The results of tenodesis of the tendo achillis to the fibula for paralytic pes calcaneus

Sixty-six consecutive tenodeses of the tendo achillis to the fibula were done in sixty patients who had paralytic pes calcaneus. The patients were followed for an average of 5.7 years (range, two to 10.8 years). The preoperative disturbance of gait was eliminated in all of the patients, and radiographic improvement was noted in the feet that had been operated on. Sixteen feet (23 per cent) required revision of the tenodesis because equinus deformity had developed. The development of equinus deformity was found to occur more often in patients who had the procedure at a younger age and in patients in whom the calcaneotibial angle measured more than 70 degrees at the time of the tenodesis. Residual cavovarus deformity was successfully treated by a plantar release.     

The importance of gastrocnemius recession in the correction of equinus deformity in cerebral palsy.

Spasm or contracture of the gastrocnemius muscle is predominantly responsible for the equinus deformity of the foot in cerebral palsy. Its release is therefore logical in the treatment of all cases which do not respond to conservative measures. The authors have demonstrated, by the use of metal markers and radiographic control at operation, that adequate release cannot be achieved by severance of the calcaneal tendon alone, and that in order to ensure relaxation of the gastrocnemius muscle, the operation of choice is gastrocnemius recession by the method of Strayer, coupled with lengthening of the calcaneal tendon to deal with such degree of the deformity as may be attributable to shortening of the soleus. A survey of 100 limbs treated by this method revealed a recurrence rate of equinus of 9% and a degree of calcaneus deformity resulting in inadequate push-off in 3% of cases after an average follow-up period of six years.     

Heel cord advancement combined with Vulpius' lengthening of the gastrocnemius

The results of Achilles tendon lengthening to treat spastic pes equinus deformity are less than satisfactory, with high recurrence rates. To improve the outcome, heel cord advancement can be done. In the current study, the patients with severe contracture of the Achilles tendon were treated by heel cord advancement. Additional lengthening of the gastrocnemius muscle using the Vulpius technique was done to reattach the Achilles tendon to the calcaneus. Seventeen patients (20 feet) with spastic pes equinus deformities were treated with this technique, and satisfactory midterm postoperative results were obtained. The mean age of the patients at surgery was 10 years, and the mean duration of followup after surgery was 8 years. The mean tibioplantar angle decreased postoperatively, and there were no recurrences of pes equinus deformity and no appearance of pes calcaneus deformity. Walking ability improved in two patients and did not deteriorate in any of the patients. Seven of the patients were able to stand on only the affected foot after the operation. Our technique provides good correction of an equinus deformity with no recurrence, and with improvement of the physical activity level.     

Isolated calf lengthening in cerebral palsy. Outcome analysis of risk factors

We assessed the medium-term outcome of three methods of isolated calf lengthening in cerebral palsy by clinical examination, observational gait analysis and, where appropriate, instrumented gait analysis. The procedures used were percutaneous lengthening of tendo Achillis, open Z-lengthening of tendo Achillis and lengthening of the gastrosoleus aponeurosis (Baker's procedure). We reviewed 195 procedures in 134 children; 45 had hemiplegia, 65 diplegia and 24 quadriplegia. We established the incidence of calcaneus and recurrent equinus and identified 'at-risk' groups for each. At follow-up, 42% had satisfactory calf length, 22% had recurrent equinus and 36% calcaneus. The incidence of calcaneus in girls at follow-up was significantly higher (p = 0.002) while boys had an increased rate of recurrent equinus (p = 0.012). Children with diplegia who had surgery when aged eight years or younger had a 44% risk of calcaneus, while those over eight years had a 19% risk (p = 0.046). Percutaneous lengthening of tendo Achillis in diplegia was the least predictable, only 38% having a satisfactory outcome compared with 50% in the other procedures. The incidence of recurrent equinus in hemiplegic patients was 38%. Only 4% developed calcaneus. The type of surgery did not influence the outcome in patients with hemiplegia or quadriplegia. Severity of involvement, female gender, age at operation of less than eight years and percutaneous lengthening of tendo Achillis were 'risk factors' for calcaneus. Hemiplegia, male gender, and an aponeurosis muscle lengthening increased the risk of recurrent equinus.     

