OT notes · Orthopaedics

Tendo-Achilles lengthening / tenotomy

Usual anaesthesia
General in children; spinal or general in adults; local skin anaesthesia in clinic or sedation for Ponseti tenotomy in infants
Position
Prone for Z-lengthening; supine with leg elevated by an assistant for Hoke and Vulpius; supine for Strayer and Baumann
Setting
elective

Operative note template for lengthening of the gastrocnemius-soleus-Achilles complex (open Z-lengthening, percutaneous Hoke hemisection, gastrocnemius recession, or Ponseti percutaneous tenotomy), with a filled example for an open Z-lengthening in a child with spastic hemiplegia and fixed equinus.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • over-lengthening with weak push-off, calcaneus heel or crouch gait
  • under-correction or recurrence of equinus, more likely in young children
  • sural nerve injury (numbness on the outer side of the foot)
  • bleeding from the peroneal artery or short saphenous vein (percutaneous tenotomy)
  • rupture of the lengthened tendon
  • wound breakdown or infection
  • toe flexion contracture unmasked after lengthening
  • cast and brace for several weeks

Pre-operative details for this operation

  1. Side and cause of equinusCerebral palsyPost-polioPost-traumaticStrokeDiabetic foot / forefoot ulcerClubfoot (Ponseti)Idiopathic
  2. Dorsiflexion with knee straight and knee bent (Silfverskiold test)degrees each way, hindfoot held in neutral / varus; isolated gastrocnemius or combined gastrocsoleus contracture
  3. Hindfoot and forefoot alignmentvarus / valgus, flexible or rigid
  4. Toe flexorstight or not with ankle dorsiflexed
  5. Walking statusAmbulatoryNon-ambulatory
  6. X-raysweight-bearing foot and ankle; bony block (osteophytes, malunion, arthritis) excluded
  7. Non-operative treatment triedstretching, AFO, serial casts, botulinum toxin
  8. Diabetes control if diabetic

Anaesthesia and position

  1. AnaesthesiaGeneralSpinalLocal skin anaesthesia (clinic)Sedation
  2. PositionProneSupine, leg elevated by assistantSupine, figure-of-four
  3. Tourniquetsite, pressure, time; or none

Operative findings

  1. Tendonthickness, quality, adhesions
  2. PlantarisPresent, dividedNot found
  3. Sural nerveposition relative to tendon / fascia; protected
  4. Correction achieveddorsiflexion with knee straight and bent, after lengthening

Procedure (steps)

  1. Procedure chosenStrayer recession (zone 1-2)Baumann recessionVulpius / BakerHoke triple hemisection (percutaneous)Open Z-lengtheningPonseti percutaneous tenotomyreason for choice (isolated gastrocnemius vs combined contracture)
  2. IncisionZ-lengthening: posteromedial, midway between tendon and medial malleolus, from calcaneus upward 4 to 5 cm or longer. Strayer: 3 cm from end of medial gastrocnemius belly. Hoke: three stab incisions. Tenotomy: small incision over tendon
  3. Exposuresheath / paratenon opened and kept for closure; saphenous or sural nerve protected
  4. Tendon / fascia cutZ-lengthening: central split, distal cut medial (varus) or lateral (valgus), proximal cut opposite (Campbell). Operative Techniques exits proximally medial and distally lateral, as a lateral proximal exit puts the sural nerve at more risk: if the proximal cut is lateral, protect the sural nerve. Hoke: distal medial, middle lateral, proximal medial hemisections. Recession: gastrocnemius fascia medial to lateral, all lateral fibres checked. Tenotomy: complete, medial to lateral
  5. Plantaris divided
  6. Soleus fascia or posterior capsuleNot neededSoleal fascia recessedPosterior ankle / subtalar capsule released
  7. Tension setZ-lengthening: tendon allowed to retract halfway back from full stretch; foot position at repair (neutral / 10 / 20 degrees dorsiflexion)
  8. Tendon repair (Z-lengthening)side-to-side or end-to-end; write suture type and size; knots not prominent. Books differ: Campbell (CP children, Technique 35.9) uses heavy absorbable; Operative Techniques (adults) uses heavy non-absorbable. Write which was used
  9. Final dorsiflexionknee straight and knee bent
  10. Toe flexors recheckedNot tightFDL / FHL lengthened

Closure, drains and dressing

  1. Paratenon / crural fasciaclosed with absorbable suture
  2. SkinSubcuticular absorbable with skin stripsInterruptedSkin strips only (stab incisions)
  3. Cast / bootShort leg castLong leg castCAM bootPonseti final long leg castankle position

Specimens and implants

  1. SpecimenNone

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Toe circulation and sensationcolour, capillary refill, movement; check sural area
  2. Bleeding from stab woundsespecially after percutaneous tenotomy
  3. Limb elevation
  4. Analgesiadrug, dose, frequency
  5. Weight bearingZ-lengthening / Hoke: non-weight bearing 2 to 4 weeks in adults; CP child: short leg cast 4 weeks, then AFO and weight bearing; recessions: may bear weight in boot
  6. Knee extensionencourage straight knee to keep the gastrocnemius stretched
  7. Wound checkbefore 2 weeks
  8. OrthosisAFO in neutral after cast (mould at surgery if follow-up uncertain); Ponseti: foot abduction brace after final cast
  9. Physiotherapy and follow-uprange of motion and strengthening; watch for recurrence and over-lengthening

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Master V.R., 10 years, 26 kg, right spastic hemiplegic cerebral palsy, walks independently on his right toes. Right ankle cannot be brought to neutral with the knee bent or straight (dorsiflexion minus 15 degrees knee straight, minus 10 degrees knee bent). Mild dynamic heel varus. Failed stretching, AFO and two courses of botulinum toxin.

