Predicting the Need for Surgical Intervention in Patients With Idiopathic Clubfoot

NewsBot · Jul 31, 2014

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Predicting the Need for Surgical Intervention in Patients With Idiopathic Clubfoot.
Goldstein RY, Seehausen DA, Chu A, Sala DA, Lehman WB.
J Pediatr Orthop. 2014 Jul 29.

BACKGROUND::
The purpose of this study was to determine the early factors associated with the need for surgical interventions in patients with idiopathic clubfoot treated with the Ponseti method.
METHODS::
All patients with idiopathic clubfoot treated with Ponseti method at our institution with >3 years of follow-up were evaluated. Age at presentation, history of previous treatment, number of casts used, need for percutaneous Achilles tenotomy (PAT), age of initiation of foot abduction orthosis (FAO), compliance with FAO, and need for additional casts were recorded. Dimeglio/Bensahel and Catterall/Piriani scores were recorded at initial presentation, at initiation of FAO, at 1, 2, 3 years of follow-up, and at the most recent follow-up.
RESULTS::
Since 2000, 86 patients (134 feet) had >3 years of follow-up from time of initial presentation, and 43 of these feet (32%) had undergone surgery beyond a PAT. Patients who were noncompliant with the FAO were 7.9 times more likely to need surgery than those who were compliant [confidence interval (CI), 2.8-22.0; P<0.001]. Female patients were 5.4 times more likely to need surgery than male patients (CI, 1.8-16.6; P=0.003). For every 1 point increase in Dimeglio/Bensahel score at presentation, patients were 1.3 times more likely to need surgery (CI, 1.0-1.5; P=0.033). For every 1 point increase in Dimeglio/Bensahel score at initiation of the FAO, patients were 1.5 times more likely to need surgery (1.1-2.0, P=0.005). Moreover, for each additional cast required before the initiation of the FAO, patients were 1.5 times less likely to need surgery (CI, 1.1-2.7; P=0.030). No other variable significantly contributed to predicting the need for surgery.
CONCLUSIONS::
There are early factors that can be used to predict increased risk for surgical intervention in patients undergoing treatment for idiopathic clubfoot. Female patients and those patients with higher Dimeglio/Bensahel scores at presentation and at initiation of the FAO are at increased risk for needing surgical intervention. Noncompliance with the FAO is associated with the highest risk for surgical intervention.
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NewsBot · Aug 28, 2014

Comparative study of complete subtalar release and Joshi's external stabilization system in the management of neglected and resistant idiopathic clubfoot
Lalit Kumar Lohia, Sanjay Meena, Rajesh Kumar Kanojia
Foot and Ankle Surgery; Available online 27 August 2014

Introduction
Various procedures have been used for the management of neglected and resistant clubfoot. The aim of our study was to assess the clinical and radiological correction by Joshi's external stabilization system (JESS Fixator) and Simons subtalar release in resistant and neglected idiopathic congenital talipes equinovarus in children between the ages of 1 to 2 years.

Material and methods
A total of 50 resistant and neglected clubfeet were randomly divided into two equal groups of 25 feet each. Group I were treated with JESS Fixator & Group II were treated with complete subtalar release as described by Simons. Assessment of correction achieved was done both clinically and radiologically. Functional outcome was assessed with Ponseti scale.

Results
The change in clinical deformity and radiological correction of deformity were statistically significant within each group, but not significant when compared to each other. In group I excellent results were obtained in 17(68%) and good in 8(32%) of the feet. In group II, excellent results were found in 16(64%) and good in 9(36%) feet out of the 25 feet. Pin site infections were seen in two cases in group I and serious skin problems occurred in two feet in group II.

Conclusion
We conclude that there was no statistical significant differences between the outcomes of the two techniques in this short term follow up of 2.4 years. Thus, functional distraction using JESS can be utilized as an alternative method in cases of neglected and resistant clubfoot.
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NewsBot · Sep 6, 2014

Evertor muscle activity as a predictor of the mid-term outcome following treatment of the idiopathic and non-idiopathic clubfoot
Y. Gelfer, et al
Bone Joint J 2014;96-B:1264–8.

