Search

Introduction: Partial foot amputation (PFA) is a common strategy used to preserve limb length for patients requiring lower-limb amputation. Equinus development following PFA results in complications that may be addressed perioperatively or postoperatively. We sought to evaluate how equinus deformity was reported in recent literature related to PFA. If it was reported, we sought to document how it was measured and/or treated. Methods: A search of the literature was conducted on February 15, 2023, using PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete online databases. Studies related to PFA were analyzed following scoping review guidelines. Results: Literature from January 1, 2013 to February 15, 2023, were included in the analysis. Twenty-seven studies reported how equinus deformity following PFA was measured, reported, or treated perioperatively, postoperatively, and/or with orthotic or prosthetic intervention. Conclusions: Although there is general consistency in reporting practices regarding development of equinus deformity following amputation at the transmetatarsal level, additional research is necessary for the standardization of reporting practices following Lisfranc and Chopart amputations to further inform clinical considerations. Clinical Relevance: This scoping review highlights a lack of standardization of reporting practices and orthotic/prosthetic interventions for management of equinus deformity following Lisfranc and Chopart amputations. [ABSTRACT FROM AUTHOR]

A gastrocnemius contracture is a common problem that results in decreased ankle dorsiflexion that contributes to an array of foot and ankle ailments. A common surgical treatment for this condition is a gastrocnemius recession (GR). Many adaptations of the original procedure have been described. Misinterpretations of proper GR procedures have potentially caused confusion when selecting a treatment. This paper proposes to identify errors between the use of GR and gastrocnemius-soleus recession (GSR) procedure techniques in the current literature. A systematic literature review was performed in June 2021, using the PubMed database and select orthopedic texts. Only studies that met the established criteria and either correctly or incorrectly described a GR or GSR procedure were included. After applying exclusion criteria, 108 publications were included. These articles and texts were reviewed for surgical technique and terminology errors in accordance with established parameters. The articles were classified as either: "Correct" or "Incorrect." Of the 108 publications and texts included, 18 articles incorrectly described either a GR or a GSR (16.67%). Ninety articles correctly described either a GR or a GSR (83.33%). The literature supports the use of a GR to treat a gastrocnemius contracture. Inaccurate articles create confusion as to what exactly a GR entails. Sources of ambiguity included terminology, inconsistent anatomical zone definition, and technique selection. Due to this confusion, it is suspected that patient outcomes can be impacted. Postoperative outcomes of GSR patients are worse than GR patients. Further investigation is necessary to determine if performing the incorrect procedure negatively affects patient outcomes. [ABSTRACT FROM AUTHOR]

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

Abstract Introduction - La forme spastique de la paralysie cérébrale (PC) est très fréquente,représentant plus de 80% des cas de PC. La spasticité entraîne des contracturesmusculaires et des déformations osseuses responsables de limitations d’activité etde restriction de participation chez des enfants en pleine croissance. L’atteinte dupied et de la cheville est fréquente chez les patients atteints d’une PC, les musclesle plus souvent trop actifs étant les gastrocnémiens et le soléus, le tibial postérieuret le tibial antérieur. Le traitement de la spasticité des membres inférieurs, lorsqu’elleest gênante, repose essentiellement sur les injections intramusculaires dela toxine botulique A et la rééducation.Les objectifs de notre étude étaient de comparer l’évolution thérapeutique de laspasticité du pied équin chez les enfants PC marchants au cours des contrôles (àun mois, à trois mois et à six mois) par rapport à l’évaluation initiale faite avant letraitement, dans les groupes traités respectivement, par la toxine botulique A, larééducation et l’association de ces deux thérapeutiques et de comparer les résultatsde l’évolution thérapeutique dans les trois groupes sur la marche.Patients et méthodes - Il s’agit d’une étude descriptive randomisée comparativedans trois groupes thérapeutiques, groupe randomisé pour des injections de toxinebotulique «A» associée à la rééducation (G1), groupe de toxine botulique «A» (TBA)seule (G2), groupe de rééducation seule (G3). Cette étude a concerné 122 membresinférieurs de 72 enfants atteints d’une PC spastique (24 enfants par groupe), classésselon le système de classification de la fonction motrice globale GMFCS (I à III)et âgés de 2 à 16 ans. L’évaluation était faite avant le traitement et au cours descontrôles (à un, trois et six mois), par l’échelle de Tardieu modifiée (MTS) pour les Abstract Ankle spasticity in the cerebral palsy walking child: comparative study botulinum toxin A versus rehabilitation. The spastic form of cerebral palsy (PC) is very common, accounting for more than 80% of PC cases. Spasticity leads to muscle contractures and bone deformities accountable for activity and participation limitations in growing children. The treatment of ankle spasticity relies mainly on intramuscular injections of botulinum toxin A and rehabilitation. Aim - The purpose of this paper was to access the efficacy and the limits of bot toxinA in comparing the therapeutic evolution of the ankle spasticity during three controls (at one month, three months and six months) in the groups treated respectively by botulinum toxin A alone, rehabilitation alone and the combination of these two the-rapies, and to compare the outcomes of therapeutic evolution in the three groups on gait. Patients and methods - A comparative randomized descriptive study in three the-rapeutic groups (botulinum toxin group «A» associated with rehabilitation (G1), bo-tulinum toxin group «A» (TBA) alone (G2), rehabilitation group alone (G3) during the controls and involving 122 lower limbs of 72 children (24 children per group) with spastic CP, classified GMFCS (I to III) and aged from 2 to 16 years. The clinical evaluation was done by the Modified Tardieu scale (MTS) for passive amplitudes and spasticity, PRS (Physicians Rating Scale) for walking. This study was carried out in the physical and rehabilitation medicine PRM department of Oran’s hospital and univer-sity center during the period of January 2016 to June 2017. The Tardieu Scale mea-sures spasticity using 2 parameters: the spasticity angle X is the difference between the angles of arrest at slow speed and of catch-and-release or clonus at fast speed, whereas the spasticity grade Y is an ordinal variable that grades the intensity and thus measures the gain of the muscle reaction to fast stretch.Results - In the intervention groups, the combination of TBA and rehabilitation gave a statistically significant improvement in the ankle of the mean angle of passive dor-siflexion of the flexed knee ankle (p = 0.04) and tense knee (p = 0.003) in the first month. This improvement continues in the third and sixth months. The decrease in the mean angle of onset of flexed knee and tense knee spasticity was statistically significant in the first month (p = 0.03, p≤10-3) and in the third month. Mean soleus and gastrocnemius tone decreased statistically significantly in all three controls. In G2, the improvement of the average angle of the dorsal flexion, flexed knee and stretched knee, occurs in the third month (p = 0.05, p = 0.003). The improvement in the average angle of onset of spasticity and tone was statistically significant in the first and third months. In the G3 improvement of the mean of all these parameters was statistically insignificant. Conclusion - Rehabilitation associated with abobotulinumtoxin «A» injections gives better results on joint amplitudes, muscle tone and walking quality in children walk-ing spastic CP. These results are maintained until the sixth month.

