Equinus Deformity Research Articles

Surgical treatment of equinus deformity in patients with cerebral palsy of preschool and early school age

BACKGROUND: Cerebral palsy is a severe disorder of the nervous and musculoskeletal systems. Equinus foot deformity is the most commonly diagnosed deformity. Surgical treatment is required in 12%–70% of patients. Existing surgical treatments are complicated by loss of improvement, relapse, and recurrent deformity in 6.7%–41.0% of cases. AIM: The aim of the study was to determine the optimal surgical treatment algorithm for preschool and early school-aged patients with cerebral palsy. MATERIALS AND METHODS: A clinical study included 102 children with cerebral palsy aged 3–10 years. Two groups of children were formed: group 1 for 3–6-year-old patients, group 2 for 7–10-year-old patients. The follow-up period was from 2014 to 2023. Equinus foot deformity was the main symptom in children. The GMFCS, Ashwort, and Boyd–Graham scales were used to assess patients. The severity of the foot deformity was evaluated by the author’s method (Invention Patent of the Russian Federation No. 2712951). Grade I deformity was reported in patients who required a force of 5–7 kg/cm2 to move the foot to a 90° angle, grade II deformity was reported with a force of 8–10 kg/cm2, and grade III deformity was reported with a force of more than 10 kg/cm2. All children underwent surgery: selective myotomy of the gastrocnemius muscle of the lower leg in 65 (63.7%) patients (Intervention Patent of the Russian Federation No. 2332180) and partial achillotomy in 37 (36.3%) patients (Intervention Patent of the Russian Federation No. 2819283). RESULTS: Spastic diplegia was diagnosed in 59 (57.8%) patients and hemiplegia was diagnosed in 43 (42.2%) patients. Grade I, II, and III equinus foot deformities were diagnosed in 29, 36, and 37 patients, respectively. Selective myotomy was performed in 37 children in group 1 and in 28 children in group 2. Partial achillotomy was performed in 18 and 19 patients in both groups, respectively. Selective myotomy was performed in 63.7% of children in both groups with grades I and II equinus foot deformity, and partial achillotomy was performed in 36.3% of children with cerebral palsy with grade III equinus foot deformity. Treatment results are considered satisfactory in 95.1% of cases. CONCLUSIONS: The surgical treatment algorithm is effective in children 3–10 years of age with intact intelligence and independent mobility. For patients with cerebral palsy with grade I and II equinus foot deformities, selective myotomy of the gastrocnemius muscle is recommended, whereas for patients with grade III deformity, partial achillotomy is recommended.

Outcomes of Triceps Surae Lengthening Surgery in Children With Charcot-Marie-Tooth Disease: A Multisite Investigation.

Orthopaedic surgical intervention in children with Charcot-Marie-Tooth (CMT) often includes triceps surae lengthening (TSL) and foot procedures to address instability and pain due to equinus and cavovarus deformities. These surgeries may unmask underlying weakness in this progressive disease causing increased calcaneal pitch and excessive dorsiflexion in terminal stance leading to crouch. The purpose of this study was to evaluate changes in ankle function during gait following TSL surgery in children with CMT. Nineteen participants (11 male; age 12.8, SD 3.6y) with CMT underwent gait analysis and clinical examination preoperatively and postoperatively to determine the outcomes of (1) triceps surae lengthening (TSL) and (2) plantar fascia release with bony foot surgery with or without TSL. TSL was performed in limbs with limited passive dorsiflexion range of motion (ROM) and decreased peak dorsiflexion in terminal stance, with gastrocnemius recession (GR) being preferred over tendo-Achilles lengthening (TAL) in cases with smaller dorsiflexion deficits. Passive dorsiflexion ROM, gait kinematics and kinetics, and foot posture index (FPI) were examined within and across surgical groups using linear mixed models. Dorsiflexion ROM, peak dorsiflexion in terminal stance and mid-swing, and peak nondimensional plantar flexor moment improved significantly after both GR (n=8 limbs) and TAL (n=11 limbs) (P≤0.02). After plantar fascia release with bony foot surgery (n=20 limbs), FPI changed significantly, indicating reduced cavovarus regardless of whether TSL was done (P<0.05). Passive and dynamic dorsiflexion and ankle kinetics (moment and power) increased only when concomitant TSL was done (P≤0.04). In patients with increased equinus due to reduced passive dorsiflexion range of motion, TSL is an effective surgery for reducing excessive equinus in terminal stance and mid-swing, decreasing toe-walking, and improving swing phase clearance. It can be combined with extensive foot surgery to correct cavovarus deformity without leading to excessive dorsiflexion in terminal stance and crouch gait. Clinical gait analysis is an important tool to help identify appropriate candidates for TSL based on the key indicator of peak dorsiflexion in terminal stance. Level IV.

