Karachi, November 23, 2022 (PPI-OT):Ponseti treatment has been well-established as the gold standard for treatment of idiopathic clubfoot in high-income countries and middle- and low-income countries (LMICs).(1) Percutaneous Achilles tendon lengthening is an integral part of clubfoot treatment when applying the Ponseti method and is done in up to 90% of affected patients.
(2) The tenotomy is usually performed in the clinic using a scalpel blade under local anaesthesia, however some surgeons prefer to perform this procedure in operating room under general anaesthesia which grossly increase the cost of procedure and also adding the risks associated with the anaesthesia. Minkowitz et al. have previously described a technique performing a tenotomy with a simple 16 Gauge (G) needle in the clinic making the procedure much simpler. (3)
Only an estimated 15% of children with clubfoot in LMICs have access to Ponseti treatment and even less will finish the entire treatment course. (1,4) Various barriers to clubfoot treatment have been identified, including lack of trained personnel in a clinic close to home, lack of parents’ understanding of the treatment and cost of the treatment.
(5) We believe that by adapting the technique from Minkowitz et al. to a low-resource setting can help address some of these barriers. Using a needle instead of a blade makes the procedure less cumbersome easier to learn and easier to understand for the provider, family and the patient.
Surgical Technique
Before initiating an Achilles tenotomy, the provider has to assure that all prerequisites have been met: plantigrade foot, 40° of abduction and consent of the patient’s guardian. The patient’s guardian is asked to leave the room when the surgeon is ready to start the procedure.
An overview of the set-up of the procedure room, including the position of the surgeon and the assistant is shown in figure 1. We place the patient in supine position on the examination table with an assistant holding the patient’s pelvis with one hand and the contralateral leg with the other hand. The surgeon holds the affected leg himself throughout the entire procedure.
Put the knee in a slightly flexed position and the hip abducted and externally rotated so that the posterior aspect of the ankle comes in front of the surgeon performing the tenotomy. We prefer the knee to be only slightly flexed so that the gastrocnemius muscle remains under sufficient tension and the Achilles tendon is taut.
Hold the foot in the non-dominant hand in full dorsiflexion so that the tendon becomes taut and disinfect the posterior aspect of ankle with povidone iodine-soaked gauze. Palpate the tendon with the index finger while wearing sterile gloves. 0.5ml of lidocaine is injected as a local anesthetic using a 1cc insulin syringe.
Insert the needle directly 1.5 cm above the insertion of tendon on the anteromedial edge of the Achilles tendon and direct the needle slightly into an anterolateral direction to avoid the posteromedial neurovascular bundle. After the injection of the local anesthetic, we introduce a 22G-needle at the same insertion site as the local anesthetic to appreciate the tendon fibres.
Using the tip of the needle as a cutting device, we section the fibres in medial to lateral direction. Any stabbing movements should be avoided and the tip of the needle should be considered as a blade. After 2 to 3 movements a pop is felt and the foot immediately achieves a dorsiflexion of about 15-20°.
A small swab is put over the needle insertion site to avoid any blood stains on the cast. A long leg cast is applied in full correction and maximum dorsiflexion with the knee flexed as described by the Ponseti protocol.
Discussion
We use a 22G instead of a 16G-needle as described by Markowitz et al. because we find it is readily available in our setting and less invasive, especially in neonates.
In our population which presents often with signs of malnutrition or under nutrition we often see that the skin is very fragile and a 16G needle or blade can cause significant skin defects.(6) Prior concerns were raised by Minkowitz et al. that any needle smaller than 16G would not be stiff enough to perform the procedure.
We have not observed any issues with using the less stiff 22G-needles. We have also noticed the same results in terms of dorsiflexion when comparing 16 to 22G-needle in our practice. The cost of a needle is slightly lower than the cost of a blade, which can help save costs, especially in large volume clinics.
We perform the tenotomy by giving the local anaesthesia first using a 1cc insulin syringe mirroring the standard practice when performing with the tenotomy with a blade in our center. We observed that when providing the local anaesthesia, it was difficult for the surgeon to adequately palpate the tendon after injecting the local anaesthesia. Markowitz et al. have proposed the sole use of EMLA cream as a local anesthetic to avoid blurring the palpation of the tendon altogether, arguing that the cutting of the tendon itself is not painful.
(3) However, EMLA cream is not readily available in our setting, and applying the cream 30-120 minutes before the intervention would be very cumbersome given the obvious time, space and financial constraints. A locally adapted solution could be to change the sequence of the intervention, by first performing the tenotomy with a 22G-needle and injecting the lidocaine afterwards using the same needle. To our knowledge no-one implements this approach on a routine basis yet.
We were able show that the needle tenotomy technique can be implemented in a low-resource setting like Pakistan, and can be performed using only one assistant and materials that are locally and readily available for the same cost.
A Randomized Control Trial comparing the effectiveness and complication rate between needle and blade tenotomy is currently ongoing at our center (clinicaltrials.gov NCT04897100). Preliminary data from our pilot study comparing 50 tenotomise showed no difference between achieved dorsiflexion and complication rate between both techniques.
We therefore believe that it is important to teach Ponseti providers in low-resource settings about the added value of this technique and how to adequately perform it given the personnel, space, time and material constraints many colleagues face. The educational videos in attachment can help in this educational endeavour.
Supplementary material
A 2-minute video describing and showcasing the surgical technique is available as a supplement in the online version of the article. The video can also be accessed on: …
Acknowledgements
MP received a grant from the Belgian Kids Fund for Pediatric Research. The other authors do not declare competing interests.
Ethics approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. IRB approval was obtained for this study under registration number IHHN_IRB_2020_03_011.
Written informed consent was obtained from the legal guardian of the patient featuring in the instructional video.
Bibliography
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