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Correcting Congenital Talipes Equinovarus in Children Using Three Different Corrective Methods: A Consort Study

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Equinus, varus, cavus, and adduction are typical signs of congenital talipes equinovarus (CTEV). Forefoot adduction remains a difficulty from using previous corrective methods. This study aims to develop a corrective method to reduce the severity of forefoot adduction of CTEV children with moderate deformities during their walking age. The devised method was compared with 2 other common corrective methods to evaluate its effectiveness. A Dennis Brown (DB) splint, DB splint with orthopedic shoes (OS), and forefoot abduct shoes (FAS) with OS were, respectively, applied to 15, 20, and 18 CTEV children with moderate deformities who were scored at their first visit according to the Diméglio classification. The mean follow-up was 44 months and the orthoses were changed as the children grew. A 3D scanner and a high-resolution pedobarograph were used to record morphological characteristics and plantar pressure distribution. One-way MAVONA analysis was used to compare the bimalleolar angle, bean–shape ratio, and pressure ratios in each study group. There were significant differences in the FAS+OS group compared to the DB and DB+OS groups (P < 0.05) for most measurements. The most salient differences were as follows: the FAS+OS group had a significantly greater bimalleolar angle (P < 0.05) and lower bean–shape ratio (P < 0.01) than the other groups; the DB+OS and FAS+OS groups had higher heel/forefoot and heel/LMF ratios (P < 0.01 and P < 0.001) than the DB group. FAS are critical for correcting improper forefoot adduction and OS are important for the correction of equinus and varus in moderately afflicted CTEV children. This study suggests that the use of FAS+OS may improve treatment outcomes for moderate CTEV children who do not show signs of serious torsional deformity.
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Correcting Congenital Talipes Equinovarus in Children
Using Three Different Corrective Methods
A Consort Study
Wei Chen, PhD, Fang Pu, PhD, Yang Yang, PhD, Jie Yao, PhD,
Lizhen Wang, PhD, Hong Liu, MD, and Yubo Fan, PhD
Abstract: Equinus, varus, cavus, and adduction are typical signs of
congenital talipes equinovarus (CTEV). Forefoot adduction remains a
difficulty from using previous corrective methods. This study aims to
develop a corrective method to reduce the severity of forefoot adduction
of CTEV children with moderate deformities during their walking age.
The devised method was compared with 2 other common corrective
methods to evaluate its effectiveness.
A Dennis Brown (DB) splint, DB splint with orthopedic shoes (OS),
and forefoot abduct shoes (FAS) with OS were, respectively, applied to
15, 20, and 18 CTEV children with moderate deformities who were
scored at their first visit according to the Dime´glio classification. The
mean follow-up was 44 months and the orthoses were changed as the
children grew. A 3D scanner and a high-resolution pedobarograph were
used to record morphological characteristics and plantar pressure
distribution. One-way MAVONA analysis was used to compare the
bimalleolar angle, bean– shape ratio, and pressure ratios in each study
group.
There were significant differences in the FASþOS group compared
to the DB and DBþOS groups (P<0.05) for most measurements. The
most salient differences were as follows: the FASþOS group had a
significantly greater bimalleolar angle (P<0.05) and lower bean –shape
ratio (P<0.01) than the other groups; the DBþOS and FASþOS groups
had higher heel/forefoot and heel/LMF ratios (P<0.01 and P<0.001)
than the DB group.
FAS are critical for correcting improper forefoot adduction and OS
are important for the correction of equinus and varus in moderately
afflicted CTEV children. This study suggests that the use of FASþOS
may improve treatment outcomes for moderate CTEV children who do
not show signs of serious torsional deformity.
(Medicine 94(28):e1004)
Abbreviations: CTEV = congenital talipes equinovarus, DB =
Dennis Brown, FAS = forefoot abduction shoes, LFF = lateral
forefoot, LMF = lateral midfoot, MANOVA = multivariate analysis
of variance, MFF = medial forefoot, MMF = medial midfoot, OS =
orthopedic shoes.
INTRODUCTION
Congenital talipes equinovarus (CTEV), or clubfoot, is a
common foot deformity that involves a complex three-
dimensional musculoskeletal abnormality.
1
The deformity has 4
main components: equinus, varus, cavus, and adduction.
1,2
If
the deformity is not corrected promptly, the ambulatory ability
of children will be seriously affected. Nonoperative treatments
are typically considered the first choice for treating CTEV in
young children.
3
During the prewalking period, the Ponseti method is
usually regarded as the standard initial treatment for
CTEV.
1,4– 6
For short-term effect of the Ponseti treatment,
corrective bracing is used following initial correction.
7
Accord-
ing to published reports,
8
the highest rate of recurrence occurs
between 1.5 and 4 years of age. Therefore, correction is still
needed even for children with CTEV who are beginning
to walk.
Foot abduction braces are typically used for continuous
correction.
7
Ponseti and Smoley
9
reported an early analysis of a
Denis Browne (DB) splint, which is a commonly used correc-
tive device. This brace consists of open-toed, high-top, straight-
lace shoes attached in external rotation to a bar,
10
and is used to
hold the affected foot at approximately 708and the unaffected
foot at approximately 408of external rotation.
7
DB splints must
be worn every night for 2–4 years.
7,11,12
Some studies con-
cluded that the DB splint could correct equinus and varus, but
residual adduction of the foot would still exist.
3,13
Furthermore,
given that the shoes are attached to a bar, there is a high rate of
noncompliance due to difficulties with use for years on end.
4
Orthopedic shoes (OS) are considered more convenient
than DB splints and can be used for walking.
14
Moreover,
weight-bearing is also important for effectively correcting
CTEV. OS are custom-made shoes with inserts that are molded
to the shape of the hind foot so as to hold it firmly. OS have been
reported with positive results for correcting equinus and varus in
weight-bearing correction.
15,16
