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

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 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.

Full text

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 0.230.02. 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