Foot and ankle in c.p.

Foot and ankle in c.p.

 In order to provide stability during
movement, the human foot must constantly
adapt to the body above and the surface
below
 In order to provide stability during
movement, the human foot must constantly
adapt to the body above and the surface
below
 In order to provide stability during
movement, the human foot must constantly
adapt to the body above and the surface
below
In addition the plantar surface must
provide maximum weight bearing
surface to prevent pressure
concentration
• ―hot spots‖ will lead to excessive
pressure/cm², and pain, callousity, or
pressure sores
– Varus
– Cavus
– Severe planovalgus
 The triceps surae, by maintaining a
ground reaction force, helps to maintain
knee extension in stance, and thereby
prevent crouch gait
As the center of mass of the body progresses forward
in middle to late stance, the triceps surae works
eccentrically to prevent the foot from going into
excessive dorsiflexion, thereby preventing excessive
knee flexion (crouch)
When The Lever Arm Of The Foot
Is Weakened, Crouch Will Result

Rodda J. et.al. J Bone Joint Surg

2006:88:2653-2664
 A reduced lever arm can come
from:
• A weak triceps surae
– This is usually due to achilles tendon
lengthening
• Any lengthening in a diplegic is likely to result
in ―overlengthening‖
– However, you occasionally see a weak
triceps surae in the absence of prior
surgery
 A reduced lever arm can come
from:
• External foot progression angle
– This can be due to
• External tibial torsion
• Subtalar instability

Add diagram
 If the achilles tendon is lengthened in a
young child with spastic diplegia (<7
years) there is a high risk of causing
excessive weakness, and worsening
the gait

THEREFORE, we try to avoid any surgery for

achilles tightness before age 7
 Equinus deformity is the most
frequent deformity in diplegic
C.P.
• Affects hip and knee
position
• Affects balance
• May cause knee
hyperextension
– Plantar flexion –knee
hyperextension couple
 Equinus deformity is the most
frequent deformity in diplegic
C.P.
• Affects hip and knee
position
• Affects balance
• May cause knee
hyperextension
– Plantar flexion –knee
hyperextension couple
 One of the worst possible
situations is a weak / over-
lengthened achilles tendon
 FIRST, try to prevent equinus
contracture
• Use of an AFO, including night use will
prevent equinus contracture in many
cases
WHAT IS THE ROLE OF BOTULINUM
TOXIN?

―golden responder‖
The Use of Botulinum Toxin A
Compared to Serial Casting in the
Treatment of Ambulatory Cerebral
Palsy.

Dev. Med child neurol,sept.

2005

Barry Russman, Jeffrey Ackman, Susan Sienko

Thomas, Cathleen Buckon, Michael Sussman, Michael
Aiona, Peter Masso, James Sanders, Jacques
D’Astous, and the Shriners Hospitals for Children-
Botox Study Group: Shriners Hospitals for Children-
Portland, Chicago, Erie, Intermountain, Springfield
 Conclusions
At one year after the baseline exam and 6
months following the last treatment:
1. Significant reduction in spasticity and/or
contracture of the gastrocnemius-soleus
complex in the:
casting group
casting + BTX group
but not the BTX only group
2.The casting + BTX was significantly different
from the casting group at 1 year.
If the child is unable to tolerate the
AFO due to high tone and/or
contracture, a 6 week period in a
short leg walking cast will reduce
tone, and correct small (<10°)
contractures
Spastic diplegic child before and
after a 6 week period of casting
If the child is over 7 years old, and
has equinus which interferes with
gait, and cannot be controlled by
an AFO, then surgery to release
the gastrocnemius only, may be
indicated
 When there is equinus in gait
The SILVERSKIOLD TEST
will demonstrate whether ankle plantar flexion
contracture is due to the gastrocnemieus,
or involves all of the triceps surae

Knee
Exten-
sion

If Silverskiold test shows adequate dorsiflexion with the

knee flexed , but the foot goes into plantar flexion as the
examiner fully extends the knee, this indicates that
contracture is present in the gastrocnemius, but not the
soleus
 The gastrocnemieus inserts above
the knee, and wraps around the
femoral condyle, so as the knee is
fully extended, the gastrocnemieus
is placed under tension, while knee
position has no influence on the
soleus which originates entirely
below the knee
Strayer / Vulpius technique
gastrocnemieus only
lengthening
 The musculotendinous junction is
usually halfway between the ankle and
the popliteal crease, and can be
localized easily with ultrasound
Strayer / Vulpius technique
gastroc only lengthening

