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					EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005                          Elhawary
___________________________________________________________________________________

      MODIFIED SCHOLDER' S OPERATION FOR TREATMENT OF
     FLEXIBLE EQUINO-VARUS DEFORMITY IN CEREBRAL PALSY

                                        By
                            Ibrahim Elhawary Ali- M.D.
                 Department of Orthopedic Surgeryand Traumatology
                           El-Minia Faculty of Medicine

ABSTRACT:
        Between 2001 and 2004, sixteen operations (16 feet) were done on 11 children
suffering from cerebral palsy with equino-varus deformity at El Minia University
Hospital. Five with diplegic cerebral palsy (10 feet) and six with hemiplegic type (4
right and 2 left side) who were able to walk and the deformity can be passively cor-
rected whether the knee is in flexion or extension. There were 6 females and 5 males,
their age at operation ranged from 6 to 11 years (mean 8 years). The procedure was
splitting tendocalcaneous in the sagittal plane and suturing its lateral half to the pe-
roneus brevis tendon. The follow up period was 18 months. Our results were good in
8 cases (12 feet; 75%) with correction of the deformity and improvement of the gait,
while recurrence of the equinous deformity only occurred in 3 cases ( 4 feet ; 25%).


KEY WORDS:
         Cerebral Palsy                                  Deformity
         Equino                                          Varus.


INTRODUCTION:                                                Equino-varus deformity is more
        Equinous deformity is comm-                 easily corrected surgically and is more
only encountered in children with cer-              functionally disabling in walking and
ebral palsy. This deformity is defined              standing, while valgus deformity is
as limitation of passive dorsiflexion               more difficult to correct surgically and
beyond the neutral position. This may               is less functionally disabling.3
be a dynamic deformity caused by an
exaggerated stretch reflex in the calf                      Root in 1984,4 had observed
muscles, or a fixed one due to contrac-             that when the child stands on his toes
ture of the triceps surae. In either case,          in equino varus, the varus is accentuat-
the result is a characteristic toe – toe or         ed by an overactive tibialis posterior
toe – heel gait, which is clumsy and                muscle, and dynamic gait studies
inefficient.1                                       showed that the tibialis posterior ten-
                                                    don is also active in the swing phase or
        Equino-varus deformity is seen              it may be active continuously, weak-
less often than valgus deformity. The               ness of the evertor muscles also con-
triceps surae is an invertor of the heel,           tributes to the deformity.
especially when the ankle is in full
planter flexion and after the correction                    A wide variety of procedures
of the equinous deformity by lengthen-              have been described for the surgical
ing of the tendocalcaneous the varus                correction of the equino varus deformi-
deformity often disappears2                         ty besides the different procedures de-
                                                    scribed for lengthening of the triceps



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surae in children with cerebral palsy                    Transfer of the tendons of the
such as:                                                  extensor hallucis longus and
     Lengthening of the tibialis pos-                    tibialis anterior to the dorsum
       terior tendon by a Z-plasty pro-                   of the foot.10
       cedure or sliding lengthe-ning
       at its musculo tendinous junc-                      The aim of the Scholder's oper-
       tion.5                                      ation for the correction of the equinous
     Rerouting tibialis posterior ten-            deformity (fig. 1) is to weaken the con-
       don anterior to the medial mal-             traction of the triceps by fixing part of
       leolus.6                                    the Achilles tendon to the tibia, thus
     Rerouting the insertion of the               reducing the traction on the calcaneum
       tibialis posterior tendon to the            and indicated when the equinous can
       dorsum of the foot through the              be passively corrected whether the
       interosseous membrane.7                     knee is in flexion or extension.11
     Split tendon transfer: the plan-
       tar half of the tibialis poste-rior                 The aim of our study is to mod-
       tendon is detached from its in-             ify the Scholder's operation by transfer
       sertion and rerouted poste-rior             of the lateral half of the Achilles ten-
       to the tibia to be sutured to the           don to the peroneus brevis tendon, thus
       peroneus brevis tendon.8                    weakening the contraction of the tri-
     Split tibialis anterior tendon               ceps and counteracting the varus de-
       and suturing its lateral half to            formity by enhancing the peroneus
       the tendon of peroneus brevis               brevis tendon to achieve the normal
       or to the cuboid bone.9                     heel – toe gait.




