Pes calcaneus deformity in Myelomeningocele

Transcription

1 Pes calcaneus deformity in Myelomeningocele Alyn hospital 25 years experience Omer Or, Keenan Joseph, Ehud Lebel, Sharon Eylon Hadassah medical center, Alyn hospital, Shaare Zedek Medical Center JERUSALEM Hadassah Medical Organization, Hadassah University Hospital.

2 Ehi Ethiopathologyh Muscle imbalance Ankle dorsiflexor/plantarflexor Spasticity/flacidity Peroneal?

3 Ehi Ethiopathologyh Progressive deformity (vertical calcaneus) Gait & bracing problem Foot wear pressure ulcers

4 Treatment Stretching/ serial casting bracing Surgery: Tibialis anterior tendon transfer Tibalis anterior tenotomy Plantigrade bracable foot Ulcer free

5 Tibialis anterior transfer Technique: Detach insertion transfer The via interosseous goal: braceless membrane to foot achilles tendon Dorsal capsulotomy +/- POP 6-8 weeks Loses at least 1 grade power (4/5)

6 Tibialis anterior tenotomy Technique (block excision): Tibialis anterior Other ankle dorsiflexor Dorsal capsulotomy/peroneii? Elastic bandage Immidiate mobilization

7 Literature review the transfer can eliminate calcaneovarus deformity but not produce a functional transfer, tendency to new deformity is great and bracing requirements not reduced. unreliable and discourage its use Posterior Transfer of Tib. Ant in Low-Level Level MMC Janda et al, DMCN 1984; 26:100-3

8 Literature review The combined power of all other muscles around the ankle is less than the power of the triceps surae ie NO combination of tendon transfers can functionally substitute. Tibialis Anterior Transfer for Calcaneal Deformity: A Postoperative Gait Analysis Scott, Zionts, Gronley, Jacquelin Perry JPO 1966; 16:792-8

9 Literature review Even if all dorsiflexors were transferred, they would not replace the paralysed triceps surae. The transfer will function as a tenodesis. The goal of surgery is to remove deforming forces rather than replace the weak plantar flexors Surgical Rx of Calcaneal Deformity in a Select Group of Pts with MMC Park et al JBJS A 2008;90:

10 Alyn s clinic i experience 31 children Offered surgery Conservative 11 patients 11 feet TA transfer 7 patients 12 feet TA tenotomy 13 patients 18 feet

11 Indication for surgery Indications feet Progressive deformity 26 Sores 4

12 Conservative treatment Patients average (n=11, 6 males) Neuro level L3 L4 8 3 Follow up 1-13 years 4.3 y Result 2 callosities No pressure sores Braceable feet

13 TA transfer treatment Patients feet (n=7, 3 males) Neuro level L4 5 9 L5 2 3 Tib Ant power 4/5 all 12 Dorsal capsulotomy 5 7 Peroneal release Associated procedures average Age at operation 3-15 yrs 7.4 yrs Period in cast 6-8 weeks 6 w Follow up 5-18 years 13yrs 2mo

14 TA transfer treatment Results yes no Required Braces: AFOs 6 1 refused complications patients feet Pressure sores & OM 1 1

15 TA tenotomy treatment Neuro level L5 L4 L3 L2 Patients** (n=13, 6 males) feet Tib Ant power 5 1 4/4++ 3 and < 8 9 Dorsal capsulotomy 4 4 Peroneal release Associated procedures 2 8 3

16 TA tenotomy treatment average Age at operation 2-15 yrs 8 yrs Period in cast 0-4 weeks 1 Follow up 1-13 years 6 yrs 9mo Results Braces: RGOs (L2, L3) KAFO (lipommc) AFOs RGO Wheel chair

17 TA tenotomy treatment Complications patients feet Recurrence 3 3 Reoperation: block excision 2 2

18 Results Pressure sore Braceable Complication Conservative 0 All 2 callosities? Transfer 1 All Needed ddbracing 1 pressure sore- osteomyelitiselitis Tenotomy 0 All 2 reoperation

19 Conclusion Conservative treatment good option future? If surgery is indicated: d TA tenotomy is technically easier with good result