Orthotic Management of CTEV ARATATRAN PATRA

1. Orthotic Management of CTEV
Aratatran Patra
MPO, MBA,MA(Socio), MARD, PGDBA
11.02.2022
Aratatran Patra
11.02.2022

2. Introduction
 Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is one
of the most common congenital foot deformity in which the foot is three-
dimensionally twisted from the normal shape of the foot. Congenital talipes
equinovarus (CTEV) is defined as fixation of the foot in Cavus, adduction,
varus, and equines (i.e.inclined inwards, axially rotated inwards, and pointing
downwards) with concomitant soft tissue abnormalities.
 Not all Clubfeet are the same and it is important that all people treating clubfoot
use the same terms to describe the different types.
 Each type of clubfoot has unique characteristics and may need specific
treatment.
 Early recognition of the type of clubfoot one is dealing can help to guide
appropriate treatment.
 Management of clubfoot consists of two methods : Conservative method &
Operative method.
 The orthotic management of CTEV is associated both with surgical and non-
surgical situations. The prognosis of the management depends on the initiation
of early interventions.
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3.  There is nearly universal agreement that the initial treatment of the CTEV
should be non-operative regardless of the severity of the deformity.
 If there is no improvement, then most of the Orthotist prefer to refer the
case to Orthopaedic Surgeons for postero-medial release (PMR) of the soft
tissue followed by Orthosis.
 It is difficult to treat CTEV without the intervention of Orthotists.
 However over the past two decades, more and more success has been
achieved in correcting CTEV without the need for surgery by Ponseti
casting technique, which has become a gold standard worldwide.
 It includes serial corrective manipulation, a specific technique of the
serial application of plaster cast supported by limited operative
intervention (percutaneous Achilles tenotomy) with foot abduction
Orthosis. The method has been reported to have success rate
approaching 90- 96% in short, mid and long-term results.
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4. Very difficult to
treat - if
neglected and
YET A
CHALLENGING
PROBLEM TO
ORTHO
SURGEON.
Very Easy to treat - since
patients are very young –
Easy for Orthotists
A C
B
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5. Aims of management of CTEV
 Aims:
 • To correct the deformity early
 • To correct the deformity fully
 • Hold the correction until growth stops.
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6. HISTORICAL PERSPECTIVES ON BRACING/ORTHOSIS FOR CTEV
 The 1895 Walsham and Hughes provided an early
account of bracing for the prevention of clubfoot.
Authors divided bracing into two categories,
 (1) instruments for use during the night, and
 (2) instruments for use during the day.
Used during
the night
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7. They further breakdown the daytime
bracing options into three subsets,
including:
 (a) instruments for holding the foot
in a restored position,
 (b) those that, in addition are
designed to overcome the tendency
for the whole limb to roll inwards,
and control inversion of the limb.
 (c) those that have the purpose of
further improving a partially
corrected clubfoot.
a
b
Sayre's
appliance
C
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8. CURRENT ORTHOTIC MANAGEMENT OF CTEV
 Under the Ponseti method recommendations, the corrected foot
should be held in an abducted and dorsiflexed position to
prevent relapses.
 This is the most important criteria to ensure that there is
maintenance of the clubfoot correction and is best achieved by
using a well-designed Foot Abduction Orthosis (FAO).
 A FAO consists of two shoes connected by a bar.
 If the deformity is unilateral, the external rotation on the
affected foot should be set to 60-70 degree and on the
unaffected foot to 30-45 degree.
 The bar should be of the length between the child’s shoulders
and should be bent to allow for 10-15 degree of dorsiflexion.
 Ideally, the bar can be lengthened over time as the child grows.
 The shoes should be comfortable and straight laced (no curves
and can fit both feet).
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9. Cont…
 The current research that is available regarding Orthosis design
focuses on increasing patient comfort and satisfaction to improve
adherence.
 Although the currently available Orthoses are widely distributed
in developed countries, access is limited to many parts of the
world.
 Locally produced orthoses with low cost materials, such as the
Steenbeek Orthosis, can provide an option to patients in
underprivileged areas and increase adherence and success rate of
the treatment.
 Although many new brace designs are being proposed and
developed, evidence in the literature regarding biomechanical
effects, clinical outcomes, functionality and patient adherence is
limited
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10. RATIONALE FOR CHOSING AN APPROPRIATE
ORTHOTIC MANAGEMENT
 Following correction of the clubfoot deformity, splinting for many
months is indispensable to help prevent relapses.
