tenotomy question

May 27, 2004

The ponseti approach usually includes the tenotomy with the final cast

in the series of 5-7. With my daughter, our doctors were new to the

ponseti approach and I believe underestimated the tendon's ability to

tighten back up with time. I was told later (when she was 11 months and

needing the tenotomy) that we probably should have gone ahead with the

tenotomy when she was 5 weeks old (with the final cast). However,

because there is a small percentage of children that do not need the

tenotomy, perhaps your doctor feels like Sophia might be one of those.

I was told to manipulate her foot on a daily basis using stretching

exercises and to contact them if she had stiffness. Is this the method

that your physician is employing? Medically, I don't really think you

lose a great deal by doing it later even though I read a couple of

years ago that it is important to do the tenotomy before the child

reaches one year for good results. (Maybe someone else is more

knowledgeable about this?!!) What I can tell you is that I believe it

is easier for the children at a younger age. did not have

general (just a local) and they did not give her a sedative (that I had

asked that they do) because at this particular hospital it would have

required an anesthesiologist. I really had hoped that they would have

since she had a heightened since of what was going on by 11 months.

When they are at a younger age, it seems like less of a procedure,

maybe it's because they have a smaller tendon to work with?!

Thankfully, I was still nursing at the time of the tenotomy

and she calmed down immediately after I latched her on. From my own

experience, I would consider asking the doctor why he is utilizing the

" wait and see approach " . I think the risk of the procedure is so low

that most doctors now would go ahead with it simply because that is

what they are encouraged to do when following ponseti's protocol. You

are doing a great service for Sophia by educating yourself and

advocating for her. Give yourself a pat on the back!

Best wishes,

Amy (mom to 6-10-01)

> There are Doctors out there who cast the babies, put them in the

> DBB/shoes, and then later do the tenotomy, recast, and then go back

> to the shoes. In contrast, there is the casting, tenotomy, then

> DBB/shoes approach. Does anyone know why the first approach is

> used? Which scenario is preferable from a child's well being

> perspective (maybe this depends on whether the tenotomy would be done

> under general vs local anesthesia?)? It seems like a hassle to have

> to go back later and do the tenotomy, since then the baby is back in

> casts. Does the heel tighten up with time and then require it? I'm

> curious what other parent's experience/knowledge about this is and

> what explainations Doctors have given you for the first scenario.

> Just trying to better educate myself here. Thanks for your reply.

>

> and Sophia 12/8/03 bcf

>

May 27, 2004

had the first scenario. Cast, brace, cast, tenotomy, cast,

brace. We started out with a doctor in the area that uses a modified

Ponseti method. He chose not to do the tenotomy because he says that

the Achilles tendon will continue to stretch. But then we switched

to Dr Ponseti because I was uncomfortable with some of his

modifications. Dr Ponseti doesn't use the wait and see approach. He

said that she had never been fully corrected and needed the tenotomy,

so that is what we had done. I would have preferred the tenotomy

right away because now we have to start the FAB 23/7 all over again

and now she is older and a little less flexible in her daily routine

and I am afraid she will be quite unhappy to have to have her feet

together. So I think it depends on if the doctor has a get it over

with approach or a wait and see approach. HTH

Tori 1/30/04 bilateral atypical cf, 1 day left in the cast if we get

our shoes

May 28, 2004

In our case my son was on the edge. His achilles tendon was considered to be

an acceptable tightness. But, his CF kept slipping out of the DBB because I

couldn't get his heel to go all the way down. We ended up doing the

tuetonomy at a later date. ALso my son was already 7 months old by the time we

switched to a new Ponseti Dr. His heel has not slipped out of the DBB since

then.

I have also noticed that there is now way more flex in his foot regarding his

achilles tendon.

Our Dr. did the procedure in office. My son had a local and did just fine.

Afterwards on the long drive home (we drive 4 hours one way to see a Ponseti

Dr.) we gave him some Tylenol or Motrin I don't remember which right now. I

did not want my son to have anethesia due to the fact that my family has

Malignant Hypothermia. MH is a very rare and deadly allergy to anethesia. My

son

has over a 50% chance of having this rare allergy.

I hope this answers your questions satisfactorily.

LaRena

Dillon 1/17/03 Right CF

August 22, 2004

Ok, I understand what the tenotomy is and because Christian's first doctor

said he didn't need it I do not fully understand why a 2nd or 3rd one would

be necessary. So, now that he will be having this done.could someone please

answer the following:

The doctor cuts the tendon..is it reattached.does it grow back..what's the

deal..how does this work?????

Why would it have to be repeated?

Thank you in advance.

Mom to 12/17/98 and

Christian 1/30/04 (unilateral clubfoot) .

August 22, 2004

Hi ,

Here is my answer from experience...

Yes, the doc cuts the Achilles tendon. The tendon reattaches itself

and heals during the 3 week cast that follows (human bodies are

amazing don't ya think?!)

