Tendon Release in Babies with Clubfoot After Ponseti Treatment
It is always distressing when a baby is born with a foot deformity known as "clubfoot." The clubfoot is unmistakable. The foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus (also known as "equinovarus"). Equinus means that the toes are pointed down and the ankle flexed forward (sort of like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.
A commonly accepted treatment for this problem is the Ponseti Method, a series of sessions involving manipulation and casting of the foot. If the foot does not fully correct, then the surgeon can release the Achilles tendon and recast the foot. The tendon release procedure is called a tenotomy. Without the constant pulling of a tight tendon, the ankle can assume and maintain a correct alignment.
In this study, surgeons from Israel evaluate the results of using the Achilles tenotomy when it was performed as an outpatient procedure without general anesthesia. The children were given a local anesthetic so they didn't feel anything. It wasn't necessary to put them to sleep and they went home an hour later. The tenotomy was done percutaneously. This means the needle used to lengthen the tendon was inserted through the skin without a large incision. Afterwards, the foot was put in a cast for three weeks and then the results measured.
Each child was followed closely to watch for any complications, need for hospital readmission, follow-up retenotomy, and to evaluate the foot correction. In the past, bleeding, nerve damage, infections, scarring, and residual equinus (from incomplete tendon release) have been reported complications. For this group, there were none of those (or other) complications.
Not all babies or young children with clubfoot treated with the Ponseti Method will need a tenotomy. In this study, all but one child required this additional procedure due to a lack of cooperation with using the foot brace that is recommended after casting. During the final stages of the Ponseti manipulation and serial casting, if the hind foot remains uncorrected, then a tenotomy to release the Achilles tendon (that is pulling on the hind foot) is considered.
The authors summarized by saying if and when a tenotomy is needed, it is safe to perform the operation as an office procedure. The skin is numbed with a topical agent and the area around the tendon numbed with a local anesthetic. The tendon is released safely and effectively without complications. When the parents follow-up diligently with the home program, the results are excellent. With good parental compliance, the need for a second tenotomy is eliminated.
Ehud Lebel, MD, et al. Achilles Tenotomy as an Office Procedure: Safety and Efficacy as Part of the Ponseti Serial Casting Protocol for Clubfoot. In Journal of Pediatric Orthopaedics. June 2012. Vol. 32. No. 4. Pp. 412-415.