İlker Abdullah SARIKAYA, Sema ERTAN BİRSEL, Ali ŞEKER, Ozan Ali ERDAL, Barış GÖRGÜN, Muharrem İNAN

The split transfer of tibialis anterior tendon to peroneus tertius tendon for equinovarus foot in children with cerebral palsy

Objective: The aim of this study was to analyze the results of the split anterior tibialis tendon transfer (SPLATT) to peroneus tertius (PT) for equinovarus foot deformity in children with cerebral palsy (CP). Methods: The medical records of 25 ambulatory CP patients (mean age: 8.7±3.2 years, range: 4-16 years) with equinovarus foot (33 feet), who underwent SPLATT to PT surgery between 2014 and 2016, were retrospectively reviewed. A senior surgeon performed all the surgical procedures. SPLATT was performed as part of a single-event multilevel surgery for the lower limb, and the concomitant procedures on the same extremity were recorded. The patients who required any additional foot or ankle surgery that could affect the clinical outcome (except heel cord lengthening) were excluded from the study. The Kling’s College Criteria were used to evaluate the procedural outcome of the foot position and gait, and the associated complications were recorded. Results: The mean follow-up time was 28.8±5 months (range: 24-42 months). The postoperative Kling scores were excellent for 27 feet of the patients who had a plantigrade foot, without fixed or postural deformity, in a regular shoe, having no calluses; good for 5 cases for those who walked with less than 5° varus, valgus, or equinus posture of the hind foot, wearing regular shoes, having no callosities; and fair for 1 case for those who had recurrence of the deformity. There was only one wound detachment, which was treated with wound care and dressing. None of the patients had overcorrection, infection, or bone fracture. Conclusion: The dynamic SPLATT to PT surgery for the management of the equinovarus foot deformities in the CP patients is a safe and less complicated surgical alternative with a good functional outcome. It is a safe and effective treatment method for the management of equinovarus foot deformities in CP.

___

1. Limpaphayom N, Chantarasongsuk B, Osateerakun P, Prasongchin P. The split anterior tibialis tendon transfer procedure for spastic equinovarus foot in children with cerebral palsy: results and factors associated with a failed outcome. Int Orthop 2015; 39: 1593-8. [Crossref]

2. Schwend RM, Drennan JC. Cavus foot deformity in children. J Am Acad Orthop Surg 2003; 11: 201-11. [Crossref]

3. Michlitsch MG, Rethlefsen SA, Kay RM. The contributions of anterior and posterior tibialis dysfunction to varus foot deformity in patients with cerebral palsy. J Bone Joint Surg Am 2006; 88: 1764-8. [Crossref]

4. Perry J, Hoffer MM. Preoperative and postoperative dynamic electromyography as an aid in planning tendon transfers in children with cerebral palsy. J Bone Joint Surg Am 1977; 59: 531-7. [Crossref]

5. Sarikaya IA, Seker A, Erdal OA, Talmac MA, Inan M. Surgical correction of hallux valgus deformity in children with cerebral palsy. Acta Orthop Traumatol Turc 2018; 52: 174-8. [Crossref]

6. Barnes MJ, Herring JA. Combined split anterior tibial-tendon transfer and intramuscular lengthening of the posterior tibial tendon. Results in patients who have a varus deformity of the foot due to spastic cerebral palsy. J Bone Joint Surg Am 1991; 73: 734-8. [Crossref]

7. Hoffer MM, Barakat G, Koffman M. 10-year follow-up of split anterior tibial tendon transfer in cerebral palsied patients with spastic equinovarus deformity. J Pediatr Orthop 1985; 5: 432-4. [Crossref]

8. Hui JH, Goh JC, Lee EH. Biomechanical study of tibialis anterior tendon transfer. Clin Orthop Relat Res 1998; 349: 249-55. [Crossref]

9. Kling TF Jr, Kaufer H, Hensinger RN. Split posterior tibial tendon transfers in children with cerebral spastic paralysis and equinovarus deformity. J Bone Joint Surg Am 1985; 67: 186-94. [Crossref]

10. Piazza SJ, Adamson RL, Moran MF, Sanders JO, Sharkey NA. Effects of tensioning errors in split transfers of tibialis anterior and posterior tendons. J Bone Joint Surg Am 2003; 85: 858-65. [Crossref]

11. Vogt JC. Split anterior tibial transfer for spastic equinovarus foot deformity: Retrospective study of 73 operated feet. J Foot Ankle Surg 1998; 37: 2-7. [Crossref]

12. Ortiz C, Wagner E. tendon transfers in cavovarus foot. Foot Ankle Clin 2014; 19: 49-58. [Crossref]

13. Hosalkar H, Goebel J, Reddy S, Pandya NK, Keenan MA. Fixation techniques for split anterior tibialis transfer in spastic equinovarus feet. Clin Orthop Relat Res 2008; 466: 2500-6. [Crossref]

14. Wu KW, Huang SC, Kuo KN, Wang TM. The use of bioabsorbable screw in a split anterior tibial tendon transfer: a preliminary result. J Pediatr Orthop B 2009; 18: 69-72. [Crossref]

15. Hoffer MM, Reiswig JA, Garrett AM, Perry J. The split anterior tibial tendon transfer in the treatment of spastic varus hindfoot of childhood. Orthop Clin North Am 1974; 5: 31- 8.