In 's case, it had to repeated because the first time it was

done, her foot was not fully corrected so the results were not

optimal. The hope is that her foot will have 10 degrees (I think

that's the number) of dorsiflexion (toes pointing toward face). Now

that her foot has been corrected to the right degree of external

rotation and the tenotomy has been repeated, I am hoping that when

this cast come off, I will be able to see a big improvement!

Hope that helps! When will Christian have his done?

Marilouise

9/9/03, LCF, 3 week cast after 2nd tenotomy

Owen and 3/20/99

> Ok, I understand what the tenotomy is and because Christian's

first doctor

> said he didn't need it I do not fully understand why a 2nd or 3rd

one would

> be necessary. So, now that he will be having this done.could

someone please

> answer the following:

>

> The doctor cuts the tendon..is it reattached.does it grow

back..what's the

> deal..how does this work?????

>

> Why would it have to be repeated?

>

> Thank you in advance.

>

> Mom to 12/17/98 and

>

> Christian 1/30/04 (unilateral clubfoot) .

>

August 22, 2004

Marilouise,

One more thing, ok, I understand that it reattaches itself.but is it

stretched then? Because if it just reattached wouldn't you be back the way

you were before the tenotomy? Do I sound like an idiot or what..I should

know this.

So, if 's was done right the first time..she wouldn't have needed a

2nd one?

Dr. Herzenberg said after his third cast he will have the tenotomy.

Mom to 12/17/98 and

Christian 1/30/04 (unilateral clubfoot) .

_____

From: Marilouise Tozier

Sent: Sunday, August 22, 2004 10:36 AM

To: nosurgery4clubfoot

Subject: Re: tenotomy question

Hi ,

Here is my answer from experience...

Yes, the doc cuts the Achilles tendon. The tendon reattaches itself

and heals during the 3 week cast that follows (human bodies are

amazing don't ya think?!)

In 's case, it had to repeated because the first time it was

done, her foot was not fully corrected so the results were not

optimal. The hope is that her foot will have 10 degrees (I think

that's the number) of dorsiflexion (toes pointing toward face). Now

that her foot has been corrected to the right degree of external

rotation and the tenotomy has been repeated, I am hoping that when

this cast come off, I will be able to see a big improvement!

Hope that helps! When will Christian have his done?

Marilouise

9/9/03, LCF, 3 week cast after 2nd tenotomy

Owen and 3/20/99

> Ok, I understand what the tenotomy is and because Christian's

first doctor

> said he didn't need it I do not fully understand why a 2nd or 3rd

one would

> be necessary. So, now that he will be having this done.could

someone please

> answer the following:

>

> The doctor cuts the tendon..is it reattached.does it grow

back..what's the

> deal..how does this work?????

>

> Why would it have to be repeated?

>

> Thank you in advance.

>

> Mom to 12/17/98 and

>

> Christian 1/30/04 (unilateral clubfoot) .

>

August 22, 2004

Hi ,

Yes, from what I understand, the doc manipulates the foot after the

tenotomy for the final cast which means the tendon reattaches in the

new position. No you are NOT an idiot. We are all learning as we

go and I still don't understand it all. We definitely have a

few " experts " on the subject on the list so hopefully they will

correct me if I am wrong

Yes, I think if 's foot had been fully corrected before the

original tenotomy than she would not have needed it again. Although

it would seem plausible that if a child have a serious relapse that

it may be needed again. Once again, I will defer to the more

knowledgable if I am wrong.

Christian's foot must be doing pretty well since ended up

with 6 castings in the second series before her tenotomy. I hadn't

expected she would need that many since most of those on the board

who went through the castings more than once only took a few more

(like what you've said for Christian). Guess 's foot was

worse than I thought.

Marilouise

9/9/03, LCF, 3 week cast after 2nd tenotomy

Owen and 3/20/99

> Marilouise,

>

> One more thing, ok, I understand that it reattaches itself.but is

it

> stretched then? Because if it just reattached wouldn't you be

back the way

> you were before the tenotomy? Do I sound like an idiot or what..I

should

> know this.

>

> So, if 's was done right the first time..she wouldn't have

needed a

> 2nd one?

>

> Dr. Herzenberg said after his third cast he will have the tenotomy.

>

> Mom to 12/17/98 and

>

> Christian 1/30/04 (unilateral clubfoot) .

>

> _____

August 22, 2004

.......This is just something kind of strange we heard from a foreign

doctor who was studying under Dr. Ponseti last year when we were there......He

said in his country (?) they would cut the Achilles tendon on prisoners to keep

them from running away and the cut had to be repeated ever few months because it

would grow back (thus allowing them to run away). I'm not sure if that is a

current practice where he came from or something from the old-days, but in

either event....Eewww! Man they take their prison system serious! haha His

point to his story however was that the tendon does grow back rather quickly

(even quicker in babies).

