Combined split anterior tibial-tendon transfer and intramuscular lengthening of the posterior tibial tendon. Results in patients who have a varus deformity of the foot due to spastic cerebral palsy

Twenty patients who had a varus deformity of the foot secondary to spastic cerebral palsy had twenty-two operations involving combined split anterior tibial-tendon transfer and intramuscular lengthening of the posterior tibial tendon, with and without concomitant lengthening of the Achilles tendon. Preoperatively, all patients had had a dynamic varus deformity of the hindfoot and adduction of the forefoot in both the stance phase and the swing phase of gait. At an average follow-up of 6.2 years (range, 2.3 to 8.8 years), there were fourteen excellent, four good, and four poor clinical results. Two patients who had a fixed varus deformity of the hindfoot and one patient who had a very weak anterior tibial muscle had a poor result. We concluded that the combined procedure is effective for correction of a flexible varus deformity of the foot in patients who have spastic cerebral palsy.     

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.     

Split tibialis posterior tendon transfer for correction of spastic equinovarus hindfoot deformity

Equinovarus hindfoot deformity is one of the most common deformities in children with spastic paralysis ; it is usually secondary to cerebral palsy. Split tibialis posterior tendon transfer is performed to balance the flexible spastic varus foot and is preferable to tibialis posterior lengthening, as the muscle does not loose its power and therefore the possibility of a valgus or calcaneovalgus deformity is diminished. We retrospectively evaluated 33 consecutive ambulant patients (38 feet) with flexible spastic varus hindfoot deformity. Twenty-eight presented unilateral and five bilateral involvement. The mean age at operation was 10.8 yrs (range 6-17) and the mean follow-up was 10; yrs (4-14). There were 20 hemiplegic feet, 11 diplegic and 7 quadriplegic. Eighteen feet also presented an equinus position of the hindfoot, requiring Achilles tendon lengthening. The surgical technique applied was similar to the one described by Green et al, with four skin incisions, two on either side of the foot and ankle. The evaluation of the results was carried out using Kling and Kaufer's clinical criteria. Results were graded excellent or good for 34 out of 38 feet (89.5%). Twenty feet were graded excellent, indicating that the children managed to walk with a plantigrade foot without fixed or postural deformity and did not have callosities. Fourteen feet were graded good in children who walked with less than 50,varus, valgus or equinus of the hindfoot and had no callosities. Four were graded poor, with recurrent equinovarus deformity. The feet with poor results presented a residual varus deformity due to intraoperative technical errors.     

The contributions of anterior and posterior tibialis dysfunction to varus foot deformity in patients with cerebral palsy

BACKGROUND: According to traditional teaching, the posterior tibialis is the main cause of varus foot deformity in patients with cerebral palsy. However, the relative frequency of anterior and posterior tibialis dysfunction has only been reported with use of dynamic electromyography in relatively small series of patients, with contrasting results. The purpose of the current study was to determine the relative prevalence of posterior and anterior tibialis dysfunction with use of gait analysis in a large group of patients with cerebral palsy and varus foot deformity. METHODS: The muscular contributors to varus foot deformity in seventy-eight patients (eighty-eight feet) who had cerebral palsy were evaluated with use of computerized motion analysis and dynamic electromyography. Data also were examined to identify any relationships between the timing of varus during gait and the contributing muscle. RESULTS: The muscular contributor to varus deformity was the anterior tibialis in thirty feet, the posterior tibialis in twenty-nine feet, both the anterior tibialis and the posterior tibialis in twenty-seven feet, and another contributor in two feet. Seventy feet had varus deformity during both stance phase and swing phase. Of these seventy feet, twenty-five exhibited dysfunction of the anterior tibialis, twenty exhibited dysfunction of the posterior tibialis, and twenty-three exhibited dysfunction of both muscles. Therefore, the timing of varus was not predictive of the contributing muscle or muscles. CONCLUSIONS: The current study demonstrated a higher prevalence of anterior tibialis dysfunction, both alone and in combination with posterior tibialis dysfunction, as a contributor to pes varus in patients with pes varus and cerebral palsy than had been reported previously. Dynamic electromyography provides clinically useful information for the assessment of such patients.     

10-year follow-up of split anterior tibial tendon transfer in cerebral palsied patients with spastic equinovarus deformity

Split anterior tibial tendon transfer was performed on 21 patients (27 feet) with cerebral palsy and spastic equinovarus deformity. All patients required orthoses preoperatively. All but two patients are now community ambulators with improved gait and without need for orthoses. There was one recurrence of deformity.     

