BRACING COMPLICATIONS IN IDIOPATHIC CONGENITAL TALIPES EQUINOVARUS

Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. We noted a moderate number of patients in our clubfoot population in a large hospital who had pressure sores with brace wear, particularly after an institutional change from Markell to Mitchell Boots. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. Retrospective analysis of medical files from 247 idiopathic clubfoot patients (374 clubfeet) was performed after identification tthrough the electronic medical record and institutional database. Inclusion criteria included patient date of birth between January 1, 2010 and January 1, 2021, a primary diagnosis of idiopathic clubfoot in infancy as well as an assessment by one of our clinicians in our paediatric clubfoot team prior to fitting the patient for boots and bar orthosis. Clinical audit met criteria for ethics exemption through our institutional review board. RedCap database was created for this study. Chart reviews were performed between October 2021 and April 2022. Patients were excluded if they had orthotics management elsewhere. Primary achilles tenotomy was performed in 92% of patients; five percent of those patients required a revision achilles tenotomy in infancy. Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 23% of Mitchell boot and 13% of Markell boot patients (X2 = 6.9, p=0.009). Mean age pressure sores of sufficient severity for clinician to recommend time out brace was 8.1 months (SD 8.6 months). The overall rate of bracing complications was 51%. Thirty-three percent of parents admitted to bracing non-compliance and 31% of patients required re-casting during the bracing period for relapse. Thirteen percent of patients had behavioural intolerance which led to admitted parental early abandonment of bracing. For patients with a minimum follow-up to age 6 years, 44% required tibialis anterior tendon transfer. Parents admitting to non-compliance with brace wear or recommended bracing hours were significantly more likely to have a child who required tibialis anterior tendon transfer (X2 = 5.7, p=0.017). Overall rate of capsular release (posteromedial release or posterior release) was two percent. Globally, few publications describe specific bracing complications in clubfoot, despite this being a notable challenge for clinicians and families. Recurrent pressure sores is a persistent complication with the Mitchell boots for patients in our centre. In our population of CTEV patients, tibialis anterior tendon transfer for relapse is common, consistent with the upper limit of tibialis anterior tendon transfer rates reported globally.