My oldest boy had two tenotomies performed because the first wasn't casted

properly afterwards so it didnt grow to the new position necessary for

correction. Not all babies need this done but it appears " most " club foot

babies do need it. It's a minor thing, please don't fret - it doesn't mean your

case is complicated or worse than you expected, etc. Your baby will be fine.

s.

Re: tenotomy question

Hi ,

Yes, from what I understand, the doc manipulates the foot after the

tenotomy for the final cast which means the tendon reattaches in the

new position. No you are NOT an idiot. We are all learning as we

go and I still don't understand it all. We definitely have a

few " experts " on the subject on the list so hopefully they will

correct me if I am wrong

Yes, I think if 's foot had been fully corrected before the

original tenotomy than she would not have needed it again. Although

it would seem plausible that if a child have a serious relapse that

it may be needed again. Once again, I will defer to the more

knowledgable if I am wrong.

Christian's foot must be doing pretty well since ended up

with 6 castings in the second series before her tenotomy. I hadn't

expected she would need that many since most of those on the board

who went through the castings more than once only took a few more

(like what you've said for Christian). Guess 's foot was

worse than I thought.

Marilouise

9/9/03, LCF, 3 week cast after 2nd tenotomy

Owen and 3/20/99

> Marilouise,

>

> One more thing, ok, I understand that it reattaches itself.but is

it

> stretched then? Because if it just reattached wouldn't you be

back the way

> you were before the tenotomy? Do I sound like an idiot or what..I

should

> know this.

>

> So, if 's was done right the first time..she wouldn't have

needed a

> 2nd one?

>

> Dr. Herzenberg said after his third cast he will have the tenotomy.

>

> Mom to 12/17/98 and

>

> Christian 1/30/04 (unilateral clubfoot) .

>

> _____

August 22, 2004

,

Tenotomies have been done for the past 100 plus years. The

difference is in the pre and post-tenotomy manipulation and casting

done in the Ponseti method that was not done in other methods that

utlized a tenotomy.

Most tendons in the body are like a stretched rubber band that

slides inside a sheath. If they are cut, then you have to go back

inside each sheath to pull the ends back together and then stitch

them together to get them to heal properly.

The achilles tendon and a few other tendons in the body are attached

to the surounding tissue. When it is cut, the ends separate a bit,

but the tendon doesn't slide away from the other cut end. Then for

some reason, the achilles tendons in baby's can regenerate the gap

left between the two tendons. (and to a lesser degree in adults).

There is no need to restitch the two ends of the tendon back

together to have it heal.

The trick is that the tendon gap will heal in the position that the

foot is casted in. The amount of additional length of the tendon

depends on how the doctor casts it. If the final cast is not put on

with the correct amount of abduction (turning out to the side) and

dorsiflexion (lifting of the foot up), then the achilles tendon will

heal with the wrong or lower amount of correction. Also if the

FAB/DBB is not set correctly, the foot could relapse easier back

into a non-corrected position.

My opinion is that these problems may occur more often with doctors

who are new to doing tenotomies and the Ponseti method and not as

experienced in the amount of overcorrection needed in the final cast

to make everything heal correctly. The foot actually needs to be

overcorrected beyond a normal position so that the natural relapsing

process will put it back to normal as the child gets out of the

FAB/DBB at 2-4 years of age.

Some additional tenotomy information although from a rather grisly

and uncomfortable source. Dr. Ponseti mentioned that during World

War II, that the Nazi's took adult and teenage males and severed

their achilles tendons to make it so that they could not escape very

easily. The Nazi's found that their prisoners achilles tendons

would regenerate in a few months and heal and that they would have

to keep redoing it every so often.

Also, I talked to a Dr. Godfried at Texas Tech, Lubbock a few

years ago. He said that when he began the use of the Ponseti

method ; he asked his radiologist technician to do an analysis of a

clubfoot he had treated with a tenotomy. I can't remember if it was

with x-rays, ultrasound or what they had used. The technician

responded that they didn't see any difference in the achilles tendon

from a normal tendon where it had regenerated back together such as

they would have with normal scar tissue on a open incision tendon.

and (3-17-99)

> Ok, I understand what the tenotomy is and because Christian's

first doctor

> said he didn't need it I do not fully understand why a 2nd or 3rd

one would

> be necessary. So, now that he will be having this done.could

someone please

> answer the following:

>

> The doctor cuts the tendon..is it reattached.does it grow

back..what's the

> deal..how does this work?????

>

> Why would it have to be repeated?

>

> Thank you in advance.

>

> Mom to 12/17/98 and

>

> Christian 1/30/04 (unilateral clubfoot) .

>

August 22, 2004

Thank you for the info.

That is sick that they did that to people just so they wouldn't run away!

Mom to 12/17/98 and

Christian 1/30/04 (unilateral clubfoot) .

_____

From: Egbert

Sent: Sunday, August 22, 2004 5:45 PM