Background: This study aimed to evaluate gait outcomes and strength following the surgical correction of equinus in cerebral palsy (CP) based on different surgical procedures. We included the Baumann and Strayer procedures, as well as the Achilles tendon lengthening (ATL). Methods: A retrospective analysis was performed in patients with infantile, bilateral CP who received instrumental 3D gait analysis before and after surgical correction (18.66 months postoperatively). Patients were divided into 3 groups: Strayer surgery, Baumann surgery, and ATL. Gait performance and muscle strengths were compared between studied surgeries. Results: A total population of 204 patients (15.43 years) with 341 operated lower limbs (LLs) was analyzed. Dorsiflexion in swing and stance phases significantly improved in all groups postoperatively. The Strayer and the ATL group showed higher postoperative dorsiflexion than the Baumann group. However, no loss of strength was observed with the Baumann method. Maximum power improved in this group postoperatively. An 8.2% loss in calf muscle strength was recorded in the Strayer group. Conclusion: Operative pes equinus treatment successfully improved the gait of children and adults with CP postoperatively. There were differences in postoperative results between studied operative techniques regarding range of motion and power. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Retrospective analytical study that aims to evaluate the kinematic and kinetic results obtained after percutaneous lengthening with an intramuscular needle (PLIN) of gastrocsoleus complex (GSC) zones I, II, and III, performed outside the operating room between 2018 and 2019, in pediatric patients with equinus gait resistant to non-operative treatment. Gait analysis was performed prior to treatment and 6 months post treatment in 48 ankles (30 patients), with a median patient age of 10.11 (2.85) years. Twelve patients had a diagnosis of idiopathic equinus, twelve spastic hemiplegia, and six spastic diplegia. Statistical analysis included pre–post comparison, correlation, and linear regression of critical kinematic and kinetic ankle values. Significant improvement was observed for the following parameters: ankle angle at initial contact, −4.57(10.31)/0.05(3.04)°; maximum ankle dorsiflexion in the stance phase (mADFStP), 3.70(7.56)/10.42(4.52)°; and maximum ankle dorsiflexion in the swing phase (mADFSwP), −6.54(8.41)/−0.35(6.17)°. In addition, an inversely proportional correlation with pre-intervention values was obtained for those parameters, with rho values of −0.864, −0.755, and −0.696, respectively (p < 0.0005). No significant changes in ankle kinetics were evidenced. Linear regression equations allowed for estimation of the post mADFStP, with a standard error (SE) = 1.82; R2 = 0.797 (p < 0.0005), and the post mADFSwP, with an SE = 2.376; R2 = 0.829 (p < 0.0005). To conclude, the addition of the GSC in patients with resistant equinus significantly improves ankle initial contact, mADFStP, and mADFSwP, with greater changes occurring with worse initial values. The regression formulas used to estimate post-procedure results will allow therapeutic indications to be adjusted.

PurposeEquinus 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.MethodsA 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.ResultsConsensus 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).ConclusionsThe results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research.Level of evidenceV.

Abstract Background Comparisons between various conservative managements of spastic equinus deformity in cerebral palsy demonstrated limited evidences, to evaluate the efficacy of conservative treatment among cerebral palsy children with spastic equinus foot regarding gait and ankle motion. Methods Studies were identified from PubMed and Scopus up to February 2022. Inclusion criteria were randomized controlled trial (RCT), conducted in spastic cerebral palsy children with equinus deformity, aged less than 18 years, compared any conservative treatments (Botulinum toxin A; BoNT-A, casting, physical therapy, and orthosis), and evaluated gait improvement (Physician Rating Scale or Video Gait Analysis), Observational Gait Scale, Clinical Gait Assessment Score, ankle dorsiflexion (ankle dorsiflexion at initial contact, and passive ankle dorsiflexion), or Gross Motor Function Measure. Any study with the participants who recently underwent surgery or received BoNT-A or insufficient data was excluded. Two authors were independently selected and extracted data. Risk of bias was assessed using a revised Cochrane risk-of-bias tool for randomized trials. I2 was performed to evaluate heterogeneity. Risk ratio (RR), the unstandardized mean difference (USMD), and the standardized mean difference were used to estimate treatment effects with 95% confidence interval (CI). Results From 20 included studies (716 children), 15 RCTs were eligible for meta-analysis (35% had low risk of bias). BoNT-A had higher number of gait improvements than placebo (RR 2.64, 95% CI 1.71, 4.07, I 2 = 0). Its combination with physical therapy yielded better passive ankle dorsiflexion at knee extension than physical therapy alone (USMD = 4.16 degrees; 95% CI 1.54, 6.78, I 2 = 36%). Casting with or without BoNT-A had no different gait improvement and ankle dorsiflexion at knee extension when compared to BoNT-A. Orthosis significantly increased ankle dorsiflexion at initial contact comparing to control (USMD 10.22 degrees, 95 CI% 5.13, 15.31, I 2 = 87%). Conclusion BoNT-A and casting contribute to gait improvement and ankle dorsiflexion at knee extension. BoNT-A specifically provided gait improvement over the placebo and additive effect to physical therapy for passive ankle dorsiflexion. Orthosis would be useful for ankle dorsiflexion at initial contact. Trial registration PROSPERO number CRD42019146373.