Equinus deformity in cerebral palsy: a retrospective analysis of treatment and function in 39 cases

Equinus deformity, due to a contracture of the triceps surae, is a frequent problem in cerebral palsy. The authors present a retrospective analysis of the functional status of 27 patients (39 feet) of equinus deformity seen in a 10-year follow-up study. When either a Hoke or White tendo Achillis surgical lengthening procedure was combined with a postoperative management program of night-bracing, the recurrence of equinus deformity was significantly reduced.     

Posterior transfer of the anterior tibial tendon in children who have a myelomeningocele

Posterior transfer of the tendon of the anterior tibial muscle through the interosseous membrane to the calcaneus to prevent or correct a calcaneus deformity was performed in twenty patients (thirty-nine feet) who had a myelomeningocele. The average age of the patients at the time of the operation was 4.6 years, and they were followed for an average of six years. Satisfactory clinical and radiographic results were obtained in thirty-seven (95 per cent) of the thirty-nine feet. Two patients, one who was unable to walk and one who walked at home only, had a mild equinus deformity of the left foot. No patient had a clinical calcaneus deformity, but there was radiographic evidence of talipes calcaneus in one patient (two feet). The anterior tibial muscle functioned more consistently when the operation was performed after the patient was four years old and in patients who had a fifth lumbar or first sacral motor level.     

Congenital paralytic vertical talus. An anatomical study.

Dissections of the feet of a three-month-old infant with paralytic congenital vertical talus secondary to lumbar myelomeningocele were compared with a dissection of a normal foot. The major differences appeared to be absence of the plantar intrinsic muscles and dorsal dislocation of the talonavicular joint. It is postulated that the pathological process begins as a failure of the intrinsic muscles to oppose the unbalanced, active dorsiflexion forces of the anterior crural muscles. This imbalance then allows disruption of the talonavicular joint, mechanically the least stable joint in the mid-part of the foot. All dorsiflexion forces acting on the ankle then become ineffective and plantar flexion forces serve only to pull the calcaneus and talus into equinus, causing a "vertical" talus. Treatment must be directed at reducing the talonavicular dislocation, correcting the equinus deformity of the hind part of the foot, and substituting for the undeveloped plantar intrinsic muscles.     

Percutaneous lengthening of the Achilles tendon in children with cerebral palsy. Technique and results

We report a series of percutaneous lengthenings of the Achilles tendon in cerebral palsy children with equinus deformity in 25 patients due to retraction of the triceps surae. This technique has several advantages over open procedures. Based on our results and data reported in the literature, we emphasize the minimally invasive nature of this technique, the low rate of complications and recurrence, and the absence of secondary deformation of the calcaneus since over-lengthening is not compatible with the technique.     

Gastrocnemius Recession or Tendo-Achilles Lengthening for Equinus Deformity in the Diabetic Foot?

Contracture of the Achilles-gastrocnemius-soleus complex leading to ankle equinus has been linked to the development of various foot disorders. Decrease in ankle dorsiflexion results in an increase in plantar pressures and in diabetes and neuropathy, increased pressures can lead to ulceration and possibly the formation of Charcot foot. Surgical management of the equinus deformity corrects this abnormality and has the potential to avert the development of Charcot foot or ankle. Gastrocnemius recession, tendo-Achilles lengthening, and Achilles tenotomy have all been offered as surgical solutions to this condition. This article reviews ankle equinus and compares the treatment options available. A video of Hoke's triple hemisection has been included with this article and can be viewed at www.podiatric.theclinics.com.     

Dynamic electromyography analysis of habitual toe-walkers

The distinction between congenital short tendo calcaneus and mild cerebral palsy may often be difficult to ascertain by standard physical examination. Dynamic electromyography (EMG) was used to study the muscular activity during walking of four children who had a clinical diagnosis of congenital short tendo calcaneus. Two children displayed EMG evidence of cerebral palsy, while two had studies similar to normal children walking on their toes. Dynamic EMG may be a useful diagnostic tool in the evaluation of children with toe-walking.     

