Updated: 10/15/2019

Cerebral Palsy - Foot Conditions

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https://upload.orthobullets.com/topic/12120/images/cpfa.jpg
https://upload.orthobullets.com/topic/12120/images/equinusheel.jpg
https://upload.orthobullets.com/topic/12120/images/tal.jpg
https://upload.orthobullets.com/topic/12120/images/cp equinovalgus_moved.jpg
https://upload.orthobullets.com/topic/12120/images/equinovalgusxr.jpg
https://upload.orthobullets.com/topic/12120/images/equinovarus-foot.jpg
Introduction
  • See Cerebral Palsy General
  • Foot deformities are common in cerebral palsy and may take several forms including
    • Equinus
    • Hallux Valgus 
    • EquinoPlanoValgus 
    • EquinoCavovarus
Equinus
  • Epidemiology
    • most common deformity in cerebral palsy
  • Pathophysiology
    • imbalance of ankle dorsiflexors and plantarflexors, resulting in plantar flexion of the hindfoot relative to the ankle, with normal mid- and forefoot alignment
    • spasticity/contracture of the gastrocsoleus complex 
  • Presentation
    • symptoms
      • shoe fitting / wear and tear
      • tripping secondary to poor foot clearance
      • instability due to decreased base of support
    • physical exam
      • inspection
        • forefoot callosities
        • toe walking or absent heel strike during gait
        • compensatory hyperextended knee with heel contact
        • equinoplanovalgus in late stages
      • motion
        • evaluate degree of spacticity and total motion
      • provacative tests
        • Silverskiold test
          • improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
          • equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
  • Imaging
    • radiographs not required unless other pathology present (hindfoot malalignment)
  • Treatment
    • nonoperative
      • serial manipulation and casting
        • indications
          • mild spasticity, dynamic, younger patients
      • botulinum toxin A intramuscular injection into gastrocnemius
        • indications
          • mild spasticity, may delay need for surgery
        • mechanism of action
          • blocks presynaptic release of acetylcholine
      • articulated or hinged AFO
        • indications
          • mild and passively correctible deformity with mild spasticity and no myostatic contractures.
        • contraindication
          • presence of excessive ankle dorsiflexion in midstance 
      • solid AFO 
        • indications
          • mild to moderate foot deformities that are partially correctible with mild to moderate spasticity and with mild myostatic contractures
        • contraindications
          • excessive ankle dorsiflexion during midstance in heavy patients, >=12 years of age and significant rigid foot malalignment
    • operative
      • tendo-Achilles lengthening (TAL) versus gastrocnemius recession 
        • indications
          • rarely indicated as an isolated procedure, except in hemiplegia
          • TAL if Silverskiold test shows gastrosoleus complex tightness
          • gastrocnemius recession if Silverskiold test shows isolated gastrocnemius tightness
  • Techniques
    • Gastrocnemius recession
      • approach
        • posterior or posterior medial calf incision
      • soft tissue
        • dissect through subcutaneous tissues, identify sural nerve and retract from field
        • dorsiflex foot and palpate aponeurosis
        • incise fascia trasnversely or in U-fashion, should see noticable increase in foot dorsiflexion
        • fascia may be sutured to underlying soleus muscle, sutured side-to-side, or left free
        • immobilize with cast in neutral dorsiflexion
      • outcomes
        • requires less immobilization but higher recurrence rate compared to TAL
    • Tendo-Achilles lengthening (TAL)
      • approach
        • percutaneous or open posterior longitudnal incision over Achilles tenodn
      • soft tissue
        • dissect through subcutaneous tissues avoiding neurovascular structures, identify tendon
        • perform tenotomies in slide or z-lengthening fashion with foot dorsiflexed
        • should see noticable increase in foot dorsiflexion
        • immobilze in walking cast for 4-6 weeks
Hallux Valgus
  • Epidemiology
    • most common in diplegics with equinus and planovalgus feet
    • associated with equinovalgus and external tibial torsion
  • Pathophysiology
    • caused by combination of adductor hallucis overactivity and externally applied forces, such as inadequate clearance resulting from equinovalgus deformity, forcing the great toe into valgus.
  • Presentation
    • symptoms
      • pain and difficulty wearing proper shoes
    • physical exam
      • inspection
        • hallux lies underneath 2nd toe
        • painful bunion/callosity over 1st MT head
  • Imaging
    • radiographs
      • recommend views 
        • standard weight-bearing series
      • findings
        • increased HVA, IMA, DMMA, HVI
  • Treatment
    • nonoperative
      • observation
        • indications
          • no pain or difficulty with footwear
    • operative
      • first metatarsophalangeal joint arthrodesis
        • indications
          • painful hallux valgus
        • outcomes
          • highest overall success rate compared to other surgeries in ambulatory and nonambulatory children with cerebral palsy
          • recurrence rate is unacceptably high with the other procedures
      • proximal phalanx (Akin) osteotomy  
        • indications
          • hallux valgus with associated valgus interphalangeus
  • Techniques 
EquinoPlanoValgus
  • Epidemiology
    • incidence
      • common foot deformity seen with cerebral palsy (spastic diplegic and quadriplegic) 
    • location
      • typically bilateral
  • Pathophysiology
    • equinus with pronation deformity
    • pathomechanics
      • due to comination of spastic peroneal muscles, weak posterior tibialis, spastic heel cord in ligamentous laxity foot
      • creates lever arm dysfunction during gait
      • leads to bearing weight on the medial border of the foot and talar head
      • external rotation of the foot creates instability during push off
  • Presentation
    • symptoms
      • painful callus over talar head secondary to weight-bearing
      • shoe wear problems
    • physical exam
      • inspection
        • typically bilaterally
        • valgus heel deformity seen when viewing feet from posterior 
        • prominent talar head appreciated in the arch
        • midfoot break occurs in attempt to keep foot plantigrade 
        • hallux valgus typically develops over time
      • motion
        • the hindfoot valgus deformity must be manually corrected first before testing for achilles contracture
          • a valgus heel can mask an equinus contracture by allowing a shortened path for the achilles
  • Imaging
    • Radiographs 
      • recommended views
