Surgical varieties in the management of tiptoeing cerebral palsied spastic children

Sixteen children with fixed equinus deformity of the ankle due to spastic cerebral palsy were evaluated and surgically treated in a prospective study held at the orthopaedic department of Rafae General Hospital during the period from March 2015 to June 2017. The aim of the study were to cite through proper clinical assessment the specific deformities that contribute to tiptoe standing or walking in these children and to choose the appropriate surgical procedures , in order to improve their functional outcome .There were 9 boys and 7 girls with their ages up to 10 years. The pattern of spastic cerebral palsy was hemiplegia in 3, diplegia in 9 and quadriplegia in 4 patients with a total number of 29 involved lower limbs. Primary equinus deformity was reported in 5 feet and secondary equinus deformity in 24 feet .A total of 68 surgical procedures was performed aiming at correcting the deformities an d improving the gait in these children. To correct fixed equinus deformity at ankle 3 types of surgical procedures were utilized in 29 feet. These procedures were sliding percutaneous lengthening of Achilles tendon in 8 feet, open z-plasty of Achilles tendon in5 feet and gastrocnemius recession in 16 feet. The functional outcome in term of deformity correction was 100% good results in gastrocnemius recession .compared to 62.5% and 40% good results in percutaneous lengthening and Z-plasty of Achilles tendon respectively. Under correction with recurrent or persistence of fixed equinus deformity was not reported in gastrocnemius recession cases but it was 25% after sliding percutaneous lengthening and 20 % after Z- plasty of Achilles tendon. Overcorrection with resultant calcaneus deformity was not reported after gastrocnemius recession but had occurred in 12.5% of sliding percutaneous lengthening and in 40% of Z-plasty cases. Satisfactory results in term of gait improvement were obtained in all children of the secondary equinus group. Those children who were only capable of standing with support before surgery were in 88.9% of cases converted into walkers (66.7% independent walkers and 22.2% walkers with aid). All children who before surgery were capable of waking with aids had become independent walkers (100% conversion rate).The study concluded that a properly selected child with spastic cerebral palsy will benefit a lot from surgical interference.