Idiopathic congenital talipes equinovarus is a common congenital musculoskeletal deformity characterized by cavus, adduction, varus and equinus. The modern treatment objective is a painless, plantigrade, flexible and functional foot while minimizing extensive soft-tissue surgery. The Ponseti method—serial manipulation and casting, followed when necessary by percutaneous Achilles tenotomy—has become the standard conservative approach because it provides high rates of initial correction and substantially reduces the need for extensive corrective surgery.[1–4] The Ponseti protocol consists of two conceptually distinct phases: correction and maintenance. After correction has been achieved, a foot-abduction brace (FAB) is used to hold the foot in abduction and dorsiflexion and to reduce the risk of recurrence. Bracing is therefore not an optional adjunct but an integral part of treatment. Published reviews emphasize that relapse is influenced by brace adherence, the duration of follow-up, and how relapse is defined.[5–8] Several FAB designs are available. The Denis Browne splint is a traditional bar-connected system, whereas the Steenbeek brace was developed as a low-cost design that can be produced with locally available materials. The Steenbeek brace has been reported to maintain correction effectively and to offer cost advantages, while its practical performance may depend on fitting, wear pattern and family adherence.[9–11] A prospective study of 25 patients (38 feet) reported maintenance of correction in 36 of 38 feet using the Steenbeek brace, with recurrence associated with non-compliance.[10] A comparative study by Runu and colleagues evaluated Denis Browne and Steenbeek braces in separate groups and provided an important precedent for direct comparison of these two commonly used braces.[12] More recent evidence continues to emphasize the importance of brace adherence. A systematic review found that relapse rates increase with longer follow-up, while an updated 2026 scoping review identified brace non-adherence, missed visits, caregiver understanding, brace tolerance and access to care as recurring factors associated with relapse.[6,13] These findings highlight the need to assess not only radiographic or clinical correction but also the practical characteristics of the brace used during maintenance. The present study was undertaken to compare Denis Browne and Steenbeek braces after Ponseti correction of idiopathic CTEV, with emphasis on maintenance of correction, Pirani score, recurrence, painful episodes and practical considerations including cost and parent/child acceptability. 2. OBJECTIVES • To compare the Denis Browne splint and Steenbeek brace for maintenance of correction after Ponseti treatment of idiopathic CTEV. • To assess Pirani severity score and residual deformity during the maintenance phase. • To document relapse and brace-related problems during follow-up. • To assess practical considerations related to brace tolerance, painful episodes and cost.

3.1 Study design and setting This was a comparative clinical study conducted in the Department of Orthopaedics and Traumatology at a tertiary-care health centre in India. Patients were identified and treated between September 2022 and August 2024. The supplied manuscript does not specify a formal randomization sequence or allocation concealment; therefore, the present publication version does not describe the study as randomized. 3.2 Study population Thirty patients with 46 idiopathic clubfeet were included. The source manuscript states that patients were selected from the outpatient or inpatient services and treated using the Ponseti method followed by either a Denis Browne or Steenbeek foot-abduction brace. Idiopathic disease was established by excluding associated conditions such as spinal abnormalities and arthrogryposis, as well as other secondary causes described in the source protocol. 3.3 Eligibility criteria Inclusion criteria were idiopathic CTEV, first presentation before 6 months of age, or previously treated CTEV in children younger than 2 years. Exclusion criteria included postural, syndromic, neglected or secondary clubfoot; previously treated CTEV in children older than 2 years; relapse at presentation; skin or soft-tissue lesions around the foot and ankle; incomplete follow-up; need for soft-tissue surgery other than Achilles tenotomy; age above 2 years; and inability or unwillingness to comply with the described treatment protocol. 3.4 Ponseti treatment and maintenance Serial manipulation and casting were performed at approximately weekly intervals. The Pirani scoring system was recorded before initial casting and at subsequent visits. After correction of the deformity, including Achilles tenotomy when required, the foot was placed in a foot-abduction brace. The source protocol instructed parents regarding prolonged brace use and follow-up to approximately 4 years of age. 3.5 Outcome assessment The main outcomes were maintenance of correction, PSS, residual deformity and relapse. Additional observations included number of casts, laterality, painful episodes during bracing, brace-related skin problems and practical acceptability. In the supplied dataset, brace comparisons are reported for 46 feet: 25 feet in the Denis Browne group and 21 feet in the Steenbeek group. Because bilateral feet from the same child are represented separately, analyses at the foot level should be interpreted as exploratory and not as fully independent patient-level observations. 3.6 Statistical analysis Categorical variables were summarized as counts and percentages. Pearson chi-square tests were used for categorical associations when expected cell frequencies were considered adequate. Fisher exact testing was used for the small 2×2 relapse comparison in this revised analysis. Statistical significance was set at p<0.05. The original manuscript contained an incorrect degrees-of-freedom value in the brace-versus-sex table; this has been corrected from df=2 to df=1 for the 2×2 comparison. 3.7 Ethical considerations The supplied manuscript does not provide an institutional ethics committee approval number or a detailed consent statement. These details should be inserted from the original institutional record before journal submission. No new patient-level information has been introduced in this publication version.

