Bracing After Ponseti Casting to Correct Clubfoot
It’s exciting to see those feet looking so nice and straight, isn’t it? Your
doctor has undoubtedly stressed how important the brace is in retaining
this correction. However, many parents have issues with the
Foot Abduction Brace (FAB)—also commonly now called Boots & Bar (BnB)—at
first.
On this page, we present information related to the use of the FAB as
well as practical tips and tricks aimed at preventing, detecting and solving
the most common problems.
We sincerely hope that this content can be of use to all of you as you start
out with the FAB. For the Markell shoes, we include a section on modifying the shoes in order to
make them more user friendly. We also have some information about modifications , instructions for putting the FAB on your
child and a troubleshooting guide should serious problems (such as sores)
arise.
It may look like some kind of torture device, but babies can be perfectly
happy, sleep peacefully and do just about anything while wearing the FAB.
When it is worn correctly, this brace does work!
The information we present here is largely born of our experiences with our
own children and the experiences of the many wonderful families from the
online support group nosurgery4clubfoot. You are not alone on this journey.
Support and help from other parents is available to you online in the way of many Clubfoot Groups.
Congratulations on reaching this step in the clubfoot treatment!
Setting up and modifying your Markell Foot Abduction Brace (FAB/BnB)
Following the Ponseti method serial casting, most babies will be placed into the standard foot
abduction brace (FAB). This brace consists of a pair of white leather open toe boots attached to a
fairly lightweight metal bar. The length of the bar is either fixed or adjustable. The shoes are
typically screwed onto sole plates which then attach to the bar with a nut and bolt or a hex head
screw. Other braces coming into use are similar in that the feet are connected with some kind of
bar but the design of the shoes, bar or both is a little different. Here we are primarily focusing on
the standard FAB that uses the Markell Tarso Open Toe Boot #1644 or #1645.
The shoes are called straight last shoes. This means that there is no left or
right shoe and either shoe can be mounted on either side of the bar (most
people find it easiest to have the shoes mounted so that the buckles are on the
inside).
The shoes have a strap, loose tongue and laces. Sometimes a child
will be given reverse last shoes (it will look like they are on the wrong feet).
However, the Ponseti method does not call for the use of reverse last shoes.
To start out, here are a few modifications you can make to the shoes in order to make them more
user-friendly. We recommend modifying the shoes before using them for the first time or as soon
as possible after they are given to your child.
♦Take the laces out and tie a knot in the center/middle of each lace. Then re-lace the shoes. Tie
a knot at the very ends of each lace so they can’t slip back through the holes. This way,
you’ll be able to pull the laces very loose without having to worry about needing to re-lace
the shoes every time. The knot in the middle will help you keep the laces even.
♦Consider slitting the tongue keeper slit up to the top of the tongue (don’t cut through the
stitching though). This allows the tongue to sit low on the top of the foot. It also allows
the top of the boot to be tightened up on the ankle so that the fatty baby calf doesn’t pull
the heel up and out. The tighter the ankle area, the more secure the foot will be in the
shoe.
♦Install the strap in the lower slot on each side of the boot. For most feet, this is the best
position for keeping the foot in the shoe. Some parents switch slots as the child’s foot
grows. As long as the foot is staying securely and deeply seated in the shoe, either slot is
fine.
♦Punch an extra hole in the end of each strap. This way you can secure the strap in the
buckle while you are putting the foot into the shoe. Longer straps do not
usually need this extra hole, although it may be more convenient for the
parents.
Cut the tongue
keeper slit here. This is where the
tongue sits before
the keeper is cut.
The tongue sits
much lower after
the tongue
keeper is cut.
If your child’s FAB is not set up correctly, it may be very uncomfortable. Here are a few
things to check to make sure your FAB is set up correctly.
Bar Length
♦Most FABs are set up so that the length of the bar is such that the baby’s heels are
shoulder-width apart. You can measure the width of your baby’s shoulders and check that
against the distance between the heels of the shoes when they are mounted on the bar. You can
also eyeball this by holding the FAB up to your baby’s shoulders as
shown in the picture. In our experience, this is the most comfortable
setting for most children although there is certainly a comfort range of
up to about 2 inches (5 cm).
♦If your child’s FAB is too short or too long and seems to be causing
your child discomfort, it must be adjusted as quickly as possible. For
those who are using the adjustable red bar, it is a matter of loosening
the clamps and sliding the bar until you have the right fit. If you are
using a fixed-length bar, you will need to get a new bar of appropriate
length: contact your doctor and your orthotist.
