Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique?

The use of foot abduction orthosis [Denis Browne boot (DBB)] is vital for maintaining correction after the Ponseti technique for treating idiopathic clubfoot. Lack of adherence to DBB regimen is reported to be a potent cause for recurrence. Adherence to the boots and bars programme is difficult and patients sometimes resist their use. The evaluation of alternatives that may facilitate adherence is therefore necessary and reasonable. There are less data published regarding the outcome after the use of alternative splints. In patients who showed poor adherence to DBB, we introduced a novel unilateral foot abduction orthosis (UFAO) as an alternative. The aim of this study was to determine whether the recurrence rates were increased by exchanging DBB with UFAO in nonadherent patients and to find out whether UFAO was more acceptable to families who had refused to use DBB. We reviewed 27 children with 35 idiopathic clubfeet. Twenty-three patients used the boots and bars programme for the first 3 months after completion of serial casting, before UFAO was introduced into the treatment plan for resistance to DBB usage. In four cases, UFAO was commenced immediately after the serial casting. The mean follow-up was 25 months (16-36 months). Most families reported that UFAO was easier for their child to use and facilitated adherence was observed. Recurrence (the need for further casting or operation) was observed in 11 feet. Six of these 11 recurrences responded favourably to a further period of serial casting with or without repeated tendoachilles tenotomy. Three of these 11 patients responded favourably to tibialis anterior transfer and two required a traditional posteromedial release. The recurrence rates in patients using UFAO were higher compared with those reported by others using DBB after Ponseti serial casting. Our results indicated that although a unilateral orthosis is preferred and accepted by families who do not adhere to a DBB regimen, recurrence with UFAO use is higher. This study therefore questions the effectiveness of UFAO as an alternative to DBB. The importance of following the original method described by Ponseti should be stressed.