Surgical management of ankle and foot deformities in cerebral palsy

A system of surgical treatment of deformities of the ankle and foot in cerebral palsy is presented on the basis of experience with 420 children. The aim of surgery is prevention or correction of deformities. There are three types of deformity (fixed, dynamic, and mixed), each of which is treated differently. Surgery should be delayed as long as there is functional improvement. The most common indication for foot surgery is equinus deformity, which makes it difficult to keep the heel in the shoe. Tendo Achillis lengthening is satisfactory for fixed equinus, and transfer of the medial belly and the tendon of the gastrocnemius to the dorsum of the foot is appropriate for dynamic equinus. Hindfoot valgus in hypertonic cerebral palsy is treated by peroneus brevis elongation when moderate and in combination with subtalar arthrodesis when severe. Hindfoot valgus in hypotonic cerebral palsy is treated by subtalar arthrodesis only. Hindfoot varus is treated by tibialis posterior lengthening, usually in combination with (1) tendo Achillis lengthening, (2) a Steindler plantar release, or (3) valgus calcaneal osteotomy. Dynamic forefoot supination is treated by split-tibialis anterior tendon transfer or, when associated with dorsiflexion of the hallux, by extensor hallucis longus transfer.