The key to this patient's presentation is the occurrence of the stroke only 3 months ago. Miller Review states at least a 6 month delay is required and the review article by Younger and Hansen state a delay of 18 to 24 months between cerebral injury and reconstructive surgery is advisable because of the possibility of various degrees of functional recovery. The critcial components to nonoperative management include AFO fitting, early intervention with physical therapy, stretching and strengthening, and maintenance of joint range of motion. Phenol or botox injections can also be useful nonsurgical adjuvants.
Equinovarus posturing is the most common ankle-foot abnormality following a stroke. The equinus component is caused by overactivity of the gastrocnemius-soleus complex. The varus is due to relative overactivity of the tibialis anterior, with contributions from the tibialis posterior, FHL, and FDL. Each of the surgical options are reasonable treatments for this patient's presentation if there had been an adequate interval between the patient's cerebral insult and he had failed conservative management.
Mann RA, Coughlin MJ, ed. Surgery of the Foot and Ankle, ed 6. St. Louis, MO, Mosby, 1993, pp 604-605
Younger AS, Hansen ST Jr. Adult cavovarus foot. J Am Acad Orthop Surg. 2005 Sep;13(5):302-15.
PMID:16148356 (Link to Abstract)