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Equinovarus Foot Deformity in Cerebral Palsy

  • Freeman Miller
Living reference work entry

Abstract

Foot deformities are very common in children with Cerebral Palsy (CP). The most common foot deformity is pure equinus. Many children as they grow the equinus either falls into varus or valgus. For those children with bilateral involvement, collapse of the foot into planovalgus is most common. Children who are unilaterally involved have more tendencies to collapse towards varus. Almost all of these deformities continue to include equinus as a component. It is important to note though that both unilaterally and bilaterally involved individuals may go either direction. Treatment in early childhood of the equinus and equinovarus feet is primarily by the use of orthotics. Those children who cannot tolerate orthotics may have a trial of botulinum toxin injection, and if not successful, only the equinus should be treated by tendon lengthening. After age 8 years, it is appropriate to investigate the possibility of doing tendon transfers of the tibialis posterior or the tibialis anterior using gait analysis and muscle electromyography. Earlier tendon transfers before age 8 years run a high risk of over correcting the foot into planovalgus. However, if there is too much delay and hindfoot stiffness occurs, then there is a high risk of recurrent varus deformity from tendon transfers. These recurrent deformities often require osteotomies or fusion for correction. The evolution of the foot deformities in young children with CP is very unpredictable; therefore, it is imperative that close clinical follow-ups occur and most of the surgical treatments for the equinovarus foot deformity should be occurring after age 8 years.

