Patients with hemiplegic cerebral palsy walk with a well recognised characteristic gait pattern. They also commonly have a significant leg length discrepancy which is less well appreciated. The typical equinus gait in these patients is assumed to be an integral part of the disease process of spasticity and a tendency to develop joint contractures. However an alternative explanation for the presence of an equinus deformity may be that it is a response to the development of a significant leg length discrepancy in these patients. The development of such an equinus deformity would have the effect of functionally lengthening the short hemiplegic leg. We set up a study to examine the correlation between leg length discrepancy and equinus deformity. We reviewed the gait analyses and clinical examinations of 183 patients with hemiplegic cerebral palsy. While 22% had no significant leg length discrepancy, 65% had a measured discrepancy of greater than 1cm. There was a linear correlation between age and limb length discrepancy. We also found that there was a linear relationship between leg length discrepancy and ankle equinus at the point of ground contact. We propose that the equinus deformity seen in the hemiplegic cerebral palsy patient is multifactorial and is related not only to the disease state but also to the presence of leg length discrepancy. The equinus deformity functionally lengthens the short hemiplegic leg. Indeed it may represent an attempt by these patients to functionally equalise their leg lengths. This factor must be taken into account when considering correction of an equinus deformity in patients with hemiplegic cerebral palsy in order to avoid either recurrence of the deformity or the production of functionally unequal leg lengths. We have also highlighted the presence of significant shortening of the hemiplegic leg in these patients

Aims. To systematically review the outcomes and complications of cosmetic stature lengthening. Methods. PubMed and Embase were searched on 10 November 2019 by three reviewers independently, and all relevant studies in English published up to that date were considered based on predetermined inclusion/exclusion criteria. The search was done using “cosmetic lengthening” and “stature lengthening” as key terms. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles. Results. A total of 11 studies including 795 patients were included. The techniques used in the majority of the patients were classic 3- or 4-ring Ilizarov fixator (267 patients; 33.6%) and lengthening over nail (LON) (253 patients; 31.8%), while implantable lengthening nail (ILN) was used in the smallest number of patients (63 patients; 7.9%). Mean end lengthening achieved was 6.7 cm (SD 0.6; 1.5 to 13.0), and the mean follow-up duration was 4.9 years (SD 2.1; 41 days to 7 years). Overall, the mean number of problems, obstacles, and complications per patient was 0.78 (SD 0.5), 0.94 (SD 1.0), and 0.15 (SD 0.2), respectively. The most common problem and obstacle was ankle equinus deformity, while the most common complications were deformation of the regenerate after end of treatment and subtalar joint stiffness/deformity. Conclusion. Cosmetic stature lengthening provides favourable height gain, patient satisfaction, and functional outcomes, with low rate of major complications. Clear indications, contraindications, and guidelines for cosmetic stature lengthening are needed. Cite this article: Bone Joint Res 2020;9(7):341–350

Purpose of the study. To assess use of Taylor Spatial Frame to correct posttraumatic equinus contracture of ankle by soft tissue distraction. Description of a successful technique. Methods and end results. We have treated five cases of severe and resistant equinus contracture (20–30 degrees) between 2005 and 2010. All cases resulted from severe soft tissue injury and compartment syndrome of affected limb. They had undergone prolonged treatment for open fracture of tibia prior to referral to our institute and failed to respond to at least six months of aggressive physiotherapy. In all cases fractures did not involve ankle articular surface and all tibial fractures had united. Three out five cases also had associated peroneal nerve palsy. Our procedure included Tendo Achilles Lengthening, ankle and subtalar capsulotomy and application of two-ring Taylor Spatial Frame. We used long bone module to correct the deformity gradually. All deformities were over corrected by 5–10% to prevent recurrence. We successfully corrected equinus deformity in all cases. Follow up ranged from three months to five years and we found no recurrence. Patients with peroneal palsy were provided with Ankle Foot Orthosis (AFO). Conclusion. Taylor Spatial Frame treatment provides a safe, finely controllable, accurate and reproducible method of correcting soft tissue equinus deformity