However, considering that OS
are usually set in a neutral alignment and fail to provide
abduction correction, they could not be used to stretch medial
structures,
17
and residual adduction is also present after treat-
ment.
18
Editor: Federico Canavese.
Received: February 3, 2015; revised: May 5, 2015; accepted: May 18,
2015.
From the Key Laboratory of Rehabilitation Technical Aids, Ministry of
Civil Affair, School of Biological Science and Medical Engineering,
Beihang University (WC, FP, YY, JY, LW, YF); State Key Laboratory of
Virtual Reality Technology and Systems, Beihang University (FP, YF);
National Research Center for Rehabilitation Technical Aids (YF); and
Rokab Pedorthic Center, Beijing, P. R. China (HL).
Correspondence: Yubo Fan, School of Biological Science and Medical
Engineering, Beihang University, No. 37 Xueyuan Road, Haidian
District, Beijing 100191, P. R. China (e-mail: yubofan@buaa.edu.cn).
This study was supported by National Natural Science Foundation of China
(Nos. 11421202, 11202017, and 1120101001).
The manuscript has not been published or submitted for publication else-
where.
The authors have no conflicts of interest to disclose.
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons
Attribution License 4.0, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
ISSN: 0025-7974
DOI: 10.1097/MD.0000000000001004
Medicine®
CLINICAL TRIAL/EXPERIMENTAL STUDY
Medicine Volume 94, Number 28, July 2015 www.md-journal.com |1
Reiman
19
proposed a dynamic splint to correct adduction.
An elastic cord on the splint’s lateral side acts to support the
cuboid and exert the necessary counter-pressure for abduction
of the forefoot. However, considering its complexity and diffi-
culty with use, the splint can only be used at night, and is thus
not commonly used in clinical practice.
This paper introduces a corrective method that consists of
the daytime and nighttime use of orthoses. Orthopedic shoes are
used during the daytime, while forefoot abduction shoes are
used at night. This paper will also explore the outcome of this
new corrective method in comparison to 2 other common
corrective methods for children with CTEV.
METHOD
Corrective Treatment Methods
DB splints comprise a pair of boots connected by a rigid
bar, as shown in Figure 1A. A kind of forefoot abduction shoe
(FAS) specially designed to correct adduction deformities is
shown in Figure 1C. Abduction of the forefoot was controlled
by a spring placed on the lateral side of the FAS, as shown in
Figure 1D. The FAS is a 2-piece orthosis with an adjustable
spring between the lateral hindfoot and lateral forefoot. An
ankle-fixing strap is placed inside the shoe to secure the heel.
The shoe was initially set with a 208to 258outflare according to
the principle of the Be
¯bax shoe.
27
When the spring contracts, the
FAS retains the outflare, and the foot remains in abduction. For
unilateral children the unaffected foot is free and for bilateral
children a pair of FAS was needed at night. Given that the DB
and FAS are only used at night, orthopedic shoes (OS) were
used while walking, as shown in Figure 1B. The OS were used
with an orthopedic insole, and the hard heel cup and upper shoe
helps to keep the heel in a neutral position. To evaluate the
function of different orthoses, these 3 different corrective
methods were evaluated on children who were in the early
stages of walking: DB, DBþOS, and FASþOS.
Subjects
This is a prospective, single-blinded, randomized, con-
trolled trial. A total of 113 children with CTEV were recruited
after Ponseti treatment. All children were participating follow-
ing successful initial management using the Ponseti method and
had been braced with a DB splint during their prewalking
stages. The feet were examined and scored at the first visit
according to the Dime´glio classification,
20
which has been
considered the most reliable classification method.
21
There
was no significant difference in equinus, varus, and addutus
deformities between them based on the scores (P>0.05). After
the Dime´glio classification, 53 children with moderate deform-
ities were recruited. All the children in this study had finished
Ponseti treatment and were wearing DB splints for the initial
period of correction, which effectively controlled torsional
deformity. When they began to walk, 15 children continued
to use a DB splint at night. A total of 20 children used DB splint
for nighttime use and OS for daytime use. A total of 18 children
accepted FAS for nighttime use and OS for daytime use. For
unilateral children, the unaffected foot was not restricted or
constrained. The data were collected when the children were
between 4–5 years of age. Informed consent was obtained from
their parents. Follow-up visits were done, and the orthoses were
changed as the children grew. The mean follow-up time was 44
months. Table 1 shows the demographics of the children after
they underwent corrective treatment. No significant differences
were found in age, height, and weight among the three groups
(P>0.05). Informed written consent was obtained from the
parents of each subject in accordance with clinical protocols.
This study was approved by the Science and Ethics Committee
FIGURE 1. From left to right: A, Dennis Brown Splint; B, orthopedic shoe with orthopedic insole in it. There are anterior and posterior
outflares on the shoes and a velcro in the malleolar area to control equinus; C, top view of forefoot abduct shoe for left foot; and D, the
schematic bottom view of the forefoot abduct shoe for left foot.
TABLE 1. Demographic Characteristics of the Participants of This Study
DB Group n ¼15 OSþDB Group n¼20 OSþFAS Group n ¼18
Sex (male:female) 9:6 12:8 8:10
Age, y
4.7 (0.7) 4.9 (1.1) 4.9 (1.0)
Height, m
1.06 (0.74) 1.10 (0.11) 1.10 (0.11)
Weight, kg
17.7 (2.5) 19.2 (3.6) 19.3 (3.8)
Affected (unilateral:bilateral) 11:4 7:13 5:13
Mean (SD).
Chen et al Medicine Volume 94, Number 28, July 2015
2|www.md-journal.com Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
of School of Biological Science and Medical Engineering at
Beihang University, Beijing, China, on November 9, 2010
(Approval ID: 20101109).
Procedure
All participants underwent three-dimensional foot scan-
ning and pedobarography. All data were captured by an experi-
enced pedorthic doctor and a bioengineer in the gait analysis
laboratory at Rokab Pedorthic Center, Beijing, China.
