Is there still a place for Achilles tendon lengthening?

Patients with diabetes and ankle equinus are at particularly high risk for forefoot ulceration because of the development of high forefoot pressures. Stiffness in the triceps surae muscles and tendons are thought to be largely responsible for equinus in patients with diabetes and underpins the surgical rationale for Achilles tendon lengthening (ATL) procedures to alleviate this deformity and reduce ulcer risk. The established/traditional surgical approach is the triple hemisection along the length of the Achilles tendon. Although the percutaneous approach has been successful in achieving increases in ankle dorsiflexion >30°, the tendon rupture risk has led to some surgeons looking at alternative approaches. The gastrocnemius aponeurosis may be considered as an alternative because of the Achilles tendon's poor blood supply. ATL procedures are a balance between achieving adequate tendon lengthening and minimizing tendon rupture risk during or after surgery. After ATL surgery, the first 7 days should involve reduced loading and protected range of motion to avoid rupture, after which gradual reintroduction to loading should be encouraged to increase tendon strength. In summary, there is a moderate level of evidence to support surgical intervention for ankle joint equinus in patients with diabetes and forefoot ulceration that is non-responsive to other conservative treatments. Areas of caution for ATL procedures include the risk for overcorrection, tendon rupture and the tendon's poor blood supply. Further prospective randomized control trials are required to confirm the benefits of ATL procedures over conservative care and the most optimal anatomical sites for surgical intervention.

Neuronox versus BOTOX for spastic equinus gait in children with cerebral palsy: a randomized, double-blinded, controlled multicentre clinical trial.

AIM: The aim of this study was to evaluate the efficacy and safety of a newly manufactured botulinum toxin, Neuronox, compared with BOTOX for the treatment of the spastic equinus gait in children with cerebral palsy. METHOD: A total of 127 children with cerebral palsy, aged 2 to 10 years, who presented at three university hospitals with spastic equinus gait were assessed for eligibility to participate in this double-blinded, randomized, controlled trial. Of the 119 eligible participants (mean age 4.33 y; SD 2.07; 76 males and 43 females; 79 with diplegia and 40 with hemiplegia), 57 were classified as Gross Motor Function Classification System level I, 29 as level II, and 33 as level III. Participants were randomly assigned to receive an injection of Neuronox (n=60) or BOTOX (n=59) to the calf muscles at a dose of 4U/kg for those with hemiplegia and 6U/kg for those with diplegia. Assessments were performed at baseline (V1) and at 4 (V2), 12 (V3), and 24 (V4) weeks after the intervention. The primary outcome measure was response rate at V3, with a positive response being defined as at least a 2-point increase in the Physicians' Rating Scale (PRS) score. The non-inferiority margin was set as -20% for the difference in the response rate. The secondary outcome measures included PRS score, passive range of motion (PROM) of the ankle and knee, and Gross Motor Function Measure 88 (GMFM-88). Any adverse events were investigated for safety implications. RESULTS: The response rate of the Neuronox group at V3 was not inferior to that of the BOTOX group (90% lower limit=-11.58%). There were significant improvements in PRS, PROM of ankle dorsiflexion, and GMFM scores at V2, V3, and V4 in both groups. The changes in PRS score were not statistically different between the two groups in serial evaluation (p=0.96). PROM of the ankle dorsiflexion increased without any significant difference between the two groups, either overall (p=0.56) or at each visit (V2, p=0.32; V3, p=0.66; V4, p=0.90). The increase in GMFM score in serial measurements were not significantly different between the two groups (p=0.16), whereas it was larger in the BOTOX group than in the Neuronox group at V2 and V4 (p=0.03 and 0.05 respectively). The frequency of adverse events was not significantly different between the two groups (p=0.97), and drug-related complications of Neuronox treatment were not addressed. INTERPRETATION: The outcomes of Neuronox, based on PRS, proved to be as effective and safe as those of BOTOX for the treatment of spasticity in individuals with cerebral palsy.

Treatment of posttraumatic equinus deformity and concomitant soft tissue defects of the heel.

