Tibialis posterior tendon transfer corrects the foot drop component of cavovarus foot deformity in Charcot-Marie-Tooth disease

Foot surgery for adults with Charcot-Marie-Tooth disease

People with Charcot-Marie-Tooth (CMT) disease often undergo foot and ankle surgery, as foot deformities are common and cause a degree of functional limitations impairing quality of life. Surgical approaches are variable and there are no evidence-based guidelines. A multidisciplinary approach involving neurology, physical therapy and orthopaedic surgery is ideal to provide guidance on when to refer for surgical opinion and when to intervene. This review outlines the range of foot deformities associated with CMT, their clinical assessment, and their conservative and surgical and postoperative management.

Effect of split posterior tibialis tendon transfer on foot progression angle in children with cerebral palsy

OBJECTIVES

A common orthopedic issue for patients with spastic cerebral palsy (CP) is hindfoot varus deformity. One method of treatment is the split posterior tibialis tendon transfer (SPOTT). There is limited literature on the effect of SPOTT on foot progression angle (FPA) in children with CP who have equinovarus deformities. The objective of our study was to evaluate the change in FPA after SPOTT to determine if this procedure can improve FPA.

RESEARCH QUESTION

This study aims to determine what axial changes are generated from a split posterior tibial tendon transfer in children with CP.

METHODS

We performed a retrospective analysis of all ambulatory children with a diagnosis of CP who underwent SPOTT at our institution. Patients with bony rotational procedures were excluded. Descriptive statistics including mean and standard deviation (SD) were used to characterize continuous variables. Paired t-tests were used to evaluate outcomes, in which a target outcome was defined as a post-operative FPA between 0-10° of external rotation.

RESULTS

44 limbs were included. Demographics were as follows: 26/13 female/male; mean age[SD] (years): 9.8[3.5]; 30 hemiplegic, 9 diplegic, and 1 triplegic. Of the 44 limbs, 18 limbs had a target outcome, 4 had no change, and 22 had a non-target outcome. Of the 22 with an outcome outside of the target, 4 limbs trended away from a target outcome. The overall change in FPA measured was - 10.9 ± 14.7° (p < 0.0001) Age at time of surgery, CP involvement, pre-operative FPA, and GMFCS level were not predictors of outcome (p > 0.05).

CONCLUSIONS

SPOTT produced a change of 10.9° external rotation in FPA post-operatively and its effects should be considered when planning a SEMLS.

Balance Evaluation Based on Walking Experiments with Exoskeleton Interference

The impairment of walking balance function seriously affects human health and will lead to a significantly increased risk of falling. It is important to assess and improve the walking balance of humans. However, existing evaluation methods for human walking balance are relatively subjective, and the selected metrics lack effectiveness and comprehensiveness. We present a method to construct a comprehensive evaluation index of human walking balance. We used it to generate personal and general indexes. We first pre-selected some preliminary metrics of walking balance based on theoretical analysis. Seven healthy subjects walked with exoskeleton interference on a treadmill at 1.25 m/s while their ground reaction force information and kinematic data were recorded. One subject with Charcot-Marie-Tooth walked at multiple speeds without the exoskeleton while the same data were collected. Then, we picked a number of effective evaluation metrics based on statistical analysis. We finally constructed the Walking Balance Index (WBI) by combining multiple metrics using principal component analysis. The WBI can distinguish walking balance among different subjects and gait conditions, which verifies the effectiveness of our method in evaluating human walking balance. This method can be used to evaluate and further improve the walking balance of humans in subsequent simulations and experiments.

Drop Foot With Posterior Tibialis Weakness Treated With Peroneus Longus Transfer in a Child: A Case Report

CASE

An 8-year-old girl with a history of acute flaccid paralysis presented with chronic valgus drop foot causing tripping and falling. Traditionally surgical correction of this deformity is accomplished by transferring the posterior tibialis tendon to enhance dorsiflexion. The authors describe a new technique which transfers the peroneus longus tendon to the dorsum of the foot in a patient with weakness of the posterior tibialis muscle. The patient's drop foot and gait were improved at the 22-month follow-up.

CONCLUSION

Successful transfer of the peroneus longus was accomplished with improved limb clearance during gait and coronal alignment in stance.

Clinical practice guidelines for the diagnosis and management of Charcot-Marie-Tooth disease

INTRODUCTION

Charcot-Marie-Tooth (CMT) disease is classified considering the neurophysiological and histological findings, the inheritance pattern and the underlying genetic defect. In recent years, with the advent of next generation sequencing, genetic complexity has increased exponentially, expanding the knowledge about disease pathways, and having an impact in clinical management. The aim of this guide is to offer recommendations for the diagnosis, prognosis, monitoring and treatment of this disease in Spain.

