Calcaneus Deformity Research Articles

Recurrent heel ulcers with calcaneal osteomyelitis in myelomeningocele: Treatment by partial calcanectomy and posterior transfer of tibialis anterior tendon

OverviewCalcaneus deformity of the foot is common in patients with myelodysplasia, mainly due to muscle imbalance. This deformity, especially in ambulatory patients, can result in gait problems and development of pressure sores, which can be complicated by calcaneal osteomyelitis. Material and methodsThis retrospective cross-sectional study included 12 patients (18 feet), with calcaneus deformity due to myelomeningocele, and presented with penetrating heel ulcers complicated by calcaneal osteomyelitis. The mean age of the included cases was 11 years. The ulcers were unilateral in six patients and bilateral in six. Sensation was absent on the plantar aspect of the foot in all cases. The treatment was done in two stages; The first stage was eradication of infection and obtaining good soft tissue coverage, and the second stage was obtaining motor balance to achieve a more plantigrade and braceable foot. ResultsThe average follow-up period was 19.2 months. In the final follow-up, twelve feet were graded as good, five as fair and one as poor according to Legaspi grading system. ConclusionThe combination of partial calcanectomy and subsequent transfer of tibialis anterior tendon, to improve the foot position and gait, can efficiently prevent ulcer recurrence in myelomeningocele patients with calcaneal deformity. Level of clinical evidence: 4Retrospective case series study.

Long-term follow-up of achillotenotomy in patients with cerebral palsy

Introduction: The surgical solution of equinus deformity is one of the most important factors in the treatment of patients with cerebral palsy. We perform open Z achillotenotomy and percutaneus triple hemisection routinely in our department. Aim: The goal of our work was to analyze the long-term results of achillotenotomies in patients with cerebral palsy, to look for predisposing factors of major complications, and to compare the results of the performed operative methods. Method: Between 1990 and 2006, we performed 347 surgical Achilles tendon lengthenings. In 261 cases, the operations were performed percutaneusly, and in 86 cases we performed open Z achillotenotomy. The average follow-up time was 15 years. The long-term outcomes were analyzed based on the age at surgery, the topographic appearance and the severity of cerebral palsy. Analysis regarding functional outcome was based on the widely known Physician Rating Scale system. Results: Due to recurrent equinus deformity, re-achillotenotomy was performed in 74 cases (21.3%), and in 14 cases (4%) the re-achillotenotomy needed to be performed a second time. We encountered overcorrection and calcaneus deformity in 12 cases (3.5%). Recurrence rate was higher in patients operated at a younger age (<7 years) and in patients with a more severe cerebral palsy (GMFCS II-III, ~26%). Recurrence showed accumulation in patients 9-14 years old. Conclusion: The major complication we encountered was recurrence of the equinus deformity. The majority of relapses occured in patients who were operated at a younger age and suffered from a more severe form of cerebral palsy. We observed that recurrence showed an association with growth and accumulated in aldolescence. Orv Hetil. 2020; 161(8): 306-312.

Pes calcaneus deformity in children and methods of surgical correction

Introduction. Pes calcaneus deformity is a rare pathology in children, which is due to the defect of long flexors of the foot caused by various neurological diseases. The treatment choice is based on the patient’s age, parameters of neuromuscular disorders, and degree of foot deformation.&#x0D; Aim. This study aimed to analyze the results of operative correction of рes calcaneus deformities in children.&#x0D; Material and methods. This analysis of surgical treatment involved 13 patients (21 feet) aged 1.5 to 15 years with рes calcaneus deformities. The different approaches and methods of surgical treatment were described. Children up to 12 years old were released joints of the foot with the elimination of deformation and tendon-muscle transposition with the transfer of functionally preserved muscles in the position of fallen muscle antagonists. Children over 12 years old underwent surgery on the bone apparatus of foot: three-articular arthrodesis or corrective osteotomy of the calcaneus, some cases were supplemented with tendon-muscle transpositions.&#x0D; Results. Treatment results were evaluated based on the radiometric parameters on the system of AOFAS. All treated patients showed improvement in foot stability with reduced deformation; АОFAS at an average of 91.14 points was observed.&#x0D; Conclusion. A record of all causes and strain components with a graded approach eliminates the pes calcaneus deformity in the long-term, despite persistent violation of neuromuscular conduction.