Keywords

Cerebral Palsy Equinovarus Varus Cavovarus Tibialis posterior Tibialis anterior 

References

  1. Baddar A, Granata K, Damiano DL, Carmines DV, Blanco JS, Abel MF (2002) Ankle and knee coupling in patients with spastic diplegia: effects of gastrocnemius-soleus lengthening. J Bone Joint Surg Am 84-A:736–744CrossRefGoogle Scholar
  2. Barnes MJ, Herring JA (1991) ‘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. J Bone Joint Surg Am 73:734–738. SRC – GoogleScholarCrossRefGoogle Scholar
  3. Chang CH, Albarracin JP, Lipton GE, Miller F (2002) Long-term follow-up of surgery for equinovarus foot deformity in children with cerebral palsy. J Pediatr Orthop 22:792–799PubMedGoogle Scholar
  4. Choi JY, Jung S, Rha DW, Park ES (2016) Botulinum toxin Type A injection for spastic equinovarus foot in children with spastic cerebral palsy: effects on gait and foot pressure distribution. Yonsei Med J 57:496–504CrossRefGoogle Scholar
  5. Coleman, SS, Chesnut WJ (1977) A simple test for hindfoot flexibility in the cavovarus foot. Clin Orthop Relat Res 123:60–62. SRC – GoogleScholarGoogle Scholar
  6. Detrembleur C, Willems P, Plaghki L (1997) Does walking speed influence the time pattern of muscle activation in normal children? Dev Med Child Neurol 39:803–807. SRC – GoogleScholarPubMedGoogle Scholar
  7. Dwyer FC (1975) The present status of the problem of pes cavus. Clin Orthop 106:254–275. SRC – GoogleScholarCrossRefGoogle Scholar
  8. Green NE, Griffin PP, Shiavi R (1983) Split posterior tibial-tendon transfer in spastic cerebral palsy. J Bone Joint Surg Am 65:748–754. SRC – GoogleScholarCrossRefGoogle Scholar
  9. Hehne HJ, Baumann JU (1979) Dwyer’s calcaneal osteotomy for varus deformity of the foot, A followup study including gait analysis authors transl. Z Orthop Ihre Grenzgeb 117:202–211. SRC – GoogleScholarPubMedGoogle Scholar
  10. Hiroshima K, Hamada S, Shimizu N, Ohshita S, Ono K (1988) Anterior transfer of the long toe flexors for the treatment of spastic equinovarus and equinus foot in cerebral palsy. J Pediatr Orthop 8:164–168. SRC – GoogleScholarCrossRefGoogle Scholar
  11. Hoffer MM, Reiswig JA, Garrett AM, Perry J (1974) The split anterior tibial tendon transfer in the treatment of spastic varus hindfoot of childhood. Orthop Clin North Am 5:31–38. SRC – GoogleScholarPubMedGoogle Scholar
  12. Hoffer MM, Barakat G, Koffman M (1985) 10-year follow-up of split anterior tibial tendon transfer in cerebral palsied patients with spastic equinovarus deformity. J Pediatr Orthop 5:432–434. SRC – GoogleScholarCrossRefGoogle Scholar
  13. Hoiness PR, Capjon H, Lofterod B (2014) Pain and rehabilitation problems after single-event multilevel surgery including bony foot surgery in cerebral palsy. A series of 7 children. Acta Orthop 85:646–651CrossRefGoogle Scholar
  14. Johnson WL, Lester EL (1989) Transposition of the posterior tibial tendon. Clin Orthop 245:223–227. SRC – GoogleScholarGoogle Scholar
  15. Kagaya H, Yamada S, Nagasawa T, Ishihara Y, Kodama H, Endoh H (1996) Split posterior tibial tendon transfer for varus deformity of hindfoot. Clin Orthop Relat Res 323:254–260. SRC – GoogleScholarCrossRefGoogle Scholar
  16. Krzak JJ, Corcos DM, Graf A, Smith P, Harris GF (2013) Effect of fine wire electrode insertion on gait patterns in children with hemiplegic cerebral palsy. Gait Posture 37:251–257CrossRefGoogle Scholar
  17. Liggio FJ, Kruse R (2001) Split tibialis posterior tendon transfer with concomitant distal tibial derotational osteotomy in children with cerebral palsy. J Pediatr Orthop 21:95–101CrossRefGoogle Scholar
  18. Minagawa A (1979) Study of weight-bearing changes of normal and abnormal feet by frontal tomography (author’s transl). Nippon Seikeigeka Gakkai Zasshi 53:181–198PubMedGoogle Scholar
  19. Mulier T, Moens P, Molenaers G, Spaepen D, Dereymaeker G, Fabry G (1995) Split posterior tibial tendon transfer through the interosseus membrane in spastic equinovarus deformity. Foot Ankle Int 16:754–759. SRC – GoogleScholarCrossRefGoogle Scholar
  20. O’Byrne JM, Kennedy A, Jenkinson A, O’Brien TM (1997) Split tibialis posterior tendon transfer in the treatment of spastic equinovarus foot. J Pediatr Orthop 17:481–485PubMedGoogle Scholar
  21. Ono K, Hiroshima K, Tada K, Inoue A (1980) Anterior transfer of the toe flexors for equinovarus deformity of the foot. Int Orthop 4:225–229. SRC – GoogleScholarCrossRefGoogle Scholar
  22. Perry J, Thorofare NJ (1992) Gait analysis: normal and pathologic function. Slack, ThorofareGoogle Scholar
  23. Renders A, Detrembleur C, Rossillon R, Lejeune T, Rombouts JJ (1997) Contribution of electromyographic analysis of the walking habits of children with spastic foot in cerebral palsy: a preliminary study. Rev Chir Orthop Reparatrice Appar Mot 83:259–264. SRC – GoogleScholarPubMedGoogle Scholar
  24. Root L, Miller SR, Kirz P, J. (1987) Posterior tibial-tendon transfer in patients with cerebral palsy. Joint Surg Am 69:1133–1139. SRC – GoogleScholarCrossRefGoogle Scholar
  25. Ruda R, Frost HM (1971) ‘Cerebral palsy’, Spastic varus and forefoot adductus treated by intramuscular posterior tibial tendon lengthening. Clin Orthop Relat Res 79:61–70. SRC – GoogleScholarCrossRefGoogle Scholar
  26. Saji MJ, Upadhyay SS, Hsu LC, Leong JC (1993) Split tibialis posterior transfer for equinovarus deformity in cerebral palsy. Long-term results of a new surgical procedure. J Bone Joint Surg Br 75(3):498–501CrossRefGoogle Scholar
  27. Sees JP, Miller F (2013) Overview of foot deformity management in children with cerebral palsy. J Child Orthop 7:373–377CrossRefGoogle Scholar
  28. Son SM, Park IS, Yoo JS (2015) Short-term effect of botulinum toxin a injection on spastic equinovarus foot in cerebral palsy patients: a study using the foot pressure measurement system. Ann Rehabil Med 39:1–9CrossRefGoogle Scholar
  29. Taussig G, Aufaure P, Pilliard D (1990) Tendon surgery in equinovarus deformity of the foot in children and adolescents with cerebral palsy. Rev Chir Orthop Reparatrice Appar Mot 76:128–136. SRC – GoogleScholarPubMedGoogle Scholar
  30. Vogt JC (1998) Split anterior tibial transfer for spastic equinovarus foot deformity: retrospective study of 73 operated feet. J Foot Ankle Surg 37:2–7. discussion 78. SRC – GoogleScholarCrossRefGoogle Scholar
  31. Walker M, Fan HJ (1998) Relationship between foot pressure pattern and foot type. Foot Ankle Int 19:379–383. SRC – GoogleScholarCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Nemours Alfred I. duPont Hospital for ChildrenWilmingtonUSA

Section editors and affiliations

  • Freeman Miller
    • 1
  1. 1.Nemours Alfred I. duPont Hospital for ChildrenWilmingtonUSA

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