Multiple tenotomies after Ponseti method for management of severe rigid clubfoot.

The purpose of the present study was to evaluate the efficacy of multiple tenotomies performed after application of the Ponseti method in reducing the tendency for recurrence in the severe rigid idiopathic clubfoot and limiting the need for application of the hyperabduction brace in the prewalking age. From November 2002 to December 2004, 30 severe (Pirani >5), rigid (nonresilient), idiopathic clubfeet in newly born infants aged 2 to 24 days were treated by the Ponseti method of weekly manipulations and castings until achieving full correction, apart from equinus. With the patient under general anesthesia, through 2 small incisions (2 cm), tenotomy of the Achilles tendon, tibialis posterior, and flexor digitorum longus was performed, together with posterior capsulotomy of the ankle to achieve >30° dorsiflexion in 26 feet. An above the knee plaster cast in extreme dorsiflexion and 70° hyperabduction was applied for 6 to 8 weeks. This was followed by a hyperabduction brace on a full-time basis (23 hours daily) for an additional 6 months. A satisfactory result was achieved after a follow-up period of 2 to 5 (mean 3.8) years. The Pirani score on initial presentation was 5 to 6 and on the final visit was 0 to 0.25, with 10° to 20° passive dorsiflexion of the ankle in those who underwent posterior capsulotomy compared with 5° to 10° in the 4 patients who had not. The number of manipulations needed before tenotomy was 5 to 7 (mean 5.9), reflecting the rigidity of the studied feet. Active plantarflexion to almost normal power was regained at 18 to 30 months of age. A relapse developed in only 1 foot that failed to respond to manipulation and casting. It required posteromedial release and tibialis anterior transfer at 2 years of age. The proposed minimally invasive procedure of open multiple tenotomies and posterior capsulotomy of the ankle is safe and effective. If performed in newly born infants with severe rigid clubfeet followed by strict application of the hyperabduction brace on a full time basis for 6 months, it will ensure full correction of the deformity. Thus, the brace can be discarded before the infant reaches walking age, with no tendency for relapse.