Necessity of Tendoachilles Tenotomy in Patients With Congenital Talipes Equinovarus (CTEV) Treated Using the Ponseti Technique: A Prospective Cohort Study.

This study aims to determine how often Achilles tenotomy is performed on patients who have congenital talipes equinovarus (CTEV) and have been managed with Ponseti serial casts. Thisprospective cohort studytook place from November 2021 to May 2023 in the orthopedic unit of Hayatabad Medical Complex, Peshawar, Pakistan. About 38 pediatric patients with CTEV, who received treatment in the form of Ponseti casting, were enrolled in the study. Clinicodemographic data of the patients were recorded. Informed consents were taken prior to enrollment. Using the Ponseti casting method, 56 feet in 38 pediatric patients with CTEV, were treated. Of 38 patients, 27 (71.05%) were male and 11 (28.94%) were female. Fourteen (36.84%) out of 38 had a right foot, 6 (15.7%) had a left foot, and 18 (47.36%) had bilateral foot involvement. The mean age was 8.8±2.5 weeks (ranging from 5 to 13 weeks) when they were subjected to Achilles tenotomy. The initial mean Pirani score was 3±0.74 while the final Pirani score was 1±0.74 after Ponseti casting, showing the efficacy of Ponseti casting correcting the cavus, varus, and adduction components of clubfoot. The mean number of casts was 5±0.84 to correct the aforementioned components of clubfoot. In 34 feet (60.71%) the residual equines deformity was persistent and Achilles tenotomy was done to make the foot plantigrade. In the end, all 38 patients had plantigrade feet. Equinus deformity was present in over 60% of the patients following Ponseti serial casting, highlighting the need for tendoachilles tenotomy to make the foot plantigrade. A combination of Ponseti casting and tendoachilles tenotomy resulted in plantigrade feet in 100% of patients.

Combined Surgical Technique of Hyperselective and Partial Motor Neurectomies for Spastic Equinus, Equinovarus, and Claw Toe Deformities.

Patients with spastic equinus, equinovarus, and claw toe deformities can experience marked pain and functional limitations in the ability to weight-bear comfortably, ambulate efficiently, or mobilize independently. Seen in 80% of patients with cerebral palsy and 18% of patients with stroke (1, 2), the spastic foot and ankle deformities, and its secondary sequelae of static joint contractures, osseous changes, and chronic pain, are unfortunately common. Adult and pediatric patients undergoing combined hyperselective and selective partial motor neurectomies for varus or claw toe deformities were reviewed. Patient demographics and complications were recorded. Pre- and postoperative Modified Ashworth Scale scores were compared. Twenty-three patients (16 adults and seven pediatric) met inclusion criteria and were included in analysis. At early 6-month follow-up, the mean preoperative Modified Ashworth Score of 2.8 in adult patients and 3.0 in pediatric patients decreased to 0.6 postoperatively. Complications in three adult patients included one patient with temporary dysesthesias to the plantar foot, one with a popliteal abscess requiring incision and drainage, and one superficial wound dehiscence that was managed conservatively. A combined technique of hyperselective and partial motor neurectomies are effective in decreasing tone in the correction of spastic foot and ankle deformities in both adult and pediatric patients in short-term 6-month follow-up.

Is the Silfverskiöld Test a valid tool for evaluating calf muscles spastic overactivity in patients with stroke? A retrospective observational study.

