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Clubfoot is a relatively common orthopaedic condition in New Zealand. The New Zealand population is currently estimated at 4.24 million, of which 22% claim to be of Māori/Polynesian descent.1 The Māori word for clubfoot is ‘waehape’, which translates directly to broken or crooked foot. While the incidence of clubfoot in the white New Zealand European population is about 1 per 1,000, the incidence of clubfoot in the Māori and Pacific population is 6 to 7 per 1,000.2,3 Clubfoot is not only common in the Māori and Pacific Island population, but also potentially more resistant, with a higher rate of recurrence than that seen overseas.4 New Zealand paediatric orthopaedic surgeons therefore treat a higher number of children with clubfoot, which may also be more severe.

The Ponseti method for non-operative treatment of idiopathic clubfoot has increasingly become the treatment modality of choice in New Zealand and around the world.4,5 Percutaneous Achilles tenotomy (PAT) is performed during the final phase of casting to correct residual equinus contracture. This is required in approximately 80–90% of patients with clubfoot.6,7 Several settings have been proposed as venues for this procedure, however there is an increasing trend to performing this in theatre under general anaesthetic (GA). Ponseti originally chose to perform this as an outpatient procedure under local anaesthesia, yielding a success rate of close to 90%.8,9 Some surgeons, however, have preference to perform this in theatre,10,11 while others believe it can be performed safely in the outpatient setting.12 General anaesthesia is expensive and not without potential risks. To date there have been no studies comparing PAT performed as an outpatient procedure to those performed in theatre that have looked at parental concerns to the procedure and evaluated cost effectiveness.

We implemented a retrospective study using prospectively gathered data to evaluate the safety and efficacy of PAT performed as an outpatient procedure compared to those performed in theatre. We assess parental satisfaction to this procedure, and analyse current practising trends among New Zealand orthopaedic surgeons in regard to Ponseti management.

Patients and methods

The study was approved by our Institutional Research Office. All infants referred to our department at Hastings Hospital for clubfoot between January 2013 to December 2015 were included in the study. Patients with a diagnosis other than non-idiopathic clubfoot were excluded from the study. All patients recruited into the study were treated according to Ponseti protocol. A single surgeon performed all outpatient releases percutaneously in a clinic setting. A comparison group of patients were recruited who had their PAT performed in theatre under a general anaesthetic by a different surgeon whose preference was to perform releases in a theatre setting. This was a group of patients who had consecutive PAT performed by this surgeon prior to the study. Both groups had identical Ponseti management. Demographic data was collected to ensure no differences between the two groups existed. Clinical and outcome data was collected prospectively at each clinic for both groups. All patients had a minimum follow-up of two years following PAT. PAT was indicated when the mid-foot deformity had been corrected (MFS = 0) and the hind-foot deformity remained in an equinus position (unable to dorsiflex past 10 degrees). The outpatient procedure was performed during the final stage of serial casting in a routine clubfoot outpatient clinic. Pain prevention protocol included application of Emla Cream 5% 1.0g/10cm area (Prilocaine/Lignocaine combination) placed topically on the surgical site one hour prior to procedure (Table 1).

Table 1: Pain prevention protocol for outpatient Achilles tenotomy.

In November 2015, a survey was emailed to members of the Paediatric Orthopaedic Society of New Zealand (POSNZ). Registrars and surgeons who did not manage patients with clubfoot were excluded. The survey was designed to evaluate current practising trends among New Zealand orthopaedic surgeons who manage and treat clubfoot. Within the email was a link to perform the survey online using the online survey website, surveymonkey.com. By emailing all members of POSNZ, this was thought to reflect an accurate cross-section of the majority of surgeons managing this deformity in New Zealand.

Patient-parental satisfaction surveys were sent to all cases performed in outpatient clinic. The survey enquired about precautions taken to manage pain, convenience of having release performed in the clinic setting, and overall quality of the care received. For those that did not respond, the Māori Health Liaison team was recruited to help meet and make contact with the family.

Cost analysis was performed using clinic and hospital billing information, and a cost of care per procedure was determined. Average cost per procedure based on national data is often an overestimate, therefore a more detailed analysis was performed. Cost of PAT performed in theatre was calculated from data for all releases performed between September 2005 to November 2015.

Statistical analysis

Statistical analysis was performed to compare demographic characteristics and outcome data. A Student t-test was used for continuous variables. A two-tailed Fisher exact test was used for categorical variables. For patients who had recurrence, a separate cox regression analysis was performed to see if one group was more likely to recur than the other. This analysis was performed to correct for the fact that the study is “right censored” (ie, has stopped before all patients that would recur have had time to). Ninety-five percent confidence intervals were used. A p value of ≤0.05 was defined as significant. All analyses were done using the R statistical package. The cox regression was performed using the “survival” library.

Results

The current study includes 59 clubfeet (40 babies, 19 bilateral cases) with a diagnosis of idiopathic congenital clubfoot. All were regularly seen in routine clubfoot outpatient clinics. PAT was performed on 26 clubfeet (19 patients) under local anaesthetic in an outpatient setting, and 33 clubfeet (21 patients) under GA in a theatre setting.

The Achilles tenotomy rate in our study was 92%. The ratio of males to females was 2:1. Ratio of Māori/Polynesian to New Zealand European referred with clubfoot was 5.6:1. The average Catterall-Pirani score for the outpatient group and theatre group was 5.26 and 5.32 respectively. Demographic comparisons were made and no significant differences were found between the two groups with regard to gender (p=0.83), ethnicity, Deprivation Index or severity (p=0.84) (Table 2).

Table 2: Demographic comparisons.

 

Tenotomy was performed at an average post-natal age of 10.5 weeks in the clinic group and 12.1 weeks in the theatre group. For age at release there was no evidence of a difference between the two groups (p=0.25). No patients had complications of infection, bleeding or neurological deficit. Those in the theatre group were exposed to a greater number of general anaesthetics before the age of four, but this did not reach statistical difference (p=0.023) (Table 3).

Table 3: Treatment comparisons.

Recurrence was defined as either early or late and requiring minor or major surgery.13,14 Early recurrence was defined as recurrence of deformity identified before six months of age. Minor recurrence was that requiring an extra-articular soft tissue procedure such as repeat PAT, open Achilles tendon lengthening or Tibialis Anterior transfer procedure. Three patients had early recurrence in the clinic group compared to one patient in the theatre group. One in the outpatient group was thought to have an incomplete release requiring repeat tenotomy (Table 4). Major recurrences were defined as those that required an intra-articular surgical approach. There was no significant difference for the probability of recurrence between the two groups (p=0.67). There was no difference in re-tenotomy rate (p=0.58). Odds ratios (OR) with respect to recurrence were calculated to see if there was an association between the setting of the release, and outcome of either major or minor recurrence. There was no statistical difference for minor revision or major revision (p=0.742, p=0.741 respectively).

