Updated: 6/8/2021

Acquired Spastic Equinovarus Deformity

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  • 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)
      • 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

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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)?

QID: 1122
1

Spastic equinovarus and split anterior tibialis tendon transfer (SPLATT)

79%

(2276/2879)

2

Flaccid equinovarus and medializing calcaneal ostetomy and flexor hallucis longus transfer

5%

(145/2879)

3

Spastic calcaneovalgus and split anterior tibialis tendon transfer (SPLATT)

4%

(121/2879)

4

Flaccid equinovalgus and split anterior tibialis tendon transfer (SPLATT)

5%

(150/2879)

5

Spastic equinovalgus and medializing calcaneal ostetomy and flexor hallucis longus transfer

6%

(176/2879)

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