Surgical prevention of foot deformity in patients with Duchenne muscular dystrophy

The purpose of this study was to evaluate the results of a modification of the posterior tibial tendon transfer in Duchenne muscular dystrophy patients with regard to foot deformity and ambulation. The records of 57 patients with Duchenne muscular dystrophy were retrospectively reviewed. Three treatment groups were studied: group 1, those who had surgery to maintain ambulation; group 2, those who had surgery to correct and maintain foot position; and group 3, those who had no surgery. All surgical patients had posterior tibial tendon transfer and Achilles tendon lengthening as part of their procedure. Thirty-four patients returned for interviews and examinations to assess outcomes and foot position. The mean age at cessation of ambulation for those who had surgery was 11.2 years versus 10.3 years for those who did not have surgery. Of 48 feet in 24 patients who underwent lower extremity surgery to correct and maintain foot position, 94% were clinically satisfactory at a mean of 8.5 years after surgery. Regardless of the desire to continue ambulation, all patients should have posterior tibial tendon transfer, Achilles tendon lengthening, and toe flexor tenotomies to maintain plantigrade feet.     

Split tibialis posterior tendon transfer with concomitant distal tibial derotational osteotomy in children with cerebral palsy

Fifteen lower extremities with a spastic equinovarus foot deformity associated with internal tibial torsion were identified. Each lower extremity underwent a split tibialis posterior tendon transfer combined with a distal tibial derotational osteotomy. The medical record of each patient was reviewed retrospectively. We paid particular attention to clinic visits, gait analyses, and surgical procedures performed. These patients were followed up for an average of 4 years and 5 months after surgery. Twenty-seven percent had an excellent result, 13% developed a rigid equinovarus deformity, and 40% developed a severe planovalgus deformity. Eight of the 15 lower extremities required further corrective surgery because their resultant deformities limited their ambulation, was painful, or both. The combination of a split tibialis posterior tendon transfer with a distal tibial derotational osteotomy increases the difficulty of balancing the muscle forces across the spastic equinovarus foot, increasing the likelihood that overcorrection and a planovalgus deformity will develop.     

The use of dynamic EMG in predicting the outcome of split posterior tibial tendon transfers in spastic hemiplegia

The purpose of this study was to assess the outcome of split posterior tibial tendon transfers in patients with spastic cerebral palsy to determine whether the use of preoperative dynamic electromyography was predictive of surgical success. The study is a consecutive case series of 25 children with spastic hemiplegia who underwent unilateral split posterior tibial tendon transfers for varus foot deformities. Three patients were considered failures because of residual varus, which required further surgery. An additional 5 patients had mild residual varus. Preoperative dynamic electromyographic data were evaluated to determine the etiology of postoperative undercorrection. Undercorrection seems to be related to unrecognized anterior tibial muscle overactivity and advanced age at surgery. Overcorrection did not occur. Dropfoot was noted postoperatively in 52% of patients and was related to early cessation of anterior tibial muscle activity in swing. Split posterior tibial tendon transfer is a successful surgery on those patients with increased posterior tibial muscle activity. Undercorrection can be avoided by assessing the activity of the anterior tibial muscle before surgery. These results are expected to assist in surgical decision making for the equinovarus foot in cerebral palsy.     

Wiederherstellung der Gehfähigkeit durch beidseitige Korrekturtriplearthrodese bei hochgradigem Pes equinovarus und Tetraspastik

A tendon transfer is the method of choice in easily reducible pes equinovarus. However, in long-time persisting deformities with spasms, a plantigrade position can not be maintained with these procedures. Therefore, we perform an additional bilateral triple arthrodesis in a patients with such bilateral deformities. A 55-year-old woman developed, within the scope of several surgical procedures on the cervical spine, marked bilateral pes equinovarus and flexion contractures of the knees. The patient's ambulation was limited to a wheelchair for 3 years. Then, in an interval of 1 year, we performed an unilateral soft tissue release, z-tenotomy of the Achilles tendon, triple arthrodesis with correction of the deformity, and posterior tibial tenden transfer. At follow-up 5 years after the second procedure, the 61-year-old patient was able to walk alone with two walking sticks. In the case described, the correction of a marked pes equinovarus with spasms, which was achieved by an extensive soft tissue release, could be stabilized through a triple arthrodesis in such way that the plantigrade position of the foot could be controlled through a posterior tibial tendon transfer.     