A Delcam Iqube scanner (Delcam, Birmingham, UK) and a
malleolar jig were used to collect and calculate the malleolar
angles (Figure 2A). The malleolar angle is determined from a
scanned image ofthe plantar aspect of the foot whilestanding still
(Figure 2B). The malleolar jig was adjusted to fit and was aligned
with the transmalleolar axis of each subject, and the medial and
lateral malleoli wereregistered to the scanned image of the foot.
22
From this image, the bean–shape ratio (Figure 2C), which was
calculated by width to length,
24
could be obtained for each feet.
FIGURE 2. A, 3D scanner and malleolar jig for measuring bimalleolar angle. B, The bimalleolar angle is formed between the bimalleolar
axis and the longitudinal axis of the foot passing through the second toe. C, Bean–shape ratio is foot width-to-length ratio.
FIGURE 3. A, Pedobarography for static and dynamic measurements; B, the 5 segments of the foot from pressure image. LFF ¼lateral
forefoot; LMF ¼lateral midfoot; MFF ¼medial forefoot; MMF ¼medial midfoot.
Medicine Volume 94, Number 28, July 2015 Congeital Talipes Equinovarus Correction
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |3
A FreeMed
1
baropodometric platform, as shown in
Figure 3A, was used to measure the dynamic foot pressure
(Rome, Italy). The platform surface was 240 50 cm, with an
active surface of 244 74 cm and thickness of 0.8 cm (Sensor-
me´dica
1
, Italy). The reliability of this baropodometric
platform has been shown in previous studies.
23
Dynamic
measurements required the children to walk at their natural
self-selected speed. Four recordings of each affected foot
were taken, and the average was considered the final measure-
ment. The FreeStep system
1
was used to provide information
during gait.
Data Processing
The bimalleolar angle and bean–shape ratio were used to
quantify the level of forefoot adduction.
2,24,25
The bimalleolar
angle is the anteromedial angle which is formed between the
bimalleolar axis and the longitudinal axis of the foot passing
through the second toe. The bean–shape ratio assesses the
curvature of the foot, thus quantifying forefoot adduction and
hindfoot varus. The average and maximum peak pressure on
each region (Figure 3B) were calculated according to methods
detailed in the literature.
26
The MFF/LFF ratio, heel/forefoot
ratio, and heel/LMF ratio were calculated to evaluate the degree
of equinus and varus deformity in CTEV children.
24,26
Statistical Analysis
Statistical analyses were performed using the SPSS for
Windows version 19.0 (IBM Corp, Armonk, NY, USA).
Continuous variables were reported as means SD. The
unaffected foot was not used for calculation during statistical
analysis. One-way MAVONA analysis was used to evaluate
the effects of different corrective methods on the bimalleolar
angle, bean– shape ratio, and pressure distribution. Least-
significant-difference tests were used for posthoc compari-
sons. Power analysis was performed using PASS software
(Jerry Hintze, Kaysville. UT). The significance level was set
at 0.05.
RESULTS
A total of 53 children were included in this study. There
were no significant differences in varus, equines, and adduction
deformities between the 3 groups according to the Dime´glio
score (P>0.05) at initial inception. A total of 15, 20, and 18
children comprised the groups DB, DBþOS, and FASþOS,
respectively. The study began in 2010 and the mean follow-up
time was 44 months. No patients withdrew from the treatment
during the study period. The FASþOS group showed better
compliance than the other 2 groups, as reported by the chil-
dren’s parents. Although physiotherapy and orthoses were
continuous, 5 children in the DB group and 1 child in the
DBþOS group exhibited severe equinus, varus, and adduction
deformities after treatment. Surgery may still be needed to
correct these severe deformities.
MANOVA revealed that the different corrective methods
had a primary influence on the bimalleolar angle and bean
shape ratio, as shown in Table 2. For the 3 groups, DB, DBþOS,
and FASþOS, the bimalleolar angle was found to successively
increase [F
(2,80)
¼3.598, P¼0.032] and bean–shape ratio to
successively decrease [F
(2,80)
¼6.852, P¼0.002], respectively.
A significant difference in bimalleolar angle was found between
the DB and FASþOS groups (posthoc comparison: P¼0.009).
Also, a significant difference in bean–shape ratio was found
between the DB and DBþOS groups (posthoc comparison:
P¼0.049), as well as between the DBþOS and FASþOS
groups (posthoc comparison: P<0.001).
It was also found that different corrective methods had a
significant impact on the peak pressure at the hindfoot, LMF,
and MFF; MANOVA results are shown in Table 3. For the DB,
DBþOS, and FASþOS groups, both the maximum and average
peak pressures successively increased at the heel
[F
(2,80)
¼12.664, P<0.001 and F
(2,80)
¼3.896, P¼0.024].
However, both the maximum and average peak pressures
successively decreased at the lateral midfoot [F
(2,80)
¼3.564,
P¼0.033 and F
(2,80)
¼5.761, P¼0.005], and both the maxi-
mum and average peak pressures successively increased in the
medial forefoot [F
(2,80)
¼5.178, P¼0.008 and F
(2,80)
¼2.892,
P¼0.049].
As shown in Table 4, MANOVA revealed that different
corrective methods had a primary influence on the peak pressure
ratios of heel/forefoot and heel/LMF. For the DB, DBþOS, and
FASþOS groups, both the heel/forefoot and heel/LMF ratio
successively increased [F
(2,80)
¼4.975, P¼0.009 and
F
(2,80)
¼14.878, P<0.001]. A significant difference in heel/
forefoot ratio was found between the DB and DBþOS groups
(posthoc comparison: P¼0.006), as well as between the DB
and FASþOS groups (posthoc comparison: P¼0.005). A
significant difference in the heel/lateral arch ratio was found
among the DB, DBþOS, DBþOS groups (posthoc comparison:
P¼0.003, P<0.001, P¼0.007). For the significantly different
variables (bimalleolar angle, bean–shape ratio, heel/forefoot,
and heel/LMF), the power ranged from 0.65 to 0.99.
DISCUSSION
When treating CTEV, the corrective method used, or
whether correction was used at all, will have a great impact
TABLE 2. Abduction Indexes Adapted From Ramanathan et al
25
Bimalleolar Angle Bean– Shape Ratio
Pressure Ratios Study Group Mean 95% Confidence Interval Mean 95% Confidence Interval
DB 72.98 (69.03– 6.92) 0.31 (0.29– 0.33)
DBþOS 75.59 (73.98– 77.21) 0.29 (0.27– 0.30)
OSþFAS 77.55 (75.57– 79.53
)

