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New Findings\ud • What is the central question of this study?\ud • What are the in vivo operating lengths of the gastrocnemius muscle in children who idiopathically toe-walk?\ud • What is the main finding and its importance?\ud • We show, for the first time, that children who idiopathically toe-walk operate at more plantarflexed positions but at longer fascicle lengths than typically developing children during gait. However, these ranges utilised during gait correspond to where children who idiopathically toe-walk are optimally strong. This should be considered when prescribing clinical treatments to restore typical gait.\ud Abstract\ud Children who idiopathically toe-walk (ITW) habitually operate at greater plantarflexion angles than typically developing (TD) children, which might result in shorter, sub-optimal, gastrocnemius fascicle lengths. However, currently no experimental evidence exists to substantiate this notion. Five children who ITW and 14 TD children completed a gait analysis, whilst gastrocnemius fascicle behaviour was simultaneously quantified using ultrasound. The moment-angle (hip, knee and ankle) and -length (gastrocnemius) relationships were determined from isometric maximum voluntary contractions (MVC) on an isokinetic dynamometer combined with ultrasound. During gait, children who ITW operated at more plantarflexed angles (Δ = 20°; p = 0.013) and longer muscle fascicle lengths (Δ = 12mm; p = 0.008) than TD children. During MVC, no differences in the peak moment of any joint were found. However, peak plantarflexor moment occurred at significantly more plantarflexed angles (-16 vs. 1°; p = 0.010) and at longer muscle fascicle lengths (44 vs. 37mm; p = 0.001) in children who ITW than TD children. Observed alterations in the moment-angle and -length relationships of children who ITW coincided with the ranges used during gait. Therefore, the gastrocnemius muscle in children who ITW operates close to the peak of the force-length relationship, similarly to TD children. Thus, this study indicates that children who ITW present with substantial alterations in the gastrocnemius muscle functional properties, which appear well adapted to the characteristic demands of equinus gait. The absence of proximal joint weakness also supports the notion that idiopathic toe-walking is truly an ankle joint pathology. These findings should be considered when prescribing clinical treatments to restore typical gait.

Purpose Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. Methods A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. Results Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). Conclusions The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. Level of Evidence V

Children who idiopathically toe‐walk (ITW) habitually operate at greater plantarflexion angles and thus, at shorter muscle‐tendon unit (MTU) lengths than typically developing (TD) children. Therefore, it is often assumed that habitual use of the gastrocnemius muscle in this way will cause remodelling of the muscle‐tendon architecture compared to TD children. However, the gastrocnemius muscle architecture of children who ITW has never been measured. It is essential that we gain a better understanding of these muscle‐tendon properties, to ensure that appropriate clinical interventions can be provided for these children. Five children who ITW (age 8 ± 2 years) and 14 TD children (age 10 ± 2 years) participated in this study. Ultrasound was combined with isokinetic dynamometry and surface electromyography, to measure muscle architecture at common positions and passive lengthening properties of the gastrocnemius muscle and tendon across full range of motion. Regardless of which common condition groups were compared under, both the absolute and normalised to MTU muscle belly and fascicle lengths were always longer, and the Achilles tendon length was always shorter in children who ITW than TD children (p 0.05); however, passive joint stiffness was greater in children who ITW at maximum dorsiflexion (p = 0.001) and at a joint moment common to all participants (p = 0.029). Consequently, the findings of this pilot study indicate a remodelling of the relative MTU that does not support the concept that children who ITW commonly experience muscle shortening. Therefore, greater consideration of the muscle and tendon properties are required when prescribing clinical interventions that aim to lengthen the MTU, and treatments may be better targeted at the Achilles tendon in children who ITW., We used ultrasound to measure the gastrocnemius medialis muscle architecture in children who idiopathically toe‐walk (ITW). Despite habitually operating at shorter muscle‐tendon unit lengths, children who ITW presented with longer muscle and shorter tendon lengths than typically developing children. Therefore, these findings indicate a remodelling of the relative muscle‐tendon unit that does not support the concept that children who ITW commonly experience muscle shortening.

