Achilles Tenotomy (Tendo-Achilles Tenotomy - TAT)

What Is It?

Primary Indication: Clubfoot (CTEV)

When is Tenotomy Needed?

1. Achieve the goal of 15 degrees of ankle dorsiflexion
2. Allow the foot to reach ~70 degrees of abduction
3. Prevent a rocker-bottom deformity by achieving true ankle dorsiflexion (not through the midfoot)

"In most children, to be able to achieve maximal abducted position of the foot with the ankle dorsiflexed 15 degrees, a percutaneous Achilles tenotomy is necessary." - Campbell's Operative Orthopaedics, 15th Ed 2026

Other Indications

• Congenital Vertical Talus (CVT): Serial manipulation and casting followed by percutaneous Achilles tenotomy and minimal talonavicular capsulotomies and pin fixation (Miller's Review of Orthopaedics, 9th Ed)
• Recurrent clubfoot after Ponseti casting: Repeat casting with or without tenotomy
• Spasticity / upper motor neuron syndrome: Achilles tendon lengthening (more commonly Z-plasty or open lengthening rather than complete tenotomy in this context)
• Cerebral palsy / neuromuscular conditions: Tenotomy/lengthening as part of multi-level surgical correction

Percutaneous Achilles Tenotomy - Technique (Ponseti Method)

Setting

• Can be performed in the clinic under local skin anaesthesia (topical or injected), or in the operating room under sedation/general anaesthesia
• Clinic setting: avoids need for fasting and general anaesthesia
• OR setting: easier control of any excess bleeding

Steps

1. The foot is held in maximum abduction and beginning dorsiflexion
2. A small open incision (not purely "blind" percutaneous) is made directly over the medial border of the tendon, just proximal to its insertion on the calcaneus
3. The tenotomy is performed from medial to lateral (Fig. 31.31 in Campbell's)
4. A rounded Beaver eye blade is recommended to reduce risk of vascular injury
5. A palpable / audible "snap" confirms complete division
6. The final cast is then applied with the foot at ~70 degrees of abduction and 15 degrees of dorsiflexion and held for 3 weeks while the tendon regenerates

Key Safety Note

"Bleeding complications have been reported after percutaneous tenotomy from injury to the peroneal artery or the lesser saphenous vein. Make a small open incision directly over the tendon before severing it, making the tenotomy from medial to lateral." - Campbell's Operative Orthopaedics, 15th Ed 2026

Clubfoot Treatment Algorithm

Post-Tenotomy Care (Maintenance Phase)

• The foot abduction orthosis (FAO) holds feet at 70° external rotation and 15° dorsiflexion
• Distance between shoes = ~1 inch wider than the child's shoulder width
• Bilateral bracing is superior to unilateral bracing
• Brace compliance is the single most important factor in preventing recurrence

Key Points Summary

• Tenotomy is performed at the end of casting (after CAVE correction), before the final cast
• Required in most (~80%) Ponseti-treated clubfeet
• Tendon regenerates within the 3-week final cast period - it does not leave a permanent gap
• The Achilles is associated with absence/diminution of the anterior tibial artery in clubfoot
• Recurrence rate with Ponseti: 10-30%; recurrent deformity is treated with repeat casting ± repeat tenotomy
• If recurrence is rigid and fails repeat casting: tibialis anterior tendon transfer (TATT) at 3-8 years of age, or à la carte surgical release
• Beyond that, options include talectomy, fusion, osteotomy, Ilizarov, or guided growth

• Campbell's Operative Orthopaedics, 15th Ed 2026, Chapter 31 (Ponseti Technique 31.10)
• Miller's Review of Orthopaedics, 9th Ed, Section 5 - Foot (Clubfoot)
• Bailey & Love's Short Practice of Surgery, 28th Ed, Chapter 44 (Summary Box 44.13)
• Recent systematic review: Ponseti method in neurogenic clubfoot (2025, PMID 41272751) confirms broad applicability of the method including tenotomy

Congenital Talipes Equinovarus (CTEV) and the Ponseti Method

Clinical Picture - Newborn Clubfoot

1. Definition

2. Incidence

• 1 in 1000 live births (one of the most common congenital orthopaedic conditions)
• Bilateral in 50% of cases; severity is highly correlated between both feet in bilateral cases
• Unilateral cases are evenly distributed between right and left sides
• No proven association with developmental dysplasia of the hip (DDH)
• More common in males (2:1 ratio)

3. Aetiology

1. Primary germplasm defect in the talus - causing continued plantarflexion and inversion, with secondary soft-tissue changes
2. Primary soft-tissue/neuromuscular abnormality - causing secondary bony changes
3. Vascular theory - many children with clubfoot have a hypertrophic anterior tibial artery or diminutive/absent anterior tibial artery; other vascular anomalies are common
4. Muscle fibre abnormality - abnormal distribution of type I and type II muscle fibres documented