Table 4: Repeat tenotomy.

c

Among practising New Zealand orthopaedic members of POSNZ, 30/39 responses were received (response rate 77%). The average number of years in practice was 17.2. All respondents preferred Ponseti method as their choice for initial management of clubfoot. One respondent chose surgical and Ponseti as preferred initial management. The majority (14/18) chose to perform this in theatre under general anaesthesia, while only four surgeons regularly perform PAT as an outpatient procedure. Of those that perform the procedure in theatre, only five said they would consider changing their practice to performing PAT as an outpatient procedure. The main concerns voiced included facility or staffing issues, concerns regarding inadequate pain control, concerns regarding incomplete release, concerns regarding distress to family and concerns regarding sterility. Only a small proportion (4/18) of practising New Zealand orthopaedic surgeons preferred to perform PAT as an outpatient procedure. The reasons given for electing to perform PAT as an outpatient procedure included avoiding potential risks associated with general anaesthesia, logistical issues, difficulty with access to theatre and potential cost savings.

A response rate of 6/19 (32%) was achieved for the parental satisfaction survey. Māori Health Liaison services were recruited to help make contact with the families. Of the replies, all reported that the clinic environment was excellent in regards to convenience of setting. Five reported precautions taken to manage pain were ‘excellent’, while the remaining reported that this was ‘very good’. Overall, the quality of care provided in clinic was reported as ‘excellent’, and there were no concerns regarding inadequate pain control.

Theatre and financial data was analysed for all PAT performed in the operating theatre between 2005 and 2015. Indicative costs were $6,061 NZD per procedure based on 2015 data at our district health board (DHB). Costs over this 10-year period increased from $4,801 NZD in 2005 to $6,061 NZD per procedure in 2015. Cost for PAT performed in clinic was determined by our finance department. Indicative cost per percutaneous procedure in outpatient clinic was $378 NZD at our DHB in 2015.

Discussion

Achilles tenotomy is an important step in Ponseti management. Performing Achilles tenotomy in the outpatient clinic can be performed safely and effectively. Performing Achilles tenotomy in theatre under general anaesthesia also has it merits, thus why many surgeons prefer this setting. Potential advantages include better ability to reduce pain, ability to perform the procedure in a more controlled manner, and the relative sterility of the operating room. No studies to date have shown that the controlled nature of the operating theatre allows the surgeon to perform a more accurate and complete release, resulting in lower re-tenotomy rate, and our study was no exception.

There has been concern in the literature regarding use of volatile anaesthetic gases and the potential adverse effects on neurocognitive development. A number of studies have shown volatiles can induce neuronal cell apoptosis due to N-methyl-D-aspartate antagonists. These hypotheses are based on animal models.15,16 Wilder et al found a statistically significant increase in the risk for developing a learning disability in those who had received general anaesthesia either two or three times before the age of four.17 Other studies have found no increased risk with general anaesthesia in this age group.11 In our study those who had PAT performed in clinic had less overall exposure to general anaesthetics before the age of four.

For those who had releases performed in clinic there were no complications such as casting issues, infection or bleeding identified. One patient, however, was thought to have an incomplete release requiring repeat tenotomy. We recognise that post-operative surgical complications following this procedure are rare and unlikely to be statistically affected whether procedure is performed in clinic or theatre. After implementing the change to performing our releases in a clinic setting, other advantages were identified. We found it allowed infants to have their release despite being unwell with concurrent viral-like illnesses that would have otherwise resulted in cancellation of the procedure. Parents were only away from their baby for a short period relative to performing releases in theatre, and the infant did not have to be nil by mouth, which parents also appreciated.

For those patients included in both the clinic and theatre group the rate of recurrence seen was higher than that reported in the overseas literature, but similar to other New Zealand studies.4,14 These findings support other New Zealand studies that propose clubfoot managed in New Zealand may be more severe and impervious to treatment than clubfoot seen elsewhere. It is uncertain if poor compliance leads to an increased risk of recurrence, or if it is due to recurrence of a stiff foot resulting in difficulty with boot and bar wear and therefore presumed poor compliance. This is a major issue and has been reported in many existing studies but remains unsolved.4,14

A study evaluating practising trends in North America was performed in 2003, and was then revisited in 2010. The majority of Achilles tenotomies were performed percutaneously (92.8%). The tenotomy was performed under local anaesthesia in 39.4% of patients, while 45.4% were performed under general anaesthesia in the operating theatre. Reasons for preferences on the setting of release were not evaluated.5,6 In our study, the majority of surgeons prefer to perform PAT in the operating theatre, and would not consider changing their practice to performing PAT in an outpatient setting. The greatest concerns to the surgeon include facility and/or staffing issues, concerns regarding inadequate pain control, concerns regarding incomplete release and concerns regarding infection risk.

Parental concerns were specifically evaluated in this study. The response rate was very low despite involvement of Māori Health Liaison services. This reflects why follow-up with these patients is so difficult and why outcomes are poor and recurrence is high. Despite this, the data received was very reassuring in regard to the convenience of having PAT performed in clinic. Effectiveness of analgesia was deemed excellent by parents including bilateral cases. There were no parental concerns with regard to this procedure performed in an outpatient setting.

Procedure costing within a DHB environment is not precise and should be taken as indicative. Notwithstanding the approximation in costing of this procedure in both theatre and clinic settings the cost differential between the two settings is clear, theatre is at least 10 times greater than clinic for the same procedure. Our study suggests that performing PAT in clinic would decrease the cost per foot significantly.

Conclusion

As implied in the current study, Achilles tenotomy as an outpatient procedure has been shown to be safe and effective. We believe it can be performed safely with results comparable to that performed in theatre. It avoids any potential risks associated with general anaesthesia and potential delays associated with theatre lists. Pain can be controlled adequately, and there is no increased risk of complications or re-tenotomy rate. Parental satisfaction to this procedure is excellent and there are significant financial savings.

Summary

Abstract

Aim

Percutaneous Achilles tenotomy (PAT) is performed during the final phase of casting with Ponseti method. Several settings have been proposed as venues for this procedure, however it is increasingly being performed in theatre under a general anaesthetic (GA). General anaesthesia, however, is expensive and not without risks. The purpose of the present study was to compare results of outpatient releases to theatre releases, and assess current practising trends among orthopaedic surgeons.

Method

Retrospective comparison of patients with idiopathic clubfoot managed by Ponseti method who had Achilles tenotomy performed in outpatient clinic and in theatre. Surveys were sent to all POSNZ members to determine current practising trends in New Zealand. Parental satisfaction surveys were performed. Comparative cost analysis was performed using hospital billing information.