Aims: To identify the distraction forces and contact pressures of the ankle joint at two different joint positions during articulated ankle distraction. Material and Methods: Four amputated lower limbs were collected from patients undergoing amputation for vascular disease and frozen at -70° C. The ankle joint of the specimens were normal. Before use the limbs were thawed at room temperature for 24 hours. The skin and subcutaneous tissues were removed. A Sheffield ring fixator consisting of a proximal tibial ring and a foot plate connected through three threaded bars and hinges aligned with ankle axis was mounted on the limb. Force transducers were placed in the threaded bars between the tibial ring and the foot plate on the lateral, medial and posterior aspect of the ankle joint to measure the ankle distraction forces. Once the ankle distraction forces have been measured an anterior ankle arthrotomy was performed to permit the insertion of Fuji pressure sensitive film within the ankle joint. The limb-fixator construct was mounted in a loading machine and axially loaded on the tibia. The ankle joint was distracted at 2 mm intervals to a maximum of 20 mm. Pressure sensitive film was introduced in the ankle joint at each distraction interval and the tibia was axially loaded at 350, 700, 1050 and 1400N (half to two times body weight). Results: The forces necessary to distract the ankle joint are almost double in the medial side than the lateral side. With 10° of plantarflexion the forces necessary to distract the lateral side increase by about 10%. We found the center of pressure of the ankle joint to be situated in the antero-medial quadrant, close to the center of the ankle joint. Distraction of the ankle joint by 5 mm eliminated any contact pressures at the ankle joint when the tibia was loaded up to 700N (one time body weight). When the joint was distracted by 10 mm no contact pressures were found in the ankle when loaded up to 1400N (two times body weight). Conclusions: With the ankle in the plantigrade position the forces necessary to distract the ankle joint are double in the medial side when compared to the lateral side. Plantarflexion increases the forces necessary to distract the lateral aspect of the ankle. This finding may have clinical implications when distracting ankle joints with equinus deformities as this can increase the risk of damaging the lateral ankle ligaments leading to ankle instability. In our opinion equinus deformities should be corrected before the start of ankle joint distraction. The center of pressure of the ankle joint is situated in the antero-medial quadrant. Distraction of 5 mm will eliminate ankle contact pressure up to one times body weight whereas distraction of 10 mm will eliminate contact pressures up to two times body weight

Purpose of Study. Lengthening of the gastrocsoleus for equinus deformity is commonly performed in orthopaedic surgery. The aim of this study was to describe the precise details of each surgical procedure and assess each biomechanically in cadaver models. Description of Methods. The surgical anatomy of the gastrocsoleus was investigated and standardized approaches were developed for the procedures described by Baumann, Strayer, Vulpius, Baker, Hoke and White. The biomechanical characteristics of these six procedures were then compared, in three randomized trials, in formalin preserved, human cadaver legs. The lengthening procedures were performed and a measured dorsiflexion force was applied across the metatarsal heads using a torque dynamometer. Lengthening of the gastrocsoleus was measured directly, by measuring the gap between the ends of the fascia or tendon. Summary of Results. The gastrocsoleus muscle-tendon-unit was divided into three zones. In Zone 1, it was possible to lengthen the gastrocnemius alone or to lengthen the gastrocnemius and soleus by different amounts. These procedures (Baumann, Strayer) were very stable but limited in the amount of lengthening achieved. Zone 2 lengthenings (Vulpius, Baker) of the conjoined gastrocnemius aponeurosis and soleus fascia were not selective but were stable and resulted in significantly greater lengthening than Zone 1 (p < 0.001) 4. Conclusion. Surgery for equinus deformity correction by lengthening of the gastrocsoleus varies in terms of selectivity, stability and range of correction with differing anatomical and biomechanical characteristics. Clinical trials are needed to determine whether these differences are of clinical importance. It may be appropriate for surgeons to select a procedure from a zone, best suited to the clinical needs of a specific patient. NO DISCLOSURES

Since 1987, we have treated 37 clubfeet with a continuous passive movement (CPM) machine rather than by surgical release. After 6 months of physiotherapy and splintage, all feet still exhibited equinus and varus deformities. CPM treatment improved equinus and varus in all cases and in 33 feet there was no need for surgery. However, there was progressive impairment: at 15-year follow-up, the results in six feet remained good, with some dorsiflexion possible, but recurrence of the equinus deformity in the other feet had necessitated surgical release, performed when patients were 2 to 10 years old. CPM treatment can eliminate the need for surgery in mild clubfeet, and delay surgery in more severe cases. Performing a surgical release after 3 years will perhaps reduce the rate of recurrence of the deformity