Long-term follow-up of surgery for equinovarus foot deformity in children with cerebral palsy

The factors associated with failed operative intervention in the treatment of equinovarus foot deformity in children with cerebral palsy (CP) were evaluated after long-term follow-up. One hundred eight children with CP who had surgery on the posterior tibialis tendon (split tendon transfer, intramuscular lengthening, or Z-lengthening) on 140 feet were reviewed at a mean age of 16.8 years with 7.3 years of follow-up. The surgery was considered a failure when a 10 degrees or greater varus or valgus hindfoot deformity was present or if an additional operative intervention was required or planned. Involvement of CP, age at operation, and preoperative status of ambulation were significant factors in the outcome of the surgery. Hemiplegic patients demonstrated the best results, regardless of age or surgical procedure. Seventy-five percent of diplegic and quadriplegic patients who were younger than 8 years or who were not capable of community ambulation failed operative intervention, and surgery on the posterior tibialis tendon is not recommended in this group of patients.     

Achilles lengthening/posterior tibial tenotomy with immediate weightbearing for patients with significant comorbidities

BACKGROUND: Fixed equinovarus deformities can be challenging to treat especially in medically debilitated patients. The purpose of this study was to evaluate Achilles lengthening with posterior tibial tenotomy and immediate weightbearing in this difficult group of patients. MATERIALS AND METHODS: Thirteen extremities in 10 patients underwent Achilles lengthening and posterior tibial tenotomy for fixed equinovarus deformities with significant medical comorbidities. Pre- and postoperative ambulatory status and deformities were noted. RESULTS: Average age at the time of surgery was 65 with an average duration of deformity 6.3 years. The average equinus corrected from 26 degrees to 1.2 degrees and the average varus deformity improved from -8.5 degrees to 2.7 degrees. All patients except one who was wheelchair-bound had a significant improvement in ambulatory status. CONCLUSION: Achilles lengthening with posterior tibial tenotomy allowed for immediate postoperative weightbearing with improvement in deformity and ambulatory status in this complicated patient group.     

Cadaveric Limb Analysis of Tendon Length Discrepancy of Posterior Tibial Tendon Transfer through the Interosseous Membrane

The posterior tibial tendon transfer through the interosseous membrane, as popularized by Watkins in 1954, is a procedure for treating reducible eversion and dorsiflexory paresis used by lower extremity foot and ankle surgeons. The posterior tibial tendon has been transferred to various locations on the midfoot for equinus and equinovarus deformities. Dorsiflexory paresis is a common symptom in equinovarus deformity, clubfoot deformity, Charcot-Marie-Tooth disease, leprosy, mononeuropathy, trauma to the common peroneal nerve, cerebrovascular accident, and Duchenne's muscular dystrophy. The main difficulty with this procedure, often discussed by surgeons, is inadequate tendon length, making anchoring to the cuneiforms or cuboid difficult. The goal of our cadaveric study was threefold. First, we sought to determine whether the tendon length is sufficient when transferring the posterior tibial tendon to the dorsum of the foot through the interosseous membrane for a dynamic or a static transfer. Second, we wished to describe the surgical technique designed to obtain the maximal length. Finally, we sought to discuss the strategies used when the tendon length for transfer is insufficient.     

Split tibialis posterior tendon transfer on peroneus brevis for equinovarus foot in CP children]

Equinovarus deformity of the foot is a result of the muscles imbalance in which inventors of the foot, mostly posterior and anterior tibialis muscle, overpower evertors. In children with cerebral palsy untreated spastic equinovarus deformity may cause severe fixed foot deformity and painful callosities under metatarsal heads and on the lateral side of the foot. The gait pattern becomes less effective and needs more energy. The study group consisted of 154 children with cerebral palsy treated in our Clinic by the multilevel soft tissue surgery. For foot problems 136 children needed surgical intervention. In 19 ambulatory patients, with hemiplegia or diplegia, split tibialis posterior tendon transfer together with tendo Achilles lengthening and plantar aponeurectomy were performed. The study was based on clinical examination, parents' questionnaire, radiology and gait analysis at least one year after surgery. The mean follow up was 4.6 years. The functional improvement was observed in 17 (89%) children with tendon transfer. At the last follow up those patients were brace free, with plantigrade foot while walking (without DAFO orthesis) and normal shoes were used. All painful callosities disappeared. On a standing AP X-ray adequate correction of the hindfoot-forefoot relation was achieved in 14 (74%) cases. Persistent equinovarus deformity over 10 degrees was observed in 2 cases. Those patients underwent additional bone surgery. With a properly planned approach the split tibialis posterior tendon transfer can bring good clinical and functional results in CP children with equinovarus deformation. We recommend this procedure in early stage of the deformity what can eliminate more harmful triple arthrodesis in severe deformities.     