Results

The current study includes 64 idiopathic congenital clubfeet (19 bilateral cases). PAT was performed on 26 clubfeet under local anaesthetic in an outpatient setting, and 33 clubfeet under GA in a theatre setting. There was no significant difference for post-operative complications, or recurrence (p=0.67). Those in theatre group were exposed to a greater number of general anaesthetics before the age of four. Among practising New Zealand paediatric orthopaedic surgeons, 77.78% perform this in theatre under general anaesthesia, while only 22.22% perform PAT in outpatient clinic. The main barriers included concerns regarding pain control, concerns regarding incomplete release, concerns regarding distress to family and concerns regarding sterility. Parental satisfaction surveys found pain management to be excellent. Financial data was analysed and indicative costs were $6,061 NZD per procedure in theatre, compared to $378 NZD per procedure in clinic.

Conclusion

PAT performed in a clinic setting is both safe and efficacious with results comparative to that performed in theatre. There was no difference in post-operative complications or recurrence. Parental satisfaction to this procedure is excellent. There are significant financial advantages. Based on this data, our institution now performs all releases in an outpatient setting.

Author Information

- Lewis Agius, Department of Orthopaedic Surgery, Hastings Hospital, Hastings; Angus Wickham, Department of Orthopaedic Surgery, Hastings Hospital, Hastings;- Cameron Walker, University of Auckland, Auckland;- Joshua Knudsen, Department of Ortho

Acknowledgements

The authors would like to acknowledge Tuakana August and Dianne Wepa from Mori Health Liaison Services for their support.

Correspondence

Dr Lewis Agius, Department of Orthopaedic Surgery, Hastings Hospital, Hastings.

Correspondence Email

lewisagius@gmail.com

Competing Interests

Nil.

  1. Statistics New Zealand. 2013 Census - Major ethnic groups in New Zealand. Retrieved January 30, 2016 from Statistics New Zealand: http://www.stats.govt.nz
  2. Chapman C, Stott N, Port R, Nicol R. Genetics of Clubfoot in Māori and Pacific People. J Med Genet. 2000; 37:680–683.
  3. Beals R. Clubfoot in the Māori: a genetic study of 50 kindreds. NZ Med J . 1978; 88:144–146.
  4. Halanski M, Davison J, Huang J, et al. Ponseti Method Compared with Surgical Treatment of Clubfoot, A Prospective Comparison. J. Bone Jt. Surg. 2010; 92-A(2):270–278.
  5. Zionts L, Sangiorgio S, Ebramzadeh E, Morcuende J. The Current Management of Idiopathic Clubfoot Revisited: Results of a Survey of the POSNA Membership. J Pediatr Orthop. 2012; 32(5):515–520.
  6. Heilig M, Matern R, Rosenzweig S, et al. Current Management of Idiopathic Clubfoot Questionnaire, A Multicentric Study. J Pediatr Orthop. 2003; 23(6):780–787.
  7. Scher D, Feldman D, Van Bosse H, et al. Predicting the need for tenotomy in the Ponseti method for correction of clubfeet. J Pediatr Orthop. 2004; 24:349–352.
  8. Ponseti IV, Smoley EN. Congenital Clubfoot: the results of treatment . J Bone Joint Surg Am. 1963; 45:261–275.
  9. Ponseti IV. Congenital Clubfoot, Fundamentals of Treatment. Great Britain: Oxford Univerity Press “The Green Book”. 1996.
  10. Halanski MA, Huang JC, Walsh SJ, Crawford HA. Resourse Utilisation in Clubfoot Management. Clin Orthop Relat Res. 2009; 467(5):1171–1179.
  11. Parada SA, Baird GO, Auffant RA, et al. Safety of Percutaneous Tendoachillies Tenotomy Performed Under General Anesthesia on Infants With Idiopathic Clubfoot. J Pediatr Orthop. 2009; 29(8):916–919.
  12. Lebel E, Karasik M, Bernstein-Weyel M, et al. Achilles Tenotomy as an Office Procedure: Safety and Efficacy as Part of the Ponseti Serial Casting Protocol for Clubfoot. J Pediatr Orthop. 2012; 32(4):412–415.
  13. Halanski M, Maples D, Davison J, et al. Separating the Chicken From the Egg: An Attempt to Discern Between Clubfoot Recurrences and Incomplete Corrections. Iowa Orthop J. 2010; 30:29–34.
  14. Haft G, Walker C, Crawford H. Early Clubfoot Recurrence After Use of the Ponseti Method in a New Zealand Population. J. Bone Jt. Sur. 2007; 89-A(3):487–493.
  15. Wang C, Slikker W. Strategies and experimental models for evaluating anesthetics: effects on the developing nervous system. Anesth Analg. 2008; 106:1643–1658.
  16. Loepke A, Soriano S. An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function. Anesth Analg. 2008; 106:796–804.
  17. Wilder R, Flick R, Sprung J, Katusic S. Early exposure to anesthesia and leaning disabilities in a population-based birth cohort. Anesthesiology. 2009; 110:796–804.

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Clubfoot is a relatively common orthopaedic condition in New Zealand. The New Zealand population is currently estimated at 4.24 million, of which 22% claim to be of Māori/Polynesian descent.1 The Māori word for clubfoot is ‘waehape’, which translates directly to broken or crooked foot. While the incidence of clubfoot in the white New Zealand European population is about 1 per 1,000, the incidence of clubfoot in the Māori and Pacific population is 6 to 7 per 1,000.2,3 Clubfoot is not only common in the Māori and Pacific Island population, but also potentially more resistant, with a higher rate of recurrence than that seen overseas.4 New Zealand paediatric orthopaedic surgeons therefore treat a higher number of children with clubfoot, which may also be more severe.

The Ponseti method for non-operative treatment of idiopathic clubfoot has increasingly become the treatment modality of choice in New Zealand and around the world.4,5 Percutaneous Achilles tenotomy (PAT) is performed during the final phase of casting to correct residual equinus contracture. This is required in approximately 80–90% of patients with clubfoot.6,7 Several settings have been proposed as venues for this procedure, however there is an increasing trend to performing this in theatre under general anaesthetic (GA). Ponseti originally chose to perform this as an outpatient procedure under local anaesthesia, yielding a success rate of close to 90%.8,9 Some surgeons, however, have preference to perform this in theatre,10,11 while others believe it can be performed safely in the outpatient setting.12 General anaesthesia is expensive and not without potential risks. To date there have been no studies comparing PAT performed as an outpatient procedure to those performed in theatre that have looked at parental concerns to the procedure and evaluated cost effectiveness.

We implemented a retrospective study using prospectively gathered data to evaluate the safety and efficacy of PAT performed as an outpatient procedure compared to those performed in theatre. We assess parental satisfaction to this procedure, and analyse current practising trends among New Zealand orthopaedic surgeons in regard to Ponseti management.

