Ultrasonographic Evaluation of Achilles Tendon Healing after Percutaneous Tenotomy for the Correction of Congenital Clubfoot by Ponseti Method

Vol 32 | Issue 2 | July – Sep 2017 | page: 5-9 | Saurabh Agarwal, Ashutosh Kumar


Authors: Saurabh Agarwal [1], Ashutosh Kumar [1]

[1]Department of Orthopaedics, M.L.B. Medical College, Jhansi, Uttar Pradesh, India.

Address of Correspondence
Dr. Ashutosh Kumar,
Room No 60, Senior Boys Hostel
M.L.B. Medical College,
Jhansi-284128


Abstract

The Study is attempt to establish the regulation of Achilis tendon after percoetaneous tenotomy in idiopathic clubfoot patient as per ponsenti method of correction clinically and evaluation by ultrasound.The prospective study was conduct on 21 patients with idiopathic clubfoot deformity admitted in orthopaedic department of M.L.B. Medical College, Jhansi (UP) with reference to age and sex for the period from Aug 2014 to Aug 2016 babies with neurological condition, syndromic condition, recurrent and complex clubfoot case are excluded from the study. Detailed personal history was
recorded including age, sex, father and mother name, address and number of cast applied etc. A mean retraction of 2.26 mm (range 2.3 to11.0 mm) between tendon stump after tenotomy was observe using ultrasound and in each foot clinical evidence of successful tenotomy was taken as a definitive increase in dorsiflexion at the ankle and lack of a palpabale heel cord. Full leg corrective cast was applied for 3 week after 3 week ultrasound showed tendon healing with the tendon gape filled with irregular hypoechoic tissue and along with transmission of muscle motion to the heel. At 6 month after tenotomy there was structural filling a fibrillar aspect, mild or moderate hypo. Echogenicity and tendon scar thickening when compared with a normal tendon. 1 year after tenotomy USG showed a fibrillar structure and echogenicity at the repair site that was similar to a normal tendon
but with persistent tendon scaring thickness. There is fast reparative process after Achilles tendon percutanous section after reestablishing conducting between stumps. The reparative tissue evolved to tendon tissue with a normal USG appearance except for mild thickening suggesting a predominating intrinsic repair mechanism.
Keywords : Clubfoot, Achilles tendon healing, Ultrasonography.


Introduction

Idiopathic congenital talipes equinovarus is a common condition affecting between 1 per 1,000 live births2,5,8. The Ponseti technique is well recognised in the management of clubfoot deformity with high success rates. This technique has decreased the need for extensive corrective surgery. Following the serial application of casts as per Ponseti’s original descriptions, a percutaneous Achilles tenotomy is undertaken to enable or improve foot dorsiflexion. The natural history of healing of the tenotomised tendon is not well understood. Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase. In previous studies3,4, the reported length of time for tendons to achieve continuity based on ultrasound images and clinical assessment varied between six weeks to 45 months. We monitored the post-tenotomy healing process using high frequency ultrasound to understand the appearances of the healing tendon and the timescale over which the tenotomy healed. We also studied patients that had undergone an Achilles tenotomy several years previously to ascertain the longer-term effect of the Ponseti treatment. Ponseti recommends the use of a beaver eye blade scalpel to divide the tendon. This procedure is considered safe, although excessive bleeding and pseudoaneurysm formation have been reported1.  We carried out percutaneous tenotomy to correct equinus in patients treated with the Ponseti technique, and found that after 6 months, all cases showed clinical and ultrasonographic connections between the divided stumps in less than 1 year of age. Ultrasonography is reliable and reproducible in evaluating tendons following Achilles tenotomy (Ponseti method) for congenital clubfeet2,7. It can be used for assessment of tendon regeneration, quantitative measurement of tendon thickness and length of reparative tissue. We measured the size of the Achilles tendons in congenital clubfeet using ultrasonography before and after percutaneous tenotomy.  Material and Methods: The aim of the present investigation was to prospectively assess and characterize the Achilles tendon healing using ultrasonographic scanning after percutaneous tenotomy in patients with congenital clubfoot treated with the Ponseti technique in the department of Orthopaedics, MLB Medical College, Jhansi. Approval was obtained from our local ethical committee and inform consent from the parents of each patients was obtain. Inclusion Criteria: 1. Children with idiopathic congenital clubfoot treated with the Ponseti method who have undergone percutaneous Achilles tenotomy to correct  the residual equinus; 2. The primary and follow-up treatment have both been performed in our institution; and 3. Minimum follow-up of 1 year. Exclusion Criteria: 1.Associated malformations 2. Syndromic cases 3. Neurologic sequelae or parental noncompliance.  INTRODUCTION: Idiopathic congenital talipes equinovarus is a common condition affecting between 1 per 1,000 live births2,5,8. The Ponseti technique is well recognised in the management of clubfoot deformity with high success rates. This technique has decreased the need for extensive corrective surgery. Following the serial application of casts as per Ponseti’s original descriptions, a percutaneous Achilles tenotomy is undertaken to enable or improve foot dorsiflexion. The natural history of healing of the tenotomised tendon is not well understood. Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase. In previous studies3,4, the reported length of time for tendons to achieve continuity based on ultrasound images and clinical assessment varied between six weeks to 45 months. We monitored the post-tenotomy healing process using high frequency ultrasound to understand the appearances of the healing tendon and the timescale over which the tenotomy healed. We also studied patients that had undergone an Achilles tenotomy several years previously to ascertain the longer-term effect of the Ponseti treatment. Ponseti recommends the use of a beaver eye blade scalpel to divide the tendon. This procedure is considered safe, although excessive bleeding and pseudoaneurysm formation have been reported1.  We carried out percutaneous tenotomy to correct equinus in patients treated with the Ponseti technique, and found that after 6 months, all cases showed clinical and ultrasonographic connections between the divided stumps in less than 1 year of age. Ultrasonography is reliable and reproducible in evaluating tendons following Achilles tenotomy (Ponseti method) for congenital clubfeet2,7. It can be used for assessment of tendon regeneration, quantitative measurement of tendon thickness and length of reparative tissue. We measured the size of the Achilles tendons in congenital clubfeet using ultrasonography before and after percutaneous tenotomy.