MATERIAL AND METHODS

This consensus guideline has been developed by a multidisciplinary panel encompassing a broad group of professionals including neurologists, neuropediatricians, geneticists, rehabilitators, and orthopaedic surgeons.

RECOMMENDATIONS

The diagnosis is based in the clinical characterization, usually presenting with a common phenotype. It should be followed by an appropriate neurophysiological study that allows for a correct classification, specific recommendations are established for the parameters that should be included. Genetic diagnosis must be approached in sequentially, once the PMP22 duplication has been ruled out if appropriate, a next generation sequencing should be considered taking into account the limitations of the available techniques. To date, there is no pharmacological treatment that modifies the course of the disease, but symptomatic management is important, as are the rehabilitation and orthopaedic considerations. The latter should be initiated early to identify and improve the patient's functional impairments, including individualised exercise guidelines, orthotic adaptation, and assessment of conservative surgeries such as tendon transpositions. The follow-up of patients with CMT is exclusively clinical, ancillary testing are not necessary in routine clinical practice.

Charcot-Marie-Tooth Disease: A Surgical Algorithm

In Charcot-Marie-Tooth (CMT) cavovarus surgery, a regimented approach is critical to create a plantigrade foot, restore hindfoot stability, and generate active ankle dorsiflexion. The preoperative motor examination is fundamental to the algorithm, as it is not only guides the initial surgical planning but is key in the decision making that occurs throughout the operation. Surgeons need to be comfortable with multiple techniques to achieve each surgical goal. There is no one operation that works for all patients with CMT. A plantigrade foot is the most important of the surgical goals as hindfoot stability and ankle dorsiflexion can be augmented with bracing.

Tendon Transfers to Improve Grip and Pinch in Patients with Sporadic Inclusion Body Myositis

Background

Sporadic inclusion body myositis (sIBM) is a rare and slowly progressive skeletal muscle disease that can cause hand dysfunction, which is a major source of disability. Tendon transfers have been reliably used to improve function in other neuromuscular settings. Given that sIBM patients often present with flexion impairments and mostly functioning extensors, we investigated the potential opportunity for tendon transfer surgery to improve hand dysfunction in sIBM patients.

Methods

We conducted a scoping review for studies of sIBM and tendon transfers, extracted descriptions of hand function and surgical technique, and recorded results in terms of hand function. We also conducted an institutional review board-approved survey with 470 participants to determine baseline patient-reported function and to determine participant perceptions and expectations for tendon transfer surgery to improve hand function in sIBM.

Results

We identified three published case reports on tendon transfers in sIBM patients with subjectively improved grip and pinch strength, but standardized measures of hand function or quality-of-life were not reported. Within the surveyed cohort, half of participants reported that they would consider surgery, yet only 8% had been referred to a hand surgeon. Fifty four percent of participants reported that they would consider surgery if there would be 1-2 years of benefit after surgery. All participants who would consider surgery also had significant upper extremity disability.

Discussion

Tendon transfer surgery has the potential to improve quality-of-life for sIBM patients, and there is significant patient interest in this approach. To objectively assess its efficacy, we propose conducting a surgical trial.

The Surgical Correction of Cavovarus Deformity in Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth (CMT) disease is the most commonly inherited neuropathy. CMT disease is a motor-sensory neuropathy with multiple genotypes. By comparison, the phenotypic expression is more uniform, with two main presentations. Most patients who need surgical care have progressive cavovarus foot deformity, with muscle imbalance causing a nonplantigrade foot, soft-tissue contractures, and abnormal bone morphology. Surgical treatment can be life-changing for these patients, allowing them to walk potentially brace free with more endurance and less pain. Early realignment procedures may reduce progression of joint arthritis. A minority of patients have diffuse paralysis below the knee. These patients are best treated with ground-reaction ankle-foot orthoses. This review article is based on the senior author's extensive experience with CMT, along with the limited evidenced-based literature.

Gait analysis of leprosy patients with foot drop using principal component analysis

BACKGROUND

Peripheral nerve injury caused by leprosy can lead to foot drop, resulting in an altered gait pattern that has not been previously described using 3D gait analysis.

METHODS

Gait kinematics and dynamics were analyzed in 12 patients with unilateral foot drop caused by leprosy and in 15 healthy controls. Biomechanical data from patients' affected and unaffected limbs were compared with controls using inferential statistics and a standard distance, based on principal components analysis (PCA).