Patients and methods

The study was approved by our Institutional Research Office. All infants referred to our department at Hastings Hospital for clubfoot between January 2013 to December 2015 were included in the study. Patients with a diagnosis other than non-idiopathic clubfoot were excluded from the study. All patients recruited into the study were treated according to Ponseti protocol. A single surgeon performed all outpatient releases percutaneously in a clinic setting. A comparison group of patients were recruited who had their PAT performed in theatre under a general anaesthetic by a different surgeon whose preference was to perform releases in a theatre setting. This was a group of patients who had consecutive PAT performed by this surgeon prior to the study. Both groups had identical Ponseti management. Demographic data was collected to ensure no differences between the two groups existed. Clinical and outcome data was collected prospectively at each clinic for both groups. All patients had a minimum follow-up of two years following PAT. PAT was indicated when the mid-foot deformity had been corrected (MFS = 0) and the hind-foot deformity remained in an equinus position (unable to dorsiflex past 10 degrees). The outpatient procedure was performed during the final stage of serial casting in a routine clubfoot outpatient clinic. Pain prevention protocol included application of Emla Cream 5% 1.0g/10cm area (Prilocaine/Lignocaine combination) placed topically on the surgical site one hour prior to procedure (Table 1).

Table 1: Pain prevention protocol for outpatient Achilles tenotomy.

In November 2015, a survey was emailed to members of the Paediatric Orthopaedic Society of New Zealand (POSNZ). Registrars and surgeons who did not manage patients with clubfoot were excluded. The survey was designed to evaluate current practising trends among New Zealand orthopaedic surgeons who manage and treat clubfoot. Within the email was a link to perform the survey online using the online survey website, surveymonkey.com. By emailing all members of POSNZ, this was thought to reflect an accurate cross-section of the majority of surgeons managing this deformity in New Zealand.

Patient-parental satisfaction surveys were sent to all cases performed in outpatient clinic. The survey enquired about precautions taken to manage pain, convenience of having release performed in the clinic setting, and overall quality of the care received. For those that did not respond, the Māori Health Liaison team was recruited to help meet and make contact with the family.

Cost analysis was performed using clinic and hospital billing information, and a cost of care per procedure was determined. Average cost per procedure based on national data is often an overestimate, therefore a more detailed analysis was performed. Cost of PAT performed in theatre was calculated from data for all releases performed between September 2005 to November 2015.

Statistical analysis

Statistical analysis was performed to compare demographic characteristics and outcome data. A Student t-test was used for continuous variables. A two-tailed Fisher exact test was used for categorical variables. For patients who had recurrence, a separate cox regression analysis was performed to see if one group was more likely to recur than the other. This analysis was performed to correct for the fact that the study is “right censored” (ie, has stopped before all patients that would recur have had time to). Ninety-five percent confidence intervals were used. A p value of ≤0.05 was defined as significant. All analyses were done using the R statistical package. The cox regression was performed using the “survival” library.

Results

The current study includes 59 clubfeet (40 babies, 19 bilateral cases) with a diagnosis of idiopathic congenital clubfoot. All were regularly seen in routine clubfoot outpatient clinics. PAT was performed on 26 clubfeet (19 patients) under local anaesthetic in an outpatient setting, and 33 clubfeet (21 patients) under GA in a theatre setting.

The Achilles tenotomy rate in our study was 92%. The ratio of males to females was 2:1. Ratio of Māori/Polynesian to New Zealand European referred with clubfoot was 5.6:1. The average Catterall-Pirani score for the outpatient group and theatre group was 5.26 and 5.32 respectively. Demographic comparisons were made and no significant differences were found between the two groups with regard to gender (p=0.83), ethnicity, Deprivation Index or severity (p=0.84) (Table 2).

Table 2: Demographic comparisons.

 

Tenotomy was performed at an average post-natal age of 10.5 weeks in the clinic group and 12.1 weeks in the theatre group. For age at release there was no evidence of a difference between the two groups (p=0.25). No patients had complications of infection, bleeding or neurological deficit. Those in the theatre group were exposed to a greater number of general anaesthetics before the age of four, but this did not reach statistical difference (p=0.023) (Table 3).

Table 3: Treatment comparisons.

Recurrence was defined as either early or late and requiring minor or major surgery.13,14 Early recurrence was defined as recurrence of deformity identified before six months of age. Minor recurrence was that requiring an extra-articular soft tissue procedure such as repeat PAT, open Achilles tendon lengthening or Tibialis Anterior transfer procedure. Three patients had early recurrence in the clinic group compared to one patient in the theatre group. One in the outpatient group was thought to have an incomplete release requiring repeat tenotomy (Table 4). Major recurrences were defined as those that required an intra-articular surgical approach. There was no significant difference for the probability of recurrence between the two groups (p=0.67). There was no difference in re-tenotomy rate (p=0.58). Odds ratios (OR) with respect to recurrence were calculated to see if there was an association between the setting of the release, and outcome of either major or minor recurrence. There was no statistical difference for minor revision or major revision (p=0.742, p=0.741 respectively).

Table 4: Repeat tenotomy.

c

Among practising New Zealand orthopaedic members of POSNZ, 30/39 responses were received (response rate 77%). The average number of years in practice was 17.2. All respondents preferred Ponseti method as their choice for initial management of clubfoot. One respondent chose surgical and Ponseti as preferred initial management. The majority (14/18) chose to perform this in theatre under general anaesthesia, while only four surgeons regularly perform PAT as an outpatient procedure. Of those that perform the procedure in theatre, only five said they would consider changing their practice to performing PAT as an outpatient procedure. The main concerns voiced included facility or staffing issues, concerns regarding inadequate pain control, concerns regarding incomplete release, concerns regarding distress to family and concerns regarding sterility. Only a small proportion (4/18) of practising New Zealand orthopaedic surgeons preferred to perform PAT as an outpatient procedure. The reasons given for electing to perform PAT as an outpatient procedure included avoiding potential risks associated with general anaesthesia, logistical issues, difficulty with access to theatre and potential cost savings.

A response rate of 6/19 (32%) was achieved for the parental satisfaction survey. Māori Health Liaison services were recruited to help make contact with the families. Of the replies, all reported that the clinic environment was excellent in regards to convenience of setting. Five reported precautions taken to manage pain were ‘excellent’, while the remaining reported that this was ‘very good’. Overall, the quality of care provided in clinic was reported as ‘excellent’, and there were no concerns regarding inadequate pain control.

Theatre and financial data was analysed for all PAT performed in the operating theatre between 2005 and 2015. Indicative costs were $6,061 NZD per procedure based on 2015 data at our district health board (DHB). Costs over this 10-year period increased from $4,801 NZD in 2005 to $6,061 NZD per procedure in 2015. Cost for PAT performed in clinic was determined by our finance department. Indicative cost per percutaneous procedure in outpatient clinic was $378 NZD at our DHB in 2015.

Discussion

Achilles tenotomy is an important step in Ponseti management. Performing Achilles tenotomy in the outpatient clinic can be performed safely and effectively. Performing Achilles tenotomy in theatre under general anaesthesia also has it merits, thus why many surgeons prefer this setting. Potential advantages include better ability to reduce pain, ability to perform the procedure in a more controlled manner, and the relative sterility of the operating room. No studies to date have shown that the controlled nature of the operating theatre allows the surgeon to perform a more accurate and complete release, resulting in lower re-tenotomy rate, and our study was no exception.

