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Purpose: To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients., Methods: 100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients., Results: After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I., Conclusion: ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients.

Objective: To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S 2 nerve root for relieving spastic equinus foot., Methods: Anatomical studies were performed on 12 adult cadaveric specimens. The S 2 nerve root and its branches were exposed through the posterior approach. Located the site where S 2 joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S 2 nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S 2 joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading., Results: The distance between the location where S 2 joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S 2 nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs., Conclusion: HSN of triceps branches combined with partial neurotomy of S 2 nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves.

Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Erich Rutz reports administrative support was provided by The Royal Children’s Hospital Melbourne. Erich Rutz reports a relationship with The Royal Children’s Hospital Melbourne that includes: employment. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of Competing Interest None.

Case: The patient was an 18-year-old man who had sustained diaphyseal fractures of the left femur and tibia in a traffic accident and underwent surgery at another hospital. A severe left foot equinovarus deformity developed in the early after surgery. The patient's left foot deformity was addressed using unconstrained gradual external fixator correction (the Matsushita method) in combination with soft-tissue contracture through Achilles tendon lengthening and was maintained after removing the external fixation., Conclusion: The Matsushita method can be effective in the correction of post-traumatic equinovarus foot deformities., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C337)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Distal Anterior Tibial Guided Growth has been shown to be useful to correct recurrent equinus deformity after open surgical release for Congenital Talipes Equinovarus. This has not been evaluated in a recurrence after use of the Ponseti method, where soft tissue releases are currently understood as the mainstay of treatment., Methods: Patients with recurrence of equinus component of CTEV, who underwent DATGG with at least 6-month follow-up were identified retrospectively. The criteria for performing this procedure were (1) equinus not correctable to neutral passively (2) the feeling of a bony block to dorsiflexion clinically as evidenced by a supple Achilles' tendon at maximum dorsiflexion and (3)a finding of a flat-top talus radiologically. Successful treatment was defined by the achievement of heel strike on observation of gait. Details of the index procedure including concurrent procedures, any complications and their treatment, past and subsequent treatment episodes were retrieved from electronic patient records. Pre-op and last available post-op X-rays were evaluated for change in the anterior distal tibial angle and for flat-top talus deformity., Results: We identified 22 feet in 16 patients, with an average follow-up was 25 (8.8-47.3) months. The mean aDTA changed from 88.9 (82.3-94.5) to 77.0 (65.0-83.9) degrees, which was statistically significant (p < 0.0001) using the Paired t-test. Clinically, 17 feet (77 %) obtained a plantigrade foot with a normal heel strike. Complications were identified in 5 feet and include staple migration, oversized staple, superficial infection, iatrogenic varus deformity. Recurrence after completed treatment was noted in one foot., Conclusion: This procedure should form a part of the armamentarium of procedures for treating equinus component of CTEV recurrences even in feet not treated previously by open procedures. When used in patients without significant surgical scarring it helps to address bony and soft-tissue factors, leading to effective treatment., Level of Evidence: Therapeutic Level IV., Competing Interests: Conflict of interest None., (Copyright © 2023 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Equinus plays an important role in flatfoot deformity. Proper evaluation and surgical management are critical to comprehensively treat and successfully resolved patients' symptoms. We have discussed the cause, evaluation, and some of the common surgical options. Each procedure has its inherent benefits and risks. It is imperative that the foot and ankle surgeon identify and include these procedures as part of the complete reconstructive surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Tendo Achilles lengthening (TAL) for the management of equinus contractures in ambulatory children with cerebral palsy (CP) is generally not recommended due to concerns of over-lengthening, resulting in weakness and plantar flexor insufficiency. However, in some cases, surgical correction of severe equinus deformities can only be achieved by TAL. The goal of this study is to assess the outcomes following TAL in these cases., Methods: A retrospective cohort study of children with CP with severe equinus contractures (ankle dorsiflexion with the knee extended of -20 degrees or worse) who underwent TAL as part of a single event multilevel surgery, with preoperative and postoperative gait analysis studies. Continuous data were analyzed by paired t test, and categorical data by McNemar Test., Results: There were 60 subjects: 42 unilateral, 18 bilateral CP; 41 GMFCS II, 17 GMFCS I; mean age at surgery was 10.6 years, mean follow-up was 1.3 years. Ankle dorsiflexion with the knee extended improved from -28 to 5 degrees (P<0.001). The ankle Gait Variable Score improved from 34.4 to 8.6 (P<0.001). The ankle moment in terminal stance improved from 0.43 to 0.97 Nm/kg (P<0.001). Significant improvements (P<0.001) were seen in radiographic measures of foot alignment following surgery. There were few significant differences in the outcome parameters between subjects with unilateral versus bilateral CP (eg, only the bilateral group showed improved but persistent increased knee flexion in mid-stance)., Conclusions: The outcomes following TAL for the management of severe equinus deformity in ambulatory children with CP were favorable 1 year after surgery, with significant improvements in all domains measured., Significance: This study does not advocate for the widespread use of TAL to correct equinus deformity in children with CP. However, it does show that good short-term outcomes following TAL are possible in properly selected subjects with severe contractures when the dosing of the surgery is optimal (correction of contracture to between 0 and 5 degrees of dorsiflexion with the knee extended) and the procedure is performed in the setting of single event multilevel surgery with subsequent proper orthotic management and rehabilitation., Competing Interests: J.R.D. is on the Editorial Board of the Journal of Pediatric Orthopaedics, has been a consultant of OrthoPediatrics Corp., and is on the Board of the Foundation for Advancing Pediatric Orthopaedics, all of which are outside the scope of the submitted work. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Equinus contracture is a serious disability and attention should be paid to proper and effective treatment. Most attention is given to neurologically impaired patients, but the incidence of equinus contracture is much higher, for example, in post-traumatic patients. In addition to conventional physical therapy, robotic rehabilitation treatment is one of the promising procedures to precede severe contraction cases and the need for surgery., Areas Covered: This study aims to cover the description of different types of stationary and wearable ankle rehabilitation devices suitable for the treatment of equinus contracture and point to deficiency in research, clinical trials, and launch of the market., Expert Opinion: This review provides insight into ankle rehabilitation devices with a focus on equinus contracture. Due to the fact that robotic devices successfully restore the condition of patients, attention should not be paid only to those with neurological impairments. This paper points that future research should be effectively linked to clinical practice with the aim of covering a wider range of disabilities and make an effort to successfully introduce devices from development into the practice.

