Bilateral Tenotomy at North Staffordshire Hospital

What is a bilateral tenotomy?

A bilateral tenotomy is a quick procedure to cut and lengthen the Achilles tendon at the back of both ankles. It's most often used to complete the correction of clubfoot in babies, allowing the ankle to flex upwards fully so the foot can sit flat on the ground.

What conditions does it treat?

Achilles tenotomy is a core part of the Ponseti method for treating clubfoot (also called talipes). It's used when the midfoot has already been corrected with plaster casts, but the ankle still can't bend upwards enough, because the Achilles tendon is thick and doesn't stretch with casting the way the foot's ligaments do.

The same technique can also be used for contractures, where a tendon becomes stiff and shortened after a period of immobilisation, once physical therapy and splinting alone haven't restored movement. Tenotomy is also used more broadly on tendons elsewhere in the body, including for tennis or golfer's elbow, plantar fasciitis, and patellar tendon problems, though this page focuses on its most common use: treating clubfoot in babies.

What are the benefits of having a bilateral tenotomy?

The main benefit is correcting the last part of a clubfoot deformity, known as equinus, which lets the ankle flex upwards properly. This movement, called dorsiflexion, matters for walking, running, jumping and everyday movements.

For the vast majority of babies, this quick procedure completes clubfoot correction without the need for more invasive open surgery, and the tendon typically regrows in its lengthened position, serving well for a lifetime.

Are there different types or surgical approaches?

Most tenotomies for clubfoot are done percutaneously, meaning through the skin, using either a small blade or a needle. This is usually carried out under local anaesthetic in a clinic room rather than an operating theatre, so your baby stays awake throughout.

Open tenotomy is reserved for more severe cases. Here, the surgeon exposes the tendon through a small incision under general anaesthetic, cuts it, and rejoins the ends with sutures to form a longer tendon, before a cast is applied.

What happens before the procedure?

For clubfoot, the tenotomy is timed for once the midfoot has been corrected, typically after four or five Ponseti casts. Further casting alone isn't a substitute at this point, since it can lead to complications such as a 'rocker bottom' foot instead of properly correcting the ankle.

On the day, your baby's casts are removed as usual and the team checks they're ready for the procedure. You'll meet the surgeon, who will explain what will happen and answer any questions before you sign a consent form. A topical anaesthetic cream is applied to the skin at the site in advance.

It's worth bringing infant paracetamol (if advised by your team), a pair of socks, a dummy if your baby uses one, and enough nappies, wipes and milk for a few hours at the clinic.

What happens during the procedure?

For a percutaneous tenotomy, the typical sequence is:

1. A topical anaesthetic is applied to the skin, followed by an injection of local anaesthetic around the Achilles tendon to numb the deeper tissue.
2. The skin is cleaned with an antiseptic solution.
3. A small blade or needle is used to cut through the skin into the tendon; as the cut edges separate, the tendon lengthens.
4. For a bilateral tenotomy, both ankles are treated this way in the same short session; the cut itself takes just seconds per foot.
5. Steristrips and a small plaster cover the tiny wounds, and a new cast is applied immediately, holding the feet in their maximally corrected position.

Parents can usually stay with their baby throughout, though you may prefer to wait outside. Either way, the final decision is made together with your care team. Comfort measures such as sucrose drops, a dummy, and breast or bottle feeding while the cast is applied can all help.

What does recovery look like?

The procedure itself takes seconds but expect to be at the hospital or clinic for around two to three hours in total. Your baby can have infant paracetamol if needed, as advised by your team.

At home, the post-tenotomy cast usually stays on for about two and a half to three weeks so the tendon heals in its new, lengthened position. This is normally the last cast of treatment. Watch closely for any sign of the cast slipping, and contact your team straight away if this happens, since a slipped cast left in place can let the tendon heal short again, meaning a repeat tenotomy may be needed.

Once the final cast comes off, your baby is fitted into a foot abduction brace (boots and bar), worn for around 23 hours a day for the first 12 weeks, then during night-times and naps until about age 5. This bracing is crucial for preventing the clubfoot from returning. A typical follow-up schedule includes a review 1 week after the brace is fitted, another at 5 weeks, and another at 6 weeks, when part-time brace wear usually begins.

What are the risks and complications?

• damage to nearby nerves or blood vessels
• infection at the site of the cut
• over-lengthening of the tendon
• the tendon shortening again as your child grows, which may need a repeat tenotomy or further treatment
• scar tissue forming, which can occasionally be painful
• if a post-tenotomy cast slips and isn't replaced promptly, the tendon can heal in a shortened position, undoing the correction.