        • weight-bearing AP radiographs of the ankles must be obtained to rule out ankle valgus as cause of deformity
      • findings 
        • decrease in the calcaneal pitch
        • negative talo-first metatarsal angle on lateral view
        • uncovering of talar head
  • Treatment
    • Nonoperative
      • bracing 
        • indications
          • flexible deformities
    • Operative
      • bony and soft tissue procedures
        • indications
          • pain or pressure sores despite bracing
        • soft tissue procedures
          • tendo-Achilles lengthening
          • peroneus brevis lengthening
          • posterior tibial tendon advancement
        • bony procedures
          • calcaneal osteotomy
          • lateral column lengthening (Evans procedure)
          • Grice procedure
          • subtalar arthroereisis
  • Techniques
    • calcaneal osteotomy and lateral lengthening  
      • approach
        • incision along lateral border of calcaneus, avoiding sural nerve
      • bone work
        • medial slide osteotomy- oblique cut through calcaneus with posterior fragment slid medially and into varus
        • lateral column lengthening- trasnverse osteotomy anterior to middle facet, trapezoidal bone graft interposed
      • instrumentation 
        • percutaneous k-wires, cannulated screws or laterally-placed plate
      • complications
        • destabilized calcaneocuboid joint if accessed during lengthening
    • Grice procedure  
      • approach
        • sinus tarsi approach
      • soft tissue
        • fatty tissue removed sinus tarsi without violating joint capsule
      • bone work
        • calcaneus decorticated, joint manipulated into varus
        • bone autograft sized and placed into graft bed, soft tissued sutured to hold graft in place
      • outcomes
        • does not interfere with tarsal bone growth
    • subtalar arthroereisis 
      • approach
        • lateral approach to subtalar joint
      • bone work
        • place polyethylene plug or staple laterally in subtalar joint
      • outcomes
        • stabilizes subtalar joint in correct alignment without fusion
      • complications
        • plug breakdown
  • Complications
    • overcorrection into varus 
      • most common complication
    • sural nerve injury
      • at risk during calcaneal osteotomy procedures
    • overlengthening of lateral column 
      • results in a painful lateral forefoot secondary to overload
EquinoCavoVarus
  • Epidemiology
    • more common in spastic hemiplegia
  • Pathophysiology
    • equinus deformity of the hindfoot coupled with supination deformities of the midfoot and forefoot
    • pathomechanics
      • invertors (posterior tibialis and/or anterior tibial tendons) overpower evertors (peroneal tendons)
      • creates lever arm dysfunction during gait
      • disrupts the second rocker by blocking ankle dorsiflexion and compromises stability function in midstance
      • shortens the length of the plantar flexor muscles, compromising their ability to generate tension
  • Presentation
    • symptoms
      • painful weight-bearing
      • shoe wear issues
    • physical exam
      • inspection
        • equinus contracture
        • callosities on lateral border of foot and 5th metatarsal 
      • motion
        • internal foot progression angle during gait
        • foot drop if weakened tibial anterior
        • supinated foot position during tibialis anterior activation (indicates main source of equinovarus)
  • Imaging
    • radiographs
      • recommended views
        • weight-bearing foot and ankle series
      • findings
        • metatarsal overlap
        • increased calcaneal pitch
  • Treatment 
    • nonoperative
      • bracing
        • indications
          • supple deformity
        • rarely successful and often worsens calluses and blisters
    • operative
      • soft tissue balancing
        • tendo-Achilles lengthening and posterior tibial tendon muscular lengthening
          • indications
            • done in combination with SPLATT to address fixed equinus contracture
        • split posterior tibial tendon transfer (SPOTT)
          • indications
            • passively correctable deformity
            • between ages of 4 and 7 years 
        • split anterior tibialis tendon transfer (SPLATT)
          • indications
            • passively correctable deformity with spastic tibialis anterior muscle
          • contraindications
            • weak tibialis anterior and footdrop
      • bony procedures
        • calcaneal osteotomy
          • indications
            • done in combination with soft tissue balancing 
            • fixed varus hindfoot deformity
        • arthrodesis
          • indications
            • done in combination with soft tissue balancing
            • severe fixed deformity
  • Technique
    • split posterior tibial tendon transfer (SPOTT)
      • approach
        • medial 1- or 2-incisions centered over PT tendon at ankle, tendon sheath opened but flexor retinaculum not released
        • lateral incision centered over peroneals, from lateral malleolus to base of 5th metatarsal
      • soft tissue
        • tendon split up to musculotendinous junction 
        • posterior portion re-routed posteriorly to tibia/fibula and anterior to neurovascular bundle
        • tendon woven and sutured into peroneus brevis tendon
        • cast applied with foot abducted and neutral flexion
      • outcomes
        • more consistent outcomes than with full tendon transfer
    • split anterior tibialis tendon transfer (SPLATT)
      • approach
        • incision centered over tibial anterior tendon
      • soft tissue
        • tendon released from 1st metatarsal and split up to musculotendinous junction
        • re-routed laterally under extensor retinaculum 
        • transosseous tunnel through cuboid, tendon sutures tied over button while foot in dorsiflexion
    • calcaneal osteotomy
      • approach
        • lateral incision along border of calcaneus, avoid sural nerve branches
      • bone work
        • slide osteotomy- oblique cut through calcaneus posterior fragment slid laterally and into valgus
        • closing wedge osteotomy- wedge taken from lateral cortex
      • instrumentation
        • two cannulated screws or staples for osteotomy fixation
    • triple arthrodesis
      • approach
        • lateral incision along border of calcaneus avoiding sural nerve
        • medial incision centered over talonavicular joint
      • bone work
        • subtalar joint accessed first to address hindfoot varus
        • calcaneocuboid and talonavicular joints denuded of cartilage
        • osteotomy may be required to fuse in slight valgus
      • instrumentation
        • percutaneous k-wires 
      • complications
        • recurrence of deformity if soft tissues not balanced
  • Complications
    • Deformity recurrence
      • failure to recognize and address all components
 

