PERCUTANEOUS orthopedics OPD in K R Hospital, Mysore

PERCUTANEOUSTENOTOMY OF THE ACHILLES TENDON USING A 16 GAUGE NEEDLE IN THE MANAGEMENT OFCLUBFOOTABSTRACT OBJECTIVE: To clinically evaluate, the effectiveness of percutaneous tenotomy of Achilles tendon using a 16 gauge needlein clubfoot treatment by ponseti technique.MATERIAL and METHODS: forty  five affectedfoot  were  prospectively evaluated in Twenty five patientswith ctev attending orthopedics OPD in K R Hospital, Mysore  and treated conservatively using ponsetitechnique between June 2016 and November 2017.

out of forty five affected feet,thirty nine feet required tenotomy and percutaneous tenotomy done using a 16gauge needle and assessed clinically.RESULTS: all 39 feet successfully managed,the reported complications of conventional tenotomy by knife excessive bleeding,pseudo-aneurysm or neurovascular compromise were not encountered with thistechnique.CONCLUSION: This percutaneous tenotomytechnique using a 16 needle is a simple procedure, safe and very effective andgives predictable results without any complications which were reported withtenotomy by knife.  INTRODUCTIONClubfoot or CTEV( congenitaltalipes equino-varus ), is one of the most common congenital pediatric foot deformitieswith an incidence of about 1 in 1000 live births 1, 2.  Equinusat ankle, hind foot varus, fore-foot adduction, and mid-foot cavus are the fourcomponents 3–6. Historically, Hippocrates introduced the conservativemanagement for clubfoot in around 400 BC 10, 11.

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Later, Kite introduced a method 12 in 1993, which included manipulationand casting technique, but the success rate was poor 7, 8, 13. Subsequently, Ponseti in 1963 developed a conservative method,called as Ponseti technique, consisting of serial manipulation, castingfollowed by possible tendoachilles tenotomy and casting and it takes about fourto five weeks to achieve the full correction of all four components of theclubfoot deformity 14, 15.       Ponseti management,over the past two decades has become accepted throughout the world as the mosteffective and less expensive treatment of ctev. The technique involves serialmanipulation and casting and possible percutaneous tendoachilles tenotomy.

About 85% of the cases treated with ponseti technique require  tendo-achilles tenotomy for correction ofresidual equinus deformity. 16-19     Percutaneoustenotomy using a surgical blade is widely used all  across the world but  Originally, as Ponseti described, tenotomy isperformed using a surgical blade, such as a no.11 or no.15 , or any other smallblade, such as an ophthalmic knife. However, complications related to theprocedure, such as excessive bleeding 23, formation of a pseudo-aneurysm 24and neurovascular injuries 25, were described. To avoid these rare butserious complications, many modifications have been introduced. Recently, newtechnique by using wide bore surgical needle is increasingly used which wasfirst described by Minkowitz et al.20,21,22.

.The technique of performingtenotomy with a needle may have advantages when compared to others tendonlengthening techniques, due to the minimally invasive approach, the simplicity ofprocedure and very low morbidity.23,24 Percutaneous tenotomy with a needle canbe performed in an outpatient setting and under local anesthesia. The surgeonavoids incising the skin.    The study is aimed to present our experiences in clinical outcome of percutaneous tenotomy of tendo-achilles using a 16Gauge needle to correct  the residualeqinus in management of congenital idiopathic clubfoot.

     MATERIALSAND METHODS                                   This prospectivestudy was performed in the Department of Orthopedics, Mysore medical collegeand research institute, Mysore. Between, June 2016 to November 2017, all thechildren with CTEV presenting to orthopedics opd in KR hospital during thisperiod were treated by the Ponseti casting technique. Only the idiopathic CTEVcases were included in the study. The Children with other other congenitaldeformities, syndromes or neurological causes of club feet and children withincomplete follow up were excluded from the study.          25 children with 20 bilateral and 5unilateral affected foot  met withinclusion  criteria were included in thestudy and managed by ponseti technique i.e. weekly manipulation and casting ofaffected foot, PIRANI scoring system used to asses  correction and tendoachilles tenotomy isplanned when midfoot – pirani score is zero.

In 2 children with bilateralaffected foot and 2 children with unilateral foot affected, acceptabledorsiflexion achieved by casting and not considered for tenotomy. Hence a totalof 39 affected feet have undergone tenotomy for tendo Achilles using a 16Gneedle.  All tenotomiesare done in an outpatient setting under oral sedative. The following techniqueas recommended by Minkowitz et al11. The child was placed in supine position,with the knee flexed to 90 degrees and the hip abducted so the posteriorportion of the leg and ankle can be easily accessible.

Position of the limb ismaintained by an assistant. The foot was forced into dorsiflexion which causestendo-achilles to become tense and easily palpable. With all the aseptic precautionsusing povidine iodine and 1%lignocaine of ~0.

2ml given using an insulin syringe,  medial border of tendo Achilles palpated anda  16 gauge sterile needle was inserted fromthe medial border of the tendo-achilles about 1 to 2 cm proximal to theinsertion of tendo-achilles.  Sectioningof the tendon performed using the beveled tip of the needle throughlateralization and elevation movements of the cutting end. A grating sensationperceived once tenotomy is completed with sudden loss of resistance to dorsiflexion  and increase in dorsiflexion . Success of thetenotomy confirmed with below mentioned clinical signs; a palpable depressionover the tendon in the sectioned region, increase in dorsiflexion and positiveThompson sign (Manual squeezing of the calf). Hemostasis achieved by lightpressure applied over the needle insertion site. The circulatory status of thetoes was observed by seeing nail blanching. The corrective POP cast is  applied with knee flexed at 90degrees and footpositioned in maximum dorsiflexion and abduction of ~70 degrees and the patientobserved for circulatory conditions of the ankles, the general state  and signs of bleeding for 30 minutes.Postoperatively, paracetamol was administered orally for pain relief