Previous studies have identified clinical and demographic risk factors for recurrence in the treatment of idiopathic clubfoot (congenital talipes equinovarus). Evertor muscle activity is not usually considered amongst them. This study aimed to evaluate whether recurrence could be predicted by demographic, clinical and gait parameters. From a series of 103 children with clubfeet, 67 had completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic and 29 with non-idiopathic deformities. The mean age was 3.2 years (2.1 to 6.3). Primary correction was obtained in all 38 children (100%) with an idiopathic deformity, and in 26 of 29 patients (90%) with a non-idiopathic deformity. Overall, 60 children (90%) complied with the abduction brace regime. At a mean follow-up of 31.4 months (24 to 62), recurrence was noted in six children (15.8%) in the idiopathic and 14 children (48.3%) in the non-idiopathic group. Significant correlation was found between poor evertor activity and recurrence in both groups. No statistically significant relationship was found between the rate of recurrence and the severity of the initial deformity, the age at the time of treatment, the number of casts required or the compliance with the brace.

After correction of idiopathic and non-idiopathic clubfoot using the Ponseti method, only poor evertor muscle activity was statistically associated with recurrence. The identification of risk factors for recurrent deformity allows clinicians to anticipate problems and advocate early additional treatment to improve muscle balance around the ankle.
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NewsBot · Nov 8, 2014

Combined double tarsal wedge osteotomy and transcuneiform osteotomy for correction of resistant clubfoot deformity (the “bean-shaped” foot)
Adham Elgeidi, Mazen Abulsaad
Journal of Children's Orthopaedics; October 2014, Volume 8, Issue 5, pp 399-404

Purpose
The “bean-shaped foot” exhibits forefoot adduction and midfoot supination, which interfere with function because of poor foot placement. The purpose of the study is a retrospective evaluation of patients who underwent a combined double tarsal wedge osteotomy and transcuneiform osteotomy to correct such a deformity.
Methods
Twenty-seven children with 35 idiopathic clubfeet were treated surgically by combined double tarsal wedge osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) and transcuneiform osteotomy between 2008 and 2012. The age of children at surgery ranged from 4 to 9 years. There were 19 boys and 8 girls. Pre- and postoperative X-rays were used, considering: on the AP radiograph, the calcaneo-fifth metatarsal angle and the talo-first metatarsal angle (indicators of forefoot adduction); on the lateral radiograph, the talo-first metatarsal angle (an indication of supination deformity) and calcaneo-first metatarsal angles (an indication of cavus deformity). These radiological parameters were compared with the clinical results.
Results
Follow-up was conducted for 24–79 months following surgery. Clinical and radiographic improvements in forefoot position were achieved in all cases. An average improvement in the anteroposterior talo-first metatarsal angle of 21°, calcaneo-fifth metatarsal angle of 14°, lateral talo-first metatarsal angle of 10°, and lateral calcaneo-first metatarsal of 12° confirmed the clinically satisfactory correction in all feet. One patient had a wound infection postoperatively, which resolved with removal of the wires and administration of oral antibiotics. Eight patients followed up for more than 5 years had no deterioration of results.
Conclusions
Combined double tarsal wedge osteotomy as well as transcuneiform osteotomy is an effective and safe procedure for lasting correction of the bean-shaped foot.
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NewsBot · Dec 11, 2014

Flexor digitorum accessorius longus muscle in resistant clubfoot patients: introduction of a new sign predicting its presence.
Shaheen S, Mursal H, Rabih M, Johari A.
J Pediatr Orthop B. 2014 Dec 9.

