Clubfoot brace types, compared

Brace designs for clubfoot fall into three groups1.

Abduction braces are the standard after Ponseti casting. Two shoes on a bar, holding the feet abducted and dorsiflexed. Every one in use descends from the orthosis Denis Browne described in 19311.

Ankle-foot orthoses cover the foot and ankle and provide dorsiflexion only, typically set to neutral. They do not provide abduction, which matters because abduction is what lengthens the medial structures. Results with a unilateral AFO alone after Ponseti treatment have been disappointing, with a high recurrence rate. They do have a place combined with an abduction bar in specific situations — myelomeningocele, arthrogryposis, fibular nerve dysfunction1.

Wheaton-type orthoses give some abduction but are custom-made and expensive, need frequent adjustment, and reach to the thigh, which promotes calf and thigh muscle atrophy. The Wheaton in full. The review is blunt about them: there is no evidence to support their efficacy, so they are not recommended for clubfoot1.

None of the three is what I wore. These are from the 1980s, before the Ponseti method was standard: shoes on metal uprights that ran up both legs to a waistband, worn 23 hours a day.

What varies is the shoe, the bar, and whether the legs can move independently.

• Mitchell — sold as the Ponseti FAB. Sandal-type leather with a molded lining and quick-release. Built for comfort; reports the highest pressure-sore rate in the one direct comparison.
• Markell — symmetrical shoes for a Denis Browne bar. Half the pressure sores of the Mitchell in that same comparison.
• Dobbs — a dynamic bar allowing independent leg movement. Much better reported compliance; costs more, and dorsiflexion is harder to hold.
• Steenbeek — Ugandan design, made locally, under ten dollars. What most clubfoot programs in the world use.
• Iowa — from a team led by Dr José Morcuende at the University of Iowa. A fixed 60 degree abduction angle, a non-adjustable bar in three lengths, 8, 10 and 12 inches, and a Flex Bar giving limited movement that returns to position1.
• Denis Browne — the original. A dorsiflexed foot brace on leather boots, with toe and heel openings so the foot can be checked for being plantigrade1.
• Horton Click — MJ Markell Shoe Company, New York. The shoe clicks into the bar and permits internal and external rotation1.
• Kessler — a flexible bar allowing some plantarflexion during kicking, returning to the dorsiflexed position when the child stops1.
• 3D-printed — open-source designs with similar features at significantly lower cost, developed with resource-limited settings in mind1.

Very little has been compared head to head. What exists is worth knowing precisely.

Mitchell against Markell, on pressure sores. Across 247 children and 374 feet, 22.9 percent against 12.6 percent, a relative risk of 1.82 with a confidence interval of 1.03 to 3.202. One retrospective study, one hospital, and it measured sores rather than correction.

Dynamic against traditional, on compliance. In 28 patients, non-compliance 7.1 percent against 41 percent, and skin lesions 7 percent against 23.5 percent1.

Bracing complications generally. In that 247-child cohort, 17.4 percent developed pressure sores severe enough to stop bracing, at a median age of 4.8 months. Non-compliance was 33.2 percent, heel lifting 25.1 percent, recasting 31.2 percent2.

What nobody has shown. That any design produces better-corrected feet than any other. Every comparison above measured complications or compliance. None measured the foot.

You do not choose your brace. The clinic does, based on the foot, the protocol and what they can supply. What this page is for is knowing which one you have and what is known about it.

Three questions worth asking: which design is this and why this one, what should I watch for on the skin and when, and what do we do if we cannot keep the hours. That last one is the important one — non-compliance runs at a third of families in the published cohorts2, and it is the strongest modifiable factor in relapse.