Maria Vlachou

Split tendon transfers for the correction of spastic varus foot deformity: a case series study

BackgroundOveractivity of anterior and/or posterior tibial tendon may be a causative factor of spastic varus foot deformity. The prevalence of their dysfunction has been reported with not well defined results. Although gait analysis and dynamic electromyography provide useful information for the assessment of the patients, they are not available in every hospital. The purpose of the current study is to identify the causative muscle producing the deformity and apply the most suitable technique for its correction.MethodsWe retrospectively evaluated 48 consecutive ambulant patients (52 feet) with spastic paralysis due to cerebral palsy. The average age at the time of the operation was 12,4 yrs (9-18) and the mean follow-up 7,8 yrs (4-14). Eigtheen feet presented equinus hind foot deformity due to gastrocnemius and soleus shortening. According to the deformity, the feet were divided in two groups (Group I with forefoot and midfoot inversion and Group II with hindfoot varus). The deformities were flexible in all cases in both groups. Split anterior tibial tendon transfer (SPLATT) was performed in Group I (11 feet), while split posterior tibial tendon transfer (SPOTT) was performed in Group II (38 feet). In 3 feet both procedures were performed. Achilles tendon sliding lengthening (Hoke procedure) was done in 18 feet either preoperatively or concomitantly with the index procedure.ResultsThe results in Group I, were rated according to Hoffers clinical criteria as excellent in 8 feet and satisfactory in 3, while in Group II according to Klings clinical criteria were rated as excellent in 20 feet, good in 14 and poor in 4. The feet with poor results presented residual varus deformity due to intraoperative technical errors.ConclusionOveractivity of the anterior tibial tendon produces inversion most prominent in the forefoot and midfoot and similarly overactivity of the posterior tibial tendon produces hindfoot varus. The deformity can be clinically unidentifiable in some cases when Achilles shortening co-exists producing foot equinus. By identifying the muscle causing the deformity and performing the appropriate technique, very satisfying results were achieved in the majority of our cases. In three feet both muscles contributed to a combined deformity and simultaneous SPLATT and SPOTT were considered necessary. For complex foot deformities where the component of cavus co-exists, supplementary procedures are required along with the index operation to obtain the best result.

Modified Chuinard-Baskin Procedure for Managing Mild-to-Moderate Cavus and Claw Foot Deformity in Children and Adolescents

Nineteen ambulant patients (children and adolescents, 23 feet), with mild-to-moderate cavus and claw feet of neuromuscular etiology, underwent a modified Chuinard-Baskin operation, combining long toe extensor tendon transfer to the metatarsals with distal tenodesis onto the proximal phalanx. The technique aims to improve forefoot deformity and metatarsophalangeal dysfunction, and to enhance ankle dorsiflexion. Transcutaneous flexor tenotomies in several toes, and additional complementary surgery in the middle and hindfoot (plantar soft tissue releases, tendon lengthenings, and/or transfers and osteotomies/fusions) were also performed, when required. Selection criteria for the target procedure were mild-to-moderate cavus deformity (<45 degrees Mearys angle), restricted ankle dorsiflexion, discomforting symptoms, age span 6 years to maturity, and follow-up had to be at least 2 years. Evaluation was based on modified Frank and Johnsons clinical criteria. Radiologically, the Mearys angle on lateral standing view (long axes of talus/first metatarsal) was used. Global results at last follow-up (mean 6.91 +/- 5.43 years) were excellent in 11 feet (48%), satisfactory in 9 (39%), and unsatisfactory in 3 (13%). This retrospective study showed that satisfactory correction can be obtained in mild-to-moderate claw foot deformity in children and adolescents with this variation of Chuinard-Baskins operation, and therefore can be used as an alternative to others that are more traditionally used.

Progressive Neuromuscular Planovalgus Foot Deformity Treated With a Modified Extra-articular Subtalar Fusion

Background: Obtaining a successful subtalar fusion in the pediatric population can be challenging. We present our results with a modified extraarticular method. Materials and Methods:- We retrospectively evaluated 12 patients (17 feet) with progressive neuromuscular planovalgus foot deformity that underwent an extra-articular subtalar arthrodesis with the combined Batchelor-Grice procedure. All patients were ambulatory and were treated conservatively with braces prior to the operation. The average followup was 10 (range, 5 to 17) years. Postoperatively the feet were immobilized in short leg casts for 6 weeks. Preoperative and postoperative appearance of the feet, the clinical symptoms and radiographic measurements were recorded. Results: Sustained correction and solid fusion took place in all feet. Foot appearance and gait pattern of the patients were improved, while preoperative complaints were reduced. Radiographic healing was noted in all cases. Conclusion: This technique is an effective treatment for the correction of the deformity as it gives a greater assurance of solidarity than when either of the two procedures is used alone. Level of Evidence: IV, Retrospective Case Series

Treatment of severe thoracolumbar kyphoscoliosis on the ground of ganglioneuroblastoma of the diaphragm: a case report.

The treatment of an unusual case with severe kyphoscoliotic deformity of the thoracolumbar spine, in association with a ganglioneuroblastoma invading the adjacent diaphragm, is presented in this report. Severe scoliotic deformity of the spine, associated with ganglioneuroblastoma of the diaphragm is a rare combination and treatment can be very challenging, as both entities require extensive surgery. To the best of our knowledge, only two reports related to a similar condition have been published in the literature so far. A 9-year-old girl had been treated in another institution since the age of 5 years for thoracolumbar kyphoscoliosis with bracing. She was referred to our department with a stiff right kyphoscoliotic curve at the thoracolumbar region (T8-L2), with measurements of 105 and 90° for the scoliotic and kyphotic elements, respectively. There were no neurological signs detected at the preoperative work-up, which included clinical and radiological evaluation (plain X-rays and computed tomographic scan). The patient was treated with a two-stage spinal fusion. During the anterior approach through a right thoracotomy, a tumor was discovered infiltrating half of the diaphragm and extended to the frontal surface of the lower thoracic vertebral bodies. The vertebrae were cleared of the tumorous masses and anterior discectomies (T8–L2) were successfully carried out according to the preoperative plan. The histopathology report indicated ganglioneuroblastoma in both the prevertebral material and the speciments excised from the diaphragm. A week later a T3–L4 posterior fusion was carried out and the deformity was corrected and fixed with an SFS instrumentation system. Both the scoliotic and the kyphotic curves were reduced to 46°. Postoperatively the patient was referred to the oncology department of another hospital for the treatment of the diaphragm tumor. During the last follow-up (4 years), the scoliotic curve remains steady and the tumor shows no recurrence. Although there are cases of ganglioneuroblastoma associated with scoliotic deformity, the combination of this tumor infiltrating the diaphragm and a very severe deformity of the spine is extremely rare. Nevertheless, the treatment undertaken has proven to be successful so far.