BACKGROUND: To evaluate the operative method and clinical outcome for the treatment of posttraumatic equinus deformity and concomitant soft tissue defect of the heel. METHODS: Between June 2006 and May 2010, seven cases of posttraumatic equinus deformity and concomitant unstable scar or ulcer of the heels were treated by using a hinged Ilizarov apparatus and reversed sural fasciocutaneous island flap transfer. Achilles tendon lengthening was also done in all patients. The average duration of follow-up was 21 months. The sizes of sural flaps were from 7 cm × 6 cm to 10 cm × 9 cm. Two weeks after the flap transfer, distraction of the Ilizarov fixator was initiated to gradually correct the equinus position of the foot. RESULTS: Results were evaluated by using the following criteria: (1) the degree of active dorsiflexion of the ankle, (2) the total active range of motion of the ankle, and (3) walking ability and flap durability. For active dorsiflexion of the ankle, the results were good in three patients and fair in four patients. For range of active motion of the ankle, the results were good in five patients and fair in two patients. For walking ability and flap durability, the results were good in six patients and fair in one patient. CONCLUSION: This study showed that posttraumatic equinus deformity accompanied by soft tissue defect of the heel can be treated effectively with Achilles tendon lengthening, reversed sural fasciocutaneous island flap transfer, and a hinged Ilizarov technique.

Casting, taping or stretching after botulinum toxin type A for spastic equinus foot: a single-blind randomized trial on adult stroke patients.

OBJECTIVE: To investigate the effect of different adjunctive treatments after botulinum toxin type A. DESIGN: Single-blind, randomized trial, with three-month follow-up. SETTING: Secondary rehabilitative care. SUBJECTS: Convenience sample of 69 chronic hemiplegic adult patients with spastic equinus foot. INTERVENTIONS: Following botulinum toxin type A injection at the plantar flexors, patients were randomly assigned to three groups and treated with either taping, casting or stretching for one week, and with stretching and gait training for the next week. OUTCOME MEASURES: Modified Ashworth Scale at plantar flexors, passive range of motion at the ankle, six-minute walking test, 10-metre walking test, Functional Ambulation Categories, ankle dorsiflexor strength were evaluated before treatment (t(0)) at 20 days (t(1)) and 90 days (t(2)) after treatment. RESULTS: At t(1) only the taping and casting groups showed significant improvements in Modified Ashworth Scale, six-minute walking test, 10-metre walking test and passive range of motion (P < 0.02). At t(2), while the results were maintained in the casting group, only six-minute walking test and Modified Ashworth Scale were still significantly improved in the taping group. Ankle dorsiflexor strength and Functional Ambulation Categories did not change in any of the groups at any time. At t(2) the casting group performed better than the taping and stretching groups at Modified Ashworth Scale and passive range of motion, and better than the stretching group at six-minute walking test (P < 0.02). CONCLUSIONS: Combining botulinum toxin type A to the ankle plantar flexors with casting or taping gives better and longer lasting results than with stretching alone.

Application of the Ilizarov technique to the correction of neurologic equinocavovarus foot deformity.

BACKGROUND: The treatment of rigid equinocavovarus foot deformities caused by neurologic disorders is often difficult and relapse is common. QUESTIONS/PURPOSES: We asked whether the Ilizarov technique could be used for correction of neurologic equinocavovarus foot deformities resulting in improved foot and ankle function and patient satisfaction. PATIENTS AND METHODS: The neurologic equinocavovarus foot deformities of 26 patients (mean age, 18.7 years; 29 feet) were treated using the Ilizarov technique. Nine feet were treated by distraction histiogenesis only with limited soft tissue release, whereas 20 feet needed additional osteotomy and/or tendon transfer/lengthening. Minimum followup was 12 months (mean, 72.9 months; range, 12-155 months). RESULTS: The mean time required for deformity correction was 27.1 days (range, 14-47 days) and the mean time for stabilization in the apparatus was 23.2 days (range, 7-53 days). A painless, stable, and plantigrade result was obtained by 22 patients (24 feet). Mild residual foot deformity was observed in the remaining five feet of four patients. Six patients (six feet) experienced postoperative complications. Three patients (four feet) experienced recurrence of the deformity requiring surgical correction. CONCLUSIONS: Ilizarov soft tissue distraction with or without callotasis of tarsal bone(s) allows a greater degree of correction of neurologic equinocavovarus foot deformities. However, to reduce the risk of recurrence after fixator removal, it may be necessary to overcorrect the deformity while in the fixator, to use nighttime splinting, and most importantly, to eliminate neuromuscular imbalance, if necessary, by combining arthrodesis with or without tendon transfer. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Flexible and rigid casting tape as a novel approach to offloading diabetic foot ulcers.

