Tuesday, July 28, 2009

Relapse

Frankly, I'm scared of relapse..That's why I'm trying very hard to strictly stick to brace protocol..tried to make it 10-12 hours per day,but sometimes it is almost impossible..Recently Dania was complaining again..her feet is in pain again and at night she was crying..She's pointed at the scar located at the heel..(the most stupid surgery that happened to her)..If it is really that surgery that caused her pains, I hope the doctors that decides to perform the surgery will never find peace in their life...will never..

I've to punish Dania whenever she is not cooperating with the brace protocol..hmm..Pity her but we're giving her our best, right?

Extracted from Ponseti International website..

Relapses are a common occurrence among children with clubfoot up to the age of six years. The following is the rate of relapse for discontinuing brace-wearing at the age designated: 1st year 90 percent, second year 70-80 percent, third year 30-40 percent, 4th year is 10-15 percent, subsequent years are about 6 percent. Bracing is an essential part of the treatment of clubfoot and prevents relapses very effectively. Severity of the deformity at birth is not a reliable indicator of the odds of relapse, therefore almost all clubfoot patients are held to the same bracing protocols in order to provide them with the best protection against regression.

Bracing protocol needs to be tailored to the individual child based on the age, the relapse rate associated with that age, and when the correction was finished. For example, bracing hours will be longer for a new born that was corrected in three weeks as opposed to an older child that is already walking when correction is achieved. Importantly, the underlying cause of clubfoot is a muscle developmental and growth problem, so it is very important that children who are using the brace maintain some degree of mobility.

The foot abduction brace is used only after the clubfoot has been completely corrected by manipulation, serial casting, and possibly a heel cord tenotomy. The foot abduction brace, which is the only successful method of preventing a relapse, when used consistently as described is effective in > 95% of the patients. Use of the brace will not cause developmental delays for the child.

A Foot Abduction Brace (also commonly mis-labeled a Denis Brown Bar or DBB) consists of an adjustable length aluminum bar with adjustable footplates onto which shoes attach. It is recommended that an adjustable bar is used in stead of a fixed length bar because the child will quickly outgrow the fixed length bar. The orientation of the footplates to the bar is set by the orthotist as recommended by your doctor. Typically, the shoes are set at 60-70 degrees of external rotation. The last cast applied by the doctor must also have been rotated to the 60-70 degrees of abduction (external rotation), otherwise the brace will be uncomfortable for the child. There should be a bend in the bar or the mounting of the footplates to obtain 10-15 degrees of dorsiflexion. The shoes are straight last, meaning there is no curvature, so they can go on either foot. If the bar does not have a quick-release mechanism, the shoes are oriented with the buckles on the inside, so that you do not have to turn the baby over to tighten the strap and laces. Importantly, the distance between the inside edges of the heels of the shoes is equivalent to the child’s shoulder width. This distance is the most comfortable for the child and prevents knee or hip problems. If you lay the brace on the floor with the shoes facing upward, the child’s shoulders should fit snugly in between the shoes. Children go through major growth spurts, so if your normally agreeable child is suddenly waking and fussing, it is appropriate to check the length of the brace to see if an adjustment needs to be made prior to their next follow up appointment with the doctor. The FAB holds the foot in the proper abduction (external rotation) and dorsiflexion (forefoot lifting up toward the calf) to keep the foot properly stretched.

Wearing Schedule:

Use the brace once the last set of casts is removed. DO NOT wait to get the brace after the cast is removed since there is a high chance of regression that can lead to discomfort and non-acceptance of the brace. If the brace is not ready, a holding cast should be applied to maintain final correction. It is also important not to end treatment early.

The following schedule is recommended:

a. For young babies with clubfeet corrected in the first few months of life:
i. 23 hours for three months.
ii. Then a gradual weaning schedule as follows: one month 20-22 hours, one month 18-20 hours, one month 16-18 hours and one month 14-16 hours. The time in the brace does not need to be consecutive, but try to have the bulk of the time while the child is sleeping nights and naps to encourage mobility during the waking hours. If your child attends a daycare, consider leaving the brace on in the morning and instructing the daycare as to what time each day that the brace should be removed, or if your daycare providers are confident and willing, instruct them how to remove and reapply the brace for nap times.
iii. As the child grows and is walking full time, maintain night-time wearing of the brace for 12-14 hours per day up to age 4-5 years.

b. If the final correction is achieved after 8-9 months of age and the child is ready for crawling or walking, it is important to allow some mobility to help in the development of the weak muscles.
i. Therefore, it is recommended to start initial bracing with 18-20 hours a day for 2 months, then go to 16 hours a day for 3-4 months, and then to the standard maintenance protocol of 12-14 hours to age 4-5 years.

c. Some children with clubfoot (about 2 or 3 percent) may also have loose joints.
i. In these cases, the abduction (external rotation) of 60 to 70 degrees may lead to flat foot, usually presenting when the patient starts walking at 10-16 months of age and after. These children should set the shoe to 30-40% abduction. Do not stop using the brace as there would be risk of relapse.

d. If the child has atypical/complex clubfoot.
i. After correction the shoe used for the affected foot should be set to 20-30 degrees. There should not be bending on the bar unless there is 10-15 degrees of dorsoflextion with the last cast. As the foot becomes more normal looking the abduction (extended rotation) of the shoe should be changed to 40-50 degrees.

e. For those children who are treated 2 and older at the time of correction please refer to Dr. Morcuende.

Details can be viewed at Ponseti Website. This website is most helpful. If you sceptical with your current doctor, pls feel free to refer to this website or email to Dr Morcuende.
 
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