Material and Methods

The aim of the present investigation was to prospectively assess and characterize the Achilles tendon healing using ultrasonographic scanning after percutaneous tenotomy in patients with congenital clubfoot treated with the Ponseti technique in the department of Orthopaedics, MLB Medical College, Jhansi. Approval was obtained from our local ethical committee and inform consent from the parents of each patients was obtain.


Inclusion Criteria: 1. Children with idiopathic congenital clubfoot treated with the Ponseti method who have undergone percutaneous Achilles tenotomy to correct  the residual equinus; 2. The primary and follow-up treatment have both been performed in our institution; and 3. Minimum follow-up of 1 year.
Exclusion Criteria: 1.Associated malformations 2. Syndromic cases 3. Neurologic sequelae or parental noncompliance.
Material Used Figure 1: Soft cotton and plaster roles Figure
2: Tenotomy kit – # 15 blade with handle,     xylocaine, syringe
Patients were placed in a prone position and the feet were dorsiflexed to maximum to make the Achilles tendon taut. Achilles tendons of both feet were scanned approximately 1 cm above the calcaneal insertion. In patients with unilateral clubfoot, the normal foot was used as a referent. Longitudinal scans assessed the echotexture, echogenicity, and continuity of the tendon. Transverse scans assessed the shape, echotexture, echogenicity, thickness, and width of the tendon. The medial aspect of the Achilles tendon was incised under general anaesthesia. The extent of tenotomy was assessed by a ‘pop’ sound and giving way, correction of equinus, and appearance of a palpable gap in the tendon. Postoperatively, a cast was applied for 3 weeks, with the foot in abduction and maximum dorsiflexion. The cast was then replaced with foot abduction braces. Ultrasound scan was done on third week, 6months and one year followed tenotomy

Results

Between august 2014 and august 2016, 21 patients fulfilled the inclusion criteria, with 30 feet. Mean age at tenotomy was 16.7 weeks, ranging from 6.3 to 40.5 weeks. The mean thickness of the affected Achilles tendon before tenotomy was 2.52mm, ranging from 1.70 to 4.20mm. In patients with unilateral deformities, the normal tendon mean thickness in the non-affected foot was 2.50mm (SD=0.43), ranging from 2.00 to 3.60mm. There was no evidence of difference between normal and affected tendons in ultrasonographic appearance figure 3 and thickness before the tenotomy (P=0.45). Results: Between august 2014 and august 2016, 21 patients fulfilled the inclusion criteria, with 30 feet. Mean age at tenotomy was 16.7 weeks, ranging from 6.3 to 40.5 weeks. The mean thickness of the affected Achilles tendon before tenotomy was 2.52mm, ranging from 1.70 to 4.20mm. In patients with unilateral deformities, the normal tendon mean thickness in the non-affected foot was 2.50mm (SD=0.43), ranging from 2.00 to 3.60mm. There was no evidence of difference between normal and affected tendons in ultrasonographic appearance figure 3 and thickness before the tenotomy (P=0.45). Figure 3: Ultrasound scan before tenotomy it shows homegenosly echoic fibrillar structures arrow.

A. Osseous Portion of Calcaneum , B. Tibia. Ultrasound performed immediately after tenotomy[Figure 4]  showed a hypoechoic area between stumps separated by a mean distance of 5.65mm (range: 2.3 to 11.0mm; . Initially the gap had a hyperechoic image with reverberating echotexture represented by air penetration, and immediately afterwards, the image became hypoechoic due to the hematoma formation. However, the residual connections between stumps persisted in some cases, and these cases required division under ultrasound guidance.

