Prupose: A report on the documented results of Ponseti Method used at Assiut University Hospital to treat 557 congenital clubfeet to full correction, and ananalysis of the frequency of percutaneous Achilles tenotomy performed and its role in achieving hindfoot correction.
Patients & Methods: Since 2006, 354 documented patients with 557 clubfeet (438 idiopathic and 119 nonidiopathic) were treated by the same surgeon (NA), reached full correction, and were followed up for a mean of 1.14±1.22 years (8months to 7 years). The presence of 2% of cases older than 6 years of age raised the mean age at start of treatment to 254 days. Half the cases were younger than41 days and 83.4% were less than one year old.
Results: The mean Pirani score was 4.7±1.2, and the average number of intervention visits was 3.8±1.6 over a mean period of 7.3±6.5 weeks. 329 feet had no previous treatment, 161 had previous casting, and 47 cases were recurrent after previous surgery. 378 feet (67.9%) had at least one tenotomy on the 4th visit on average, while 14 feet (2.5%) needed a formal posterior release. 35 feet needed a second tenotomy, while 10 feet needed a third tenotomy. Remanipulation was needed in 133 feet (23.9%), Tibialis anterior transfer was needed in 47 feet (8.4%), while double mid-tarsal osteotomy was needed in 5 feet (0.9%) and a soft tissue release was needed in 1 foot (0.2%). 503 feet (90.3%) were satisfactory at latest follow up. The tibio-calcaneal angle (TCA) was measured on a lateral radiograph of the foot and leg (normally between 70° and 80°) in 198 feet at some point in follow up to verify hindfoot position in maximum dorsiflexion, and was found to be significantly less in 153 feet with Achilles tenotomy (mean TCA of63°±15.3°) than in 45 feet with no tenotomy (mean TCA of 74.2°±21.9°), p<0.002. Half the cases with no tenotomy had a TCA over 76°, indicating abnormal hindfoot position, and would have benefited from a tenotomy. There was no supported relationship between the age at the start of treatment and the TCA (p=0.437), but there was a significantly less mean TCA in 139 feet (25%), that received donated Bangla/Steenbeek braces by WFL from Bengladesh (62.5° vs 67.6°, p<0.05) compared to feet that received local braces. As an observation, the rate of tenotomy has increased in this series from 54.5% in the first half of the series, to 81.3% in the second half, and to 86.7% and 88.2% for the last 150 and50 cases respectively.
Conclusion: Achilles tenotomy and use of the proper brace has significantly improved hindfoot position in treated clubfeet in Assiut as proven by radiographic measurements of the tibio-calcaneal angles.