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

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.

Introduction. The goal of arthrodesis around the ankle or of triple (hind foot) arthrodesis is a painless, plantigrade, and stable foot. Stress fracture is a differential diagnosis for pain following an ankle/subtalar arthrodesis. Management of stress fractures following sound ankle/subtalar fusion is extremely difficult as the entire movement tends to occur at the fracture site, hence hampering healing. Methods and materials. 33 patients underwent ankle/subtalar arthrodesis at our institute from 2000-2008. The average age of the patients was 69 years and the male: female ratio was 2:1. The minimum follow-up was for one year. Although there were some variations in technique, all the arthrodesis were performed by removal of articular cartilage, bone grafting of any defects and rigid internal fixation. Results. 2/33 patients developed a stress fracture of the distal tibia following successful ankle/subtalar fusion. An angle of ankle/subtalar fusion showed an average of 0 degrees +/− 3 degrees in the sagital plane, except for the two cases that developed the stress fracture. The angles in these cases were 13 and 11 degrees. The stress fractures occurred proximal to the level of the previous arthrodesis internal fixation devices (arthrodesis nail/cancellous screws). Intramedullary and extramedullary devices were utilised to obtain union across the stress fracture sites, without success. Discussion. Equinus of more than 10 degrees following ankle/subtalar arthrodesis is a high risk factor for developing a stress fracture of the distal tibia following ankle/subtalar arthrodesis. Stress fracture following successful ankle/subtalar arthrodesis causes severe morbidity. They are extremely difficult to treat, hence are best avoided if possible

Equinus contracture of the ankle due to a tight Gastrocnemius has been implicated in the pathogenesis of a number of foot and ankle conditions. There are numerous described procedures for release of the Gastrocnemius such as the Strayer procedure. Our indications for release are in patients with a symptomatic forefoot and an equinus contracture of 5 degrees or more in extension as defined by the Silfverskiöld test. The release is usually combined with a reconstructive procedure. The advantages of our technique are its simplicity, excellent visualisation of the tendon and sural nerve, good wound healing and patient comfort post-operatively. The procedure can be performed without tourniquet. A 2.5cm incision is made over the medial calf, just distal to the Gastrocnemius muscle indentation. The deep fascia is incised and the edge of the tendon can be visualised. Blunt digital dissection is performed on either side of the tendon to develop a plane. A metal Cusco speculum is inserted to visualise the full width of the tendon. The tenotomy is performed starting medially and the last 5mm of the lateral tendon is left uncut. This reduces the chance of iatrogenic injury to the nerve. The tendon bridge can be left if correction is sufficient, otherwise passive dorsiflexion of the ankle results in completion. Post-operatively, patients are able to mobilise fully with crutches and passive ankle physiotherapy is commenced immediately. We performed 22 MAGS procedures in 17 patients. There were no Sural nerve injuries and no wound complications. All patients were delighted with cosmesis. Average pre-operative equinus contracture with the leg extended was 18 degrees. Average intra-operative correction of 24 degrees was obtained and at 3 months follow-up, all patients were able to dorsiflex past neutral

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed.

The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60).

One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation.

We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.