clinics in developing countries.
The Steenbeek brace (SFAB) designed in Uganda by Michiel Steenbeek, and endorsed by Dr Ponseti, is an effective low-cost option for developing countries.
Studies by various Ponseti doctors have shown that correct compliance with brace wear makes the Ponseti Method over 95% successful. The more resistant cases may still have recurrence ,even with correct brace wear. In these cases, children will have a few more casts and go back into the brace. If the recurrence problem persists, the standard Ponseti protocol is to do a tendon transfer, either TATT or ATTT (the tendon anterior tibialis is repositioned in surgery). This surgery is less invasive than a postero-medial release and has good results, if done correctly. After a ATTT/TATT it is usually not necessary to continue wearing a brace as it acts as an internal splint and prevents recurrence.
For more information on brace wear, download one of our parent information leaflets,’Maintaining Clubfoot Correction’ here Ponseti for Parents