3.1 Study design and setting This was a comparative clinical study conducted in the Department of Orthopaedics and Traumatology at a tertiary-care health centre in India. Patients were identified and treated between September 2022 and August 2024. The supplied manuscript does not specify a formal randomization sequence or allocation concealment; therefore, the present publication version does not describe the study as randomized. 3.2 Study population Thirty patients with 46 idiopathic clubfeet were included. The source manuscript states that patients were selected from the outpatient or inpatient services and treated using the Ponseti method followed by either a Denis Browne or Steenbeek foot-abduction brace. Idiopathic disease was established by excluding associated conditions such as spinal abnormalities and arthrogryposis, as well as other secondary causes described in the source protocol. 3.3 Eligibility criteria Inclusion criteria were idiopathic CTEV, first presentation before 6 months of age, or previously treated CTEV in children younger than 2 years. Exclusion criteria included postural, syndromic, neglected or secondary clubfoot; previously treated CTEV in children older than 2 years; relapse at presentation; skin or soft-tissue lesions around the foot and ankle; incomplete follow-up; need for soft-tissue surgery other than Achilles tenotomy; age above 2 years; and inability or unwillingness to comply with the described treatment protocol. 3.4 Ponseti treatment and maintenance Serial manipulation and casting were performed at approximately weekly intervals. The Pirani scoring system was recorded before initial casting and at subsequent visits. After correction of the deformity, including Achilles tenotomy when required, the foot was placed in a foot-abduction brace. The source protocol instructed parents regarding prolonged brace use and follow-up to approximately 4 years of age. 3.5 Outcome assessment The main outcomes were maintenance of correction, PSS, residual deformity and relapse. Additional observations included number of casts, laterality, painful episodes during bracing, brace-related skin problems and practical acceptability. In the supplied dataset, brace comparisons are reported for 46 feet: 25 feet in the Denis Browne group and 21 feet in the Steenbeek group. Because bilateral feet from the same child are represented separately, analyses at the foot level should be interpreted as exploratory and not as fully independent patient-level observations. 3.6 Statistical analysis Categorical variables were summarized as counts and percentages. Pearson chi-square tests were used for categorical associations when expected cell frequencies were considered adequate. Fisher exact testing was used for the small 2×2 relapse comparison in this revised analysis. Statistical significance was set at p<0.05. The original manuscript contained an incorrect degrees-of-freedom value in the brace-versus-sex table; this has been corrected from df=2 to df=1 for the 2×2 comparison. 3.7 Ethical considerations The supplied manuscript does not provide an institutional ethics committee approval number or a detailed consent statement. These details should be inserted from the original institutional record before journal submission. No new patient-level information has been introduced in this publication version

The present study examined the maintenance phase after Ponseti correction of idiopathic clubfoot, focusing on two foot-abduction braces commonly used in clinical practice. The central finding was that most treated feet remained corrected during the available follow-up with either brace. Relapse occurred in four feet in three children, with one relapse among 25 Denis Browne feet and three among 21 Steenbeek feet. Although the observed proportion was higher in the Steenbeek group, Fisher exact testing did not demonstrate a statistically significant difference. The importance of the maintenance phase is well established. Ponseti treatment has substantially reduced the need for extensive soft-tissue release and provides high initial correction rates.[1–4] However, relapse remains a recognized long-term problem. Systematic reviews have shown that reported relapse rates vary widely and tend to increase with longer follow-up, partly because definitions of relapse and follow-up durations differ among studies.[6,7] The present study had a relatively short observation window for a condition in which relapse can occur years after initial correction; consequently, its relapse estimate should not be interpreted as the ultimate recurrence risk. The observed 4.0% relapse proportion in the Denis Browne group and 14.3% in the Steenbeek group are numerically different from, but not statistically distinguishable in this small cohort. The 2018 comparative study by Runu et al. directly evaluated Denis Browne and Steenbeek braces in the maintenance phase and provides a useful comparator for the current findings.