Bracing Protocol Research Articles

Healing of Acute Anterior Cruciate Ligament Rupture on 3-month MRI in 235 People Managed with the Cross Bracing Protocol

Healing of Acute Anterior Cruciate Ligament Rupture on 3-month MRI in 235 People Managed with the Cross Bracing Protocol

Non-operative treatment for ACL rupture, rehabilitation and Cross bracing protocol, have unacceptably high failure rates relative to surgical stabilisation for return to pivoting sports.

Non-operative treatment for ACL rupture, rehabilitation and Cross bracing protocol, have unacceptably high failure rates relative to surgical stabilisation for return to pivoting sports.

Proximal Hamstring Repair With All-Suture Anchors and an Accelerated Rehabilitation and Bracing Protocol Demonstrates Good Outcomes at 1-Year Follow-Up

To evaluate patient-reported outcomes and risk for rerupture after surgical treatment of proximal hamstring tendon ruptures using all-suture anchors and a unique postoperative bracing strategy. A retrospective review of a prospectively collected database was conducted of patients undergoing proximal hamstring repair or reconstruction from 2020 to 2022 at a tertiary, academic institution. Patients were included if they reached minimum 1-year follow-up and completed postoperative patient-reported outcomes. The surgical protocol for proximal hamstring repairs included all-suture anchors placed either in an open or endoscopic fashion in the ischial tuberosity. After surgery, all patients underwent an accelerated rehabilitation protocol, including 6 weeks touchdown weight-bearing in a hinged knee brace locked in extension for ambulation, allowing passive knee flexion to 90° while seated. Descriptive statistics were used to analyze the data. Twenty-one patients were included (mean age 50.4 ± 9.5 years, body mass index 24.4 ± 3.5, 66.7% female). Lower Extremity Functional Scale score achieved postoperatively was 74.2 ± 7.5 (out of 80). Patients had minimal pain (mean visual analog scale pain score of 0.9 ± 1.2). 61.9% of patients were able to return to the same level of activity after based on Tegner score by 1 year. Postoperative Single Assessment Numeric Evaluation activity of daily living was 94.3 ± 8.3, and Single Assessment Numeric Evaluation Sports was 82.3 ± 19.0. Mean Short Form Survey (SF-12) postoperative scores were 51.6 ± 6.8 for SF-12 Physical Component Score and 53.9 ± 9.7 for Mental Component Score. 95.2% (20 of 21) patients were satisfied with their outcome. There were no reruptures, infections, or reoperations. One patient of 21 (4.8%) incurred a postoperative deep venous thrombosis, which was treated with therapeutic anticoagulation for 3 months. All-suture anchors for proximal hamstring repair with a unique accelerated postoperative rehabilitation and bracing protocol result in good outcomes and patient satisfaction with minimal risk of complications. Level IV, case series, therapeutic.

Exploring Bracing Adherence in Ponseti Treatment of Clubfoot: A Comparative Study of Factors and Outcomes in Uganda.

The Ponseti method of clubfoot treatment involves two phases: initial correction, usually including tenotomy; and bracing, to maintain correction and prevent relapse. Bracing should last up to four years, but in Uganda, approximately 21% of patients drop from clinical oversight within the first two years of using the brace. Our study compared 97 adherent and 66 non-adherent cases to assess the influential factors and effects on functional outcomes. We analyzed qualitative and quantitative data from clinical records, in-person caregiver interviews, and assessments of foot correction and functionality. Children who underwent tenotomy had 74% higher odds of adherence to bracing compared to those who did not undergo tenotomy. Conversely, children from rural households whose caregivers reported longer travel times to the clinic were more likely to be non-adherent to bracing (AOR 1.60 (95% CI: 1.11-2.30)) compared to those without these factors. Adhering to bracing for a minimum of two years was associated with improved outcomes, as non-adherent patients experienced 2.6 times the odds of deformity recurrence compared to adherent patients. Respondents reported transportation/cost issues, family disruptions, and lack of understanding about the treatment method or importance of bracing. These findings highlight the need to address barriers to adherence, including reducing travel/waiting time, providing ongoing education for caregivers on bracing protocol, and additional support targeting transportation barriers and household complexities.

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol

ObjectiveInvestigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP).MethodsEighty consecutive patients...

Elimination of a Postoperative Brace Does Not Increase Complications Following Hip Arthroscopy.

