Re: Brace after 2 years of age?/references

October 21, 2005

a,

I believe that Dr Ponseti has--in the past 2 years--started to

recommend that most children wear the FAB/DBB for at least 4 years

because he and his colleagues were seeing a high number of severe and

sudden relapses in children at about 2.5 to 3 years old. The basic

idea is that the " disfunction " that caused the clubfoot in the first

place remains active for the first 3 or 4 years of life. The

tendency to relapse is very strong, but can be counteracted by

continued use of the FAB.

2 years old has been the youngest chidren have been released from the

FAB, and reserved for the most mild cases. If your daughter is

tolerating the FAB (and if she is not, we can help you troubleshoot),

she should be fine continuing to wear it. It's certainly worth that

extra year or so to avoid a relapse and the casting on an active

toddler. I know of several parents here who have had to deal with

relapses after discontinuing the brace at around 2 years, hopefully

they will chime in.

Here are a couple of references regarding relapses. Taken together,

they paint a pretty grim picture when it comes to discarding the

brace prematurely.

From Iowa Orthopedic Journal: Volume 22, 55-56, 2002

RELAPSING CLUBFOOT: CAUSES, PREVENTION, AND TREATMENT, Ignacio V.

Ponseti

The full article is available at:

http://health.groups.yahoo.com/group/nosurgery4clubfoot/message/13223

" In recent years, I have treated 90 patients - 52 of them initially

seen from birth to three months of age, and 38 from three Months to

one year of age. Seventy Percent of the patients had plaster casts or

physical therapy elsewhere. Forty patients had been previously

indicated for surgery by the initial treating Physician. To my

surprise, it was possible to successfully correct all these feet with

manipulations, and four or five plaster casts, changed every five

days. I performed percutaneous Achilles tenotomy in 84 percent of the

patients. Eighty-eight percent of the patients were compliant with

the use of the foot abduction splint. There were 14 relapses. The

rate of relapse was seven percent in compliant patients, compared to

78 Percent in non-compliant patients. Relapses were unrelated to age

at presentation or to the number of casts required for correction. "

Note that Dr Ponseti does not state what he means by compliance and

non-compliance, or at what stage of the bracing relapses occurred.

Here is a (I believe) personal communication from Dr Morcuende

at Iowa. From information presented at a professional conference

earlier this year:

" The rate of relapse decreases with age until about 5-6 years of age.

Overall, the odds of relapse if no bracing is used whatsoever is

something like: <12 months = 80-90 %; <2 years: 60-70%; 3-4 years:

20%, 4-6 years; 1%. However, it is not possible to know in which

group a particular patient is in, so you have to treat everyone

cautiously. We are working on determining criteria that will help

indicate odds of relapse, but we have not found any reliable criteria

at this time. "

The whole message is at:

http://health.groups.yahoo.com/group/nosurgery4clubfoot/message/29612

The Global HELP booklet states, in the section on bracing:

http://www.global-help.org/publications/cf.2.pdf

" 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. "

Again, it is not clearly stated what is meant by compliance/non-

compliance. And there is no reference cited.

From PEDIATRICS Vol. 113 No. 2 February 2004, pp. 376-380

Radical Reduction in the Rate of Extensive Corrective Surgery for

Clubfoot Using the Ponseti Method

A. Morcuende, MD, PhD, Lori A. Dolan, PhD©, Frederick R.

Dietz, MD and Ignacio V. Ponseti, MD

The full article is available at:

http://pediatrics.aappublications.org/cgi/content/full/113/2/376

" Consecutive case series were conducted from January 1991 through

December 2001. A total of 157 patients (256 clubfeet) were evaluated.

