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Updated: Jun 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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