Clubfoot, talipes equino varus (TEV), is a common congenital foot anomaly. Some cases are resistant to conservative treatment. Many causes of resistance have been reported, among these, the presence of anomalous muscles; however, the effect of the presence of anomalous muscles on the outcome of conservative management is not well studied. These aberrant muscles are discovered during the extensive surgical release as an abnormal finding. The aim of this work is to study the demographic characteristics of patients with resistant TEV that necessitated extensive soft tissue release at Sudan Clubfoot Clinic and to document the prevalence of flexor digitorum accessorius longus (FDAL) muscle in a large series of clubfoot patients treated by extensive surgery: posteromedial release. Also, we introduce a new observation as an indication by which the surgeon can predict the presence of FDAL. On the basis of an observation that there is a special posture of the big toe in extension in relation to other flexed toes associated with the presence of FDAL, records of patients of clubfoot treated by extensive surgery between 2007 and 2012 at the Sudan Clubfoot Project were reviewed. Demographic characteristics were studied. Only patients with idiopathic TEV were included. Resistant clubfeet necessitated extensive release in 261 patients, 197 males and 64 females. Their ages ranged between 1 day and 15 years at presentation. FDAL muscle was found in 48 patients (54 feet) out of 261 patients (411 feet, 13.14%). In 46 of the 48 patients (95.8%), the presence of the FDAL could be predicted by a sign. FDAL is prevalent in 13% of resistant TEV cases requiring extensive soft tissue release, and the surgeon can expect resistant clubfoot and predict the presence of the FDAL in over 95% before he operates by observing the Samir-Adam sign.
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NewsBot · Jul 28, 2015

The Influence of Sex and Laterality on Clubfoot Severity.
Zionts, Lewis E. MD; Jew, Michael H. BS; Ebramzadeh, Edward PhD; Sangiorgio, Sophia N. PhD
Journal of Pediatric Orthopaedics: July 24, 2015

Background: Idiopathic clubfoot is bilateral in approximately 50% of cases and has been widely reported to affect males more frequently than females. Despite these observations, the correlation between sex and severity of the deformity has not been established. As well, the difference in severity between unilateral and bilateral clubfeet has not been extensively investigated. Therefore, the goals of the present study were to: (1) examine the relationship between sex and severity of deformity and (2) determine the relationship between laterality and severity of deformity.

Methods: The families of infants with idiopathic clubfoot deformity treated at our institution were prospectively invited to participate in this institutional review board-approved study. Severity of the deformity was assessed by a single surgeon for each patient using the Dimeglio criteria at the first clinic visit. After evaluating the distributions, the correlations were quantified by nonparametric analyses.

Results: Over 8 years, 240 infants met the inclusion criteria. There was no significant difference in the severity of deformity due to sex (P=0.61): the median Dimeglio score for males was 13 (variance 4.8) and for females, the median was 13.0 (variance of 5.1). In contrast, severity was distributed differently among unilateral versus bilateral patients. Although both unilateral and bilateral patients had a median Dimeglio score of 13, the ratio of bilateral patients was higher among those with moderate or very severe deformities compared with those with severe deformities (P<0.01).

Conclusions: Although idiopathic clubfoot is commonly considered to affect male patients disproportionately, this is the first study to document no difference in severity due to sex. Further, this study demonstrated that on average, bilateral patients did not have increased severity, but presented with a larger range of severity than those patients with unilateral deformity.
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NewsBot · Aug 11, 2015

COMPARISON OF PERCUTANEOUS TENOTOMY TECHNIQUES FOR CORRECTION OF EQUINUS DEFORMITY IN CONGENITAL TALIPES EQUINO VARUS (CTEV) IN CHILDREN: A RANDOMIZED CLINICAL TRIAL.
Raghvendra Choubey, Ashish Jain
Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 57, July 16; Page: 9865-9870, DOI: 10.14260/jemds/2015/1427

Tendo-achillies tenotomy is required as last step of ponseti method of treatment of Congenital Talipes Equino Varus (CTEV). By this study we compared the two methods of percutaneous tenotomy for correction of equinus deformity in congenital talipes equino varus (ctev) in children. METHODS: It is a prospective randomized clinical study, conducted during the period of Nov. 2012 to April 2015 at the Department of orthopedics in the tertiary level hospital. RESULTS: Total fifty five CTEV feet were treated. Twenty seven feet were of blade tenotomy variety and twenty eight feet were of needle tenotomy variety. In this study mean pre-treatment Pirani score was 5.62 vs 5.58 in blade and needle tenotomy group respectively. Out of 57 feet 56 were managed successfully. One patients of needle tenotomy variety developed relapse of the deformity due to poor and faulty application of D-B Splint. Author do not find any significant difference between the two methods of percutaneous tenotomy. CONCLUSION: In the treatment of equines deformity of CTEV, the percutaneous needle tenotomy technique is a simple, excellent, minimally invasive, effective, less expensive, takes less time and which is possible without general anesthesia even in neonates.
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NewsBot · Jan 20, 2017

Nonoperatively Corrected Clubfoot at Age 2 Years: Radiographs Are Not Helpful in Predicting Future Relapse.
Richards BS et al
J Bone Joint Surg Am. 2017 Jan 18;99(2):155-160. doi: 10.2106/JBJS.16.00693.

