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Achilles tenotomy during Ponseti's clubfoot treatment: better early than late
Ismat Ghanem1, Diane Ghanem2, Joe Rassi1
1Orthopaedic Department, Hôtel-Dieu de France Hospital, Saint Joseph University.
Insights
Early Achilles tenotomy in neonates with stiff clubfoot leads to superior outcomes compared to the conventional late tenotomy. This approach reduces complications and technical difficulties in the Ponseti method treatment.
Area of Science:
- Orthopedics
- Pediatric Orthopedics
- Foot and Ankle Surgery
Background:
- The Ponseti method is a standard treatment for congenital clubfoot.
- Achilles tenotomy is a crucial step in correcting severe clubfoot deformities.
- Timing of Achilles tenotomy in relation to casting remains a subject of investigation.
Purpose of the Study:
- To compare the outcomes of early versus late Achilles tenotomy in neonates with stiff clubfoot treated with the Ponseti method.
- To assess technical difficulties and short- and long-term complications associated with each timing.
Main Methods:
- Prospective randomized trial involving 140 neonates with stiff clubfoot (Dimeglio grades III-IV).
- Two groups: early tenotomy (first cast) and late tenotomy (fourth to sixth casts).
- Procedures performed under local anesthesia; outcomes assessed at an average 12.4-year follow-up.
Main Results:
- The early tenotomy group showed significantly better results (82% excellent/good) compared to the late group (70% excellent/good) (P=0.048).
- Technical difficulties were substantially lower in the early group (3% vs. 38%, P<0.0001).
- Talar dome flattening was less frequent in the early group (4% vs. 16%, P<0.001).
Conclusions:
- Early Achilles tenotomy during the Ponseti method for stiff clubfoot yields superior clinical outcomes.
- Performing tenotomy earlier reduces technical challenges and long-term complications like talar dome flattening.
- Early release of the posterior tether may alleviate joint compressive forces, contributing to better results.
Abstract:
To evaluate the outcome of Achilles tenotomy at first cast in neonates with stiff clubfoot undergoing Ponseti's method of treatment. One hundred forty stiff clubfeet (Dimeglio grades III and IV) scheduled for Ponseti's method were prospectively randomized into two groups of 70 each: (1) early, tenotomy at first cast; (2) late, tenotomy at fourth to sixth casts (conventional). The procedure was performed under local lidocaine spray in an office setting using a needle. The results were assessed at an average follow-up of 12.4 years. Technical difficulties and short and long-term complications were recorded. At last follow-up, the results were rated excellent, good, fair, and poor in 70, 18, 9, and 3% of patients in the late group, respectively, and 82, 13, 4, and 1% in the early group ( P = 0.048). Technical difficulties were encountered in 38% of the late group and 3% in the early group ( P < 0.0001). Flattening of the talar dome of mild to moderate severity was found in 16% of the late group and 4% in the early group ( P < 0.001). Early Achilles tenotomy seems to give better results than the conventional late tenotomy, with less short and long-term complications. This may be explained by the greater ease to palpate the Achilles tendon on a previously untreated foot, and the less amount of compressive forces across the tibiotalar and subtalar joints produced by early release of the posterior tether.
