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Ankle Equinus: in CP

- See: Equinovarus:

- Discussion:
    - most common problem;
    - in those w/ diplegia, it is bilateral & almost always flexible in child under three years;
    - diff dx: toe walking

- Exam:
    - it is essential that the ankle and hindfoot be held in varus while the amount of dorsiflexion is measured;
    - be sure to exam the popiteal angle for hamstring contracture;

- Non Operative Rx:
    - anterior tibial tendon f(x) determines whether child will be brace free;
    - ankle position can be controlled with an orthosis until myostatic contracture occurs or when child is closer to 5 years of age;
    - despite widespread use of plastic AFO (and similar braces) prospective evidence which proves long term efficacy (for prevention of 
            contracture) is not available;

- Operative Intervention
    - method of correcting spastic equinus deformity in older children (above age 5) remains operative;
    - open Hoke Method:
    - open Z lengthening:
    - aponeurotic lengthenings of gastrocnemius (Olney et al.)
            - advantage is that this procedure preserves the strength of the soleus muscle was achieved;
            - performed in 156 patients (219 procedures);
            - there were no instances of over-lengthening resulting in pes calcaneus;
            - equinus deformity recurred in 48 % of ankles;
                   - there were more recurrences in children who were operated on before the age of five years;
            - duration of postop immobilization, did not affect result or rate of recurrence;
    - botox injections:
            - has been recommended for temporary reduction of muscle tone;
            - in the report by Metaxiotis D, et al, the efficacy of repeated botulinum toxin A injections in the calf muscles was evaluated in a 
                   clinical trial involving 21 children with cerebral palsy and dynamic equinus foot deformity who were able to ambulate;
                   - mean age of the children was 5.7 years;
                   - all patients received at least 2 injections, 6 patients received at least 3 injections, and 3 patients received 4 injections.
                   - significant improvements of the gait parameters were observed at 6 and 18 weeks after the first and second injections;
                   - botulinum toxin A injections in gastrocnemius and soleus muscles may change the natural history of equinus foot deformity in patients with spastic diplegia;
                   - ref: Repeated Botulinum Toxin A Injections in the Treatment of Spastic Equinus Foot   
    - postop care:
            - immobilization in above-knee cast for six weeks, followed by use of a night splint or orthosis;
                   - recurrence may occur in approx 20%;
            - in the study by Katz, et al (2000), the authors evaluated the long-term result of postop immobilization for two weeks in a below-knee 
                    cast and early weight bearing, without the use of a splint or orthosis;
                   - 36 children (52 feet) with spastic cerebral palsy underwent sliding Achilles tendon lengthening;
                   - at five to ten years, there was recurrence rate of 19.2%;
                   - most recurrences occured in children operated on before five years of age;
                   - Early mobilization after sliding Achilles tendon lengthening in children with spastic cerebral palsy.

- Complications:
    - overlengthening and crouched gait:
            - overlengthening is to be avoided at all costs;
            - crouched gait is the classic iatrogenic error in which the child walks w/ the ankles in maximum dorsiflexion and the knees flexed 
                   throughout the gait cycle;
                   - results from Achilles tendon overlengthening and neglect of hamstring contracture;
            - in CP, hamstring contracture should be corrected at the same time as the equinus contracture;
            - non operative treatment of crouched gait, involves an anterior floor reaction AFO which limits dorsiflexion during stance phase

Kinematic and kinetic evaluation of the ankle after lengthening of the gastrocnemius fascia in children with cerebral palsy.

Calcaneus deformity in cerebral palsy.

Surgical correction of equinus deformity in cerebral palsy.

The pathomechanics of crouch gait in spastic diplegia.

Early mobilization after sliding Achilles tendon lengthening in children with spastic cerebral palsy.