Spastic equinus (plantar flexed) foot is a common postural pattern in patients who suffer from post-stroke spasticity. To date, some clinicians use the Silfverskiöld Test in their practice to differentiate between gastrocnemius and soleus muscle overactivity in patients with spastic equinus (plantar flexed) foot. This use of the Silfverskiöld Test goes beyond its original aim, which was to distinguish isolated gastrocnemius contracture in patients with equinus deformity. The aim of this study was to investigate the Silfverskiöld Test validity for evaluating spastic equinus (plantar flexed) foot (i.e., differentiation between gastrocnemius and soleus muscle overactivity) by checking its outcome against those of selective diagnostic nerve block of tibial motor nerve branches to the soleus, gastrocnemius and tibialis posterior muscles. The design of the study was retrospective observational. The study was set in a university hospital. Sixty-seven adult stroke patients with spastic equinus (plantar flexed) foot. Each patient underwent selective diagnostic nerve block of tibial motor nerve branches to the soleus, gastrocnemius and tibialis posterior muscles. All patients were evaluated before diagnostic nerve block by means of the Silfverskiöld Test which was considered positive when ankle joint passive dorsiflexion was greater with the knee flexed than extended. Furthermore, they were assessed before and after nerve block by means of the modified Ashworth Scale and the Tardieu Scale. Our sample included 41 males and 26 females (mean age 57.6 years) suffering from spastic equinus (plantar flexed) foot due to chronic stroke (mean time from onset 2.4 years). Forty-eight patients out of 67 presented with positive Silfverskiöld Test. The χ2 test showed no association between the Silfverskiöld Test and spastic overactivity of the gastrocnemius (P=0.253), soleus (P=0.605) and tibialis posterior (P=0.462) muscles as evaluated by serial selective diagnostic block of the tibial nerve motor branches. Our findings do not support the Silfverskiöld Test as a valid tool for evaluating spastic equinus (plantar flexed) foot to differentiate between gastrocnemius, soleus and tibialis posterior spastic muscle overactivity in adult patients with stroke. The choice for an appropriate management of spastic equinus (plantar flexed) foot in adults with stroke should not be mainly defined on the base of Silfverskiöld Test.

Temporary Circular External Fixation for Spanning the Traumatized Ankle Joint.

Temporary ankle-spanning circular fixation aims to provide osseous stability while (1) allowing access to and recovery of the traumatized soft-tissue envelope and (2) facilitating safe, comfortable, and clinically relevant cross-sectional imaging for surgical planning. It is most commonly utilized in a "span-scan-plan" treatment strategy in cases of peri-articular fractures around the ankle2. Conventional monolateral fixators are prone to morbidity at the half-pin sites in the foot and variation in construct stability. Temporary ankle-spanning circular external fixation of the traumatized ankle joint can mitigate these issues. A circular external fixator construct is assembled beginning with a single tibial ring that is fixed to the tibia by half-pins that are spread on either side of the ring and forming a "virtual ring block." A foot ring is attached via 2 crossed tensioned fine wires in the calcaneum and a single midfoot fine wire in order to prevent an equinus deformity. The tibial virtual ring block and the foot ring are interconnected by 3 polyaxial "rapid-adjust struts" that are evenly distributed around the limb. The fracture is then reduced, and the polyaxial rapid-adjust struts are locked1. Numerous constructs have been proposed to optimally immobilize the ankle joint while also allowing limb elevation and access to the ankle for soft-tissue care3-6. A commonly utilized construct is the monolateral "bar-and-clamp" spanning external fixator, which relies on half-pin fixation in the foot that may induce bone lysis, result in pin-site infections, and prevent weight-bearing. Calcaneal half-pins are particularly troublesome and can lead to adjacent lysis, instability, and potential loss of initial reduction as a result of the cancellous bone quality. The principal objective of temporary joint-spanning external fixation is to realign the traumatized joint and to maintain this reduction until definitive surgery while facilitating soft-tissue treatment and surgical planning7-11. This strategy forms the first step in the "span-scan-plan" approach to pilon fractures described by Sirkin et al.2. Multiple subsequent studies have confirmed the superiority of external fixation over splinting for initial soft-tissue care following distal tibial and ankle trauma12,13. Temporary circular external fixation has been shown to outperform monolateral fixation in terms of both the adequacy of the initial reduction and the maintenance of this reduction1. Harrison et al. demonstrated that temporary circular fixation of the traumatized ankle yielded 100% good or excellent initial reduction compared with 91% for monolateral fixation. This initial reduction was also better maintained by circular fixator constructs compared with monolateral ones (96% versus 78%). Placement and orientation of the rings should take into account the zone of injury, access for orthoplastic procedures, and the maximum length of adjustable struts.Orthogonal frame application allows the best biomechanical environment for stabilization of fracture and/or dislocation of the tibiotalar joint to facilitate soft-tissue care. Care should be taken in the operating room to ensure orthogonal mounting of both the proximal and the distal ring to their respective bone segments.Avoid transverse fine wires in the calcaneus to prevent translation while in the frame; consider the use of tensioned olive wires to further protect against translation.Place the midfoot wire through the base of the metatarsals or along the cuneiforms to maximize fixation.Take care to avoid placing the ankle or forefoot in equinus. CEF = circular external fixatorPAD = pronation adductionPER = pronation external rotationSAD = supination adductionSER = supination external rotation.

