Acquired Spastic Equinovarus Deformity - Foot & Ankle

Introduction

Acquired spastic equinovarus deformity is most commonly caused by
- cerebrovascular accident (CVA)
- traumatic brain injury (TBI)
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.
Associated conditions
- joint contractures
- hyperextension of knee in stance phase
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

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)
- osteotomies and fusions
  - indications
    - recurrence of deformity despite proper soft tissue procedures

Surgical 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

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(OBQ05.236) A 65-year-old female developed a right foot deformity 3 years ago following a cerebrovascular accident. She initially underwent early intervention with physical therapy and splinting. However, passively correctable contractures persist and the braces are causing skin problems on the leg. What is the most likely foot and ankle deformity in this patient and the most appropriate surgical treatment to be combined with a planned tendoachilles lengthening (TAL)? Review Topic

QID: 1122

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Spastic equinovarus and split anterior tibialis tendon transfer (SPLATT)

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Flaccid equinovarus and medializing calcaneal ostetomy and flexor hallucis longus transfer

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Spastic calcaneovalgus and split anterior tibialis tendon transfer (SPLATT)

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Flaccid equinovalgus and split anterior tibialis tendon transfer (SPLATT)

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Spastic equinovalgus and medializing calcaneal ostetomy and flexor hallucis longus transfer

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