Objectives: Functional impairment is a common complaint in patients with venous malformations. Equinus can occur when the venous malformation involves the lower limb, a challenging condition with only a few studies to guide treatment choices. This study was aimed to investigate the operative management of equinus associated with lower limb venous malformations., Method: Between August 2015 and September 2017, a total of 12 patients presented with equinus associated with lower limb venous malformations and underwent surgical correction. Preoperative and postoperative clinical symptoms, physical examination and orthopaedic evaluation were retrospectively reviewed. 8 patients who experienced pain underwent percutaneous sclerotherapy prior to the operation. Surgical management included gastrocnemius intramuscular aponeurotic recession, Z-lengthening of the Achilles tendon, Hoke technique and Taylor Spatial Frame external fixation., Results: There were eight female and four male patients with a mean age of 14.3 ± 5.9 years. The mean follow-up period was 34.8 ± 9 months. The range of motion of ankle dorsiflexion (with knee extended) improved for each patient (mean, 25.4 degrees; standard deviation, 8.5 degrees). No neurovascular complications were observed., Conclusion: Operative correction of equinus associated with lower limb venous malformations is safe and effective. Selective preoperative sclerotherapy is necessary for optimal outcomes.

Pediatric equinus is broadly defined as generalized limited dorsiflexion at the ankle joint. It may result from either congenital or acquired causes and exhibit varying characteristics such as flexible, rigid, or spastic types. It has been extensively studied in literature and is known to be associated with the pathological condition of the bone, soft tissue, or combined deformity. In children, rigid plantarflexed cases can be debilitating and prevent them from ambulating without pain, if at all. As this volume in Clinics has chapters on comprehensive pediatric examination and neuromuscular disorders, this article will focus on (non-neurologic equinus) and its treatment via conservative and surgical methods with an emphasis on gradual correction., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications., Methods: We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period., Results: Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2., Conclusion: Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results., Level of Evidence: Level IV, retrospective case series.

Children with cerebral palsy frequently develop foot deformities, most commonly equinus contractures, which can be managed with orthotics up to age 5 to 7 years. Plantar flexor lengthening, typically around this age, should be restricted to the offending muscle only, usually with a fascia release of the gastrocnemius. Equinovarus, mainly a problem in children with unilateral cerebral palsy, often responds to plantar flexor lengthening. If further tendon transfers are needed, they should be done when the child is older to avoid overcorrection. Planovalgus mostly improves spontaneously up to age 5 years. Surgical correction is best done in adolescence., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: Treatment of joint contractures after burn injury is challenging because various factors influence the treatment options including the lack of local tissue, significant fibrotic changes with associated loss of joint pliability, increased prevalence of infection in burn patients, and patient-related medical comorbidities.We present a case of a 60-year-old woman who had severe bilateral postburn ankle equinus deformities after self-immolation in the setting of significant soft tissue injury, fibrosis, and loss of joint movement. This deformity deprived her of the ability to walk, even aided, and she was unable to progress with her rehabilitation. We used the tibialis posterior tendon transfer to completely correct her postburn ankle equinus allowing for the restoration of both her feet to a neutral position, which enabled the patient to walk unaided after the surgery. This is a simple and effective solution to a complex problem when soft tissue reconstruction is limited. Patients with this complication are wheelchair dependent, and we suggest that posterior tibialis transfer should be considered as a surgical intervention for burns with severe equinus contracture even if there is a fixed deformity to allow for their full rehabilitation after injury., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Two populations commonly presenting with equinus gait are Idiopathic Toe-Walkers and children with Cerebral Palsy. Surgical intervention to treat equinus is defined by three zones. Zone three surgery, performed at the Achilles tendon, is most commonly used clinically. There is however, evidence from simulation studies that zone two surgery, performed at the muscle belly, might provide better functional outcomes. The purpose of this study was to investigate the effect of zone two calf-lengthening on post-operative gait in these populations., Methods: A retrospective audit of the Queensland Children's Motion Analysis Service database identified 17 toe-walkers (mean age 10.13 (SD 2.625)) and 11 Cerebral Palsy (mean age 9.72 (SD 4.04)) participants that received calf-lengthening surgery for plantarflexion contracture and had pre- and post-surgery 3D gait analysis. Inverse kinematics, dynamics, and muscle analysis were performed in OpenSim (v3.3) using a modified gait2392 model. Pre to post-surgery comparisons were performed in MATLAB using statistical parametric mapping. Dependent variables included ankle kinematics, powers and muscle-tendon length estimates., Findings: The primary outcome of this study was that ankle dorsiflexion increased in both Idiopathic Toe Walking and Cerebral Palsy groups post-calf lengthening across 90% and 85% of the gait cycle respectively. There was an increase in modelled muscle-tendon lengths, specifically in the medial gastrocnemius, of 78% (toe-walkers), and 100% (Cerebral Palsy) of the gait cycle. Power generation during push-off was not affected., Interpretation: Overall, the results appear to support the efficacy of zone 2 calf-lengthening for children with Cerebral Palsy and Idiopathic Toe Walking., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

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.

