Effectiveness of the Dennis Brown Bar in Preventing Recurrence After Ponseti Treatment for Clubfoot Deformity: A Ten Year Experience
David E. Westberry, MD and Linda I. Pugh, RN
Clubfoot deformity, also known as talipes equinovarus, is a complex three-dimensional deformity secondary to a congenital, contractual malalignment of the bones and joints of the foot and ankle. (Figure 1 ) Over the past two decades, treatment has evolved from surgical strategies to nonsurgical methods as described by Ponseti.1, 2, 3, 4, 5 With this method of correction, the clubfoot deformity is corrected by a series of corrective casts during the newborn period. (Figure 2 ) In most cases, a heel cord tenotomy is performed in the clinic setting providing final correction of the deformity. The correction is maintained during the early years by an external rotation, abduction bracing protocol. (Figure 3 )
The post-correction bracing protocol is essential for prevention of relapse or recurrent deformity. (Figure 4 ) Previous studies have demonstrated poor results in patients noncompliant with the bracing protocol. Ramirez et al. in a study of 73 corrected clubfeet demonstrated a recurrence rate of 33%. Patients who were noncompliant with the bracing program were more likely to have recurrence.6 Other authors have shown similar patterns when the bracing program was not followed.7, 8, 9, 10
Currently, there are several options for external rotation, abduction braces. Ponseti utilized a pair of straight last shoes externally rotated at an angle of 70 degrees attached by a Dennis Brown bar. A custom brace was developed by Mitchell in conjunction with Ponseti which utilized custom molded shoe orthoses with leather strapping to assist in preventing foot slippage while wearing the device.11 More recently, a dynamic orthosis allowing independent motion of the lower extremities was introduced.12
At our institution, the Ponseti method of clubfoot treatment was adopted in 2002. Over the past 10 years, we utilized the standard Dennis Brown bar with straight last shoes as the device of choice in our clubfoot population. A retrospective review of our experience with this device was performed to determine overall compliance with the bracing program, review outcomes related to noncompliance, and review alternative solutions.
Materials & Methods
All patients who were enrolled in the Ponseti program, completed treatment with casting and bracing, and were followed for a minimum of four years were included in the review. The current bracing protocol requires full time wear of the device for three months, followed by night time and nap-wear until age four.
Compliance was defined as successful if the patient was fully compliant with the bracing protocol until age four. Compliance was defined as unsuccessful if the patient developed recurrence prior to age four and required additional treatment, refused to wear the brace as prescribed, or wore the device on a limited basis.
Treatment outcomes were grouped based on the methods utilized to provide correction of the clubfoot deformity. The cast-corrected group was corrected by utilizing only the Ponseti method and bracing program. No other interventions were required. The minor surgery group, in addition to Ponseti casting, typically required a limited surgical event including posterior soft tissue release and/or anterior tibialis tendon transfer. The major surgery group required an extensive soft tissue procedure.
One hundred thirty-two patients with 199 feet were included in the study cohort. There were 94 males and 38 females with 104 left clubfeet and 95 right clubfeet. Eighty-three per cent were Caucasian. The average age for placement of the initial casts was 44 days (range, 0-259 days). Forty-five per cent had cast treatment prior to presentation at our institution. The average follow up was 6.8 years (range, 3.1-10.6).
Success with Bracing Protocol
Of the 199 feet, 132 (66%) met criteria for successful compliance with the bracing program during the first year of treatment. During year two of the four year bracing program, 53 out of 199 were successful (27%). By year four, only 10% (20/199) were considered successfully compliant with the bracing program.
Of the 199 feet, 102 (51%) were successfully corrected by use of the casting and bracing protocol (cast corrected group). Of these 102 feet, 80 were fully compliant with bracing during the first year of brace treatment. By year four, only 17 of the 102 feet continued with the bracing program.
Eighty-nine out of 199 (45%) required a minor surgery, with the remaining eight feet requiring major surgery for correction. Of these 89 feet, 50 were compliant with bracing during the first year of brace treatment. During year two of bracing, only 12 of the 89 feet were fully compliant with the bracing program.
Challenges with Bracing
Families reported numerous challenges with adherence to the bracing protocol. The most common reason for lack of compliance was patient refusal to wear the brace. This was manifested as either the child refusing to don the brace or removing the brace during the middle of the night. In rare cases, other circumstances prevented compliance such as losing the brace, incorrect application by other family members, or chronic skin conditions.
In our current review, success with the bracing protocol following cast treatment for clubfoot deformity was limited. Only 10% of the patient cohort was fully compliant during the four years of recommended bracing. Despite the lack of compliance, treatment outcomes were favorable and comparable to prior studies with a 50% minor surgery rate and significant reduction in the need for extensive releases.
Previous authors have demonstrated that bracing is an important factor in reducing recurrence in clubfoot deformity. Thacker et al. in a review of 44 feet showed recurrent deformity in those noncompliant with bracing as measured by two clubfoot scoring systems.7 Ramirez et al. had similar results in a cohort of 73 feet. He showed a recurrence rate of 33% with noncompliance with bracing as a significant correlation with recurrence risk.6
Currently, there are several brace designs available in today's market. In a study by Hemo et al., the traditional combination of Markel shoes and Dennis Brown bar was compared with the Ponseti Mitchell brace. In his study, no differences in patient compliance or treatment outcomes were identified.13
The question remains, what is the relationship between recurrent deformity and noncompliance of bracing. Studies have demonstrated that lack of compliance with bracing can lead to increased risk of recurrence. Parent factors, poor fitting devices, or intolerance of bracing can lead to noncompliance with bracing and potential for recurrent deformity. Recurrence or relapsed deformity is a known entity and has been described in both cast corrected as well as surgically treated clubfoot. (Figure 2 ) As a clubfoot relapses, the brace may no longer capture the foot adequately leading to brace intolerance, further complicating compliance with a brace.
The bracing protocol following cast treatment for clubfoot deformity is challenging for patients, families, and practitioners. The Ponseti method is an effective method of clubfoot treatment and most likely will remain the standard of care on a worldwide basis. Improvement in brace design, foot capture, parental education and involvement will hopefully improve success with bracing and reduce recurrence during the growing years of the child.
Shriners Hospital for Children: Greenville
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