Effectiveness of achillotomy in children with arthrogryposis

Abstract

Introduction. Ponseti method is a widespread treatment for clubfoot in children with arthrogryposis. Closed subcutaneous achillotomy in these patients could not completely rectify the equinus deformity due to tissue rigidity which often leads to reconsideration of the tenotomy principles. Aim. This study aimed to formulate the anticipating criteria to assess the effectiveness of achillotomy in order to develop a different achillotomy approach for children with arthrogryposis. Materials and methods. This study retrospectively analyzed closed subcutaneous achillotomy in 28 patients (56 feet) with arthrogryposis. The mean age of the patients was 5.4 months (range 2–8 months). The children were subdivided into two groups according to the residual equinus deformity after the completion of Ponseti serial casting. All patients were physically and radiographically examined. Results and discussion. The first group included 12 patients (24 feet), which achieved foot neutral position or dorsiflexion ≥5° after achillotomy. The second group consisted of 16 patients (32 feet) with residual equinus after achillotomy who required surgery. X-ray images showed that the patients in the second group had significantly wider tibiocalcaneal angle and smaller talocalcaneal angle in lateral view (р < 0.01). The correction values of the equinus deformity after achillotomy in the children with arthrogryposis were greatly limited: 27° (20°–30°) and 19° (10°–30°) in the first and second groups, respectively. Conclusion. Closed subcutaneous achillotomy for effective equinus elimination during clubfoot treatment by Ponseti method should be performed only after complete correction at the level of tarsal joints. X-ray examination of the feet is recommended for the children with arthrogryposis in order to evaluate the talocalcaneal divergence and heel position more comprehensively. Furthermore, the values of tibiocalcaneal and talocalcaneal angles in lateral view prior to achillotomy are essential prognostic factors of its effectiveness. Moreover, the severity of equinus contracture should be considered prior to achillotomy. Achilles tenotomy is inappropriate if equinus deformity exceeds 30°. In such cases, open surgery should be considered.