Pathophysiology of Charcot-Marie-Tooth disease

The etiology of the foot deformity in patients with Charcot-Marie-Tooth disease has not previously been discussed in relation to the extrinsic muscle function around the foot and ankle. Eight adult patients with a strong familial history were evaluated, and their foot findings were remarkably similar. All demonstrated a marked cavus deformity that was secondary to a forefoot equinus associated with contracture of the plantar fascia and a varus deformity of the calcaneus. The muscle function demonstrated marked weakness of the tibialis anterior and peroneus brevis muscles, whereas the peroneus longus and posterior calf muscles were rated as good to normal. Based on the relative strengths of these muscles and the progression of weakness, the authors hypothesize that the deformity observed in patients with Charcot-Marie-Tooth disease is secondary to the weakness of the tibialis anterior, peroneus brevis, and the intrinsic muscles, with their natural antagonists, the peroneus longus and the tibialis posterior muscles causing most of the deformity noted in these adult patients.     

Limb salvage treatment for congenital deficiency of the tibia

Nine limb salvage treatments were performed in 7 patients with congenital deficiency of the tibia. All feet showed equinovarus deformity and were centralized in a slightly equinus position by placing the distal end of the fibula into the posterior facet of the calcaneus. Tibiofibular fusion was performed in 4 patients with partial deficiency, and fibular transfer (fibular centralization; Brown procedure) in 5 with complete deficiency of the tibia. Callus distraction lengthening was performed repeatedly for leg-length discrepancy on either the femur or the centralized fibula. Satisfactory functional and cosmetic results were obtained in all limbs with partial deficiency, whereas in limbs with completely deficiency, none of the 5 knees treated by fibular transfer achieved a satisfactory functional result because of insufficient quadriceps strength, progressive knee flexion contracture, and persistent ligamentous instability. Nevertheless, in these 5 cases, all patients were ultimately able to withstand weight-bearing.     

Complete tendon transfer and inverse Lambrinudi arthrodesis: preliminary results of a new technique for the treatment of paralytic pes calcaneus

BACKGROUND: Paralytic pes calcaneus is commonly associated with myelomeningocele and continues to be one of the most difficult deformities to treat. The purpose of the present study is to describe and report the preliminary results of a new procedure to dynamically correct paralytic pes calcaneus. MATERIALS AND METHODS: Since 2002, the senior surgeon operated on six patients with myelomeningocele and developed a new procedure to dynamically correct paralytic pes calcaneus. This new procedure combines a complete tendon transfer (tibialis anterior and posterior, peroneus brevis and longus, and extensor digitorum and hallucis longus) to the Achilles tendon and an additive triple arthrodesis. The extent of the calcaneus deformity was evaluated by measuring the talocalcaneal angle. The mean followup was 32 months. RESULTS: Excellent results were achieved in five of the six patients with a mean age of 17.5 years. Using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale, pain and function improved from an average of 41.6 preoperatively to 72.0 postoperatively. The deformity as assessed by the talocalcaneal angle, the calcaneal pitch, and the talometatarsal I angle improved after surgery significantly (p < 0.004). After 12 months, an additional surgery was required in two patients due to disabling drop-foot. CONCLUSION: This new surgical technique to correct paralytic pes calcaneus including complete tendon transfer and triple arthrodesis is promising. Although this is a technically demanding procedure, it provides an excellent functional result without the residual complications associated with ankle arthrodesis.     

Heel cord advancement for treatment of equinus deformity in cerebral palsy

Spastic equinus deformity is common in patients with cerebral palsy. Since 1981, 612 anterior transpositions of the Achilles tendon as described by Murphy have been performed. One hundred patients with at least 30 months' follow-up were selected and retrospectively reviewed. Good correction of the equinus deformity was obtained without the need for prolonged bracing. No patient had a calcaneal gait or recurrence of equinus.     

Surgical management of ankle and foot deformities in cerebral palsy

A system of surgical treatment of deformities of the ankle and foot in cerebral palsy is presented on the basis of experience with 420 children. The aim of surgery is prevention or correction of deformities. There are three types of deformity (fixed, dynamic, and mixed), each of which is treated differently. Surgery should be delayed as long as there is functional improvement. The most common indication for foot surgery is equinus deformity, which makes it difficult to keep the heel in the shoe. Tendo Achillis lengthening is satisfactory for fixed equinus, and transfer of the medial belly and the tendon of the gastrocnemius to the dorsum of the foot is appropriate for dynamic equinus. Hindfoot valgus in hypertonic cerebral palsy is treated by peroneus brevis elongation when moderate and in combination with subtalar arthrodesis when severe. Hindfoot valgus in hypotonic cerebral palsy is treated by subtalar arthrodesis only. Hindfoot varus is treated by tibialis posterior lengthening, usually in combination with (1) tendo Achillis lengthening, (2) a Steindler plantar release, or (3) valgus calcaneal osteotomy. Dynamic forefoot supination is treated by split-tibialis anterior tendon transfer or, when associated with dorsiflexion of the hallux, by extensor hallucis longus transfer.     