脑瘫尖足内翻畸形的功能重建及A型肉毒毒素配合治疗的临床分析

目的 探讨脑瘫尖足内翻畸形的功能重建及A型肉毒毒素配合治疗的临床疗效.方法 收集2000年1月至2009年1月在我科住院行尖足内翻畸形矫正的痉挛性脑瘫,术后小腿三头肌的肌张力Ⅱ级以上者共32例,给予A型肉毒毒素局部注射治疗,观察手术和药物注射前后的功能改善情况并进行比较.结果 检杳治疗前踝背伸肌力在0～2级,随访时踝背伸的肌力为4～5级,采用配对t检验,术前后比较差异有统计学意义(P＜0.05).治疗前足内翻在30°～75°之间,随访时足内翻在0°～25°,采用配对t检验,治疗前后数据的差异有统计学意义(P＜0.05).小腿三头肌2个月复查时,肌张力在Ⅱ～Ⅳ级,随访时肌张力在Ⅰ～Ⅱ级.采用配对t检验,术前后比较差异有统计学意义(P＜0.05).结论 胫后肌前移配合A型肉毒毒素可同时减轻肌张力和改善踝背伸肌力,提高脑瘫的足部畸形的临床疗效.

Abstract：

Objective To observe the clinical therapial value of functional reconstruction with Botulinum Toxin A (BTA) on spasitic cerebral palsy. Methods Thirty-two patients were treated by Achilles tendon lengthening and anterior transfer of posterior tibial tendon.According to the spasticity of triceps surae muscle,all cases were arranged by BTA injection 2 months later after operation.Results From Jan.2000 to Jan.2009,thirty-two cases with equinovarus foot of spasticitical cerebral palsy were collected,the muscle strength of ankle dorsal extensor increased from 0-2 grades to 4-5 grades,there was significant difference between preoperational muscle strength and postoperational one.There was also significant improvement to adjust yarus degrees of ankle joint.the musclar tension of triceps muscle of calf decreased from Ⅱ-Ⅳ grades to Ⅰ-Ⅱ grades. Conclusion Anterior transfer of posterior tibial tendon corresponding with Botulinum Toxin A injection not only release muscle spasticity but also improve dorsal extending strength of ankle joint.The clinical effect of these methods was reliable on cerebral palsy.     

Treatment of spastic club foot]

In 38 patients with spastic cerebral palsy, treatment was carried out for talipes equinovarus. There were 12 children with spastic hemiplegia, while 24 had diplegia or tetraplegia. Surgery was done with the goal of achieving plantigrade and muscle-balanced feet. In 24 feet of 19 children tibialis anterior transfer was performed, while tibialis posterior transfer was done in 20 feet of 19 patients. Without exception, additional surgery was performed on the triceps surae (30 x ATLs and 16 Vulpius operations); medial arthrolysis was also necessary in 6 cases. The clinical results were assessed by the senior author in the weekly neuro-orthopedic clinic an average of 3.2 years after surgery. An additional questionnaire was sent to all patients' families asking for their subjective assessment of the surgery performed. Figures were collected for 30 patients with 38 treated feet. The results were evaluated according to Kling's criteria. We saw good and very good results in 75% of the patients (4 feet very good, 23 feet good), while 25% of the patients (9 feet in 7 patients) showed poor results with over-corrections and calcaneo-valgus foot as the main problem. The best results were seen in spastic hemiplegia and the poorest in patients with severe tetraplegia and total body involvement.     

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.     

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.     

Extra-articular subtalar arthrodesis. A long-term follow-up in patients with cerebral palsy

Of 23 children (35 feet) with cerebral palsy who had undergone a Grice extra-articular subtalar arthrodesis for a valgus hindfoot between 1976 and 1981, we reviewed 17 (26 feet), at a mean of 20 years (17 years 3 months to 22 years 4 months) after operation. Seven were quadriplegic, eight spastic diplegic, and two hemiplegic. They were all able to walk at the time of operation. Thirteen patients (20 feet) were pleased with the Grice procedure, 13 had no pain and 15 (23 feet) were still able to walk. The clinical results were satisfactory for most feet. Radiography showed that the results had been maintained over time but 14 feet developed a mean ankle valgus of 11 degrees (6 to 18) with a compensatory hindfoot varus in 12 feet. No deformity of the talus or arthritis of adjacent joints was noted. The Grice procedure gives good long-term results in children with cerebral palsy.     

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.     