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(SAE07PE.24) Figure 12 shows the radiograph of a 15-year-old boy with cerebral palsy who has pain at the first metatarsophalangeal joints. He is a community ambulator. Management consisting of accommodative shoes has failed to provide relief. What is the treatment of choice? Review Topic

QID: 6084
FIGURES:
1

Custom-molded night orthotics

3%

(6/194)

2

Double osteotomy of the first metatarsals

50%

(97/194)

3

Crescentic osteotomy of the first metatarsals

10%

(19/194)

4

Distal realignment (modified McBride)

13%

(26/194)

5

First metatarsophalangeal joint arthrodeses

24%

(46/194)

L 5

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SUBMIT RESPONSE 5

You have 100% on this question.
Just skip this one for now.

(SAE07PE.47) Split posterior tibial tendon transfer is used in the treatment of children with cerebral palsy. Which of the following patients is considered the most appropriate candidate for this procedure? Review Topic

QID: 6107
1

A 6-year-old child with athetosis and a flexible equinovarus deformity of the foot

9%

(15/168)

2

A 6-year-old child with spastic hemiplegia and a rigid equinovarus deformity of the foot

10%

(16/168)

3

A 6-year-old child with spastic hemiplegia and a flexible equinovarus deformity of the foot

74%

(124/168)

4

A 10-year-old child with spastic quadriplegia and rigid valgus deformities of the feet

1%

(1/168)

5

A 15-year-old child with spastic diplegia and rigid equinovalgus deformities of the feet

7%

(11/168)

L 1

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SUBMIT RESPONSE 3
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