0.27 (0.25– 0.28)

,##
DB vs. DBþOS:
§
P<0.05,
§§
P<0.01,
§§§
P<0.001. DB vs. OSþFAS:
P<0.05,

P<0.01,

P<0.001. DBþOS vs. OSþFAS:
#
P<0.05,
##
P<0.01,
###
P<0.001.
Chen et al Medicine Volume 94, Number 28, July 2015
4|www.md-journal.com Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
on patient outcome. This article introduces a novel corrective
method for CTEV that combines the daytime use of orthopedic
shoes (OS) and nighttime use of forefoot abduction shoes
(FAS). The outcome of this new approach was studied in
comparison with the use of a Dennis Brown (DB) splint and
a combination of DBþOS.
Our results demonstrate that the FASþOS group exhibits
superior correction of abnormal adduction (has the greatest
bimalloeolar angle of 77.558and the lowest bean–shape ratio
of 0.27). A bimalleolar angle of less than 808is considered
abnormal.
25
Although the use of FASþOS resulted in an angle
of less than 808, it achieved a higher value than the other 2
groups and a significant difference was observed between the
FASþOS and the DB groups (posthoc comparison: P¼0.009).
The bean– shape ratio is a comprehensive index that indicates
forefoot adduction as well as hindfoot varus.
3
The more curved
the foot in the transverse plane, the higher the ratios were. If
values are greater than 0.267, a bean-shaped foot is indicated,
and if the value is greater than 0.34, a marked deformity is
denoted.
24
The bean–shape ratio in the FASþOS group was
0.27, which is the closest to the normal value of 0.230.02. A
significantly greater bimalloeolar angle and lower bean–shape
ratio was observed in the FASþOS group compared with the
DB and DBþOS groups (posthoc comparison: P<0.001,
P¼0.049). The result demonstrates that FAS may be critical
to correcting forefoot adduction, and OSþFAS has a positive
effect in correcting forefoot adduction and varus. Some studies
have proposed that if the medial soft tissue is released, the
release of the medial plantar fascia, tendon, and ligament can
help to correct varus.
28
The bean–shape ratio has been con-
sidered a sensitive indicator of relapse.
24
Our results suggest
that FASþOS placed the foot into a position with a low bean
shape ratio, which could help decrease adduction relapse in
patients with CTEV.
Our results also demonstrate that OS have a positive
effect on the correction of equino-varus deformities in the
OS and FASþOS groups. These results are reflected by the
heel/forefoot and heel/ LMF ratios. If the value of heel/fore-
foot ratio is less than 0.8, an equinus deformity is considered.
If the value is less than 0.4, severe equinus deformity is
considered.
25
The average values of heel/forefoot ratios of
the DB and DBþOS groups were 0.44 and 0.72, respectively.
A significant difference was observed in the DBþOS group
when compared with the DB group (posthoc comparison:
P¼0.006). The results demonstrated that OS is critical to
the correcting equinus in CETV. The heel/LMF ratio is
considered a sensitive indicator of equino-varus deformity.
24
If the ratio is less than 2.5, an equino-varus deformity is
typically diagnosed. If the ratio is less than 1.0, a severe
equino-varus deformity is considered.
25
The average values
of the heel/LMF ratios of the DB and DBþOS groups were
0.77 and 1.45, respectively. A significant difference was
observed among the DB and DBþOS groups (posthoc com-
parison: P¼0.003, and P¼0.007). The results also demon-
strate that OS have a positive effect on the correction of
equino-varus deformities in CETV.
Compared with previous research,
26
this study found lower
values for both heel/forefoot and heel/LMF pressure ratio in the
DB group. This difference may be attributed to the younger age
of the children in our study, and their noncompliance to the DB
splint. Noncompliance may be considered to be the greatest
barrier to successful DB splinting.
3,12
A lack of adherence to the
bracing protocol increases the risk of relapse. In this study, most
DB group parents found it difficult to persist in donning the DB
TABLE 3. Results for Pressure and Forces Expressed as the Estimated Mean and the 95% Confidence Intervals From the Linear Mixed Model Analysis
Hindfoot Lateral Midfoot Medial Midfoot Lateral forefoot Medial forefoot
Study
Group Mean
95% Confidence
Interval Mean
95% Confidence
Interval Mean
95% Confidence
Interval Mean
95% Confidence
Interval Mean
95% Confidence
Interval
Average peak DB 57.48 (39.47– 75.49) 94.97 (66.38– 123.59) 59.58 (43.14 76.01) 66.09 (50.02– 82.15) 89.34 (66.31– 112.33)
Pressure, kPa DBþOS 74.1 (64.02–84.18) 62.21 (53.35–71.06) 55.51 (41.82 69.21) 55.44 (46.02– 64.87) 95.54 (83.89– 107.19(
OSþFAS 83.18 (71.78– 94.58) 60.9 (49.26–72.54) 47.5 (41.20 53.80) 55.15 (42.37– 67.94) 122.58 (100.78–124.38)

§§,

NS NS
Maximum peak DB 105.51 (85.73– 125.29) 105.89 (84.27– 127.52) 56.8 (45.64–67.96) 120.53 (104.55 136.51) 101.26 (81.02 –121.51)
Pressure, kPa DBþOS 148.71 (135.49–161.94) 99.14 (89.06– 109.22) 63.69 (51.88 –75.50) 118.48 (105.96 –131.00) 115 (101.83– 128.16)
OSþFAS 164.05 (148.22–179.90) 82.38 (71.87–92.90) 56.44 (46.69 66.20) 129.77 (112.98 146.55) 135.87 (122.10– 149.64)
#,

§§,

#,
NS NS
NS ¼not significant differences between the groups. DB vs. DBþOS:
§
P<0.05,
§§
P<0.01,
§§§
P<0.001. DB vs. OSþFAS:
P<0.05,

P<0.01,

P<0.001. DBþOS vs. OSþFAS:
#
P<0.05,
##
P<0.01,
###
P<0.001.
Medicine Volume 94, Number 28, July 2015 Congeital Talipes Equinovarus Correction
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |5
splint every night, and this may be why the DB group in our
study exhibited more evident equinus and varus deformities.
Better compliance was observed in FASþOS group. Most
CTEV children could persist wearing these 2 kinds of orthoses
every day and night, and their parents were satisfied with the
new corrective methods.
This work presents essential information on foot morpho-
logical characteristics and pressure characteristics in children
with CTEV treated with different corrective techniques. This
quantitative description is not only objective but also reprodu-
cible, and could provide more useful parameters than single
recurrence rates or clinical evaluation. However, this study has
some limitations:
The corrective methods used do not consider severe foot
deformities. Also, FAS is used for controlling adduction, it is
not effective for controlling other types of deformity. FASþOS
design applies on those children who do not have serious
torsional deformity.
The bias of the patients recruited in the study is extremely
wide, even though it is a randomized study. There are many
other conditions such as muscle strength, cooperation with
physiotherapy, and cognitive skills which may have an effect
on the results.
CONCLUSION
This article developed a simple manner of correction that
consists of the daytime and nighttime use of orthoses for
moderate CTEV children. OS used during the day mainly
control equinus and varus, while FAS are used at night to
correct forefoot adduction. This novel method achieves better
corrective results for controlling equinovarus, especially in
forefoot adduction, in comparison to other conventional treat-
ment regimes. Compliance is also improved. Therefore, this
approach may be a more appropriate treatment option for CTEV
children with moderate foot deformities and without serious
torsional deformity.
ACKNOWLEDGMENT
The authors would like to thank all participants in this
study and the Rokab Pedorthic Center in Beijing for their help
with recruiting patients. The authors also acknowledge Colin
Joseph McClean for his recommendations on the preparation of
this manuscript.
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TABLE 4. Peak Pressure Ratios Adapted From Herd et al
Medial/Lateral Forefoot Heel/Forefoot Heel/LMF
Study Group Mean
95% Confidence
Interval Mean
95% Confidence
Interval Mean
95% Confidence
Interval
Pressure ratios
DB 1.37 (0.96 –1.78) 0.44 (0.29 –0.58) 0.77 (0.47 –1.08)
DBþOS 1.52 (1.28– 1.76) 0.72 (0.58–0.87) 1.45 (1.19 –1.72)
OSþFAS 1.52 (1.28– 1.75) 0.73 (0.61–0.86) 1.98 (1.68 –2.29)
NS
§§,