 Fig.1: Scholder's operation by fixing part of the Achilles tendon to the tibia, thus re-
                        ducing the traction on the calcaneum.
PATIENTS AND METHODS:                                   Our study include 11 children
                                                (16 feet), 5 with diplegic cerebral palsy


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   EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005                          Elhawary
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   (10 feet), and 6 with hemiplegic type             asked to flex the hip against the re-
   (4 with right side affection and 2 with           sistance of the examiner's hand on the
   left side), who were able to walk and             thigh. Active dorsiflexion become ap-
   the deformity can be passively correct-           parent. There were very weak active
   ed whether the knee is in flexion or              dorsiflexion. Passive inversion and
   extension. There were 6 females and 5             eversion of the hind-foot and forefoot
   males, their age at operation ranged              with ankle in dorsiflexion and in plant-
   from 6 to 11 years (mean 8 years).                er flexion also examined. Limited in-
                                                     version when the ankle is dorsiflexed
          All of the patients had an intel-          indicates that there is shortness of the
   ligence quotient of 80 or more. Ac-               peronei, whilst passive inversion may
   cording to the criteria of Tachdjian,             indicate forwards peronei subluxation
   198512 (All had the ability to compre-            or peronei are tight.13
   hend instructions and were able to
   walk without the use of walking aids,             Gait: the patient's gait was observed
   no defects of hearing or vision).                 and classified as:
                                                          TOE-TOE Gait: failure of the
   PRE-OPERATIVE ASSESSMENT:                             heel to strike at all, even when the
   ( table 1)                                            patient walked slowly. (8 cases)
           Physical examination included                  TOE-HEEL Gait: the toes
   assessment of the active and passive                  strikes first and the heel strikes lat-
   range of movement, as well as of fixed                er. (3 cases)
   deformities in the joint of the lower             There were 3 cases which had adductor
   limb and if there is previous correction          tenotomy 2 years ago.
   of other deformities. Co-spasticity of
   muscles makes it difficult to test the            Our criteria for selection were:
   power of a single muscle group in pa-             1- spastic diplegia or hemiplegia.
   tient with cerebral palsy. Active dorsi-          2- ability to walk independently
   flexion of the ankle is more difficult to             without aids.
   assess accurately, so the dorsiflexion            3- flexible equino-varus deformity.
   confusion test is used. The child sits            4-no deformity at the hip or the knee.
   with knee flexed at right angle and is

    Table (1) : Pre-operative assessment
Case Age in                                                 Dorsiflexion
                 Sex side         type          Gait                        Previous surgery
No. years.                                                 confusion test
  1        6      M     RT hemiplegic          Toe-heel      Very weak              No
  2        7      M     LT hemiplegic          Toe-toe       Very weak              No
  3        8       F            diplegic       Toe-toe       Very weak     Adductor tenotomy
  4       11       F            diplegic       Toe-toe       Very weak              No
  5       10       F            diplegic       Toe-toe       Very weak              No
  6        9      M     RT hemiplegic          Toe-heel      Very weak              No
  7        7       F            diplegic       Toe-toe       Very weak      Adductor tenotomy
  8        8      M     RT hemiplegic          Toe-toe       Very weak              No
  9        6       F    LT hemiplegic          Toe-toe       Very weak              No
 10        6      M             diplegic       Toe-toe       Very weak      Adductor tenotomy
 11       10       F    RT hemiplegic          Toe-heel      Very weak              No
    Surgical technique:                             the use of a tourniquet, a longitudinal
          Under general anesthesia, with            incision about 10 cm along the
    the patient prone in position and with          posterolateral    border     of     the