• Maternal and paternal smoking
• Maternal obesity
• Family history (autosomal dominant with incomplete penetrance)
• Amniocentesis
• Some SSRIs (selective serotonin reuptake inhibitors)
• Spina bifida, arthrogryposis, chromosomal abnormalities (non-idiopathic clubfoot)

4. Pathoanatomy

• Talar neck is internally rotated relative to the ankle mortise
• Talar body is externally rotated in the mortise
• Calcaneus is significantly internally rotated

5. Clinical Assessment

• Foot is small, stiff, held in equinus-varus-adductus position
• Transverse plantar crease
• Posterior skin crease
• Calf muscle wasting (smaller calf on affected side)
• Assess passivity / rigidity (distinguish positional from structural)

6. Radiographic Evaluation

7. The Ponseti Method

Principles

• Begin as early as possible, ideally within the first 4 weeks of life
• Gentle manipulation followed by long leg plaster cast (above knee essential)
• The key manipulation: abduct the foot around the stable talar head (thumb on the lateral head of talus as the fulcrum)
• NEVER pronate the foot; never directly manipulate the heel
• NEVER try to dorsiflex first - correct CAVE in order

Order of Correction: C → A → V → E (CAVE sequence)

The heel must NOT be directly manipulated. Forefoot derotation must occur about the talus, not the calcaneocuboid joint.

Number of Casts

• Typically 5-6 casts, each held for ~1 week (accelerated biweekly schedules are also acceptable)
• Long leg casts are essential to maintain external rotation force
• Plaster of Paris and fiberglass have similar outcomes

Step 6: Percutaneous Achilles Tenotomy

• Required in ~80% of infants to achieve 15° dorsiflexion
• Corrects the residual equinus that cannot be fully addressed by casting alone
• Can be done in clinic (local anaesthesia) or OR (sedation/GA)
• Technique: medial-to-lateral tenotomy through small incision over medial tendon border; Beaver eye blade recommended
• Risks: peroneal artery injury, lesser saphenous vein injury
• Final cast applied for 3 weeks at 70° abduction / 15° dorsiflexion
• Tendon regenerates during the 3-week cast period

8. Treatment Algorithm

9. Maintenance Phase (Foot Abduction Orthosis - FAO)

• Shoes fixed to a bar at 70° external rotation and 15° dorsiflexion
• Bar width = ~1 inch wider than the infant's shoulder width
• Bilateral bracing is superior to unilateral

Brace compliance is the single most important factor in preventing recurrence. (Campbell's, 15th Ed)

10. Management of Recurrence

• Recurrence rate: 10-30% after initial Ponseti treatment
• First-line: Repeat manipulation and casting (+ repeat Achilles tenotomy if needed)
• Tibialis anterior tendon transfer (TATT): indicated at age 3-8 years for persistent dynamic supination (swing-phase inversion) with flexible plantigrade foot
• Rigid recurrence: à la carte surgical release (posteromedial release via Turco or Cincinnati incision)
• Subsequent rigidity after failed release: talectomy, fusion, osteotomy, Ilizarov frame, guided growth

11. Special Situations

12. Key Points Summary

• Campbell's Operative Orthopaedics, 15th Ed 2026, Chapter 31 (Ponseti Technique 31.10, pp. 1305-1310)
• Miller's Review of Orthopaedics, 9th Ed, Section 5 - Foot
• Schwartz's Principles of Surgery, 11th Ed, Chapter 43
• Bailey & Love's Short Practice of Surgery, 28th Ed, Chapter 44 (Summary Box 44.13)
• Recent meta-analysis: Accelerated vs standard Ponseti (2026, PMID 41549019) - confirms equivalent efficacy and safety of accelerated casting schedules

The Ponseti Casting Technique - Complete Guide

Overview

1. Treatment Phase - serial manipulation and casting
2. Maintenance Phase - foot abduction orthosis (FAO) brace

Assessment Before Casting: Pirani Scoring System

PHASE 1: TREATMENT PHASE (Technique 31.10)

When to Start

• Ideally within the first 4 weeks of life
• Older children can also be treated but results are less reliable
• Casts changed weekly (accelerated biweekly schedules are also acceptable)

Order of Correction: C → A → V → E

Equinus MUST be corrected last. Attempting to dorsiflex before correcting varus causes a rocker-bottom deformity.