Accessory soleus muscle as a cause of congenital talipes equino varus. A case report

The authors report a case of congenital clubfoot in a one-year-old male child, in which an accessory soleus muscle was noted intraoperatively, running anteromedially to the Achilles tendon and with a distinct insertion on the postero-medial aspect of the calcaneus. Correction of the varus and equinus of the hindfoot could only be achieved after cutting the tendon of the accessory soleus muscle at its insertion on the calcaneus.     

Spastic equinus foot

Pes equinus is the most common deformity in cerebral palsy. A primarily dynamic pes equinus without shortening of the calf muscle in many cases turns into a structural pes equinus. This is due to insufficient linear growth of the calf muscle compared to bone growth. Structural pes equinus has to be distinguished from marked, compensatory and forefoot pes equinus. Conservative as well as operative treatment options are often applied in combination or sequentially. In dynamic pes equinus botulinum toxin A is the therapy of choice. Only slight structural pes equinus may improve under botulinum toxin A injection with and without additional casting. Usually, structural pes equinus requires operative treatment or lengthening of the gastrocnemius and/or soleus muscle (operation according to Baumann). Because of its side effect of inducing loss of power of the calf muscle, lengthening of the Achilles tendon should only be performed with caution. Especially in bilateral spastic cerebral palsy, the increased risk of causing talipes calcaneovalgus and crouch gait has to be considered.     

The Baumann procedure to correct equinus gait in children with diplegic cerebral palsy: long-term results

Although equinus gait is the most common abnormality in children with spastic cerebral palsy (CP) there is no consistency in recommendations for treatment, and evidence for best practice is lacking. The Baumann procedure allows selective fractional lengthening of the gastrocnemii and soleus muscles but the long-term outcome is not known. We followed a group of 18 children (21 limbs) with diplegic CP for ten years using three-dimensional instrumented gait analysis. The kinematic parameters of the ankle joint improved significantly following this procedure and were maintained until the end of follow-up. We observed a normalisation of the timing of the key kinematic and kinetic parameters, and an increase in the maximum generation of power of the ankle. There was a low rate of overcorrection (9.5%, n = 2), and a rate of recurrent equinus similar to that found with other techniques (23.8%, n = 5). As the procedure does not impair the muscle architecture, and allows for selective correction of the contracted gastrocnemii and soleus, it may be recommended as the preferred method for correction of a mild fixed equinus deformity.     

Spastischer Spitzfu?

Pes equinus is the most common deformity in cerebral palsy. A primarily dynamic pes equinus without shortening of the calf muscle in many cases turns into a structural pes equinus. This is due to insufficient linear growth of the calf muscle compared to bone growth. Structural pes equinus has to be distinguished from marked, compensatory and forefoot pes equinus. Conservative as well as operative treatment options are often applied in combination or sequentially. In dynamic pes equinus botulinum toxin A is the therapy of choice. Only slight structural pes equinus may improve under botulinum toxin A injection with and without additional casting. Usually, structural pes equinus requires operative treatment or lengthening of the gastrocnemius and/or soleus muscle (operation according to Baumann). Because of its side effect of inducing loss of power of the calf muscle, lengthening of the Achilles tendon should only be performed with caution. Especially in bilateral spastic cerebral palsy, the increased risk of causing talipes calcaneovalgus and crouch gait has to be considered.     

Treatment of spastic equinus by aponeurosis lengthening

The aponeurosis lengthening described in this study was performed on 156 patients (219 procedures) with spastic equinus deformities. There was only one wound complication and no calcaneus deformities from overlengthening. The recurrence rate requiring relengthening was high (48% of the procedures), particularly if the initial operation was performed before the age of 5 years. The length of postoperative immobilization did not affect the recurrence rate. The aponeurosis lengthening technique described is a simple lengthening of the aponeurosis, leaving the soleus largely intact without the use of internal sutures. It has a negligible complication rate, but a high rate of recurrent equinus.