Split anterior tibialis tendon transfer to peroneus brevis for spastic equinovarus in children with hemiplegia

Peter Wong; Shaneil Fransch; Charles Gallagher; Kate Louise Francis; Abhay Khot; Erich Rutz; H Kerr Graham

doi:10.1302/1863-2548.15.210033

Split anterior tibialis tendon transfer to peroneus brevis for spastic equinovarus in children with hemiplegia

J Child Orthop. 2021 Jun 1;15(3):279-290. doi: 10.1302/1863-2548.15.210033.

Authors

Peter Wong¹, Shaneil Fransch¹, Charles Gallagher¹, Kate Louise Francis², Abhay Khot¹, Erich Rutz¹, H Kerr Graham^{1

3}

Affiliations

¹ Orthopaedic Department, The Royal Children's Hospital, Melbourne, Australia.
² Murdoch Children's Research Institute (MCRI), Melbourne, Australia.
³ Department of Paediatrics, University of Melbourne.

Abstract

Purpose: The aim of this study is to report the safety and eff-cacy of soft-tissue surgery incorporating split transfer of tibi-alis anterior to peroneus brevis (SPLATT-PB) for children with hemiplegic spastic equinovarus.

Methods: This was a retrospective case series of children and adolescents with spastic hemiplegia who had a novel combination of SPLATT-TB, intramuscular tenotomy of tibialis posterior and either spasticity management or gastrocsole-us lengthening as the index surgery. The principal outcome measures were changes in pain and difficulty with shoe wear and radiological parameters obtained from weight-bearing anteroposterior and lateral radiographs of the affected foot before and after surgery.

Results: A total of 63 patients with symptomatic spastic equinovarus met the inclusion criteria. Mean age at surgery was 9.8 years (6 to 18) and the mean follow-up was seven years (range 3 to 10 years). Foot pain and problems with shoe wear improved after surgery. Seven radiological criteria showed a clinically and statistically significant improvement at follow-up, the majority being in the normal range. There were 11 surgical adverse events, all classified as Modified Cla-vien-Dindo Grade II. Three patients required further surgery for recurrent equinus, eight patients required further surgery for valgus deformities and four patients required bony surgery for residual varus deformities.

Conclusion: Soft-tissue surgery for spastic equinovarus was successful in the majority of children with spastic hemiplegia, particularly between ages eight and 12 years, resulting in a plantigrade, flexible foot with minimal pain or limitations in shoe-wear. Children younger than 8 years at index surgery were more prone to overcorrection into valgus. Children older than 12 years had persistent varus deformities requiring bony surgery.

Level of evidence: Level IV, retrospective case series.

Keywords: Spastic equinovarus; gastrocsoleus lengthening; spastic hemiplegia; split anterior tibial tendon transfer; tibialis posterior lengthening.