1.
THE FOOT IN
CEREBRAL PALSY- Part
2
Topic Presentation
Amala Institute of Medical Sciences, Thrissur
Department of Orthopaedics
Dr. Libin Thomas Manathara
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2.
TOPICS
• PART 1- Equinus deformity
• PART 2- Valgus or varus deformity
• Equinovarus deformity
• Split tendon transfers
• Osteotomy of the calcaneus
• PART 3- Valgus or varus deformity, continued…
• Equinovalgus deformity
• Calcaneus deformity
• Cavus deformity
• Forefoot adduction deformity
• Hallux valgus deformity
• Claw toes
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3.
Varus or Valgus Deformity
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4.
Varus or Valgus Deformity- Introduction
• Varus and valgus deformities can occur in patients with cerebral
palsy, most commonly in association with an equinus deformity
• It has been shown that TA (tibialis anterior or anterior tibial muscle)
muscle dysfunction alone or in combination with dysfunction of the
TP (tibialis posterior or posterior tibial muscle) muscle is more
commonly the cause of Varus deformity than isolated TP dysfunction
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5.
Varus or Valgus Deformity
• In hemiplegia the foot deformity has been found to be either equinus
or equinovarus
• In diplegia and quadriplegia it was valgus or varus
• Although less common, varus deformities are
• more functionally disabling
• more difficult to manage nonoperatively and
• easier to correct operatively
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Varus or Valgus Deformity
• Consequently, surgery is done more often and more successfully for
varus than for valgus deformities
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7.
Varus or Valgus Deformity
• The biomechanics of the hip and knee also influence whether a varus
or valgus deformity is present
• Diplegic patients typically have
• internally rotated and adducted hips
• flexed knees
• external rotation deformity of the tibia
• This combination of deformities causes the foot to assume a valgus
position
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8.
Varus or Valgus Deformity
• In hemiplegic patients, the internally rotated thigh with the knee
coming to full extension in stance phase causes the foot to internally
rotate and produce a varus deformity
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9.
Equinovarus Deformity
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10.
Equinovarus Deformity
• The normal posterior tibial muscle is active during stance phase to
stabilize the foot and inactive during swing phase
• In cerebral palsy, the TP contracts during swing phase, leading to the
varus position of the foot at heel strike
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11.
Equinovarus Deformity
• It is essential to determine which muscles are responsible for the
deformity before any attempt at surgical correction
• It also is important to determine whether the deformity is flexible and
correctable or rigid
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12.
Equinovarus Deformity
• Patients with flexible deformities are more likely to be successfully
treated nonoperatively with orthotics and shoe modifications and
operatively with soft tissue procedures such as tendon lengthenings,
releases, or transfers (usually of the abnormally active muscle)
• Patients with rigid varus deformities generally require bone
procedures, such as calcaneal osteotomy
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13.
Lengthening of the
Posterior Tibial Tendon
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14.
Lengthening of the Posterior Tibial
Tendon
• The posterior tibial tendon can be lengthened in a variety of ways,
including open Z-plasty of the tendon itself and various recession
procedures, such as step-cut lengthening and intramuscular
lengthening
• A Z-plasty lengthening of the tendon, although it gives a large amount
of correction, can cause scarring and tethering of the tendon in its
sheath, leading to recurrence of deformity
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15.
Lengthening of the Posterior Tibial
Tendon
• Recession procedures such as lengthening at the musculotendinous
junction have a lower risk of overlengthening and scarring of the
tendon sheath
• Recession procedures, because the tendon itself is spared, are good
for patients at high risk of recurrence or in whom a posterior tibial
transfer may be needed in the future
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16.
Musculotendinous Recession of the
Posterior Tibial Tendon
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17.
Musculotendinous Recession of the
Posterior Tibial Tendon
• Place the patient supine, and make a 3-cm longitudinal incision over
the posteromedial aspect of the tibia, at the junction between the
middle and distal thirds
• Incise the deep fascia, and identify the flexor digitorum longus and
retract it posteriorly
• Identify the posterior tibial musculotendinous junction by placing a
hemostat beneath it and observing its action when inverting the foot
without flexing the toes
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Musculotendinous Recession of the
Posterior Tibial Tendon
• Pass a hemostat around the tendinous portion of the
musculotendinous junction to isolate it from the surrounding muscle,
protecting the neurovascular bundle
• Divide the tendinous portion of the posterior tibial musculotendinous
unit, leaving its muscular fibers intact
• Manipulate the foot into an overcorrected position
• Close the wound, and apply a short-leg walking cast
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22.
Split Tendon Transfers
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23.
Split Tendon Transfers
• Depending on the muscles that are out of phase, split tendon
transfers of the posterior or anterior tendon can be done
• Full tendon transfers should be avoided because of the higher risk of
complications and overcorrection of the deformity
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24.
Split Tendon Transfers
• Preoperatively, it is essential to ensure that the deformity is flexible
and to identify the correct tendon to be transferred
• The split transfer not only improves active muscle function during gait
but also acts as a dynamic sling, balancing the abnormal forces evenly
across the foot
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25.
KLING, KAUFER, HENSINGER-
Posterior tendon transfer
• Begin the first of two incisions 5 cm proximal and medial to the
medial malleolus, and extend the incision distally, ending over the
navicular
• Identify the posterior tibial muscle and tendon
• Identify and protect the neurovascular bundle
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27.