Abstract Background Restriction in foot and ankle joint range of motion, such as an ankle equinus, has been associated with increased plantar pressure and its complications. However, previous research is limited by its scope of measures and study populations. The aim of this study was to investigate the relationship between foot and ankle joint range of motion on barefoot plantar pressures during walking in healthy older adults. Methods This cross-sectional study recruited 49 older adults. Participants underwent measures of foot (first metatarsophalangeal dorsiflexion range of motion, and navicular drop and drift) and ankle joint range of motion, foot posture, body mass index, and plantar pressure during barefoot walking. Spearman Rank Order Correlations were used to explore the relationship between foot and ankle measures, body mass index, and plantar pressure, with significant correlations explored in a hierarchical regression analysis. A Mann-Whitney U test was performed to compare plantar pressure values between those with and without ankle equinus per region of the foot. Results Mean (SD) age and BMI were 72.4 years (5.2) and 29.8 kg/m2 (5.9) respectively. A total of 32 of the 49 participants (65%) identified as female sex. Mean (SD) ankle joint range of motion was 32.7 (6.4) degrees with 17/49 (34.7%) participants classified as having an ankle equinus (defined as

Gastrocsoleus lengthening (GSL) is the most common surgical procedure to treat equinus deformity in ambulant children with cerebral palsy (CP). Foot drop, where the ankle remains in plantarflexion during swing phase, can persist in some children post-operatively. There is currently limited understanding of which children will demonstrate persistent foot drop after GSL. Which children develop persistent foot drop after GSL surgery for equinus? We conducted a retrospective cohort study on ambulant children with CP who had GSL surgery for fixed equinus deformity. The aims of the study were: to determine the frequency of persistent foot drop post-operatively and to compare outcome parameters from physical examination and three-dimensional gait analysis for children with hemiplegia or diplegia. One hundred and ten children functioning at GMFCS Levels I/II/III of 28/75/7 met the inclusion criteria for this study. There were 71 boys and mean age was 9.1 years at time of GSL surgery. The overall frequency of persistent foot drop was 25%, with a higher frequency of persistent foot drop in children with hemiplegia (42%) than children with diplegia (19%). There were significant improvements in dorsiflexor strength and in selective motor control in children with diplegia but not in children with hemiplegia. Mean (SD) pre-operative mid-swing ankle dorsiflexion for children with hemiplegia was − 14.0° (9.9°) and improved post-operatively to − 1.6° (5.5°). For children with diplegia, the pre-operative mid-swing ankle dorsiflexion was − 12.1° (12.9°) and improved post-operatively to + 4.2° (6.9°). Foot drop is present following GSL surgery for fixed equinus deformity in a significant number of children with hemiplegia and to a lesser extent in children with diplegia, which may reflect a difference in the central nervous system lesion between these groups. New management approaches are required for this important and unsolved problem. • Foot drop may persist after gastrocsoleus lengthening surgery for equinus deformity. • Higher frequency in children with hemiplegia (42%) than those with diplegia (19%). • Greater dorsiflexor strength and selective motor control in children with diplegia. • This may reflect differences in the underlying central nervous system lesion. • Improved management strategies are required to prevent post-operative foot drop. [ABSTRACT FROM AUTHOR]

Running had been known producing a posterior muscle tightness in lower extremity, particularly calf muscles, resulting in a relative equinus deformity. Numerous study reported the association between equinus deformity and foot pain, partially due to the increased plantar pressure of forefoot. This study was directed to find a relation between running intensity and increased forefoot plantar pressure. Subjects were divided into two groups according to running intensity as classified as runner or non-runner. Forefoot plantar pressures data were obtained using a foot imprinter and analyzed into numerical values. Ankle maximum dorsiflexion was also examined in an extended knee to detect the calf tightness. Mean forefoot plantar pressure value was Grau 2.89 (range 2-4) in runner group, and Grau 2.15 (range 1-4) in non-runner group (p=0.004). Ankle maximum dorsiflexion was also limited in runner group (16.05±1.98°) compared with 19.30±1.38° in non-runner group (p<0.001). There was an association found between running intensity and plantar pressure elevation. Considering the potential damaging effects to the foot, it is recommended for runners or treating physician to look into this problem as well as to make sure that regular calf stretching is advocated. [ABSTRACT FROM AUTHOR]

PURPOSE: In children with cerebral palsy (CP), gastrocnemius muscle spasticity may lead to pes equinus posture which causes insufficient ankle joint dorsiflexion for normal gait. The aim of this study was to analyze the stiffness of gastrocnemius and tibialis anterior muscles by shear wave elastography (SWE) in children with pes equinus deformity due to spastic CP. METHODS: 24 legs of 12 children (6 females and 6 males, mean age 45.8 months) with CP were prospectively included in the study. Tissue stiffness quantification with shear-wave velocity (SWV) was analyzed. RESULTS: The mean SWVs of the gastrocnemius and tibialis anterior muscles were 3.91±0.26 m/s and 2.67±0.18 m/s, respectively. The stiffness of the gastrocnemius muscle was significantly higher than the stiffness of the tibialis anterior muscle (p < 0.0001). There was no correlation between the stiffness of these muscles (r = 0.129, p > 0.05). CONCLUSION: Gastrocnemius muscles were stiffer than tibialis anterior muscles in patients with spastic CP. But stiffness between these muscles was not correlated with each other. Pes equinus may be related to stiff gastrocnemius in these patients. This study demonstrates the clinical potential for SWE as a non-invasive tool for analyzing calf muscle stiffness. [ABSTRACT FROM AUTHOR]

