Orthotic Management of CTEV-A.Patra

Orthotic Management of CTEV
ARATATRAN PATRA

1. Orthotic Management of CTEV
AratatranPatra
MPO, MBA,MA(Socio), MARD, PGDBA
11.02.2022
Aratatran Patra11.02.2022

2. Introduction
Congenitaltalipesequinovarus(CTEV),commonlyknownasclubfoot,isone
ofthemostcommoncongenitalfootdeformityinwhichthefootisthree-
dimensionallytwistedfromthenormalshapeofthefoot.Congenitaltalipes
equinovarus(CTEV)isdefinedasfixationofthefootinCavus,adduction,
varus,andequines(i.e.inclinedinwards,axiallyrotatedinwards,andpointing
downwards)withconcomitantsofttissueabnormalities.
NotallClubfeetarethesameanditisimportantthatallpeopletreatingclubfoot
usethesametermstodescribethedifferenttypes.
Eachtypeofclubfoothasuniquecharacteristicsandmayneedspecific
treatment.
Earlyrecognitionofthetypeofclubfootoneisdealingcanhelptoguide
appropriatetreatment.
Managementofclubfootconsistsoftwomethods:Conservativemethod&
Operativemethod.
TheorthoticmanagementofCTEVisassociatedbothwithsurgicalandnon-
surgicalsituations.Theprognosisofthemanagementdependsontheinitiation
ofearlyinterventions.
Aratatran Patra11.02.2022

3. ThereisnearlyuniversalagreementthattheinitialtreatmentoftheCTEV
shouldbenon-operativeregardlessoftheseverityofthedeformity.
Ifthereisnoimprovement,thenmostoftheOrthotistprefertoreferthe
casetoOrthopaedicSurgeonsforpostero-medialrelease(PMR)ofthesoft
tissuefollowedbyOrthosis.
ItisdifficulttotreatCTEVwithouttheinterventionofOrthotists.
Howeveroverthepasttwodecades,moreandmoresuccesshasbeen
achievedincorrectingCTEVwithouttheneedforsurgerybyPonseti
castingtechnique,whichhasbecomeagoldstandardworldwide.
Itincludesserialcorrectivemanipulation,aspecifictechniqueofthe
serialapplicationofplastercastsupportedbylimitedoperative
intervention(percutaneousAchillestenotomy)withfootabduction
Orthosis.Themethodhasbeenreportedtohavesuccessrate
approaching90-96%inshort,midandlong-termresults.
Aratatran Patra11.02.2022

4. Very difficult to
treat -if
neglected and
YET A
CHALLENGING
PROBLEM TO
ORTHO
SURGEON.
VeryEasytotreat-since
patientsareveryyoung–
EasyforOrthotists
AC
B
Aratatran Patra11.02.2022

5. Aimsof management of CTEV
Aims:
• To correct the deformity early
• To correct the deformity fully
• Hold the correction until growth stops.
Aratatran Patra11.02.2022

6. HISTORICAL PERSPECTIVES ON BRACING/ORTHOSIS FOR CTEV
The1895WalshamandHughesprovidedanearly
accountofbracingforthepreventionofclubfoot.
Authorsdividedbracingintotwocategories,
(1)instrumentsforuseduringthenight,and
(2)instrumentsforuseduringtheday.
Used during
the night
Aratatran Patra11.02.2022

7. Theyfurtherbreakdownthedaytime
bracingoptionsintothreesubsets,
including:
(a)instrumentsforholdingthefoot
inarestoredposition,
(b)thosethat,inadditionare
designedtoovercomethetendency
forthewholelimbtorollinwards,
andcontrolinversionofthelimb.
(c)thosethathavethepurposeof
furtherimprovingapartially
correctedclubfoot.
a
b
Sayre's
appliance
C
Aratatran Patra11.02.2022

8. CURRENT ORTHOTIC MANAGEMENT OF CTEV
UnderthePonsetimethodrecommendations,thecorrectedfoot
shouldbeheldinanabductedanddorsiflexedpositionto
preventrelapses.
Thisisthemostimportantcriteriatoensurethatthereis
maintenanceoftheclubfootcorrectionandisbestachievedby
usingawell-designedFootAbductionOrthosis(FAO).
AFAOconsistsoftwoshoesconnectedbyabar.
Ifthedeformityisunilateral,theexternalrotationonthe
affectedfootshouldbesetto60-70degreeandonthe
unaffectedfootto30-45degree.
Thebarshouldbeofthelengthbetweenthechild’sshoulders
andshouldbebenttoallowfor10-15degreeofdorsiflexion.
Ideally,thebarcanbelengthenedovertimeasthechildgrows.
Theshoesshouldbecomfortableandstraightlaced(nocurves
andcanfitbothfeet).
Aratatran Patra11.02.2022