[12] Differences between studies may arise from sample size, brace prescription, patient selection, follow-up duration, compliance, severity distribution and the unit of analysis. Importantly, the current study had 25 Denis Browne and 21 Steenbeek feet, whereas the cited comparative study had larger groups; therefore, the present study has limited power to detect modest differences. The baseline PSS findings require particular attention. PSS before equinus correction differed significantly between brace groups in the supplied dataset (p=0.016), while PSS at initiation of bracing did not differ significantly (p=0.281). This suggests that some baseline differences may have been reduced by the time the maintenance phase began. Nevertheless, because the original study was not described as randomized, residual confounding cannot be excluded. A future comparative study should prospectively standardize allocation, severity, age at treatment, tenotomy status and brace prescription. The findings concerning Steenbeek brace use are consistent with the broader literature describing the brace as a low-cost and practical FAB. Dinesh et al. reported maintenance of correction in 36 of 38 feet (94.7%) using the Steenbeek brace and found recurrence to be significantly associated with non-compliance.[10] The Steenbeek brace has also been evaluated biomechanically; pilot data demonstrate that it can maintain corrected foot dorsiflexion and pronation, supporting its role as a true FAB rather than merely a low-cost substitute.[11] These observations are relevant to resource-constrained settings in which affordability can determine whether families can sustain the maintenance protocol. At the same time, brace choice cannot be reduced to cost. Bracing must be tolerated by the child and correctly fitted and worn by caregivers. Reviews emphasize that non-adherence is a major modifiable risk factor for relapse and may be influenced by discomfort, skin problems, caregiver understanding, family circumstances and access to follow-up.[5,8,13] The current study recorded pressure sores, blisters, bruising and eczema as manageable brace-related problems and highlighted compliance as an important practical issue. However, compliance was not quantified with an objective measure such as brace-hours per day. This is a major limitation because a comparison of brace types is difficult to interpret without standardized adherence data. The sex distribution differed between brace groups in the supplied foot-level table (p=0.040). However, this analysis should be interpreted cautiously because 46 feet came from only 30 children, and both feet from bilateral cases are represented separately. Treating each foot as an independent observation can underestimate uncertainty. The same issue applies to several chi-square analyses. A future study should use the patient as the primary unit for patient-level characteristics and either a patient-level outcome or clustered statistical methods for bilateral feet. The study also demonstrates why clear reporting of the Ponseti protocol is important. Published systematic reviews have identified substantial variation in how manipulation, casting, Achilles tenotomy, bracing type and brace duration are reported.[5,8] In the current study, the mean number of casts was described in different sections using slightly different denominators and timepoints. The revised manuscript therefore reports the detailed cast-frequency table while avoiding a single recalculated mean that cannot be independently verified from the supplied patient-level dataset. The literature increasingly supports prolonged follow-up. Thomas et al. found that reported relapse rates increase with longer follow-up, and the 2026 updated scoping review emphasized the importance of adherence, caregiver factors, access and continuity of care.[6,13] Therefore, the 6-month outcome window represented in the supplied PSS graphs should be viewed as an early maintenance-phase outcome rather than definitive long-term success. Follow-up to at least 4 years, and ideally toward skeletal maturity when feasible, would provide a more clinically meaningful assessment of recurrence. From a practical perspective, the current findings support the continued use of a well-fitted foot-abduction brace after Ponseti correction. The choice between Denis Browne and Steenbeek should consider affordability, availability, fit, caregiver preference, child tolerance and the ability to maintain the prescribed schedule. The source investigators considered the Denis Browne splint more child- and parent-friendly but more expensive, whereas the Steenbeek brace was more economical. These observations are descriptive rather than definitive comparative conclusions because the study was small and did not use a standardized patient-reported acceptability instrument. The principal strengths of this study are its real-world clinical setting, use of the Ponseti method, serial PSS assessment, direct comparison of two commonly used braces, and documentation of brace-related problems. Its principal limitations are the small sample, foot-level analysis of bilateral disease, lack of a documented randomization method, absence of a quantified compliance measure, limited follow-up relative to the natural history of relapse, and incomplete reporting of ethics approval and allocation methodology. The significant baseline difference in PSS before equinus correction also indicates that confounding may be present. Overall, the study contributes local clinical data on two practical brace options in the maintenance phase of idiopathic clubfoot treatment. Its findings are broadly compatible with the established principle that successful Ponseti correction requires prolonged brace maintenance, but they do not establish superiority of one brace over the other. A larger multicentre prospective study with patient-level allocation, objective adherence monitoring, standardized relapse definitions, cost analysis and long-term follow-up would better determine whether brace type independently affects recurrence.