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Residual or recurrent equinus deformity is a common problem in surgically treated clubfeet. This deformity may occur due to soft tissue-related reasons or due to bony deformity. An increased anterior distal tibial angle (ADTA) was previously found in 48% of the operated clubfeet. This study aimed to determine the efficacy and safety of anterior distal tibial hemiepiphysiodesis (ADTE) in the treatment of recurrent equinus deformity in patients with an increased ADTA., Methods: Eighteen children (23 feet) treated by ADTE to correct recurrent equinus deformity in surgically treated clubfeet were included in this retrospective, single-center study. ADTE using 8 plates was performed in children with an increased ADTA (>82 degrees) and inability to dorsiflex the ankle (≤0 degree of dorsiflexion). The mean patient age was 11.3 years (range: 10.2 to 12.9 y). All patients had completed treatment with implant removal after an average of 20.3 months (range: 9 to 37 mo)., Results: The mean preoperative ankle dorsiflexion significantly improved from -3.3 degrees (range: -20 to -0 degrees) to 6.1 degrees (range: -15 to 10 degrees) at the time of 8-plate removal (correction rate: 9.4 degrees; P<0.0001). The ADTA was a mean of 87.5 degrees (range: 83 to 110 degrees) before surgery and significantly improved to 75.8 degrees (range: 63 to 106 degrees) at the time of implant removal (correction rate: 11.7 degrees; P<0.0001). Average follow-up was 43.9 months (range: 10 to 76 mo). Follow-up examinations were continued in 11 patients (13 feet) after implant removal. Changes of ankle dorsiflexion (mean: -2.5 degrees) and ADTA (mean: 3.6 degrees) occurred in this group., Conclusions: ADTE was safe and effective in the treatment of recurrent equinus deformity in surgically treated clubfeet with increased ADTA. Deterioration of ankle dorsiflexion and ADTA occurred after implant removal in some cases. The results of this study have to be analyzed with caution due to the limited number of included patients and its retrospective nature., Level of Evidence: Level IV-retrospective case series.

Background: The Ponseti method effectively treats idiopathic clubfoot, but its effectiveness in treating the stiffer clubfoot associated with arthrogryposis is less clear. The purpose of this study was to assess the comparative effectiveness of the Ponseti method in 5-year-old children with either idiopathic clubfoot or clubfoot due to arthrogryposis., Methods: The outcomes of the Ponseti method were retrospectively evaluated in children with idiopathic clubfoot and clubfoot associated with arthrogryposis. The children with clubfoot were seen at our hospital between 2012 and 2019 and were 4.0 to 6.9 years old at the time of their evaluation. Outcomes of the 2 groups of children with clubfoot were assessed using passive range of motion, foot pressure analysis, the Gross Motor Function Measure Dimension-D, and parent report using the Pediatric Outcomes Data Collection Instrument. These results were also compared with the same measures from a group of typically developing children. Surgical and bracing history was also recorded., Results: A total of 117 children were included (89 idiopathic clubfoot and 28 associated with arthrogryposis) with an average age of 4.8±0.8 years. The historical gait analyses of 72 typically developing children were used as a control, with an average age of 5.2±0.8 years. Significant residual equinovarus was seen in both children with idiopathic clubfoot and associated with arthrogryposis according to passive range of motion and foot pressure analysis when compared with normative data. Children with arthrogryposis demonstrated limited transfer and basic mobility, sports functioning, and global functioning while children with idiopathic clubfoot were significantly different from their typically developing peers in only transfer and basic mobility., Conclusions: Although children with idiopathic clubfoot continue with some level of residual deformity, the Ponseti method is effective in creating a pain-free, highly functional foot. In children with clubfoot associated with arthrogryposis, the Ponseti method is successful in creating a braceable foot that can delay the need for invasive surgical intervention., Level of Evidence: Level III, Therapeutic Studies-Investigating the Results of Treatment.

Equinus deformity is one of the most common gait deformities in children with cerebral palsy. We examined whether estimates of gastrocnemius length in gait could identify limbs likely to have short-term and long-term improvements in ankle kinematics following gastrocnemius lengthening surgery to correct equinus. We retrospectively analyzed data of 891 limbs that underwent a single-event multi-level surgery (SEMLS), and categorized outcomes based on the normalcy of ankle kinematics. Limbs with short gastrocnemius lengths that received a gastrocnemius lengthening surgery as part of a SEMLS (case limbs) were 2.2 times more likely than overtreated limbs (i.e., limbs who did not have short lengths, but still received a lengthening surgery) to have a good surgical outcome at the follow-up gait visit (good outcome rate of 71% vs. 33%). Case limbs were 1.2 times more likely than control limbs (i.e., limbs that had short gastrocnemius lengths but no lengthening surgery) to have a good outcome (71% vs. 59%). Three-fourths of the case limbs with a good outcome at the follow-up gait visit maintained this outcome over time, compared to only one-half of the overtreated limbs. Our results caution against over-prescription of gastrocnemius lengthening surgery and suggest gastrocnemius lengths can be used to identify good surgical candidates., Competing Interests: The authors have declared that no competing interests exist.

Background and Purpose: Contracture and toe-walking in children due to vascular anomaly of the calf musculature is rarely described, and there is limited evidence regarding treatment. The purpose of this case is to describe the novel use of serial casting, combining the knee and ankle, to reduce contracture in a child with hemangioma of the calf., Case Description: An 11-year-old girl received 12 casts of the ankle and knee, followed by custom orthotics, to address chronic contracture and gait impairments caused by a vascular anomaly in the posterior compartment of the lower extremity., Outcomes: After casting, the patient had fully restored knee range of motion and improved ankle range of motion by 45 degrees. She received custom orthotics and maintained her range of motion 4 months after casting., Discussion: Serial casting of the knee and ankle may be a useful alternative to surgical lengthenings in patients with chronic contractures caused by vascular anomalies of the lower extremity., (© 2019 American Physical Therapy Association.)