Background: U-osteotomy with Taylor Spatial Frame correction is a rarely reported treatment method particularly well-suited for severe rigid equinus deformity in adults. The purpose of this study was to evaluate the effectiveness and efficacy of deformity correction and clinical outcome using this technique. Methods: We present a retrospective review of 30 feet in 26 patients who received U-osteotomy with Taylor Spatial Frame. Radiologic outcomes were measured using the anterior tibiotalar angle (TTA) with conventional weightbearing radiographs. Functional assessments included American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores and patient satisfaction using Likert scale. Results: The etiology included trauma (9), neglected or relapsed clubfoot (6), spina bifida (5), poliomyelitis (4), Charcot-Marie-Tooth disease (4), and iatrogenic (2). All patients had equinus deformity with TTA more than 140 degrees (median 157.5, 141-177). There were varus deformity in 19 feet, limb length discrepancy in 6 legs, and genu procurvatum deformity in 2 legs. The duration of gradual correction was 53.6±13.5 days (33-73 days), and the external fixation time was 147.8±25.2 days (98-203 days). At last follow-up, TTA in all patients improved significantly (P <.001) to 113.5 degrees (111.8-116.0). All patients had plantigrade feet, except for 2 cases of residual mild equinovarus deformity, 2 cases of residual mild hindfoot varus deformity, 1 case of moderate hindfoot varus recurrence. The AOFAS scores significantly improved (P <.001) from 51.0 points (29.0-66.0) to 76.0 points (69.5-88.0). Eighteen patients were very satisfied, 6 patients were somewhat satisfied, and 2 patients were somewhat dissatisfied. Conclusion: Using minimally invasive U-osteotomy with Taylor Spatial Frame to gradually correct the adult severe rigid equinus deformity proved to be an effective and relatively safe method associated with high patient satisfaction rates. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Orthoses are an important part of both conservative and operative treatment of acute Achilles tendon rupture as they can be used to position the foot in equinus and protect the torn tendon from strain in the healing phase. The aim of the study was to test four different orthoses ability to position the foot in equinus. The study was performed as a cross-sectional study. 15 healthy study participants underwent radiographic examination with 11 true lateral radiographs of the right ankle and foot, one with the ankle joint in neutral position; one of a circular equinus cast (CEC); three of an adjustable equinus boot (AEB) with the foot in 30°, 15°, and 0° of plantar flexion, respectively; three of a fixed angle orthosis with 1, 2, and 3 wedges with a plateau (WWP); and three of a fixed angle orthosis with 1, 2, and 3 wedges without plateau (WWOP). The primary outcome was the Achilles Relief Distance (ARD). Secondary outcomes were the tibiocalcaneal angle (TCA), the tibiotalar angle (TTA), and the tibio- 1st metatarsal angle (1MTP). All measurements were performed by a radiologist. The mean (SD) ARD was 11 mm (7) in CEC, 23 mm (6) with 3 WWP, 11 mm (5) with 3 WWOP, and 15 mm (5) using AEB in 30° of plantarflexion. The mean (SD) TCA was 86° (7,8) in CEC, 76° (7,3) with 3 WWP, 90° (6,9) with 3 WWOP, and 84° (6,6) using the AEB in 30° of plantarflexion. CEC, AEB, and WWOP showed statistically significantly larger plantarflexion than WWP. CEC, AEB and WWOP produced significantly greater plantarflexion compared to WWP. [ABSTRACT FROM AUTHOR]

Inclusion body myopathy (IBM) is a form of distal myopathy which is characterized by progressive muscle weakness and wasting.1 A healthy 23-year-old male with unremarkable past medical history presented with left ankle pain and contracture of approximately one year duration. Physical exam findings revealed a markedly rigid ankle contracture as well as left calf atrophy. After a multi-specialty workup, the decision was made for the patient to undergo an open z-plasty of the left achilles tendon in conjunction with surgical biopsy of the left soleus muscle belly. The pathology report showed “myopathy with rimmed vacuoles and chronic inflammation suggestive of inclusion body myopathy”. In the nearly three years since surgery, patient has achieved a plantigrade foot without ankle equinus. He ambulates without pain and without an assistive device in standard shoe gear. Inclusion Body Myopathy is a progressive disorder which ultimately has no cure. While genetic testing and imaging modalities can be useful, the gold standard for most forms of distal myopathy requires a muscle biopsy. Treatment should be geared towards alleviating associated symptoms. While rare, distal myopathies in all their forms should be included among a podiatric surgeon's differential diagnoses when signs of muscle imbalance are present, such as equinus contracture, anterior compartment weakness, and gastrocnemius atrophy. Open surgical correction can help alleviate pain and symptoms associated with distal myopathy. Level of clinical evidence: Level 4, case-control study

Ankle arthritis following ankle fractures or other traumatic injuries is a common complication, which can lead to osseous equinus in some cases. Although the multiplanar dynamic external fixator has been utilized for various orthopedic conditions, it is not often used to correct long-standing osseous equinus and subsequent soft tissue contracture in the presence of post-traumatic ankle arthritis. This research presents a case study of a 44-year-old woman who had severe osseous and soft tissue equinus and post-traumatic arthritis in her right ankle, and who underwent gradual correction using a multiplanar dynamic external fixator followed by total joint arthroplasty. This study is the first to report on the use of a multiplanar dynamic external fixator to correct a severe osseous equinus deformity during a staged procedure for total ankle arthroplasty. The patient was able to resume normal activities and maintain adequate ankle joint range of motion at 3 years without the need for revisional procedures.