Offloading diabetic ulceration is a key component to the success in healing ulcers on the plantar aspect of the foot. New advances in offloading techniques allow for differing approaches in sometimes complex diabetic foot pathologies with associated ulceration. This case study looks at the use of flexible and rigid casting technique as part of the treatment in offloading plantar foot ulceration.

Split anterior tibial tendon transfer for varus equinus spastic foot deformity Initial clinical findings correlate with functional results: A series of 132 operated feet.

Spastic equinovarus foot deformity commonly occurs after stroke or head trauma. Management by split anterior tibial tendon transfer to the lateral border of the foot was chosen by the authors. The purpose of that work was to assess the reliability of this method to improve patient's functional autonomy and investigate the relationship between the initial clinical examination findings and the quality of the functional results. 84 feet, operated in 82 patients out of 130, of mean age 46 years, were reviewed at a mean follow-up of 65 months. Very few complications were observed. Toe deformities remain a commonly associated problem. 80 patients were able to walk barefoot, 74 reported an increase in their walking distance, and 73 could regularly wear normal shoes. There is a strong relationship (p<0.001) between the preservation of deep foot sensitivity and the level of functional autonomy.

Does the treatment of spastic equinovarus deformity following stroke with botulinum toxin increase gait velocity? A systematic review and meta-analysis.

While botulinum toxin-A (BT-A) has been used to treat lower-limb focal spasticity successfully, its effect on characteristics of gait has not been well defined. The objective of this systematic review was to establish the treatment effect associated with the use of BT-A for equinovarus to improve gait velocity following stroke, using a meta-analytic technique. Relevant studies were identified through a literature search encompassing the years 1985 to November 2009. Studies were included if (i) the sample was composed of adult subjects recovering from either first or subsequent stroke, presenting with spastic equinovarus deformity of the ankle preventing full active dorsiflexion, and (ii) subjects who received BT-A were compared with subjects who had received a placebo, or (iii) in the absence of a placebo-controlled condition, subject had received BT-A and was assessed before and after treatment. A standardized mean difference (SMD) ± standard error and 95% confidence interval (CI) for gait velocity between the treatment and control group was calculated for each study, using Hedges's g, and the results pooled. Eight trials, five randomized controlled trials, and three single group intervention studies were included. Data representing 228 subjects were available for pooled analysis. Treatment with BT-A was associated with a small improvement in gait velocity (Hedge's g = 0.193 ± 0.081; 95% CI: 0.033 to 0.353, P < 0.018) representing an increase of 0.044 meters/s. The use of BT-A for lower-limb post-stroke equinovarus because of spasticity was associated with a small, but statistically significant increase in gait velocity.

Endoscopic gastrocnemius recession for treating equinus in pediatric patients.

UNLABELLED: Gastrocnemius recessions have been performed as open or endoscopic procedures. Most of the literature describes the outcomes of these procedures in children with specific neurologic limitations. We report an alternative approach to endoscopic gastrocnemius recessions in neurologically healthy pediatric and adolescent patients whose gastrocnemius equinus could not be corrected nonoperatively. We prospectively followed 23 patients (16 boys, seven girls) who underwent 40 procedures for equinus deformity (n = 22) or osteoarthritis (n = 1). All patients had been directly referred for surgical treatment because all previous nonoperative treatments (stretching, night splints, orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy) had failed. The indications for surgery were patients age 18 years or younger experiencing symptomatic equinus unresponsive to nonoperative care. Pre- and postoperative ankle dorsiflexion were measured. The minimum followup for study inclusion was 1 year (mean, 2.9 years; range, 2-5.1 years). For every patient, dorsiflexion range of motion improved (mean, 15 degrees ; standard deviation, 4 degrees ). No patient had diminished nerve sensation postoperatively. This technique can be used to correct gastrocnemius equinus in otherwise healthy children who have not benefited from prior nonsurgical treatment. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Overview of Metatarsalgia.