Introduction. Taylor Spatial Frame (TSF) has been designed to treat complex tibial, foot and ankle deformities using computer software. We have performed various osteotomies in combination with different soft tissue procedures, with the use of TSF. Material and Methods. A retrospective study of 20 consecutive patients operated by, senior author SSM, from 2004 onwards who underwent surgical correction of tibia, ankle, midfoot and hind foot including lateral column lengthening, calcaneal and midfoot osteotomies. Demographic details, diagnosis, procedures (including previous operations), length of follow-up, outcome and complications were recorded. Of the 20 patients, 13 were men and 7 women. The mean age was 39 years (range 18 to 70). 5 patients had TSF for malunion or non-union of ankle fractures, malunion of tibia (5), congenital talipes equino-varus(3), acute fracture of ankle (2), one patient each for spina bifida, Poliomyelitis, Charcot-Marie-Tooth disease, equino-varus due to periventricular leuco-encephalopathy and avascular necrosis of the talus. Bilateral TSF for torsional malalignment of tibia (1). Results. Follow up 6 to 54 months (mean 19.4). Patient based foot and ankle outcome criteria were used. Of the 20 patients, 16 had no pain and satisfactory range of movement and function at the last follow up. Post-operative complications included pin site infection(2) and frame hardware malfunction (2)patients, residual deformity requiring surgical correction at 22 months, (1) delayed union, neuropathic pain in (1), residual equinus deformity requiring Botox injections(1) and osteomyelitis requiring debridement(1). Conclusion. We present this series of complex congenital and acquired conditions of the foot and ankle treated with corrective osteotomies and Taylor Spatial Frame with good results

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7-71). The mean length of the defect was 4.5 cm (Range 1-12). Union of the fusion site occurred in 88 % (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centres for highly motivated patients to achieve good functional results

Outcome studies of the Ponseti method from various centres have reported success rates ranging from 85–95%. The vast majority of patients can expect a supple, functional and pain free foot. The small percentage of feet that are resistant to Ponseti treatment often require open surgical correction, leading to scarring and stiffness. We present a method of correcting resistant equinus by a tenotomy and calcaneal pulldown technique. This method is complimentary to the Ponseti technique. Method. Prospective study of 40 feet in 28 patients who underwent an Achilles tenotomy and calcaneal pulldown technique. The indications for this method were resistant equinus and problems with casting. Feet scored with the Pirani method. Under a general anaesthetic, a standard Achilles tenotomy was performed. The equinus deformity corrected by traction of the calcaneum with a “catspaw” retractor and dorsiflexion of the forefoot. Further treatment was performed according to the Ponseti method. The Ponseti clubfoot brace was used to maintain correction. Results. 28 patients 40 feet. Mean preoperative Pirani score:3.0 (left 3.0, right 3.1 range 1.5–6). Mean preoperative Hindfoot Pirani score:2.5 (left 2.55, right 2.5 Range 1.5–3). Mean post operative Pirani score:2.0(left 2.0, right 2.0 Range 0.5–6). Mean postoperative Hindfoot pirani score:1.45. Three patients had severe arthrogryphosis, of whom 2 did not correct requiring open surgery. All idiopathic CTEV feet corrected with a range of 5–20 degrees of dorsiflexion at last follow up. The mean follow up was 43.64 months (range 7–96 months). Conclusions. The calcaneal pulldown technique is a useful complmentary adjunct to the Ponseti method. It enables the correction of equinus without the need for open surgery. Since the introduction of the technique to our unit it has negated the need for open surgery. The results are encouraging, it is a simple effective technique that can help in difficult CTEV cases

