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

Purpose of Study. In children with spastic diplegia, surgery for equinus has a high incidence of both over and under correction. We wished to determine if conservative (mainly Zone 1) surgery for equinus gait, in the context of multilevel surgery, could result in the avoidance of calcaneus and crouch gait as well as an acceptable rate of recurrent equinus, at medium term follow-up. Description of Methods. This was a retrospective, consecutive cohort study of children with spastic diplegia, between 1996 and 2006. All children had distal gastrocnemius recession or differential gastrocsoleus lengthening, on one or both sides, as part of Single Event Multilevel Surgery. The primary outcome measures were the Gait Variable Scores (GVS) and Gait Profile Score (GPS) at two time points after surgery. Summary of Results. Forty children with spastic diplegia, GMFCS Level II and III were eligible for inclusion in this study. There were 25 boys and 15 girls, mean age 10 years at surgery. The mean age at final follow-up was 17 years and the mean postoperative follow-up period was seven years. The mean ankle GVS improved from 18.5° before surgery to 8.7° at short term follow-up (P<0.005) and 7.8° at medium term follow-up. Equinus gait was successfully corrected in the majority of children with a low rate of over-correction (2.5%) but a high rate of recurrent equinus (35.0%), as determined by sagittal ankle kinematics. Conclusion. Surgery for equinus gait, in children with spastic diplegia, was successful in the majority of children, at a mean follow-up of seven years, when combined with multilevel surgery, orthoses and rehabilitation. No patients developed crouch gait and the rate of revision surgery for recurrent equinus was 12.5%. NO DISCLOSURES

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.

Purpose: The purpose of this study is to report on the outcomes of children with ITW who received Botulinum A Toxin (BTX-A) as an adjunct treatment to manipulations/casting and maintenance protocol. Method: ITW severity was classified using gait analysis and defined by the absence of 1. st. ankle rocker, early 3. rd. rocker and an early and increased first ankle moment. 1. Subjects who met the three severity criteria received a single BTX-A injection into both gastrocsoleus and placed immediately in below-knee casts. Casts were changed two weeks later for a total casting period of four weeks. Subjects then entered a maintenance protocol involving use of night splints or articulated ankle-foot-orthotics. Outcome measures collected at all follow-up visits were ankle dorsiflexion with knee in 90° flexion (DFF) and extension (DFE). Results: Thirteen subjects with severe bilateral ITW participated. Subjects were followed for an average of 48 weeks (range 7 – 168 weeks) post BTX-A injection. Given the variability in subject outcomes, analyses and reporting were stratified according to subjects’ right and left feet. At day of BTX-A, right foot DFF/DFE were 1.7° ± 14.4 and −1.5° ± 13.0 and mean left DFF/DFE were −1.5° ± 12.8 and −6.5° ± 12.1. Immediate improvement following BTX-A (2 weeks) were seen as right foot DFF/DFE were 14.1° ± 10.0 and 6.3° ± 7.7 and left DFF/DFE were 9.6° ± 14.1 and 3.9° ± 10.6. At 4 weeks, right DFF/DFE were 16.6° ± 9.5 and 11.7° ± 9.1 and left DFF/DFE were 13.1° ± 8.6 and 7.3° ± 8.3. At the half-life of BTX-A (12 weeks), right DFF/DFE were 15.2° ± 12.2 and 10.8° ± 10.5 and left DFF/DFE were 15.8° ± 12.4 and 13.0° ± 11.6. At follow-up visits, correction was maintained as right DFF/DFE were 15.6° ± 9.1 and 10.4° ± 10.3 and left DFF/DFE were 16.9° ± 11.2 and 9.8° ± 10.7. Conclusion: This is the first study to show early outcomes (improved DFF/DFE) following BTX-A injections in ITW and provides evidence for obtaining and maintaining the correction from a single BTX-A injection over a short-term follow-up period

Introduction Plantar fasciitis is a common presenting problem and there are multiple treatments available. There is little scientific data to assist in the selection of the most efficacious or cost-effective treatment. This study compared the efficacy of corticosteroid injection and low-dose ESWT for the treatment of chronic proximal plantar fasciitis. Methods One hundred and thirty-two cases of plantar fasciitis were enrolled into this prospective study over five years. Eligible patients performed a stretching program for the gastrocsoleus. In addition, patients randomized to group A received an intralesional corticosteroid injection, while group B received low dose ESWT (3 x 1000 pulses, energy flux density 0.08/mm2). Nineteen patients were not randomized and comprised a control group C. Patients were assessed before, and then three and 12 months post treatment using a VAS, and algometer (tenderness threshold, TT). The groups were compared using generalized linear models for repeated measures of VAS and TT scores, with orthogonal contrasts. Results The three groups were significantly different in their VAS scores post treatment. Over the 12 months, pain levels reduced for all groups, but the trends between them differed significantly. The corticosteroid (CSI) group, had significantly lower levels of pain than the ESWT or controls. At 12 months, the CSI and ESWT had similar levels of pain, both significantly lower than that in the controls. Similar trends were found for TT. Threshold levels increased for all three groups post treatment but the trends between the groups were significantly different. At three months, the CSI group had significantly higher TTs than both the ESWT and control groups. By 12 months, all groups had higher TTs but they were similar. The TT of the CSI group had plateaued by three months. Of the 64 heels that received CSI, there were no infections and no cases of rupture of the plantar fascia. There were eight cases of post-injection pain. All patients found the injection unpleasant. Of the 61 heels treated with ESWT, six reported throbbing pain and erythema. Four reported a severe headache. All patients found the procedure unpleasant. Conclusions Intralesional corticosteroid injection is more efficacious, and much more cost-effective, than ESWT, in the treatment of plantar fasciitis present for at least six weeks. The injection achieves a significant and lasting reduction in pain and tenderness within three months. Correctly used, this treatment has a low incidence of complications

Aims

The aim of this study was to establish a reliable method for producing 3D reconstruction of sonographic callus.

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.