Metatarsalgia can be viewed as more of a symptom rather than a distinct diagnosis. Timing of forefoot pain during the gait cycle and evaluation of whether the pain is from anatomic abnormalities, indirect overloading, or iatrogenic causes can suggest a specific metatarsalgia etiology. A thorough physical examination of the lower extremity, especially evaluation of the plantar foot, and weight-bearing radiographs are critical for diagnosis and treatment. Nonoperative treatment consists of physical therapy, orthotics, shoe wear modification, and injections. If conservative treatment fails, surgical options may be considered. [Orthopedics. 2019; 42(1):e138-e143.].

Assessment protocol for serial casting after botulinum toxin a injections to treat equinus gait.

PURPOSE: The purpose of this study was to investigate feasibility of an assessment protocol for a trial of post-Botox casting to treat equinus gait in cerebral palsy. METHODS: Ten children (ages, 26-75 months) were recruited. Nine were assessed 1 week before botulinum toxin-A injections and reassessed 1 week after removal of the final cast. The assessment protocol included Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), Gross Motor Function Measure-66 (GMFM-66), Pediatric Evaluation of Disability Inventory (PEDI), and GAITRite. Feasibility was based on acceptability of the protocol, inter-rater reliability, and responsiveness of outcome measures. RESULTS: The assessment protocol was acceptable and practical. Inter-rater reliability for MAS, MTS, and GMFM ranged from moderate to excellent. Improvements were found in MTS and MAS scores for dorsiflexion and hamstring (p < 0.01), GMFM-66 (p = 0.01), and Pediatric Evaluation of Disability Inventory mobility (p = 0.01), self-care (p = 0.01), and social function (p = 0.00). GAITRite revealed reductions in speed (p = 0.00) and cadence (p = 0.01). CONCLUSIONS: Feasibility was confirmed. Recommendations include raising minimum age and delaying gait analysis.

The role of isolated gastrocnemius and combined Achilles contractures in the flatfoot.

In the absence of bony deformity, ankle equinus is generally the result of shortening within the gastrocnemius-soleus complex. Restriction of ankle dorsiflexion as a proxy for equinus contracture has been linked to increased mechanical strains and resultant foot and ankle pathology for a long time. This entity has many known causes, and data suggest it can manifest as either an isolated gastrocnemius or combined (Achilles) contracture. Numerous disorders of the foot and ankle have been linked with such "equinus disease", and although some of these relationships remain controversial, a reasonably convincing relationship between equinus contracture and the development of flatfoot exists. What is still perhaps most misunderstood is the temporal association between these two pathologies, and hence higher levels of evidence are needed in the future to define more precisely the interplay between flatfoot deformity and gastrocnemius-soleus tightness.

The surgical management of equinus in the adult acquired flatfoot.

Ankle joint equinus plays a significant role in the pathogenesis of adult and pediatric flatfoot. The surgical management of ankle equinus is a widely debated topic, and procedure selection is often based on surgeon preference because there is no consensus regarding the superiority of a single procedure. Gastrocnemius recession offers acceptable cosmesis and minimizes perceived weakness, yet requires increased operating time and is indicated only in mild to moderate contractures. Whereas tendo-achilles lengthening is efficient and technically undemanding, and one may achieve large amounts of required length, final length is sometimes unpredictable and may markedly decrease posterior muscle group strength.

The effects of unilateral gastrocsoleus recession.