Characterization of a Novel Calcific Achilles Tendinopathy Model in Mice: Contralateral Tendinopathy Induced by Unilateral Tenotomy.

Achilles tendinopathy is a significant clinical disease characterized by activity-related pain, focal movement limitation, and intratendinous imaging changes. However, treatment of Achilles tendinopathy has been based mainly on theoretical rationale and clinical experience because of its unclear underlying pathogenesis and mechanism. The purpose of the study was to develop a simple but reproducible overuse-induced animal model of Achilles tendinopathy in mice to better understand the underlying mechanism and prevent calcific Achilles tendinopathy. A total of 80 C57/B6 mice (8 or 9weeks old) were employed and randomly divided into control and experimental groups. Unilateral Achilles tenotomy was performed on the right hind limbs in the experiment group. 12 weeks after unilateral Achilles tenotomy, the onset of Achilles tendinopathy in the contralateral Achilles tendon was determined by radiological assessment, histologic analysis, electron microscopy observation, and biomechanical test. The onset of calcific Achilles tendinopathy in contralateral Achilles tendon was confirmed after 12 weeks of unilateral tenotomy. The contralateral Achilles tendon in the experimental group was characterized as hypercellularity, neovascularization, and fused collagen fiber disarrangement, compared with the control group. Importantly, intra-tendon endochondral ossification and calcaneus deformity were featured in contralateral Achilles tendon. In addition, poor biomechanical properties in the contralateral Achilles tendon revealed the incidence of Achilles tendinopathy. We hereby introduce a novel, simple, but reproducible spontaneous contralateral calcific Achilles tendinopathy model in mice, which represents overuse conditions during tendinopathy development in humans. It should be a useful tool to further study the underlying pathogenesis of calcific Achilles tendinopathy.

Guided Growth of the Distal Posterior Tibial Physis and Short Term Results: A Potential Treatment Option for Children With Calcaneus Deformity.

We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity around the ankle. Our study included 9 consecutive patients (11 ankles) with calcaneus deformity, over a period of 4 years. Surgical treatment with extra periosteal application of flexible 2 hole plate and screws on posterior aspect of distal tibial physis was carried out.The indications for treatment were residual clubfoot deformity in 9, posttraumatic in 1, and neurologic in 1. The average age of the patients was 10 years (range, 4 to 13 y). There were 7 males and 2 females.Serial preoperative and postoperative radiographs were used to measure deformity correction and anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA), and Screw Divergence Angle (angle subtended by lines passing through the screws) were measured. A 2-tailed student t test was used to determine statistical significance. The ADTA showed mean correction of 8.41 degrees (range, 3.1 to 16.6 degrees) this was statistically significant with P-value of 0.0003.The change in LDTA was not statistically significant (P-value=0.05) reinforcing the aptness of the procedure and that the procedure did not result in coronal plane deformities. Six ankles required revision of fixation: 4 due to metalwork reaching its maximum limit of divergence at an average of 1 year, 1 ankle had screw pull-out, and another ankle was revised due to technical error in screw selection. In our study there were no cases of infection. We report satisfactory short-term results of correction of calcaneus deformity using flexible tension band plates and screws. In our opinion this is an effective alternative providing gradual correction with easy and minimally invasive surgical technique. It does not violate the physis and is easy to remove and revise. It is safe and well tolerated and can be grouped with other procedures with ease. Level IV—case series.

Acquired Calcaneus Deformity Secondary to Osteomyelitis of the Distal Tibia

Osteomyelitis of the distal tibia with involvement of the distal physis can lead to various deformities around the ankle and foot. Calcaneus deformity of the foot is usually secondary to paralytic disorders. A 14-year-old boy presented with calcaneus deformity as a result of osteomyelitis of the distal tibia. Involvement of the distal tibial epiphysis as a result of osteomyelitis of the distal tibia can lead to calcaneus deformity. This deformity has not been reported in the literature. Osteomyelitis of the distal tibia should also be included as a differential diagnosis of calcaneus deformity.

