日小整会誌（J Jpn Ped Orthop Ass）25（1）：124–128, 2016.
第 26 回日本小児整形外科学会学術集会 JPOA Asian Fellows

Declining of Timing in Brace, Is It the Factor of Recurrent Clubfoot?
Prangthong Unprasert, M.D.1
Perajit Eamsobhana, M.D.2
12Department of Orthopedic Surgery, Ratchiburi Hospital, Ratchiburi, Thailand

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Background: The treatment of the clubfoot with Ponseti casting technique is the most popularand becoming the standard treatment. Early study shown high recurrent rate so bracing aftercasting was introduce worldwide. Due to tropical weather, Bracing became burden of the treatment. Although health care providers provided information, treatment, and financial support, thebrace were not proper worn as the recommendation protocol.
Objective: to identify if the declining of timing in brace is the factor of recurrent clubfoot.
Methods: The retrospective study of clubfoot who treated with casting and percutaneous tendo Archilles lengthening successfully. The data of timing of brace in first three months, timing ofnight splint after the first three month and outcome were collected. Descriptive statistics wereemployed from data analysis by the SPSS program.
Results: From 109 feet, recurrent clubfoot was found in 23 feet（21％）. There were 12 feet innon-brace group and 97 feet in the brace group, second group shown statistically significant ofbetter outcome（11％ VS 89％, p＝0.003）. 55 feet worn brace for less than eight hours（50.5％）
and 42 feet worn brace for more than eight hours（38.5％）shown the later group have 9.1 times
better outcome with statistically significant（p＝0.001, odd ratio 9.1, median＝6.5 hours, max＝18hours）. The recurrent rate of the non-brace, worn less than eight hours , and worn more thaneight hours are 58.3％, 25.5％, and 4.8％（p＜0.001）. After first three months, 62 feet didn’t wear
the night brace（63.9％）and 35 feet wear the night brace.
Conclusion: After Ponseti casting technique, Declining of bracing time have risk of recurrent.
To our knowledge, eight hours per day is enough and result comparable to report by the Ponseti
groups.

Introduction

which could decrease the recurrent rate. Theseorthosis were recommended to be worn full

The treatment of the clubfoot with Ponseti

time for 3 months and night time up to 2-4

casting technique is the most popular, high suc-years. Bracing in clubfoot is a critical part ofcess rate, high function and slightly less stiff-

most current treatment. Many countries pro-6）

ness . Unfortunately 56 percent had recurrent.

pose the bracing protocol claiming the main fac-

Later, Ponseti introduces foot abduction orthosis

tor for long-term success of the treatment3）.

Key words：clubfoot, night bracing, recurrent
Correspondence to：Eamsobhana P, Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok 10700, Thailand.
Phone: 08-9674-3554
E-mail: peerajite@gmail.com

124 日本小児整形外科学会雑誌 Vol. 25, No. 1, 2016

Declining of Timing in Brace, Is It the Factor of Recurrent ClubfootDue to tropical weather and cultures, bracing

The data collection

became burden of the treatment. Althoughhealth care providers provided information,

72 patients were treated with Ponseti castingtreatment, and financial support, the brace weretechnique and percutaneous tendoachilles tenot-

not proper worn as the recommendation proto-

omy at Siriraj Hospital. 60 patients were en-col.

rolled, 12 patients were dropout due to lack of

The purpose of this study is to identify if therecording problems. The data of starting age of

declining of timing in brace is the factor of re-bracing（mean＝6 months, minimum＝9 months,current clubfoot.

maximun＝16 months）, timing of brace in firstMethods

three months（mean＝7.6 hours, minimum＝1hour, maximun＝18 hours）, Age of stop using

The retrospective study were collected fromnight splint after the first three month（mean＝the orthopedic department of Siriraj Hospital,

24.5 month old, minimum＝5 month old, maxi-outpatient data between January 2006 and De-

mun＝144 month old）and recurrent outcome

cember 2014, Our study focused on the duration

were collected（Table 1）.

of bracing after the foot was corrected to proper
position.

In the first three month of bracing, we divided the patient into two groups; non-brace andInclusion criteria

bracing group. On bracing group, we also divided this group into two subgroup; on brace for

All clubfoot patients who were diagnosed byless than eight hours group and on brace fora pediatric orthopedist. Both unilateral and bilat-

more than eight hours group. The night bracing

eral Idiopathic congenital clubfoot was included.

after the first three month was divided in toExclusion criteria
Acquired clubfoot patient who was diagnosed
by a pediatric orthopedist. Recurrent and re-

two group as night bracing and non night bracing（Fig. 1）.
Statistics analysis

lapsed clubfoot as the result of failed surgical

Descriptive statistics were employed fromtreatment and/or other conservation treatment

data analysis by the SPSS program. Chi square

was excluded.

test was used to compare categorical veriable

Ponseti casting technique and percutaneous

between groups. Student’s T-test, odd ratio,

tendoachilles tenotomy at Siriraj Hospital wasand Mann-Whitney test was used to assess thedone with Ponseti protocol. At the ending ofdifference of the recurrent and non-recurrent

casting treatment, which the foot had neutral

group. A p-value of less than 0.05 w as consid-heel and external rotation up to 60-70 degree,

ered statistically significant.

the percutaneous tendoachilles tenotomy wasdone, the foot can dorsiflexion at least 15 degree.