BACKGROUND: Gastrocsoleus recession is commonly performed to correct equinus contracture of the ankle that may accompany foot and ankle disease in adults. There is concern that mechanical lengthening of the myotendinous unit causes permanent weakness and disability. This retrospective study reviewed the short-term and long-term objective and subjective results of patients who have had this procedure to determine if it is an appropriate adjunct to corrective foot surgery. METHODS: Forty patients who had unilateral gastrocsoleus recession either as an isolated procedure or in conjunction with other surgeries were available for evaluation at an average 25.3 (range 6 to 50) months. Followup evaluation included the AOFAS ankle hindfoot score, subjective questionnaire, and physical examination. Preoperative and postoperative ranges of motion were compared. Mechanical strength testing was done using the contralateral extremity as a control. Maximal strength was measured by peak torque using a Cybex device (CYBEX International, Inc., Ronkonkoma, New York). Fatigue resistance was measured by comparing the maximal number of toe raises between the operative and nonoperative sides. RESULTS: Range of motion improved from -3.5 to 15.3 degrees average dorsiflexion. Subjectively, two patients reported pain at the operative site, and one patient reported moderate weakness. The AOFAS score improved from 62.3 to 79.5. Strength testing of plantarflexion peak torque found the operative extremity to be 74% of the contralateral leg at followup. Peak torque improved from an average of 62.6% at 6 to 18 months to 82.2% after 18 months compared to the contralateral extremity. Fatigue resistance improved from 37.6% to 50.3% at 18 months. Two patients reported paresthesias in the sural nerve distribution. CONCLUSION: Gastrocsoleus recession is an effective procedure to correct equinus contracture either as an isolated procedure or as an adjunct to other foot surgery. While both fatigue resistance and strength decreased initially, both demonstrated improvement over time. Four patients had subjective complaints after the procedure.

The relationship between foot posture index, ankle equinus, body mass index and intermetatarsal neuroma.

BACKGROUND: The main purpose of this study was to investigate the presence of an association between intermetatarsal neuroma and foot type, as measured by the Foot Posture Index. The study also examined whether there was a relationship between foot type and the interspace affected with intermetatarsal neuroma, and whether ankle equinus or body mass index had an effect. METHODS: In total, 100 participants were recruited from The University of Western Australia's Podiatry Clinic, 68 of whom were diagnosed with inter-metatarsal neuroma from 2009 to 2015. There were 32 control participants recruited from 2014 to 2015. The age of subjects was recorded, as were weight and height, which were used to calculate body mass index. The foot posture index and ankle dorsiflexion were measured using standard technique. Independent t-tests and Kruskal-Wallis tests were used to compare differences in foot posture index, body mass index and ankle dorsiflexion between the inter-metatarsal neuroma and control groups. Multivariable logistic regression was also used to model relationships for outcome. RESULTS: The 68 intermetatarsal neuroma subjects had a mean age of 52 years (range 20 to 74 years) and comprised of 56 females and 12 males. The 32 control subjects had a mean age of 49 years (range 24 to 67 years) with 26 females and six males. There were no significant differences between the control and the intermetatarsal neuroma groups with respect to the mean foot posture index scores of the left and right foot (p = 0.21 and 0.87, respectively). Additionally no significant differences were detected between the affected intermetatarsal neuroma interspace and foot posture index (p = 0.27 and 0.47, respectively). There was no significant difference in mean body mass index between the intermetatarsal neuroma (26.9 ± 5.7) and control groups (26.5 ± 4.1) (p = 0.72). There was, however, a significant difference in mean ankle dorsiflexion between the intermetatarsal neuroma and control groups (p < 0.001 for both feet). Logistic regression models, adjusted for age, sex, foot posture index and body mass index estimated that the odds of having an intermetatarsal neuroma in the right foot increased by 61% (OR 1.61; 95% CI 1.32-1.96) with each one degree reduction of ankle dorsiflexion, and in the left foot by 43% (OR 1.43; 95% CI 1.22-1.69). CONCLUSION: No relationships were found between foot posture index and body mass index with intermetatarsal neuroma, or between foot posture index and the interspaces affected. However, a strong association was demonstrated between the presence of intermetatarsal neuroma and a restriction of ankle dorsiflexion.

Comparison of Efficacy and Side Effects of Oral Baclofen Versus Tizanidine Therapy with Adjuvant Botulinum Toxin Type A in Children With Cerebral Palsy and Spastic Equinus Foot Deformity.