Split anterior tibialis tendon transfer to peroneus brevis for spastic equinovarus in children with hemiplegia

PurposeThe aim of this study is to report the safety and eff-cacy of soft-tissue surgery incorporating split transfer of tibi-alis anterior to peroneus brevis (SPLATT-PB) for children with hemiplegic spastic equinovarus.MethodsThis was a retrospective case series of children and adolescents with spastic hemiplegia who had a novel combination of SPLATT-TB, intramuscular tenotomy of tibialis posterior and either spasticity management or gastrocsole-us lengthening as the index surgery. The principal outcome measures were changes in pain and difficulty with shoe wear and radiological parameters obtained from weight-bearing anteroposterior and lateral radiographs of the affected foot before and after surgery.ResultsA total of 63 patients with symptomatic spastic equinovarus met the inclusion criteria. Mean age at surgery was 9.8 years (6 to 18) and the mean follow-up was seven years (range 3 to 10 years). Foot pain and problems with shoe wear improved after surgery. Seven radiological criteria showed a clinically and statistically significant improvement at follow-up, the majority being in the normal range. There were 11 surgical adverse events, all classified as Modified Cla-vien-Dindo Grade II. Three patients required further surgery for recurrent equinus, eight patients required further surgery for valgus deformities and four patients required bony surgery for residual varus deformities.ConclusionSoft-tissue surgery for spastic equinovarus was successful in the majority of children with spastic hemiplegia, particularly between ages eight and 12 years, resulting in a plantigrade, flexible foot with minimal pain or limitations in shoe-wear. Children younger than 8 years at index surgery were more prone to overcorrection into valgus. Children older than 12 years had persistent varus deformities requiring bony surgery.Level of evidenceLevel IV, retrospective case series     

A novel surgical option for the operative treatment of clubfoot

Clubfoot (talipes equinovarus) is a condition well known since the time of Hippocrates. Numerous conservative treatments have been introduced for this condition; few are still in favour. Conservative treatment was used in our department up to the third month of age. The indication for surgery was failure to correct or maintain the correction after conservative treatment. We report on 134 children (206 feet) who had operative treatment for clubfoot in our department during the period 1990-1996, using a novel surgical technique based on extensive posteromedial release combined with the lateral spread of the "extensor forces" of the foot. This new technique has produced excellent results.     

Surgery for equinovarus deformity in Friedreich's ataxia improves mobility and independence

Friedreich's ataxia results in morbidity because of many factors; progressive equinovarus deformity is one of these. We studied the risk factors and incidence of this deformity. We sought to assess whether surgical management of fixed equinovarus deformity leads to functional improvement. Thirty-six patients with Friedrich's ataxia were assessed for this deformity. These patients were treated by splinting, botulinum toxin Type A injection, and surgery, as indicated by the severity, followed by an ongoing rehabilitation program. The effect of surgery was assessed using subscales of the Barthel index and functional independence measure. Severe foot deformities in which either surgery or botulinum toxin injection was recommended correlated with current age, years since disease onset, and years that the patient required a wheelchair for mobility, but not with the GAA repeat size or age at disease onset. Function and mobility were improved after surgery compared with a similar period before surgery. Three of seven patients who had surgery had significant complications. Aggressive management of foot deformities should be considered, and active measures to prevent permanent foot deformities should be pursued to maximize quality of life and independence of patients with Friedreich's ataxia.Level of Evidence: Therapeutic study, Level IV (case series-no, or historical control group).     

改良手术治疗脑瘫痉挛性双侧下肢瘫

[目的]2004年以来对重症脑瘫痉挛性双侧瘫治疗方法进行改进,探索提高其治疗效果的方法.[方法]23例重症脑瘫痉挛性双侧瘫.男14例,女9例;年龄3～12岁,平均5.7岁;主要症状不能独自站立和行走,双下肢肌紧张,家长扶持站立,双下肢呈剪刀步态,双髋、膝关节屈曲,踝关节跖屈,双足马蹄内翻畸形,足尖着地行走.体格检查双髂腰肌、内收肌、腘绳肌、小腿三头肌、胫前肌、胫后肌、(足母)长屈肌、趾长屈肌部分或多数不同程度肌张力增高.依Ashworth分级,为3～4级.治疗方法对动态性肌痉挛,采用肌内肌腱切断或肌筋膜切断;对静态性肌痉挛行肌腱滑动延长,胫前肌腱劈开外侧1/2移位.然后用自制外固定器矫形固定,保持膝关节伸直,双踝、足中立位,双下肢外展30°,6周后去除外固定康复训练.[结果]本组病例随访1～3年,平均2.2年.优良21例,有效2例.[结论]严重脑瘫痉挛性双侧瘫,一期多关节软组织松解,肌力平衡,外固定矫形,术后配合家庭长期康复训练,是一种有效的治疗方法.     