Background The practice of routine postoperative bracing to limit abduction and internal rotation, along with weight-bearing restrictions after hip arthroscopy (HA), varies significantly among surgeons. It is unclear whether the use of a postoperative brace improves short-term outcomes in patients undergoing HA. The purpose of this study was to determine the differences in patient outcomes before and after eliminating routine usage of a postoperative brace. Methods A retrospective review was conducted of 176 adult patients undergoing HA by a single, high-volume surgeon. The no-brace protocol was implemented in October 2020. The patients were divided into two groups: pre-implementation (January-October 2020) and post-implementation (October 2020-April 2021). Twenty-three patients that used a brace during the post-implementation period were excluded. All patients had weight-bearing restrictions with crutches for three weeks postoperatively. The primary endpoint was any complication in the first sixweeks postoperatively. Results There were no significant differences in demographics between groups, although the body mass index in the brace group was higher (28.1 vs. 26.4 kg/m2, p = 0.066) and the rate of additional procedures performed was higher in the brace group (55.2% vs. 40.1%, p = 0.056). There was no significant difference in postoperative outcomes between groups when looking at 90-day emergency department visits (1.7% vs. 0%, p = 0.548), complications at two (1.7% vs. 1.7%, p = 1.000) and six weeks (0% vs. 1.7%, p = 0.341) postoperatively, all complications in the first six weeks (1.7% vs. 1.7%, p = 1.000), and continued pain at six weeks (10.3% vs. 16.7%, p = 0.238). Conclusion The brace and no-brace groups were similar demographically. Patients undergoing HA with no brace and crutches experienced no significant differences in pain or complications in comparison to those receiving a traditional bracing protocol. Routine use of a postoperative brace may not be necessary in this population.

A Novel Non-Surgical Bracing Protocol May Facilitate Healing Of Anterior Cruciate Ligament Rupture And Improve Clinical Outcomes

A Novel Non-Surgical Bracing Protocol May Facilitate Healing Of Anterior Cruciate Ligament Rupture And Improve Clinical Outcomes

Healing of a ruptured anterior cruciate ligament and patient-reported outcomes following non-surgical management with a novel bracing protocol

Introduction: A common belief amongst clinicians, researchers and the public is that a ruptured anterior cruciate ligament (ACL) has no healing capacity. This belief has contributed to the high rate of ACL reconstruction, with substantial health costs. We hypothesised that immobilisation in a knee brace at 90-degrees flexion (reducing the distance between the torn ends of the ACL) after acute ACL rupture would facilitate healing. The objective was to investigate MRI evidence of ACL healing, patient-reported outcomes and knee laxity in the first 80 individuals with ACL rupture managed with a novel non-surgical bracing protocol.

Sensor based braces: Challenges ahead

Sensor based brace is a new technology driven initiative to address the adherence issues associated with clubfoot treatment. It encompasses various engineering fields (sensors, batteries, data transfer) to measure precise brace wear timings. Still in preliminary usage, yet they have lead to several significant findings; foremost being that caretakers tend to over report their brace usage. Enhanced surveillance and reinforcements is thus possible with sensor devices as defaulters can be picked up early. The introduction of these devices in common practice is postulated to lessen relapse rates by upto 40%. However, many challenges obscure the path of newer braces. Robust study designs and longer follow up is lacking in majority of studies detailing sensor based clubfoot braces. None of the currently available studies demonstrate effectiveness of patient interventions/changes based on the research data. Behavioral changes in caretakers may be difficult to achieve and could require repeated reinforcements. Since braces need to be worn for prolonged periods in clubfoot treatment, sensor data generated per patient would be colossal. It's processing and interpretation would be an uphill task. The cost of advanced inventory may burden ongoing clubfoot care programmes in low income countries. There is also a possibility that the newer technology may tone up the bracing protocol into a highly sophisticated and supervised medical intervention rather than a simplified maintenance phase. Till further development and evidence, sensor based clubfoot braces may find their initial application for high risk groups susceptible to relapse.

