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Updated: Nov 29 2021

Cerebral Palsy - Foot Conditions

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Images
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
  • summary
    • Foot Conditions are the most common deformity seen in Cerebral Palsy which are caused by lower extremity spasticity and can take several forms including equinus, hallux valgus, equinocavovarus, and equinoplanovalgus. 
    • Diagnosis is made clinically with presence of spasticity/contracture of the gastrocsoleus complex in equinus, presence of a spastic hallux valgus, and supination deformities of the midfoot and forefoot.
    • Treatment is usually bracing and shoe modifications for mild and flexible conditions. Surgical management is indicated for progressive deformities that are not amenable to bracing. 
  • Etiology
    • 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
          • Silfverskiold 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 Silfverskiöld test shows gastrocsoleus complex tightness
            • gastrocnemius recession if Silfverskiöld 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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