Complete Tendon Transfer and Inverse Lambrinudi Arthrodesis: Preliminary Results of a New Technique for the Treatment of Paralytic Pes Calcaneus

Paralytic pes calcaneus is commonly associated with myelomeningocele and continues to be one of the most difficult deformities to treat. The purpose of the present study is to describe and report the preliminary results of a new procedure to dynamically correct paralytic pes calcaneus. Since 2002, the senior surgeon operated on six patients with myelomeningocele and developed a new procedure to dynamically correct paralytic pes calcaneus. This new procedure combines a complete tendon transfer (tibialis anterior and posterior, peroneus brevis and longus, and extensor digitorum and hallucis longus) to the Achilles tendon and an additive triple arthrodesis. The extent of the calcaneus deformity was evaluated by measuring the talocalcaneal angle. The mean followup was 32 months. Excellent results were achieved in five of the six patients with a mean age of 17.5 years. Using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale, pain and function improved from an average of 41.6 preoperatively to 72.0 postoperatively. The deformity as assessed by the talocalcaneal angle, the calcaneal pitch, and the talometatarsal I angle improved after surgery significantly (p < 0.004). After 12 months, an additional surgery was required in two patients due to disabling drop-foot. This new surgical technique to correct paralytic pes calcaneus including complete tendon transfer and triple arthrodesis is promising. Although this is a technically demanding procedure, it provides an excellent functional result without the residual complications associated with ankle arthrodesis.

Tibialis Anterior Tendon Transfer for Calcaneus Deformity in Children with Myelomeningocele: A Preliminary Report

Purpose : To examine the results of tibialis anterior tendon transfer for the treatment of a calcaneus deformity in children with a myelomeningocele. Materials and Methods : Twenty-seven feet in sixteen children were examined in this study. The mean age at the time of surgery was 7+2 years (range, 4+11-14+9) and the mean follow up duration was 25 months (range, 15-50). Three-dimensional gait analysis and dynamic foot-pressure measurement were performed to analyze the results of the index operation. Results : There was no recurrence or aggravation of the deformity. The sagittal kinematics of the ankle improved, and the relative impulse of the calcaneus decreased postoperatively. Those patients with an increased range of motion of the pelvic rotation during gait showed less improvement in the relative impulse of the calcaneus than those with a good range of pelvic rotation. They also had a lower range of knee sagittal motion and an increased range of abduction of the hip, and up-obliquity of the pelvis. Conclusion : A good range of motion of the hip and pelvis in coronal and transverse planes, and of the knee in the sagittal plane are important predictors of the functional transfer of tibialis anterior tendon in patients with a calcaneal gait in a myelomeningocele.

Heel Cord Advancement Combined with Vulpius??? Lengthening of the Gastrocnemius

The results of Achilles tendon lengthening to treat spastic pes equinus deformity are less than satisfactory, with high recurrence rates. To improve the outcome, heel cord advancement can be done. In the current study, the patients with severe contracture of the Achilles tendon were treated by heel cord advancement. Additional lengthening of the gastrocnemius muscle using the Vulpius technique was done to reattach the Achilles tendon to the calcaneus. Seventeen patients (20 feet) with spastic pes equinus deformities were treated with this technique, and satisfactory midterm postoperative results were obtained. The mean age of the patients at surgery was 10 years, and the mean duration of followup after surgery was 8 years. The mean tibioplantar angle decreased postoperatively, and there were no recurrences of pes equinus deformity and no appearance of pes calcaneus deformity. Walking ability improved in two patients and did not deteriorate in any of the patients. Seven of the patients were able to stand on only the affected foot after the operation. Our technique provides good correction of an equinus deformity with no recurrence, and with improvement of the physical activity level.

Gait Analysis in Children With Severe Clubfeet

Ninety children between the ages of 2 and 3 years with 127 clubfeet underwent gait analysis. Fifty-one feet had undergone posteromedial releases, 52 feet had no surgery following correction of the deformity using the French physical therapy program, and 24 feet had either tendo Achilles lengthening or posterior releases following physical therapy. Persistent internal rotation of the foot during gait was the most frequent gait disturbance and was seen in all treatment groups. Limited ankle dorsiflexion was most common in the nonoperated feet, while calcaneus deformity occurred in the posteromedial release group. Ankle motion during gait was normal in 54% of nonoperated feet compared with 39% of feet that had posteromedial releases. While gait abnormalities were common in all clubfeet, fewer deviations were documented in feet treated with physical therapy that did not require surgery. Aggressive release leads to a higher likelihood of abnormal ankle motion and internal rotation during gait.