Aims: We wanted to study the outcome of bone transport by Ilizarovñs method in simple and complicated gap non-unions where other conventional methods have little role to play. Methods: Sixty-six consecutive patients with an age range of 23–64 years (58 males and 8 females) were included in this study. Forty-four patients (67%) had associated problems like infection, deformity and shortening along with gap non unions of varying length. All the patients were treated with ring þxators and the principles of Ilizarovñs treatment were adopted. Corticotomy was carried out in all the cases. Appropriate arrangement of apparatus assembly was done according to the requirement of individual gap non-unions. Follow up ranged from 6 to 46 months. Results: In all but three cases, union was achieved along with satisfactory correction of other associated problems. In one case the patient had previously undiagnosed hypothyroidism and showed signs of callus at corticotomy site after treatment with thyroxine. This patient lost to follow-up. Two other cases needed further surgery (Ilizarovñs ring þxator). In one case, cancellous bone grafting had to be carried out. In six tibial gap non-unions, residual equinus deformity persisted. Conclusions: Ilizarovñs method of bone transport is quite effective in treatment of gap non-unions associated with complex problems, where other methods have proven to be less successful

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7–71). The mean length of the defect was 4.5 cm (Range 1–12). Union of the fusion site occurred in 88% (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centers for highly motivated patients to achieve good functional results

Purpose of study: To compare the medial gastrocnemius (MG) muscle belly length and volume in children with spastic diplegic cerebral palsy (SDCP) with that of normally developing (ND) children, and to assess the effect of gastrocnemius recession (GR) on MG muscle belly length and volume in the SDCP group. Method: The MG muscle belly length and volume at the resting ankle angle were assessed with 3D ultrasound in 10 ND children, mean age 9.4 years, and in 7 children (9 limbs) with SDCP (mean age 8.1 years) who had fixed equinus deformities (mean 24 degrees). The children with SDCP were assessed just before, and at 7 weeks and 1 year after GR surgery. Muscle length was normalised to fibular length, and muscle volume was normalised to body mass. Results: In both the ND and SDCP groups, muscle length was significantly related to fibular length (p=0.001) and muscle volume was significantly related to body mass (p< 0.001). The MG in the SDCP group had a mean reduction in normalised length of 19% and in normalised volume of 59% when compared to the ND group (p< 0.001). GR surgery lead to a further reduction in MG length (p=0.014) and a mean reduction of MG volume of 10% at 7 weeks (p=0.025). However, there was an increase in muscle volume of 39% (24% increase compared to the preoperative assessment) at 1 year following surgery (p< 0.001). Conclusions: The MG belly is significantly shorter and thinner in children with SDCP compared to ND children. GR surgery reduces MG length but leads to an improvement in MG volume and thus in the ability of the MG to generate power

Introduction: the prevalence of diabetics in the old population, and the enhancement of medications actually cause an enormous augmentation of the incidence of diabetic foot. Aim: aim of the study is to report authors’ experience about the transmetatarsal amputation. Patients were enrolled according to skin conditions, arteriography and life expectation. However, based on personal experiance arteriography has not been one of the main criteria in selecting the level of amputation. Methods: Since jenuary 1997 up to december 2002 thertyfour patients were treated. 26 were male, 8 females, the mean age was 69 years. The total amount of transmetatarsal amputation has been 36 surgical procedures. Those were performed after a peripheral anesthesia, the surgeon always avoided the use of torniquette. A short leg cast was made in order to let the wound heal and to avoid equinus deformity untill the weightbearing gait was allowed. Results: At a mean follow-up of 48 months 28 patients were able to walk using one or without crutches, two patients needed two crutches full time, four patients underwent to a further procedure of resection at a more proximal level. Conclusion: the outcome showed to be dependent by many variables, however middle term results are encouraging, patients can walk and attend again their own daily activities fairly soon. Although it is well understood that the long term result will be worst, we suggest to try whenever it is possible to perform a transmetatarsal amputation expecially in old people who can not easily ricover from a leg resection

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients. A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured. In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%. After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients. A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured. In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%. After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care

Aims

Leg length discrepancy (LLD) is a common pre- and postoperative issue in total hip arthroplasty (THA) patients. The conventional technique for measuring LLD has historically been on a non-weightbearing anteroposterior pelvic radiograph; however, this does not capture many potential sources of LLD. The aim of this study was to determine if long-limb EOS radiology can provide a more reproducible and holistic measurement of LLD.

