Spasm or contracture of gastrocnemius causes an equinus deformity of the ankle in both cerebral palsy and hemiplegia. Its release is therefore required in the treatment of those patients who do not respond to conservative measures. The Vulpius procedure is a simple and effective method for the release of gastrocnemius and is particularly indicated when long periods of immobilisation of the foot and ankle are not desirable. We have used this procedure with good results to correct an equinus deformity in 230 adults with a cerebrovascular accident and various associated medical conditions. It is not only effective in cerebral palsy, but should be considered at an early stage in all adult patients with deformity of the ankle and foot in whom spasm of gastrocnemius is the major cause

Spasm or contracture of the gastrocnemius muscle is predominantly responsible for the equinus deformity of the foot in cerebral palsy. Its release is therefore logical in the treatment of all cases which do not respond to conservative measures. The authors have demonstrated, by the use of metal markers and radiographic control at operation, that adequate release cannot be achieved by severance of the calcaneal tendon alone, and that in order to ensure relaxation of the gastrocnemius muscle, the operation of choice is gastrocnemius recession by the method of Strayer, coupled with lengthening of the calcaneal tendon to deal with such degree of the deformity as may be attributable to shortening of the soleus. A survey of 100 limbs treated by this method revealed a recurrence rate of equinus of 9% and a degree of calcaneus deformity resulting in inadequate push-off in 3% of cases after an average follow-up period of six years

Equinus deformity of the ankle is one of the serious orthopaedic problems associated with Duchenne muscular dystrophy. Sixty-nine patients (age range 4 to 17 years) were treated, 43 conservatively and 26 operatively. They were followed up at six-monthly intervals for a minimum of two years and a maximum of six years. The patients were divided into three groups: independently mobile, mobile in calipers, and wheelchair-bound. It was found that conservative treatment could at best only minimise progression of the deformity. The indications for surgery, the operative procedure and the postoperative management are described; all varied according to the stage of the disease. The postoperative follow-up suggests that, though the deformity recurs, the patients have several years of benefit from the procedure.

Aims. As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. Methods. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). Results. A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Conclusion. Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated. Cite this article: Bone Joint J 2024;106-B(3):293–302

Patients with diabetes mellitus may develop plantar flexion contractures (equinus) which may increase forefoot pressure during walking. In order to determine the relationship between equinus and forefoot pressure, we measured forefoot pressure during walking in 27 adult diabetics with a mean age of 66.3 years (sd 7.4) and a mean duration of the condition of 13.4 years (sd 12.6) using an Emed mat. Maximum dorsiflexion of the ankle was determined using a custom device which an examiner used to apply a dorsiflexing torque of 10 Nm (sd 1) for five seconds.

Simple linear regression showed that the relationship between equinus and peak forefoot pressure was significant (p < 0.0471), but that only a small portion of the variance was accounted for (R² = 0.149). This indicates that equinus has only a limited role in causing high forefoot pressure. Our findings suggest caution in undertaking of tendon-lengthening procedures to reduce peak forefoot plantar pressures in diabetic subjects until clearer indications are established.

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

Although equinus gait is the most common abnormality in children with spastic cerebral palsy (CP) there is no consistency in recommendations for treatment, and evidence for best practice is lacking. The Baumann procedure allows selective fractional lengthening of the gastrocnemii and soleus muscles but the long-term outcome is not known. We followed a group of 18 children (21 limbs) with diplegic CP for ten years using three-dimensional instrumented gait analysis. The kinematic parameters of the ankle joint improved significantly following this procedure and were maintained until the end of follow-up. We observed a normalisation of the timing of the key kinematic and kinetic parameters, and an increase in the maximum generation of power of the ankle. There was a low rate of overcorrection (9.5%, n = 2), and a rate of recurrent equinus similar to that found with other techniques (23.8%, n = 5). As the procedure does not impair the muscle architecture, and allows for selective correction of the contracted gastrocnemii and soleus, it may be recommended as the preferred method for correction of a mild fixed equinus deformity