There has been concern in the literature regarding use of volatile anaesthetic gases and the potential adverse effects on neurocognitive development. A number of studies have shown volatiles can induce neuronal cell apoptosis due to N-methyl-D-aspartate antagonists. These hypotheses are based on animal models.15,16 Wilder et al found a statistically significant increase in the risk for developing a learning disability in those who had received general anaesthesia either two or three times before the age of four.17 Other studies have found no increased risk with general anaesthesia in this age group.11 In our study those who had PAT performed in clinic had less overall exposure to general anaesthetics before the age of four.

For those who had releases performed in clinic there were no complications such as casting issues, infection or bleeding identified. One patient, however, was thought to have an incomplete release requiring repeat tenotomy. We recognise that post-operative surgical complications following this procedure are rare and unlikely to be statistically affected whether procedure is performed in clinic or theatre. After implementing the change to performing our releases in a clinic setting, other advantages were identified. We found it allowed infants to have their release despite being unwell with concurrent viral-like illnesses that would have otherwise resulted in cancellation of the procedure. Parents were only away from their baby for a short period relative to performing releases in theatre, and the infant did not have to be nil by mouth, which parents also appreciated.

For those patients included in both the clinic and theatre group the rate of recurrence seen was higher than that reported in the overseas literature, but similar to other New Zealand studies.4,14 These findings support other New Zealand studies that propose clubfoot managed in New Zealand may be more severe and impervious to treatment than clubfoot seen elsewhere. It is uncertain if poor compliance leads to an increased risk of recurrence, or if it is due to recurrence of a stiff foot resulting in difficulty with boot and bar wear and therefore presumed poor compliance. This is a major issue and has been reported in many existing studies but remains unsolved.4,14

A study evaluating practising trends in North America was performed in 2003, and was then revisited in 2010. The majority of Achilles tenotomies were performed percutaneously (92.8%). The tenotomy was performed under local anaesthesia in 39.4% of patients, while 45.4% were performed under general anaesthesia in the operating theatre. Reasons for preferences on the setting of release were not evaluated.5,6 In our study, the majority of surgeons prefer to perform PAT in the operating theatre, and would not consider changing their practice to performing PAT in an outpatient setting. The greatest concerns to the surgeon include facility and/or staffing issues, concerns regarding inadequate pain control, concerns regarding incomplete release and concerns regarding infection risk.

Parental concerns were specifically evaluated in this study. The response rate was very low despite involvement of Māori Health Liaison services. This reflects why follow-up with these patients is so difficult and why outcomes are poor and recurrence is high. Despite this, the data received was very reassuring in regard to the convenience of having PAT performed in clinic. Effectiveness of analgesia was deemed excellent by parents including bilateral cases. There were no parental concerns with regard to this procedure performed in an outpatient setting.

Procedure costing within a DHB environment is not precise and should be taken as indicative. Notwithstanding the approximation in costing of this procedure in both theatre and clinic settings the cost differential between the two settings is clear, theatre is at least 10 times greater than clinic for the same procedure. Our study suggests that performing PAT in clinic would decrease the cost per foot significantly.

Conclusion

As implied in the current study, Achilles tenotomy as an outpatient procedure has been shown to be safe and effective. We believe it can be performed safely with results comparable to that performed in theatre. It avoids any potential risks associated with general anaesthesia and potential delays associated with theatre lists. Pain can be controlled adequately, and there is no increased risk of complications or re-tenotomy rate. Parental satisfaction to this procedure is excellent and there are significant financial savings.

Summary

Abstract

Aim

Percutaneous Achilles tenotomy (PAT) is performed during the final phase of casting with Ponseti method. Several settings have been proposed as venues for this procedure, however it is increasingly being performed in theatre under a general anaesthetic (GA). General anaesthesia, however, is expensive and not without risks. The purpose of the present study was to compare results of outpatient releases to theatre releases, and assess current practising trends among orthopaedic surgeons.

Method

Retrospective comparison of patients with idiopathic clubfoot managed by Ponseti method who had Achilles tenotomy performed in outpatient clinic and in theatre. Surveys were sent to all POSNZ members to determine current practising trends in New Zealand. Parental satisfaction surveys were performed. Comparative cost analysis was performed using hospital billing information.

Results

The current study includes 64 idiopathic congenital clubfeet (19 bilateral cases). PAT was performed on 26 clubfeet under local anaesthetic in an outpatient setting, and 33 clubfeet under GA in a theatre setting. There was no significant difference for post-operative complications, or recurrence (p=0.67). Those in theatre group were exposed to a greater number of general anaesthetics before the age of four. Among practising New Zealand paediatric orthopaedic surgeons, 77.78% perform this in theatre under general anaesthesia, while only 22.22% perform PAT in outpatient clinic. The main barriers included concerns regarding pain control, concerns regarding incomplete release, concerns regarding distress to family and concerns regarding sterility. Parental satisfaction surveys found pain management to be excellent. Financial data was analysed and indicative costs were $6,061 NZD per procedure in theatre, compared to $378 NZD per procedure in clinic.

Conclusion

PAT performed in a clinic setting is both safe and efficacious with results comparative to that performed in theatre. There was no difference in post-operative complications or recurrence. Parental satisfaction to this procedure is excellent. There are significant financial advantages. Based on this data, our institution now performs all releases in an outpatient setting.

Author Information

- Lewis Agius, Department of Orthopaedic Surgery, Hastings Hospital, Hastings; Angus Wickham, Department of Orthopaedic Surgery, Hastings Hospital, Hastings;- Cameron Walker, University of Auckland, Auckland;- Joshua Knudsen, Department of Ortho

Acknowledgements

The authors would like to acknowledge Tuakana August and Dianne Wepa from Mori Health Liaison Services for their support.

Correspondence

Dr Lewis Agius, Department of Orthopaedic Surgery, Hastings Hospital, Hastings.

Correspondence Email

lewisagius@gmail.com

Competing Interests

Nil.

