Children's therapy

Percutaneous achilles tenotomy in clubfoot (Ponseti method)

What is a percutaneous Achilles tenotomy?

A percutaneous Achilles tenotomy is a small surgical procedure in which the Achilles tendon (heel cord) is cut. It allows the ankle to flex upwards (dorsiflex). Percutaneous means ‘through the skin’, so the incision is very small.

Why is it recommended for my baby?

Achilles tenotomy is an integral part of the Ponseti Method and is required in up to 95% of babies. It allows the tendon to heal in a lengthened position, which in turn enables the ankle to flex upwards (dorsiflex). The ability to dorsiflex is functionally very important for walking, jumping and for lots of activities and games that children play.

When will my baby be ready for an Achilles tenotomy?

The tenotomy is performed when the midfoot components of the clubfoot have been corrected with Ponseti casting. The Ponseti Team will advise you when your baby is ready for the procedure; this is typically after 4 or 5 Ponseti casts.

Can my baby have more casting instead of the achilles tenotomy?

No. Ponseti casting is very effective at improving the midfoot deformity in clubfoot, because the ligaments stretch relatively easily. The Achilles tendon is thick and less pliable, so it doesn’t respond to casting in the same way. Further casting, instead of proceeding to a tenotomy, can lead to complications such as a ‘rocker bottom’ foot. The Achilles tenotomy is therefore vital in correcting the hindfoot tightness  and enabling greater ankle range of movement. Most babies will require the Achilles tendon tenotomy. 

How is the Achilles tenotomy performed?

The Achilles tenotomy is performed under local anaesthetic - this means that your baby will be awake. It will take place in the clinic room, which you will already be familiar with, rather than in an operating theatre.  The casts will be removed at the hospital, in the usual way, and the team will assess your baby to ensure he/she is ready for the tenotomy. A topical anaesthetic is applied onto the skin, where the incision will be made. You will meet the Paediatric Orthopaedic Surgeon who will discuss the procedure with you, answer any questions that you have, and ask you to sign a consent form. Lidocaine (local anaesthetic) is injected into the area around the Achilles tendon, to numb the deeper tissues. The baby’s skin is cleaned with iodine, just prior to the tenotomy. The actual procedure lasts just seconds. Steristrips and a sticking plaster are applied. A new Ponseti plaster cast is applied, holding the foot in its new, maximally corrected position

Will I be able to stay with my baby throughout the procedure?

Parents can typically stay with their baby during the tenotomy, but you may wish to wait outside. The final decision will be made in conjunction with the Ponseti Team.

What pain relief will my baby have?

Your baby will be able to have infant paracetamol, which you will be advised on, if they need it. Your baby can also have sucrose drops during the procedure, which helps to make them feel more comfortable. He/she can use a dummy for comfort and your baby can breast or bottle-feed when the plaster cast is being applied. They will also have received two forms of local anaesthetic.

How long will we be in hospital for and when can we go home?

The procedure itself only takes seconds. However, you should expect to be in the hospital for around two or three hours.

What should we bring to the hospital on the day?

You should bring baby paracetamol, a pair of socks and a dummy, if your baby is using one, in addition to nappies, wipes, sufficient milk if bottle-feeding etc.

When is the final plaster cast removed?

The post-tenotomy cast is usually removed after two and a half weeks. Occasionally, there is a change of cast after 10 days.

What happens next?

Congratulations – your baby will have completed the correction phase of the Ponseti Method! After the cast has been removed, your baby will be fitted into their foot abduction brace (boots and bar).The foot abduction brace is crucial in maintaining the correction and helping to prevent a relapse. 

How long will they be in the boots and bar for?

Your baby will need to wear the boots and bar for 23 hours a day for the first 12 weeks, followed by night-times and nap times until they are 5 years old.

What follow-up appointments will my baby need after the tenotomy?

This can vary for each baby, but the schedule below will give you an idea.

  • Two and a half weeks post-tenotomy: Removal of post-tenotomy cast. Fitted into foot abduction brace (to be worn for 23 hours per day).
  • One week later: Review appointment.
  • Five weeks later: Review appointment.
  • Six weeks later: Review appointment and progress to part-time foot abduction brace wear

Contact information

Children’s Physiotherapy Department
T: 020 3315 1604