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I am treating a 14 year old female with neurological impairment and severe bilateral talipes equino-varus especially on the left. Inversion of the calcaneus is achievable but not eversion. Dorsiflexion of the ankle joint with subtalar in neutral is almost 90°. The triceps surae are like rock. Does anyone have experience in surgery with this type of condition at such an advanced age? What's the success rate? I’d appreciate the forum’s comments.

Peter Norton
Body Clinic
Jl. Prapanca Raya # 25A
Kebayoran Baru, Jakarta Selatan
Indonesia
Tel: +62 21 72783827
Email: podprofs@bigpond.com

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Peter

It does depend to some extent on the degree of neurological impairment, and what effect this has on motor function. This will determine if tendon transfer is appropriate, or purely osseous correction +TAL is worth pursuing.

Try a Coleman block test to determine flexibility of the STJ, and whether a dorsiflexion osteotomy of the 1st MT is worth doing to bring the hindfoot out of varus. Otherwise, there are a variety of other approaches to correcting cavo-varus deformities. They are usually quite large procedures with long recovery times.

You havent said what the primary complaint is though.

LL

Related threads:
Ilizarov Method for Clubfoot
Club foot: treatment in the child, outcome in adults
Overcorrection of talipes equino-varus
President Lincoln's Gait

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Hi LuckyLisfranc,

Thanks for your comments.

The patient is too mentally impaired to have a primary complaint, but that of the parents is to achieve a more normal gait. Bilaterally there is no flexibility in the STJ in eversion.

What next?

Peter Norton

Having discussed this with a Physio collegue we came up with the following.

First let me say there is nothing more annoying than having a fellow clinician use the phrase 'too mentally impaired to have a primary diagnosis'. Surely this is a key part of the treatment, if you don't look at all the reasons for the presentation then nothing is likely to work long term.

What is the underlying diagnosis - this could affect the choice of solutions. Could it be CP or Rett?- Is the 'neurological impairment' from birth or an acquired brain injury?

Does the child want to walk? What is the quality of the walking? Is it so energy expensive that she spends an hour recovering and cannot function once she arrives at her goal?

Surgery will only work in the long term if it includes something to stop the spasticity which caused the problem in the first place. In our experience even a triple osteotomy does not work in the long term if nothing is done with the muscle.

Botox may only useful if there is intensive (ie daily physio input) for the first 2-14 days post injection to optimise the effectiveness with splinting added as soon as there is improvement in range. Not sure if botox is even done on gastroc. You can only botox a fusiform or the occasional bipennate muscle owing to the need to inject the motor end plates. Also there is leakage to surrounding structures, which limits which muscles are possible to botox.

Since the calcaneus is inverted it will be impossible (in our opinion) to hold it with an orthotic or shoe or ankle foot orthosis. We have yet to find something which can hold the calcaneus effectively once the spasticity kicks in. Especially if you then want the child to walk which is the aim.

Daily stretches should enable the calcaneus to be brought to neutral and then a TA stretch to follow. We have had experience where we have been able to achieve this over a two year period! If the calcaneus is not brought to a neutral position before the stretch, then it will be ineffective

Ultimately it should be the best interests of the child which is considered- not the parents!

Nikki

Dear Nikki,

Thank you for your comments. I’m sorry my clumsy expression annoyed you.

I am in a third world country with limited access to inter-disciplinary medical services one ordinarily relies on in a first world country. My client, despite consulting amongst other local health professionals an eminent professor of neurology, as well as seeking medical advice in Singapore, does not actually have a primary ‘diagnosis’, nor does she have a ‘primary complaint’ which is what I actually said in my reply to Lucky Lisfranc.

The parents report her neurological condition is congenital although they were told she was ‘normal’ but has a low IQ. Brain scans are not normal according to the parents. I am not able to converse with the child directly because I don’t speak Bahasa Indonesia and even if I did, neurological disorders are not my specialty. I’m just trying to get an idea of what avenues might be available to the client.

In my opinion, other than mental retardation and gait abnormalities, she doesn’t fit the criteria for Rett Syndrome. She doesn’t appear to have spasticity as there are no signs of involuntary muscle control. She doesn’t really fit the progressive nature of CP which, if it were the case, one would expect a neurologist to diagnose.

The child wants to walk; she seeks assistance from parents and siblings bilaterally during ambulation. She has a transverse type gait with a lot of upper body torsional movement and can pick up quite a bit of speed, but sweats profusely with the exersion. She has hyperkeratosis on the plantar metatarsal area and lateral malleoli especially on the left.

Stretching along the lines of your suggestions had already been implemented, but I can see according to your experience, it’s going to be a long road.

Interestingly, while assisting the family with appropriate footwear, the client tried on her sister’s 3cm heel sandals. Despite the complete lack of ankle support, I was interested to see that her gait improved marginally.

Has anyone prescribed a higher heel boot to such a client with success?

Regards,

Peter Norton

Apology accepted. I’m definitely not trying to be politically correct about descriptions or ‘labelling’, but just want all patients to be treated equally, without prejudice. (I’ve got off my soap box now)

If there is ' no sign of involuntary muscle control' - what the heck is causing the tight TA's????

Is she diplegic? From the description of the gait it sounds as if she might be, in which case what about her core stability? does she have any or is there low tone hiding there?

If walking is so much effort what about supplying her with a walking aid such as a Kaye walker - this would give support and is usually a good way of supplying core stability whilst allowing the person to be able to approach tables etc directly as the bulk of the frame is behind It would at least give her support and independence, but no free hands!

I have to say though that I am confused about the picture here? No spasticity and yet a solid triceps surae??

Is it possible to achieve plantar grade foot? What about night splints when she is relaxed and not needing to mobilise?

Could it be an undiagnosed club foot as a baby?

Is there any possibility you could post some pictures to help visualise the problem?

My Physio collegue mentioned to me that she has a gentleman with CP who has boots with a good 6cm high buildup, but this is effectively inside the shoe giving support all through the sole of the foot. I don't think this has helped stop the spasticity, but it does at least give him a firm base of support.

Sorry for more questions but need the info to help.

Nikki