Is percutaneous heel cord tenotomy a necessary component in the Ponseti treatment of idiopathic clubfoot deformity?

This study aimed to compare outcomes of idiopathic clubfeet (IC) treated with a percutaneous heel cord tenotomy (PHCT) at the conclusion of Ponseti casting with those that were not. A retrospective review of patients enrolled in a single institution prospective clubfoot registry over 19 years was performed. Patients under the age of 3 months with untreated IC managed via the Ponseti method that had a minimum of 2 years follow-up were included. Dimeglio score, number of casts to achieve correction, bracing compliance, need for subsequent procedures, and outcomes using the Richards classification were compared between patients who underwent a PHCT as part of their initial treatment and those that did not. A total of 1184 clubfeet in 791 patients met inclusion criteria; and 863 feet (73%) underwent a PHCT in clinic as part of initial Ponseti treatment. A total of 23% (75/321) of feet that did not undergo initial PHCT ultimately required a later PHCT or tendo-Achilles lengthening for recurrent equinus. Multivariate analysis demonstrated that an initial PHCT decreased the likelihood of requiring any additional surgical procedure by 30% (odds ratio: 0.70, P = 0.02). While an initial tenotomy was not predictive of clinical outcomes (P = 0.09), the rate of fair and poor outcomes is more than double from 13.6 to 30% when an initial tenotomy was not performed in feet with Dimeglio scores of 13 or greater (P = 0.02). Incorporation of a PHCT at the conclusion of Ponseti casting may reduce the need for subsequent and more invasive surgical interventions in IC patients, especially those with Dimeglio scores of 13 or greater. Level of evidence: therapeutic level III.