Prevalence of Specific Gait Abnormalities in Children With Cerebral Palsy

The authors retrospectively reviewed a series of 492 consecutive cerebral palsy patients undergoing computerized motion analysis. The prevalence of 14 specific gait abnormalities was evaluated and compared based on involvement (hemiplegia, diplegia, or quadriplegia), age, and history of previous surgery (lower extremity orthopaedic surgery or rhizotomy). Stiff knee in swing, equinus, and intoeing were all seen in more than 50% of the subjects in each of the hemiplegic, diplegic, and quadriplegic groups. Increased hip flexion and crouch were also present in more than 50% of the subjects in the diplegic and quadriplegic groups, and hip adduction occurred in more than 50% of the quadriplegic subjects. The likelihood of having stiff knee in swing, out-toeing, calcaneus deformity, and crouch increased with prior surgery. The likelihood of having rotational malalignment of the leg (internal hip rotation with out-toeing), calcaneus, out-toeing, varus and valgus foot deformities, and hip internal rotation increased with age. These findings provide important information for counseling ambulatory children with cerebral palsy and their families.

Prevalence of Specific Gait Abnormalities in Children With Cerebral Palsy

The authors retrospectively reviewed a series of 492 consecutive cerebral palsy patients undergoing computerized motion analysis. The prevalence of 14 specific gait abnormalities was evaluated and compared based on involvement (hemiplegia, diplegia, or quadriplegia), age, and history of previous surgery (lower extremity orthopaedic surgery or rhizotomy). Stiff knee in swing, equinus, and intoeing were all seen in more than 50% of the subjects in each of the hemiplegic, diplegic, and quadriplegic groups. Increased hip flexion and crouch were also present in more than 50% of the subjects in the diplegic and quadriplegic groups, and hip adduction occurred in more than 50% of the quadriplegic subjects. The likelihood of having stiff knee in swing, out-toeing, calcaneus deformity, and crouch increased with prior surgery. The likelihood of having rotational malalignment of the leg (internal hip rotation with out-toeing), calcaneus, out-toeing, varus and valgus foot deformities, and hip internal rotation increased with age. These findings provide important information for counseling ambulatory children with cerebral palsy and their families.

Anterior bone block: treatment of calcaneus deformity after failed soft-tissue operations.

Calcaneus deformity is almost always the result of a neural disorder. It is progressive, disabling, and resistant to bracing and usually requires surgery. In immature feet, soft-tissue operations are the procedures of choice but have the disadvantage of recurrence due to stretching of soft tissues. However, bony operations will lead to growth center damage. Anterior bone block corrects the deformity without damaging the growth centers.

Hematogenous osteomyelitis of the calcaneus in children.

Fourteen children (average 9 years) with primary hematogenous osteomyelitis of the calcaneus are reported. Four were seen early and 10 late. Clinical presentation was dramatic, with fever, pain, swelling, and fluctuance around the foot and ankle. The diagnosis was missed initially in 8 cases because the patients were treated for septic arthritis of the ankle, cellulitis, and subcutaneous abscess. The 4 patients seen early healed well, with no complications. The 10 patients seen late had chronic osteomyelitis with growth arrest; shortening of the foot; limb length deficiency; fusion of subtalar, calcaneocuboid, and ankle joints; calcaneus and equinus deformity; avascular necrosis of the talus; and phalangeal loss. Hospital stay was prolonged in 4 patients. Total calcanectomy (3 patients) and talectomy (2 patients) with heel pad preservation were useful salvage procedures avoiding ablation of the limb in chronic cases.

Incidence and Type of Hindfoot Deformities in Patients with Low-Level Spina Bifida

In a consecutive series of 174 children with low-level spina bifida, there was hindfoot deformity in 263 of the 348 feet; 86 were in equinus, 108 were in calcaneus, 41 were in valgus, 20 were in varus, and eight had convex pes valgus. Surgery was performed on 222 (64%) feet. The deformities were symmetric in 114 children. Spasticity causing deformity necessitated surgery in only 44 feet. Calcaneus deformity in the foot is considerably more common in patients with L4 lesions, and in these circumstances, muscle imbalance is clearly a major factor. However, many patients with calcaneus deformity had L5 or sacral lesions. This suggests that muscle imbalance is not so important a factor as has been thought in the causation of deformity in the lower limb in myelomeningocele.