9. Cont…
ThecurrentresearchthatisavailableregardingOrthosisdesign
focusesonincreasingpatientcomfortandsatisfactiontoimprove
adherence.
AlthoughthecurrentlyavailableOrthosesarewidelydistributed
indevelopedcountries,accessislimitedtomanypartsofthe
world.
Locallyproducedorthoseswithlowcostmaterials,suchasthe
SteenbeekOrthosis,canprovideanoptiontopatientsin
underprivilegedareasandincreaseadherenceandsuccessrateof
thetreatment.
Althoughmanynewbracedesignsarebeingproposedand
developed,evidenceintheliteratureregardingbiomechanical
effects,clinicaloutcomes,functionalityandpatientadherenceis
limited
Aratatran Patra11.02.2022

10. RATIONALE FOR CHOSING AN APPROPRIATE
ORTHOTIC MANAGEMENT
Followingcorrectionoftheclubfootdeformity,splintingformany
monthsisindispensabletohelppreventrelapses.
Sincethemaincorrectiveforceofthevarusandadductionofthe
clubfootisabduction(thatis,externalrotationofthefootunderthe
talus),asplintisneededtomaintainthefootinthesamedegreeof
abductionasitwasinthelastplastercast.
Thisisbestaccomplishedwiththefeetinwell-fitted,open-toed,high
topshoesattachedinexternalrotationtoabarofaboutthelength
betweenthebaby’sshoulders.
Unlesstheyaresplintedinfirmexternalrotation,thepullofthe
retractingfibrosisintheligamentsofthemedialaspectoftheankle
andofthetibialisposteriorandtoeflexorsisstrongenoughtocause
arecurrenceofthedeformityinmostfeet.
Aratatran Patra11.02.2022

11. DIFFERENTFOOTABDUCTIONORTHOSES
1.Denis brownebar’ or ‘Denis brownesplint
2.Steen beekfoot abduction Orthosis
3.Kessler Brace
4.The Horton Click brace
5.The Dobb’s Dynamic Clubfoot Brace
6.The Mitchell Brace
7.MarkellBrace
8.Dynamic AFO
9.CTEV shoe
Aratatran Patra11.02.2022

12. DENIS BROWNE SPLINT
Thebracesmostcommonlyusedtoday
employaconnectingbarandareoften
referredtoasa‘DenisBrowneBar’made
upAluminumbarof20mmwidthand4-
4.5mmthicknessisusedformountingthe
shoes.Everybarisprovidedwithadditional
6mmholesoneithersideforincreasingthe
gapbetweentheshoesaspertheneed.A
pairofCTEVShoeswithstraightmedial
border,opentoesboxwithanklestraps,
lateralsolewedgewithpairoflaces
attachedtoitwiththehelpofshoe
attachmentplateassembly.
Aratatran Patra11.02.2022

13. HereBrownestatesthatmaintainingtheclubfoot
correction“canbeobtainedbyconnectingthe
feethorizontallyatthedesiredanglestothe
Sagittalplane.”
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 Patra11.02.2022

14. STEEN BEEK FOOT ABDUCTION ORTHOSIS
TheSteenbeekbrace,developedinUgandaby
MichielSteenbeekandDavidOkello,ismade
withlocaltools(leathersewingmachine,metal-
workingequipment,weldingtools)and
materials(leather,lining,plywood,mildsteel
rodstock).
Thecostisunder10USdollarsandmatchesthe
recommendationsprovidedbyDr.Ponseti.
ADVANTAGES-Abductionangleisfixand
cannotchangeitsposition,Easilyunderstoodby
parentsthathowtobeartheabductionbraceas
abductionangleisfix,costeffective
Aratatran Patra11.02.2022

15. KESSLER BRACE
FAOsareconstantlybeingredesignedto
improvecomfortandtoincreaseadherenceto
therapeuticrecommendations.
Althoughthefunctionalaspectsofmost
FAOsarealignedwiththePonsetimethod
recommendations,differentmaterialsare
usedtoattemptanincreaseinpatient
utilizationandsatisfaction.
Forexample,theKesslerBraceclosely
followstheanglesrecommendedbythe
Ponsetimethod,butthebarhassome
flexibilitytoallowthechildsomeabilityfor
plantarflexionduringkicking.
Thebarreturnstotheoriginaldorsiflexed
positiononcethechildstopskicking.
thebarismadeof1/8”thickpolypropylene.
Aratatran Patra11.02.2022