Background: Comparisons between various conservative managements of spastic equinus deformity in cerebral palsy demonstrated limited evidences, to evaluate the efficacy of conservative treatment among cerebral palsy children with spastic equinus foot regarding gait and ankle motion. Methods: Studies were identified from PubMed and Scopus up to February 2022. Inclusion criteria were randomized controlled trial (RCT), conducted in spastic cerebral palsy children with equinus deformity, aged less than 18 years, compared any conservative treatments (Botulinum toxin A; BoNT-A, casting, physical therapy, and orthosis), and evaluated gait improvement (Physician Rating Scale or Video Gait Analysis), Observational Gait Scale, Clinical Gait Assessment Score, ankle dorsiflexion (ankle dorsiflexion at initial contact, and passive ankle dorsiflexion), or Gross Motor Function Measure. Any study with the participants who recently underwent surgery or received BoNT-A or insufficient data was excluded. Two authors were independently selected and extracted data. Risk of bias was assessed using a revised Cochrane risk-of-bias tool for randomized trials. I2 was performed to evaluate heterogeneity. Risk ratio (RR), the unstandardized mean difference (USMD), and the standardized mean difference were used to estimate treatment effects with 95% confidence interval (CI). Results: From 20 included studies (716 children), 15 RCTs were eligible for meta-analysis (35% had low risk of bias). BoNT-A had higher number of gait improvements than placebo (RR 2.64, 95% CI 1.71, 4.07, I2 = 0). Its combination with physical therapy yielded better passive ankle dorsiflexion at knee extension than physical therapy alone (USMD = 4.16 degrees; 95% CI 1.54, 6.78, I2 = 36%). Casting with or without BoNT-A had no different gait improvement and ankle dorsiflexion at knee extension when compared to BoNT-A. Orthosis significantly increased ankle dorsiflexion at initial contact comparing to control (USMD 10.22 degrees, 95 CI% 5.13, 15.31, I2 = 87%). Conclusion: BoNT-A and casting contribute to gait improvement and ankle dorsiflexion at knee extension. BoNT-A specifically provided gait improvement over the placebo and additive effect to physical therapy for passive ankle dorsiflexion. Orthosis would be useful for ankle dorsiflexion at initial contact. Trial registration PROSPERO number CRD42019146373. [ABSTRACT FROM AUTHOR]

Background: Restriction in foot and ankle joint range of motion, such as an ankle equinus, has been associated with increased plantar pressure and its complications. However, previous research is limited by its scope of measures and study populations. The aim of this study was to investigate the relationship between foot and ankle joint range of motion on barefoot plantar pressures during walking in healthy older adults.Methods: This cross-sectional study recruited 49 older adults. Participants underwent measures of foot (first metatarsophalangeal dorsiflexion range of motion, and navicular drop and drift) and ankle joint range of motion, foot posture, body mass index, and plantar pressure during barefoot walking. Spearman Rank Order Correlations were used to explore the relationship between foot and ankle measures, body mass index, and plantar pressure, with significant correlations explored in a hierarchical regression analysis. A Mann-Whitney U test was performed to compare plantar pressure values between those with and without ankle equinus per region of the foot.Results: Mean (SD) age and BMI were 72.4 years (5.2) and 29.8 kg/m2 (5.9) respectively. A total of 32 of the 49 participants (65%) identified as female sex. Mean (SD) ankle joint range of motion was 32.7 (6.4) degrees with 17/49 (34.7%) participants classified as having an ankle equinus (defined as < 30 degrees of ankle joint dorsiflexion range of motion). We found that an ankle equinus predicted a statistically significant amount of peak forefoot plantar pressure (p = 0.03). Participants with an ankle equinus displayed significantly higher forefoot peak pressure 677.8 kPa (589.9 to 810.4) compared to those with no equinus 565.58 kPa (447.3 to 651.2), p = 0.02. A statistically significant correlation was found between body mass index and midfoot peak pressure (p < 0.01) and pressure-time integral (p < 0.01). No other significant correlations were found.Conclusion: Clinicians should consider screening for an ankle equinus and body mass index as a simple way to identify which healthy older adults may be at risk of pressure-related complications in the mid- and forefoot. [ABSTRACT FROM AUTHOR]

Background: Equinus foot is the deformity most frequently observed in patients with cerebral palsy (CP). While there is widespread agreement on the treatment of equinus foot, a clear clinical definition has been lacking. Therefore, we conducted this study to evaluate functional changes in gait analysis in relation to maximum possible dorsiflexion (0°, 5°, 10° and 15°) and in two subgroups of CP patients (unilateral and bilateral). Methods: In this retrospective study, CP patients with different degrees of clinically measured maximum dorsiflexion were included. We further subdivided patients into unilaterally and bilaterally affected individuals and also included a healthy control group. All participants underwent a 3D gait analysis. Our goal was to determine the degree of maximum clinical dorsiflexion where the functional changes in range of motion (ROM) and ankle moment and power during gait were most evident. Then, a subgroup analysis was performed according to the affected side. Results: In all, 71 and 84 limbs were analyzed in unilaterally and bilaterally affected subgroups. The clinically 0° dorsiflexion group barely reached a plantigrade position in the 3D gait analysis. Differences in ROM were observed between subgroups. Ankle moment was quite similar between different subgroups but to a lower extent in the unilateral group. All CP patients had reduced ankle power compared to controls. Conclusions: A cutoff value of clinical ≤ 5° dorsiflexion is the recommended value for defining a functionally relevant equinus foot in CP patients. [ABSTRACT FROM AUTHOR]

Purpose: The effective mechanical advantage (EMA) of the plantarflexor muscles is important for gait function and is likely different from typical in equinus gait. However, this has never been quantified for children who idiopathically toe-walk (ITW), despite being routinely altered through clinical intervention. Methods: This study quantified the Achilles tendon and ground reaction force (GRF) moment arms, and the plantarflexor EMA of 5 children who ITW and 14 typically developing (TD) children, whilst walking on an instrumented treadmill. Results: There was no difference in the Achilles tendon moment arm length throughout stance between groups (p > 0.05). Children who ITW had a significantly greater GRF moment arm length in early stance (20–24% p = 0.001), but a significantly shorter GRF moment arm length during propulsion (68–74% of stance; p = 0.013) than TD children. Therefore, children who ITW had a greater plantarflexor EMA than TD children when active plantarflexion moments were being generated (60–70% of stance; p = 0.007). Consequently, it was estimated that children who ITW required 30% less plantarflexor muscle force for propulsion. Conclusion: Clinical decision making should fully consider that interventions which aim to restore a typical heel-toe gait pattern risk compromising this advantageous leverage and thus, may increase the strength requirements for gait. [ABSTRACT FROM AUTHOR]