  1. Statistics New Zealand. 2013 Census - Major ethnic groups in New Zealand. Retrieved January 30, 2016 from Statistics New Zealand: http://www.stats.govt.nz
  2. Chapman C, Stott N, Port R, Nicol R. Genetics of Clubfoot in Māori and Pacific People. J Med Genet. 2000; 37:680–683.
  3. Beals R. Clubfoot in the Māori: a genetic study of 50 kindreds. NZ Med J . 1978; 88:144–146.
  4. Halanski M, Davison J, Huang J, et al. Ponseti Method Compared with Surgical Treatment of Clubfoot, A Prospective Comparison. J. Bone Jt. Surg. 2010; 92-A(2):270–278.
  5. Zionts L, Sangiorgio S, Ebramzadeh E, Morcuende J. The Current Management of Idiopathic Clubfoot Revisited: Results of a Survey of the POSNA Membership. J Pediatr Orthop. 2012; 32(5):515–520.
  6. Heilig M, Matern R, Rosenzweig S, et al. Current Management of Idiopathic Clubfoot Questionnaire, A Multicentric Study. J Pediatr Orthop. 2003; 23(6):780–787.
  7. Scher D, Feldman D, Van Bosse H, et al. Predicting the need for tenotomy in the Ponseti method for correction of clubfeet. J Pediatr Orthop. 2004; 24:349–352.
  8. Ponseti IV, Smoley EN. Congenital Clubfoot: the results of treatment . J Bone Joint Surg Am. 1963; 45:261–275.
  9. Ponseti IV. Congenital Clubfoot, Fundamentals of Treatment. Great Britain: Oxford Univerity Press “The Green Book”. 1996.
  10. Halanski MA, Huang JC, Walsh SJ, Crawford HA. Resourse Utilisation in Clubfoot Management. Clin Orthop Relat Res. 2009; 467(5):1171–1179.
  11. Parada SA, Baird GO, Auffant RA, et al. Safety of Percutaneous Tendoachillies Tenotomy Performed Under General Anesthesia on Infants With Idiopathic Clubfoot. J Pediatr Orthop. 2009; 29(8):916–919.
  12. Lebel E, Karasik M, Bernstein-Weyel M, et al. Achilles Tenotomy as an Office Procedure: Safety and Efficacy as Part of the Ponseti Serial Casting Protocol for Clubfoot. J Pediatr Orthop. 2012; 32(4):412–415.
  13. Halanski M, Maples D, Davison J, et al. Separating the Chicken From the Egg: An Attempt to Discern Between Clubfoot Recurrences and Incomplete Corrections. Iowa Orthop J. 2010; 30:29–34.
  14. Haft G, Walker C, Crawford H. Early Clubfoot Recurrence After Use of the Ponseti Method in a New Zealand Population. J. Bone Jt. Sur. 2007; 89-A(3):487–493.
  15. Wang C, Slikker W. Strategies and experimental models for evaluating anesthetics: effects on the developing nervous system. Anesth Analg. 2008; 106:1643–1658.
  16. Loepke A, Soriano S. An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function. Anesth Analg. 2008; 106:796–804.
  17. Wilder R, Flick R, Sprung J, Katusic S. Early exposure to anesthesia and leaning disabilities in a population-based birth cohort. Anesthesiology. 2009; 110:796–804.

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contact nzmj@nzma.org.nz

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Clubfoot is a relatively common orthopaedic condition in New Zealand. The New Zealand population is currently estimated at 4.24 million, of which 22% claim to be of Māori/Polynesian descent.1 The Māori word for clubfoot is ‘waehape’, which translates directly to broken or crooked foot. While the incidence of clubfoot in the white New Zealand European population is about 1 per 1,000, the incidence of clubfoot in the Māori and Pacific population is 6 to 7 per 1,000.2,3 Clubfoot is not only common in the Māori and Pacific Island population, but also potentially more resistant, with a higher rate of recurrence than that seen overseas.4 New Zealand paediatric orthopaedic surgeons therefore treat a higher number of children with clubfoot, which may also be more severe.

The Ponseti method for non-operative treatment of idiopathic clubfoot has increasingly become the treatment modality of choice in New Zealand and around the world.4,5 Percutaneous Achilles tenotomy (PAT) is performed during the final phase of casting to correct residual equinus contracture. This is required in approximately 80–90% of patients with clubfoot.6,7 Several settings have been proposed as venues for this procedure, however there is an increasing trend to performing this in theatre under general anaesthetic (GA). Ponseti originally chose to perform this as an outpatient procedure under local anaesthesia, yielding a success rate of close to 90%.8,9 Some surgeons, however, have preference to perform this in theatre,10,11 while others believe it can be performed safely in the outpatient setting.12 General anaesthesia is expensive and not without potential risks. To date there have been no studies comparing PAT performed as an outpatient procedure to those performed in theatre that have looked at parental concerns to the procedure and evaluated cost effectiveness.

We implemented a retrospective study using prospectively gathered data to evaluate the safety and efficacy of PAT performed as an outpatient procedure compared to those performed in theatre. We assess parental satisfaction to this procedure, and analyse current practising trends among New Zealand orthopaedic surgeons in regard to Ponseti management.

Patients and methods

The study was approved by our Institutional Research Office. All infants referred to our department at Hastings Hospital for clubfoot between January 2013 to December 2015 were included in the study. Patients with a diagnosis other than non-idiopathic clubfoot were excluded from the study. All patients recruited into the study were treated according to Ponseti protocol. A single surgeon performed all outpatient releases percutaneously in a clinic setting. A comparison group of patients were recruited who had their PAT performed in theatre under a general anaesthetic by a different surgeon whose preference was to perform releases in a theatre setting. This was a group of patients who had consecutive PAT performed by this surgeon prior to the study. Both groups had identical Ponseti management. Demographic data was collected to ensure no differences between the two groups existed. Clinical and outcome data was collected prospectively at each clinic for both groups. All patients had a minimum follow-up of two years following PAT. PAT was indicated when the mid-foot deformity had been corrected (MFS = 0) and the hind-foot deformity remained in an equinus position (unable to dorsiflex past 10 degrees). The outpatient procedure was performed during the final stage of serial casting in a routine clubfoot outpatient clinic. Pain prevention protocol included application of Emla Cream 5% 1.0g/10cm area (Prilocaine/Lignocaine combination) placed topically on the surgical site one hour prior to procedure (Table 1).

Table 1: Pain prevention protocol for outpatient Achilles tenotomy.

In November 2015, a survey was emailed to members of the Paediatric Orthopaedic Society of New Zealand (POSNZ). Registrars and surgeons who did not manage patients with clubfoot were excluded. The survey was designed to evaluate current practising trends among New Zealand orthopaedic surgeons who manage and treat clubfoot. Within the email was a link to perform the survey online using the online survey website, surveymonkey.com. By emailing all members of POSNZ, this was thought to reflect an accurate cross-section of the majority of surgeons managing this deformity in New Zealand.

Patient-parental satisfaction surveys were sent to all cases performed in outpatient clinic. The survey enquired about precautions taken to manage pain, convenience of having release performed in the clinic setting, and overall quality of the care received. For those that did not respond, the Māori Health Liaison team was recruited to help meet and make contact with the family.

Cost analysis was performed using clinic and hospital billing information, and a cost of care per procedure was determined. Average cost per procedure based on national data is often an overestimate, therefore a more detailed analysis was performed. Cost of PAT performed in theatre was calculated from data for all releases performed between September 2005 to November 2015.

Statistical analysis

Statistical analysis was performed to compare demographic characteristics and outcome data. A Student t-test was used for continuous variables. A two-tailed Fisher exact test was used for categorical variables. For patients who had recurrence, a separate cox regression analysis was performed to see if one group was more likely to recur than the other. This analysis was performed to correct for the fact that the study is “right censored” (ie, has stopped before all patients that would recur have had time to). Ninety-five percent confidence intervals were used. A p value of ≤0.05 was defined as significant. All analyses were done using the R statistical package. The cox regression was performed using the “survival” library.