The current understanding is that gastrocnemius equinus is caused by a pathologic tightening of the muscle leading to decreased ankle joint dorsiflexion. However, an alternative hypothesis is that it is a normal limitation of available muscle length. Passive muscular insufficiency of the gastrocnemius muscle acts on a pathologic foot, which is poorly prepared to accept the forces from the gastrocnemius-soleus complex. In this manner, a normal gastrocnemius muscle exerts abnormal forces across the foot. This alternative hypothesis leads to a different interpretation of the current research literature and a potential new area of biomechanical research., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Childhood cerebral palsy, a non-progressive brain injury, occurs before, during or after delivery, with variable neurological damage from mild to disabling. The deformity in equine is treated conservatively at an early age, but when is surgical management indicated?, Objective: Our goal was to determine the optimal age for surgical management of the equine foot in CCP patients., Material and Methods: Retrospective study, in patients diagnosed with CCP (all types), treated surgically with open or percutaneous Achilles tendon elongation, assessed with external consultation notes, in patients aged 1-16 years, and average follow-up of 6 years, evaluating progress with relapse of deformity and gait with plantigrade support., Results: 55 patients, 74 equinus feet (29 in girls, 45 in boys) were analyzed with surgical treatment. Those treated before six years old presented relapses, with vulnerable period in 4-6 years. Monoplegia presented 100% relapses, and triplegia presented 0%. Open surgery presented 50% recurrence and percutaneous technique only 19%., Conclusion: In our institution, the optimal age is suggested in 6-12 years. Percutaneous technique over the open, should be preferred, and greater attention should be paid to monitoring monoplexy.

Purpose: For children with cerebral palsy (CP) and equinus, the conventional practice of setting the ankle angle in an ankle-foot orthosis (AA-AFO) at 90∘ may not adequately accommodate gastrocnemius length/stiffness. Therefore, this study compared the effects of statically-optimized solid AFOs with individualized AA-AFOs (iAA-AFOs) and conventionally-prescribed AFOs on gait for children with CP and equinus., Methods: Ten children with CP and equinus (15 limbs with AFOs), and 15 typically-developing (TD) children participated. For the children with CP, solid AFOs with iAA-AFOs (range = 5∘-25∘ plantarflexion) were compared with their usual AFOs using three-dimensional gait analysis. TD children walked in shoes only. Peak values and Gait Variable Scores (GVS) for joint and segment variables were calculated for stance phase. Responses were categorized using 90% confidence intervals relative to TD data, for each affected leg., Results: Net responses to iAA-AFOs were positive for 60% of limbs and negative for 40%. Knee variables (GVS and peak extension, flexion, and midstance moment) were most positively affected, and foot-floor angle and vertical ground reaction force were most negatively impacted., Conclusion: Individualized AFO prescription and iAA-AFOs can impact gait biomechanics for some children with equinus, compared to conventionally-prescribed AFOs. Optimizing dynamic alignment for walking may further improve outcomes.