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

The purpose of the study was to evaluate the usefulness of the techniques introduced for correction of the deformities associated with fibular hemimelia. Material. 10 children (6 boys and 4 garils) with affected 11 limbs were analyzed. All presented Achterman-Kalamchi type II fibular hemimelia (absence of the fibula, anterior tibial bowing and hypoplastic foot). Limb length discrepancy ranged from 2 to 9 cm. Only 2 feet had 5 rays, 4 – 4 rays and 5 three rays. In 10 feet talo-calcaneal synostosis was diagnosed intra-operatively. Age at operation ranged from 7 to 23 months (mean 13.2). Follow-up was 4.7 years (1 – 8.5). Technique. Two groups of patients were analyzed. The 1st group consisted of 3 children (3 affected limbs) operated on by partial or complete release of the ankle. Correction of the equinus and valgus deformity was possible by rotation of the talus in the ankle joint in coronal and sagittal plain (the oval shape of talar dome allowed its rotation in the ankle joint). In 2 patients the tibial osteotomy were made as a separate procedure. The 2nd group consisted of 7 children (8 affected limbs) operated on by one-stage technique consisting of (1) trapezoid resection of the tibia for correction of anterior bowing and internal torsion (2) posterior and lateral release of the foot with lengthening of tendo Achilles and peroneals tendons (3) •opening wedge osteotomy through talo-calcaneal synostosis with bone graft taken from the tibia for correction of valgus and equinus deformity (4) skin plasty with subcuteneous flap for wound covering. In this group relationships between talus and tibia were not changed by operation (flat top talus). Results. Both techniques resulted in stabile and properly aligned tibia and hindfoot. Five children were treated later by Ilizarov method at age of 57 months (53 – 80). Other five patients walked independently in orthopaedic or normal shoes. Two of them wait for limb lengthening. The method used in the 2nd group was especially useful for patients with bilateral deformity. The relapse of hindfoot valgus deformity was observed after limb lengthening. Conclusion. One-staged correction of the complex deformity in fibular hemimelia is safe and cost effective. The treated limb was properly prepared for lengthening, wear-bearing in shoes (bilateral cases), orthosis or pros-thesis

Conservative management of talipes equinovarus has a good effect on adductus deformity of the forefoot, whereas equinus deformity cannot usually be treated well conservatively. However, adductus is the most common recurrent deformity after operations. The aim of the study was to use radiological analysis to explore the reasons that lead to recurrent adductus. In 86.7% of the cases, either a correction was evaluated as radiologically inadequate but seemed to be good physically, or compensation for an operative over-correction resulted in recurrent adductus some years later. In spite of adequate correction from both a physical and radiological view, recurrent adductus developed in 13.3% of the cases. In our opinion, these recurrences were due to persistent muscle imbalance. In our department, 458 children were operated on for clubfoot from 1982 to 1997. The patients involved in this study were those managed by medial and posterior soft tissue release after an ineffective six to nine month period of conservative treatment that was started when they were one to two weeks old. Children treated previously in another hospital were excluded from the study. We controlled 228 feet and 42 cases of recurrent adductus were found 2 to 16 years (mean 6.8) after the operations. The radiographs were examined at the end of ineffective conservative treatment, during the early postoperative days, and finally at the follow-up. The anteroposterior talocalcaneal (ATC) angle, the talometatarsal (TM) angle and the naviculometatarsal (NM) angle were measured in all of the radiographs. Based on the measured angles, three main groups of patients were formed. Recurrent adductus in 24 feet (Group A) was caused by inadequate operative corrections, including inappropriate correction of either the hind foot (reduced ATC angle) or the forefoot (reduced NM angle), or both. Although the talocalcaneal and talometatarsal positions were normal in early postoperative radiographs, adductus developed again two to five years later in seven cases (Group B). In these cases, we think that persistent muscle imbalance was responsible for the recurrent deformity. In 11 feet the ATC angles were in normal range or increased (Group C). These adductus deformities were caused by either an overcorrected talocalcaneal position resulting in compensatory metatarsal varus or medial subluxation of the talonavicular joint, which had been only partially compensated by the lateral deviation of the 1st ray

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.