KLING, KAUFER, HENSINGER
• Open the anterior aspect of the tendon sheath preserving the
posterior tunnel to prevent dislocation of the tendon
• Dissect the plantar portion of the posterior tibial tendon from its
insertion on the navicular, preserving as much length for transfer as
possible
• Deliver this portion of the tendon into the proximal aspect of the
wound, and place a nonabsorbable suture in the free end of the
tendon
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28.
KLING, KAUFER, HENSINGER
• Make a second incision over the lateral side of the ankle 2 cm
proximal to the lateral malleolus, and extend it to the insertion of the
peroneus brevis tendon at the base of the fifth metatarsal
• Open the sheath of the peroneus brevis tendon
• Through the medial incision, create a tunnel posterior to the tibia and
anterior to the neurovascular bundle, directed laterally toward the
fibula
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29.
KLING, KAUFER, HENSINGER
• Pass the free end of the tendon through the tunnel, ensuring that the
transferred tendon is posterior to the tibia and fibula and anterior to
the neurovascular bundle and toe-flexor tendons to prevent
neurovascular and flexor tendon compression during muscle
contraction
• Weave the end of the tendon through the peroneus brevis tendon,
and suture it to the tendon
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30.
KLING, KAUFER, HENSINGER
• Adjust tension on the transferred tendon so that the hindfoot is in
neutral with the ankle in neutral dorsiflexion
• If the Achilles tendon was lengthened with a Z-plasty, repair it at this
time
• Close the wounds in routine fashion, and apply a long-leg cast with
the knee slightly flexed and the foot in neutral
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31.
Split Anterior Tibial
Tendon Transfer
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32.
HOFFER ET AL.
• Three incisions are used for the split anterior tibial tendon transfer
• With the patient supine, make the first incision medially over the
anterior tibial insertion on the medial cuneiform and first metatarsal
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34.
HOFFER ET AL.
• Identify the anterior tibial tendon, protecting the dorsalis pedis
artery, and split the tendon with an umbilical tape (Fig.)
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37.
HOFFER ET AL.
• Make a second incision over the anterior aspect of the leg at the
musculotendinous junction, and identify the anterior tibial tendon;
pass the umbilical tape into the second incision (Fig.)
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38.
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39.
HOFFER ET AL.
• Identify the lateral half of the tendon, release it from its insertion,
and secure it with a locking stitch (Fig.), preserving as much length as
possible, and then pass it into the second incision as well
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40.
HOFFER ET AL.
• Make the third incision on the foot over the dorsal aspect of the
cuboid
• Pass the lateral half of the tendon subcutaneously into the third
incision, and close the first two incisions (Fig.)
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42.
HOFFER ET AL.
• Drill a hole into the cuboid, preserving a roof of bone
• Pass the lateral slip of tendon through the drill hole, and suture it to
itself with nonabsorbable suture with the ankle in slight dorsiflexion
and hindfoot eversion
• If this is combined with lengthening of the Achilles tendon or
posterior tibial tendon recession, these procedures should be done
before the anterior tibial tendon transfer
• Carefully hold the foot in the corrected position during wound closure
and application of a short-leg cast
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44.
Osteotomy of the
Calcaneus
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45.
Osteotomy of the Calcaneus
• When the heel becomes fixed in varus, a corrective procedure on the
bone is required, combined with a muscle balancing soft tissue
procedure
• Osteotomy of the calcaneus as advocated by Dwyer corrects the
varus of the heel and, in contrast to a triple arthrodesis, does not
impair mobility in the subtalar or midtarsal joints
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46.
Osteotomy of the Calcaneus
• Good long-term results have been reported after a modified Dwyer
calcaneal osteotomy (Silver et al.)
• A minimum age of 3 years is recommended for this osteotomy
• Triple arthrodesis is recommended in children 9 years old or older
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47.
Osteotomy of the Calcaneus
• Opening wedge osteotomies of the calcaneus are not recommended
• The skin laterally and medially along the bone is only slightly mobile,
and opening wedges put tension on the suture line and tend to cause
incisional skin sloughs
• The medial calcaneal nerves also may be stretched by an opening
wedge osteotomy made from the medial side, causing painful
neuromas
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48.
Osteotomy of the Calcaneus
• For these reasons, a closing wedge resection osteotomy of the
calcaneus is recommended
• For varus deformities, the incision is lateral and the base of the
wedge of bone removed is lateral
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49.
Calcaneal Osteotomy (DWYER)
• Expose the lateral aspect of the foot through a curved incision parallel
and about 1 cm posterior and inferior to the peroneus longus tendon
(Fig.)
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51.
Calcaneal Osteotomy (DWYER)
• Retract the superior wound edge until the tendon sheath of the
peroneus longus is exposed
• Strip the periosteum from the superior, lateral, and inferior surfaces
of the calcaneus posterior to this tendon
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52.
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53.
Calcaneal Osteotomy
• Remove a wedge of bone from the calcaneus just inferior and
posterior to the tendon and parallel with it
• Make the base of the wedge 8 to 12 mm wide as needed for
correction of the deformity, and taper the wedge medially to, but not
through, the medial cortex of the calcaneus
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54.
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55.
Calcaneal Osteotomy
• Manually break the medial cortex, and close the gap in the bone
• Bring the bony surfaces snugly together by pressing the foot into
dorsiflexion against the pull of the Achilles tendon
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57.
Calcaneal Osteotomy
• Failure to close the gap in the calcaneus indicates that a small piece
of bone has been left behind at the apex of the wedge and should be
removed
• Ensure that the varus deformity has been corrected, and that the heel
is in the neutral or a slightly varus position
• Close the wound, and apply a cast from the toes to the tibial
tuberosity
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58.
THANK YOU
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