Tenotomy

Tenotomy is a very common surgical procedure for children with clubbed feet. This and related procedures are also called tendon release, tendon lengthening, and heel-cord release (for tenotomy of the Achilles tendon). I was lucky to avoid all surgeries with my son, but since my daughters achilles tendon does not appear to be stretching as well as his does I am worried that surgery will be our fate.

A tenotomy happens in 80% of all clubbed foot cases. The surgery involves cutting and stretching of the achilles tendon. Sounds horrible, right? Well, without it a child's feet wouldn't heal properly and they'd end up walking on tip toes for the rest of their life since their calves would be so tight the heel of the foot couldn't reach the ground.

Tenotomy is performed in order to lengthen a muscle that has developed improperly, or become shortened and is resistant to stretch.

Club foot is a common developmental deformity in which the foot is turned inward, with shortening of one or more of the muscles controlling the foot and possibly some bone deformity as well.

A muscle can become shortened and resistant to stretch when it remains in a shortened position for many months. When this occurs, the tendon that attaches muscle to bone can shorten, and the muscle itself can develop fibrous tissue within it, preventing it from stretching to its full range of motion. This combination of changes is called contracture.

During a tenotomy, the tendon is cut entirely or partway through, allowing the muscle to be stretched. Tenotomy may be performed through the skin (percutaneous tenotomy) or by surgically exposing the tendon (open tenotomy). The details of the operation differ for each tendon.

During a percutaneous lengthening of the Achilles tendon, a thin blade is inserted through the skin to partially sever the tendon in two or more places. This procedure is called a Z-plasty, and is very rapid, requiring only a few minutes. It may be performed under local anesthesia.

Tenotomy carries a small risk of excess bleeding and infection. Tenotomy performed under general anesthesia carries additional risks associated with the anesthesia itself.

After tenotomy, the patient may receive pain medication. This may range from over-the-counter aspirin to intravenous morphine, depending on the severity of the pain. Ice packs may also be applied. The patient will usually spend the night in the hospital, especially children with swallowing or seizure disorders, who need to be monitored closely after anesthesia.

Casts are applied to the limb receiving the surgery. Before the cast is applied, the contracted muscle is stretched to its normal or near-normal extension. The cast then holds it in that position while the tendon regrows at its extended length. Braces or splints may also be applied.

After the casts come off (typically two to three weeks), intensive physical therapy is prescribed to strengthen the muscle and keep it stretched out.

Properly performed, tenotomy does not carry the risk of mortality. It may cause temporary pain and bleeding, but these are usually easily managed.

Reference: http://www.surgeryencyclopedia.com/St-Wr/Tenotomy.html

4 Weeks In...

Well, todays appointment raised my blood pressure a little bit. Sometimes it's hard to be going through this a second time because the medical staff assumes that I am old hat at it, but we must remember that I had it pretty "easy" with my son and everything was 'best case scenario' with his recovery.

In conversation with the casting technician I mentioned that I thought the doctor was having us do these extra few weeks of casts to avoid the tenotomy surgery (where they cut the achilles tendon). The casting technician told me casually, "Oh no, she'll be getting it done, her cords are very tight still." Gasp! No! :( Not my baby!

Then another casting technician came in to assist with putting on the new cast. I was making

small talk conversation again and mentioned how I kept forgetting to buy a pacifier to use during this procedure. It takes about 90 minutes to remove old casts and put on new casts. That's a long time for my aching back to be bent over letting my baby suck on my thumb. There are no breaks for breastfeeding, and crying baby most of the time because her sensitive legs are being messed with. Initially we decided not to do a pacifier for her because it was only supposed to be 2 or 3 casts. We let our son have a pacifier during the procedure 2 years ago because we knew that it would be 6 weeks of it. I joked that I hadn't picked up the pacifier yet because I was in denial that we're still on the casting phase. She then casually mentions to me that I should get mentally prepared for the tenotomy next time I see the doctor (which is 11/29/2010). I inquire further and find out that after the casts are removed it is highly likely that the tenotomy will happen right then and there. They do a numbing cream on the skin and then local anesthetic to block all sensation to her ankles/feet. Then a little slice... cut and stretch the achilles tendon... and close her back up. Very quick procedure... but surgery on a 7 week old baby none-the-less. Eek gads!! I'm glad that the techs were so frank with me, even if it was disheartening to hear. Without talking to them I would have walked into the appointment on the 29th with thoughts that we'd be taking off casts for the last time and then going to get her pretty AFO shoes set up. Surgery immediately never even occurred to me. Now I know to make sure my husband is with me at the hospital and that we have extra child care for her son set up at home (Yay for Grandma!)

So, random info about her process... it's still raw behind her knees and now she has another raw spot forming in between her toes on the right foot. She did the cast extra high this time so we can separate her toes for cleaning, but we have to keep an eye out for swelling with that much of her foot exposed. She's also started a habit of curling her pinky toe under, and the tech suggested that I should try to uncurl it every time I see her doing it otherwise it can lead to other problems. She'll end up walking with the top of her toe on the bottom if that makes any sense.