Cerebrovascular accident frequently causes spastic equinovarus contracture of the foot and ankle, for which traditional surgical correction involves tendon transfer, osteotomy, and hindfoot fusion, which can be challenging for patients after cerebrovascular accident. We prospectively assessed the efficacy of a minimally invasive, ambulatory approach to correct this complex deformity in 12 consecutive patients. Surgery included Achilles tendon lengthening, lengthening of the posterior tibial tendon, and flexor tenotomy of all 5 digits. The 10-cm visual-analog scale and the Bristol Foot Score were used to assess pain and subjective foot-related quality of life, respectively. The mean patient age was 61.5 ± 5.68 years, and the duration of follow-up was 29.3 ± 18.5 (range 12.2 to 63.3) months. All patients had a preoperative equinovarus foot structure and all had a rectus foot in weightbearing stance at the 1-year postoperative evaluation. Nine (75.0%) patients showed no residual or recurrent deformity, whereas 3 (25.5%) displayed incomplete release of digital contractures; all patients were treated with in-office flexor tenotomy. Preoperative maximum ankle dorsiflexion was ≤90° in 12 (100%) patients and >90° in 9 (75.0%) patients postoperatively. The mean visual-analog scale score decreased in 10 (83.3%) patients, although a statistically significant decrease was not observed (p = .0535). The Bristol Foot Score improved from 55.17 ± 11.10 preoperatively to 36.83 ± 13.26 postoperatively, and this improvement was statistically significant (p = .0022). These outcomes demonstrate the effectiveness of the minimally invasive, ambulatory surgical approach to spastic equinovarus contracture without identified patient harm., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The literature is sparse regarding treatment of burn scar equinus contracture, with focus primarily on staged procedures, serial casting, and gradual correction using external fixation in combination with soft-tissue procedures. This case study describes a single-stage ambulatory approach for late-stage correction of burn scar equinus contracture associated with toe walking. A case report is presented of an 11-year-old male with focus on procedure selection, surgical technique, and 12-month follow-up results. Surgery involved a single-stage approach with open Achilles lengthening, in addition to multiple skin Z-plasty in parallel with immediate protected weightbearing to correct toe walking. Inadequate release of contracture was noted intraoperatively after Achilles lengthening. Full correction was achieved after converting the longitudinal incision into multiple Z-plasty in parallel, with full heel purchase at 2 weeks postoperatively. The patient was completely healed with pain-free range of motion at 6 weeks postoperatively. At 12 months postoperatively, he continued to ambulate normally without overcorrection or recurrence of deformity. This case study describes a late-stage, minimally invasive, single-stage approach to correction of burn scar equinus contracture. The surgical principles and technique are described. Allowance of immediate weightbearing was possible because all other burn wounds were healed at late-stage presentation that avoided the need for gradual correction with external fixation or serial procedures., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Botulinum toxin type A (BoNT-A) injection is an effective treatment for lower-limb spasticity and should be offered as first-line treatment for focal manifestations. Although its possible role has been hypothesized, the efficacy of electrical stimulation (ES) of antagonists of the injected muscles for improving clinical outcome after BoNT-A injection remains to be established., Objectives: This randomized single-blind pilot study aimed to investigate the efficacy of ES of antagonist muscles as adjunct treatment after BoNT-A injection to plantar flexor muscles in hemiplegic patients with spastic equinus foot., Methods: After BoNT-A injection at triceps surae, patients were randomly allocated to 2 groups: group 1, single ES session on injected muscles plus 5 sessions of ES on antagonist muscles, and group 2, single ES session on injected muscles alone. Both groups underwent daily physical therapy for 60min for 2 weeks (5 days/week). Assessments were performed before treatment (T 0 ) and at 10 days (T 1 ), 20 days (T 2 ), and 90 days (T 3 ) after treatment. Our primary outcome was gait velocity at a comfortable speed at T 2 (10-m walk test [10MWT]). The following were secondary outcomes: triceps surae spasticity (Modified Ashworth Scale), ankle passive range of motion (pROM), strength of tibialis anterior muscle, and 2-min walk test (2MWT)., Results: The 30 patients enrolled were randomly allocated to the 2 groups: 15 in group 1 and 15 in group 2. At T 1 , T 2 and T 3 , both groups showed a significant reduction in muscle tone and an increase in ankle pROM (P<0.05). At T 2 and T 3 , both groups showed a significant increase in 10MWT and 2MWT. The groups did not significantly differ in tibialis anterior strength or primary or secondary outcome measures., Conclusions: ES of antagonist muscles does not improve clinical outcomes in the post-stroke spastic equinus foot after BoNT-A injection., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: Equinus of the ankle is a common deformity in spastic cerebral palsy. Achilles tendon lengthening is one of the effective options for the treatment of equinus deformity., Methods: In the study, a new stair-shaped Achilles tendon lengthening (ATL) procedure that preserves of the tendon continuity was performed in 28 tendons with equinus deformity (20 patients, mean age=10.5±2.6 years). The results were compared with a group of patients treated with the Z-lengthening procedure. During the latest follow-up visit, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scale score was much higher in the stair-shaped ATL group than in the Z-lengthening group (p<0.05)., Results: The two groups showed similar surgical correction angle after ATL(37.2±3.5° for stair-shaped ATL and 36.1±4.5° for Z-lengthening). During the latest follow-up visit, the correction angle in the Z-lengthening group decreased to 21.6±4.3°, which was lower than in the stair-shaped ATL group (29.0±3.1°; p<0.05). In addition, the data regarding the time required by each patient before being able to start rehabilitation and walking as well as gaining better stability for running indicated that the stair-shaped ATL group recovered significantly quicker than the Z-lengthening group., Conclusions: The stair-shaped ATL procedure resulted in a successful correction of the equinus deformity in spastic cerebral palsy, with the advantage of preserving a degree of continuity without a complete section of the tendon. This confers greater antigravity stability and quicker recovery in patients., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Aim: To study the effects of single versus serial casting post-Botulinum toxin A (BoNT-A) injections on hypoextensibility of triceps surae in children, 2-7 years old, with cerebral palsy and equinus gait., Methods: A randomized, stratified, parallel, two-group trial was conducted at a pediatric health center with assessments at baseline, precast, postcast and, 1-, 2-, and 6-month follow-ups. One week following BoNT-A injections into triceps surae muscle, a single below-knee cast (n = 10) or 3 serial casts (n = 10) were applied for 3 weeks. Primary outcome measure was the Modified Tardieu Scale (MTS), secondary outcome measures were Modified Ashworth Scale (MAS), GAITRite™, Gross Motor Function Measure-66 (GMFM-66), and Pediatric Evaluation of Disability Inventory (PEDI)., Results: Significant effects of time, but not group-by-time, were found for MTS R1 (P < 0.001), MTS R2 (P < 0.001), MAS (P = 0.001), GMFM-66 (P = 0.002), and PEDI (P < 0.001-0.009). One participant who received a single cast did not complete the 6-month assessment., Conclusions: Magnitudes of improvements were similar using single or serial casting. If these findings are corroborated in a larger scale study, the recommendation of a single cast may be appropriate due to its greater convenience for families and clinicians.

Background: The evidence-based approach to guide clinical practice has gained great importance in the medical field. High-quality evidence is of paramount importance to inform clinical decision-making and optimize patient outcomes. The generation of high-quality evidence relies on sound methodology and study design to facilitate appropriate interpretation and subsequent application of the clinical findings. The purpose of this review is to objectively critique the methodological design and clinical findings of 2 pediatric orthopaedic studies on children with cerebral palsy (CP) to assess their potential to impact clinical practice., Methods: This is the second in a series of evidence-based reviews in pediatric orthopaedics. The pediatric orthopaedic literature was reviewed for randomized controlled trials (RCTs) published in 2015 and 2016. One RCT was selected from the journal Pediatrics, and one RCT was selected from the journal Developmental Medicine and Child Neurology, both investigating the use of botulinum toxin for the treatment of spastic equinus in children with CP. These RCTs were subjected to in-depth methodological review by orthopaedic surgeons with advanced research degrees and a PhD researcher. Two clinical experts then reviewed the articles to rate the clinical impact or value of each study. Methodological and clinical reviews were compiled, and a final recommendation on impact to change clinical practice was made based on both review components at the consensus of the panel., Results: The first study reviewed investigated the single-dose efficacy and safety of botulinum neurotoxin type-A (1BoNT-A) in children with CP-associated spasticity and equinus foot deformity. The reviewers deemed the placebo-controlled study to be of sound design, and conclusions appropriate for the methodology used and clinical findings. Although findings suggest 1BoNT-A may provide benefit in treating equinus foot deformity, the optimal dose for achieving maximal impact on functional improvement remains undetermined. The second study reviewed investigated the impact of multiple dosing schedules on spastic equinus in CP. Although of relatively sound design, this study was limited by a small sample size and lack of justification for the chosen effect size. Without further study, no recommendation to change clinical practice could be made., Conclusions: Both RCTs reviewed were superiority studies, the first demonstrating efficacy of botulinum toxin over placebo, the second showing no significant difference in 4- and 12-monthly botulinum toxin injections., Significance: Despite a positive result demonstrating an effect of botulinum toxin treatment on spastic equinus in CP, the long-term functional impact and optimal dose remains to be determined. In addition, the negative result in the second study demonstrates the need for a noninferiority trial design to appropriately demonstrate no difference between 2 treatment options.