Treatment of infantile idiopathic scoliosis using a novel thoracolumbosacral orthosis: a case report

BackgroundThe recommended treatment for mild to moderate infantile idiopathic scoliosis curves involves serial casting. There are concerns, however, regarding the safety of repeated casting in very young children owing to the requirement for anesthetization during the casting process. Very little research has been conducted on the influence of bracing as an initial treatment for scoliosis in this age group. This report details the successful treatment of a large thoracic curve using a thoracolumbosacral orthosis in an infant diagnosed with infantile idiopathic scoliosis.Case presentationThe Dutch-Australian patient presented at 11 weeks of age with a 44° thoracic scoliosis and a rib vertebral angle difference of 14°. The history and physical examination failed to reveal a cause of the curvature, and a diagnosis of infantile idiopathic scoliosis was made. The patient was prescribed a thoracolumbosacral orthosis (ScoliBrace) to be worn on a part-time basis for a period of 8 months. At the end of the bracing program, the patient’s curve had been reduced to 7° and a rib–vertebral angle difference of 0°. A final follow-up of the patient at 2 years after the cessation of treatment revealed no evidence of scoliosis. The parents were compliant with the bracing protocol and reported that the treatment was tolerated by the infant.ConclusionThe use of an orthosis as a standalone treatment in this patient resulted in significant reduction in a large thoracic scoliosis. Based on the results witnessed in this patient, further investigation into bracing as an alternative to casting is warranted.

Two-year retrospective cohort results on use of a dynamic unilateral brace for treatment of clubfoot: Can compliance and prevention of recurrence both be achieved?

ObjectivesThe Ponseti method has led to vast improvements in outcomes for infants born with clubfoot deformity, but challenges with compliance during the bracing phase of the protocol remain. Unilateral braces promise higher compliance but often have led to unacceptably high recurrence.MethodsWe have developed a novel unilateral brace for clubfoot deformity that strategically applies patient-specific, anatomically-targeted forces to the lower limb to maintain correction. We retrospectively reviewed the cases of 26 patients with minimum follow-up of 24 months. The data were analyzed for recurrence rates, caregiver-reported compliance, and differences in Pirani score, dorsiflexion, abduction, hindfoot eversion, and resting rotation between initial and final follow-up.ResultsMost patients (N = 23, 88%) were compliant with the bracing protocol. Two patients showed recurrence of deformity (8%). There were statistically significant improvements in Pirani score, dorsiflexion, abduction, hindfoot eversion, and resting external rotation. A subset of patients with sub-optimal correction at baseline showed improvement in all parameters across the course of bracing.ConclusionsThis novel unilateral brace for maintenance of clubfoot correction after Ponseti treatment demonstrates rates of recurrence rates and caregiver-reported compliance at 2 years of follow up that are comparable to outcomes with traditional bilateral foot abduction orthoses.

Clinico-Radiological and Functional Outcome of Difficult Talipes Equinovarus Deformity Corrected With an Ilizarov Fixator

Relapsed, resistant, and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical, and functional outcomes, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant, or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological, and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 ± 3.6 (range 4-17) years. The postoperative clinical, radiological, and functional scores showed statistically significant improvement among all patients when compared with the preoperative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favorable outcome.

Prognostic factors for recurrent idiopathic clubfoot deformity: a systematic literature review and meta-analysis

Background and purpose — After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods — PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results — 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30–2,190), brace non-compliance (OR = 10, CI 5–21), no additional stretching (OR = 31, CI 10–101), more casts (OR = 3.5, CI 1.6–7.8), lower education level of parents (OR = 1.8, CI 1.2–2.6), non-marital status of parents (OR = 1.8, CI 1.1–3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2–3.3) were associated with higher recurrence rates. Interpretation — Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.

Clubfoot: current concept of treatment

Introduction Idiopathic clubfoot (IC), also referred to as congenital talipes equinovarus, is one of the most common lower limb deformities observed in newborns, leading to significant functional impairment when left untreated. Early minimally invasive treatment has been praised as one of the most successful practice of modern pediatric orthopedics. This review aims to report current knowledge and controversies about clubfoot treatment. Material and methods We describe the main trends in clubfoot managing, identifying peculiarities, difficulties and prognostic factors related to the treatment. Results Many treatment techniques either conservative, surgical or hybrid have been used over the past decades. Based on good and excellent results during long-term follow-up, Ponseti method has been globally accepted by paediatric orthopaedic surgeons as standard method of treatment. However, some other conservative methods are still widely applied in the clinical setting, such as the French Physical Therapy method. Adherence to the bracing protocol is critical for the long-term success of the treatment, being a better predictor for relapse than severity of the deformity at birth. Conclusions Taking care of the manipulation and casting details by trained professionals, together with enhancing the child and patents’ adherence to the brace, are essential for the success of conservative treatment. Surgery should be performed only when strictly needed, preferably on a “a la carte” approach.

Flat Top Talus: Complication of Ponseti Method or Overcorrection?