BACKGROUND:
Nonoperative treatment of idiopathic clubfoot is standard. The purpose of this study was to determine if measurements made on standing lateral radiographs of successfully treated clubfeet made at 18 to 24 months of age were predictive of late recurrence.
METHODS:
Inclusion criteria were idiopathic clubfoot with an age at presentation of ≤3 months, nonoperative treatment resulting in a clinically plantigrade foot at 2 years of age, standing lateral radiograph of the involved foot made at 18 to 24 months of age, and a minimum age of 4 years at the time of follow-up. The radiographs were assessed for the talocalcaneal angle and the tibiocalcaneal angle, with measurements made by 2 trained practitioners. The average values of the 2 raters were used. The interobserver reliability was calculated using intraclass correlation coefficients (ICCs). A total of 211 patients with 312 clubfeet were evaluated. The average age at the time of follow-up was 8.0 years (range, 4.0 to 13.3 years). Results at the time of follow-up were rated as good (maintained plantigrade foot), fair (required limited surgery to maintain, or return to, a plantigrade position), or poor (required posteromedial release).
RESULTS:
Over time, 75% of the feet had a good result, 19% had a fair result, and 6% had a poor result. With regard to radiographic assessment, the ICCs were 0.97 (talocalcaneal angle) and 0.98 (tibiocalcaneal angle), demonstrating excellent agreement between the raters. The mean talocalcaneal angle differed significantly between the feet with a good clinical outcome and those with a fair outcome (28° versus 24°; p < 0.02), but did not differ significantly between those with a good versus poor outcome (28° versus 26°), or a fair versus poor outcome (24° versus 26°). There were no significant differences in the mean tibiocalcaneal angle among the groups (86°, 90°, and 84°, respectively) (p = 0.17).
CONCLUSIONS:
Most clubfeet that were clinically plantigrade at 2 years of age remained so, while one-fourth subsequently required some surgery for late recurrence, primarily limited procedures. The tibiocalcaneal angle and talocalcaneal angle from standing lateral radiographs made at 18 to 24 months of age were not helpful in predicting future relapse.
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NewsBot · Jun 2, 2020

In-toeing gait in children with clubfoot and the effect of tibial rotation osteotomy
Westberry, David E ET AL
Journal of Pediatric Orthopaedics B: July 2020 - Volume 29 - Issue 4 - p 348-354

In-toeing gait is common after treatment for clubfoot deformity and is often secondary to residual internal tibial torsion. The purpose of the current study was to characterize the gait pattern in children with an intoeing gait pattern associated with talipes equinovarus (TEV) deformity, identify secondary changes at the hip that occur with intoeing, and determine if these secondary effects resolve after correction of tibial torsion. Patients with a diagnosis of TEV deformity, in-toeing gait secondary to residual internal tibial torsion corrected with tibial rotation osteotomy (TRO) and complete preoperative and postoperative motion analysis studies obtained approximately 1 year apart, were included in the study. Nineteen children (19 left extremities) with a TRO at a mean age of 8.2 years met inclusion criteria. Clinical examination showed improvement in tibial torsion assessment by measure of the thigh foot axis and transmalleolar axis. Kinematically, an abnormal internal FPA was present in all cases preoperatively, was corrected to normal in 12 (63%), remained internal in 5 (26%), and was abnormally external in 2 (11%). External hip rotation was identified in 13 (68%) cases preoperatively. Hip rotation was normalized postoperatively in 7 (54%), and was unchanged in the remaining 6 (46%). TRO provides effective correction of excessive internal tibial torsion, resolution of kinematic internal knee rotation, and normalization of the internal foot progression angle in the majority of patients with TEV deformity. External hip rotation resolved in approximately 50% of cases. Overcorrection of the internal FPA is possible when secondary changes at the hip do not resolve.
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NewsBot · Apr 16, 2021

Well though-out introduction of percutaneous Achilles tenotomy during functional treatment of congenital talipes equinovarus: Which indications produce the best results?
Virginie Nguyen Khac et al
Orthop Traumatol Surg Res. 2021 Apr 12;102932

Introduction: Percutaneous Achilles tenotomy (PAT) was recently added to functional treatment of congenital talipes equinovarus (aka clubfoot). The aim of this study was to determine the relevance of a carefully chosen radiological criterion for the PAT indication and to evaluate its results.