Background: Recent studies have suggested that either focused or radial shock wave therapy is an effect method for the treatment of spasticity in patients with stroke. However, no previous study compared these two types of extracorporeal shock wave on spasticity in patients with stroke. This study aimed to compare the effect of focused and radial shock wave therapy for the treatment of spastic equinus in patients with stroke., Design: Randomized control trial., Setting: Outpatient rehabilitation center in a medical center., Population: Thirty-two stroke patients with spastic equinus (18 males and 14 women; mean age, 60.1±10.6 years)., Methods: Patients were randomly assigned to receive three sessions of either focused or radial shock wave therapy at 1-week intervals. The intensities that were used during focused shock wave therapy (0.12 mJ/mm2) and radial shock wave therapy (2.4 bar) were comparable. The patients were evaluated at baseline and at 1, 4, and 8 weeks after the final shockwave treatment. The primary outcome measure was change of modified Ashworth Scale Score of gastrocnemius muscle. The secondary outcome measures were Tardieu Scale, ankle passive range of motion, dynamic foot contact area and gait speed. A linear mixed model with repeated measures was used to compare each outcome measure between the two groups., Results: Both groups improved significantly in terms of modified Ashworth Scale Score and Tardieu Scale, and no differences were found between the two groups. In terms of ankle passive range of motion and plantar contact area during gait, the radial shock wave therapy yielded a significantly greater improvement than the focused shock wave therapy. No significant changes were observed in gait speed in either group., Conclusions: Our study suggested that focused and radial shock wave therapy resulted in similar significant improvements in the modified Ashworth scale score and Tardieu scale, but those in the radial shock wave therapy group experienced greater improvements in the ankle passive range of motion and plantar contact area during gait., Clinical Rehabilitation Impact: Both focused and radial shock wave therapy yielded similar improve the spasticity of gastrocnemius muscle. Radial shock wave therapy is superior to focused shock wave therapy in terms of improving the ankle passive range of motion and plantar contact area during gait in patients with stroke.

Hemophilia is a disorder of blood coagulation with X-linked recessive inheritance. It is characterized by uncontrollable hemorrhage, and 80% of these occur intraarticularly. With recurrent hemarthrosis, recurrent synovitis occurs, which eventually leads to the formation of articular contractures. The key to the prevention of hemophilic joint complications is successful prevention of bleeding and management of the initial hemarthrosis. However, after the development of a rigid contracture, surgical correction remains the only method to correct the deformity. Achilles tendon lengthening, synovectomy, anterior osteophyte resection, corrective osteotomies, external fixators, or arthrodesis should be considered as surgical options. In the present report, we describe our experience using hybrid-type external fixators to manage bilateral neglected rigid equinus contractures in a hemophilic patient, with 78 months of follow-up data., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Residual equinus deformity is present in up to 20% of clubfeet treated by the Ponseti method. These patients may require surgical release to restore dorsiflexion. Despite complete posterior release; persistent intraoperative equinus may be present and suggest concurrent joint incongruity. The purpose of this study was to characterize differences in ankle morphology in toddlers with residual equinus following the Ponseti method., Methods: Preoperative magnetic resonance imaging (MRI) data from 10 patients who underwent reconstruction (17 feet; 7 bilateral, 3 unilateral clubfeet) for persistent equinus were compared with 16 age-matched controls. Through reverse engineering software, MRI data were used to generate 3-dimensional (3D) models. Four talus-based measures were performed on both MRI data and 3D models-neck depth, neck angle, width, and length. Models were also used to calculate talus volume and arc of curvature (plafond and talar dome). Standard statistical analyses were performed., Results: Talus volumes, width, and length were less in clubfeet then in control feet. Although some measures were significant there was no mismatch with the ankle mortise dimensions or arc curvature that could account for any decrease in dorsiflexion. We found that from MRI measures the clubfoot neck depth was 2.3 versus 3.6 mm in controls (P<0.001) and from 3D modeling the clubfoot neck depth was 2.3 and 3.5 mm in controls (P=0.003). With 3D modeling talus clubfoot neck angle was 153.7 versus 140.4 degrees in controls (P=0.01). The clubfoot neck angle obtained from MRI measures were also different yet not significant [126.6 in clubfeet versus 122.5 degrees in controls (P=0.12)]., Conclusions: In comparison to age-matched feet; we have noted a decrease in talar neck depth and an obtuse talar neck angle in clubfeet treated in the manner of Ponseti. This may result in anterior ankle impingement and be the cause of residual equinus despite posterior release. In these procedures, the surgeon should recognize this possibility when the amount of dorsiflexion is less than expected., Level of Evidence: Level III-case control study.

Using Tibialis Anterior Shortening (TATS) in combination with Achilles Tendon Lengthening (TAL) to treat spastic equinus in children with cerebral palsy (CP) was described in 2011. Short-term results have indicated a good outcome, especially an improvement of the drop foot in swing phase and the correction of equinus in stance phase. The aim of this study was to analyse the results of the long-term follow-up and to determine the relapse rate of TATS and TAL. The kinematics of the sagittal, frontal and transversal planes were measured by using instrumented 3D gait analysis at three defined time points and then described using the Gait Profile Score (GPS) and Movement Analysis Profile (MAP). The data was exported into Gaitabase and then the preoperative (T0), short- term (T1) and long-term (T2) follow-up data was statistically compared. 23 patients (mean age at index-surgery=14.9years) were included, there was a mean follow-up time of 5.8 years. 3 children (13%) have shown a relapse. The data of 12 children with spastic hemiplegia (12 legs), as well as 8 children with spastic diplegia (10 legs) has been analysed. There has been a significant (p<0.05) improvement in GPS and MAP for ankle dorsiflexion (describes equinus and drop foot) of the operated legs versus not operated legs. TATS in combination with TAL shows a satisfactory long-term result after 5.8 years in the correction of fixed equinus and drop foot in children with CP. Postoperatively all subjects were able to walk without an AFO., (Copyright © 2017 Elsevier B.V. All rights reserved.)