Foot Abduction
♦In order for the brace to be effective, the shoes must be set at the proper degree of exter- nal rotation (abduction). This is 70o
for each clubfoot and 20o
-45o
for a non-clubfoot. 70o
of
abduction may seem like a lot, but your baby’s last cast will have been turned out at least that far
so it is not an uncomfortable angle. If you saved your baby’s last cast, you can check the abduction using a protractor. If the external rotation on the last cast is much less than 60o
, consider
talking to your doctor about another cast and proper abduction.
♦Make a mark on the sole plate to show where the shoe lines up with the bar. This way, if
you remove the shoes, or if they come loose for some reason, you can easily set them back to
where they should be.
Dorsiflexion
♦Dorsiflexing the foot means tipping it up so that the toes point towards the head. The bar
should be bent so that the feet are held in 10o
-15o
of dorsiflexion. The red adjustable bars are
bent at either side, just under the boots. The non-adjustable bars, which are bent by the orthotist, may have 2 bends (one at each end) or a single curving bend in the middle.
Set the heel of the cast on the mid-point of the straight edge of the protractor
and line the knee of the cast up with the same edge. An imaginary line
passing through the middle of the foot section should hit the 70o mark on the
protractor.
The longer bar has a bend at each end.
The shorter bar has one bend in the middle.
Kori’s Tips for putting the FAB on a wiggly baby
without causing pain or sores
♦Some parents feel most comfortable having the child sitting on their lap facing away from them
while they put the brace on; others say it’s easiest for them to have the baby lying down in front of
them. Many parents work together installing the FAB, especially at first. If you can do it when
your child is relaxed and calm, you will probably have a much easier time. Find out what works
for you and your child.
♦You won’t have to do this step forever—in fact before you know it, you’ll be able to put the FAB
on your child with your eyes shut—but it really does help for the first few months.
At first, it is much easier to put the shoes on your child separate from the bar
and then, when they are on nice and snug, attach the shoes to the bar.
If you have a gold fixed-length bar, taking the shoes off the bar is very simple:
you just need to unscrew the nut on each shoe and the bar slips right off. Once
you’ve taken the shoe off the bar, screw the nut back onto the bolt so that you
don’t lose track of it (and so that you don’t get kicked with that sharp bolt).
If you have the red adjustable bar, it is harder to get the shoes back on correctly
once they’re off. Instead, take the bar itself apart by loosening the black clamps.
Mark your bar so that you can easily set it back to the right length before taking
it apart for the first time. This method will lead to wear on the clamps. Should
they break, you can substitute metal automotive hose clamps (available at
hardware or auto parts stores) in a pinch. Your orthotist can also provide you
with replacement parts.
♦Open the shoe up as far as you can by loosening the laces up all the way to the knots and
pulling the tongue up as far as it will go under the laces. If you punched a new hole at the end of
the strap, buckle the strap into that hole loosely so that it doesn’t get pulled into the shoe when
the foot goes in.
♦Insert the foot into the shoe and bend the knee 90o
. Push on the top of the knee and hold the
sole of the shoe. Press the heel deeply into the back of the shoe and flex the toes upward (dorsiflex) as far as possible. Make SURE the heel is seated well into the bottom and back of the shoe.
When working with the shoes attached to the bar, follow the same procedure one foot at a time.
If the child is unilateral (left or right clubfoot), start with the clubfoot.
♦With the knee still bent, press a finger on the strap where it goes through the tongue keeper slit:
this will hold the heel in the back of the shoe. Buckle the strap but don’t thread it through the
lower portion of the buckle just yet. Dorsiflex the foot again and press on the bent knee with one
hand and on the sole of the shoe with the other to make sure the heel is in properly. Re-tighten
the strap: you may get it another hole or two tighter. If there is any wiggle or looseness, press the
foot into the shoe again, put pressure on the strap and re-tighten.
♦Now try to pull the shoe off by bending at the ankle and dorsiflexing the foot. If the foot slips in
the shoe, it is not tight enough: retighten using the above technique until the foot is secure in the
shoe.
♦Center the tongue and pull it down over the toes so that the top of the tongue lies at or just
below the ankle of the boot. The strap is essential to keeping the foot well seated in the shoe, it
needs to be tight—probably tighter than you think it should be at first. Don’t worry, if the heel is
well-seated at the back of the shoe, you will not be able to make the strap too tight. If the foot
cannot slip around in the shoe, blisters and friction sores cannot form. Pay attention to which
hole on the strap you are using and remember to adjust as your baby’s foot grows and the leather
on the strap stretches out.