§§,

,##
NS ¼not significant differences between the groups. DB vs. DBþOS:
§
P<0.05,
§§
P<0.01,
§§§
P<0.001. DB vs. OSþFAS:
P<0.05,

P<0.01,

P<0.001. DBþOS vs. OSþFAS:
#
P<0.05,
##
P<0.01,
###
P<0.001.
Chen et al Medicine Volume 94, Number 28, July 2015
6|www.md-journal.com Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
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Medicine Volume 94, Number 28, July 2015 Congeital Talipes Equinovarus Correction
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |7
... Footwear is used as an intervention to aid ambulation in mobility-impaired children [6][7][8][9][10]. Footwear intended for therapeutic purposes in children consists of a broad range of designs and clinical applications including pes planus, talipes equino varus, toe walking, cerebral palsy and developmental delay [9,[11][12][13][14][15][16]. Footwear appears to be widely prescribed as an assistive device by some healthcare professionals [17], and a number of studies demonstrate that conventional footwear has significant effects on typically developing children's gait [18,19]. ...
... These three studies focused on the effects of the footwear on lower limb alignment pes planus (n=2) [12,37] and congenital talipes equino varus (CTEV) (n=1 ) [16] ( Table 1). The studies were all randomised controlled trials (level II evidence). ...
... The studies were all randomised controlled trials (level II evidence). Two of the studies were of fair QI [16,37] and one of poor QI [12]. A total of 196 children were examined across the studies with an age range from 11 months to 5 years (Table 1, Additional file 2). ...
Article
Full-text available
Background It is estimated that 2% of the global childhood population is living with some form of mobility impairment. Although footwear interventions are proposed to aid ambulation, there appears to be a paucity in the understanding of the effects of therapeutic footwear. This review aims to explore the effectiveness of footwear as an intervention for mobility impairment in children. Methods A systematic search of MEDLINE, CINAHL, PubMed, SPORTdiscus and Scopus databases were performed. Studies which focused on children with some form of mobility impairment, age of 9 months to 18 years, therapeutic footwear that allowed walking, and outcome measures that had explored biomechanical or skeletal geometry or psychosocial aspects were included in this review. Modified Downs and Black quality assessment index of randomised and non-randomised studies were used to assess the methodologies of included papers. Results Out of 5003 articles sourced, 13 met the inclusion criteria for this review. These were grouped into two titled “corrective and “functional” based on the types of footwear used for intervention. Studies within the corrective footwear group included participants aged 11 months to 5 years with moderate congenital talipes equino varus or mobile pes planus. While using skeletal geometry as an outcome, there was a limited fair quality (level II) evidence that corrective footwear has no significant effect on the development of pes planus but may assist in the reduction of deformity in congenital talipes equino varus. The functional footwear group included participants aged 3 to 17 years, predominantly with mobile pes planus or cerebral palsy. Based on biomechanical measures as an outcome, there was a limited fair quality (level III) evidence that functional footwear alters biomechanical parameters in mobile pes planus (spatiotemporal) and cerebral palsy (spatiotemporal, kinematic). Although psychosocial outcomes were considered within two studies, the analysis was limited. Conclusion Only a limited number of studies have explored the effects of therapeutic footwear and only in a narrow range of mobility impairments. Further high-quality research is required to improve the evidence base for the effectiveness of therapeutic footwear. This should include a wide range of mobility impairments and should focus both on physical and psychosocial outcomes.
... Therapeutic footwear for children consists of a number of footwear modifications that may be either bespoke or off-the-shelf [23,24]. These modifications have been used in an attempt to achieve efficient walking patterns or to correct skeletal alignment in children with a range of clinical presentations such as: flat feet, talipes equino varus, toe walking, cerebral palsy, and developmental delay [23,[25][26][27]. Footwear intended for therapeutic use ranges in design and application from those whose role is to simply accommodate a foot orthosis to those that act as an independent mobility or corrective device [8,24,28]. ...
... Corrective footwear was defined in this review as footwear that was designed to bring about correction of congenital skeletal lower limb alignment [8,65]. Corrective footwear research yielded several footwear design modifications that were used to treat a range of structural lower limb issues (e.g., Talipes Equino Varus, genu varum, genu valgum, tibial torsion, paediatric pes planus, metatarsus adductus and hallux valgus) [27,43,56,[66][67][68]. The types of footwear included Thomas heel, high topped, reverse last, straight last, in-built arch support, reinforced steel shank, and loop sandals [7,43,56,62,68]. ...
... The types of footwear included Thomas heel, high topped, reverse last, straight last, in-built arch support, reinforced steel shank, and loop sandals [7,43,56,62,68]. The effects of corrective footwear have been mainly assessed by prospective studies (n = 11) examining anthropometric measures of the medial longitudinal arch including radiographic, laser scanning, and footprint analysis [24,27,43,56,62,[69][70][71][72][73]. Other articles (n = 13) included expert opinion on corrective footwear in terms of design and conditions treated [59,[74][75][76], review articles (n = 7) [31,33,67,77], psychosocial considerations (n = 4) [78,79] and clinical prescription surveys (n = 3) [7,69]. ...
Article
Full-text available
Background Reports suggest that children with mobility impairment represent a significant proportion of the population living with a disability. Footwear is considered to be the key extrinsic factor affecting children’s gait and footwear modifications have been historically postulated to assist with locomotory difficulty. Although therapeutic footwear has been considered within the literature, there is a lack of consistency on terminology and paucity on the overall understanding. A scoping review was performed to chart the key concepts in children’s footwear and to establish the range of studies that considered therapeutic footwear. Methods A systematic search of MEDLINE, CINAHL, PubMed, SPORTdiscus, and Scopus electronic databases was performed using MeSH headings and free text terms in relation to children’s footwear. All studies that used footwear as an intervention in children aged 9 months to 18 years with the outcome measures including design, fit, and the effects on development and health were included. Studies were charted by textual narrative synthesis into research groupings dependent on the topics discussed and the methods used in the studies. Results The search yielded a total of 5006 articles with 287 of these articles meeting the inclusion criteria. Two overarching areas of research were identified; articles that discussed footwear design and those that discussed the effects of footwear. Eight further general groupings were charted and apportioned between the overarching areas and therapeutic footwear was charted into three subgroupings (corrective, accommodative and functional). Conclusion Children’s footwear has become an increasing area of research in the past decade with a shift towards more empirical research, with most of the included articles examining biomechanical and anthropometric aspects. However, children’s therapeutic footwear has not shared the same recent impetus with no focused review and limited research exploring its effects. Empirical research in this area is limited and there is ambiguity in the terminology used to describe therapeutic footwear. Based on the findings of this review the authors suggest the term children’s therapeutic footwear be used as the standard definition for footwear that is designed specifically with the purpose to support or alleviate mobility impairment in childhood; with subgroupings of corrective, accommodative and functional dependent on the intended therapeutic role. Electronic supplementary material The online version of this article (10.1186/s13047-019-0336-z) contains supplementary material, which is available to authorized users.