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.

Spasticity is common in stroke and multiple sclerosis. To treat spasticity we have a wide range of interventions, whose application may depend not only on the severity of spasticity but also on its etiology. Consequently, a better understanding of muscle spasticity in different neurological diseases may inform clinicians as to the more appropriate therapeutic approach. Our aim was to compare the clinical and ultrasonographic features of spastic equinus in patients with chronic stroke and multiple sclerosis. Thirty-eight patients with secondary progressive multiple sclerosis and 38 chronic stroke patients with spastic equinus were evaluated at the affected ankle according to the following outcomes: modified Ashworth scale, Tardieu scale, passive range of motion, spastic gastrocnemius muscle echo intensity and thickness. Affected calf muscles tone was significantly greater in patients with chronic stroke (modified Ashworth scale P=0.008; Tardieu scale angle P=0.004) as well as spastic gastrocnemius muscle echo intensity (P<0.001). Affected ankle range of motion was significantly greater in patients with multiple sclerosis (P<0.001) as well as spastic gastrocnemius muscle thickness (medialis: P=0.003; lateralis: P=0.004). Our findings evidenced that the same pattern of spasticity (equinus foot) has some different features according to its etiology. This may help the management of spasticity., (Copyright © 2017 Elsevier B.V. All rights reserved.)

This secondary analysis of a large (n = 241), randomized, double-blind study evaluated the efficacy of 2 doses of abobotulinumtoxinA + standard of care (SOC) versus placebo + SOC in enabling children with dynamic equinus due to cerebral palsy to achieve their functional goals using Goal Attainment Scaling. Most parents/caregivers selected goals targeting aspects of gait improvement as most relevant. Mean (95% confidence interval) Goal Attainment Scaling T scores at week 4 were higher for both abobotulinumtoxinA groups versus placebo (treatment difference vs placebo: 10 U/kg/leg: 5.32 [2.31, 8.32], P = .0006, and 15 U/kg/leg 4.65 [1.59, 7.71], P = .0031). Superiority of both abobotulinumtoxinA doses versus placebo was maintained at week 12. Best goal attainment T scores were higher in the abobotulinumtoxinA groups versus placebo for the common goals of improved walking pattern, decreased falling, decreased tripping, and improved endurance. These findings demonstrate that single injections of abobotulinumtoxinA (10 and 15 U/kg/leg) significantly improved the ability of pediatric cerebral palsy patients to achieve their functional goals.

Gastrocnemius equinus is a frequent comorbidity with traumatic injuries of the foot and ankle. Gastrocnemius lengthening at the time of definitive treatment facilitates obtaining and maintaining an anatomic reduction of the injury. The lengthening procedure is accomplished in 5 steps and results in fewer long-term, problematic sequelae., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Injury of the medial head of the gastrocnemius, also called "tennis leg," is known to heal uneventfully in most cases with compression and immobilization therapy. Failure to heal or long-term complications, including ongoing pain and pes equinus, have been documented in only a limited number of case reports. To the best of our knowledge, a severe concomitant contracture of the knee and ankle joint as a consequence of a maltreated gastrocnemius muscle rupture has not been previously reported in English-language reports. The purpose of the present study was to report a serious complication of neglected tennis leg with a review of the published data., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Equinus deformity is common in ambulant children with cerebral palsy (CP). Although lower leg casting is frequently used, the physiological basis for casting and effects beyond range of motion (ROM) gains are unclear. This review critically evaluates the updated evidence for casting in the management of ankle equinus in children with CP., Methods: Comprehensive searches were conducted using electronic databases AMED, MEDLINE, CINAHL, Scopus, PEDro and the Cochrane Database of Systematic Reviews, publication years 2005-2014, in order to identify literature published since an earlier comprehensive systematic review. Only studies evaluating lower leg casting for conservative management of equinus deformity in children with CP were considered. Two independent raters critically appraised studies against the hierarchy of levels of evidence and rigour of study conduct questions proposed by the American Academy of Cerebral Palsy and Developmental Medicine's methodology for systematic review., Results: Four relevant systematic reviews were identified, although these largely concerned earlier literature. Five original studies were included, all demonstrating improvement in dorsiflexion ROM. Combined treatment with botulinum toxin and casting offered greater and/or more sustained ROM gains than botulinum toxin alone in three studies. Effects on gait parameters and motor function were inconsistent. Participation outcomes were not evaluated. Methodological limitations make firm conclusions difficult., Conclusions: Recent years have offered little progress in the state of evidence for casting in the management of equinus deformity. Casting appears to offer at least short-term improvement in ankle dorsiflexion, although the proposition that this improves function or avoids surgery is not well substantiated. Future research needs to ensure more robust study design and broader evaluation across domains of the International Classification of Functioning, Disability and Health to determine the functional and long-term effect of casting for equinus deformity. Greater knowledge is required of the effect of casting on muscle structure and function in spastic CP. Copyright © 2015 John Wiley & Sons, Ltd., (Copyright © 2015 John Wiley & Sons, Ltd.)

Triceps surae contracture, or equinus, is a known deforming force in the foot and ankle. Biomechanical studies have shown that ankle equinus significantly alters gait and plantar pressures, and in the diabetic neuropathic patient population, this can propagate plantar ulceration and/or Charcot neuroarthropathy (CN). Surgical correction of equinus is globally and frequently used to aid in plantar wound healing in the neuropathic diabetic patient, with and without CN. Treatment guidelines for equinus correction in this medically complex population are undefined and lack evidence from high-quality published peer-reviewed studies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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 (±5.6months) 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°, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p=0.024). 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., (Copyright © 2016 Elsevier B.V. All rights reserved.)