Equinus deformity is a common cause of foot and ankle pathology. The purpose of our study was to evaluate the role of the plantaris in equinus. Secondary aims were to describe the role of the plantaris in intramuscular gastrocnemius recession and to determine the prevalence of the plantaris in our patient population. We measured ankle dorsiflexion during the steps of a Baumann-type intramuscular gastrocnemius recession. Eighty-nine patients were enrolled in our study. Fourteen of 89 (15.7%) patients did not have a plantaris. A mean dorsiflexion of 9 (interquartile range 6-12)° was obtained after transection of the plantaris tendon and an additional mean 8 (interquartile range 5-10)° was obtained after recession of the gastrocnemius aponeurosis. There was a strong positive correlation (rs = 0.842) of dorsiflexion increase after plantaris transection and dorsiflexion increase after gastrocnemius recession (p <.00). Linear regression showed that for every one-degree of dorsiflexion increase with plantaris transection, there was a predicted dorsiflexion increase of 0.69° with gastrocnemius recession. These results indicate that the plantaris is a component of equinus deformity. [ABSTRACT FROM AUTHOR]

Acute correction of rigid drop foot deformity can be problematic due to the skin defect that may occur in the medial part of the ankle. The purpose of this study is to present an innovative solution for this problem. We hypothesized that acute correction for rigid ankle contractures without arthrosis might be possible if the medial skin defect could be closed. Therefore, we described a surgical technique for acute functional correction of rigid drop foot deformities. The closure of the medial defect was performed by applying a flap and partial-thickness skin graft. We have retrospectively evaluated the results of 18 patients who were treated between 2010 and 2016 with this technique. The mean age of the patients was 37 ± 9.5 (22-56) years. Foot drop etiology was firearm-related nerve injury. Corrections were performed after 14.6 ± 7.9 (8-38) months following the injury. At the end of an average follow-up period of 44.4 ± 6.2 (37-60) months, 14 of 18 patients (78%) recovered without complications, 3 patients experienced partial loss in the medial skin graft region, and 1 patient developed a superficial infection. None of the patients have developed pes planus. We observed that the ankle flexion contracture, which was 34° ± 9.2° (20°-50°) preoperatively, could reach an average of 2.2° ± 2.5° (0°-6°) dorsiflexion after surgery. We suggest that acute correction and tibialis posterior tendon transfer in the treatment of rigid foot drop deformity can be performed with an effective skin closure with low soft tissue complications. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Recurrence in cerebral palsy (CP) patients who have undergone operative or non-operative correction varies greatly from one study to another. Therefore, we conducted this meta-analysis to determine the pooled rate of equinus recurrence following its correction either surgically or non-surgically. Methods: Nine electronic databases were searched from inception to 6 May 2021, and the search was updated on 13 August 2021. We included all studies that reported the recurrence rate of equinus following its correction among CP patients. The primary outcome was recurrence, where data were reported as a pooled event (PE) rate and its corresponding 95% confidence interval (CI). We used the Cochrane's risk of bias (RoB-II) tool and ROBINS-I tool to assess the quality of included randomized and non-randomized trials, respectively. We conducted subgroup analyses to identify the sources of heterogeneity. Results: The overall rate of recurrence was 0.15 (95% CI: 0.05–0.18; I2 = 88%; p < 0.01). Subgroup analyses indicated that the laterality of CP, study design, and intervention type were significant contributors to heterogeneity. The recurrence rate of equinus differed among interventions; it was highest in the multilevel surgery group (PE = 0.27; 95% CI: 0.19–0.38) and lowest in the Ilizarov procedure group (PE = 0.10; 95% CI: 0.04–0.24). Twelve studies had a low risk of bias, eight had a moderate risk, and nine had a serious risk of bias. Conclusion: The recurrence of equinus following its correction, either surgically or non-surgically, in CP patients is notably high. However, due to the poor quality of available evidence, our findings should be interpreted with caution. Future studies are still warranted to determine the actual risk of equinus recurrence in CP. [ABSTRACT FROM AUTHOR]

Background and Objectives: Ambulant children with cerebral palsy can demonstrate persistent "foot drop" after successful gastrocsoleus lengthening (GSL) surgery for equinus deformity. This may be due to inadequate strength and/or selective motor control of the ankle dorsiflexor muscles. A procedure has been developed to reduce foot drop—Tibialis Anterior Tendon Shortening (TATS), to be performed in conjunction with GSL. However, it is currently unclear how ankle dorsiflexor function changes after surgery and which children could benefit from TATS. This review summarises changes in ankle dorsiflexor function after GSL for equinus, as reported in the literature. Methods: A search was performed of the Medline, Embase and PubMed databases from 1980 to 5 March 2021. Keywords included "cerebral palsy", "equinus deformity", "orthopedic procedures" and "gait analysis". The search identified 1974 studies. Thirty-three cohort studies met the inclusion criteria for this review. Results: Twenty-two studies reported improvement in swing phase ankle dorsiflexion kinematics, after GSL. There was also evidence that clinical measures of ankle dorsiflexor strength improved after surgery. Four studies reported changes in selective motor control, with mixed results across the studies. Conclusions: There is good evidence that swing phase ankle dorsiflexion improves after GSL surgery. Although, there is limited evidence that this correlates with reduced foot drop or diminished need for an ankle-foot orthosis. Future research should be prospective, randomised, include a large sample size, and should focus on identifying the optimal candidates for TATS. [ABSTRACT FROM AUTHOR]