Hypothesis: When the tibiocalcaneal angle (aTiCa) is larger than 75° at 4 months, doing PAT will improve the results of the functional method in the medium term and will reduce the surgery rate.

Patients and methods: This prospective study involved 101 patients (151 feet) born between 2011 and 2014 with clubfoot who were treated with the French functional method and had at least 4 years' follow-up. The initial severity of the deformity was evaluated using the Diméglio scoring system. In our sample, 30 feet had a Diméglio rating of II (20%), 61 had a Diméglio rating of III (40%) and 60 feet had a Diméglio rating of IV (40%). The indication for PAT was made at 4 months of age when the aTiCa on a lateral radiograph of the foot in maximum correction was greater than 75°. The mean follow-up was 5 years. The final assessment was done using the modified Ghanem and Seringe classification.

Results: In the entire cohort, PAT was done in 113 feet (75%). None of the feet required a repeat PAT. Surgical release of the soft tissues was done in 20 feet (13%). None of the feet developed a rocker bottom deformity. Two feet were operated in the absence PAT (out of 38 in this subgroup) and 18 feet after PAT (out of 113 in this subgroup). The aTiCa angle did not vary in the PAT group based on whether surgical release was indicated afterwards or not. At the final assessment, 140 feet (93%) were classified as very good and 11 feet (7%) as good.

Discussion: The tibiocalcaneal angle is a relevant radiological criterion for the PAT indication in children with clubfoot. PAT has a positive impact on the outcomes.
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NewsBot · Jun 24, 2021

Evaluation of a surgical treatment algorithm for neglected clubfoot in low-resource settings
Manon Pigeolet, Saiful Imam, Gheorghe Cristian Ninulescu, Shafiul Kabir, Pierre R. Smeesters & Hasib Mahmud
International Orthopaedics (2021)

Purpose
Idiopathic clubfoot affects approximately 1/1000 alive-born infants, of whom 80–91% are born in low- or middle-income countries (LMICs). This retrospective study aimed to evaluate the morphological, functional, and social outcomes in patients with neglected clubfoot in rural Bangladesh, after receiving surgical treatment.

Methods
Patients received a posteromedial release (PMR) with or without an additional soft tissue intervention (group 1), a PMR with an additional bony intervention (group 2), or a triple arthrodesis (group 3) according to our surgical algorithm. Patients were followed until two year post-intervention. Evaluation was done using a modified International Clubfoot Study Group Outcome evaluation score and the Laaveg-Ponseti score.

Results
Twenty-two patients with 32 neglected clubfeet (ages 2–24 years) received surgical treatment. Nineteen patients with 29 clubfeet attended follow-up. At two year follow-up an excellent, good, or fair Laaveg-Ponseti score was obtained in 81% (group 1), 80% (group 2), and 0% (group 3) of the patients (p value 0.0038). Age at intervention is inversely correlated with the Laaveg-Ponseti score at two year follow-up (p < 0.0001). All patients attended school or work and were able to wear normal shoes.

Conclusion
Our treatment algorithm is in line with other surgical algorithms used in LMICs. Our data reconfirms that excellent results can be obtained with a PMR regardless of age. Our algorithm follows a pragmatic approach that takes into account the reality on the ground in many LMICs. Good functional outcomes can be achieved with PMR for neglected clubfoot. Further research is needed to investigate the possible role of triple arthrodesis.
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NewsBot · Oct 8, 2021

Percutaneous Achilles tenotomy under local anaesthetic in the clubfoot clinic was safe during the COVID-19 pandemic, for both children and parents
Benjamin Barkham, Thomas McNally, Aishling Russell, Anna Bridgens & Yael Gelfer
International Orthopaedics volume 45, pages2271–2276 (2021)

Purpose
An Achilles tenotomy is routinely required to correct the equinus deformity in Congenital talipes equinovarus (CTEV) patients as part of the gold standard treatment using the Ponseti method. This procedure can be performed in clinic under local anaesthetic or in theatre under general anaesthetic. The COVID-19 pandemic reduced theatre capacity and caused a delay to CTEV patients’ treatment. A new standard operating procedure that allowed the tenotomies to be performed under local anaesthetic in the clinic was introduced. This study was looking into the safety, feasibility and parents’ perspective of this procedure.

