A 6-month-old female infant is brought to the orthopedic clinic by her mother. The child was born with bilateral clubfeet and was treated with Ponseti casting from age 2 weeks. Serial casts were applied weekly for 8 weeks, followed by a percutaneous Achilles tenotomy at 8 weeks of age. The feet now appear well-corrected on clinical examination. However, the mother reports poor compliance with the Denis Browne abduction brace, wearing it only 4–5 hours per day instead of the recommended 23 hours per day. What is the most likely consequence of this non-compliance?

Explanation

## Relapse in CTEV: Role of Maintenance Bracing **Key Point:** The Denis Browne abduction brace (or similar foot abduction orthosis) is not optional — it is essential to prevent relapse after successful Ponseti casting and tenotomy. Non-compliance is the leading cause of recurrence. ### Phases of CTEV Management and Relapse Risk | Phase | Duration | Goal | Relapse Risk if Skipped | |-------|----------|------|------------------------| | **Casting** | 6–8 weeks | Achieve anatomic correction | High | | **Tenotomy** | Single event | Release equinus contracture | Moderate | | **Maintenance Bracing** | 3–4 years | Prevent soft tissue recontraction | **Very High** | **High-Yield:** Relapse rates are 10–15% with adequate brace compliance (>20 hours/day) but rise to 40–60% with poor compliance (<10 hours/day). ### Mechanism of Relapse 1. **Intrinsic Muscle Imbalance** — The tibialis posterior and medial foot muscles remain relatively stronger than the peroneal muscles 2. **Soft Tissue Memory** — Even after correction, the shortened medial capsule and ligaments retain contractile tendency 3. **Growth-Related Recontraction** — During childhood growth, uncorrected muscle imbalance reasserts the deformity 4. **Inadequate Bracing** — Without sustained abduction positioning, the foot drifts back into inversion and adduction ### Clinical Presentation of Relapse - **Early relapse** (months 6–12): Gradual loss of abduction, return of inversion - **Late relapse** (years 1–3): Progressive equinovarus recurrence, often subtle - **Signs**: Inversion of sole, medial deviation of forefoot, plantarflexion worsening **Clinical Pearl:** Relapse is insidious and often goes unnoticed by parents until the deformity becomes visually obvious. Regular orthopedic follow-up at 3, 6, 12, 24, and 36 months is essential to detect and intervene early. ### Management of Relapse ```mermaid flowchart TD A[Relapse detected]:::outcome --> B{Severity?}:::decision B -->|Mild| C[Reinitiate bracing<br/>+ physiotherapy]:::action B -->|Moderate| D[Short course of<br/>repeat casting]:::action B -->|Severe| E[Surgical correction<br/>posteromedial release]:::urgent C --> F[Increase brace hours<br/>to 23 hrs/day]:::action D --> F E --> G[Reassess at 3 months]:::outcome ``` **Warning:** Relapse does not spontaneously resolve with growth. Delayed recognition and intervention make subsequent correction more difficult and may necessitate surgery.