Achilles Tenotomy: Difference between revisions

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The maximum age when tenotomy can be used has not been established, however, so the authors suggested that a lengthening procedure using three incisions could be used in place of complete tenotomy in older children.<ref name=":1" />
The maximum age when tenotomy can be used has not been established, however, so the authors suggested that a lengthening procedure using three incisions could be used in place of complete tenotomy in older children.<ref name=":1" />
Percutaneous tendo Achilles tenotomy is safe,  inexpensive, effective, and an easy office procedure used to expedite the  correction of equinus deformity in idiopathic clubfeet with a very low complication rate.<ref>Percutaneous Tendo Achilles Tenotomy in the management of Equinus Deformity in conservatively treated CTEV. ''Riyaz Ahmad Dar, Mohd Shafi Bhat, Mohmad Yaseen Rather, Ansar ul Haq, Shera Ifran Ali.''
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== Errors During Tenotomy ==
== Errors During Tenotomy ==

Revision as of 15:36, 7 September 2017

Introduction[edit | edit source]

After the final manipulation it is time to correct the equinus. Note that at this stage the total midfoot Pirani score is usually 0, the cavus, adductus, and varus are all corrected, the lateral head of talus is fully covered, and the foot is 50– 70° abducted. In a few cases the equinus can be corrected by manipulation, but in 90% the tendo Achilles is too tight and a tenotomy is needed.

The tenotomy corrects the rigid equinus. It is a complete cut through of the Achilles tendon, not a tendon lengthening. It creates a very small incision – it is known as a percutaneous (“through the skin”) tenotomy.

In infants the tendon heals sufficiently in 3 weeks.

It is necessary because although tissues yield to gentle stretch, collagen of the Achilles tendon is more restrictive than the joint capsule and ligaments and does not respond to stretching as predictably. [1]

Remember: In most cases tenotomy is needed”

Indication for Tenotomy[edit | edit source]

Are the following all present?

If yes then proceed to tenotomy. If no then the foot may need more manipulation and casting:

  • Talar Head Covered (Piranni Midfoot Score Usually = 0)
  • Foot Abducts to 50 - 70 Degrees
  • Heel in Valgus or at least Neutral

In some rare cases when the above criteria are reached, the Achilles Tendon will not be tight, and if it allows Dorsiflexion to greater than 15° then tenotomy can be avoided. Our experience is that over 90% of cases need a tenotomy. [1]

Remember: Cover talus before tenotomy

Considerations[edit | edit source]

  • Communicate with surgeon BEFORE tenotomy
  • Anticipate date through Pirani Scores, using graph if possible
  • Allow time for questions from parents
  • Decide on holding / casting roles
  • Measure the foot to organize a brace, which will be needed next visit
  • Paperwork and informed consent of parent
  • Set up equipment
  • Clinic environment: calm, quiet, baby feeding [1]

Equipment Required[edit | edit source]

  • Sterile area, linen or paper sterile field
  • Antiseptic
  • Small syringe with small gauge needle (25g or smaller – an insulin syringe is perfect)
  • Local anaesthesia Lignocaine 1–2% (inject 0.5–1ml)
  • Gloves
  • #15 blade
  • Sterile gauze
  • A watch or phone to time 5 minutes (pressure over wound), or until bleeding stops
  • The right size underwrap and padding need to be ready
  • 2 Trained People:
    • 1 to perform the Tenotomy
    • 1 to Assist [1]

Procedure[edit | edit source]

This may be done in the clinic by an orthopaedic clinical officer or experienced clinician. One needs a foot holder and a tenotomist. The foot holder grips the leg below the knee and the midfoot, with the child’s knee in extension. A generous antiseptic prep of the heel and ankle is applied, extending medially and laterally. A small amount of local anaesthetic is placed medial to the Achilles tendon 1cm proximal to its insertion. (Do not use a lot or the tendon is difficult to feel.)

