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Unilateral Clubfoot Orthosis


Introduction

The conservative management of clubfeet at Texas Scottish Rite Hospital for Children is a high priority. Our orthopedic teams, physical therapists and orthotists put significant effort into conservatively managing our clubfoot population. We continue to use both the Ponseti technique and the French Functional (Physiotherapy) technique. This subject has also been a research priority, leading to publication.1

One of our highest priorities and most difficult challenges with the Ponseti technique has been maintaining adequate abduction orthosis wear to maintain the correction obtained through the casting process. Initially we utilized a rigid bar and high top orthopedic shoes. As families experienced difficulties with the donning of two shoes attached together with the rigid bar, we developed and had manufactured quick disconnect plates that allowed the shoes to be donned independently prior to being attached to the abduction bar. Once a quick disconnect system became commercially available (Horton Click), we purchased those rather than having our own made. Subsequently, an alternative abduction bar with soft AFO/shoe became commercially available (MD Orthopaedics). We currently utilize either the high top orthopedic shoes (Markell) with the quick disconnect bar (Horton Click) or the soft AFO/shoe (MD Orthopaedics) depending on the physician preference and orthotist evaluation.

Bent Knee KAFO

Our physical therapists have been fabricating bent knee KAFOs out of low temperature thermoplastic for children undergoing the French Functional Physiotherapy method since 1996. Occasionally a child has been too strong and active to be maintained in a low temperature orthosis. These children are referred to the orthotics department for high temperature orthoses. Molding these children and fabricating these orthoses has been a significant challenge. Furthermore, the time available for fabricating these orthoses is very short, with same day delivery often required. To address these issues, a modular adjustable bent knee KAFO has been developed.

Bent knee KAFOs for clubfoot control have been reported in the literature.2,3 The current design varies somewhat from those reported and has fit our needs well. The feet are fit with soft AFOs/shoes (MD Orthopaedics), while the thighs are fit with premade thermoplastic sections. The thigh sections are initially trimmed large and are customized for the specific patient. One half of an abduction bar (MD Orthopaedics) is bent at 90 degrees and attached to the medial portion of the thigh cuff. Use of this location preserves the accuracy of the angles and side designations molded into the end of the abduction bar. Whenever there is adequate length available, an extension bar is attached to the thigh cuff and clamped to the bent abduction bar using the original Ponseti clamp. As the child grows, the soft AFO/shoe is replaced with larger sizes and the height of the knee center is adjusted. The thigh cuff can be adjusted for some growth, but may need to be replaced eventually.

Successfully using the modular bent knee KAFO has required that we maintain an adequate stock of all components. We maintain the soft AFOs/shoes and abduction bars from MD Orthopaedics as part of our standard care. However, we keep some extra long abduction bars pre-bent for this purpose. Our technical staff vacuum forms thigh cuffs over a selection of saved plaster models. Occasionally, we have not had an appropriately sized thigh cuff available. In those situations we have used low temperature thermoplastics to mold one of the saved models, or the patient's thigh and knee.

With the modular bent knee KAFO design finalized, we discussed with the orthopedic staff using these for unilateral Ponseti patients who do not tolerate having both feet held in the traditional Ponseti method. This use has been embraced, but is not our standard of care. We continue to use the two types of foot abduction orthoses (FAO) for the majority of our patients. We try the modular bent knee KAFO when children or families are not tolerating the FAO.

Maintaining the knee bent reduces the opportunities for the Gastrocnemius to be stretched. For this reason, a manual of the Ponseti method recommends against bent knee orthoses.4 Two articles have compared bent knee KAFOs to FAOs in maintaining clubfoot correction.2,3 Both papers state that the FAO is the preferred treatment method with improved outcomes. However, the bent knee KAFO remains a viable alternative.

Conclusion

This modular bent knee KAFO allows us to provide a child with a unilateral orthosis to abduct and dorsiflex the foot in order to maintain clubfoot correction. The initial manufacturing and fitting of the orthosis takes about an hour. Subsequent growth adjustments take substantially less time. This design fulfills the requests from our therapists and orthopedists while being reasonably easy to provide during a single patient visit.

Acknowledgements

The design of this orthosis is the result of the collaborative efforts of our entire staff, with Kevin Field, CPO making a huge contribution.

Disclosures

I have nothing to disclose. We have no special agreements with any of the vendors that we use.

Kevin Felton is Education Coordinator, Orthotics Department, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219-3883

References:

  1. Richards BS, Faulks S, Rathjen KE, Karol LA, Johnston CE and Jones SA. "A comparison of two nonoperative methods of idiopathic clubfoot correction: The Ponseti method and the French functional (physiotherapy) method," Journal of Bone and Joint Surgery , Vol. 90, pp. 2313-21, 2008.
  2. George HL, Unnikrishnan PN, Garg NK, Sampath J and Bruce CE. "Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique?" Journal of Pediatric Orthopaedics B, Vol. 20 (1), pp. 22-25, 2011.
  3. Saetersdal C, Fevang JM, Fosse L and Engesaeter LB. "Good results with the Ponseti method: A multicenter study of 162 clubfeet followed 2-5 years," Acta Orthopaedica , Vol. 83 (3), pp. 288-293, 2012.
  4. Staheli, L (ed.). Clubfoot: Ponseti Management (Third Ed.). Global-Help Publication ( global-help.org ); 2009. Accessed 11/8/13: www.global-help.org/publications/books/help_cfponseti.pdf