summary Acquired Spastic Equinovarus Deformity is a progressive foot deformity most commonly seen in patients following a cerebrovascular accident or traumatic brain injury. Diagnosis is made clinically with presence of a spastic equinovarus foot deformity in a patient with a prior CVA or TBI. Treatment is an initial trial of observation with bracing. Surgical management is indicated for fixed contractures that persist after the period of neurologic recovery and are not braceable. Etiology Pathophysiology equinus secondary to overactivity of the gastrocnemius-soleus complex varus due to relative overactivity of the tibialis anterior, with lesser contributions from the FHL, FDL, and tibialis posterior. Etiology cerebrovascular accident (CVA) traumatic brain injury (TBI) Associated conditions joint contractures hyperextension of knee in stance phase Presentation Symptoms deformity and difficulty with gait Physical exam most common physical finding is spastic equinovarus deformity increased tone hyperreflexia Imaging Radiographs recommended views AP, lateral, oblique of foot and ankle Treatment Nonoperative physical therapy, injections, orthoses indications as first line of treatment modalities therapy focus on stretching and strengthening, maintenance of joint range of motion injections phenol blocks and botulinum toxin injections are used AFO should be used while the patient is in bed or wheelchair Operative Achilles tendon lengthening with split anterior tibialis tendon transfer (SPLATT) indications fixed contractures persist after the period of neurologic recovery and are not braceable. functional deficits skin problems secondary to deformity technique equinus deformity is treated with lengthening of the Achilles tendon varus deformity is treated with a split anterior tibialis tendon transfer (SPLATT) Bridle procedure technique posterior tibialis tendon is transferred through the interosseous membrane to the dorsum of the foot dual anastomosis to the tendon of the anterior tibial and a rerouted peroneus longus in front of the lateral malleolus osteotomies and fusions indications recurrence of deformity despite proper soft tissue procedures Techniques Split anterior tibialis tendon transfer (SPLATT) often done in conjunction with achilles lengthening (open or percutaneous) gastrocnemius recession lengthening or dorsal transfer of the posterior tibialis tendon (PTT) may also be necessary the tibialis anterior is split and the lateral half is attached to the cuboid through a drill hole and sutured in place Complications Hindfoot valgus inadvertent lengthening of PTT can result in over correction Prognosis Neurologic recovery can take 6 to 18 months in patients who have had a CVA 25% regain normal ambulation 75% regain some level of ambulation neurologic recovery can take years with TBI