<!-- PERSPECTIVE --> Clubfoot is one of the most common birth defects. Two hundred thousand babies are born with clubfoot each year, and left untreated, they will be subjected to a life of pain and disability. The Ponseti method is the standard treatment globally. Serial casting of the infant's feet during the first six to eight weeks of life is followed by positioning the feet in an externally rotated position using reverse last footwear attached to a bar; a tenotomy is often performed as well. The Ponseti method has satisfactory results, but can be problematic, particularly in less-resourced countries with limited access to healthcare. Casting requires significant weekly travel, maintaining consistent hygiene can be difficult, and fixing the feet to a bar is often poorly tolerated by the child and resisted by parents, making compliance an issue. The French functional method, a lesser known but effective technique, uses extensive stretching and taping of the foot between clinic appointments, making it labor intensive and requiring parental training. Twelve years ago, I was approached by an orthopedist seeking a solution for clubfoot that caregivers would find more acceptable than the boots and bar method. This started a journey that has culminated in a radically different approach with excellent early results. I set out to create a brace that would recreate the French technique, but uses a plastic brace to duplicate the dynamic stretching, allowing for full-time management of the condition. Since then, I have developed a low-tech, open source brace that requires about $12 in materials and allows movement in any plane. At rest, the foot is dynamically connected to the thigh-the foot is externally rotated, abducted, and dorsiflexed with a spiral of plastic. The child is free to roll over, crawl, or walk. The brace is now modular, so adjustments can allow it to continue to fit over six to nine months as the infant grows. Two sizes take the baby from casting to completion in about 24 months-a third of the treatment time required with the Ponseti method. Using the same spiral brace concept, I developed a third brace that can replace Ponseti casting for a newborn. My daughter, Jordan, while studying healthcare delivery in Africa, decided she wanted to bring this treatment to Kenya. Her initiative attracted the attention of CURE International, a volunteer-based group that works to correct clubfoot globally, providing care for 20,000 babies every year using the Ponseti method. Excited about the potential for a modular, reusable brace that could be fabricated locally and inexpensively, CURE invited us to initiate a trial. Using money that Jordan raised from fundraisers, she and I traveled to Kijabe Hospital, Kenya. We brought materials and fabrication forms and taught local orthotists how to fabricate and fit the brace, and follow up on the treatment. It was fascinating melding our techniques with their technology. For example, they vacuum form AFOs but use small pieces of broken glass to smooth the edges. Our initial trial involved six babies and has recently been expanded to include 60 more. Going to Kijabe with my daughter was an overwhelming experience; so many things had come together unexpectedly along the way so that this simple idea could eventually make such a huge difference. <em>Jerald Cunningham, CPO, is the owner of Cunningham Prosthetic Care, Wells, Maine. Images, discussions, and a video link showing the brace can be found at <a href="https://opedge.dev/4076">www.cunninghamprostheticcare.com/clubfoot-bracing</a>.</em>
<!-- PERSPECTIVE --> Clubfoot is one of the most common birth defects. Two hundred thousand babies are born with clubfoot each year, and left untreated, they will be subjected to a life of pain and disability. The Ponseti method is the standard treatment globally. Serial casting of the infant's feet during the first six to eight weeks of life is followed by positioning the feet in an externally rotated position using reverse last footwear attached to a bar; a tenotomy is often performed as well. The Ponseti method has satisfactory results, but can be problematic, particularly in less-resourced countries with limited access to healthcare. Casting requires significant weekly travel, maintaining consistent hygiene can be difficult, and fixing the feet to a bar is often poorly tolerated by the child and resisted by parents, making compliance an issue. The French functional method, a lesser known but effective technique, uses extensive stretching and taping of the foot between clinic appointments, making it labor intensive and requiring parental training. Twelve years ago, I was approached by an orthopedist seeking a solution for clubfoot that caregivers would find more acceptable than the boots and bar method. This started a journey that has culminated in a radically different approach with excellent early results. I set out to create a brace that would recreate the French technique, but uses a plastic brace to duplicate the dynamic stretching, allowing for full-time management of the condition. Since then, I have developed a low-tech, open source brace that requires about $12 in materials and allows movement in any plane. At rest, the foot is dynamically connected to the thigh-the foot is externally rotated, abducted, and dorsiflexed with a spiral of plastic. The child is free to roll over, crawl, or walk. The brace is now modular, so adjustments can allow it to continue to fit over six to nine months as the infant grows. Two sizes take the baby from casting to completion in about 24 months-a third of the treatment time required with the Ponseti method. Using the same spiral brace concept, I developed a third brace that can replace Ponseti casting for a newborn. My daughter, Jordan, while studying healthcare delivery in Africa, decided she wanted to bring this treatment to Kenya. Her initiative attracted the attention of CURE International, a volunteer-based group that works to correct clubfoot globally, providing care for 20,000 babies every year using the Ponseti method. Excited about the potential for a modular, reusable brace that could be fabricated locally and inexpensively, CURE invited us to initiate a trial. Using money that Jordan raised from fundraisers, she and I traveled to Kijabe Hospital, Kenya. We brought materials and fabrication forms and taught local orthotists how to fabricate and fit the brace, and follow up on the treatment. It was fascinating melding our techniques with their technology. For example, they vacuum form AFOs but use small pieces of broken glass to smooth the edges. Our initial trial involved six babies and has recently been expanded to include 60 more. Going to Kijabe with my daughter was an overwhelming experience; so many things had come together unexpectedly along the way so that this simple idea could eventually make such a huge difference. <em>Jerald Cunningham, CPO, is the owner of Cunningham Prosthetic Care, Wells, Maine. Images, discussions, and a video link showing the brace can be found at <a href="https://opedge.dev/4076">www.cunninghamprostheticcare.com/clubfoot-bracing</a>.</em>