Results

The patient was given foot abduction orthosis,

From 109 feet, recurrent clubfoot were foundinformation, and bracing protocol. The Ponseti

in 23 feet（21％）. There were 12 feet in non-protocol was used as guidelines for the treat-brace group（recurrent 7：58％）, and 97 feet inment and follow the patients.

the brace group（recurrent 16：16％）. The
日本小児整形外科学会雑誌 Vol. 25, No. 1, 2016125

Declining of Timing in Brace, Is It the Factor of Recurrent Clubfoot

Table 1．Demographics
Parameter

Number of feet（N＝109）

GenderFemale
MaleMean

Minimum Maximum

4366

Age of starting bracing（month）
First three monthNon-brace
Brace
Timing of bracing（ hour）

1297

After three monthNon-brace
Night brace
Up to age（month old）

74
35

6916

7.6

1

18

24.5

5144

Fig. 1．Patients

brace group shown statistically significant bybetter outcome with statistically significant（p＝Fisher’s Exact test of better outcome（p＝0.003）

0.001, odd ratio 9.1, median＝6.5 hours, max＝18（Fig. 2）. By Pearson Chi-Square, 55 feet wornhours）（Table 2）. The recurrent rate of thebrace for less than eight hours（50.5％）and 42

non-brace, worn less than eight hours, and worn

feet worn brace for more than eight hours

more than eight hours are 58.3％, 25.5％, and（38.5％）shown the later group have 9.1 times

4.8％（p＜0.001）.After first three months, 62 feet

126 日本小児整形外科学会雑誌 Vol. 25, No. 1, 2016

Declining of Timing in Brace, Is It the Factor of Recurrent Clubfootwere worn until 6-42 month old（Mean＝24month old）（Fig. 3）. The data also shown thelater group have 4.8 times better outcome withstatistically significant（p＝0.032, odd ratio 4.8）
（Table 3）.
Discussion
Clubfoot had become more concerned thepast decade. Better and better treatments have
Fig. 2．The comparing outcome of the non-bracing
group and bracing group in the first month after
the foot was corrected. The brace group shown statistically significant by Fisher’s Exact test of better
outcomedidn’t wear the night brace（63.9％）and 35 feetwear the night brace（36.1％）. The night brace

been developed worldwide. Both prevention andtreatment method were proposed to help treat
the clubfoot, still recurrent occur. To preventthe recurrent of clubfoot, brace had been developed some note as critical part of treatment.
Bracing time frame was recommended.
There was limitation of distribution and com-

Table 2．Timing of wearing brace in the first three month（p＝0.001, odd ratio 9.1）
GoodRecurrent

Brace ＜8 hours（n＝55）

41（74.5％）

14（25.5％）

Brace ＞8 hours（n＝42）40（95.2％）（4.8％）
2Fig. 3．Night brace duration after the first three month
Table 3．After first three months, the night brace worn data.
（p＝0.032, odd ratio 4.8）
GoodRecurrent

Night brace after three month（n＝35）

35（100％）（0％）
0Non-night brace after three month（n＝62）

46（74.2％）

16（25.8％）

日本小児整形外科学会雑誌 Vol. 25, No. 1, 2016127

Declining of Timing in Brace, Is It the Factor of Recurrent Clubfootpliant of brace. Different kind of brace and tech-Referencesnique were introduced worldwide. Multiple sur-1）B e n s a h e l H , G u i l l a u m e A , C z u k o n y i Z ,geons identified bracing as a major risk factorfor the recurrence of the deformity2）4）7）.However
in some surgeons didn’t use brace but give thehome stretching program achieved 77-95 percent of non extensive surgeries1）5）.
It is very difficult for the parents and child togo with the ponseti protocol especially when thechild develops gross motors, they will remove
brace by themselves. From our study eight
hours per day may be enough and result comparable to report by the ponseti groups. The
night brace is also one of the problem we facing
due to financial problem, cultures, and weather.
The night brace become difficult to wear although it is the essential part of the treatment.
In our study, only a small number of the patients wear the night brace and almost all didwear the brace until the recommendation age offour.
We have to find a innovation for the children
with clubfoot in order for them to worn easily
and to be able to walk and stand easily in bracewithout limiting by connecting bar.

128 日本小児整形外科学会雑誌 Vol. 25, No. 1, 2016

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