Comparison of Z-Technique and Sliding Technique for Achilles Tendon Lengthening in Cerebral Palsy with Equinus Deformity: A Meta-Analysis

Comparison of Z-Technique and Sliding Technique for Achilles Tendon Lengthening in Cerebral Palsy with Equinus Deformity: A Meta-Analysis

Single-stage correction of severe rigid ankle Equinus deformity caused by Volksmann’s ischemic contracture: A case report

Single-stage correction of severe rigid ankle Equinus deformity caused by Volksmann’s ischemic contracture: A case report

Innovation of Adjustable Ankle Joint Orthoses for Patients with Flexible Equinus Deformity

The limited dorsiflexion at the ankle joint is characterized by Equinus deformity. It has a large impact on mobility and functionality at all ages. Usually, Achilles tendon stretching and Ankle Foot Orthosis (AFOs) are used as a treatment but have low efficiency and flexibility. Frequently adjustment to AFOs required through dynamic foot positioning makes this treatment very expensive due to repeated molding. An experimental research design was used to measure plantar flexion angles with a goniometer at many follow-ups. This research showed that a decreased plantar flexion angle, this study indicated the effectiveness of locally made adjustable ankle joints. Developing an adjustable ankle joint addresses both the practical and economic challenges of traditional orthotic treatments. This innovation not only provides clinical outcomes but also expands the opportunity to care for patients with equinus deformity. This adjustable joint gives a flexible and cost-effective solution and improves the management of equinus deformity.

The Efficacy of General Anesthesia with Sevoflurane for Pain Management in Neonates and Infants with Idiopathic Clubfoot Treated with Ponseti Technique and Percutaneous Achilles Tenotomy

Background: Idiopathic clubfoot deformity is a relatively common congenital pediatric foot deformity. A percutaneous Achilles tenotomy (PAT) is required to correct the equinus deformity as it is the most resistant component of clubfoot deformity. Although this procedure is mainly performed with local anesthesia, performing this procedure with general anesthesia has significant advantages. Aims: The purpose of this study was to compare the safety and efficacy of post-procedural pain management of PAT in the treatment of clubfoot with the Ponseti method when performed in a clinic setting with local anesthetic or under general anesthesia Methods: This is a multicentric prospective observational evaluation on children less than one year of age with idiopathic clubfoot whom referred for Ponseti casting and PAT. This procedure was done in the control group with local anesthesia and in the intervention group with Sevoflurane mask 8% (MAC 2) and maintenance of anesthesia with Sevoflurane mask 4% (N2O/O2, 50%). The neonatal infant pain scale (NIPS), the amount of milk, and mood changes were evaluated as a criterion to measure the pain level. Results: NIPS score in the intervention group was significantly lower than the control group. Children in the intervention group consume significantly more milk than the control group. Furthermore, 76% of children in the intervention group were classified as "calm," 24% as "relatively restless," and no child was classified as "severely restless." While in the control group, 54% of children were classified as "severely restless," and the remaining 46% as "relatively restless." Conclusion: Our result showed that using general anesthesia to perform achillotomy in the treatment of clubfoot in children could be associated with less pain in these patients and without significant complications.