Results

The current study includes 59 clubfeet (40 babies, 19 bilateral cases) with a diagnosis of idiopathic congenital clubfoot. All were regularly seen in routine clubfoot outpatient clinics. PAT was performed on 26 clubfeet (19 patients) under local anaesthetic in an outpatient setting, and 33 clubfeet (21 patients) under GA in a theatre setting.

The Achilles tenotomy rate in our study was 92%. The ratio of males to females was 2:1. Ratio of Māori/Polynesian to New Zealand European referred with clubfoot was 5.6:1. The average Catterall-Pirani score for the outpatient group and theatre group was 5.26 and 5.32 respectively. Demographic comparisons were made and no significant differences were found between the two groups with regard to gender (p=0.83), ethnicity, Deprivation Index or severity (p=0.84) (Table 2).

Table 2: Demographic comparisons.

 

Tenotomy was performed at an average post-natal age of 10.5 weeks in the clinic group and 12.1 weeks in the theatre group. For age at release there was no evidence of a difference between the two groups (p=0.25). No patients had complications of infection, bleeding or neurological deficit. Those in the theatre group were exposed to a greater number of general anaesthetics before the age of four, but this did not reach statistical difference (p=0.023) (Table 3).

Table 3: Treatment comparisons.

Recurrence was defined as either early or late and requiring minor or major surgery.13,14 Early recurrence was defined as recurrence of deformity identified before six months of age. Minor recurrence was that requiring an extra-articular soft tissue procedure such as repeat PAT, open Achilles tendon lengthening or Tibialis Anterior transfer procedure. Three patients had early recurrence in the clinic group compared to one patient in the theatre group. One in the outpatient group was thought to have an incomplete release requiring repeat tenotomy (Table 4). Major recurrences were defined as those that required an intra-articular surgical approach. There was no significant difference for the probability of recurrence between the two groups (p=0.67). There was no difference in re-tenotomy rate (p=0.58). Odds ratios (OR) with respect to recurrence were calculated to see if there was an association between the setting of the release, and outcome of either major or minor recurrence. There was no statistical difference for minor revision or major revision (p=0.742, p=0.741 respectively).

Table 4: Repeat tenotomy.

c

Among practising New Zealand orthopaedic members of POSNZ, 30/39 responses were received (response rate 77%). The average number of years in practice was 17.2. All respondents preferred Ponseti method as their choice for initial management of clubfoot. One respondent chose surgical and Ponseti as preferred initial management. The majority (14/18) chose to perform this in theatre under general anaesthesia, while only four surgeons regularly perform PAT as an outpatient procedure. Of those that perform the procedure in theatre, only five said they would consider changing their practice to performing PAT as an outpatient procedure. The main concerns voiced included facility or staffing issues, concerns regarding inadequate pain control, concerns regarding incomplete release, concerns regarding distress to family and concerns regarding sterility. Only a small proportion (4/18) of practising New Zealand orthopaedic surgeons preferred to perform PAT as an outpatient procedure. The reasons given for electing to perform PAT as an outpatient procedure included avoiding potential risks associated with general anaesthesia, logistical issues, difficulty with access to theatre and potential cost savings.

A response rate of 6/19 (32%) was achieved for the parental satisfaction survey. Māori Health Liaison services were recruited to help make contact with the families. Of the replies, all reported that the clinic environment was excellent in regards to convenience of setting. Five reported precautions taken to manage pain were ‘excellent’, while the remaining reported that this was ‘very good’. Overall, the quality of care provided in clinic was reported as ‘excellent’, and there were no concerns regarding inadequate pain control.

Theatre and financial data was analysed for all PAT performed in the operating theatre between 2005 and 2015. Indicative costs were $6,061 NZD per procedure based on 2015 data at our district health board (DHB). Costs over this 10-year period increased from $4,801 NZD in 2005 to $6,061 NZD per procedure in 2015. Cost for PAT performed in clinic was determined by our finance department. Indicative cost per percutaneous procedure in outpatient clinic was $378 NZD at our DHB in 2015.

Discussion

Achilles tenotomy is an important step in Ponseti management. Performing Achilles tenotomy in the outpatient clinic can be performed safely and effectively. Performing Achilles tenotomy in theatre under general anaesthesia also has it merits, thus why many surgeons prefer this setting. Potential advantages include better ability to reduce pain, ability to perform the procedure in a more controlled manner, and the relative sterility of the operating room. No studies to date have shown that the controlled nature of the operating theatre allows the surgeon to perform a more accurate and complete release, resulting in lower re-tenotomy rate, and our study was no exception.

There has been concern in the literature regarding use of volatile anaesthetic gases and the potential adverse effects on neurocognitive development. A number of studies have shown volatiles can induce neuronal cell apoptosis due to N-methyl-D-aspartate antagonists. These hypotheses are based on animal models.15,16 Wilder et al found a statistically significant increase in the risk for developing a learning disability in those who had received general anaesthesia either two or three times before the age of four.17 Other studies have found no increased risk with general anaesthesia in this age group.11 In our study those who had PAT performed in clinic had less overall exposure to general anaesthetics before the age of four.

For those who had releases performed in clinic there were no complications such as casting issues, infection or bleeding identified. One patient, however, was thought to have an incomplete release requiring repeat tenotomy. We recognise that post-operative surgical complications following this procedure are rare and unlikely to be statistically affected whether procedure is performed in clinic or theatre. After implementing the change to performing our releases in a clinic setting, other advantages were identified. We found it allowed infants to have their release despite being unwell with concurrent viral-like illnesses that would have otherwise resulted in cancellation of the procedure. Parents were only away from their baby for a short period relative to performing releases in theatre, and the infant did not have to be nil by mouth, which parents also appreciated.

For those patients included in both the clinic and theatre group the rate of recurrence seen was higher than that reported in the overseas literature, but similar to other New Zealand studies.4,14 These findings support other New Zealand studies that propose clubfoot managed in New Zealand may be more severe and impervious to treatment than clubfoot seen elsewhere. It is uncertain if poor compliance leads to an increased risk of recurrence, or if it is due to recurrence of a stiff foot resulting in difficulty with boot and bar wear and therefore presumed poor compliance. This is a major issue and has been reported in many existing studies but remains unsolved.4,14

A study evaluating practising trends in North America was performed in 2003, and was then revisited in 2010. The majority of Achilles tenotomies were performed percutaneously (92.8%). The tenotomy was performed under local anaesthesia in 39.4% of patients, while 45.4% were performed under general anaesthesia in the operating theatre. Reasons for preferences on the setting of release were not evaluated.5,6 In our study, the majority of surgeons prefer to perform PAT in the operating theatre, and would not consider changing their practice to performing PAT in an outpatient setting. The greatest concerns to the surgeon include facility and/or staffing issues, concerns regarding inadequate pain control, concerns regarding incomplete release and concerns regarding infection risk.

