Introduction

Introduction
Foot deformities caused by altered or abnormal muscle forces are
common in patients with cerebral palsy, with 70% to 90% of children
affected.
The most common deformity is ankle equinus, with equinovarus and
equinovalgus deformities being equally common.

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Introduction
A foot deformity can have significant effects on the patients overall
ambulatory level.
The presence of a bilateral as opposed to a unilateral foot deformity,
regardless of the type, has been shown to have a significant effect on
overall level of ambulation.

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Introduction
A patients deformity may change over time, especially in young
children.
For example, in a very young child with a valgus foot deformity,
persistent tonic reflexes and abnormal muscle forces may over time
cause a varus foot position to develop.

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Introduction
Spasticity of the smaller muscles of the foot can lead to other
deformities, such as hallux valgus, claw toes, and forefoot adduction.
These can occur in isolation but more often occur in association with
other deformities related to abnormal extrinsic foot musculature.

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Equinus Deformity
Equinus Deformity
Equinus deformity is the most common foot deformity in patients
with cerebral palsy, affecting 70% of children, of whom approximately
25% develop a deformity severe enough to require operative
treatment.
Conservative treatment consisting of stretching, bracing, botulinum
toxin A (BTX-A), and, occasionally, casting remains the primary form
of treatment or means of delaying operative intervention.

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Equinus Deformity
The deformity is caused by spasticity of the gastrocnemius-soleus
muscle, which often worsens during periods of rapid growth because
of overgrowth of the tibia relative to the gastrocnemius-soleus.
Animal models have shown that muscles in mice with hereditary
spasticity grow at a slower rate than normal muscle.

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Equinus Deformity
Ultrasound evaluation of the musculotendinous junction showed that
patients with cerebral palsy have longer Achilles tendons and shorter
muscle bellies than normal controls.
Whereas ankle dorsiflexion increases in operatively treated patients,
the muscle-tendon architecture remains abnormal.

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Equinus Deformity
Bracing, especially at night, to prevent the foot from going into the
equinus position is essential.
The exact indications for surgery are unclear given the variable nature
of cerebral palsy; however, surgery typically is indicated when the
ankle cannot be brought into the neutral position in an ambulatory
child and when it leads to difficulties with hygiene, foot wear, and
standing programs in a nonambulatory child.

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Surgical Correction of
Equinus Deformity
Surgical Correction of Equinus Deformity
Because of the variable nature of cerebral palsy and the fact that
numerous procedures and postoperative regimens have been used in
the treatment of equinus contracture, it is difficult to compare studies
and success rates.
In addition, many recurrences are more than 5 years after the initial
operation and may not be included in short-term studies.

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Surgical Correction of Equinus Deformity
The recurrence rate in the literature ranges from 0% to 50%,
depending on the type of patient and the length of follow-up.
Younger patients, especially those younger than 3 years, and
hemiplegics are most likely to have recurrence.
Recurrence in patients older than 6 years is very rare.

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Surgical Correction of Equinus Deformity
The gastrocnemius-soleus can be lengthened at either the
musculotendinous junction with an aponeurotic recession or at the
level of the Achilles tendon through an open or percutaneous
approach.
For mild to moderate contractures, it is recommended that
lengthening be done at the level of the musculotendinous junction;
the higher rate of overlengthening seen with the use of open Z-plasty
techniques leads to residual weakness.

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Surgical Correction of Equinus Deformity
The use of the percutaneous approach has been shown in a small (28
feet) randomized, blinded study to provide rapid healing as
demonstrated on ultrasound evaluation of the tendon, shorter
operative and hospitalization times, postoperative dorsiflexion, and
higher parental satisfaction.
Larger studies are necessary to further evaluate this.

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Surgical Correction of Equinus Deformity
Overlengthening of the gastrocnemius-soleus should be avoided,
especially in an ambulatory child, because it can cause weakness in
push-off and crouch gait.
Because overlengthening is much less common with an aponeurosis
recession,this is preferred in ambulatory children and open Achilles
lengthening may be reserved for patients with severe deformities that
cannot be corrected by recession and for nonambulatory patients.