Idiopathic toe walking: What’s New? An Integrative Review

Objective: Consolidate the current knowledge on idiopathic toe walking, provide a critical overview, and identify areas for potential future research. Methods: An electronic search was conducted in the following databases up to June 2023: MEDLINE, EBSCO, Embase, CINAHL Plus, and PubMed. The PICO framework was employed to define search terms. Results: Despite considerable methodological heterogeneity among studies, a stronger inclination was found to investigate etiological and prognostic factors. There is a trend for a higher prevalence in boys with a positive family history. Novel classifications have been proposed to improve differential diagnosis. Among conservative treatment options, there is stronger evidence for gait improvement using serial casting followed by orthoses. Severe cases may benefit from surgical zone III gastrocsoleus lengthening. Conclusion: Further studies with standardized methodologies are required to clarify questions about this condition’s etiology, classification, and treatment. Nonetheless, there is a higher level of evidence supporting conservative treatments with serial casting and orthoses and zone III gastrocsoleus lengthening for severe cases in the second decade of life. Level of evidence II; Diagnostic studies. Keywords: Walking; Equinus Deformity; Foot;

Reliability of Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot.

Talipesequinovarus is a congenital ankle/foot malformation that commonly affects newborns. In its treatment using the Ponseti method, an Achilles tenotomy is frequently needed to correct residual equinus deformity. Percutaneous (PC) tenotomy is the most commonly used technique and needs to be thoroughly evaluated. The question we needed to answer was: "Does PC Achilles tenotomy result in complete tendon sectioning"? This clinical study included 56 idiopathic clubfeet in 36 patients who presented during the first 6 months of life and were treated with Ponseti manipulation and casting followed by PC Achilles tenotomy. PC tenotomy was done under general anesthesia, and Thompson's calf squeeze test was performed intraoperatively just after tenotomy. In case of a negative test (ie, ankle plantar flexion with calf squeeze), the percutaneous incision was extended to assess the cause of the negative test. Forty-nine feet (87.5%) had a complete tenotomy, as evidenced by a positive Thompson's calf squeeze test. While 7 feet (12.5%) showed a negative test, and therefore the percutaneous incision was extended and all were found to have an incompletely divided Achilles tendon. The tendons were then completely divided, after which Thompson's test became positive in all. Percutaneous Achilles tenotomy is a reliable procedure, but was found to result in incomplete tendon sectioning in 12.5% of cases, affecting the range of ankle dorsiflexion. Thompson's squeeze test is reliable in picking up cases of incomplete tenotomy after the PC technique, and in these cases the incision should be extended for complete sectioning. Level I.

Magnetically driven antegrade intramedullary lengthening nails for tibial lengthening.

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated.

Anterior Hemiepiphysiodesis of the Distal Tibia: A Step-by-step Surgical Technique Guide.

This paper aims to serve as a guide for surgeons to prepare, execute, and perfect anterior hemiepiphysiodesis of the distal tibia (AHDT). Treatment of persistent or recurrent equinus deformity following multiple conservative and surgical interventions in patients with idiopathic clubfoot or neuromuscular conditions can be challenging, and multiple surgical options are presented in the existing literature. Anterior hemiepiphysiodesis of the distal tibia is an option that seems to be safe and efficient in treating this entity. To the best of our knowledge, there is not yet any detailed description of this surgical technique in the English literature. The AHDT detailed surgical technique includes patient positioning, careful distal anterior tibial approach, placement of guided growth plates, fixation with epiphyseal and metaphyseal screws under fluoroscopic guidance, meticulous closure, and postoperative measures. This guide can be used pre-operatively to plan the surgery, intra-operatively to aid in smooth and safe step progression, and post-operatively to assist in critical critiquing. By understanding the various stages of the surgery as well as the anatomy, pitfalls can be avoided and AHDT can be performed efficiently. Katz A, Dumas É, Hamdy R. Anterior Hemiepiphysiodesis of the Distal Tibia: A Step-by-step Surgical Technique Guide. Strategies Trauma Limb Reconstr 2023;18(3):174-180.