 Since the main corrective force of the varus and adduction of the
clubfoot is abduction (that is, external rotation of the foot under the
talus), a splint is needed to maintain the foot in the same degree of
abduction as it was in the last plaster cast.
 This is best accomplished with the feet in well-fitted, open-toed, high
top shoes attached in external rotation to a bar of about the length
between the baby’s shoulders.
 Unless they are splinted in firm external rotation, the pull of the
retracting fibrosis in the ligaments of the medial aspect of the ankle
and of the tibialis posterior and toe flexors is strong enough to cause
a recurrence of the deformity in most feet.
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11. DIFFERENT FOOT ABDUCTION ORTHOSES
1. Denis browne bar’ or ‘Denis browne splint
2. Steen beek foot abduction Orthosis
3. Kessler Brace
4. The Horton Click brace
5. The Dobb’s Dynamic Clubfoot Brace
6. The Mitchell Brace
7. Markell Brace
8. Dynamic AFO
9. CTEV shoe
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12. DENIS BROWNE SPLINT
 The braces most commonly used today
employ a connecting bar and are often
referred to as a ‘Denis Browne Bar’ made
up Aluminum bar of 20mm width and 4-
4.5mm thickness is used for mounting the
shoes. Every bar is provided with additional
6mm holes on either side for increasing the
gap between the shoes as per the need. A
pair of CTEV Shoes with straight medial
border, open toes box with ankle straps,
lateral sole wedge with pair of laces
attached to it with the help of shoe
attachment plate assembly.
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13.  Here Browne states that maintaining the clubfoot
correction “can be obtained by connecting the
feet horizontally at the desired angles to the
Sagittal plane.”
 Advantage- Abduction angle can be changed
from 70° to 50–60° if brace is too much
cumbersome to child for 5–7 days and then again
adjusted to 70°
 Disadvantage-Chances of change in abduction
angle, Chance of loosening of sole screw,.
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14. STEEN BEEK FOOT ABDUCTION ORTHOSIS
 The Steenbeek brace, developed in Uganda by
Michiel Steenbeek and David Okello, is made
with local tools (leather sewing machine, metal-
working equipment, welding tools) and
materials (leather, lining, plywood, mild steel
rod stock).
 The cost is under 10 US dollars and matches the
recommendations provided by Dr. Ponseti.
 ADVANTAGES- Abduction angle is fix and
cannot change its position, Easily understood by
parents that how to bear the abduction brace as
abduction angle is fix, cost effective
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15. KESSLER BRACE
 FAOs are constantly being redesigned to
improve comfort and to increase adherence to
therapeutic recommendations.
 Although the functional aspects of most
FAOs are aligned with the Ponseti method
recommendations, different materials are
used to attempt an increase in patient
utilization and satisfaction.
 For example, the Kessler Brace closely
follows the angles recommended by the
Ponseti method, but the bar has some
flexibility to allow the child some ability for
plantar flexion during kicking.
 The bar returns to the original dorsiflexed
position once the child stops kicking.
 the bar is made of 1/8” thick polypropylene.
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16. THE HORTON CLICK BRACE
 The Horton click is a foot rotation bar that allows the feet
to be internally or externally rotated.
 This bar was designed by an orthotist who understood
there was a need for a more patient friendly / orthotist
friendly device.
 TheHortonClick is easier to fit on the child because you fit
the shoes on independently then click them on the foot
rotation bar.
 This allows for better positioning of the foot in the shoe
which reduces the child from being able to kick the shoes
off.
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17.  One of the many advantages of the Horton Click is the
ease of dressing the child.
 With just a click you can quickly remove the bar from
the shoes, change the child, and click the shoes back
on the bar.
 The Horton Click is an excellent choice for kids going
through the Ponseti protocol for clubfoot treatment.
Aratatran Patra
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18. THE DOBB’S DYNAMIC CLUBFOOT BRACE
 Dr. Matthew Dobbs, MD an orthopedic surgeon who specializes in
clubfeet at St. Louis Children ’ s Hospital has invented a new
dynamic clubfoot brace “ Dobbs Bar.”
 The Dobbs Bar lets children move and kick their legs
independently which gives clubfoot kids new-found freedom when
it comes to crawling and being more active in the brace.
 Children sleep better in the Dobbs Bar because it ’ s more
comfortable and less restrictive.
