The clubfoot brace
The brace worn after casting consists of two shoes attached to a bar at a specific angle. The clubfoot brace (sometimes called a Foot Abduction Brace [FAB], or Ankle Foot Orthosis) is an extremely important part of the Ponseti method. It holds the correction of the foot and helps to prevent relapse.
Once the foot is corrected to 70º external rotation, your baby’s feet will be measured to ensure that the correct size shoes are fitted once out of the final cast. These shoes are always attached to an adjustable bar that holds them at the correct angle to maintain correction.
There are a few brace types available. Until the past few years, the brace usually available in South Africa was the Markell brace. It is an open-toed leather boot with strap and laces, with a hole in the sole so that it can be attached to the bar with a bolt.
The Ponseti AFO Brace (also known as the Mitchell brace) made by MD Orthopaedics has been available since 2005. It’s more expensive than the Markell product but is more comfortable and easier for the baby to adjust to. Dr Ponseti is involved in the design of the Ponseti AFO/Mitchell brace and it is especially recommended for children with very small feet or complex clubfoot.
The setup of bars and shoes is according to Dr Ponseti’s protocol and should not be altered, unless the clubfoot is atypical or complex. It’s essential that the foot is corrected 100% before starting in the shoes and also that the orthotist fitting the shoes is competent in the Ponseti method and knows how to set them up correctly.
For Markell setup, the shoes are set at 70º abduction (i.e. just short of a 90º outward angle from neutral position of the foot in order to hold the outward correction) and at 15º dorsiflexion (i.e. the toes will be 15º higher than the heel – the necessary angle to hold the stretch of the Achilles tendon). In cases where the baby has only one (unilateral clubfoot), the non-clubfoot will be held at 40º abduction.
For the Ponseti/MItchell AFO the shoe is set at 60º of abduction which has the same effect as the Markell shoe set to 70º.
The space between the heels of the shoes should be the same as the width of the baby’s shoulders. This is why the bar is adjustable in length. It can be widened as the baby grows.
For children with loose ligaments it may be necessary to reduce the 70º to 40-50º. This is usually decided by doctors if at about two years of age, the foot is still in the over-corrected position, i.e. even after six months or more of walking.
For the first three months after the foot is corrected, the baby should wear the FAB for 23 hours a day. It can be removed for an hour at bath time. After that, it’s usually worn while the baby is sleeping (night and daytime naps), for between 12-18 hours up until the age of four years, gradually reducing and depending on the individual case.
There are other braces available worldwide. As long as the shoes are at the correct angle and are comfortable to wear, they all work the same way.
The Steenbeek brace (SFAB) designed in Uganda by Michiel Steenbeek, and endorsed by Dr Ponseti, is an effective low-cost option for developing countries.
Studies by various Ponseti doctors have shown that correct compliance with FAB wear makes the Ponseti Method almost 100% successful with very few relapses.