16. Anghelescu DL, Faughnan LG, Oakes LL, Windsor KB, Pei D, Burgoyne LL. Parent-controlled PCA for pain management in pediatric oncology: is it safe? J Pediatr Hematol Oncol 2012; 34: 416-20. [Crossref]

17. Anghelescu DL, Zhang K, Faughnan LG, Pei D. The safety and effectiveness of patient-controlled analgesia in outpatient children and young adults with cancer: A retrospective study. J Pediatr Hematol Oncol 2015; 37: 378-82 [Crossref]

18. Nelson KL, Yaster M, Kost-Byerly S, Monitto CL. A national survey of American Pediatric Anesthesiologists: patient-controlled analgesia and other intravenous opioid therapies in pediatric acute pain management. Anesth Analg 2010; 110: 754-60. [Crossref]

19. Berry J. Morphine Patient Controlled Analgesia (PCA), Paediatric Analgesia Guidelines V5.2 2017 sept. pp 9-10.

20. Scott AC, Scarborough N. The use of dynamic EMG in predicting the outcome of split posterior tibial tendon transfers in spastic hemiplegia. J Pediatr Orthop 2006; 26: 777-80. [Crossref]

21. Mulhern JL, Protzman NM, Brigido SA. Tibialis anterior tendon transfer. Clin Podiatr Med Surg 2016; 33: 41-53. [Crossref]

22. Vogt JC, Bach G, Cantini B, Perrin S. Split anterior tibial tendon transfer for varus equinus spastic foot deformity Initial clinical findings correlate with functional results: A series of 132 operated feet. Foot Ankle Surg 2011; 17: 178-81. [Crossref]

23. Fuller DA, McCarthy JJ, Keenan MA. The use of the absorbable interference screw for a split anterior tibial tendon (SPLATT) transfer procedure. Orthopedics 2004; 27: 372-4. [Crossref]

24. Kuo KN, Hennigan SP, Hastings ME. Anterior tibial tendon transfer in residual dynamic clubfoot deformity. J Pediatr Orthop 2001; 21: 35-41. [Crossref]

25. Joshi SD, Joshi SS, Athavale SA. Morphology of peroneus tertius muscle. Clin Anat 2006; 19: 611-4. [Crossref]

26. Sirasanagnadla SR, Bhat KM, Nayak SB, Shetty P, Thangarajan R. A rare case of variant morphology of peroneus tertius muscle. J Clin Diagn Res 2014; 8: AD01-2. [Crossref]

27. Green NE, Griffin PP, Shiavi R. Split posterior tibial-tendon transfer in spastic cerebral palsy. J Bone Joint Surg Am 1983; 65: 748-54. [Crossref]

28. Kagaya H, Yamada S, Nagasawa T, Ishihara Y, Kodama H, Endoh H. Split posterior tibial tendon transfer for varus deformity of hindfoot. Clin Orthop Relat Res 1996; 323: 254-60. [Crossref]

29. Medina PA, Karpman RR, Yeung AT. Split posterior tibial tendon transfer for spastic equinovarus foot deformity. Foot Ankle 1989; 10: 65-7. [Crossref]

30. Synder M, Kumar SJ, Stecyk MD. Split tibialis posterior tendon transfer and tendo-achillis lengthening for spastic equinovarus feet. J Pediatr Orthop 1993; 13: 20-3.

31. Chang CH, Albarracin JP, Lipton GE, Miller F. Long-term follow- up of surgery for equinovarus foot deformity in children with cerebral palsy. J Pediatr Orthop 2002; 22: 792-9. [Crossref]

32. Saji MJ, Upadhyay SS, Hsu LC, Leong JC. Split tibialis posterior transfer for equinovarus deformity in cerebral palsy. Long-term results of a new surgical procedure. J Bone Joint Surg Br 1993; 75: 498-501. [Crossref]

33. Vlachou M, Dimitriadis D. Split tendon transfers for the correction of spastic varus foot deformity: A case series study. J Foot Ankle Res 2010; 3: 28. doi: 10.1186/1757-1146-3-28. [Crossref]

34. Lee CL, Bleck EE. Surgical correction of equinus deformity in cerebral palsy. Dev Med Child Neurol 1980; 22: 287-92. [Crossref]

35. Edwards P, Hsu J. SPLATT combined with tendo achilles lengthening for spastic equinovarus in adults: results and predictors of surgical outcome. Foot Ankle 1993; 14: 335-8. [Crossref]