The main complications of open tibiotalocalcaneal arthrodesis are wound healing disorders and nonunion. Our hypothesis was that arthroscopy and interlocking intramedullary nailing decrease these complications. We retrospectively reviewed six patients (mean age: 58 years; mean preoperative Kitaoka score: 51/100) having undergone arthroscopic tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing between January and November 2011 for equinus deformity of the hindfoot and subtalar instability of neurological origin. Postoperative pain disappeared completely in four cases, one patient presented some pain associated with projection of the proximal locking screw head under the skin and the remaining patient presented fibular tendinitis that resolved after infiltration of anti-inflammatory drugs. The mean postoperative Kitaoka score was 64/100. None of the patients presented any wound healing complications or nonunion. The observed incidence of wound complications and bone consolidation disorders after tibiotalocalcaneal arthrodesis was lower than the ones reported for open tibiotalocalcaneal arthrodesis. Level of clinical evidence IV: retrospective case series.

Background: Although botulinum toxin is a well-established treatment of focal spasticity in cerebral palsy, most trials have been small, and few have simultaneously assessed measures of muscle tone and clinical benefit., Methods: Global, randomized, controlled study to assess the efficacy and safety of abobotulinumtoxinA versus placebo in cerebral palsy children with dynamic equinus foot deformity. Patients were randomized (1:1:1) to abobotulinumtoxinA 10 U/kg/leg, 15 U/kg/leg, or placebo injections into the gastrocnemius-soleus complex (1 or both legs injected). In the primary hierarchical analysis, demonstration of benefit for each dose required superiority to placebo on the primary (change in Modified Ashworth Scale from baseline to week 4) and first key secondary (Physician's Global Assessment at week 4) end points., Results: Two hundred and forty-one patients were randomized, and 226 completed the study; the intention to treat population included 235 patients (98%). At week 4, Modified Ashworth Scale scores significantly improved with abobotulinumtoxinA; mean (95% confidence interval) treatment differences versus placebo were -0.49 (-0.75 to -0.23; P = .0002) for 15 U/kg/leg and -0.38 (-0.64 to -0.13; P = .003) for 10 U/kg/leg. The Physician's Global Assessment treatment differences versus placebo of 0.77 (0.45 to 1.10) for 15 U/kg/leg and 0.82 (0.50 to 1.14) for 10 U/kg/leg were also significant (both Ps < .0001). The most common treatment-related adverse event was muscular weakness (10 U/Kg/leg = 2; placebo = 1)., Conclusions: AbobotulinumtoxinA improves muscle tone in children with dynamic equinus resulting in an improved overall clinical impression and is well tolerated., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: Plantar skin has similar histologic features to the palmar area and appears to be the ideal tissue for reconstruction of the palmar region. In this study, an anatomic examination was performed to determine the superficial venous architecture of the instep area, and the use of arterialized venous instep flaps for palmar contracture release was assessed., Methods: The anatomical study was performed on 12 fresh cadaver feet. The arterialized venous instep flap, including the skin, subcutaneous tissue and superficial venous plexus, was harvested. To determine the venous structure, dissection (n = 6) and injection-corrosion (n = 6) techniques were used. In the clinical study, nine arterialized venous instep flaps were used for palmar contracture release. All flaps were harvested above the deep fascia and included skin, subcutaneous fat, and the superficial venous plexus. At the plantar site of the flap, two or three veins, one of which was used, were dissected for a sufficient length for the arterial anastomosis. The saphenous vein was used for the venous anastomosis., Results: Dissection and injection-corrosion techniques revealed that the flap had 7-12 and 4-6 veins at its plantar and superior edges, respectively, with numerous anastomoses and interconnections between the veins. The flap dimensions were between 3 × 5 cm and 4 × 6 cm. All flaps survived, with two partial flap necrosis that healed with spontaneous epithelization. No debulking procedures were undertaken and all flaps adapted well to the recipient site., Conclusions: The arterialized venous instep flap is a good alternative to reconstruct palmar contractures by adding similar tissue that is thin and pliable with minimal donor site morbidity., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Recurrence of equinus deformity after surgery is common in patients with cerebral palsy. This retrospective study was undertaken to estimate the recurrence rate of the equinus deformity after tendo-Achilles lengthening (TAL) in patients with cerebral palsy and to investigate the risk factors associated with the recurrence., Methods: Two-hundred forty three ambulatory patients with cerebral palsy, who underwent TAL for equinus foot deformity since 1995, and had undergone a preoperative and postoperative 3-dimensional gait analysis, were included. Cox proportional hazards model was used to determine the significant contributing factor for the recurrence of equinus foot deformity., Results: The mean patient age at surgery was 7.8±2.7 years and the mean follow-up duration was 8.1±3.4 years. Equinus deformity recurred in 22 of the 243 patients (9.1%) and the Kaplan-Meier survival estimate was shown to be 89.4% at 10 years not needing repeat surgery. According to the multivariate analysis using the Cox proportional hazard model, preoperative ankle dorsiflexion at initial contact (P=0.016) was the only significant factor for recurrence of equinus deformity after surgery. Age at surgery and the type of limb involvement were not associated with the recurrence (P=0.433 and 0.269). The cutoff values of preoperative gait kinematics between the nonrecurrence and recurrence groups were -19 degrees of ankle dorsiflexion at initial contact (P=0.018)., Conclusions: This study showed that the severity of preoperative equinus deformity was a risk factor associated with recurrence after TAL in patients with cerebral palsy. Therefore, surgeons should consider the recurrence and later revision surgery for the patients with severe equinus foot deformity., Level of Evidence: Therapeutic level III.