Comprehensive instrumented muscle and joint assessments should be considered when prescribing Botulinum NeuroToxin-A (BoNT-A) treatment in spastic paresis. In a child with spastic paresis, comprehensive evaluation following treatment with BoNT-A, serial casting, and physiotherapy showed that short-term improvements in gait occurred without changes in muscle morphology. Rather, foot flexibility increased. ispartof: Clinical Case Reports Wiley vol:7 issue:9 pages:1-10 ispartof: location:England status: Published online

Equinus contracture is the most common deformity at clubfoot relapse and causes pain and functional limitation. It presents a challenge to the orthopaedic surgeon throughout childhood. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were: (i) original articles, (ii) investigating management of relapsed idiopathic clubfoot, (iii) with at least a partial study population of primarily equinus deformity, and (iv) a paediatric study population of independent walking age. Nine studies were included with a total of 163 patients (207 feet). Studies presented five management paradigms: gastrocnemius-soleus complex release, extensive posterior soft tissue and joint release, anterior distal tibial hemi-epiphysiodesis, distal tibial osteotomy, and circular frame distraction. All approaches reported success in at least one of our selected outcome domains: plantigrade status, range of motion, clinical outcome scores, functional status, radiographic outcomes, patient-reported outcomes, and complications. Younger children tend to be managed with soft tissue release while older children tend to require more extensive bone/joint procedures. Relapse in surgically treated feet is harder to treat. Comparison across treatment approaches is limited by the small size and low evidence level of the literature, as well as a lack of consistent outcome reporting. It is therefore not possible to recommend any one treatment option in any age group. This review highlights the need for a validated core outcome set to enable high-quality research into the management of equinus deformity. Cite this article: EFORT Open Rev 2021;6:354-363. DOI: 10.1302/2058-5241.6.200110

Background and Objectives: Equinus is the most common deformity in children with cerebral palsy, and surgical lengthening of the gastrocsoleus muscle-tendon unit is the most commonly performed operation for children with cerebral palsy. Treatment outcomes of orthopaedic surgery can be measured objectively with three-dimensional gait analysis. This study examined the quality of evidence for gastrocsoleus lengthening surgery based on objective measures. Materials and Methods: A search was performed with Medline, Embase and PubMed from 1990 to 25 August 2020 using the keywords “cerebral palsy”, “equinus”, “surgery” and “gait analysis”. Only studies of gastrocsoleus lengthening surgery using three-dimensional gait analysis were included, yielding 34 studies. Results: Fourteen studies reported swing phase kinematics and all studies reported a significant improvement. Rates of recurrent equinus and calcaneus were reported in 21 studies and varied widely based on follow-up period and surgical technique. Conclusions: Poor study quality and marked variability in study samples and interventions made comparison difficult. Future studies should consider prospective design, controls or comparison groups and more detailed breakdowns of outcomes by cerebral palsy subtype, sagittal gait pattern, and equinus type in order to allow more rigorous treatment recommendations to be made.