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.     

Early mobilization after sliding achilles tendon lengthening in children with spastic cerebral palsy

Equinus deformity is a common finding in children with cerebral palsy and may be treated by Achilles tendon lengthening. To prevent recurrence, some authors recommend immobilizing the operated leg with an above-knee cast for six weeks, followed by use of a night splint or orthosis. Nevertheless, there are recurrence rates of up to 20.5%. The aim of this study was to evaluate the long-term result of postoperative immobilization for two weeks in a below-knee cast and early weight bearing, without the use of a splint or orthosis. Thirty-six children (52 feet) with spastic cerebral palsy underwent sliding Achilles tendon lengthening. Follow-up of five to ten years showed a comparable recurrence rate (19.2%) to that reported with the standard, more stringent management approach. Most of the recurrences were in children operated on before five years of age. We believe earlier motion helps to sustain the tendon length achieved at surgery and allows for earlier independent gait.     

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.     

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.     

Gait electromyographic evaluation of the long-toe flexors in children with spastic cerebral palsy

In a prospective study of the phasic activity of the long-toe flexors of patients with spastic cerebral palsy, the electrical activity of the long-toe flexors in 37 children with varus or valgus hindfoot deformity was measured by wire electrode dynamic electromyography. Although gross abnormalities in the phasic timing of the flexor hallucis longus and flexor digitorum longus were observed, these muscles could not be implicated in the etiology of hindfoot deformity. In planning gait analysis protocols for children with cerebral palsy and hindfoot deformity, electromyography of the long-toe flexors is not necessary unless toe curling is clinically evident.     

Calcaneal lengthening for planovalgus foot deformity in children with spastic cerebral palsy

The purpose of this study was to evaluate the effectiveness of calcaneal lengthening in the treatment of planovalgus foot deformity of children with spastic cerebral palsy. Sixteen children (27 feet) with spastic cerebral palsy underwent calcaneal lengthening along with peroneal tendons. The results were assessed clinically and radiographically. Over an average of 3.2 years of follow-up (2.0-5.0), 20 (74.1%) feet showed a satisfactory clinical result, and 21 (77.8%) feet showed a satisfactory radiographic result, according to the modified Mosca's criteria. Dependent ambulators with severe pes planovalgus showed unsatisfactory results compared with independent ambulators with mild to moderate pes planovalgus. These findings suggest that for severe pes planovalgus of children with cerebral palsy, it may be difficult to correct the foot deformity by calcaneal lengthening with peroneal tendons.     

Bridle手术治疗儿童轻度痉挛性脑瘫足畸形

目的：探讨Bridle手术治疗儿童轻度痉挛性脑瘫足畸形的疗效。方法：1993年2月－1999年4月,应用Bridle手术治疗儿童轻度痉挛性脑瘫足畸形32例57足,男20例,女,12例,年龄4－14岁,平均为7．5岁,双侧足畸形25例,单足畸形7例,呈尖足行走15例26足,马蹄内翻足畸形8例13足,剪式步态9例18足,结果：随访6－74个月,平均38个月,畸形完全纠正48足,占84．2％,畸形复发7足,占12．3％,并发足外翻畸形2足,占3．5％,结论：Bridle术式操作简便,能较好地纠正足畸形,是治疗儿童轻度痉挛性脑瘫足畸形的有效方法。     

Brachioradialis re-routing for the restoration of active supination and correction of forearm pronation deformity in cerebral palsy

A brachioradialis muscle rerouting procedure was used to restore active supination in five children with cerebral palsy and a pronation deformity. Following release and lengthening of the pronator quadratus and pronator teres muscles, respectively, the brachioradialis tendon was divided as a Z plasty and the distal part of the tendon was passed through the interosseous space in a dorsal to palmar direction, and then sutured to its proximal end. The procedure resulted in a gain of 81 degrees of active supination.     

Dynamic correction for forefoot varus in stage II-A adult flatfoot: Technique tip

Posterior tibial tendon dysfunction (PTTD) is a progressive disorder and a common cause of adult acquired flatfoot deformity, and forefoot varus is a frequent component in advanced cases. The author proposes peroneus brevis-to-longus transfer as an additional step to correct the forefoot varus component of stage II-A posterior tibial tendon dysfunction. We have performed this dynamic correction of forefoot varus in 12 patients at our institution, and observed promising clinical and radiographic improvement. It is a soft tissue procedure that avoids additional incisions and represents a favorable alternative to more demanding techniques, such as osteotomy or arthrodesis.