The high incidence of foot deformity in patients with high-level spina bifida

In a consecutive series of 124 children with spina bifida we found that 220 (89%) of the 248 feet were deformed: 70 had a calcaneus deformity; 126 were in equinus; 16 were in valgus; 3 were in varus; and 5 had convex pes valgus. Operations were performed on 171 (78%) of the deformed feet. Spasticity of the muscles controlling the foot was detected in 36 (51%) of the 70 calcaneus feet and in 22 (17%) of the 126 equinus feet. The deformities were symmetrical in 94 children. There is a high incidence of foot deformity in patients with spina bifida who have no voluntary activity in the motors of the feet.

Chronologic Outcome of Surgical Tendoachilles Lengthening and Natural History of Gastroc-Soleus Contracture in Cerebral Palsy

Medical records of 59 patients with cerebral palsy were reviewed retrospectively to evaluate results of tendoachilles lengthening. Surgical lengthening resulted in highly significant (p < 0.0001) initial average gains in dorsiflexion compared with baseline. These average improvements maintained their statistical significance for seven years postoperatively. The arc of motion was not significantly different postoperatively. The initial ambulatory level was improved in 55% of the patients and maintained in the remainder. However, 14 ankles (11.9%) in eight patients (13.6%) required repeat tendoachilles lengthening during the study period, primarily after gastrocnemius procedures. Calcaneus deformity occurred in 1.7% of the surgically treated ankles. To evaluate the potential for spontaneous improvement over time in fixed equinus deformity, the records of a group of 68 additional cerebral palsy patients were reviewed. Patients treated nonoperatively despite two examinations that demonstrated fixed lack of dorsiflexion, while not representing a true control group, showed no spontaneous improvement in equinus deformity through seven years postoperatively.

Achilles Tenodesis for Calcaneus Deformity in the Myelodysplastic Child

Calcaneus deformity in patients with neurologic disorders leads to gait disturbances, a high incidence of osteomyelitis, cellulitis, and skin breakdown, and a major problem in the fitting of shoes of orthoses. Correction of this deformity remains a difficult challenge for the orthopedic surgeon. Twelve tenodeses of the tendo Achillis to the fibula or tibia were performed in eight patients with myelodysplasia in an attempt to control calcaneus deformity. The average age of the patients at the time of surgery was 7.4 years (range, 3.1-13.5 years) with an average follow-up period of 6.3 years (range, two to 10.9 years). The clinical examination demonstrated definite improvement in the ability to brace, prevent skin breakdown, and improve gait in all but one patient who had progressive hindfoot valgus. Roentgenographically, there was improvement in the tibiocalcaneal angle in 67%, fibular station in 58%, talar tilt in 25%, and growth of the posterior aspect of the calcaneus in 58%.

Transfer of the tibialis anterior for calcaneus deformity in myelodysplasia.

We evaluated the results of transfer of the tibialis anterior in the management of calcaneus deformity in young patients who had myelodysplasia; fifteen patients (twenty-two feet) were operated on between 1978 and 1985. The neural deficit was at the fourth and fifth lumbar levels. The average age at the time of the operation was seven years and two months (range, two to nineteen years). The average age at the latest follow-up was thirteen years (range, five to twenty-four years). The average duration of follow-up was five years and ten months (range, two to eleven years). Seventeen feet (twelve patients) had a good result (no ulceration of the heel or osteomyelitis and correction of the calcaneus deformity), and five feet (three patients) had a poor result (persistent ulceration, signs of osteomyelitis, recurrent or persistent calcaneus deformity, or the need for additional operative intervention). Children who were less than five years old had a better outcome, as determined by the Fisher exact test (p less than 0.5).

Calcaneus deformity in the ambulant patient with myelomeningocele

We reviewed our experience of tibialis anterior transfer and anterior release for calcaneus deformity in 46 feet of 26 ambulant patients with myelomeningocele. At an average follow-up of 8.4 years (2 to 17.6) there were 89% who had satisfactory results; 64% of the patients having tibialis anterior transfers were able to stand on their toes. Hip abductor power was a good predictor of a functional transfer. Pre-operative trophic ulceration of the heel increased from 3.2% to 33% if surgery was delayed. Secondary deformities, two-thirds of them into valgus, developed in 76% of feet.