Background An equinus deformity interferes with activities of daily living. Correction of the deformity ranges from conservative (heel cord stretching, orthotics) to surgical treatment (Baumann, Strayer, Achilles lengthening, soft tissue releases). Severe contractures increase surgical intervention with extensive dissections to release soft tissues. This study investigated the clinical outcomes of gradual overcorrection using a Taylor spatial frame (TSF) with tendo-Achilles lengthening (TAL) added as necessary. Materials and methods This retrospective chart review evaluated patients with significant equinus treated with a TSF at a single large tertiary referral centre. Data collected included: diagnosis; patient demographics; laterality; time in frame; additional procedures; complications; degree of equinus deformity preoperatively and at every follow-up visit. Patients were followed at 1 week, 3 weeks, 6 weeks, 3 months, and 6 months intervals, and yearly thereafter. Results Twenty-four patients (26 procedures) were treated with a TSF for equinus and had complete preoperative and follow-up measurements over 2 years. The angle of deformity increased from a preoperative –21.5 (range, –69.0 to –1.0) degrees to a postoperative 4.9 (range, –17.0 to 17.0) degrees (z = –4.4573, p = 0.0001, N = 26, Wilcoxon signed-rank test). A secondary outcome was a weak association (not statistically significant) between time in the TSF and the postoperative deformity angle. Four complications occurred during the follow-up (two pin site infections, one broken pin, and one plantar abscess). Three patients had recurrence of equinus deformity at time of last follow-up. Conclusion Using a TSF for correcting severe, fixed equinus contractures of the ankle joint is successful with minimal soft tissue-related complications. Overcorrection should be achieved in order to compensate for the loss of some dorsiflexion after frame removal. No added benefit was observed from having the frame on for a long time after correcting the deformity. Adding TAL is not necessary in all cases and required only in severe deformities of more than 25°. How to cite this article Dabash S, Potter E, Catlett G, et al. Taylor Spatial Frame in Treatment of Equinus Deformity. Strategies Trauma Limb Reconstr 2020;15(1):28–33.

Data Availability Statement: The datasets generated for this study are available on request to the corresponding author. Copyright © 2020 Harkness-Armstrong, Debelle, Maganaris, Walton, Wright, Bass, Baltzopoulos and O’Brien. Aim: To study the causes of locomotor dysfunction, estimate muscle forces, or understand the influence of altered sarcomere and muscle properties and behaviours on whole body function, it is necessary to examine the leverage with which contractile forces operate. At the ankle joint, current methods to quantify this leverage for the plantarflexors do not account for curvature of the Achilles tendon, and so may not be appropriate when studying equinus gait. Thus, novel methodologies need to be developed and implemented to quantify the Achilles tendon moment arm length during locomotion. Methods: Plantarflexor internal moment arm length and effective mechanical advantage of 11 typically developed young adults were calculated throughout stance, while heel-toe walking and voluntarily toe-walking on an instrumented treadmill. Achilles tendon moment arm was defined in two-ways: (1) assuming a straight tendon, defined between the gastrocnemius medialis myotendinous junction and Achilles tendon insertion point, and (2) accounting for tendon curvature, by tracking the initial path of the Achilles tendon from the calcaneal insertion. Results: When accounting for tendon curvature, Achilles tendon moment arm length and plantarflexor effective mechanical advantage did not differ between walking conditions (p > 0.05). In contrast, when assuming a straight tendon, Achilles tendon moment arm length (p = 0.043) and plantarflexor effective mechanical advantage (p = 0.007) were significantly greater when voluntary toe-walking than heel-toe walking in late stance. Discussion: Assuming a straight Achilles tendon led to a greater Achilles tendon moment arm length and plantarflexor effective mechanical advantage during late stance, compared to accounting for tendon curvature. Consequently, plantarflexor muscle force would appear smaller when assuming a straight tendon. This could lead to erroneous interpretations of muscular function and fascicle force-length-velocity behaviour in vivo, and potentially inappropriate and ineffective clinical interventions for equinus gait. Liverpool John Moores University Ph.D. scholarship.

Aim: The aim of this study was to evaluate the surgical outcome, in terms of gait improvement, of endoscopic transverse Vulpius gastrocsoleus recession in children with cerebral palsy compared to the traditional open surgery. Methods: Twenty-seven children with cerebral palsy who had undergone endoscopic transverse Vulpius gastrocsoleus recession were reviewed. For the comparison of gait improvement, independent ambulatory spastic diplegic patients who had undergone only endoscopic transverse Vulpius gastrocsoleus recession on both legs were selected. Seven (14 legs) children were included and the median age was 7 years (6-9 years). Seven age-matched patients with the same inclusion/exclusion criteria who underwent open surgery were selected as the control group. Physical examination and gait parameters were evaluated and compared between groups, including the gait deviation index (GDI), and gait profile score (GPS). Results: There was no significant complication in twenty-seven children after endoscopic transverse Vulpius gastrocsoleus recession. However, one patient required a revision open surgery at postoperative 1 year 9 months due to the recurrence of equinus and the incomplete division of the midline raphe which was noted during surgery. When comparing gait improvements, there were no differences between the endoscopic and open surgery groups in ankle dorsiflexion angle, ankle kinetics, GDI, and GPS. The postoperative peak ankle dorsiflexion during stance phase was slightly higher in the open group. Conclusion: This is the first study that evaluates gait improvement exclusively for children with spastic diplegia after endoscopic transverse Vulpius gastrocsoleus recession. The gait improvements after endoscopic surgery were comparable to the open surgery, however, the possibility of reduced improvement in ankle kinematics should be considered.