New posterior distal femoral hemiepiphysiodesis for treatment of recurvatum knee in a patient with cerebral palsy: a case report

Hyperextension of the knee (Genu recurvatum) is a rare deformity in the sagittal plane which can impact on walking by pelvis’, ankle’s and foot’s biomechanics changes. It can be caused by cerebral palsy, arthrogryposis poliomyelitis, traumatic tibial tuberosity arrest and generalized ligamentous hyperlaxity. Specially in cerebral palsy, factories like hamstrings lengthening and equinus deformity of the foot can produce this knee condition. The treatment methods to correct this deformity are more aggressive to date, such as quadricepsplasty, hamstring tenomyoplasty and femur or tibia osteotomies. We describe here the treatment of a patient with mild hemiparetic hypertonic cerebral palsy GMSCF I, with unilateral genu recurvatum, using a safe and minimally invasive technique with posterior hemiepiphysiodesis of the distal femur, performed with two transphyseal cannulated screws for correction. This technique has great potential for correcting the recurvatum knee in the immature skeleton during growth and can be a good alternative to the more aggressive methods currently used for the treatment of this deformity.

Lever Arm dysfunction of Hips in Cerebral Palsy

In cerebral palsy, hip dysfunction is the second most common problem after equines deformity. Abnormal skeletal development of the proximal femur due to abnormal forces in cerebral palsy leads to lever arm function by reducing the length of the lever arm contributing to one of very important causes of gait abnormality. High hip anteversion, high neck shaft angle, subluxation, and dislocation are the most common lever arm dysfunctions at the hip joint. This lever arm dysfunction increases progressively with age and correspondence to GMFCS level. If not identified at a very early stage then it may progress to completely deform the femoral head &amp; hip joint. Early identification and preventive surgery help in preventing progression in GMFCS I to III but can progress despite of preventive surgery in non-walker children FMFCS IV &amp; V. Recurrence of the problem is also very common in non-walker children. So we need detailed information about the lever arm problem in the hip and how to deal with this problem in cerebral palsy children. In this article, we have discussed etiology, and how to identify and management protocols for different lever arm dysfunctions of the hip in cerebral palsy. Keywords: Cerebral palsy, Lever arm dysfunction of hip, Hip subluxation, Anteversion

Current advancements in diagnosing and managing cavovarus foot in paediatric patients.

The cavovarus deformity is a pathological condition characterised by an anomalous elevation of the longitudinal arch. This condition results from a significant hindfoot varus and forefoot equinus deformity. This phenomenon comprises diverse anomalies and therapies and exhibits a prevalence of 25% within the populace. A thorough clinical evaluation is required to identify deformities in the cavovarus foot. Weight-bearing radiographs play a crucial role in identifying the apex of deformity and quantifying the required extent of correction. Cavus feet are frequently linked with neurological conditions affecting sensory and motor nerves. Identifying the optimal treatment for individual patients necessitates the performance of clinical and radiographic evaluations. Inaccurate diagnosis of a neurological disorder can lead to inappropriate surgical intervention, relapse, and inadequate reconstruction. When faced with progressive anomalies, it is crucial to implement a phased surgical protocol promptly to avoid exacerbating malalignment. Various surgical procedures have been recorded, including soft tissue releases, tendon transfers, osteotomies, and arthrodesis, which are selected based on the nature and extent of the deformity assessment findings, with the ultimate goal of reaching a foot that is both plantigrade and balanced. Due to a lack of research on this topic, the present review aims to furnish the most recent literature update on the manifestation, imaging evaluation, and optimal therapeutic interventions currently accessible for individuals afflicted with cavovarus deformities and to assist healthcare providers in selecting the most suitable therapy for paediatric patients with this condition in their routine clinical practice.

Prevention of Equinus Deformity after External Fixation for Open Tibia Fractures: A Comparison between Plaster of Paris Backslab and Passive Ankle Physiotherapy.