Ankle spasticity in the cerebral palsy walking child: comparative study botulinum toxin A versus rehabilitation. The spastic form of cerebral palsy (PC) is very common,accounting for more than 80% of PC cases. Spasticity leads to muscle contractures and bone deformities accountable for activity and participation limitations in growing children. The treatment of ankle spasticity relies mainly on intramuscular injections of botulinum toxin A and rehabilitation. Aim - The purpose of this paper was to access the efficacy and the limits of bot toxinA in comparing the therapeutic evolution of the ankle spasticity during three controls (at one month, three months and six months) in the groups treated respectively by botulinum toxin A alone, rehabilitation alone and the combination of these two therapies, and to compare the outcomes of therapeutic evolution in the three groups on gait. Patients and methods - A comparative randomized descriptive study in three therapeutic groups (botulinum toxin group «A» associated with rehabilitation (G1), botulinum toxin group «A» (TBA) alone (G2), rehabilitation group alone (G3) during the controls and involving 122 lower limbs of 72 children (24 children per group) with spastic CP, classified GMFCS (I to III) and aged from 2 to 16 years. The clinical evaluation was done by the Modified Tardieu scale (MTS) for passive amplitudes and spasticity, PRS (Physicians Rating Scale) for walking. This study was carried out in the physical and rehabilitation medicine PRM department of Oran’s hospital and university center during the period of January 2016 to June 2017. The Tardieu Scale measures spasticity using 2 parameters: the spasticity angle X is the difference between the angles of arrest at slow speed and of catch-and-release or clonus at fast speed, whereas the spasticity grade Y is an ordinal variable that grades the intensity and thus measures the gain of the muscle reaction to fast stretch. Results - In the intervention groups, the combination of TBA and rehabilitation gave a statistically significant improvement in the ankle of the mean angle of passive dorsiflexion of the flexed knee ankle (p = 0.04) and tense knee (p = 0.003) in the first month. This improvement continues in the third and sixth months. The decrease in the mean angle of onset of flexed knee and tense knee spasticity was statistically significant in the first month (p = 0.03, p≤10-3) and in the third month. Mean soleus and gastrocnemius tone decreased statistically significantly in all three controls. In G2, the improvement of the average angle of the dorsal flexion, flexed knee and stretched knee, occurs in the third month (p = 0.05, p = 0.003). The improvement in the average angle of onset of spasticity and tone was statistically significant in the first and third months. In the G3 improvement of the mean of all these parameters was statistically insignificant. Conclusion - Rehabilitation associated with abobotulinumtoxin «A» injections gives better results on joint amplitudes, muscle tone and walking quality in children walking spastic CP. These results are maintained until the sixth month.

Background: In patients with rheumatoid arthritis (RA), the pathological progression of lower limb biomechanics is established. Although specific aspects of RA gait patterns have been studied and described, we are aware of no studies of gait pattern compensations over the entire disease course. This study aimed to describe a model that could predict the evolution of lower limb pathomechanics in patients with RA., Methods: A literature review was conducted of electronic databases (MEDLINE, PEDro, Trip Database, DOAJ, BioMed Central, PLOS clinical trial, ScienceDirect, and CRD York University, AHRQ, NICE, Cochrane Library) to October 3, 2023., Results: A theory was developed that all people with RA induce or augment gait evolution syndromes following the same biomechanical course. Specifically, we postulate the "rheumatoid equinus syndrome," the "rheumatoid abnormal pronation syndrome" and the "rheumatoid shuffle syndrome," which have never been described before., Conclusions: A new model of the evolution of gait compensation in RA is proposed. An important challenge of RA is that it increases the risk of ulcerative lesions, falls, pain, fractures, and healthcare costs. The proposed model can be used to reduce morbidity in this patient group by helping to explain and reduce the pain, deformity, and ankylosis of foot RA.

Background: The most common form of movement disorder presented in children with cerebral palsy is spasticity, and dynamic equinus is the most common spastic ankle deformity. Botulinum toxin (BT) injection is now an established first-line treatment for focal spasticity., Aim: To assess the effects of BT injection with casting in the treatment of dynamic equinus in children diagnosed with cerebral palsy with spastic diplegia., Setting and Design: A prospective randomized controlled trial was conducted among patients aged 2-12 years with cerebral palsy and spastic diplegia, attending the general outpatient department and admitted to the indoor facility of the Department of Physical Medicine and Rehabilitation and the Department of Pediatric Orthopedics at King George's Medical University, Lucknow., Material and Methods: Two groups of 19 patients each were formed. Group A received BT injection with casting, whereas in group B, only a cast was applied. Outcome measures including spasticity by Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), range of motion (ROM), passive ankle dorsiflexion, and Gross Motor Function Measure (GMFM-66) (dimensions D and E) were assessed before and after the intervention., Results: The participants in groups A and B were age-matched. A statistically significant difference was seen within group A and group B for MAS, passive ROM-dorsiflexion (PROM-DF), and passive ROM-plantarflexion (PROM-PF) at various follow-ups. In the 3rd week, MAS in each group was statistically insignificant (p-value> 0.05)., Conclusion: There was a significant improvement in tone and a significant increase in the passive range of motion in both groups., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics Committee, King George's Medical University, Lucknow issued approval 795/ethics/2020. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Vishwakarma et al.)

Purpose: To compare muscle strength, ankle dorsiflexion range of motion (ROM), motor coordination and balance, between children with and without Idiopathic Toe Walking (ITW). Materials and methods: This is an observational case-control study. The primary outcome is the triceps surae muscle strength. The secondary outcomes are the anterior tibialis muscle strength, lower limb balance, motor coordination, and ankle dorsiflexion ROM. Thirty-eight children were recruited: 19 between 5 to 11 years old with ITW and 19 healthy (control). Ankle dorsiflexion ROM, triceps surae, anterior tibialis muscle strength, motor coordination, and balance were assessed. Results: Children with ITW showed reduced triceps surae strength [mean difference (MD): 16.2 kgf/kg*100; 95% confidence interval (CI) −32.72 to 0.28; p =.05], reduced anterior tibialis strength (MD: 8.5 kgf/kg*100; 95% CI −13.35 to −3.05; p ≤ 0.001), reduced ankle dorsiflexion ROM (MD: 19.6 degrees; 95% CI 15.43 to 23.77; p ≤ 0.001) and impaired motor coordination and balance (MD: 17.7; 95% CI −25.54 to −9.82; p ≤ 0.001) compared to healthy children. Conclusion: Children with Idiopathic Toe Walking, presented in this study, demonstrated triceps surae and anterior tibialis muscle strength reduction, ankle dorsiflexion ROM reduction, impaired motor coordination, and balance compared to healthy children. [ABSTRACT FROM AUTHOR]