 The independent movement prevents heel ulcers and keeps the kids
from pulling out of the booties. The results are happier parents,
happier kids and improved compliance.
Aratatran Patra
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19. Cont…
 Children can kick and move their
legs independently so they can
crawl and be more active.
 The independent movement and
greater mobility of the brace
prevents the kids from escaping
and pulling out of the booties.
 The Dobbs Bar is completely
adjustable from 8 to 14 inches in
order to keep up with the growth
of the child.
Aratatran Patra
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20. Padmapada dynamic foot abduction Orthosis
 In the Padmapada dynamic foot abduction Orthosis the abduction bars are
connected to the shoes through a four-bar linkage. This allows freedom of
movement of the orthosis in the coronal plane and independent unilateral
flexion–extension movement of hip and knees while maintaining the foot
abduction.It helps for easy “rolling over” and crawling in babies. The angles
maintained at the foot and ankle are the same as per the recommendation
of Ponseti.
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21. The Mitchell Brace
 It was developed by John Mitchell
 It is widely distributed in developed
countries; however it is quite
expensive. The brace was designed
under the direction of Dr. Ponseti for
the treatment of Complex Clubfeet
given the difficulty maintaining a
good correction with the Markell
shoes.
 This brace consist of shoes made of a
very soft leather and a plastic sole that
is moulded to the shape of the childs
foot,making this shoe very
comfortable and easy to use.
 DISADVANTAGE-HIGHER PRICE
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22. Markell Brace
 The Markell brace was the standard FAO at
the University of Iowa for decades.
 It was developed by M.J Markel that allows
the parent to first placed the shoe on the
infant and then click each shoe onto the bar
 The device consists of a pair of open-toed
shoes mounted on an aluminum spreader
bar
 The flat bar is available in various sizes to
allow widening of the distance between the
shoes as the child grow.
 Foot plates are attached to the bar by a steel
bolt that fixes a serrated disk, which allows
for the adjustment of rotation of the foot
plates
 DISADVANTAGE-HEAVY IN WEIGHT
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23. Ankle Foot Orthosis (AFO)
 In specific circumstances, an AFO can be useful in
combination with an abduction brace, i.e., when the
child’s foot has relatively limited dorsiflexion (i.e.,
spina bifida, arthrogryposis, neurologic dysfunction of
the peroneal nerve, etc.
 There is little muscular support in these conditions, so
the brace provides the necessary structural support to
the child’s foot.
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24.  The foot should be maintain in neutral position
 The medial border/wall of foot should be straight.
 The medial foot trimline should be higher wall
 The instep strap should be located corrected position
24
PROVISIONS OF MOULDED AFO
24
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25. LIMITATION-AFO for CTEV
 LIMITATION-AFO fully covers both the foot and
ankle, thus providing only the dorsiflexion built into
the brace, which is usually set at neutral.
 Importantly, it does not provide abduction, which is
important for the stretching of the medial structures.
 In addition, because of the lack of motion at the ankle,
it contributes to calf muscle atrophy which is already
abnormal in clubfoot.
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26. Aratatran Patra
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27. CTEV SHOE
 The CTEV shoes are made out of different types of
high quality leather with specified lasts. The CTEV
shoes do not have any heel and has flat soles. For
ambulatory children who need to continue the use of
the CTEV shoes the last layer of the leather piece is
replaced with hard rubber used for soles in general.
 These are modified shoes, used once a child starts
walking.
 The following modifications are made in the shoe:-
I. Straight inner border to prevent forefoot adduction.
II. Outer shoe raise to prevent foot inversion.
III. No heel to prevent equinus.
 These shoes are used until the child is 5 years old.
 CTEV high top shoes with lateral wedges should be
used for walking as they provide good stability for the
ankle.
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28.  Every CTEV shoes should have an ankle strap
attached to it which originates at 45 degrees to the
heel axis on the medial aspects of the shoe as shown
below, enters into through the slot provided, and
comes out through another slot on the corresponding
location on the lateral aspect and crosses into the
buckle and loop.
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29. WEARING INSTRUCTIONS FOR THE FOOT ABDUCTION
BRACE
1. Always use cotton socks
2. Check that the child’s heel is down
3. Lace the shoes tightly but do not cut off circulation.
4. Be sure that all of the baby’s toes are out straight
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30. Helpful tips for the foot
abduction brace
 Expect your child to fuss in the brace for the first 2 days.