Step 1 - Setting

Step 2 - First Cast: Correct Cavus

• Supinate the forefoot to bring it in line with the heel
• Elevate (dorsiflex) the first metatarsal
• Align the forefoot with the hindfoot - do NOT pronate the foot
• Apply cast in two stages: short leg first (below the knee), then extend above the knee once plaster sets

Long leg (above-knee) casts are essential - they maintain the external rotation force on the foot beneath the talus, allow adequate stretching of medial structures, and prevent cast slippage.

Step 3 - First Cast Change (Week 1)

• Remove the first cast
• Perform ~1 minute of gentle manipulation
• Apply the next toe-to-groin (above-knee) cast

Step 4 - Key Manipulation Principle: Abduction Around the Talar Head

• Place your thumb on the lateral head of the talus as a fulcrum
• Abduct the foot around the talar head - the navicular is felt reducing over the talar head
• Forefoot derotation must occur about the talus, NOT the calcaneocuboid joint
• NEVER directly manipulate the heel
• Maintain forefoot supination throughout - never actively pronate
• Gradually decrease the amount of supination over successive casts until the forefoot is in neutral

Correctly correcting the talonavicular subluxation (without rocker-bottom) causes the calcaneus to automatically abduct and evert - do not force the heel separately.

Step 5 - Subsequent Casts (Weeks 2-4): Progressive Abduction

• Continue weekly manipulation and casting for 2-3 more weeks
• Each cast abducts the foot progressively further around the talar head
• Gradually decrease supination toward neutral
• Cast is removed just before each manipulation and recasting session

Step 6 - Percutaneous Achilles Tenotomy (in ~80% of cases)

NOTE: "Bleeding complications have been reported after percutaneous tenotomy from injury to the peroneal artery or the lesser saphenous vein. Make a small open incision directly over the tendon before severing it, making the tenotomy from medial to lateral." - Campbell's, 15th Ed 2026

Step 7 - Final Cast

Technique of Ponseti casting - cast progression diagram

FIGURE 31.30 description (Campbell's): A = First cast: forefoot aligned with heel, outer edge still tilted downward (Achilles tightness). B = Second cast: outer edge still down, forefoot moved slightly outward. C = Third cast: Achilles stretched, outer edge moving toward normal, forefoot turned further outward. D = Final cast: Achilles fully stretched, foot pointed upward at 70°/15°.

PHASE 2: MAINTENANCE PHASE (Foot Abduction Orthosis)

• Shoes on a bar at 70° external rotation and 15° dorsiflexion
• Bar width = ~1 inch wider than infant's shoulder width
• Bilateral bracing is superior to unilateral
• Compliance is the #1 factor preventing recurrence

Key "Do's and Don'ts" (Campbell's Concepts)

Modifications Proven Equivalent

Recurrence and What to Do

• Recurrence rate: 10-30%
• Most recurrences: equinus + heel varus (early, mild)
• First line: repeat manipulation and casting
• Repeat Achilles tenotomy if dorsiflexion insufficient
• TATT (tibialis anterior tendon transfer): for persistent dynamic supination (swing-phase inversion) in a flexible foot; performed between ages 3-8 years
• Rigid recurrence: à la carte posteromedial surgical release (Turco/Cincinnati incision)
• Rate of surgical procedures beyond tenotomy: ~35% in recent studies

• Campbell's Operative Orthopaedics, 15th Ed 2026, Technique 31.10 (pp. 1307-1310)
• Bailey & Love's Short Practice of Surgery, 28th Ed, Chapter 44 (Summary Box 44.13)
• Miller's Review of Orthopaedics, 9th Ed, Section 5
• Network meta-analysis of RCTs - optimal clubfoot treatment (PMID 38015923) - confirms Ponseti as first-line
• Accelerated vs standard Ponseti 2026 SR/MA (PMID 41549019) - biweekly casting is safe and effective

Intra-articular Injections for Osteoarthritis

Overview

1. Corticosteroids (CSC)
2. Hyaluronic acid / viscosupplementation (HA)
3. Platelet-rich plasma (PRP)
4. Bone marrow aspirate concentrate (BMAC)

1. Corticosteroid Injections

Mechanism

• Suppress synovial inflammation by inhibiting phospholipase A2, reducing prostaglandins, leukotrienes, and cytokines
• Combined with a local anaesthetic (e.g., lidocaine) for immediate diagnostic and therapeutic effect
• Diagnostic value: Immediate pain relief after injection localises the source of pain to the joint (useful in distinguishing hip OA from lumbar spine pathology)

Common Agents Used

Efficacy

• Hip OA: Transient (~1 month) pain relief in up to 90% of patients with mild arthritis; only 9-20% benefit with severe arthritis (Campbell's, 15th Ed 2026)
• Knee OA: Short-term pain relief and improved function; well-established for acute flares
• Shoulder, small joints (CMC thumb, etc.): Benefit supported by evidence