Parental concerns were specifically evaluated in this study. The response rate was very low despite involvement of Māori Health Liaison services. This reflects why follow-up with these patients is so difficult and why outcomes are poor and recurrence is high. Despite this, the data received was very reassuring in regard to the convenience of having PAT performed in clinic. Effectiveness of analgesia was deemed excellent by parents including bilateral cases. There were no parental concerns with regard to this procedure performed in an outpatient setting.

Procedure costing within a DHB environment is not precise and should be taken as indicative. Notwithstanding the approximation in costing of this procedure in both theatre and clinic settings the cost differential between the two settings is clear, theatre is at least 10 times greater than clinic for the same procedure. Our study suggests that performing PAT in clinic would decrease the cost per foot significantly.

Conclusion

As implied in the current study, Achilles tenotomy as an outpatient procedure has been shown to be safe and effective. We believe it can be performed safely with results comparable to that performed in theatre. It avoids any potential risks associated with general anaesthesia and potential delays associated with theatre lists. Pain can be controlled adequately, and there is no increased risk of complications or re-tenotomy rate. Parental satisfaction to this procedure is excellent and there are significant financial savings.

Summary

Abstract

Aim

Percutaneous Achilles tenotomy (PAT) is performed during the final phase of casting with Ponseti method. Several settings have been proposed as venues for this procedure, however it is increasingly being performed in theatre under a general anaesthetic (GA). General anaesthesia, however, is expensive and not without risks. The purpose of the present study was to compare results of outpatient releases to theatre releases, and assess current practising trends among orthopaedic surgeons.

Method

Retrospective comparison of patients with idiopathic clubfoot managed by Ponseti method who had Achilles tenotomy performed in outpatient clinic and in theatre. Surveys were sent to all POSNZ members to determine current practising trends in New Zealand. Parental satisfaction surveys were performed. Comparative cost analysis was performed using hospital billing information.

Results

The current study includes 64 idiopathic congenital clubfeet (19 bilateral cases). PAT was performed on 26 clubfeet under local anaesthetic in an outpatient setting, and 33 clubfeet under GA in a theatre setting. There was no significant difference for post-operative complications, or recurrence (p=0.67). Those in theatre group were exposed to a greater number of general anaesthetics before the age of four. Among practising New Zealand paediatric orthopaedic surgeons, 77.78% perform this in theatre under general anaesthesia, while only 22.22% perform PAT in outpatient clinic. The main barriers included concerns regarding pain control, concerns regarding incomplete release, concerns regarding distress to family and concerns regarding sterility. Parental satisfaction surveys found pain management to be excellent. Financial data was analysed and indicative costs were $6,061 NZD per procedure in theatre, compared to $378 NZD per procedure in clinic.

Conclusion

PAT performed in a clinic setting is both safe and efficacious with results comparative to that performed in theatre. There was no difference in post-operative complications or recurrence. Parental satisfaction to this procedure is excellent. There are significant financial advantages. Based on this data, our institution now performs all releases in an outpatient setting.

Author Information

- Lewis Agius, Department of Orthopaedic Surgery, Hastings Hospital, Hastings; Angus Wickham, Department of Orthopaedic Surgery, Hastings Hospital, Hastings;- Cameron Walker, University of Auckland, Auckland;- Joshua Knudsen, Department of Ortho

Acknowledgements

The authors would like to acknowledge Tuakana August and Dianne Wepa from Mori Health Liaison Services for their support.

Correspondence

Dr Lewis Agius, Department of Orthopaedic Surgery, Hastings Hospital, Hastings.

Correspondence Email

lewisagius@gmail.com

Competing Interests

Nil.

  1. Statistics New Zealand. 2013 Census - Major ethnic groups in New Zealand. Retrieved January 30, 2016 from Statistics New Zealand: http://www.stats.govt.nz
  2. Chapman C, Stott N, Port R, Nicol R. Genetics of Clubfoot in Māori and Pacific People. J Med Genet. 2000; 37:680–683.
  3. Beals R. Clubfoot in the Māori: a genetic study of 50 kindreds. NZ Med J . 1978; 88:144–146.
  4. Halanski M, Davison J, Huang J, et al. Ponseti Method Compared with Surgical Treatment of Clubfoot, A Prospective Comparison. J. Bone Jt. Surg. 2010; 92-A(2):270–278.
  5. Zionts L, Sangiorgio S, Ebramzadeh E, Morcuende J. The Current Management of Idiopathic Clubfoot Revisited: Results of a Survey of the POSNA Membership. J Pediatr Orthop. 2012; 32(5):515–520.
  6. Heilig M, Matern R, Rosenzweig S, et al. Current Management of Idiopathic Clubfoot Questionnaire, A Multicentric Study. J Pediatr Orthop. 2003; 23(6):780–787.
  7. Scher D, Feldman D, Van Bosse H, et al. Predicting the need for tenotomy in the Ponseti method for correction of clubfeet. J Pediatr Orthop. 2004; 24:349–352.
  8. Ponseti IV, Smoley EN. Congenital Clubfoot: the results of treatment . J Bone Joint Surg Am. 1963; 45:261–275.
  9. Ponseti IV. Congenital Clubfoot, Fundamentals of Treatment. Great Britain: Oxford Univerity Press “The Green Book”. 1996.
  10. Halanski MA, Huang JC, Walsh SJ, Crawford HA. Resourse Utilisation in Clubfoot Management. Clin Orthop Relat Res. 2009; 467(5):1171–1179.
  11. Parada SA, Baird GO, Auffant RA, et al. Safety of Percutaneous Tendoachillies Tenotomy Performed Under General Anesthesia on Infants With Idiopathic Clubfoot. J Pediatr Orthop. 2009; 29(8):916–919.
  12. Lebel E, Karasik M, Bernstein-Weyel M, et al. Achilles Tenotomy as an Office Procedure: Safety and Efficacy as Part of the Ponseti Serial Casting Protocol for Clubfoot. J Pediatr Orthop. 2012; 32(4):412–415.
  13. Halanski M, Maples D, Davison J, et al. Separating the Chicken From the Egg: An Attempt to Discern Between Clubfoot Recurrences and Incomplete Corrections. Iowa Orthop J. 2010; 30:29–34.
  14. Haft G, Walker C, Crawford H. Early Clubfoot Recurrence After Use of the Ponseti Method in a New Zealand Population. J. Bone Jt. Sur. 2007; 89-A(3):487–493.
  15. Wang C, Slikker W. Strategies and experimental models for evaluating anesthetics: effects on the developing nervous system. Anesth Analg. 2008; 106:1643–1658.
  16. Loepke A, Soriano S. An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function. Anesth Analg. 2008; 106:796–804.
  17. Wilder R, Flick R, Sprung J, Katusic S. Early exposure to anesthesia and leaning disabilities in a population-based birth cohort. Anesthesiology. 2009; 110:796–804.

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