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Scientific Articles   |    
Ultrasonographic Phases in Gap Healing Following Ponseti-Type Achilles Tenotomy
Karanjit Singh Mangat, MRCS1; Raj Kanwar, MRCS1; Karl Johnson, FRCR1; George Korah, MRCS1; Hari Prem, FRCS(Orth)1
1 Department of Paediatric Orthopaedics, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom. E-mail address for K.S. Mangat: Karanjit_mangat@hotmail.com
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Paediatric Orthopaedics, Birmingham Children's Hospital, Birmingham, United Kingdom

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jun 01;92(6):1462-1467. doi: 10.2106/JBJS.I.00188
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Abstract

Background: 

The Ponseti technique is well established in the management of clubfoot deformity, and an Achilles tenotomy is frequently performed to facilitate dorsiflexion of the foot. This report describes the ultrasonographic phases of healing of the tendon gap created by the Achilles tenotomy and how the healing varies, if at all, with patient age.

Methods: 

A prospective ultrasonographic study of gap healing following a Ponseti-type tenotomy in twenty-seven tendons in twenty patients with idiopathic congenital clubfoot was performed. Serial ultrasound examinations (both static and dynamic) were performed at three, six, and twelve weeks after the tenotomy. The casts were removed routinely three weeks after the tenotomy. The end point of healing was defined as the observation of tendon homogeneity across the gap zone on ultrasound, with the divided tendon ends being indistinct.

Results: 

Three phases of healing were apparent on ultrasound assessment at three, six, and twelve weeks after the tenotomy. These sequential phases are similar to those previously described in the healing of tendons with no gap. The transition to normal structure was frequently demonstrated by ultrasonography only at twelve weeks (in thirteen of twenty-one tendons).

Conclusions: 

Although there is evidence of continuity of the Achilles tendon by three weeks after tenotomy, healing is not complete until at least twelve weeks. The time needed for the tendon to completely heal should be taken into consideration before a revision Achilles tenotomy is planned.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Karanjit Singh Mangat, MRCS
    Posted on October 14, 2010
    Drs. Mangat and Prem respond to Dr. Maranho and colleagues
    Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom

    The final version of the paper had already been compiled and submitted at the time of the publication of the article by Dr. Maranho (1). Due to the lag between expert review and subsequent publication it misleadingly appears that we have omitted this reference. We agree with all the comments made by Dr. Maranho, especially the fact that in difficult cases an ultrasound guided tenotomy may be useful to confirm complete release of the tendon. The parallel findings in both studies of the healing process extending beyond three weeks when the casts are removed is useful information for those considering repeat tenotomy. We agree that in some cases remodeling may continue beyond 12 weeks and that it would be useful to undertake a further ultrasound study with a larger cohort of older children to better understand the healing process. This would also help to select the upper age limit for tenotomy.

    We thank Dr. Maranho for his comments.

    Reference

    1. Maranho DA, Nogueira-Barbosa MH, Simão MN, Volpon JB. Ultrasonographic evaluation of Achilles tendon repair after percutaneous sectioning for the correction of congenital clubfoot residual equinus. J Pediatr Orthop. 2009;29:804-10.

    Daniel A.C. Maranho, MD
    Posted on August 20, 2010
    In Vivo Tendon Healing after Percutaneous Tenotomy with the Ponseti Method for Treating Clubfoot
    School of Medicine of Ribeirão Preto, University of São Paulo, Brazil

    To the Editor:

    The article, “Ultrasonographic Phases in Gap Healing Following Ponseti-Type Achilles Tenotomy”, by Mangat et al. (2010;92:1462-7) is a very interesting study, which makes a significant contribution to the comprehension of the Achilles tendon healing process in clubfoot after closed tenotomy. As pointed out by the authors, only a few in vivo studies on this theme have been published and the ultrasonography may be an effective non-invasive method for tendon evaluation, when the histological analysis is not available. However, our previously published study is not referenced.

    Almost one year ago, we published a similar study with 37 primary tenotomies in clubfeet treated with the Ponseti method. The ultrasonographic evaluation was performed during the tenotomy and for intermediary periods up until one year post-operation (1). We found that, despite the occurrence of clinical findings of complete tendon section such as sudden dorsiflexion, gap creation and absence of heel motion with calf squeezing (Thompson maneuver) ultrasonography may be useful to depict some residual tendon fibers not perceived clinically. Adding this practice as a routine may prevent some complications and guarantee a complete tendon section, but it increases the duration and costs of procedure(1-3). Consequently, we feel that percutaneous tenotomy under real time sonographic examination may be particularly useful for some selected cases of marked equinus in overweight babies, for example. An incomplete tenotomy presents some residual tendon fibers that may not be easily identified by clinical examination and, theoretically, may interfere with the equinus correction.

    Our three-week post-tenotomy findings strongly agree with Mangat et al.'s paper. Initially, the gap was filled with healing tissue with irregular and hipoecogenic ultrasonographic aspect and thickening. At this time, the dynamic inspection showed mechanical transmission of movements between the stumps. Later on, there was a progressive reduction of the thickness, presence of fibrillar echotexture and, eventually, the regenerated segment was similar to a normal tendon but still maintaining some mild residual thickening, thus suggesting that the remodeling tendon stage may persist after twelve weeks post-tenotomy. The end point of this process still remains to be determined.

    There is still doubt about what is the maximum age to perform percutaneous tenotomy, what is the ideal time to perform a revision tenotomy and what is the ideal immobilization time for older children. We believe that an ultrasound study may contribute to clarify these issues. Our studies reinforce the hypothesis that when performed on the baby, the tenotomy gap heals by an intrinsic type process of regeneration that may not occur entirely in older children.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Maranho DA, Nogueira-Barbosa MH, Simão MN, Volpon JB. Ultrasonographic evaluation of Achilles tendon repair after percutaneous sectioning for the correction of congenital clubfoot residual equinus. J Pediatr Orthop. 2009;29:804-10.

    2. Maranho DAC. Ultrasonographic evaluation of Achilles tendon repair after percutaneous sectioning for the correction of congenital clubfoot residual equinus [Master thesis]. Ribeirão Preto: University of São Paulo; 2009. Portuguese.

    3. Maranho DAC, Nogueira-Barbosa MH, Simao MN, Volpon JB. [Use of a large gauge needle for percutaneous sectioning of the Achilles tendon in congenital clubfoot]. Acta Ortop Bras. 2010;18:271-6. Portuguese.

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