Insert the knife (a number 15 scalpel or beaver blade works well) on the medial side, parallel to and beneath (anterior to) the tendon approximately 1cm above its insertion into the calcaneum. Turn the sharp edge of the knife to the tendon and perform the tenotomy. The “release” obtained after a complete tenotomy is easily felt. Often there is a “pop” sound. 10–20 degrees of additional dorsiflexion will be obtained.

Clean skin with alcohol to remove the betadine. Place a sterile dressing over the wound. Apply firm pressure for 5 mins (or until bleeding stops) over the incision site. Apply the post-tenotomy cast: keep knee in 90 degrees flexion. Wrap with under-cast padding. Place a well-moulded above-knee plaster cast with the foot in maximum dorsiflexion (at least 15 degrees) and 50-70 degrees of abduction (with no eversion). This last cast should be worn for 3 weeks. The patient should remain in the department for 1 hour to check for bleeding and circulation.[1]

Achille tenotomy procedure - clubfoot

Effectiveness of Tenotomy[edit | edit source]

Some clinicians have expressed concerns about performing a complete tenotomy (completely severing) of the Achilles tendon, fearing this procedure will cause damage. However, an ultrasound study on children who had undergone Achilles tenotomy as part of their clubfoot treatment showed tendon re-growth; most tendons were clinically intact after 3 weeks and after 6 weeks all were intact.[2]

Even in a study of older children (7-11 years old) Achilles tenotomies were performed on all participants; none of the participants had weakness of the gastrocnemius or soleus muscles.[3]

The maximum age when tenotomy can be used has not been established, however, so the authors suggested that a lengthening procedure using three incisions could be used in place of complete tenotomy in older children.[3]

Percutaneous tendo Achilles tenotomy is safe,  inexpensive, effective, and an easy office procedure used to expedite the  correction of equinus deformity in idiopathic clubfeet with a very low complication rate.[4]

Errors During Tenotomy[edit | edit source]

  • Premature equinus correction

Attempts to correct the equinus before the heel varus and foot supination are corrected will result in a rocker-bottom deformity. Equinus through the subtalar joint can be corrected only if the calcaneus abducts. Tenotomy is indicated after cavus, adductus, and varus are fully corrected.

  • Failure to perform a complete tenotomy

The sudden lengthening with a “pop” or “snap” signals a complete tenotomy. Failure to achieve this may indicate an incomplete tenotomy.Repeat the tenotomy maneuver to ensure a complete tenotomy if there is no “pop” or “snap.” [5]

Management Post Tenotomy[edit | edit source]

  • Cast after tenotomy stays on for 3 weeks
  • Book date for brace fitting and order brace
  • Foot must be in a dorsiflexed and abducted position to fit into brace. The last cast is applied with the foot in 50-70 degrees of abduction and at least 15 degrees of dorsiflexion. After removal of the last cast 3 weeks later there is correction of cavus, adductus, varus, and equinus (CAVE).

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 Africa Clubfoot Training Project. Chapter 7 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
  2. Barker S, Lavy C (2006) Correlation of clinical and ultrasonographical findings after Achilles tenotomy in idiopathic club foot. The Journal of Bone and Joint Surgery 88-B (3): 377-379
  3. 3.0 3.1 Khan S & Kumar A (2010) Ponseti’s manipulation in neglected clubfoot in children more than 7 years of age: a prospective evaluation of 25 feet with long term follow-up.  Journal of Pediatric Orthopedics B 19: 385-389
  4. Percutaneous Tendo Achilles Tenotomy in the management of Equinus Deformity in conservatively treated CTEV. Riyaz Ahmad Dar, Mohd Shafi Bhat, Mohmad Yaseen Rather, Ansar ul Haq, Shera Ifran Ali.
  5. Lynn Staheli, Ignacio Ponseti, & Others. Clubfoot: Ponseti Management, 3rd Edition. Global Help, 2009. p13-15