Background Accurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion

BACKGROUND: This study determined if the body mass index, dynamic plantar-pressures, plantar surface contact-area, velocity of the centre of pressure (COP), gastrocnemius equinus, and gastrocnemius soleus equines are related to calcaneal apophysitis (Sever's disease) in athletic children. METHODS: This case-control study examined 106 boys enrolled in a soccer academy, including 53 with Sever's disease and 53 age-matched healthy controls. The dynamic average and maximum peak plantar-pressures, plantar surface contact-area, and velocity of the COP were evaluated with a digital pressure sensor platform. Goniometry was used to measure the ankle dorsiflexion range of motion and thereby identify gastrocnemius equinus and gastrocnemius soleus equinus. RESULTS: Participants with Sever's condition had significantly higher BMI and peak plantar-pressures (maximum and average) at the heel (Cohen's d > 3 for pressures) than the controls. Those with Sever's disease also had significantly slower velocity of the COP (Cohen's d > 3). Boys with Sever's disease were also 8 times more likely to have bilateral gastrocnemius equinus than disease controls. CONCLUSIONS: High heel plantar pressure and low velocity of COP are related to Sever's condition in boys, although it is not clear whether these factors predispose individuals to the disease or are consequences of the disease. Gastrocnemius ankle equinus could be a predisposing factor for Sever's condition. Sin financiación 1.983 JCR (2018) Q2, 56/125 Pediatrics 1.115 SJR (2018) Q1, 47/318 Pediatrics, Perinatology and Child Health No data IDR 2018 UEM

Category: Ankle, Hindfoot, Trauma Introduction/Purpose: Equinus deformity is a debilitating condition which interferes with the activity of daily living. Correction of the deformity ranges from conservative (heel cord stretching, orthotics) to surgical treatment (Baumann, Strayer, Achilles lengthening, soft tissue releases). Severe contractures need surgical intervention with extensive dissections to release soft tissues. This study investigated the clinical outcomes of gradual equinus contracture overcorrection using a Taylor Spatial Frame with tendo-Achilles lengthening or toe flexor tenotomy as necessary. Methods: This retrospective chart review evaluated patients with significant equinus treated with a Taylor Spatial Frame at a single large tertiary referral center. Data collected included: diagnosis; patient demographics; laterality; time in frame; additional procedures; complications. Patients were assessed preoperatively and were followed at one-week, three-week, six-week, three- month, and six-month intervals, and yearly after. Results: 24 patients (26 procedures) were treated with a Taylor Spatial Frame for equinus and had complete preoperative and eighteen-month follow-up measurements. The angle of deformity increased from a preoperative -21.5 (range, -69.0 to -1.0) degrees to a postoperative 4.9 (range, -17.0 to 17.0) degrees (z = -4.4573, p = 0.0001, N = 26, Wilcoxon signed rank test). Four complications occurred during the follow up (two pin site infections, one broken pin, and one plantar abscess). Three patients had recurrence of of equinus deformity at time of last follow-up. Conclusion: Taylor Spatial Frame is a successful method for correcting severe, fixed equinus contractures of the ankle joint with minimal soft tissue related complications. Over correction should be achieved in order to compensate for the loss of some dorsiflexion after frame removal.

