Ponseti method for congenital idiopathic clubfoot correction has traditionally included a percutaneous Achilles tenotomy in more than 90% of stiff cases. The latter is usually performed during the fourth to sixth cast application and has proven to be the key factor for success of nonoperative treatment. However, in some cases it may not be easy to palpate the tendon and perform the procedure percutaneously owing to the swelling produced by repeated casting and a mini-incision may be required. The purpose of this paper was to evaluate the influence of early Achilles tenotomy during management of clubfoot using Ponseti method in neonates with Dimeglio types III and IV deformities.

Ninety neonates with 140 stiff clubfeet, according to Dimeglio, scheduled to undergo Ponseti method were prospectively randomly assigned into 2 groups - 70 feet underwent the percutaneous tenotomy during the first casting session (early group EG) and 70 during the 6th casting session (late group LG). Procedure is performed in an outpatient clinic setting without any anesthesia other than local skin application of lidocaine spray. Achilles tendon is palpated and an 18-gauge needle is introduced through the skin along its medial border few millimeters above its distal insertion on the calcaneus. Tendon is cut from medial to lateral in 1–3 needle swipes while foot is held in forced dorsiflexion. Cast is then applied according to Ponseti. Patients were reviewed at an average follow-up of 7.4years (5.2–10.8) and results were assessed using Ghanem-Seringe score. Technical difficulties, postoperative blood staining on cast and short- and long-term complications were recorded.

Results were rated excellent, good, fair, and poor in 70%, 18%, 9% and 3% of patients respectively in LG and 82%, 13%, 4% and 1% of patients, respectively in EG (P=0.05). Flattening of the talar dome of mild to moderate severity was found in 16% in LG and 4% of EG (P<0.001). Technical difficulties mainly those related to palpation of Achilles tendon and tenotomy “feeling” were encountered in 38% in LG and 3% in EG (P<0.0001). Blood staining on cast was found in 13% in LG and 3% in EG (P<0.001).

Percutaneous Achilles tendon performed as early as during first casting session seems to give greater excellent results than when performed during 6th casting session as described by Ponseti, with less short- and long-term complications. This may be explained by greater ease to palpate Achilles tendon and perform a clear-cut and selective tenotomy on a virgin foot, and early decrease in compressive forces over talar dome during corrective maneuvers.