And this, of
course, is the
tasty gold bar!
♦Pull the sock at the toes to make sure the seams aren’t going to press into baby’s toes. This also
helps make sure the heel is well seated. Run a fingertip under the baby’s toes to make sure that
they have a little room to wiggle and that you haven’t folded any of them under.
♦Tighten the laces nice and snug all the way up and tie them. The shoe should get a little tighter.
In particular, make sure that the ankle area of the shoe is very tight. If you’ve been having issues
with slipping, try lacing the shoes only to the second hole from the top and tying them off there.
♦Check whether the foot can slip out of the shoe at all. If it can, you will need to repeat the
procedure. Most important is to put pressure on the knee and push the heel into the bottom of
the shoe with the foot dorsiflexed (toes pointing toward the baby’s head) all at the same time. This
isn’t easy at first, but it will soon become second nature. It is absolutely essential that your
baby’s feet not slip in the shoes. Slipping feet are not held in correction and can compromise the
effectiveness of the FAB and lead to relapse. Slipping feet may also cause painful sores and
blisters.
♦Once you have the shoes on both feet nice and snug, re-assemble the FAB. For the non-adjustable bar, this is a matter of slipping the bolts back through the holes in the bar, making sure the
shoes are set at the right degree of abduction and re-tightening the nuts. Secure the nuts by
hand, but take care to make them very tight. Not only do loose bolts not maintain correction, they
also will strip the teeth on the aluminium bar. With the adjustable bar, you just need to set the
pieces back to the right length and tighten down the clamps.
♦Until you are very comfortable with the process, you can expect to spend a fair amount of time
and energy getting the FAB on your child. However, you—and your child—will get used to it.
Veteran parents can get their child into a FAB in 4 minutes flat!
♦Over the first few days of FAB wear, you may want to take the FAB off your baby every few
hours. This will allow you to check for beginning sores or blisters(both of which are often signs of
improper foot position or slipping in the shoes). You will also get some good practice in putting
the FAB on. A normal-tempered baby is usually a sign that you have the FAB on correctly and
you don’t need to keep checking so often.
Pad Your FAB!
It is very easy to make a simple pad for the FAB. This will help keep your baby’s head as well as
your shins, arms, walls, floors, crib slats and so on from being beat up by that metal bar.
Buy a piece of pipe insulation foam at your local hardware store and cut it to fit on the bar between the shoes with a flap to cover the bolts. Tape it in place with althetic tape.
Some families have wrapped their FAB with carseat strap covers or bike handlebar tape. There is
also a simple pattern to make FAB covers out of any material you want available at the
nosurgery4clubfoot site.
Troubleshooting
♦You may not have any problems except for some fussiness over the first few days and nights.
You can use an infant strength pain reliever (acetaminophen or ibuprofen) if you feel that it will
help. This fussiness is perfectly normal for a child whose feet have been fully corrected and
remain deeply seated in the shoes.
♦The cause of the fussiness is not likely to be more than muscle tenderness and skin sensitivity
following the casting period. It will get better with time. It’s fine to use a little lotion on your
baby’s dried out skin, but try to keep it off of the feet themselves as this can cause slipping in the
shoes. If your baby’s skin seems to be sensitive, use a firm touch—a gentle touch can be even
more irritating.
♦Many babies new to the FAB seem frustrated at not being able to move their legs independently.
Show your child how to move both legs together by playing gently with the bar, moving it from
side to side and up and down. You probably won’t need to do this very much, they figure it out on
their own pretty quickly.
♦If your baby is irritable, consider co-sleeping the first few nights so everyone gets some sleep.
With a pillow under your baby’s feet to prop up the FAB, you and your baby can lie on your sides
to nurse.
♦If your child is not tolerating the FAB past the first few days, cries in pain all of the time, wakes
up every half hour or less through the night and seems unhappy and miserable and if you see
evidence of blisters or sores forming, there is a problem that you need to tackle and rectify. We
hope that this guide can help you do just that. As always, we encourage you to post to the
nosurgery4clubfoot online support group if you need help, reassurance and sympathy.
♦You may see red spots on your child’s feet. Usually red spots are nothing to worry about and
they should fade during your child’s daily break from the FAB. Pressure sores are a different
story. These start as dark red areas that keep getting darker until they turn purple or black.
Eventually, they become open sores that can become infected. They will not get better unless the
pressure against them is relieved.