Methods
The study was prospectively registered as a service improvement project and followed the SQUIRE guidelines (Ogrinc et al. in BMJ Qual Saf 25:986–992, 2016). All consecutive patients requiring a tenotomy were included. Data was collected prospectively including demographics, Pirani score and a carers’ satisfaction questionnaire.

Results
Twenty five patients (36 tenotomies) were included in the study. The median age was 9 weeks. All patients achieved ankle dorsiflexion of greater than 15° post-op. None of the patients nor their parents contracted the COVID 19 virus. All parents reported a positive experience and 99% felt less anxious about having the tenotomy done in clinic rather than theatre.

Conclusions
The new service offering clinic tenotomies was found to be safe and clinically successful. This study is the first to show parents preference and excellent satisfaction with a tenotomy performed under local anaesthetic. The service has improved the allocation of resources and due to its success, will continue beyond the pandemic.
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NewsBot · May 12, 2022

Achilles tendon surgery in clubfoot: Are long term sequelae predictable?
Luisella Pedrotti et al
Pediatr Med Chir. 2022 May 3;44(1)

Congenital Clubfoot (CCF) treatment involves a surgical procedure on the Achilles tendon most of the time, i.e. tenotomy or, in selected cases, Z-plasty lengthening. Many authors have studied the outcomes of Achilles tenotomy, describing complete clinical and ultrasound tendon fibers integrity restoration 3-6 weeks after surgery. Nevertheless, little is known about the mechanical properties of the operated tendon. Recently, cases of subcutaneous rupture of the Achilles tendon have been described in adolescents who practiced sports and who had undergone Achilles tenotomy for congenital clubfoot in childhood. Authors report two cases of atraumatic Achilles tendon injury (subcutaneous rupture and intratendinous ossification) in adult patients who had been treated for congenital clubfoot in childhood. In both cases, no causes determining the injury were identified; in the medical history there was a Z-plasty lengthening of the Achilles tendon, performed within the first year of life, which could be considered a predisposing factor. The usefulness of long-term monitoring of patients treated for CCF with surgical procedures on the Achilles tendon is therefore hypothesized, in order to promptly identify by symptoms, clinical pictures and ultrasound criteria, tendon suffering that may predispose subcutaneous rupture.
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NewsBot · Jul 16, 2022

Tibialis anterior tendon transfer using bone anchor for dynamic supination in congenital talipes equinovarus
Ayub, Anouska A.A.; Firth, Gregory B.; Green, Gemma L.; Bijlsma, Paulien; Ramachandran, Manoj
Journal of Pediatric Orthopaedics B: July 14, 2022 - Volume - Issue - 10.1097/BPB.0000000000000997

Tibialis anterior tendon transfer (TATT) is a recognised procedure for the treatment of recurrent congenital talipes equinovarus. The most common technique in use requires three skin incisions and breaching of the plantar tissues, risking pressure areas and damage to neurovascular structures. There have been no studies showing the clinical results of the use of a bone anchor to secure the tendon without drilling through the lateral cuneiform. This study presents the largest series of outcomes for such a procedure. Retrospective case series. Electronic records for all children under 18 undergoing TATT with anchor fixation included. Outcomes recorded were a failure of the tendon transfer and complications. Seventy-seven feet were identified in 61 children with a male-to-female ratio of 2.5:1, the average age at surgery of 5.6 years, and an average follow-up of 4.4 years. There were no cases of pullout of the anchor. Seventy-six cases (98.7%) had no recurrence of dynamic supination on follow-up. No revision surgery was required. Consistently reliable, reproducible and safe fixation of the tibialis anterior tendon in TATT can be achieved using a bone anchor for the treatment of dynamic supination in children with clubfeet following correction using the Ponseti method and is a quick and straightforward alternative method to traditional techniques.
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NewsBot · Aug 25, 2022