Case details

Date: 17/06/2026. Elective. OT 2.

In OT 09:30. GA 09:40. Tourniquet up 10:05. Tourniquet down 10:40. Cast done 10:55.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: fixed equinus right ankle due to gastrocnemius and soleus contracture in spastic hemiplegia (Silfverskiold: tight with knee straight and bent).

X-ray right foot and ankle weight-bearing: no bony block.

Consent: taken from mother in Marathi, child assented. Explained over-lengthening and weak push-off, recurrence, sural nerve numbness, wound problems, 4 weeks cast then AFO.

WHO checklist sign in and time out done. Right side marked. No antibiotic prophylaxis: clean foot procedure without implant.

Anaesthesia and position

General anaesthesia. Prone, bolster under the right shin. Thigh tourniquet at 250 mmHg after exsanguination. Parts painted with povidone-iodine and draped.

Findings

Thick, tight Achilles tendon. Plantaris present on the medial side. Sural nerve lateral to the tendon, not in the field.

Procedure

Posteromedial longitudinal incision 5 cm, midway between the Achilles tendon and the medial malleolus, from the upper border of the calcaneus upward.

Tendon sheath opened longitudinally along its full exposed length and tendon freed.

Tendon split in the centre from proximal to distal. Distal half cut transversely towards the medial side, for the heel varus. Proximal half cut towards the lateral side, keeping the blade inside the sheath away from the sural nerve. Plantaris divided on the medial side.

Proximal stump pulled to full stretch with a Kocher clamp, then allowed to come back halfway, and sutured to the distal stump at that length, side-to-side, with heavy absorbable suture (Campbell Technique 35.9), with the foot at 10 degrees dorsiflexion.

Dorsiflexion after repair: 10 degrees with knee straight, 15 degrees with knee bent. Toe flexors not tight.

Tourniquet released at 10:40 (35 min). Haemostasis secured.

Closure

Sheath closed over the tendon with absorbable suture. Skin with absorbable subcuticular suture and skin strips.

Short leg cast with the ankle in 10 degrees dorsiflexion.

End of procedure

Blood loss minimal, about 10 ml. Mop, needle and instrument count correct.

No intra-operative complications. No specimen. No implant.

Shifted to ward, stable. Toes pink.

Post-op orders

Right leg elevated. Check toe colour, capillary refill and movement 2-hourly for 12 hours.

Encourage knee straight in bed.

Analgesia as per paediatric anaesthesia chart.

Wound window check before 2 weeks if the cast allows, or at cast change.

Cast for 4 weeks, then AFO with the ankle in neutral and start weight bearing. Physiotherapy referral.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 17/06/2026, 11:10.

Must document for this operation

  • Silfverskiold test result before surgery and dorsiflexion reached after lengthening. It shows why this level of lengthening was chosen and what correction was actually achieved.
  • Which technique, and in Z-lengthening the direction of the distal cut. The direction of the cut affects heel varus or valgus, and a revising surgeon needs it.
  • The tension and foot position at repair. Over-lengthening causes weak push-off and crouch gait, which is hard to reverse.
  • Sural nerve seen or protected. Numbness on the lateral foot is a common complaint, and the note should show the nerve was considered.
  • Toe flexor check after lengthening. Tight toe flexors unmasked by the lengthening cause toe-tip walking if missed.
  • Cast position and weight-bearing plan. Early loading of a Z-lengthened or Hoke-lengthened tendon risks rupture or over-lengthening.

Common mistakes in these notes

  • Writing 'TA lengthened' with no technique, no angles and no tension.
  • Not recording the pre-operative Silfverskiold test.
  • Leaving out the direction of the hemisection or Z cuts.
  • Not documenting bleeding control after a percutaneous tenotomy.
  • Forgetting the orthosis and weight-bearing plan.

Indian practice and paperwork

  • For a child, consent is taken from the parent or guardian. It must explain the procedure, risks, benefits, alternatives and who will operate, in a language they understand. (NABH 5th ed. (2020), PRE.4(c))
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed. (2020), COP.14(e) and (f))

Sources

  • Wiesel SW, Albert TJ, eds. Operative Techniques in Orthopaedic Surgery. 3rd ed. Vol 4. Wolters Kluwer; 2022, Ch 109, Achilles tendon lengthening (LaMothe JM, Levine DS), e-book PDF pp. 1100-1109.
  • Azar FM, Sawyer JR, et al., eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 35, Cerebral palsy: surgical correction of equinus, Techniques 35.8 (gastrocnemius-soleus lengthening) and 35.9 (Z-plasty of Achilles tendon); Ch 31, Ponseti method with percutaneous Achilles tenotomy (Technique 31.10), pp. 1256-1258; 1052-1055.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 2: clean procedures of the hand, knee or foot without implants: no prophylaxis recommended. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, pp. 137-138: 175-305 mmHg satisfactory for the lower limb; 2 hours or less.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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