Lengthening of the conjoined tendon of the gastrocnemius aponeurosis and soleus fascia is frequently used in the treatment of equinus deformities in children and adults. The Vulpius procedure as described in most orthopaedic texts is a division of the conjoined tendon in the shape of an inverted V. However, transverse division was also described by Vulpius and Stoffel, and has been reported in some clinical studies. We studied the anatomy and biomechanics of transverse division of the conjoined tendon in 12 human cadavers (24 legs). Transverse division of the conjoined tendon resulted in predictable, controlled lengthening of the gastrocsoleus muscle-tendon unit. The lengthening achieved was dependent both on the level of the cut in the conjoined tendon and division of the midline raphé. Division at a proximal level resulted in a mean lengthening of 15.2 mm (. sd . 2.0, (12 to 19), which increased to 17.1 mm (. sd . 1.8, (14 to 20) after division of the midline raphé. Division at a distal level resulted in a mean lengthening of 21.0 mm (. sd. 2.0, (18 to 25), which increased to 26.4 mm (. sd . 1.4, (24 to 29) after division of the raphé. These differences were significant (p < 0.001). Cite this article: Bone Joint J 2014; 96-B:778–82

We compared the complications and outcome of tibial lengthening using the Ilizarov method with and without the use of a supplementary intramedullary nail. In a retrospective case-matched series assembled from 176 patients with tibial lengthening, we matched 52 patients (26 pairs, group A with nail and group B without) according to the following criteria in order of importance: 1) difference in amount of lengthening (± 2 cm); 2) percentage difference in lengthening (± 5%); 3) difference in patient’s age (± seven years); 4) aetiology of the shortening, and 5) level of difficulty in obtaining the correction. The outcome was evaluated using the external fixator index, the healing index and an outcome score according to the criteria of Paley. It was found that some complications were specific to group A or B respectively, but others were common to both groups. The outcome was generally better in lengthenings with a nail, although there was a higher incidence of rectifiable equinus deformity in these patients

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

Joint deformity secondary to extensive haemangiomatous involvement of the soft tissues has been well described and is easy to diagnose. If the haemangioma is small, localised and within the belly of a muscle the diagnosis is more difficult. In equinus deformity of obscure aetiology localised calf tenderness may be the only diagnostic sign. Three children with equinus deformity caused by a small haemangioma in the calf muscles were treated by simple excision with satisfactory results

In paralytic lesions in which the triceps surae is the only active muscle in the leg, elongation or division of the tendo calcaneus alone may not be enough to prevent recurrence of equinus deformity. In 10 patients (13 limbs) with this pattern of muscle activity, equinus deformity was treated by hemitransplantation of the tendo calcaneus. At follow-up, which was beyond the end of growth in seven limbs, there was no recurrence of deformity in nine. In three of the four failures, a technical fault may have caused loss of activity in the transplanted part of the tendon. The two-stage operation described is recommended in the management of this pattern of paralytic deformity

1. Correction of equinus deformity in cerebral palsy either by elongation of the tendo calcaneus or by gastrocnemius recession gives satisfactory results without splintage or bracing after operation. 2. Gastrocnemius recession is the operation of choice in paraplegic spastic cerebral palsy, and wherever possible in tetraplegic cerebral palsy. In hemiplegia the whole of the triceps surae is usually involved, and elongation of the tendo calcaneus is almost always needed. 3. Correction at operation should aim to result in a mild degree of equinus deformity at the end of the growth period in hemiplegic spastic cerebral palsy. Over-enthusiastic gastrocnemius recession can lead to excessive weakness of the calf in some patients

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

For equinus deformity in spastic hemiplegia, correction by the White slide technique has been studied in a group of 35 patients followed up for 14 to 20 years. It is a simple, effective method of lengthening the calcaneal tendon, and is free from significant complications with an acceptable rate of recurrent deformity. The majority of patients achieved a heel-toe gait

Eight children with paralytic drop foot after intramuscular injections later developed gluteal fibrosis. Sciatic palsy, presenting as equinovarus or equinus deformity, was diagnosed on average 3.8 months after the intragluteal injections, but gluteal fibrosis was not diagnosed until 5.1 years after the injections. In three patients the equinovarus recurred after surgical correction due to persistent muscle imbalance and the effect of the external rotation contracture of the hip

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

For clinical, psychological and social reasons the diagnosis of Duchenne muscular dystrophy should be established as early as possible. In a survey of 83 families with 93 affected boys, the diagnosis was missed in every case referred to an orthopaedic surgeon (37 patients). In the whole group there was a mean delay of 2.0 years (0 to 6 years) during which time inappropriate treatment, difficulties in communication with parents, much parental anxiety and further pregnancies occurred. A serum creatine kinase estimation is a simple outpatient test which should be carried out on any boy with clumsy or abnormal gait, with flat feet or with an unexplained equinus deformity

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