... A nighttime forefoot abduction shoe (FAS) could possibly correct foot adduction and stretch medial structures and a daytime orthopedic shoe (OS) responsible for the correction of equinus and varus in a weight-bearing position. 29 McCartney's device was a dynamic foot brace permitting both inversioneversion and plantar flexion-dorsiflexion. 30 However, this modular design had a high mechanical failure rate as well. Manousaki et al. utilized two separate braces for different ages. ...
... Next, during the maintenance phase (duration, 1-3 years), a Denis Browne splint was used at night to prevent recurrence [13]. Participants were fully informed of the treatment plan prior to the start of treatment and confirmed that the plan would be followed. ...
Article
Full-text available
Background: Treatment of idiopathic congenital talipes equinovarus (CTEV) is challenging for pediatric orthopedic surgeons. The Ponseti method is an effective protocol for treatment due to its technique of manipulation, casting, and limited surgery. Plaster casting is an essential component of the Ponseti method. In this report, we describe a new brace that was developed for use in the treatment of clubfoot in newborns instead of a plaster cast. Methods: This retrospective study was performed in two orthopedic medical centers. Between January 2011 and October 2013, 89 newborns with CTEV (131 ft) underwent corrective treatment using fixation braces in the experiment group (E-group) in our hospital, and 107 newborns with CTEV (141 ft) underwent plaster casting in the control group (C-group) in another medical center. All patients were treated according to the Ponseti method after the application of the inclusion and exclusion criteria. Plaster casts were applied to patients in the C-group. The patients in the E-group received the custom-made polyaxial fixation braces instead of plaster casts. Prospective follow-up was performed for a mean duration of 36 months. The efficacy of the treatment was assessed using Pirani's scoring system. Chi-squared and independent t tests were used for statistical analyses. Results: In the E-group, 85 patients (125 ft) achieved good appearance within 3 months of treatment initiation (average, 1.7 months). Four patients (6 ft) required percutaneous Achilles tenotomy. Seven patients developed sores during treatment because of improper brace application, but all sores healed without scarring with timely treatment. In the C-group, 96 patients (123 ft) achieved good appearance within 3 months of treatment initiation (average, 1.6 months). Eleven patients (18 ft) required percutaneous Achilles tenotomy. Twenty-one feet developed sores during treatment because of plaster cast pressure on the dorsum of the feet. Sixteen sores healed without scarring with timely treatment, and 5 ft had obvious scars. The overall mean Pirani scores 1 year after treatment were 0.26 ± 0.06 in the E-group and 0.25 ± 0.03 in the C-group, and the Pirani scores 3 years after treatment were 0.23 ± 0.05 in the E-group and 0.22 ± 0.03 in the C-group. There were significant differences in the percutaneous Achilles tenotomy and skin sores but no significant difference in the Pirani scores between these two groups. Conclusions: Our results showed that the new polyaxial fixation brace used in this study was an effective tool for the corrective treatment of CTEV in newborns. We propose the use of this brace as an alternative treatment for newborns.
... Clubfoot is a complex three axis musculoskeletal abnormality where the affected foot appears to have been rotated internally at the ankle [22]. Foot is rotated along coronal, sagittal and transverse axis of plane (with adduction-abduction, inversioneversion and dorsiflexion-plantarflexion range of motions) with severity ranging from mild to severe [23]. ...
Book
This paper deals in identifying a complex geometry problem related to health care sector. Paper focuses on identifying a problem in health care which is identified in the area of deformities. Non-surgical treatment for congenital talipes equino varus (clubfoot) deformity known as Ponseti method involves many complications thereby leading to the recurrence of the deformity. In this regard, design and development of customized orthosis that can be used as an alternate solution for Ponseti method for treating clubfoot deformity through AM technology is carried out in this work.
... A good reference point could be the experience gained based on the use of the two-piece adjustable orthosis ini! ally set for 20-25° ou& lare in the case of fl exible or rigid metatarsus adductovarus and allowing the manipula! on of the posi! on of the forefoot rela! ve to the rearfoot in the transversal plane [33,34]. Important to be men! ...
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Full-text available
Medical footwear is a medical device used in the conservative treatment of foot and lower limb pathomechanics. The standard EN ISO 9999:2016 - "Assistive products for person with disability-Classification and terminology", includes orthopedic shoes in the category of foot orthoses which are medical devices that encompass the whole or part of the foot, being divided in two categories: prefabricated or custom fabricated. According to the legal requirements, a custom fabricated device is based on a medical prescription containing the specific design characteristics as established by the medical practitioner. In many situations from clinical practice, the medical prescription does not contain the specific design characteristics but only some generic data such as the name and type of the orthopedic footwear. The purpose of this paper is to review the basic prescription variables of the medical footwear according to the experience from developed foot care systems.
... 1 Differential distraction by fixator for the correction of neglected idiopathic CTEV is an effective and patientfriendly method of management. 2 The mean strength of the JESS was 32.5 N/mm in experiments and 35.3 N/mm infinite element analysis; the difference was 8.4%. 3 Forefoot adduction remains a difficulty from using previous corrective methods. 4 The initial management of CTEV by Ponseti method has many advantages. The Ponseti group also scored higher than the surgical group in terms of patient satisfaction with significantly better parent-rated OxAFQ scores in the "emotional" and "school and play" domains. ...
Article
