We got great news at the doctor on Friday--M's feet were nicely turned out and he was deemed ready for the Achilles tenotomy, aka "heel cord release."
I strongly suspect that the reason we made such good progress the last few weeks was because we left the last few casts on until very shortly before the next set was put on. We had been told earlier that there wouldn't be a problem taking them off the night before for a bath, or even the weeks he spent out of them. Perhaps that is true for milder cases, but it was a remarkable difference in speed of correction when we stopped following that advice. In retrospect, I have since seen advice in several places to leave the casts on until either right before leaving for the appointment for a quick bath or even until arriving at the clinic. Our journey might have been shorter if we had been told that, but we can't go back in time.
The doctor we saw last week does the tenotomy procedure in clinic, using a local anesthetic, which is what we were hoping for. General anasthesia in babies is coming under scrutiny for possible long term consequences, so it was nice to avoid that risk. (It seems likely that the biggest risk is from repeat exposure, so minimizing use of it to situations where it is absolutely necessary is a good goal.)
Everything (from the doctor arriving in clinic through the final casting!) about the process took twice as long as we were told it would, so it was a very long morning, but we are grateful it's done. I'm going to share the details for anyone curious about the procedure, or for other clubfoot parents who may one day find the information useful.
We had been previously told that they would apply emla cream to his heels to numb the area before injecting the anesthetic, but when it came time to do it they told me they no longer did that. Emla is available without prescription from pharmacies here, so if I were to do it againi would pick up my own and apply it. M likely would have screamed through the injections anyway, since being held face down on the exam table was clearly no fun, but it would have been nice to space him that bit of pain.
He calmed down quickly after and actually fell asleep in my arms while we waited for the shots to take effect. Eventually the doctor came back to do the actual procedure, which I suspect was not a pleasant way to wake up!
I have heard some doctors have parents wait outside, and others give them a choice. We had been told I would be able to stay, and in fact I wasn't even asked about it--the nurse just told me where to stand (crouched down by M's head) and they carried on. The first nurse actually excused herself because she doesn't like to watch the procedure. I would have been able to hear him crying from the waiting room, soI think it was easier on me to be there than to be outside hearing him.
I was focused on talking to M to try to soothe him as much as possible, and staying out of the way, so I didn't actually see anything, but my understanding is that the doctor makes a small cut on each side of the tendon, to allow it to be stretched to the proper length. It was very quick, and pressure bandages were quickly applied to control the bleeding. (Between the injections and the surgery, there was a reasonable amount of blood. I could see how some parents might do OK with seeing that).
The bandages were left on for a while, then new dressings were applied and casts put on over them. The casts are the same as the ones he has had all along, except now his foot is held in flexion while the cord hopefully heals into the correct length. The casts stay on for two weeks this time while that happens. I expect there will be one more cast after this, but we don't know for sure. But hopefully in2-3 weeks time we will be done with all casting!
In the three days since he has been a bit less cheerful than usual, but he is also suffering from a bad cold and potentially working his first tooth, so it's hard to say what portion of his misery isfromhisfeet hurting. He seems to respond well to ibuprofen as treatment, though, and overall is doing well.