Retrocalcaneal exostosis can be debilitating and in severe cases, surgical resection is indicated. Complications can arise from surgical resection of the exostosis and reattachment of the Achilles tendon, including irritation of the suture knot, recurrence of the bony prominence, and dehiscence. The use of a buried knot technique with functional lengthening of the Achilles tendon and gastroc-soleal muscle complex can minimize these complications. Complete detachment of the Achilles tendon allows for aggressive and thorough resection of the exostosis and functional lengthening with reattachment. The buried cruciate knot technique allows for firm reattachment with buried knots to prevent soft tissue irritation. A total of fourteen patients (14 limbs) underwent retrocalcaneal enthesophyte resection with functional Achilles tendon lengthening, (8/14) of which had difficultly wearing shoe gear, (10/14) had edema, and (2/14) had erythema preoperatively. Postoperatively, (11/14) of patients returned to full activities and sports, and (11/14) returned to normal shoe gear. Complications included (1/14) of patients with Achilles tendon avulsion and (3/14) of patients with surgical site dehiscence requiring revisional surgery. Overall, this technique helps prevent short-term complications and long-term recurrence due to the functional lengthening mitigating insertional forces on the Achilles tendon. [ABSTRACT FROM AUTHOR]

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; large effect sizes). The passive lengthening properties of the muscle and tendon were not different between groups (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. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of surgical release and Botulinum Toxin injections for treating foot equinus in Cerebral Palsy (CP) patients. Methodology: This Quasi-experimental study was conducted in the Orthopedic Department, Khyber Teaching Hospital (KTH) Peshawar-Pakistan. The study enrolled 60 patients from 1st March 2018 to 1st June 2019 via non-probability consecutive sampling. All diagnosed cases of CP with equinus foot of either gender and age between 4-18 years with no previous surgery or botulinum injections and no joint deformity were included; while all patients with myasthenia gravis, neuromuscular junction disease, use of aminoglycoside, and those with discontinued physiotherapy were excluded. The patients were distributed into two equal groups, group A (botulinum group) and group B (surgery group). The outcome of the interventions in each group was measured based on improvement in Gross Motor Function Measure-66 (GMFM-66). Data was analysed using SPSS v.21.0, descriptive and analytical analysis was conducted where needed. Results: The mean age of patients was 11.47±4.01 years with male to female ratio of 1.22:1. The right and left foot distribution among the patients was 31 (52%) and 29 (48%) respectively. Botulinum type A (BTX-A) injection resulted in improvement of GMFM-66 score in 27 (90%) patients in group A while the surgical release was effective in 20 (66.7%) patients in group B in terms of improvement in GMFM-66 score. Conclusion: The study concluded that Botulinum Toxin has much better effectiveness as compared to surgical release in treatment of foot equinus among CP patients. [ABSTRACT FROM AUTHOR]

New Findings: What is the central question of this study?What are the in vivo operating lengths of the gastrocnemius muscle in children who idiopathically toe‐walk?What is the main finding and its importance?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. 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 moment–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 = 12 mm; 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. 37 mm; P = 0.001) in children who ITW than TD children. Observed alterations in the moment–angle and moment–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 idiopathic toe‐walking is truly an ankle joint pathology, and children who ITW present with substantial alterations in the gastrocnemius muscle functional properties, which appear well adapted to the characteristic demands of equinus gait. These findings should be considered when prescribing clinical treatments to restore typical gait. [ABSTRACT FROM AUTHOR]

The objective of this investigation was to analyze the surgical anatomy of the endoscopic gastrocnemius recession procedure with reference to the curved nature of the aponeurosis. A consecutive series of 34 magnetic resonance imaging scans were evaluated under the direction of a musculoskeletal radiologist. An angular calculation of the effective curvature of the aponeurosis was measured 2 cm distal to the musculotendinous junction based on the maximal posterior excursion and terminal medial and lateral edges. A frequency count was additionally performed of the number of deep intramuscular septa extending from the aponeurosis, as well as a description of the location of the neurovascular bundle in this location. The mean effective curvature was 126.5 degrees (standard deviation [SD] = 6.3 degrees, range 115-143 degrees, 95% confidence interval 124.3-128.7 degrees). We observed an average of 1.2 (SD = 0.5, range = 0-2) deep intramuscular septa extending from the aponeurosis, and that 20.6% of neurovascular bundles were located superficial to the aponeurosis in this location. In conclusion, we found that a straight cannula needs to be navigated around an approximate 125-degree angle during performance of the EGR procedure. We think that this information provides evidence of potentially unrecognized complications of this procedure and leads to future investigations demonstrating anatomic and procedural outcomes. [ABSTRACT FROM AUTHOR]

Background: Equinus foot is the deformity most frequently observed in patients with cerebral palsy (CP). While there is widespread agreement on the treatment of equinus foot, a clear clinical definition has been lacking. Therefore, we conducted this study to evaluate functional changes in gait analysis in relation to maximum possible dorsiflexion (0°, 5°, 10° and 15°) and in two subgroups of CP patients (unilateral and bilateral). Methods: In this retrospective study, CP patients with different degrees of clinically measured maximum dorsiflexion were included. We further subdivided patients into unilaterally and bilaterally affected individuals and also included a healthy control group. All participants underwent a 3D gait analysis. Our goal was to determine the degree of maximum clinical dorsiflexion where the functional changes in range of motion (ROM) and ankle moment and power during gait were most evident. Then, a subgroup analysis was performed according to the affected side. Results: In all, 71 and 84 limbs were analyzed in unilaterally and bilaterally affected subgroups. The clinically 0° dorsiflexion group barely reached a plantigrade position in the 3D gait analysis. Differences in ROM were observed between subgroups. Ankle moment was quite similar between different subgroups but to a lower extent in the unilateral group. All CP patients had reduced ankle power compared to controls. Conclusions: A cutoff value of clinical ≤ 5° dorsiflexion is the recommended value for defining a functionally relevant equinus foot in CP patients.