♦Some parents have resorted to cutting a large hole in the heels of the shoes thereby relieving
pressure so that their baby can continue to wear the FAB while the sore heals. After cutting the
hole, many parents have found that they were not getting the heel down all
the way. While this is a short-term fix for the larger problem of properly
fitting the shoes, it can be helpful if you have concerns about whether you are
getting the heel all the way down.
Markell has recently released a new shoe design incorporating the hole in the
heel. These shoes are available in the smaller sizes: 0000, 000, 00, 0 and 1.
Contact your orthotist or the Markell shoe company if you are interested in
these shoes. http://www.markellshoe.com
♦Blisters—which can also become open sores when the skin breaks—are caused by slipping or
friction of the foot against the inside of the shoe. First of all, make sure that your baby’s socks fit
well and are not bunching up and causing friction. There can be absolutely no slipping out of the
shoes, even after a few hours of wear. If the feet do slip eventually, the shoes need to be tighter in
the first place. Again, it is important to get the heel as snug in the back of the shoe as possible.
♦You should do everything you can to make sure your baby stays in the FAB. A clubfoot has an
extraordinary tendency to relapse: these little feet can show signs of relapsing within hours.
However, you need to listen to your child and follow your heart. Do not keep putting the FAB on a
child who has a weeping sore. This is painful and you wouldn’t put a tight shoe on your own foot
with a sore like that. Occasionally, a baby will be placed back in casts to maintain the correction
while a sore heals.
♦If nothing you do seems to help, you may want to consider that your child’s foot has lost some
correction or that it was never fully corrected to begin with. The FAB will not complete the correction and will be very uncomfortable. If you feel that you need to seek a second opinion, go for it.
Chances are we can help you find an experienced doctor in your area.
Life with the FAB
As with any new medical device, the FAB takes some getting used to and requires some working
around. Here are a few general tips and tricks related to daily life with an infant and older child in
the FAB.
♦Clothing concerns:
Use medium thickness cotton socks with small seams. The Old Navy, Gymboree,
Baby Gap socks with the rubber grippers on the bottom work very well. They run
7pairs for $10 at Old Navy. You might as well stock up: baby socks get lost on a
regular basis. Tights work with the FAB as well, the thicker the better.
During the initial three-month period of full-time wear, most people dress their
babies in outfits that snap along the inseam.
Outfits with attached feet are out, but many parents simply cut off the feet of
outfits they would still like to use.
♦Equipment concerns:
Most infant carseats and convertible carseats work perfectly well with the
FAB.
Try to find an infant swing and highchair that you can place your baby in without
having to remove the FAB.
Infant carriers such as the Baby Bjorn and Kelty Koala work very well as you can
put your baby in them without having to remove the FAB. It may take a little time
to find a comfy position, but the FAB should not interfere with wearing your child
in a sling.
♦Sleeping concerns:
If your child seems uncomfortable at night, check the length of the bar and adjust
it if necessary. A too short bar is a frequent culprit for nightime restlessness.
Many children wake themselves up at night because their FAB has become tangled
in their covers. Using heavier pajamas or a sleep sack will eliminate this problem.
A simple sleep sack pattern is available at the nosurgery4clubfoot site.
Make putting the FAB on part of your bedtime routine. Many children wind up so
that they have a hard time going to bed without the bar or even ask for it to be put
on when they are tired! You will be amazed at how quickly this just becomes part
of your everyday.
♦Some atypical clubfeet respond very poorly to the standard FAB. These feet are short, plump,
sausage feet with a deep transverse skin fold across the sole of the foot and another crease above
the heel. You should seek the opinion of an experienced doctor if this describes your child’s foot.
Additional information can be found at: http://adifferentfoot.freeservers.com
♦Occasionally, problems will come up when a baby’s hours in the FAB are first reduced. These
are almost always due to the hours being reduced too dramatically, from 23 hours a day to
“nights only” (roughly 12 hours for most children). It is important for avoiding both immediate
tolerance problems and future problems with correction that a baby’s time in the FAB be reduced
slowly. The recommended protocol is full-time (23/7) wear for the first three months followed by
20/7 for a month, then 16-18 hours a day until the child is walking. Only at that point should
the time in the FAB be dropped down to “nights and naps”. Most doctors are recommending that
in most cases the FAB be worn until the child is at least 4 years old.
Life with the FAB
As with any new medical device, the FAB takes some getting used to and requires some working
around. Here are a few general tips and tricks related to daily life with an infant and older child in
the FAB.
