Dear Editor,

We read with interest the article by Grigoriou et al. [1]. The authors discussed clubfoot patients treated with serial Ponseti casting with equinus corrected either by percutaneous Achilles tenotomy (AT) or combined open Achilles tenotomy and posterior capsulotomy (PC + AT).

We would like to make some comments regarding the manuscript.

  1. 1.

    The protocol observed at authors’ institution does not appear to conform to a standard Ponseti casting protocol [2]. The foot abduction criteria/talar head reduction prior to tenotomy procedure is not accounted. The equinus correction by PC + AT at the surgeon’s preference, even in a neonate, is probably also not aligned with the Ponseti method.

  2. 2.

    The PC + AT procedure was chosen for those cases which had a higher degree of equinus (34.83) compared to PC (27.31). The authors also acknowledge these findings in discussion. Thus there seems a selection bias in cases with PC + AT; this procedure being reserved for more severe cases. It is further not clarified whether PC implies just opening of the ankle or the ankle with the subtalar joint, as both are closely related in a younger child with equinus. We would like to inquire from authors about the average age of performance of PC + AT, as in a neonate it is a technically demanding procedure.

  3. 3.

    World over, bracing and patient education are considered most important confounders for recurrence in clubfoot [2]. Although the authors describe these in limitations, the conclusions drawn regarding AT + PC and AT alone in the study seems less justified in the absence of these.