Supplemental Digital Content is available in the text, Background: A novel splint, the assisting ankle-foot orthoses (AFO), was developed to provide adjustable sustained stretching to improve conservative treatment for equinus deformities in children with cerebral palsy (CP). The treatment effect was validated by follow-up visits. Methods: This study involved subjects between 2 and 12 years old, including 28 CP children treated with splint-assisted AFO correction, 30 CP children treated with static AFO correction, and 30 normal children with typical development (TD). Quantitative pedobarographic measurements were taken to evaluate the effect of splint-assisted AFO correction. The heel/forefoot ratio was introduced to indicate the degree of the equinus deformity during treatment. Results: The results showed that the heel/forefoot ratios were 1.41 ± 0.26 for the TD children; 0.65 ± 0.41, 1.02 ± 0.44, and 1.24 ± 0.51 for the splint-assisted AFO correction before and after 6-month and 12-month treatments; 0.59 ± 0.37, 0.67 ± 0.44, and 0.66 ± 0.42 for the static AFO correction before and after 6-month and 12-month treatments. Conclusions: This study suggests that correction with the adjustable splint-assisted AFO is an effective treatment for equinus deformity in CP Children.

Botulinum toxin A is considered an important tool to control spasticity in children with cerebral palsy. Several factors are known to affect the efficacy of botulinum toxin, such as dosage, appropriate muscle selection and application, age, and accompanying therapy. A multicenter, double-blind, randomized, prospective phase III clinical trial of botulinum toxin A for the treatment of dynamic equinus in 144 children with cerebral palsy was performed to compare the efficacies of letibotulinumtoxin A and onabotulinumtoxin A. Secondary analyses were performed to evaluate factors that affected the outcome, focusing on the number of times injections were repeated. Effectiveness was defined as a change of 2 or more in the physician’s rating scale. Multivariate regression analyses were performed with multiple variables. The first injection of botulinum toxin A significantly improved D subscale of Gross Motor Function Measure-88 scores at 3 months compared to repeated injections (p < 0.05). After 6 months, patients who had one injection or none before the study showed significantly better outcomes than those who had more than one injection in terms of observational gait scores.

Introduction: The consensus among orthopedic surgeons on the management of equinus deformity in cerebral palsy (CP) children has not been reported previously despite being a prevalent deformity. The goals of this study were to examine the orthopedic surgeons’ current practice regarding the management of equinus deformity in children with ambulatory CP, and analyze variations in current practice between general orthopedic and pediatric orthopedic surgeons. Methods: We implemented a brief cross-sectional self-reported questionnaire that addressed the areas of clinical examination and decision-making skills of management of equinus deformity in CP children. We targeted a convenience sample of 400 participants. Surgeons that provided complete responses to the questionnaire were 223 with a response rate of 56%, of which 123 (55%) were general orthopedic surgeons, whereas 100 (45%) were pediatric orthopedic surgeons. The target population consisted of orthopedic surgeons who were further sub-classified in accordance with practice age, general versus pediatric, and exposure to children’s orthopedics during the last three years of their practice. For analytical statistics, the Chi-Square test and Fisher’s exact test were used to examine the relationship between two qualitative variables. Results: The overall clinical practice preferences of all survey participants were unimpressive with discordant survey responses. Pediatric orthopedic surgeons generally demonstrated a statistically significant difference regarding clinical assessment skill items of the survey, in contrast to general orthopedic surgeons. However, we found no differences between pediatric orthopedic and general orthopedic surgeons regarding most of the decision-making/knowledge items. Discussion: Generally, there are insufficient clinical practice trends of both general and pediatric orthopedic surgeons regarding equinus treatment in CP children. This may indicate a knowledge–practice gap with potential risks to CP children undergoing surgery for equinus. There is a need for a more competent exposure to CP in orthopedic surgeons’ educational curricula and an updated health referral system.