16. THE HORTON CLICK BRACE
TheHortonclickisafootrotationbarthatallowsthefeet
tobeinternallyorexternallyrotated.
Thisbarwasdesignedbyanorthotistwhounderstood
therewasaneedforamorepatientfriendly/orthotist
friendlydevice.
TheHortonClickiseasiertofitonthechildbecauseyoufit
theshoesonindependentlythenclickthemonthefoot
rotationbar.
Thisallowsforbetterpositioningofthefootintheshoe
whichreducesthechildfrombeingabletokicktheshoes
off.
Aratatran Patra11.02.2022

17. OneofthemanyadvantagesoftheHortonClickisthe
easeofdressingthechild.
Withjustaclickyoucanquicklyremovethebarfrom
theshoes,changethechild,andclicktheshoesback
onthebar.
TheHortonClickisanexcellentchoiceforkidsgoing
throughthePonsetiprotocolforclubfoottreatment.
Aratatran Patra11.02.2022

18. THE DOBB’S DYNAMIC CLUBFOOT BRACE
Dr.MatthewDobbs,MDanorthopedicsurgeonwhospecializesin
clubfeetatSt.LouisChildren’sHospitalhasinventedanew
dynamicclubfootbrace“DobbsBar.”
TheDobbsBarletschildrenmoveandkicktheirlegs
independentlywhichgivesclubfootkidsnew-foundfreedomwhen
itcomestocrawlingandbeingmoreactiveinthebrace.
ChildrensleepbetterintheDobbsBarbecauseit’smore
comfortableandlessrestrictive.
Theindependentmovementpreventsheelulcersandkeepsthekids
frompullingoutofthebooties.Theresultsarehappierparents,
happierkidsandimprovedcompliance.
Aratatran Patra11.02.2022

19. Cont…
Childrencankickandmovetheir
legsindependentlysotheycan
crawlandbemoreactive.
Theindependentmovementand
greatermobilityofthebrace
preventsthekidsfromescaping
andpullingoutofthebooties.
TheDobbsBariscompletely
adjustablefrom8to14inchesin
ordertokeepupwiththegrowth
ofthechild.
Aratatran Patra11.02.2022

20. Padmapadadynamic foot abduction Orthosis
InthePadmapadadynamicfootabductionOrthosistheabductionbarsare
connectedtotheshoesthroughafour-barlinkage.Thisallowsfreedomof
movementoftheorthosisinthecoronalplaneandindependentunilateral
flexion–extensionmovementofhipandkneeswhilemaintainingthefoot
abduction.Ithelpsforeasy“rollingover”andcrawlinginbabies.Theangles
maintainedatthefootandanklearethesameaspertherecommendation
ofPonseti.
Aratatran Patra11.02.2022

21. The Mitchell Brace
ItwasdevelopedbyJohnMitchell
Itiswidelydistributedindeveloped
countries;howeveritisquite
expensive.Thebracewasdesigned
underthedirectionofDr.Ponsetifor
thetreatmentofComplexClubfeet
giventhedifficultymaintaininga
goodcorrectionwiththeMarkell
shoes.
Thisbraceconsistofshoesmadeofa
verysoftleatherandaplasticsolethat
ismouldedtotheshapeofthechilds
foot,makingthisshoevery
comfortableandeasytouse.
DISADVANTAGE-HIGHERPRICE
Aratatran Patra11.02.2022

22. MarkellBrace
TheMarkellbracewasthestandardFAOat
theUniversityofIowafordecades.
ItwasdevelopedbyM.JMarkelthatallows
theparenttofirstplacedtheshoeonthe
infantandthenclickeachshoeontothebar
Thedeviceconsistsofapairofopen-toed
shoesmountedonanaluminumspreader
bar
Theflatbarisavailableinvarioussizesto
allowwideningofthedistancebetweenthe
shoesasthechildgrow.
Footplatesareattachedtothebarbyasteel
boltthatfixesaserrateddisk,whichallows
fortheadjustmentofrotationofthefoot
plates
DISADVANTAGE-HEAVYINWEIGHT
Aratatran Patra11.02.2022

23. Ankle Foot Orthosis(AFO)
Inspecificcircumstances,anAFOcanbeusefulin
combinationwithanabductionbrace,i.e.,whenthe
child’sfoothasrelativelylimiteddorsiflexion(i.e.,
spinabifida,arthrogryposis,neurologicdysfunctionof
theperonealnerve,etc.
Thereislittlemuscularsupportintheseconditions,so
thebraceprovidesthenecessarystructuralsupportto
thechild’sfoot.
Aratatran Patra11.02.2022

24. Thefootshouldbemaintaininneutralposition
Themedialborder/walloffootshouldbestraight.
Themedialfoottrimlineshouldbehigherwall
Theinstepstrapshouldbelocatedcorrectedposition
24
PROVISIONS OF MOULDED AFO
24
Aratatran Patra11.02.2022