Background: Congenital talipes equinovarus (CTEV), also known as clubfoot, is a common congenital orthopaedic condition characterised by an excessively turned-in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical. Different treatments might be effective at different stages: at birth (initial presentation); when initial treatment does not work (resistant presentation); when the initial treatment works but the clubfoot returns (relapse/recurrent presentation); and when there has been no early treatment (neglected presentation). This is an update of a review first published in 2010 and last updated in 2014. Objectives: To assess the effects of any intervention for any type of CTEV in people of any age. Search methods: On 28 May 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, AMED and Physiotherapy Evidence Database. We also searched for ongoing trials in the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (to May 2019). We checked the references of included studies. Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs evaluating interventions for CTEV, including interventions compared to other interventions, sham intervention or no intervention. Participants were people of all ages with CTEV of either one or both feet. Data collection and analysis: Two review authors independently assessed the risks of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available. When required we attempted to obtain individual patient data (IPD) from trial authors for re-analysis. If unit-of-analysis issues were present and IPD unavailable we did not report summary data, MAIN RESULTS: We identified 21 trials with 905 participants; seven trials were newly included for this update. Fourteen trials assessed initial cases of CTEV (560 participants), four trials assessed resistant cases (181 participants) and three trials assessed cases of unknown timing (153 participants). The use of different outcome measures prevented pooling of data for meta-analysis, even when interventions and participants were comparable. All trials displayed high or unclear risks of bias in three or more domains. Twenty trials provided data. Two trials reported on the primary outcome of function using a validated scale, but the data were not suitable for inclusion because of unit-of-analysis issues, as raw data were not available for re-analysis. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials in participants at initial presentation. The Pirani score is a scale ranging from zero to six, where a higher score indicates a more severe foot. At initial presentation, one trial reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 points lower than that of the Kite group (mean difference (MD) -1.15, 95% confidence interval (CI) -1.32 to -0.98; 60 feet; low-certainty evidence). A second trial found the Ponseti technique to be superior to a traditional technique, with mean total Pirani scores of the Ponseti participants 1.50 points lower than after serial casting and Achilles tenotomy (MD -1.50, 95% CI -2.28 to -0.72; 28 participants; very low-certainty evidence). One trial found evidence that there may be no difference between casting materials in the Ponseti technique, with semi-rigid fibreglass producing average total Pirani scores 0.46 points higher than plaster of Paris at the end of serial casting (95% CI -0.07 to 0.99; 30 participants; low-certainty evidence). We found no trials in relapsed or neglected cases of CTEV. A trial in which the type of presentation was not reported showed no evidence of a difference between an accelerated Ponseti and a standard Ponseti treatment in foot alignment. At the end of serial casting, the average total Pirani score in the accelerated group was 0.31 points higher than the standard group (95% CI -0.40 to 1.02; 40 participants; low-certainty evidence). No trial assessed gait using a validated assessment. Health-related quality of life was reported in some trials but data were not available for re-analysis. There is a lack of evidence for the addition of botulinum toxin A during the Ponseti technique, different types of major foot surgery or continuous passive motion treatment following major foot surgery. Most trials did not report on adverse events. Two trials found that further serial casting was more likely to correct relapse after Ponseti treatment than after the Kite technique, which more often required major surgery (risk differences 25% and 50%). In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas), and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting. Authors' conclusions: From the evidence available, the Ponseti technique may produce significantly better short-term foot alignment compared to the Kite technique. The certainty of evidence is too low for us to draw conclusions about the Ponseti technique compared to a traditional technique. An accelerated Ponseti technique may be as effective as a standard technique, but results are based on a single small comparative trial. When using the Ponseti technique semi-rigid fibreglass casting may be as effective as plaster of Paris. Relapse following the Kite technique more often led to major surgery compared to relapse following the Ponseti technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and the unavailability of raw data. Future RCTs should address these issues.
Chapter
This paper deals in identifying a complex geometry problem related to health care sector. Paper focuses on identifying a problem in health care which is identified in the area of deformities. Non-surgical treatment for congenital talipes equino varus (clubfoot) deformity known as Ponseti method involves many complications thereby leading to the recurrence of the deformity. In this regard, design and development of customized orthosis that can be used as an alternate solution for Ponseti method for treating clubfoot deformity through AM technology is carried out in this work.
Article
Full-text available
We have assessed the reliability of four classification systems for club foot. Four observers evaluated nine children (18 feet) at different stages in the first six months of life, a total of 180 examinations. Each observer independently assessed all feet according to the classification systems described by Catterall, Diméglio et al, Harrold and Walker, and Ponseti and Smoley. The variation between observers was assessed using the kappa test which for no more agreement than chance has a value of 0, and for complete agreement between observers a value of 1. The kappa values varied between 0.14 and 0.77 depending on which classification system was used. The system of Diméglio et al was found to have the greatest reliability. Our findings suggest that current classification systems for the analysis of congenital talipes equinovarus are not entirely satisfactory.
Article
Full-text available
The Ponseti method is a safe and effective treatment for congenital clubfoot, and radically decreases the need for extensive corrective surgery. But a group of patients will still present with under corrected residual equinovarus deformities despite the proper use of the Ponseti method. About 25% of operated clubfeet will develop recurrence or show a marked residual deformity (recurrent clubfoot); however, in the recent literature, the failure rate of the Ponseti method, defined by the need for corrective surgery, ranges from 3% to 5%. Deformities encountered in patients with residual clubfeet comprise of various degrees of equinus, varus, adduction, supination, cavus, and toe deformity. Joint flexibility or stiffness, tarsal dysmorphism, articular incongruence, and progressive degrees of degeneration may be also present. We try to emphasize the current solutions for these deformities.
Article
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To analyze the short-term effects of a proprioceptive session on the monopodal stabilometry of athletes. [Subjects] Thirty-seven athletes were divided into a control group (n=17) and an experimental group (n=20). [Methods] Both groups performed a conventional warm-up, after which a 25-minute proprioceptive session on ustable platforms was carried out only by the experimental group. Before the training session, all athletes carried out a single-leg stabilometry test which was repeated just after training, 30 minutes, 1 hour, 6 hours and 24 hours later. [Results] Analysis of covariance (α=0.05) revealed that the experimental group had lower values than the control group in length and velocity of center of pressure (CoP) of left-monopodal stance and in velocity of CoP of right-monopodal stance in post-training measurements. Also, the experimental group had values closer to zero for the CoP position in the mediolateral and anteroposterior directions of left-monopodal stance (Xmeanl and Ymeanl) and the anteroposterior direction in on right-monopodal stance (Ymeanr) in post-training measurements. Within-group analysis of Xmeanl and Ymeanl, length and velocity of CoP in right-monopodal stance showed continuous fluctuations of values between sequential measurements in the control group. [Conclusion] Proprioceptive training on unstable platfoms after a warm-up stabilizes the position of CoP in the anteroposterior and mediolateral directions and decreases CoP movements in short-term monopodal stability of athletes.