All patients were treated by serial manipulation and casting as

described by Ponseti. Main outcome measures included initial

correction of the deformity, extensive corrective surgery rate, and

relapses. "

Later:

" After correction, a foot-abduction brace is used to maintain the

correction. This brace consists of a bar with shoes attached at the

ends at 70¡ã of outward rotation on the affected side and 40¡ã on the

normal side. The length of the bar should be equal to the width of

the child¡¯s shoulders (Fig 3). The brace is used on a full-time basis

for 2 to 3 months and at night and during naptime for 3 to 4 years.

Parent self-report on brace wear was used to assess compliance.

Noncompliance was defined when the foot abduction brace was not used

for at least 10 hours a day. "

Farther on:

" There were 17 (10%) relapses after initial successful treatment.

Relapse of the deformity was not significantly related to age at

presentation, previous unsuccessful treatment at other institution,

or the number of casts required for correction (used as a measure of

severity; all P > .05). Relapses were associated with noncompliance

with the foot-abduction brace (P = .001; Table 1). Noncompliance was

associated with a 17 times greater odds of relapse (15 of 17)

compared with compliance (6 of 140; P = .0001). Relapses were treated

with a second series of manipulation and casting, followed by the use

of the foot-abduction brace. Three patients required a second

tendoachilles tenotomy. For preventing additional relapses in 4

(2.5%) patients who were noncompliant with the foot-abduction brace,

an anterior tibial tendon transfer to the third cuneiform and a

tendoachilles lengthening were performed. "

That's 88% of all relapses related to non-compliance (as reported by

the parents and as defined in the article). Again, it is not clearly

stated at which stage in the bracing the relapses occured.

From THE JOURNAL OF BONE & JOINT SURGERY VOLUME 86-A ¡¤ NUMBER 1 ¡¤

JANUARY 2004

Factors Predictive of Outcome After Use of the Ponseti Method for the

Treatment of Idiopathic Clubfeet

BY MATTHEW B. DOBBS, MD, J.R. RUDZKI, MD, DEREK B. PURCELL, MD,

TIM WALTON, RN, BSN, KRISTINA R. PORTER, RN, BSN, AND CHRISTINA A.

GURNETT, MD, PHD

" The families of twenty-one infants (41%) reported that

they had not complied with use of the orthosis; all but one

discontinued use during the first three months after the

orthosis was prescribed. Noncompliance was reported as

complete discontinuation of the use of the orthosis. The most

common reason given for noncompliance was inconvenience,

which was the greatest problem in the first three months after

the orthosis was prescribed, as it was to be worn for twentythree

hours a day. Relapse was detected in sixteen infants

(31%; twenty-seven feet) at a mean age of six months (range,

three to eighteen months), when there was ¡Ý5¡ã of hindfoot

varus and/or <15¡ã of ankle dorsiflexion. The parents of all sixteen

infants who had a relapse reported noncompliance with

the use of the orthosis. Five infants whose parents had not

complied with the protocol did not have a relapse. "

This is dealing with noncompliance very early on in the bracing,

still that is 76% of noncompliant families experiencing a relapse.

So.... There are some numbers for you. Please let us know if you

have any other questions.

Best,

Naomi

The Family

Naomi Hannah(02/21/01) Jonah(06/20/03, corrected bilateral

clubfoot, FAB 14/7)

>

> My daughter Sofia was born w/ 2 club feet. We had the casts till

she

> was 4 months old with the Tendectomy at 2 months.

> Anyway, she has been in the DBB since she was 4 months old and at 9

> months went to night time use only.

> Our Dr, here in Kansas City, told me today that it all looks

great.

> Sofia is 1 1/2 and he thinks that she might be out of the brace by

2

> years of age.

> I know that up in Iowa they keep the children in the DBB till they

are

> 3 years old or older.

> I'm wondering what difference does it make to have them stay on the

> brace till they are 3 or 4 years old?

> Has anybody had their children's feet not keep the correction if

they

> went off the brace at 2 years of age?

> My Dr uses the Ponsetti method, but he is not in the " Ponsetti

List "

> of Doctors.

> Thank you very much

> a

>

October 21, 2005