Frequency / Limits

• Generally no more than 3-4 injections per year per joint
• Repeated corticosteroid injections destroy remaining cartilage over time and should be avoided in posttraumatic arthritis (Rockwood & Green, 10th Ed 2025)
• Recent MRI studies have raised concerns about accelerated cartilage loss, subchondral insufficiency fractures, and osteonecrosis with repeated use

Complications

Contraindications

• Active local or systemic infection
• Prosthetic joint (relative - specialist injection only)
• Overlying skin infection or psoriasis at injection site
• Uncontrolled coagulopathy
• Known hypersensitivity to steroid preparation

2. Viscosupplementation (Hyaluronic Acid - HA)

Rationale

• In OA, synovial fluid loses its normal viscoelastic properties (reduced molecular weight and concentration of hyaluronan)
• Exogenous HA aims to restore lubrication and shock absorption
• Mechanism not fully understood; may also have anti-inflammatory and analgesic effects beyond viscosity alone

Products

• Multiple preparations available: single-injection (e.g., Synvisc-One), 3-injection (e.g., Supartz), or 5-injection courses
• Molecular weight varies (low vs high MW products)

Efficacy by Joint - Guideline Positions

"The efficacy of hyaluronic acid injections has been questioned by recent evidence summarised in the American Academy of Orthopaedic Surgeons' Clinical Practice Guidelines." - Schwartz's Principles of Surgery, 11th Ed

Complications

• Joint infection
• Cartilage injury from the needle
• Haemarthrosis
• Post-injection pain flare ("pseudoseptic" reaction - more common with some products)
• Failure to benefit

3. Platelet-Rich Plasma (PRP)

Rationale

• Autologous blood is centrifuged to concentrate platelets (containing growth factors: PDGF, TGF-β, VEGF, IGF-1, EGF)
• Aims to stimulate tissue repair, modulate inflammation, and potentially promote chondroprotection

Preparation

• Venous blood drawn, centrifuged, platelet-rich layer isolated
• Platelet concentration matters: high-platelet PRP (≥1,000,000 platelets/μL) is more effective than low-platelet PRP

Efficacy - Best Current Evidence

PRP and PRP+HA were the most successful in improving function and alleviating pain at 3, 6, and 12 months. No therapy increased treatment-related adverse events compared to placebo.

• PRP exceeds the Minimal Clinically Important Difference (MCID) for functional improvement (WOMAC) at all timepoints and for pain (VAS) at 3-6 months
• High-platelet PRP provides superior and more durable pain relief vs low-platelet PRP; the benefit for pain is maintained to 12 months with high-platelet, but not low-platelet PRP

Key Points on PRP

• Considered safe; no increase in adverse events vs placebo
• Results depend on platelet concentration - standardisation of preparation is important
• More durable benefit than corticosteroids, but onset may be slower
• Not universally covered by insurance/NHS; evidence still evolving

4. Bone Marrow Aspirate Concentrate (BMAC)

• Contains mesenchymal stem cells, growth factors, and anti-inflammatory cytokines
• Used in posttraumatic arthritis and early OA as a biological bridge before arthroplasty
• May "carry the patient for a period of time" when viscosupplementation or PRP has been tried (Rockwood & Green, 10th Ed 2025)
• Less evidence than PRP; currently considered investigational in most guidelines

Comparative Summary

Practical Considerations

• Ultrasound guidance improves accuracy of injection and reduces pain, especially for hip and shoulder joints; superior to palpation-guided for some joints (Rheumatology, Elsevier 2022)
• Pre-arthroplasty injections: Intraarticular steroid injection within 3 months of arthroplasty may increase infection risk - counsel patients accordingly
• Diabetic patients: Warn about transient blood glucose elevation lasting 24-72 hours after corticosteroid injection
• Frequency: No more than 3-4 corticosteroid injections per joint per year; repeated steroid injections are cartilage-destructive and should be discouraged in young patients with remaining cartilage

• Campbell's Operative Orthopaedics, 15th Ed 2026, Chapter 7 (Hip Osteoarthritis)
• Schwartz's Principles of Surgery, 11th Ed, Chapter 43 (Joint Injections)
• Rockwood & Green's Fractures in Adults, 10th Ed 2025, Chapter 64 (Posttraumatic Arthritis)
• Rheumatology, 2-Volume Set (Elsevier, 2022), Chapter references for IA injections
• Network MA: CSC vs HA vs PRP for knee OA - Qiao et al. 2023 (PMID 38037038) - PRP + PRP+HA best at 3, 6, 12 months
• Meta-analysis PRP for knee OA - Bensa et al. 2025 (PMID 39751394) - high-platelet PRP clinically significant benefit to 12 months