A Conversation Regarding FAB Use


        FAB, noun; abbreviation for Foot Abduction Brace,
    "shoes on a bar" ; a clubfoot brace as used in the Ponseti
    Method Treatment Plan; also known as a DBB.


    I will try to give you FAB wear tips here, however, there is a lot to
    say about this subject and much to know before you can
    understand why it works, and how important wearing the foot
    abduction brace is to your child.

    Regarding the use of the FAB there is one law of physics you
    need to know.  With out proper use of the FAB, your child’s
    clubfoot/feet will relapse.   No If's And's or But's about it.

     Dr. Ponseti says he does 20% of the treatment with his casts but
    the parent does the remaining 80% with the FAB usage at home.  
    The best casting treatment in the world will be for naught if it is not
    maintained with a FAB.

    Which brings us to Point #2:  There are doctors and parents who
    misinterpret the use of the foot abduction brace, believing the
    FAB gives correction, much like a cast.   This is wrong.  The FAB
    does not give, it maintains.  That is a big difference yet a very
    key point to keep in mind.

    Over the years we have narrowed down three main reasons for
    FAB failure.  They are:  

    1)  The FAB is not set up correctly prior to use.    
    2)  The feet are not corrected fully, thus they are not ready for      
    FAB wear; and
    3)  Misinformation on the part of both parents and doctors.


    1.        Setting the FAB up correctly is paramount to success.  
    Wearing the wrong adjustment twenty three hours a day for three
    months will not work.  It will cause pain and suffering and relapsed
    conditions for the child.

    2.        Putting a FAB on a baby’s feet when those feet are not
    fully corrected likewise will result in failure, at the cost of pain,
    suffering and relapsed conditions for the child.

    3.        Misinformation leads to FAB’s being set up incorrectly or
    applied incorrectly whether the feet are corrected or not.

Let's examine each of these three points in more detail:

    1)  FAB set up incorrectly:   Believe it or not, there are doctors
    and brace specialists who know less about this than you do!  Yet
    these are the professionals who are advising and instructing
    you….   We as parents must use this thing,  and our children must
    wear it,  therefore it stands to reason we must be educated  
    regarding its use.

    Briefly, there are two styles of braces popularly used in clubfoot
    treatments:  They are the Markell (white shoes on a red or a gold
    bar), and the Mitchell's (leather sandals on an adjustable
    aluminum bar).   They work on the same principal with only one
    minor difference.   The Markells are set to 70 degrees while the
    Mitchells are set to 60 degrees (of outward rotation).   The photo
    to your right of my baby Garrison in his Mitchell FAB shows how
    the toes are pointed outwards - that is the outward rotation.   A
    clubbed foot set to less rotation will likely suffer relapse, or at
    least a decreased rate of success in the end.

    The shoes on your clubfoot brace should be shoulder width
    apart.  Again, misinformation haunts this fact.  The actual
    heel of the shoe is not the actual heel of the child’s foot inside the
    shoe.  Make sure the child’s heels are shoulder width apart, not
    just the exterior of the shoes.   In the event of  confusion, err on
    the side of being too wide, not too narrow.  A good rule of thumb
    is to simply lay the brace on the floor, then lay your child on top of
    it, so the child's shoulders are between the shoes.  If it's a snug
    but not cramped fit, you're good.  If it's too tight, or has a lot of
    room left over, the bar needs to be adjusted.

    Too narrow of a bar is probably the #1 reason babies cry
    and carry on in their brace - it is literally painful to have the
    feet too close together.

    If your baby has been wearing the foot abduction brace well for
    some time and suddenly objects to it, kicks a lot, flops in the bed,
    cries for no apparent reason - check the width of the bar, it is
    likely the child grew, making the bar too narrow.

    2)   Feet Not Corrected:   No amount of FAB wear will
    correct a deformed foot.   Wearing shoes on a deformed foot
    will lead to blisters, pressure sores, infections, sleeplessness, loss
    of appetite, inconsolable crying, failure of the baby to thrive,
    failure to bond, lack of wear, divorce, abuse and eventual relapse
    leading to further casting if you are lucky, and surgery if your are
    unlucky.

    Any doctor proposing to put a FAB on an uncorrected foot
    in an attempt to “finish” correcting the foot should be
    avoided at all cost.     I  can not stress enough that the foot
    abduction brace is designed to MAINTAIN correction
    achieved through serial casting, it is NOT designed to give
    correction to an un-corrected foot!

           
    3)  Misinformation:   This heading is wide open as the variety of
    misinformation parents can get is as varied as the parents
    themselves.   

    If you are misinformed, your FAB may be set up wrong.  

    Misinformed parents will put a FAB on an un-corrected foot;

    Nisinformed parents will put a FAB on a perfectly corrected foot
    wrong, leading to serious problems, i.e. blisters, pressure sores,
    etc. leading to a relapsed condition requiring further casting
    treatments.

    A shoe applied incorrectly to the child is going to slip.  
    A shoe that slips leads to sores.  
    Sores lead to pain.  
    Pain leads to crying.  
    Crying leads to the parent taking the damn shoe off the
    child to get some rest.  
    Taking the shoe off leads to relapse.
    Relapse leads to more casting followed again by the FAB.  

    It’s a vicious cycle once it starts, so try to use it right from the very
    start to avoid a lot of trauma to both your child and yourself.