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Surgical Correction of Equinus Deformity
It is important to evaluate patients after release for toe flexion
contractures that have been unmasked after Achilles tendon
lengthening, because this can lead to abnormal weight bearing on the
tips of the toes.
This can be treated with simultaneous Z-lengthenings of the flexor
digitorum longus and flexor hallucis longus.

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Open Lengthening of the
Achilles Tendon
Open Lengthening of the Achilles Tendon
(WHITE MODIFICATION)
Use a posteromedial incision to expose the Achilles tendon from its
insertion to approximately 10 cm proximally, preserving the sheath.
Divide the posteromedial two thirds of the tendon near its insertion.
Apply a moderate dorsiflexion force to the foot, and divide the medial
two thirds of the tendon 5 to 8 cm proximal to the site of the distal
division.

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Sliding lengthening of Achilles tendon.
A, Posteromedial incision.
B, Two cuts are made through one half of tendon in opposite directions. Rotation of fibers must be followed accurately. As foot
is placed in dorsiflexion, tendon fibers separate.

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Open Lengthening of the Achilles Tendon
(WHITE MODIFICATION)
Dorsiflex the foot so that the tendon lengthens to the desired length.
The tendon can be sutured in a side-to-side fashion with absorbable
suture.
Carefully close the tendon sheath and subcutaneous tissues to
prevent adherence of the tendon to the overlying skin.
Apply a short-leg cast with the ankle in maximal dorsiflexion.

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Postoperative Care
The patient is allowed to bear full weight on the leg postoperatively.
The cast is left on for approximately 4 weeks.
During this time, knee extension is encouraged to maintain the
lengthening of the gastrocnemius-soleus complex.
The cast is removed, and an ankle-foot orthosis is fitted with the
ankle in maximal dorsiflexion.

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Z-Plasty Lengthening of the
Achilles Tendon
Z-Plasty Lengthening of the Achilles Tendon
Make a posteromedial incision midway between the Achilles tendon
and the posterior aspect of the medial malleolus.
The lower extent of the incision is at the superior border of the
calcaneus, and it continues cephalad for 4 to 5 cm.

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Z-Plasty Lengthening of the Achilles Tendon
Expose the Achilles tendon with sharp dissection directed posteriorly
toward it.
Incise the sheath of the Achilles tendon longitudinally from the
superior to the inferior extent of the incision.
Free the tendon from the surrounding tissues.

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Z-plasty lengthening of Achilles tendon.
A, Longitudinal incision, halfway between posterior aspect of medial malleolus and tendon. Longitudinal cut in tendon is
brought out proximally in one direction and distally in opposite direction.
B, Ends are sutured to repair tendon.

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Z-Plasty Lengthening of the Achilles Tendon
Make a longitudinal incision in the center of the Achilles tendon from
proximal to distal.
Turn the scalpel either medially or laterally distally, and divide that
half of the tendon transversely.

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Z-Plasty Lengthening of the Achilles Tendon
Make the distal cut toward the medial side for a varus deformity and
toward the lateral for a valgus deformity.
Hold this cut portion of the tendon with forceps, and bring the scalpel
to the proximal portion of the longitudinal incision in the tendon.

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Z-Plasty Lengthening of the Achilles Tendon
Turn the scalpel opposite the distal cut, and divide that half of the
tendon transversely to free the Achilles tendon completely.

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Z-Plasty Lengthening of the Achilles Tendon
Allow the tendon to retract halfway back to its resting length, and
suture it to the distal tendon end at that point.
Control tension further by adjusting the foot position: neutral for mild
spasticity, 10 degrees of dorsiflexion for moderate involvement, and
20 degrees of dorsiflexion for severe deformity.