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tendocalcaneous down to the midway                curred in the first 3 cases. Then, physi-
between the tip of the lateral malleolus          otherapy and rehabilitation program is
and      the     insertion     of     the         begun for 6 weeks.
tendocalcaneous. Divide the superficial
and deep fascia, expose the                       FOLLOW-UP:
tendocalcaneous and divide it after                      Each patient was followed up
opening the sheath in the sagittal plane          for a period of 18 month. Every 3
to medial and lateral halves and cut the          months the patient was examined clini-
lateral half from its insertion on the            cally. Observation and analysis of the
calcaneus bone, then expose the pe-               patient's gait is an important part of
roneus brevis tendon after the release            cerebral palsy evaluation. Normal gait
of the superior peroneal retinaculum              should have stable plantigrade stance,
not interfering with the inferior                 floor clearance in swing phase , heel
peroneal retinaculum over the lateral             toe pattern, adequate step length and
surface of the calcaneus to avoid                 minimal energy expenditure. Clinical
peroneal subluxation. Then the distal             examination at the end of follow up
end of the lateral half of the                    showed a significant improvement in
tendocalcaneous was sutured to the                active and passive dorsiflexion of the
peroneus brevis tendon. Close the deep            ankle. There was no decrease in the
fascia and skin. In cases of diplegia the         power of the planter flexion of the an-
operation was done for both feet at the           kle after surgery.
same setting.
                                                  RESULTS:
POST-OPERATIVE                                             Our results were good in 8 cas-
MANAGEMENT:                                       es (12 feet); 75%, while recurrence of
       The leg was immobilized in a               equinus deformity was present in
high above knee cast with the knee ful-           3cases (4 feet); 25%. In good cases
ly extended and ankle in neutral posi-            there were correction of the deformity
tion for 3 weeks, (The stitches was re-           and improvement of the gait. No
moved after 2 weeks through a win-                equino-valgus deformity occurs. Su-
dow) changed by another below knee                perficial pressure sores occurred in the
cast for 3 weeks.                                 first three cases only which healed af-
        A window is cut from the se-              ter a short period of medical treatment
cond cast over the apex of the heel to            .
prevent pressure sores which was oc-




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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005                          Elhawary
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Fig. 2: A female patient 8 years old,         Fig. 3: intraoperative view showing
diplegic type with equino-varus de-           both tendo calcaneus and peroneal
              formity                                     brevis tendon.




        Fig. 4: intraoperative view showing split of tendo calcaneus and
       cut its lateral half distally to be sutured at peroneal brevis tendon.




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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005                          Elhawary
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        A: From front                             B: From behind


         Fig. 5: (a &b) 6-weeks post-operative showing plantigrade foot
                  with superficial pressure sores at the right foot




Fig. 6: the same patient after the end of the follow up (18 months post-operative),
                  the foot is plantigrade without any deformity.




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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005                          Elhawary
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DISCUSSION:                                        months follow up, good result was
        In children with hemiplegia,               achieved in 12 from 16 feet (75%).
equinus deformity is usually real and
not apparent, while in children with                       After long term follow up after
diplegia and quadriplegia the situation            surgery for equino varus foot in cere-
is more complicated. Equinus defor-                bral palsy, Chang et al in 200220, 108
mity is often more apparent than real.             patients who had surgery on tibialis
Spasticity and flexion contractures at             posterior tendon (split tendon transfer,
the hip and knee may dictate an                    intramuscular lengthening or z-plasty
equinus posture at the ankle.14                    lengthening) in 140 feet were reviewed
                                                   at a mean age of 16.8 years with 7.3
       So we selected our patients                 years of follow up, 75% diplegic and
with flexible equino varus deformity               quadriplegic who were younger than 8
without any hip or knee contracture.               years failed operative intervention.

        Bisla, Louis and Albano in                         In our cases and according to
197615, had reported an anterior rerout-           the type of cerebral palsy were good in
ing of the tibialis posterior tendon in            4 cases hemiplegic type (66.65%) and
21 feet of 16 patients with cerebral pal-          recurrence occurred in 2 cases
sy. Their results were improvement in              (33.35%) while in diplegic type, 4 cas-
4 feet, in 14 feet there was no signifi-           es were good; (80%), and one case
cant change and three cases showed                 showed recurrence after one and half
recurrence of equino varus deformity.              year from the operation; (20%).