Figure 4: Achilies tendon longitudinal image just after tenotomy showing stump retraction is initially filled by air and soon replace by hematoma. There was 1 case of unusual bleeding, which was controlled by digital pressure, and this did not compromise foot perfusion or interfere with the treatment. Three weeks after tenotomy,[Figure 5] the ultrasound scans showed that the tendinous gap was filled with hypoechoic, disorganized repair tissue, with a loss of the fibrillar architecture, ill-defined margins, and scarring with varied characteristics. Figure 5: Achilles tendon longitudinal image 3 week after tenotomy The tenotomy space is filled with hypoechoic tissue displaying disorganized fibrillar pattern.Six months after the tenotomy[Figure 6], a well-formed tendinous structure could be observed, with a fibrillar appearance similar to normal tendon, but with slight or moderate hypoechogenicity and focal tendon thickening at the tenotomy site.   Figure 6: Achilles tendon longitudinal image 6 month after tenotomy. Tendon tissue regeneration occurred with fibirllar pattern near normal echogenicity. One year after tenotomy[Figure 7], focal tendon thickening persisted in the repaired area, although the fibrillar pattern and echogenicity were similar to those of normal tendons . The mean thickness in operated tendons at this time was 4.03mm.   Figure 7: Achilles tendon longitudinal image 1 year after tenotomy.Echotexture similar to a normal tendon with slight thickening at the tenotomy site.

Discussion

Healing of the tendon has classically been described as involving extrinsic or intrinsic factors or a combination of the two. Recent studies2-7 has suggested that embryonic mechanism may responsible for healing in the adult tendon. Thus the rapid healing in infants aged one to two months in whom progenitor cell are abundant, could involve the same mechanism.

Ultrasound tendon examination is accepted as a reliable method for routine tendon assessment providing tendon measurement, morphology and texture, ultrasound scan of 6 months shows maturation of healing tissue evidenced by an increasingly normal echogenicity and a fibrillar aspect of the parallel linear echotexture leading to conclude as predominantly intrinsic mechanism is responsible for the formation of a normal or near normal tendon2-7. Ultrasonography is a non invasive and dynamic tool for assessing prenatal clubfoot, severity of clubfoot, correction using single and different methods and Achilles tendon regeneration. Ponseti recommended tenotomy in patients up to 1 year age although we extend this age limit for revision in resistant cases it is possible that the prolonged healing seen in children older than one and half year of age a similar to that seen in adults in whom the gap in the Achilles heals with fibrous tissue rather than tendon fiber. We conclude that healing in percutaneous Achilles tenotomy follows sequential phases similar to those described in healing of tendons in a previous studies6,7. We should be cautious about performing Achilles tenotomies for clubfeet in children over the age of one and half year as such patients appear to have slower healing with an added potential risk of adhesion formation.


References

1. Dobbs MB, Gordon JE, Walton T et al. Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity. J Pediatr Orthop 2004: 24: 353-357.
2. Barker SL, Lavy CB, Correlation of clinical and ultrasonographic findings after Achilles tenotomy in idiopathic clubfoot. J Bone Joint Surg Br. 2006: 88: 377-379.
3. Govind Kumar Gupta, Sudha Rani, Chinmany Sahu and SB Singh : Redevelop of Achilles tendon after percutaneous tenotomy in idiopathic clubfoot patients as per ponseti’s method of orrection clinical and using two needle. International Journal of Recent Scientific Research, Aug 2015,Vol 6, Issue 8, : 5665-5671
4. S. Marleix, M. Chapuis, B. Fraisse, C. Tréguier, P. Darnault, C. Rozel, M. Rayar, P. Violas : Idiopathic club foot treated with the Ponseti method. Clinical and sonographic evaluation of Achilles tendon tenotomy. A review of 221 club feet. Orthopaedics & Traumatology: Surgery & Research, Volume 98, Issue 4, Pages S73-S76.
5. Saini R,Dhillon MS, Tripathy SK, Goyal T, Sudesh P, Gill SS, Gulati A. Regeneration of the Achilles tendon after percutaneous tenotomy in infants: a clinical and MRI study. Journal of pediatric orthopedics. Part B 19:4 2010 Jul pg 344-7.
6. Mangat KS,Kanwar R, Johnson K, Korah G, Prem H. Ultrasonographic phases in gap healing following Ponseti-type Achilles tenotomy. The Journal of bone and joint surgery. American volume 92:6 2010 Jun pg 1462-7.
7. Agarwal A, Qureshi NA, Kumar P, Garg A, Gupta N. Ultrasonographic evaluation of Achilles tendons in clubfeet before and after percutaneous tenotomy. Journal of orthopaedic surgery (Hong Kong) 20:1 2012 Apr pg 71-4.
8. Ponseti IV. Congenital club foot: fundamentals of treatment. New York, NY: Oxford University Press; 1996:82–84.


How to Cite this Article: Agarwal S, Kumar A. Ultrasonographic Evaluation of Achilles Tendon Healing after Percutaneous Tenotomy for the Correction of Congenital Clubfoot by Ponseti Method. Journal of Bone and Joint Diseases Jul-Sep 2017;32(2):5-9.

 


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