HEAD
Strayer / Vulpius technique
gastroc only lengthening

Soleus fascia

Gastrocnemieus
fascia
Strayer / Vulpius technique
gastroc only lengthening

Soleus fascia remains intact

• Children with spastic hemiplegia may have
contracture of both gastrocnemius and
soleus, and thereby require lengthening of
the achilles tendon
– However the risk of over-lengthening is much
less in children with hemiplegia, than diplegia
 If there is fixed contracture >10°
with knee flexion,
do open achilles tendon lengthening
Achilles Tendon Lengthening
 Achilles Tendon Lengthening

plantaris
Achilles Tendon Lengthening

Dorsifle
x to 5º-
Below knee
10º
walking
Cast@ 90º

AVOID EXCESSIVE LENGTHENING

 Post op management
Achilles/gastroc lengthening
• Below knee cast
• Immediate ambulation
• 4 weeks in cast
– Possibly less for Strayer
• AFO following cast
removal
– Hinged following Strayer
– Continue night use until
maturity
 SUMMARY :
Achilles/Gastroc lengthening
• Significant benefit
• High risk of over-lengthening in
Diplegia/quadriplegia
– May require simultaneous hamstring lengthening
– Less risk in hemiplegic
• Higher risk of over lengthening <7years old-so
try to delay (Graham)
– PREVENTION: AFO use—including night AFO
– Casting
– Botulinum toxn
AVOID ACHILLES
LENGTHENING
WHENEVER
POSSIBLE!!
 If there is crouch gait due to an
overlengthened achilles tendon, I
recommend the following treatment
approach
• Ground reaction AFO
• Hamstring lengthening if hamstrings are
tight
• Surgery to tighten achilles is ineffective
A Ground reaction AFO can provide support
in the case of a weak triceps surae

WEAK
TRICEPS
SURAE

Rodda J. et.al. J Bone Joint Surg

2006:88:2653-2664
A Ground reaction AFO can provide support
in the case of a weak triceps surae

WEAK
TRICEPS
SURAE

Rodda J. et.al. J Bone Joint Surg

2006:88:2653-2664
The ground reaction AFO may be modified
by using a removable pretibial portion
 10 months Post op bilateral
hamstring lengthening/transfer
+GRAFO’s
 OTHER
FOOT
DEFORMITIES
Planovalgus foot deformity is
very common in children with
spastic diplegia

Valgus deformity is due to subtalar instability due to lack of the

medial sling—not over pull of peroneals
 Valgus foot deformity is treated
only when severe

Indications for surgery

– Pain
– Evidence of pressure at
the talo-navicular area
– instability
 Valgus foot deformity
subtalar arthrodesis
• Preferred technique:
– Staple fixation
• temporary
supplemental fixation
for 6 weeks with large
threaded pin
– Decorticate bone
surrounding sinus tarsi
– Autogenous iliac crest
bone graft-morsellized
to stimulate fusion
– Weight bearing at 4
weeks
 If the valgus foot deformity
is severe and interfering with function,
subtalar arthrodesis may be indicated

• Preferred technique:
– Staple fixation
• temporary supplemental
fixation for 4 weeks with
large threaded pin
– Decorticate bone
surrounding sinus tarsi
– Autogenous bone graft-
morsellized to stimulate
fusion
– Weight bearing at 4
weeks
• ONCE THE VALGUS FOOT IS
STABILIZED BY SUBTALAR
ARTHRODESIS, THE FOOT MAY BE IN
FIXED EQUINUS AND MAY REQUIRE
CONCOMMITANT GASTROCNEMIUS
LENGTHENING OR CAREFUL
ACHILLES TENDON LENGTHENING
Subtalar arthrodesis may improve
stability during gait significantly!

p<.001
Another example

Note: staple is directed into

the body of the talus
8 weeks post operative
Alternative fixation technique
Alternative fixation with Arthrex
compression screw
In older patients with more severe
deformity triple arthrodesis may be
necessary moreno garcia
 Varus foot deformity

-Varus is primarily a problem of HEMIPLEGICS and those with

EXTRAPYRAMIDAL involvement
-Hindfoot varus is unusual in Diplegia
-In most patients varus progresses with time and causes problem
due to concentration of pressure on the lateral plantar weight
bearing surface
 Varus foot - treatment
• My Approach:
– Mild and passively correctable:
• Fractional (intramuscular) lengthening of tibialis
posterior
– If there is fixed equinus TAL should be added
 Varus foot - treatment
• My Approach:
– More severe / fixed
• Fractional lengthening tibialis posterior plus
• anterior tibial tendon transfer to lateral cuneiform
– If there is fixed equinus TAL should be added
– If there is cavus plantar fasciotomy should be added

+
 Remember, in order to function in
the upright position we must have a
stable, plantigrade foot
The foot is the base of support for
the upright body
Mt. St. Helens