Both Denis Browne and Steenbeek foot-abduction braces maintained correction in most feet following Ponseti treatment in this cohort. Four feet in three children relapsed, corresponding to 4.0% of Denis Browne-treated feet and 14.3% of Steenbeek-treated feet; this difference was not statistically significant. The study supports the importance of the maintenance phase and continued brace use after correction. The Denis Browne splint was described as more child- and parent-friendly but more costly, whereas the Steenbeek brace offered an economical option. Larger studies with standardized compliance measurement and long-term follow-up are required before meaningful comparative conclusions about relapse can be drawn. 8. STRENGTHS AND LIMITATIONS • Direct comparison of two commonly used foot-abduction braces in a tertiary-care clinical setting. • Serial assessment using the Pirani scoring system. • The study includes both bilateral and unilateral idiopathic clubfeet, reflecting routine clinical practice. • Small sample size and unequal brace-group sizes limit statistical power. • Bilateral feet were analyzed separately although they were clustered within patients. • The supplied manuscript does not document randomization or allocation concealment. • Objective brace adherence in hours/day was not reported. • Follow-up represented in the available PSS graphs is short relative to the known possibility of late relapse. • Institutional ethics approval number and detailed consent information were not present in the supplied document and require completion.

1. Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. J Bone Joint Surg Am. 1963;45-A:261-344. 2. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics. 2004;113(2):376-380. doi:10.1542/peds.113.2.376. 3. Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop. 2002;22(4):517-521. 4. Göksan SB. Treatment of congenital clubfoot with Ponseti method. Acta Orthop Traumatol Turc. 2002;36(4):281-287. 5. Zhao D, Liu J, Zhao L, Wu Z. Relapse of clubfoot after treatment with the Ponseti method and the function of the foot abduction orthosis. Clin Orthop Surg. 2014;6(3):245-252. doi:10.4055/cios.2014.6.3.245. 6. Thomas HM, Sangiorgio SN, Ebramzadeh E, Zionts LE. Relapse rates in patients with clubfoot treated using the Ponseti method increase with time: a systematic review. JBJS Rev. 2019;7(5):e6. doi:10.2106/JBJS.RVW.18.00124. 7. Gelfer Y, Wientroub S, Hughes K, Fontalis A, Eastwood DM. Congenital talipes equinovarus: a systematic review of relapse as a primary outcome of the Ponseti method. Bone Joint J. 2019;101-B(6):639-645. 8. Alves C. Bracing in clubfoot: do we know enough? J Child Orthop. 2019;13(3):258-264. doi:10.1302/1863-2548.13.190071. 9. Agarwal A, Kumar A, Mishra M. The foot abduction characteristics following Steenbeek foot abduction brace. J Orthop Surg (Hong Kong). 2017;25(1):2309499016684085. doi:10.1177/2309499016684085. 10. Dinesh TS, Kotian P, Sujir P, Joe V, Rajendra A. Steenbeek foot abduction brace for clubfoot: cost-effective but is it effective? A prospective study. Asian J Pharm Clin Res. 2017;10(5):99-102. doi:10.22159/ajpcr.2017.v10i5.16296. 11. Steenbeek brace: patterns of wear. J Child Orthop. 2015;9(3):257-264. doi:10.1007/s11832-015-0660-2. 12. Runu R, Kumar S, Kumar A, Sagar V, Kumar M. Comparison of short-term functional outcome and complication rate between two commonly used braces (Denis Browne splint and Steenbeek brace) in maintenance phase of congenital talipes equinovarus. J Orthop Traumatol Rehabil. 2018;10(1):7-12. doi:10.4103/jotr.jotr_23_17. 13. Arvati S, Zokou H, Luc F. Brace non-adherence and relapse after Ponseti treatment for idiopathic clubfoot: a focused updated scoping review. J Pediatr Orthop B. 2026. doi:10.1097/BPB.0000000000001383. 14. Agarwal A, Rastogi A, Rastogi P. Relapses in clubfoot treated with Ponseti technique and standard bracing protocol—a systematic analysis. J Clin Orthop Trauma. 2021;18:199-204. doi:10.1016/j.jcot.2021.04.029. 15. Zhao D, Li H, Zhao L, Liu J, Wu Z, Jin F. Results of clubfoot management using the Ponseti method: do the details matter? A systematic review. Clin Orthop Relat Res. 2014;472(4):1329-1336. doi:10.1007/s11999-014-3463-7.