PurposeDeformation of talus in idiopathic clubfoot is a common problem both surgically and after treatment with the Ponseti technique, although the cause of deformation and its clinical impact on the function of the ankle is not yet known. The goal of this research was to evaluate factors leading to talar dome deformation (flat-top talus) after the Ponseti techniqueMethodsThis was a single-center, cross-sectional study. Fifty patients with virgin idiopathic clubfoot were enrolled from our consecutive series of data from August 2017 to January 2018 from our clubfoot patients who completed their casting and bracing protocol. Weight-bearing lateral X-rays of the ankle were examined in patients to determine the flattening of the talus dome and its correlation with age, sex, BMI, number of casts, and casting period. In these patients, the frequency of tenotomy and its relationship to the flat top talus was also examined.ResultsThe study included a total of 50 children, of which 36 (72%) were boys and 14 (28%) were girls. The mean age, height, weight, and BMI of the children were 5.06 ± 0.79 years, 101.6 ± 6.34 cm, and 19.7 ± 1.57 kg, respectively. No significant difference between the normal and flat top talus category was found in age and BMI (p=0.611 and 0.997, respectively). Whereas, relative to normal children, the children who had flat-top talus were on casts for a longer period of time (median: 9 vs. 6 weeks, p=0.026). In addition, a higher proportion of children with more than six casts developed flat-top talus than those with fewer than six casts (69.2% vs. 30.8%, p=0.005). After treatment, a total of 13 (26%) patients developed flat top talus, of which 11 (84.6%) were boys and two (15.4%) were girls (p=0.303). No substantial association between tenotomy and flat top talus (p=0.340) could be identified.ConclusionFlat top talus is a complication of improper manipulation specifically correlated with the number of Ponseti casts applied. Maintenance of cast treatment for more than three months may result in flat-top talus with no significant association with tenotomy of the tendoachilles.

Delayed ossification and abnormal development of tarsal bones in idiopathic clubfoot: should it affect bracing protocol when using the Ponseti method?

PurposeTo point out the need to take into account the dysplastic nature of tarsal bones when treating idiopathic clubfoot (CF).MethodsReview the published evidence on the developmental abnormalities of tarsal bones in idiopathic CF.ResultsThe literature review provides abundant proof of the existence of delayed appearance and slower development of ossification centres of tarsal bones in idiopathic clubfoot.ConclusionGentle manipulations and casting are the cornerstone of the Ponseti method. The biological response of all foot elements is critical for a successful outcome. Delayed ossification and abnormal development of tarsal bones in idiopathic CF may affect the results. Development of a personalized tailored bracing protocol based on severity assessment and response to casting treatment will improve results and quality of care in CF management.Level of EvidenceV

Results of Modified Ponseti Technique in Difficult Clubfoot and a review of literature

IntroductionSerial Ponseti casting achieves deformity correction in early presenting idiopathic clubfoot cases normally in around 7 casts. However, there are resistant patients where correction requires more casts than usual. In such patients a modification in standard technique might be required right from the beginning. Such patients were collectively called as difficult clubfoot. The aim of this study was to assess the outcome of our modification to Ponseti technique in difficult clubfoot. MethodsAll idiopathic clubfoot cases who were 75th percentile or more in WHO age for weight chart (chubby infants) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age (late presenters and neglected cases) were included in the study. Patients who had been previously surgically intervened elsewhere, patients over 7 years of age, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study. The patients were treated by early tenotomy of tendoachillis and a plantar fascia release before starting serial casting by Ponseti technique. Post correction, strict bracing protocol was followed with regular follow up. Pirani scoring was done at each stage. Measurement of Talocalcaneal angle on AP radiograph, maximum degree of abduction and dorsiflexion was noted once every year. ResultsThere were total 28 patients in our study. In all, 47 feet were subjected to modified Ponseti protocol. There were 21 male patients. Median age at presentation was 4 months. Mean centile of weight for age as per WHO growth chart was 64. Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Mean number of casts required for correction was 3.75 ± 1.10. Maximum followup period was 25 months. ConclusionThis modification of Ponseti casting for difficult clubfoot patients achieves correction in shorter duration with less number of casts.

Effectiveness of Compressive External Bracing in Patients with Flexible Pectus Carinatum Deformity: A Review.

