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Equinovarus Foot

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Topic updated on 01/13/15 5:24pm
Introduction
  • Epidemiology
    • incidence
      • common foot deformity seen with
        • cerebral palsy (usually spastic hemiplegia)
        • Duchenne muscular dystrophy
        • residual clubfoot deformity
        • tibial deficiency (hemimelia)
  • Pathophysiology
    • pathomechanics
      • spasticity of
        • tibialis posterior and/or tibialis anterior 
        • gastoc-soleus complex
        • absence of ligamentous laxity
    • foot deformity muscle imbalance overview 
Presentation
  • Symptoms
    • painful weight bearing over the lateral border of the foot
    • instability during stance phase
    • poor shoe fitting and shoe wear problems
  • Physical Exam
    • inspection
      • intoed gait
      • inverted heel (tib post)
      • supinated forefoot (tib ant)
      • callous and pain along lateral border
    • provocative tests
      • confusion test 
        • helps to distinguish TA vs TP as the primary muscle involved
          • patient performs active hip flexion against resistance while seated
            • in a positive confusion test, the tibialis anterior fires with active hip flexion and is typical in patients with CP
            • if the foot supinates with dorsiflexion, tibialis anterior is most likely contributing to the equinovarus deformity
Imaging
  • Radiographs
    • recommended views
      • AP + lateral of ankle
    • findings
      • forefoot adduction is seen on the AP radiograph 
      • stress fractures along the base of the fifth metatarsal can develop secondary to repetitive load along the lateral border of the foot.
Studies
  • EMG
    • useful in distinguishing whether tibialis anterior or tibialis posterior is causing the varus
Treatment
  • Nonoperative
    • AFO / serial casting / botulinum toxin injection into tibialis posterior and gastrocnemius
      • indication
        • flexible or dynamic deformities
  • Operative
    • TAL with split-posterior tibialis tendon transfer [SPOTT]
      • indications 
        • spastic hemiplegia in patient ages 4 to 7
        • flexible equinovarus hindfoot
        • tibialis posterior spastic in both stance and swing phase (continous activity)
      • technique
        • reroute half of tendon dorsally and insert into peroneus brevis
    • split-anterior tibialis tendon transfer [SPLATT] 
      • indications
        • overactive anterior tibialis
        • flexible equinovarus deformity
      • technique
        • split anterior tibialis transfer to cuboid with TAL and intramuscular lengthening of the posterior tibial tendon
    • calcaneal osteotomy 
      • indications
        • is required in a rigid hindfoot varus deformity
      • technique
        • lateral closing wedge osteotomy to incur valgus to the heel
Complications
  • Overcorrection (resultant valgus deformity)
    • increased risk in
      • children who undergo surgery at younger age
      • children with diplegia (as oppose to hemiplegia)

 

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