    The heel must be seated deeply in the shoe.  There are a
    couple tips to help a new parent achieve this:

    A.  Remove the laces of your Markell style shoe, open the shoe
    up wide, insert the child’s foot with a sock on and plant it deeply in
    to the heel pocket of the shoe while bending the knee to 90
    degrees and pushing the ball of the foot up slightly to achieve
    good dorsiflexion (stretching the heel tendon).  Use an ink
    pen to mark the edge of the toes, drawing a line on the shoe
    where the toes reach to when the foot is completely in the shoe.   
    Now when you apply the shoe with laces, the child's toes should
    be behind that line you made.

    B.  Cut a hole in your Markell style shoe, a “window” at the heel to
    see if the heel is seated or not.

    If using the Mitchell shoes, the hole is already there and you
    can clearly see if the heel is seated or not.  A word of CAUTION
    though - it is very typical that when you first begin using a
    Mitchell shoe, the heel will NOT seat completely.  This is
    completely normal for the Mitchell shoe ONLY, as long as
    the straps are buckled very snug and the foot is pushed
    back as far as it can go there will be no ill effects and soon
    the heel will seat nicely.

    If the foot continues to slip in either style of shoe, creating sores
    or blisters, look further.
    A) The shoe is the   wrong size.
    B) the foot is not ready for the shoe.
    C) the bar is the wrong length
    D) you are not strapping it on tight enough.

    This all brings us to one last detail:  if you are having problems
    with the FAB, at least you are trying to use it.  The Number ONE
    reason clubbed feet relapse is PARENTAL NON-COMPLIANCE - a
    fancy term meaning parents just don't use the darn thing.

    With out a brace (or with the wrong kind of brace) your child’s
    clubfeet/foot will relapse.  No “maybe”…it WILL.   Using it
    according to Ponseti Protocol is completely necessary if you
    expect your child to enjoy life long results of this treatment!

    A quick note on FAB’s vs. AFO’s or KAFO’s, etc:    Some
    doctors prescribe what is known as an AFO or a variation known
    as a KAFO, DAFO, etc.  These are not designed for clubfoot
    correction and do NOT maintain correction.  They have no place
    whatsoever in the Ponseti Method of Clubfoot Treatment - or
    in any clubfoot treatment under normal circumstances.

    The reason being this:  to maintain correction the clubbed
    foot/feet must be held at an outward rotation of 60 to 70 degrees,
    with a dorsiflexion of 10 to 15 degrees.   

    An AFO cannot do this anymore than an Army boot could.  An
    Army boot would be  just about as effective, in fact.

    It is the bar on the FAB that facilitates these angles and
    degrees.  Even if your child only has one clubbed foot, he or she
    still must wear a FAB (with the bar!)  to maintain the correction,
    however the non-clubbed foot will be set at approximately 30 or
    40 degrees instead of the full 60-70.   With out the bar holding
    the feet, stretching the necessary muscle / tendon mass,
    the foot will relapse.  

    If you and your child continue to have problems with FAB wear, I
    highly recommend that you join the nosurgery4clubfoot group,
    detailing your treatment history and current situation so the
    thousand plus members there can help you sort it out.

    Happy Feet!

    Shawnee and Family
FAB Wear Tips:
How to Make Wearing the Foot
Abduction Brace (FAB) a Success.
    Statistics from
    the Ponseti
    Clubfoot Clinic
    in Iowa :

    ".... in our experience,
    (children who do not use
    the FAB properly) the
    rate of relapse is almost
    100% in the first year of
    life;

    80-90% in the second
    year;

    50-60% in the third year;

    15-20% in the fourth year,


    5-10% in the fifth,

    and 6% afterwards."


    In short, don't cheat on
    FAB wear or you'll only
    cheat your child out of
    good feet.
"My FAB is fun!"  says Everett.  
Don't try this at home!
Hey Kids!  
Wearing this brace ain't so bad!
MD Orthopaedics, Inc.

Makers of the Ponseti
Clubfoot Brace Mentioned on
this Website and worn by my
own children.

The Ponseti FAB
by John Mitchell
For Further Information, I
recommend you read
"A Parent's Guide To The
Foot Abduction Brace"

Everything You Need to
Know About Using the FAB
Right Here!

By Kori Rush and Naomi Powell
Markell clubfoot shoe with hole cut in it.
This Markell style foot abduction
brace shoe has a large hole cut
in the heel to let a pressure sore
(caused by the shoe) heal up.  
The hole also lets the parent see
if the heel is completely seated in
the shoe or not.

Some parents who do not need to
let a sore heal but do need help
seeing if the heel is seated will
drill a small hole through the
shoe with a large drill bit.
AFO clubfoot brace
AFO clubfoot brace
These two photos of Garrison
wearing an AFO clubfoot brace
demonstrate why the AFO is not
effective - notice how the feet are
free to move with no bar to
stabilize them.  Thumbnail
photos, click to enlarge.
The Ponseti Bracing
Protocol:

Typically speaking, if there
are no factors complicating
the case such as atypical,
loose ligaments, or an older
child who has been treated
with a non-Ponseti technique
to begin with, children
"should wear the brace
23 hours a day for 2 ½ to 3
months and then go to 20
hours a day for a month,
then 18 hours a day for a
month, then 16 hours a
day."

I.V. Ponseti, M.D.