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Orthotic Management of CTEV-A.Patra

The document discusses the orthotic management of congenital talipes equinovarus (CTEV), or clubfoot. It begins by defining CTEV and describing the two main treatment methods: conservative and operative. The orthotic management is associated with both surgical and non-surgical situations, and the prognosis depends on early intervention. Non-operative treatment is preferred initially through serial casting and bracing. If no improvement, surgery may be considered followed by orthotic management. Current best practice is the Ponseti method using serial casting and bracing with an abduction foot orthosis to correct and maintain the correction of the deformity. The document describes various foot abduction orthoses and considerations for choosing an appropriate orthotic

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Orthotic Management of CTEV Aratatran Patra MPO, MBA,MA(Socio), MARD, PGDBA 11.02.2022 Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
 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. Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
Aims of management of CTEV  Aims:  • To correct the deformity early  • To correct the deformity fully  • Hold the correction until growth stops. Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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). Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
 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,. Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
 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 11.02.2022
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 11.02.2022
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 11.02.2022
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. Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
 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 Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
 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. Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
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). Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
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]. Aratatran Patra 11.02.2022
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. Aratatran Patra 11.02.2022
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 Aratatran Patra 11.02.2022
Aratatran Patra 11.02.2022