Relapse

 

*Non-compliance with bracing protocol was reported to be the leading cause of relapse and has a direct effect on the success of treatment. The most common reason for non-compliance with the brace treatment is discomfort

*Nearly all relapses occur in the maintenance phase of treatment (bracing)

*Inappropriate wearing of BNB does not maintain the correction effectively

 

What is Relapse?

-When the clubfoot comes back.  The muscles and tendons on the inside of the foot and calf are stronger than on the opposite side.  They tend to pull the foot back in to the clubfoot position

 

Causes

-the soft tissues have a “deforming power” causing recurrences; relapses are caused by the same pathology that initiated the deformity; regardless of the mode of treatment, clubfoot has a stubborn tendency to relapse

-it is wrongly assumed that relapse occurs because the deformity has not been completely corrected

-non-compliance with BNB, and/or a growth spurt, and/or a muscle imbalance in the foot, and/or stiff ligaments

 

Notable Age Info:

Babies and Infants: the rapid collagen synthesis immediately following birth seems to be one cause of the great tendency of the clubfoot deformity to rapidly relapse after correction in premature babies and early infancy

1-2: relapse usually occurs after 1 or 2 years of age when ossification is more advanced; this is when x-rays will be helpful

3-4: the navicular, the most displaced component of the deformity, does not ossify until the age of 3 or 4 years old

4: the ossific centers for all the foot bones do not appear until 4 years old

5: relapse is rare after 5; clinical results cannot be evaluated before at least 5 years of age when relapses become infrequent

5-6: collagen synthesis tapers down gradually until 5 or 6 years of age when collagen accretion in the ligaments is very low

6: the axes of the foot bones can be drawn accurately only after the age of 6

7-relapse is extremely rare after 7

 

Preventing Relapse

-only after the deformity is fully corrected is a bar attached to boots in 60 or 70 degrees of external rotation (this is hopefully what was achieved by the final cast,) effective in maintaining the correction, and preventing relapse (non-clubfoot 30 or 40 degrees), feet should be in 10-15 degrees of dorsiflexion and bar should be shoulder width

-post-correction braces worn for 3-4 years is an indispensable part of treatment

 

Treatment of the Relapsed Clubfoot

-relapsed clubfoot should be treated with 2 or 3 stretching casts changed every 2 weeks first, followed by a possible tenotomy when dorsiflexion of the ankle is less than 15 degrees, then, to prevent future relapse, the tendon of the tibialis anterior muscle is transferred to the third cuneiform (ATTT; tendon transfer) after the first or second relapse after the child is 2 ½ years old if this muscle tends to strongly supinate the foot

 

Who has an increased risk of relapse?

-stiff, severe clubfeet with a small calf are more prone to relapse than less severe feet

-If BNB Is not used for at least 10 hours a day (Morcuende et al) *14-16 hours is suggested after 3 months of 23 hour wear

-premature discontinuation of BNB during the maintenance phase

 

Signs of Relapse

Tightness in heel

Loss of dorsiflexion

Toe walking

Forefoot turn in

Dynamic supination in walking children

Not tolerating BNB suddenly

 

What to do if you suspect relapse

-Contact your doctor promptly for a physical exam; inquire about Physical Therapy and/or stretching exercises

 

Other

-When toddlers learn to stand, they sometimes bear weight on the outside of their foot. This might not be due to a relapse.  If the foot is still flexible and can move in to a normal position, then, given time and practice, your child will most likely figure out how to balance themselves. 

 

Stats

-90% of children relapsed in the 1st year when they discontinued brace wear

-70-80% of children relapsed in the 2nd year when they discontinued brace wear

-30-40% of children relapsed in the 3rd year when they discontinued brace wear

 

 

 

*References:  www.ponseti.info, clubfoot families, medical practitioners, The Parents’ Guide to Clubfoot by Betsy Miller, Dr. Ponseti’s Book, Congenital Clubfoot, and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4143509/

 

 

 

 

*Disclaimer*

The information compiled is from clubfoot family experiences, and the medical community. Doctors and those in the medical field have opinions that may differ. This document is not a substitute for professional medical advice. Consult your doctor with questions. Every clubfoot situation and every clubfoot child's treatment plan may differ slightly.

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