We are currently in the process of discovering that many, if not the majority, of the non-traumatic acquired adult foot and ankle problems are caused by a singular etiology: non-neuromuscular equinus or the isolated gastrocnemius contracture. There is no question that this biomechanical association exists and in time much more will be uncovered. There are three basic questions that must be answered: why would our calves tighten as we normally age, how does a tight calf, or equinus, actually cause problems remotely in the foot and ankle, and how do the forces produced by equinus cause so many seemingly unrelated pathologies in the foot and ankle? The purpose of this paper is to address the second question: how does a tight calf mechanically cause problems remotely in the foot and ankle? There has been little evidence in the literature addressing the biomechanical mechanisms by which equinus creates damaging forces upon the foot and ankle, and as a result, a precise, convincing mechanism is still lacking. Thus, the mere concept that equinus has anything to do with foot pathology is generally unknown or disregarded. The split second effect, described here, defines exactly how the silent equinus contracture creates incremental and significant damage and injury to the human foot and ankle resulting in a wide variety of pathological conditions. The split second effect is a dissenting theory based on 30 years of clinical and academic orthopedic foot and ankle experience, keen clinical observation along the way, and review of the developing literature, culminating in examination of many hours of slow motion video of normal and abnormal human gait. To my knowledge, no one has ever described the mechanism in detail this precise.

The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus.Prospectively collected data was analysed in 26 patients with hemiplegic (n = 13) and diplegic (n = 13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (+/- 5.6 months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15 degrees, p = 0.032), maximum ankle dorsiflexion during swing phase (11.68 degrees, p The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP. (C) 2016 Elsevier B.V. All rights reserved.

The purpose of this study was to evaluate how soft tissue surgery for correcting equinus deformity affects the kinematic and kinetic parameters of the ankle and proximal joints. Sixteen children with spastic hemiplegic cerebral palsy and equinus deformities (age range 3-16 years) were included. Soft tissue surgeries were performed exclusively on the ankle joint area in all subjects. Using computerized gait analysis (Vicon 370 Motion Analysis System), the kinematic and kinetic parameters during barefoot ambulation were collected preoperatively and postoperatively. In all 16 children, the abnormally increased ankle plantar flexion and pelvis anterior tilting on the sagittal plane were significantly improved without a weakening of push-off (p < 0.05). In a group of 8 subjects with a recurvatum knee gait pattern before operation, the postoperative kinematic and kinetic parameters of the knee joint were significantly improved (p < 0.05). In a group of 8 subjects with ipsilateral pelvic external rotation before operation, the postoperative pelvic deviations on the transverse plane were significantly decreased (p < 0.05). These findings suggest that the soft tissue surgery for correcting equinus deformity improves not only the abnormal gait pattern of the ankle, but also that of the knee and pelvis.

International audience; In children with hemiplegia, it is important to distinguish between equinus with hindfoot varus (equinovarus) or valgus (equinovalgus). Premature onset of medial gastrocnemius (GM) EMG in individuals with equinus is well documented. Premature onset of Peroneus longus (PL) EMG has been described in neurologically impaired adults with equinovalgus, but not in children. Our aim was to record the onset of PL and GM activity on the hemiplegic side of children with equinovalgus deformity. Fifteen children GMFCS 1 (3.8 yrs ± 2) with hemiplegia had a goniometric assessment of passive ankle range of motion and assessment of ankle function from video and surface EMG recording during gait. The clinical and video observations were used to determine the equinovalgus, as defined by Wren, at initial contact (IC). The premature onset of muscle activity was normalised as a swing (SW) percentage prior to IC of the following stance (ST). A paired T-test compared the onset of muscle activity between PL and GM. The ankle passive dorsiflexion was 13° ± 12° (hemiplegic side) versus 18° ± 10° (non-involved side) (p

