Background: The Ponseti method for treatment of idiopathic clubfeet
involves the use of serial casts, percutaneous Achilles tenotomy in most
cases, and bracing with an abduction orthosis to prevent relapse. Although
Ponseti recommended evaluation of the infant clubfoot strictly by palpation,
many orthopaedic surgeons still rely on radiographs for decision-making during
treatment. The aim of this study was to document with radiographs the effect
of percutaneous Achilles tenotomy as described by Ponseti.
Methods: We conducted a study of idiopathic clubfeet treated, at two
centers, with the Ponseti method, including percutaneous Achilles tenotomy.
Cast treatment was started within three weeks after birth, and radiographs
were made before and after the tenotomy. Lateral radiographs with the foot in
maximal dorsiflexion at the ankle were made for all patients, and
anteroposterior radiographs of the foot were made at one center. The lateral
tibiocalcaneal angle, the anteroposterior talocalcaneal angle, and the lateral
talocalcaneal angle were measured on the radiographs. Foot dorsiflexion at the
ankle was evaluated clinically. The results from both centers were evaluated
separately and in combination.
Results: Lateral dorsiflexion radiographs that showed the foot and
ankle were evaluated for eighty-seven clubfeet, and anteroposterior
radiographs that showed the foot were evaluated for sixty-five clubfeet. The
mean improvement in the lateral tibiocalcaneal angle after the tenotomy was
16.9°. The mean change in the anteroposterior talocalcaneal angle was
2.1°, and the mean change in the lateral talocalcaneal angle change was
1.4°. The mean increase in clinically measured dorsiflexion after the
tenotomy (in sixty-five feet) was 15.1°. Only the lateral tibiocalcaneal
angle and dorsiflexion as measured clinically changed significantly after the
Achilles tenotomy (p < 0.05). When the results at each center were analyzed
separately, they were found to be nearly identical.
Conclusions: The increase in the lateral tibiocalcaneal angle after
Achilles tenotomy is essentially the same as the increase in ankle
dorsiflexion seen on clinical examination. The anteroposterior and lateral
talocalcaneal angles are not influenced significantly by the tenotomy.
Radiographs confirmed that the additional dorsiflexion obtained from the
percutaneous Achilles tenotomy is true dorsiflexion occurring in the ankle and
hindfoot and not in the midfoot.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.