♦Clothing concerns:
Use medium thickness cotton socks with small seams. The Old Navy, Gymboree,
Baby Gap socks with the rubber grippers on the bottom work very well. They run
7pairs for $10 at Old Navy. You might as well stock up: baby socks get lost on a
regular basis. Tights work with the FAB as well, the thicker the better.
During the initial three-month period of full-time wear, most people dress their
babies in outfits that snap along the inseam.
Outfits with attached feet are out, but many parents simply cut off the feet of
outfits they would still like to use.
♦Equipment concerns:
Most infant carseats and convertible carseats work perfectly well with the
FAB.
Try to find an infant swing and highchair that you can place your baby in without
having to remove the FAB.
Infant carriers such as the Baby Bjorn and Kelty Koala work very well as you can
put your baby in them without having to remove the FAB. It may take a little time
to find a comfy position, but the FAB should not interfere with wearing your child
in a sling.
♦Sleeping concerns:
If your child seems uncomfortable at night, check the length of the bar and adjust
it if necessary. A too short bar is a frequent culprit for nightime restlessness.
Many children wake themselves up at night because their FAB has become tangled
in their covers. Using heavier pajamas or a sleep sack will eliminate this problem.
A simple sleep sack pattern is available at the nosurgery4clubfoot site.
Make putting the FAB on part of your bedtime routine. Many children wind up so
that they have a hard time going to bed without the bar or even ask for it to be put
on when they are tired! You will be amazed at how quickly this just becomes part
of your everyday.
References
For information regarding the Ponseti method of treating clubfoot, please refer to the following:
Dr. Ponseti’s website at the University of Iowa:
http://www.vh.org/pediatric/patient/orthopaedics/c...
A very informative booklet in pdf format:
http://www.global-help.org/publications/cf.2.pdf
A comprehensive list of links concerning the Ponseti method:
http://members.tripod.com/ponseti_links-ivil/
Specific information regarding how to set up the FAB is available at:
http://members.tripod.com/ponseti_links-ivil//id9.html
For information concerning alternatives to the standard FAB, refer to the following:
When a child is utterly miserable in the FAB, it is natural to wonder about other bracing options
available. A very commonly used device in the treatment of clubfoot is the Ankle-Foot Orthotic
(AFO). This is a molded plastic boot secured with velcro straps that is meant to hold the foot in a
neutral position. While it may look much easier to deal with day-to-day, it cannot hold the foot in
external rotation and has been shown to be useless for a Ponseti-corrected foot. Its cousin the
Knee-Ankle-Foot Orthotic (KAFO, Wheaton Brace) does allow the required external rotation.
However, it immobilizes both the knee and the ankle which can lead to significant muscle atrophy.
Two new versions of the FAB have been introduced over the past few years. Each has features
that set it apart from the standard FAB, yet they function in much the same way and are at least
as effective as the FAB you are using.
The Dobbs’ Brace is an FAB designed by Dr Matthew Dobbs of
Children’s Hospital of St Louis, MO. It is very similar to the standard
FAB with an articulated bar so that the baby can move her or his legs
independently. This brace may be used with the Markell boots or with
custom-made molded plastic shoes (modified AFOs). For more information, contact Dr Dobbs at: mattdobbs@earthlink.net
The Ponseti Brace, or Mitchell Brace, has been developed in Iowa
City by John Mitchell in close collaboration with Dr Ponseti. Originally reserved for use in cases of atypical clubfoot, it is now being
more widely used. This FAB sports soft leather sandals instead of
the Markell boots. It is currently being hand-made on demand.
For more information, visit: http://www.mdorthopaedics.com
Please keep in mind that we are not medical professionals but parents
of children with clubfoot. This guide is meant as a help to parents
who are new to the FAB and should not take the place of physician
supervision.
Please send any comments regarding this guide to Kori Rush
kori@frogabog.com
Wheaton Brace: http://www.wheatonbrace.com/products/wbrace.html
Steenbeck Brace: http://www.global-help.org/publications/books/help_cfponseti.pdf
Steenbeck Brace (image): http://www.global-help.org/publications/books/help_steenbeekbrace.pdf
Horton Click Brace: http://www.hortontechnology.com/index.html
Dobb's Brace: http://www.dobbsbrace.com/
ALFA-Flex Brace: http://www.semeda.de/25-1-alfa-flex.html
ALFA-Flex Brace (image): http://institutsantjoan.com/pie-zambo/
Mitchel: http://www.mdorthopaedics.com/home.html
