SURGICAL TREATMENT OF SPASTIC TALIPES EQUINOVARUS IN HEMIPLEGIC ADULTS: 57 PATIENTS

Abstract

Purpose: We report a retrospective consecutive series of 57 hemiplegic patients (32 men and 25 women) who underwent surgery between 1995 and 2000 for spastic talipes equinovarus associating fascicular neurotomy of the tibial nerve and tendon release in order to recover sole to floor walking capacity.

Material and methods: Mean patient age was 47 years (16–75). The hemiplegia resulted from stroke (n=41), trauma (n=8), and other causes (n=8). All patients had spastic talipes equinovarus and 46 required a walking aid. Triceps force and spasticity were scored 2.1 (MRC) and 3.66 (Ashworth) respectively. Pedial hypoaesthesia was present in 23 patients. The mean functional ambulation classification (FAC) score was 3.3, with severe disability (FAC 1 or 2) in 13 patients. Surgery was performed three years (average) after the causal event. After identification by electrical stimulation, we performed microsurgical section of 4/5 nerve fibres of the terminal branches of the tibial nerve in 55 patients. After physical exploration of musculotendon retraction (triceps and toes flexors) and dorsiflesion palsy, we released tendons as needed. The Achilles tendon was lengthened percutaneously in 13 patients, Bardot tenodesis or transfer of the anterior hemi-tibial anterior tendon was performed in 29, and tenotomy of the toe flexors in 12.

Results: Mean follow-up was three years (1–6). Triceps force and foot sensitivity were not modified by the surgery. Spasticity was scored 1.08 and 1.19 (Ashworth) postoperatively and at last follow-up respectively. The FAC walking score was 4.13 and 4.15 postoperatively and at last follow-up respectively. The walking aid was no longer necessary or was improved in 52 patients. Tibiotalal arthrodesis was necessary for recurrent spasticity in three patients.

Discussion: The preoperative assessment of foot deformity and gait is an essential element. Correct preoperative assessment enables microsurgery for fascicular neurotomy of the posterior tibial nerve and tendon lengthening or tenodesis during the same operation. These procedures are indicated for severe deformity and should be used as the first intention treatment before arthrodesis which involves greater morbidity.