There has been a growing interest in the nonoperative treatment of chest wall deformities over the last few decades; with the advent of external compressive orthotics, similar outcomes have been reported compared with surgical intervention. There have been fewer major complications reported with dynamic compression bracing on the chest wall; however, the Achilles heel of this approach still lies with treatment tolerability and compliance. A Medline literature search was undertaken to evaluate the evidence concerning the techniques, modifications, and outcomes associated with external compressive bracing in the setting of pectus carinatum. Sixteen articles were integrated after literature review and data were collected on methods of assessing pectus carinatum (degree of severity as well as type), patient selection protocol (i.e., suitability for external compressive bracing), the bracing protocol itself, duration of treatment, metrics used to assess outcome, and success, compliance, and dropout rate, and length of long-term follow-up. Compressive external bracing appears to be a safe and well tolerated nonsurgical treatment option for young patients with flexible pectus carinatum deformities. However, there is still a need for robust level I randomized data from multiple centers with a clearly standardized bracing protocol, objective measurement of outcomes, and recording of results at the end of the bracing treatment program in sufficiently powered sample sizes over a significant follow-up period.

The Ponseti method of clubfoot treatment in walking age children: is it effective? A study of 56 children from 1 to 10 years of age

The Ponseti method is well-established for the treatment of clubfoot in younger babies; however, its effectiveness in older children is still unclear. The aim of our study was to report our results of the 'traditional' Ponseti method in the management of clubfoot in children of walking age. A total of 56 (81 clubfeet) children with a mean age of 3.16±2.35 years (1-10 years) were divided into two groups: group I consisted of 12 (18 clubfeet) patients with a mean age of 3.36±2.7 years (range: 1-8.4 years) who presented with an untreated clubfoot whereas group II consisted of 44 (63 clubfeet) patients with a mean age of 3.19±2.34 years (range: 1-10 years) who presented with a recurrent clubfoot. All children underwent the standard manipulation and casting technique described by Ponseti, including a percutaneous tenotomy of the Tendo Achilles. The bracing protocol was modified appropriately. All feet corrected with a mean of 7.36 (3-17) casts in group I and 4.49 (1-12) casts in group II. All children in group I and 70.45% in group II underwent a percutaneous Tendo Achilles tenotomy. There was a statistically significant change between the pretreatment and post-treatment Pirani scores in both groups. Nineteen (30.86%) patients underwent relapse at a mean follow-up of 2.84±1.25 years (1.2-5.4 years), who were treated by re-casting, bracing and tibialis anterior tendon transfer. The Ponseti method is effective even in walking age children upto the age of 10 years with a good success rate, although approximately one-third of the clubfeet relapsed and needed further treatment. No modifications to the standard casting protocol are required. Despite a high relapse rate, a supple, plantigrade and pain-free foot is achievable without the need for extensive soft-tissue surgeries or bony procedures. The Ponseti method lends itself well to developing a nation-wide program for clubfoot treatment in countries with limited resources. Level of Evidence: Level III.

Relapse following use of Ponseti method in idiopathic clubfoot.

PurposeWe assessed the pattern of relapse as well as the correlation between the number of casts required for correction and Pirani and Dimeglio scores at presentation, and age at presentation. We hypothesized that the Ponseti method would be effective in treatment of relapsed clubfoot as well.MethodsWe evaluated 115 idiopathic clubfeet in 79 children presenting with relapse following treatment by the Ponseti method. The mean age was 33.8 months with mean follow-up of 24 months. All patients were assessed for various patterns of relapsed deformities. Quantification of deformities was done using the Pirani and Dimeglio scores. All relapsed feet were treated by a repeat Ponseti protocol.ResultsNon-compliance to a foot abduction brace was observed to be the main contributing factor in relapse, in 99 clubfeet (86%). Combination of three static deformities (equinus, varus and adduction) together was observed most commonly (38.3% feet). Overall, relapse of equinus deformity was noted most commonly followed by adduction. A painless plantigrade foot was obtained in all 115 feet with a mean of five casts. In all, 71 feet (61.7%) underwent percutaneous tenotomy. A total of 15 feet (13%) required tibialis anterior tendon transfer. Re-relapse rate in group 1 was 21% compared with 12.6% in group 2 and overall 16.5%.ConclusionWe conclude that the Ponseti method is effective and the preferred initial treatment modality for relapsed clubfeet. Surgical intervention should be reserved for residual deformity only after a fair trial of Ponseti cast treatment. Regular follow-up and strict adherence to brace protocol may reduce future relapse rates. Further research is required to identify high-risk feet and develop individualized bracing protocol.Level of evidence:IV