Ankle equinus deformity is a common complication of prolonged external fixator use in tibia fractures with an incidence of 15%-16%. It affects gait and may lead to foot, leg, and back problems. Treatment of equinus deformity increases the cost of treatment of open tibia fractures and increases the time spent off work. Several preventive modalities have been suggested in literature with variable success, but no standard protocol exists. The aim of this study was to determine the most appropriate method of preventing equinus deformity of the ankle joint during the management of open tibia fractures with unilateral uniplanar external fixators by comparing plaster of paris (POP) backslab application with passive ankle physiotherapy using strips of car tyre inner tubing. The study was a prospective randomised study involving patients with open tibia fractures who were managed with external fixators at the Korle Bu Teaching Hospital between April 2020 and February 2021. Patients were randomised into two groups; one group had below knee POP backslab and the other group did passive ankle physiotherapy using a strip of car tyre inner tubing. The passive ankle range of motion was measured at the beginning and after 6 weeks using a goniometer. Fifty-six participants were recruited with 29 in the POP backslab group and 27 in the ankle physiotherapy group. The median age was 35.0 years. Male-to-female ratio was 4.6:1. Motor vehicle crash contributed to over 90% with 42.9% being motorbike riders. Initial and final mean ankle measurements for the POP backslab group were 6.79° and 10.14° for dorsiflexion and 29.93° and 34.52° for plantarflexion, respectively. The ankle physiotherapy group had initial and final dorsiflexion of 7.19° and 12.85° and plantarflexion of 30.44° and 34.52°, respectively. The ankle physiotherapy group had a better range of motion (47.37°) than the POP group (40.66°) with a P value of 0.008. One participant (3.7%) from the ankle physiotherapy group had equinus deformity compared with seven (24%) from the POP backslab group, a difference which gives a P value of 0.029. Passive ankle physiotherapy with car tyre inner tube is a better and cheaper modality of preventing ankle equinus deformity and maintaining ankle range of motion.

A PROSPECTIVE OBSERVATIONAL STUDY OF OUTCOME IN CHILDREN OF CLUB FOOT TREATED FOR EQUINUS CORRECTION WITH WIDE BORE NEEDLE TENOTOMY

Introduction: Congenital talipes equinovarus is an idiopathic and common congenital deformity. Clubfoot treatment includes series stretching, manipulation, and immobilization; and for the relapse and resistant cases, management includes soft tissue releases, osteotomy, and immobilization. Tenotomy of the tendo-Achilles is an essential step in the Ponseti treatment of congenital talipes equinovarus (CTEV). In this study, we did a wide bore needle tenotomy, a minimally invasive technique for the management of equinus deformity. Materials and Methods: The study included 50 patients with 73 idiopathic clubfeet treated with the Ponseti technique. Out of which, 58 feet were treated by a wide bore needle tenotomy with aseptic precautions. Results: Out of all 73 feet managed with the Ponseti technique, 58 feet equinus were treated with a wide bore needle tenotomy, and the rest of the 15 feet equinus were corrected with a cast. The mean age at presentation of all the patients was 4.44 months. Mean cast applied was 7.24, equinus correction in age more than 6 months was only tenotomy. Conclusion: The results of our study showed good correction of deformity with low expenditure and minimal surgical intervention. The percutaneous needle tenotomy procedure offers a reliable and effective procedure for correcting equinus in club foot deformity with less chances of infection and other complications. We found that correction of equinus with cast is more effective at an early age of presentation and with a low Pirani severity score.

Clinical and Sonographic Evaluation of Percutaneous Achilles Tendon Tenotomy in Idiopathic Clubfoot: A Prospective Study

Objectives: Idiopathic Congenital Talipes Equino Varus (CTEV), commonly referred to as Clubfoot, is a complex musculoskeletal deformity affecting infants. The Ponseti technique, a gold standard approach, has emerged as an effective treatment. This study aims to evaluate the clinical and sonographic outcomes of percutaneous Achilles tendon tenotomy in children with idiopathic clubfoot who underwent the Ponseti procedure. Methods: A prospective study was conducted at the JIPMER Department of Orthopaedics, involving 41 feet with residual equinus deformity following Ponseti treatment. Infants with idiopathic clubfoot were included. Clinical and sonographic evaluations were performed, percutaneous Achilles tendon tenotomy was performed. Parameters were measured, Data were statistically analyzed using Kolmogorov-Smirnov tests, paired t-tests, ANOVA, and correlation analysis. Results: 29 infants (41 feet), primarily boys (89.7%) were studied. Following percutaneous tenotomy, clinical improvement was observed, with a mean increase in dorsiflexion of 20-25 degrees. Sonographic parameters showed significant improvement in tibio calcaneal distance, talocalcaneal divergence, and metaphyseal-talocalcaneal angle post-tenotomy (p&lt;0.05). Positive correlations were found between clinical and sonographic improvements. Conclusion: Clinical improvement of hindfoot deformity following percutaneous Achilles tendon tenotomy in idiopathic clubfeet correlates with the sonological improvement of talo calcaneal, tibio calcaneal angles and tibio calcaneal distance.