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Z-Plasty Lengthening of the Achilles Tendon
Perform the repair in a side-to-side manner with heavy absorbable
sutures.
Close the wound with absorbable sutures or subcuticular sutures and
skin strips, and apply a long-leg cast.

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Postoperative Care
Ambulation is allowed as soon as the patient is comfortable. When
pain is gone (usually 5 to 10 days), the cast is changed to a short-leg
cast, and walking is continued.
Cast immobilization is continued for a total of 6 weeks.

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Percutaneous Lengthening of
the Achilles Tendon
Percutaneous Lengthening of the Achilles
Tendon
Moreau and Lake found that when done as an outpatient procedure,
percutaneous lengthening of the Achilles tendon was quick,
inexpensive, and free of complications.
Of the 90 legs treated in this fashion, 97% showed improvement in
gait function.

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Percutaneous Lengthening of the Achilles
Tendon (MOREAU AND LAKE)
With the patient prone and the leg prepared to the midthigh to
include the toes, extend the knee and dorsiflex the ankle to tense the
Achilles tendon so that it is subcutaneous, easily outlined, and away
from the neurovascular structures anteriorly.
Make three partial tenotomies in the Achilles tendon.
Make the first medial cut, just at the insertion of the tendon onto the
calcaneus, through one half of the width of the tendon.

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Incisions for percutaneous Achilles tendon lengthening. Cut ends slide on themselves with forceful dorsiflexion of foot.

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Percutaneous Lengthening of the Achilles
Tendon (MOREAU AND LAKE)
Make the second tenotomy proximally and medially, just below the
musculotendinous junction.
Make the third laterally through half the width of the tendon midway
between the two medial cuts.

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Percutaneous Lengthening of the Achilles
Tendon (MOREAU AND LAKE)
Place the two incisions on the medial side if the heel is in varus as it
usually is and on the lateral side if the heel is in valgus.
Dorsiflex the ankle to the desired angle.
The incisions do not require closure, only a sterile dressing and a
long-leg cast with the knee in full extension.

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 Lengthening of the
Gastrocnemius-Soleus
Muscle
Lengthening of the Gastrocnemius-Soleus
Muscle
Strayer, in 1950, described an operation in which the aponeurotic
tendon of the gastrocnemius is divided transversely near its junction
with that of the soleus, the ankle is dorsiflexed into the neutral
position, and the retracted proximal part of the tendon is sutured to
the underlying soleus.

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Lengthening of the Gastrocnemius-Soleus
Muscle
Many modifications of this procedure have been described, including
that by Vulpius, in which the aponeurotic tendon of the
gastrocnemius is divided and the distal part is allowed to retract
distally but is not sutured to the soleus.

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Gastrocnemius-Soleus
Lengthening (STRAYER)
Gastrocnemius-Soleus Lengthening (STRAYER)
Make a posterior longitudinal incision over the middle of the calf at
the level of the musculotendinous junction, expose the aponeurosis
of the gastrocnemius, and make an inverted or transverse incision
through it.
Release this in a lateral-to-medial fashion to ensure complete release.
Release the raphes of the gastrocnemius-soleus and the plantaris
tendon completely.

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Gastrocnemius lengthening.
A, Incision over posterior aspect of calf.
B, Transverse cut through tendon.
C, Foot is placed in dorsiflexion to neutral to separate tendon ends.

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Gastrocnemius-Soleus Lengthening (STRAYER)
Bring the ankle into slight dorsiflexion, which separates the ends of
the tendon.
If the aponeurosis of the soleus tendon is contracted, and further
correction is desired, divide it, but do not disturb the soleus muscle
itself.

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Gastrocnemius-Soleus Lengthening (STRAYER)
Postoperative Care
Patients are placed in a short-leg cast for 4 weeks and allowed to bear
weight as tolerated.
Knee extension is encouraged, and physical therapy to maintain ankle
dorsiflexion is started after cast removal.
Patients are placed in a maximal dorsiflexion ankle-foot orthosis for
nighttime use for 6 months postoperatively.

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