This retrospective study aimed to compare the therapeutic response, including side effects, for oral baclofen versus oral tizanidine therapy with adjuvant botulinum toxin type A in a group of 64 pediatric patients diagnosed with static encephalopathy and spastic equinus foot deformity. Following botulinum toxin A treatment, clinical improvement led to the gradual reduction of baclofen or tizanidine dosing to one-third of the former dose. Gross Motor Functional Measure and Caregiver Health Questionnaire scores were markedly elevated post-botulinum toxin A treatment, with scores for the tizanidine (Gross Motor Functional Measure: 74.45 ± 3.72; Caregiver Health Questionnaire: 72.43 ± 4.29) group significantly higher than for the baclofen group (Gross Motor Functional Measure: 68.23 ± 2.66; Caregiver Health Questionnaire: 67.53 ± 2.67, P < .001). These findings suggest that the combined use of botulinum toxin A and a low dose of tizanidine in treating children with cerebral palsy appears to be more effective and has fewer side effects versus baclofen with adjuvant botulinum toxin A.

Interest of peripheral anesthetic blocks as a diagnosis and prognosis tool in patients with spastic equinus foot: a clinical and electrophysiological study of the effects of block of nerve branches to the triceps surae muscle.

OBJECTIVE: To evaluate clinically and electrophysiologically the effects of selective anesthetic blocks of motor nerve branches to the triceps surae muscle on lower limb stretch reflex in patients with spastic equinus foot. METHODS: Eleven patients were assessed before and after selective anesthetic block of the superior soleus nerve or the gastrocnemius nerves, performed by lidocaine injection. The stretch reflex (SR) of the ankle with the knee flexed or extended and the Achilles tendon reflex (TR) were scored clinically. Additionally, the direct M response and the H reflex to tibial nerve stimulation were recorded on the three heads of the triceps surae muscle. The ratio of H reflex to M response of maximal amplitudes (H(max)/M(max)) was calculated. RESULTS: The SR and TR mean scores were significantly reduced after soleus nerve block but not after gastrocnemius nerve block. Electrophysiologically, H(max) and H(max)/M(max) ratios were significantly reduced for the soleus muscle after soleus nerve block and for the lateral (but not medial) gastrocnemius muscle after gastrocnemius nerve block. CONCLUSIONS: Soleus nerve block appeared more appropriate than gastrocnemius nerve block to relieve spasticity clinically. In addition, the decrease in H(max)/M(max) ratio suggested that lidocaine preferentially blocked proprioceptive Ia fibers rather than A-alpha motor fibers. SIGNIFICANCE: Selective anesthetic blocks of nerve branches to the triceps surae muscle are useful in the assessment of lower limb spasticity and can benefit from H reflex investigation. H reflex recordings showed a preferential susceptibility of muscle spindle afferents to local anesthetics and supported the hypothesis of a prominent role of the soleus muscle in spastic ankle. The clinical and electrophysiological effects induced by anesthetic blocks may help to guide therapeutic interventions, such as neurotomy, neurolysis or botulinum toxin injection.

Equinus deformity as a factor in forefoot nerve entrapment: treatment with endoscopic gastrocnemius recession.

Forefoot nerve entrapments are common, and they are usually mistakenly categorized under the misnomer of "Morton's neuroma." Although the complete etiology of these forefoot entrapments is still not known, exogenous mechanical factors must be considered when patients present with clinical signs of forefoot nerve entrapment. It has been well established that equinus deformity can increase plantar forefoot pressures. This article provides a brief overview of equinus deformity as it relates to forefoot pathology, specifically, its mechanical contribution to forefoot nerve entrapment, and the use of endoscopic gastrocnemius recession for the treatment of forefoot nerve entrapment.

Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot.

BACKGROUND: Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity. METHODS: We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications. RESULTS: Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems. CONCLUSIONS: Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Botulinum toxin treatment in cerebral palsy: evidence for a new treatment option.

Intramuscular injections of botulinum toxin type A (BTX-A) have increasingly been used to reduce spasticity in specific muscle groups in children with cerebral palsy. Targets of therapeutic efforts are improvement of gross motor function, alleviation of pain or facilitation of hygienic care. Placebo-controlled studies have shown the local and functional effectiveness of BTX-A for the treatment of dynamic pes equinus. Whether long-term treatment with BTX-A improves motor development and delays contractures is still under investigation.