Posterior tibial tendon transfer in the spastic brain-damaged adult does not lead to valgus flatfoot

BackgroundWe studied the possible development of valgus flat foot after transfer of the posterior tibial tendon to the lateral cuneiform, used for surgical restoration of dorsiflexion in brain-damaged adult patients with spastic equinovarus foot.MethodsTwenty hemiplegic patients were reviewed with a mean postoperative follow-up of 57.9 months. Weightbearing radiographs, static baropodometry analysis and functional evaluation were used to assess postoperatively outcomes.ResultsOn the operated side, weightbearing radiographs showed an absence of medial arch collapse and a symmetrical and physiological hindfoot valgus; static baropodometric analysis showed a reduced plantar contact surface with a pes cavus appearance. The surgical procedure yielded good functional results. Nineteen patients were satisfied with the outcome of their surgery.ConclusionsOur findings support that transfer of the posterior tibial tendon does not lead to valgus flat foot in the spastic brain-damaged adult, and is still a current surgical alternative for management of spastic equinovarus foot.     

Posterior tibial tendon transfer in spastic equinovarus

Summary Twenty-eight posterior tibial tendon transfers through the interosseous membrane were performed to correct spastic equinovarus. All patients improved their gait, and 82% discarded their brace. Foot striking at the beginning of the stance phase was good or satisfactory in 82%; 68% had a neutral position of the heel. The overall score was good in 68%, satisfactory in 21%, and poor in 11%. The main requirements for obtaining good results with this type of transfer are: no fixed varus deformity preoperatively, age at operation between 5 and 10 years, and reinsertion near the midline of the foot.     

Adult-acquired flatfoot deformity

Originally known as posterior tibial tendon dysfunction or insufficiency, adult-acquired flatfoot deformity encompasses a wide range of deformities. These deformities vary in location, severity, and rate of progression. Establishing a diagnosis as early as possible is one of the most important factors in treatment. Prompt early, aggressive nonsurgical management is important. A patient in whom such treatment fails should strongly consider surgical correction to avoid worsening of the deformity. In all four stages of deformity, the goal of surgery is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex. However, controversy remains as to how to manage flexible deformities, especially those that are severe.     

Complex post traumatic foot deformities – Outcomes after corrective surgery

IntroductionComplex posttraumatic foot deformity results in painful foot, altered gait and affects cosmesis. We did a retrospective study on 16 patients to analyse the etiology, types of foot deformity and their outcomes after corrective surgery.MethodsThis retrospective study was done on a consecutive series of patients who underwent corrective surgery for complex post-traumatic foot and ankle deformities. There were 16 patients with 18 foot deformities. The duration of deformity, soft tissues, radiographic changes and measurements, type and anatomic localisation of the deformity determined the surgery needed to correct the deformity.ResultsAmong the 18 foot injuries, 16 were open injuries. Among the type of foot deformity, isolated equinus deformity was seen in 12 feet followed by equinovarus and equinocavovarus in three feet each. Seven patients needed modified footwear. None of the patients required walking aid for ambulation at the end of one year follow up.ConclusionTo conclude, soft tissue injuries were the most common cause of posttraumatic foot deformities compared to bony injuries. Equinus deformity was the commonest deformity. Fifteen patients returned to their preinjury work status.     