        Ziv et al in 198416 showed that            CONCLUSION:
spastic gastrocnemius muscle grows at                      The aim of the operation for the
only 55% of the rate of the bone and               correction of the deformed foot in cer-
this explains the development of                   ebral palsy is improvement of function
equinus contracture.                               with a heel-toe gait and adequate push
                                                   off. The ideal correction is rarely
       Several studies have docum-                 achieved because the primary disorder
ented a higher rate of recurrence after            is a central one and the site of surgery
operation at less than 6 years old.17-19           is peripheral, however, if parents are
                                                   advised that relative improvement ra-
       In our cases the recurrence oc-             ther than a normal gait is the aim of
curs in 3 cases (cases no. 1, 9 &10)               treatment the majority will be satisfied.
which were below 7 years old.                      Recurrent equinus is clearly related to
                                                   the patient's age at the time of the op-
         In 1985 Kling, Kaufer and                 eration in this as in other series.
Hensinger 8 had reported excellent and                     Early surgery in cerebral palsy
good results in 34 of 37 cerebral pal-             is not advised as the delayed matur-
sied patients with equino varus de-                ation of the central nervous system
formity (91.9%) treated by split tibialis          characteristic of this condition may
posterior tendon transfer with the                 produce variable and unpredictable re-
planter half of the tendon rerouted pos-           sults. We advise long term period of
terior to the tibia and is then sutured to         follow up until age of skeletal maturi-
the peroneus brevis tendon.                        ty.

       In our study with a modified                REFERNCES:
Scholder's operation and after 18


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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005                          Elhawary
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    1- Etnyre B; Chambers C.S.; Scar-                  11- Scholder J.C.; Scholder C., and
borough N.H., and Cain T.H.: Preoper-             Saundan Y: Techniques et resultats du
ative and postoperative assess-ment of            freinage du tendon d'Achille dans le
surgical intervention for equinus gait in         traitement de l' equinisme spastique.
children with cerebral palsy. J.Pediatr.          Rev. chir. Orthop. 43-72, 1957. quoted
Orthop.1993:13:24-31.                             from Banks H.H.: The management of
    2- Gaines R.W., and Ford T.B.: A              spastic deformities of the foot and an-
systemic approach to the amount of                kle. Clin. Orthop. 1977: 122, 70-76.
Achilles tendon lengthening in cerebral                12- Tachdjian M.O.: The child's
palsy.J.Pediatr.Orthop.1984:4:448-451.            foot . Philadelphia: W.B. Saunders Co.
    3- Sharrard W.J.W., and Bernstein             1985: 556-597.
S.: Equinus deformity in cerebral pal-                 13- Cottalorda J.; Gautheron V.;
sy: a comparison between elonga-tion              Metton G.; Charmet E., and Chavrier
of the tendocalcaneous and gastro-                Y.: Toe-walking in children younger
cnemius recession. J. Bone & Joint                than six years with cerebral palsy. J.
Surg. (Br.) 1972: 54-B: 272-276.                  Bone&Joint Surg. 2000, 82-B: 4: 541-
    4- Root L.: Varus and valgus foot             544.
in cerebral palsy and its management.                  14- Borton D.C.; Walker K.;
Foot Ankle 4:174, 1984.                           Pirpiris M.; Nattass G.R. and Graham
    5- Root L.; Miller S.R., and Kirz             H.K.: isolated calf lengthening in cere-
P.: Posterior tibial tendon transfer in           bral palsy. Outcome analysis of risk
patients with C.P.: J. Bone&Joint Surg.           factors. J. Bone &Joint. Surg.: 2001,
1987: 69-A: П33.                                  83-B:3, 364-370.
    6- Williams P.F.: Restoration of                   15- Bisla R.S. Louis H.J., and Al-
muscle balance of the foot by transfer            bano P.: Transfer of tibialis posterior
of the tibialis posterior. J. Bone &              tendon in cerebral palsy. J. Bone & j.
Joint. Surg. 58-B: 1976, 217.                     Surg. 1976, 58-A : 497.
    7- Gritzka T.L.; Staheli L.T., and                 16- Ziv I.; Blackburn N.; Rang M.,
Duncan W.R.: Posterior tibial tendon              and Koreska J.: Muscle growth in
transfer through the interosseous                 normal and spastic mice. Dev Med.
membrane to correct equino varus de-              Child Neurol, 1984: 26, 94 – 99. Quot-
formity in cerebral palsy: an initial ex-         ed from Saraph V.; Zwick E.B.;Uitz
perience. Clin. Orthop.1972:89: 201.              C.; Linhart W., and Steinwender G.:
    8- Kling T.F.; Kauffer H.; and                The Baumann procedure for fixed con-
Hensinger R.N.: Split posterior tibial            tracture of the gastrosoleus in cerebral
tendon transfer in children with cere-            palsy. J. Bone & Joint Surg . 2000, 82-
bral spastic paralysis and equino varus           B : 545-540.
deformity. J. Bone & J. Surg. 1985:                    17- Craig J.J., and Van Huren J.:
67-A: 186.                                        The importance of gastrocnemius re-
    9- Hoffer M.M.; Barakat G., and               cession in the correction of equinus
Koffman M.: 10 year follow up of split            deformity in cerebral palsy . J. Bone &
anterior tibial tendon transfer in cere-          J. Surg. 1976,58-B : 84-87 .
bral palsied patients with spastic                     18- Olney B.W.; Williams P.F.,
equino varus deformity. J. Pediatr.               and Menelaus M.B.: Treatment of
Orthop.: 1985:5: 432.                             spastic equinus by aponeurosis length-
    10- Fred P.Sage.: cerebral palsy,             ening . J . Pediatr. Orthop. 1988, 8 :
Campbell's Operative Orthopedics, Ed-             422-425.
itor Crenshaw A H, The C.V. Mosby                      19- Ratty T. E.; Leahey L.; Hynd-
Company, Seventh editions Chapter                 man J.; Brown D.C., and Gross M.:
65, 2843-2923, 1987.                              Recurrence after Achilles tendon


