Specific problems

Foot and ankle

Tendon transfers

· most commonly performed for drop foot

Dorsiflexor weakness

· foot falls into plantarflexion

· anterior soft tissue structures stretch

Tibialis anterior paralysis

Deformity

· loss of dorsiflexion and inversion

· develop equinovalgus deformity

· long toe extensors become overactive in swing phase

· results in cockup hallux and claw toes

Treatment

· initial treatment aimed at correcting equinus

· stretching and serial casts to overcome equinus

· lengthening of triceps surae not indicated as weakens muscle

· then transfers performed

· anterior transfer of peroneus longus to base of 2nd metatarsal

· peroneus brevis sutured to distal stump of peroneus longus

· long-toe extensors transferred to metatarsal necks for claw-toes

Tibialis posterior paralysis

Deformity

· hindfoot valgus and forefoot eversion

Treatment

· FDL used as substitute

· rerouted through tib post tunnel and attached to navicular

Tibialis anterior and tibialis posterior paralysis

Deformity

· causes more rapid equinovalgus deformity

Treatment

· initial equinus correction

· then transfers

· peroneus longus for tib ant

· FDL for tib post

Tibialis anterior, toe extensor and peronei paralysis

Deformity

· unopposed tibialis posterior and triceps surae

· leads to severe equinovarus deformity

Treatment

· initial equinus correction

· may require surgical lengthening

· then transfers

· anterior transfer of tibialis posterior to base of 3rd metacarpal

Triceps surae paralysis

Deformity

· initial calcaneus deformity

· then cavus develops

· remaining muscles force foot into equinus

· plantar fascia shortens

· if unbalanced, develop

· calcaneocavo-valgus with weak invertors

· calcaneocavo-varus with weak peronei

Treatment

· if pure calcaneocavus, transfer tibialis anterior to heel

· through interosseous membrane

· into distal stump of tendo Achilles

· if associated valgus, transfer peronei instead

· if associated varus, transfer tib post and FHL instead

Bony procedures

Calcaneal osteotomy

· for correction of hindfoot valgus or varus in growing children

Extra-articular subtalar arthrodesis

· for equinovalgus deformity from tibialis anterior and posterior paralysis

· extra-articular fusion developed by Grice for patients aged 3-8

· modified to use cancellous graft and internal fixation

· ideal indication is

· valgus localised to subtalar joint (cf. ankle joint)

· forefoot mobile enough to be made plantigrade when hindfoot corrected

· most common complication is overcorrection with varus deformity

Triple arthrodesis

Triple

· indicated when most of deformity at subtalar and midtarsal joints

· reserved for severe deformity in children age 12+

· most common complications are

· pseudarthrosis

· ankle arthritis

· avascular necrosis of talus

Lambrinudi

· equinus can be treated with Lambrinudi triple arthrodesis

· uses fixed equinus talus as bone block

· rest of foot brought up to desired dorsiflexion to rest against anterior talar beak

Astragalectomy

· for calcaneus or calcaneovalgus deformity

· for children age 5-12 where arthrodesis cannot be performed

· limits dorsiflexion by creating physiological tibiotarsal bone block

Elmslie double wedge tarsal osteotomy

· for calcaneus deformity in children over age 10

· dorsal wedge excised from talonavicular joint

· posterior wedge excised from subtalar joint

Ankle fusion and pantalar arthrodesis

· ankle fusion performed for flail foot

· also used for recurrence of deformity after triplle arthrodesis

· pantalar arthrodesis used for flail foot with paralysed quadriceps

· eliminates need for long leg brace

· should be fused in 10^o equinus

trunk

Pelvic obliquity

· due to

· abduction contracture of the hip (most common)

· scoliosis (from paralysis of trunk musculature)

· treated by correcting cause

· hip abduction treated with division of iliotibial band

· scoliosis treated with fusion

· if correction not possible, pelvic rotation osteotomy can be performed

hip

Flexion contracture

· commonest deformity is flexion/abduction/external rotation (frog leg)

· usually due to tightness of iliotibial band and contracture of hip flexors

· mild degree treated with iliotibial and anterior release

· more severe deformity treated with complete transfer of iliac crest

Paralysis of glutei

· leads to Trendelenberg gait

· treated with iliopsoas transfer to greater trochanter

knee

Instability

· unaided walking still possible

· provided hip has good extensor power and foot has good plantarflexion power (or fixed equinus)

· knee stabilised by being thrust into hyperextension

· may require full-length caliper

· may perform arthrodesis for flail knee

Fixed flexion contracture

· due to tightness of iliotibial band and quads weakness

· may be corrected by

· hamstring division

· hamstring to quadriceps transfer

· supracondylar osteotomy

Recurvatum

· mild is helpful for back knee gait

· more severe recurvatum leads to

· bony changes

· stretching of posterior soft tissues

· treated with

· osteotomy of proximal tibia

· tenodesis of capsule and hamstrings

shoulder

Weak deltoid

· if scapular muscles strong, can perfom arthrodesis to restore abduction

Elbow

Weak flexion

· may transfer pectoralis major (Clark)

· detach insertion and suture to biceps

· may advance forearm flexors proximally (Steindler)

hand

Weak opponens

· can transfer ring finger sublimus