25. LIMITATION-AFO for CTEV
LIMITATION-AFOfullycoversboththefootand
ankle,thusprovidingonlythedorsiflexionbuiltinto
thebrace,whichisusuallysetatneutral.
Importantly,itdoesnotprovideabduction,whichis
importantforthestretchingofthemedialstructures.
Inaddition,becauseofthelackofmotionattheankle,
itcontributestocalfmuscleatrophywhichisalready
abnormalinclubfoot.
Aratatran Patra11.02.2022

26. Aratatran Patra11.02.2022

27. CTEV SHOE
TheCTEVshoesaremadeoutofdifferenttypesof
highqualityleatherwithspecifiedlasts.TheCTEV
shoesdonothaveanyheelandhasflatsoles.For
ambulatorychildrenwhoneedtocontinuetheuseof
theCTEVshoesthelastlayeroftheleatherpieceis
replacedwithhardrubberusedforsolesingeneral.
Thesearemodifiedshoes,usedonceachildstarts
walking.
Thefollowingmodificationsaremadeintheshoe:-
I.Straightinnerbordertopreventforefootadduction.
II.Outershoeraisetopreventfootinversion.
III.Noheeltopreventequinus.
Theseshoesareuseduntilthechildis5yearsold.
CTEVhightopshoeswithlateralwedgesshouldbe
usedforwalkingastheyprovidegoodstabilityforthe
ankle.
Aratatran Patra11.02.2022

28. EveryCTEVshoesshouldhaveananklestrap
attachedtoitwhichoriginatesat45degreestothe
heelaxisonthemedialaspectsoftheshoeasshown
below,entersintothroughtheslotprovided,and
comesoutthroughanotherslotonthecorresponding
locationonthelateralaspectandcrossesintothe
buckleandloop.
Aratatran Patra11.02.2022

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
Aratatran Patra11.02.2022

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.
Aratatran Patra11.02.2022

31. ORTHOTIC TREATMENT PROTOCOL
Themaintenancephaseinvolvestheuseofafootabduction
Orthosis(FAO)for23hadayforthreemonths,followedbynightuse
untilfourtofiveyearsofage.
After3monthsthechildshouldwearthebracefor12hoursatnightand2
to4hoursinthemiddleoftheday(naptime),foratotalof14to16hours
duringeach24-period.
Thisprotocolcontinuesuntilthechildis4to5yearsofage.
Oncethechildstartedwalking,theyweregivenCTEVshoeindaytime
andsplint/braceinthenight.
Afterthebracewasgiven,followupshouldbedoneinamonthlyor
weeklybasis.
Duringthefirstandsecondnightsofwearingthebrace,babymaybe
uncomfortableashe/sheadjuststothelegsbeingtetheredtogether.itis
veryimportantthatthebracenotberemoved.
Afterthesecondnight,thebabywillhaveadaptedtothebrace.
Earlyvisitwasencouragedincaseofanyskincomplicationorother
issues(breakageordamageofbrace/ctevshoes,orchangeinsize).
Aratatran Patra11.02.2022

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
 Itis 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 Patra11.02.2022

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].
Aratatran Patra11.02.2022

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.
Aratatran Patra11.02.2022

35. REFERENCES
BalasankarG,LuximonA,Al-JumailyA.Currentconservativemanagementand
classificationofclubfoot:Areview.JPediatrRehabilMed.2016;9(4):257–264.
doi:10.3233/PRM-160394
Wedge,J.H.,Daniels,T.R.,&Alman,B.A.(2001).Congenitalclubfoot.Current
Paediatrics,11(5),332–340
Anand,A.,&Sala,D.A.(2008).Clubfoot:Etiologyandtreatment.Indianjournalof
orthopaedics,42(1),22.
Alves,C.(2019).Bracinginclubfoot:doweknowenough?.Journalofchildren's
orthopaedics,13(3),258-264.
Garg,S.,&Porter,K.(2009).Improvedbracingcomplianceinchildrenwithclubfeetusing
adynamicorthosis.Journalofchildren'sorthopaedics,3(4),271-276.
Chen,R.C.,Gordon,J.E.,Luhmann,S.J.,Schoenecker,P.L.,&Dobbs,M.B.(2007).A
newdynamicfootabductionorthosisforclubfoottreatment.JournalofPediatric
Orthopaedics,27(5),522-528.
BrowneD.TalipesEquino-Varus.Congenitaltalipesequino-varus.BrMedJ1931;2:696-699
SteenbeekHM,DavidCO.Steenbeekbraceforclubfoot(2ndedition)
KesslerJI.AnewflexiblebraceusedinthePonsetitreatmentoftalipesequinovarus.J
PediatrOrthopB.2008:17(5):247-50
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36. Aratatran Patra11.02.2022