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‫5002 ,.‪EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN‬‬                          ‫‪Elhawary‬‬
‫___________________________________________________________________________________‬

‫.‪lengthening in cerebral palsy . J‬‬               ‫‪varus foot deformity in children with‬‬
‫.781-481 ,31: 3991 .‪Pediatr. Orthop‬‬              ‫.‪cerebral palsy . J Pediatr. Orthop‬‬
    ‫;.‪20- Chang C.H.; Albarracin J.P‬‬             ‫.997 - 297 ,6 : 2002‬
‫– ‪Lipton G.E., and Miller F.: Long‬‬
‫‪term follow-up of surgery for equino‬‬




       ‫عملية اسكولدر المعدلة فى عالج تشوه القدم الحنف األبخسى القفدى‬
                       ‫المرن فى مرضى الشلل المخى‬

                                  ‫إبراهيم الهوارى على‬
                              ‫قسم جراحة العظام واإلصابات‬
                                    ‫كلية طب المنيا‬

‫الدراسة كانت على أحد عشر طفالً ، ستة من اإلناث وخمسة ذكور ممن يعانون من‬
‫مرض الشلـل المخـى. أجريـت العملية على ستة عشر قدما ً بها تشوه القدم الحنف األبخسى‬
‫القفدى المرن وذلك فى مستشفى المنيا الجامعى فى الفترة ما بين عام 2001 وإلى عام 2001م.‬
‫خمسة من األطفال كانوا يعانون من شلل فى الجانبين بينما ستة مرضى يعانون من شلل فى‬
                    ‫الجانب الواحد ، أربعة منهم فى الجانب األيمن وإثنان فى الجانب األيسر.‬

‫العملية كانت تتم بنقل النصف الوحشى لوتر العرقوب إلى وتر العضلة الشظيية‬
‫القصيرة ثم يتم وضع جبس فوق مفصل الركبة لمدة ثالثة أسابيع يعقبها جبس آخر تحت مفصل‬
                    ‫الركبة لمدة ثالثة أسابيع أخرى ، ثم تبدأ بعد ذلك فترة العالج الطبيعى.‬

‫كانت فترة المتابعة ثمانية عشر شهراً وكانت النتائج جيدة بنسبة 75% حيث تم إصالح‬
‫التشوه وتحسنت طريقة المشية بينما عاد التشوه بعد فترة المتابعة إلى ثالث حاالت "أربعة أقدام"‬
                                                                              ‫بنسبة 71%.‬




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