Article
Full-text available
Clubfoot is a common pediatric orthopaedic deformity Despite the popularity of Ponse its method and night splints such as the Denis-Browne method there is still an 11-47% rate of deformity relapse reported in the literature The technique to make traditional orthotics is dependent on a nonweight bearing casting or foot imprint These splints outdate clinical treatment trends and only apply to patients who are of nonwalking age This study shows that a new procedure utilizing computer aided design and the finite element method can be employed to develop a customized weight bearing dynamic orthotic In addition the plantar pressure distribution and the trajectory of the center of this pressure distribution are used to design the orthotic It is shown that the trajectory of the center of pressure traditionally used in gait analysts can be used not only to quantify the severity of the foot deformity but to design a custom orthotic as well Also the new procedure allows the custom orthotic to be designed and analyzed within a day The new orthotic design is composed of soft foam interior layers and a polymer supportive exterior layer It is proved that rapid prototyping technologies employing selective laser sintering can be used to construct these layers to produce a custom orthotic within a 24 h time frame [DOI 10 1115/1 4001814]
Chapter
Congenital clubfoot is charaterized by a malalignement of talocalcaneal, talonavicular and calcaneocuboid joints, the cause of which is still unknown. Its management must begin shortly after birth. During the last years, The Ponseti method has been spreading throughout the world, and its protocol of management followed almost everywhere. It consists of manipulation followed by a toe-to-groin plaster cast application every 5–7 days (usually, 4–5 casts). A percutaneous tenotomy of the Achilles tendon is required in about 85% of the cases. A modified Danis-Browne splint is thereafter applied up to 3-4 years of age. Relapse is the re-appearance of clubfoot deformity after full correction, the highest incidence occurring between 1.5 and 4 years of age. Tibialis anterior tendon transfer to the third cuneiform is indicated in relapsing cases. Relapse must be differentiated from mal-treated clubfeet in which the original deformity has never been fully corrected. Mal-treated cases are difficult to treat, and their management depends on the age at diagnosis.
Article
A survey was mailed to 541 members of the Pediatric Society of North America to define currently accepted treatment options in the management of talipes equinovarus. Four hundred sixteen (77%) responses were received, representing a total of 6125 years in practice (average of 17.4 years per physician) and 8595 clubfeet treated in the past year (average of 26 feet treated per physician). While specific trends were reported and great variability exists, certain principles are universal: initial nonoperative management followed by surgery for persisting deformities. A renewed interest in Ponseti's techniques of casting and surgery to address specific persisting deformities was reflected in this survey.
Article
Clubfoot is the most common extremity birth defect. It causes the feet of affected individuals to point inward and downward, preventing them from walking normally. Neglected clubfoot causes disabilities that result in a lack of social integration, creating a psychological and financial burden for the family and community. Clubfoot has been effectively treated through the Ponseti method, a treatment utilizing serial casts to correct the deformity followed by use of an abduction brace for approximately 2-4 years. sustained use of the brace is necessary to prevent relapse and ensure a successful outcome. Brace compliance in the setting of limited resources in the developing world can be challenging. The purpose of this study was to identify the barriers to bracing compliance in southeastern Brazil. In addition to socioeconomic and cultural barriers, this study also looked at improper prescribing practices by physicians as a potential cause of noncompliance. The study sought to identify the role of physician education in the use of the Ponseti method and physicians' knowledge of the bracing process. Identify the barriers to bracing adherence that could negatively impact the treatment of children with clubfoot. Forty-five orthopedists from several centers in southeastern Brazil were interviewed. Physicians were asked about their training in the Ponseti method, their protocol when prescribing the brace, their evaluation of its importance, and a series of open-ended questions designed to identify the positive and negative qualities of local braces. They were also asked what they perceived to be the biggest challenges to sustained brace use. sixteen of the physicians interviewed were orthopedic residents, and 29 had completed their residencies. Of these two groups, only 25% and 65%, respectively, appropriately prescribe the abduction brace for patients, with the majority recommending use of the brace for an inadequate period of time. The high costs and delays in acquisition of the brace and a lack of orthopedic stores able to adequately construct the orthotic, also present considerable barriers to sustained brace use. Many of the causes of noncompliance with bracing protocol stem from systemic inequities and challenges, rather than a lack of collaboration from the families themselves. Furthermore, insufficient prescription of the brace by physicians may represent a major barrier to bracing compliance in southeastern Brazil. This research indicates a need to evaluate physician training and continuing medical education in order to ensure that physicians are adequately utilizing the brace.
Article
The Ponseti technique for treatment for Congenital Talipes Equinovarus (CTEV) was introduced in the authors' institution in 2001, substituting a more traditional orthopaedic approach which involved surgery. There is currently limited published information regarding the differences in clinical outcomes between these two techniques, particularly in relation to plantar pressure analysis. This study aims to determine differences in pedobarographic outcome in children with CTEV, treated with either a surgical or Ponseti approach. A high resolution pedobarograph was used to record plantar pressure distribution in 52 children with CTEV and 26 children with typical development. Data were imported into Matlab where a custom programme was developed for processing and analysing pedobarographic recordings. There were significant differences in both treatment groups compared to the typically developed group (p<0.05) for most measurements. The most salient differences between treatment groups were (i) at the hind-foot where the Ponseti group had significantly lower maximum peak pressures (p<0.05); (ii) at the lateral mid-foot where children treated by the Ponseti approach showed significantly larger peak force (p<0.001), average peak pressure (p<0.001) and maximum peak pressure (p<0.01); (iii) at the lateral fore-foot where the surgical group showed lower average peak pressure (p<0.05); and (iv) in the medial/lateral fore-foot ratio where the Ponseti group showed significantly lower values (p<0.05). Plantar pressure analysis is a complementary measurement for the assessment of gait in children with CTEV. Data presented in this study showed that while there were deviations in children with CTEV, the differences observed between treatment groups suggest children in the Ponseti group have some level of under correction or recurrence.