Complications of diabetes mellitus constitute the most common indications for hospitalization and nontraumatic amputations in the USA. The most important risk factors for the development of diabetic foot ulcerations include the presence of peripheral neuropathy, vasculopathy, limited joint mobility, and preexisting foot deformities. In our study, 500 diabetic patients treated for plantar forefoot ulcerations were enrolled in a prospective study from 2000 to 2008 at the Federal University of Sao Paulo, Brazil. Fifty-two patients in the study met the criteria and underwent surgical treatment consisting of percutaneous Achilles tendon lengthening to treat plantar forefoot ulcerations. The postoperative follow-up demonstrated prevention of recurrent foot ulcerations in 92% of these diabetic patients that maintained an improved foot function. In conclusion, our study supports that identification and treatment of ankle equinus in the diabetic population may potentially lead to decreased patient morbidity, including reduced risk for both reulceration, and potential lower extremity amputation. Keywords: foot ulceration; diabetic neuropathy; equinus; amputation; Achilles tendon (Published: 25 November 2011) Citation: Diabetic Foot & Ankle 2011, 2 : 10358 - DOI: 10.3402/dfa.v2i0.10358

To describe our Ilizarov technique for the treatment of acquired equinus deformity in children and to determine if compliance with continuous use of an ankle foot orthosis (after removal of the fixator and until skeletal maturity) can influence the severity of recurrence. A cohort of 26 children with post-traumatic or post-burn contractures producing an equinus deformity was followed up for a minimum of 2 years after skeletal maturity. Cases with a bony deformity and/or nerve injury were excluded from this study. All patients were managed by a percutaneous tendo-Achilles lengthening followed by application of an Ilizarov external fixator. Post-operative treatment was in the form of gradual correction at a rate of 0.5 mm per day. Correction started from the second postoperative day until an over-correction of 15 degrees dorsiflexion was achieved. Ankle range of movement was encouraged 4 weeks prior to removal of the external fixator. On removal of the fixator, a posterior splint was applied until substituted by an ankle foot orthoses (AFO). The AFO was used continuously during the first 2–3 months and at nighttime thereafter until skeletal maturity. Fifteen children were compliant with the use of the AFO until skeletal maturity and 11 non-compliant. We compared the recurrence and the size of deformity between the two groups. The rate of recurrence, degree of equinus at recurrence and number of episodes of external fixation surgery showed statistical significant differences (P

Purpose The purpose of this paper is to test the hypothesis that combination therapy of serial cast and botulinum toxin type A (BTX-A) injection can further enhance the effects of a BTX-A injection in ambulant children with cerebral palsy (CP) who have an equinus foot. Materials and Methods Children in group A (30 legs of 21 children) received a serial casting application after an injection of BTX-A, and children in group B (25 legs of 17 children) received only a BTX-A injection. Assessments were performed before the intervention and 1 month after the intervention. Results After the intervention, there were significant improvements in tone, dynamic spasticity, and passive range of motion (ROM) in both groups. However, the changes were greater in group A than in group B. Dimension D (standing) in Gross Motor Function Measure (GMFM)-66 was significantly improved in group A but not in group B. On the other hand, there were no significant changes in di-mension E (walking, running, jumping) in GMFM-66 in either group. Conclusion The results of our study suggest that a serial casting application after BTX-A injection can enhance the benefits of BTX-A injection in children with cerebral palsy.

IntroductionSpastic cocontraction [1] is a form of muscle overactivity [1,2] that may alter gait in infant hemiparesis. We quantified EMG activity in Gastrocnemius Medialis (GM) and Peroneus Longus (PL) during the swing phase (SW) of gait in very young hemiparetic children with an equino-valgus pattern [3], comparing the paretic and non-paretic side.Materials and methodsTen hemiparetic children (age 3±1, mean±SD) were monitored for GM and PL EMG during gait. The SW was divided into three thirds (initial-T1, middle-T2 and end-T3). In each period, a Cocontraction Index (CCI) [4], ratio of the Root Mean Square (RMS) EMG from each muscle during that period to the peak 500-ms RMS obtained from voluntary plantar flexion during a selected submaximal state (standing on tiptoes) was measured.ResultsGM and PL CCIs during SW were higher on the paretic than on the non-paretic side (Wilcoxon:CCIGM, P