Assessment of early Achilles tenotomy in the newborn idiopathic pes equinovarus
Ersin Mutlu, Mehmet Kaymakoglu, Zirvecan Gunes, Guney Yilmaz, Cemalettin Aksoy
Acta Orthop Belg. 2022 Jun;88(2):231-236

We aimed to evaluate the clinical and radiological results of early Achilles tenotomy which was performed before Ponseti method in PEV deformities. 37 feet of 26 patients with Dimeglio type 3 and 4 deformities were included in the study. Unlike the classical Ponseti method, patients underwent a mini-open Achilles tenotomy before the first cast. 6-month follow-up of the foot deformities were assessed using Dimeglio classification clinically and lateral talocalcaneal and tibiocalcaneal angles radiologically. There were 20 male and 6 female patients with the median age of 14 days (4-37 days) and 11 bilateral and 15 unilateral deformities. The average follow-up period was 7 months (6-12 months). The mean Dimeglio scores before the Achilles tenotomy and Dimeglio score at the 6 th month follow-up were 14 (11-16) and 4 (4-6) for the right feet, 13 (10-16) and 4 (4-6) for the left feet respectively. The mean number of casting was 3.8 ± 0.4 for right feet and 3.7 ± 0.4 for left feet. The mean talocalcaneal angle was 24 ± 8.2 degrees for the right feet and 27 ± 8.2 degrees for the left feet. The mean tibiocalcaneal angle was 69 ± 12 for the right feet and 72 ± 14 degrees for the left feet. Early Achilles tenotomy can decrease the total number of cast for deformity correction in Ponseti method and provide good clinical and radiological outcomes at 6 th month follow-up in severe PEV deformities according to Dimeglio classification.
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NewsBot · May 14, 2023

Indication for Achilles Tenotomy in Congenital Clubfoot: Effectiveness of Using the Tibio-Plantar Fascia Angle as a Radiographic Parameter
Yoshinobu Oka, MD, PhD et al
May 07, 2023

Congenital clubfoot is one of the most common deformities in children, and currently, the Ponseti method is used worldwide because of its favorable short-term results. With the Ponseti method, the indication for Achilles tenotomy is traditionally based on only physical examination findings; however, some surgeons have also utilized plain radiographs. Because using physical examinations to determine the degree of hindfoot dorsiflexion for the indication of tenotomy can lead to underestimation. We developed and utilized the effectiveness of the Tibio-Plantar fascia angle (Ti-P angle) in the lateral maximum dorsiflexion view in determining the need for Achilles tenotomy.
A retrospective analysis of consecutive 26 patients with congenital idiopathic clubfeet (37 feet) was performed. Whether Achilles tenotomy was indicated was determined based on physical examination for a former period (Group P). For the latter period, whether tenotomy was indicated was determined by referencing radiographs (Group X). No significant differences were found in any of the background factors or severity between Group P and Group X. Cases with larger Tibiocalcaneal and Ti-P angles were more likely to require Achilles tenotomy or additional soft tissue release. An angle of more than 72° of the Ti-P angle demonstrated adequate specificity for the indication of Achilles tenotomy. The radiographic lateral Tibio-Plantar fascia angle is useful for deciding whether a tenotomy needs to be performed.
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NewsBot · Mar 2, 2024

Can the Achilles tendon regenerate completely following percutaneous tenotomy in older children with clubfoot?
Alaric Aroojis et al
Int Orthop. 2024 Feb 10.

Purpose: The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration.

Methods: A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 was studied. Clinical assessment of ankle range of motion and calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed.

Results: Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 ± 2.14 years (1-10.2 years). At a mean follow-up of 4.86 ± 1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64° (0-25°) and mean plantarflexion range of 37.95° (10-40°). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17-30) and mean height of heel rise of 6.29 cm (range 4-10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7 mm (3.3-16 mm) and thickness of 5.1 mm (1.8-15 mm), comparable with unaffected feet.

Conclusions: Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles.
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