Posterior tibial tendon transfer: results of fixation to the dorsiflexors proximal to the ankle joint

BACKGROUND: Most techniques for posterior tibial tendon transfer attach the posterior tibial tendon somewhere at the dorsum of the foot. Inadequate tendon length and difficulties in securing the tendon to bone or tendon can complicate these procedures. Performing the tenodesis proximal to the ankle joint can prevent these problems. The present study is the first to describe the results of posterior tibial tendon transfer through the interosseous membrane attaching only the posterior tibial tendon to the extensor tendons proximal to the ankle joint. METHODS: We examined 13 feet in 12 patients with a foot-drop, equinovarus deformity, or both. The median (range) followup was 3.7 years (9 to 81 months) and the median age at surgery as 30 (13 to 59) years. Evaluation included recording patient satisfaction, use of ankle-foot orthoses (AFO), video-assisted gait analysis, physical examination, the Stanmore system, modified Ninkovi? method, and complications. RESULTS: At followup, patient satisfaction was excellent to good in nine feet. Ten of the 11 feet that needed an AFO preoperatively did not need one after surgery. Gait analysis demonstrated a good to fair gait in 10 patients. Median dorsiflexion was 0 (-25 to 12) degrees, with dorsiflexion to a neutral position or beyond in nine feet. The Stanmore system and modified Ninkovi? method showed excellent to good results in 10 feet. Three complications were recorded including one failed tendon transfer. CONCLUSIONS: Attachment of a split posterior tibial tendon to the extensor tendons proximal to the ankle joint provides results equivalent to other procedures and can be considered a viable operative alternative because it is less difficult and more straightforward than other techniques.     

Neuro-Orthopedic Surgery for Equinovarus Foot Deformity in Adults: A Narrative Review

Neuro-orthopedic surgery is an alternative to the conservative treatment of spastic equinovarus foot (SEF) in adults. The objective of the present narrative review was to summarize current practice with regard to patient assessment, the choice of treatment, the various neuro-orthopedic procedures, and the latter's outcomes. We searched literature databases (MEDLINE, EMBASE, Cochrane) for original articles or opinion papers on surgical treatment of spastic equinovarus foot in adults. Neuro-orthopedic approaches require a careful analysis of the patient's and/or his/her caregiver needs and thus relevant treatment goals. Surgical planning requires detailed knowledge of impairments involved in the spastic equinovarus foot deformity based on a careful clinical examination and additional information from diagnostic nerve blocks and/or a quantitative gait analysis. Procedures mainly target nerves (neurotomy) and tendons (lengthening, transfer, tenotomy). These procedures reduce impairments (spasticity, range of motion, and foot position), improve gait and walking function, but their impact on participation and personalized treatment goals remains to be demonstrated. Neuro-orthopedic surgery is an effective treatment option for spastic equinovarus foot in adults. However, practice is still very heterogeneous and there is no consensus on the medical strategies to be applied before, during and after surgery (particularly the type of anesthesia, the need for immobilization, rehabilitation procedures).     

Congenital Diastasis of the Inferior Tibiofibular Joint With Clubfoot and Imperforate Anus

Congenital diastasis of the inferior tibiofibular joint is a rare condition of unknown etiology, first described in 1972. Although its clinical presentation at birth is a talipes equinovarus deformity of the foot, it may be associated with limb length discrepancy and other skeletal and visceral abnormalities. We present one such case of congenital inferior tibiofibular diastasis of Onimus type A variety (vertical diastasis) with talipes equinovarus, high imperforate anus, short first ray of the foot, intact superior tibiofibular joint, and no limb length discrepancy. Closed manipulation and casting had been unsuccessful, and at this time, the patient had not pursued any treatment during the past one year. A colostomy for the imperforate anus had been performed 36 hours after his birth and was planned for subsequent posterior sagittal anorectalplasty to reestablish continuity. His ankle joint was reconstructed along with soft tissue release for talipes equinovarus. Two years after surgery, he has a plantigrade stable foot with no limb length discrepancy. We propose that if the reconstructed joint is carried out in early childhood, it will provide better reciprocal joint surfaces with less chances of degenerative arthritis in later life. However, leg length inequality and recurrence of the deformities are not uncommon, necessitating further surgical interventions.     

Spastische Fußdeformitäten im Kindesalter

Although the neurological defects associated with cerebral palsy are not progressive, secondary musculoskeletal disorders due to growth and gravity are variable. In the clinical analysis of spastic foot deformities different mechanisms that produce a variety of deformities have to be analyzed. The goals of surgical treatment are correction of the deformity, reestablishment of stability of the foot and preservation of functionally important ranges of motion and muscle strength. The most common spastic foot deformities are equinus, planovalgus, equinovarus and calcaneus. For treatment soft tissue surgery, such as muscle lengthening and transfer together with bone surgery, such as osteotomy or arthrodesis are used and combinations of these methods are often required. Subsequently postoperative plasters are necessary followed by dynamic orthotic management.