This is not because the brace is painful but because it is
something new and different.
 Play with your child in the brace- This is key to getting
over the irritability that is often due to the inability of the
child to move his/her legs independently of each other.
 Pad the bar -By padding the bar, you will protect your child,
yourself, and your furniture from being hit by the bar when
the child is wearing it
 Never use lotion on any red spot on the skin. Lotion makes
the problem worse.
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31. ORTHOTIC TREATMENT PROTOCOL
 The maintenance phase involves the use of a foot abduction
Orthosis(FAO) for 23 h a day for three months, followed by night use
until four to five years of age.
 After 3 months the child should wear the brace for 12 hours at night and 2
to 4 hours in the middle of the day(nap time), for a total of 14 to 16 hours
during each 24-period.
 This protocol continues until the child is 4 to 5 years of age.
 Once the child started walking, they were given CTEV shoe in day time
and splint/brace in the night.
 After the brace was given, follow up should be done in a monthly or
weekly basis.
 During the first and second nights of wearing the brace, baby may be
uncomfortable as he/she adjusts to the legs being tethered together .it is
very important that the brace not be removed.
 After the second night, the baby will have adapted to the brace.
 Early visit was encouraged in case of any skin complication or other
issues (breakage or damage of brace/ctev shoes, or change in size).
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32. Strategies to increase compliance to bracing protocol
 The most compliant families are those who understand Ponseti
management and the importance of bracing.
1. CONTINUED EDUCATION
 Take every opportunity to educate the family about Ponseti
management.
i. WRITTEN MATERIAL
 It is very helpful when available. Often published material is more
convincing than information given verbally.
ii. PREPARE FAMILY FOR BRACING
 Anticipate that failures are most likely due to premature
discontinuation of bracing.
 Repeatedly emphasize the importance of this phase of management.
 Make families aware that maintaining the correction with bracing is
equally important to gaining the correction by casting and tenotomy.
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33. 2. INSTRUCTIONS FOR BRACING
i. Assigning responsibility- Once correction has been
achieved, clearly pass the responsibility to the family to
maintain the correction with bracing. Assigning that
responsibility to the father may be appropriate in some
situations.
ii. Preparing the infant- For the first few days, suggest
that the brace may be removed for brief periods to
improve tolerance. Advise the parents to avoid removing
the brace if the infant cries. If the infant learns that by
crying the brace will be removed, the pattern will be
difficult to correct. Encourage the family to make the
bracing a part of the normal life of the infant [3].
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34. 3. FOLLOW-UP
i. Schedule a return visit- in 10–14 days to monitor
the use of the brace. If the bracing is going well,
schedule the next visit in about 3 months. At that
time, the bracing may be discontinued during the
day. The brace must be applied for naps during the
day and sleep during the night.
ii. Offer help- Should the family experience difficulty
with bracing, encourage the family to call or to
return to clinic.
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35. REFERENCES
 Balasankar G, Luximon A, Al-Jumaily A. Current conservative management and
classification of club foot: A review. J Pediatr Rehabil Med. 2016;9(4):257–264.
doi:10.3233/PRM-160394
 Wedge, J. H., Daniels, T. R., & Alman, B. A. (2001). Congenital clubfoot. Current
Paediatrics, 11(5), 332–340
 Anand, A., & Sala, D. A. (2008). Clubfoot: Etiology and treatment. Indian journal of
orthopaedics, 42(1), 22.
 Alves, C. (2019). Bracing in clubfoot: do we know enough?. Journal of children's
orthopaedics, 13(3), 258-264.
 Garg, S., & Porter, K. (2009). Improved bracing compliance in children with clubfeet using
a dynamic orthosis. Journal of children's orthopaedics, 3(4), 271-276.
 Chen, R. C., Gordon, J. E., Luhmann, S. J., Schoenecker, P. L., & Dobbs, M. B. (2007). A
new dynamic foot abduction orthosis for clubfoot treatment. Journal of Pediatric
Orthopaedics, 27(5), 522-528.
 Browne D. Talipes Equino-Varus. Congenital talipes equino-varus. Br Med J 1931;2:696-699
 Steenbeek HM, David CO. Steenbeek brace for clubfoot (2nd edition)
 Kessler JI. A new flexible brace used in the Ponseti treatment of talipes equinovarus. J
Pediatr Orthop B. 2008: 17(5):247-50
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36. Aratatran Patra
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