FINDINGS

Patients walked slower than controls (0.8 ± 0.2 vs. 1.1 ± 0.2 m/s, p = 0.003), with a reduced stance and increased swing percentage. The affected limb increased (p < 0.05) plantar flexion at the initial contact (-16.8^o ± 8.3), terminal stance (-29.1^o ± 11.5), and swing (-12.4^o ± 6.2) in the affected limb compared to unaffected (-6.6^o ± 10.3; -14.6^o ± 11.6; 2.4^o ± 7.6) and controls (-5.4^o ± 2.5; -18.8^o ± 5.8; -1.4^o ± 3.9). Increased pelvic tilt and knee adduction/abduction range, with lower hip adduction, were observed. The second peak of ground reaction force (98.6 ± 5.2 %BW), ankle torque (0.99 ± 0.33 Nm/kg), and net ankle work in stance (-0.03 ± 5.4 J/Kg) decreased in the affected limb compared to controls (104.1 ± 5.5 %BW; 1.24 ± 0.4 Nm/kg; -4.58 ± 5.19 J/kg; p < 0.05). There were decreasing multivariate standard distances in the affected limb compared with the unaffected and controls. PCA loading factors highlighted the major differences between groups.

INTERPRETATION

Leprosy patients with foot drop presented altered gait patterns in affected and unaffected limbs. There were remarkable differences in ankle kinematics and dynamics. Rehabilitation devices, such as ankle foot orthosis or tendon transfer surgeries to increase ankle dorsiflexion, could benefit these patients and reduce deviations from normal gait.

Tendon transfer in foot drop: a systematic review

INTRODUCTION

Foot drop is a disorder that impairs walking and leads to tripping and falling. Tendon transfer (e.g., tibialis posterior tendon) is a typical secondary procedure in foot drop treatment. The purpose of this systematic review was to identify the most common tendon transfer techniques for treating foot drop and to analyze the reported functional outcomes. Furthermore, it was of interest if the type of surgical technique affects the functional outcome.

METHODS

A PubMed and MEDLINE literature search was performed according to PRISMA guidelines. The search terms used were ("tendon transfer" OR "tendon transposition") AND ("foot drop" OR "peroneal neuropathies"). Any study published before January 2020 was considered for inclusion. No case reports or reviews were included. Common outcome measures (Stanmore score, AOFAS, FAAM, AFO use, patient satisfaction and active ankle dorsiflexion) were evaluated. The quality of the included studies was assessed using the Coleman Methodology Score.

RESULTS

Of the 125 reviewed publications, 37 met the inclusion criteria. 42 cohorts were analyzed. The frequently reported tendon transfer technique was the tibialis posterior tendon transfer through the interosseus membrane. The most used fixation technique was tendon on tendon fixation; however in recent years, a tendon to bone fixation has gained popularity. There was an increase in Stanmore scores and AOFAS postoperatively and a decrease of AFO use postoperatively observed.

CONCLUSIONS

Due to various outcome measures and lack of preoperative assessment in the included studies, a meta-analysis of the pooled results was not possible. Nevertheless, the findings of this study show that tendon transfer increases mobility and self-independency leading to patient satisfaction. The choice of the surgical technique does not affect the outcome. A prospective collection of patient data and standardized outcome measures will be important to further analyze the efficacy of tendon transfer techniques.

Evaluation and Management of Adult Footdrop

Footdrop is a common musculoskeletal condition defined by weakness in ankle joint dorsiflexion. Although the etiology varies, footdrop is characterized by specific clinical and gait abnormalities used by the patient to overcome the loss of active ankle dorsiflexion. The condition is often associated with deformity because soft-tissue structures may become contracted if not addressed. Patients may require the use of special braces or need surgical treatment to address the notable level of physical dysfunction. Surgical treatment involving deformity correction to recreate a plantigrade foot along with tendon transfers has been used with notable success to restore a near-normal gait. However, limitations and postoperative dorsiflexion weakness have prompted investigation in nerve transfer as a possible alternative surgical treatment.

Foot Drop, Hindfoot Varus, and Tibialis Posterior Tendon Transfer in Cerebral Palsy

The transfer of the tibialis posterior tendon has been used to correct hindfoot varus and dorsiflexion weakness in cerebral palsy. It is expendable, has a favorable direction for dorsiflexion and eversion posterior to the tibia, and is the source of hindfoot varus in most cases. However, the foot and ankle must be flexible without skeletal deformity. The electromyography of the tibialis posterior should be present in the swing phase for the tendon transfer to function correctly. Techniques and pitfalls are described to plan and execute a successful tibialis posterior tendon transfer.

Evaluation and Management of Cavus Foot in Adults: A Narrative Review

Objective: Cavus foot is a deformity defined by the abnormal elevation of the medial arch of the foot and is a common but challenging occurrence for foot and ankle surgeons. In this review, we mainly aim to provide a comprehensive evaluation of the treatment options available for cavus foot correction based on the current research and our experience and to highlight new technologies and future research directions. Methods: Searches on the PubMed and Scopus databases were conducted using the search terms cavus foot, CMT (Charcot–Marie–Tooth), tendon-transfer, osteotomy, and adult. The studies were screened according to the inclusion and exclusion criteria, and the correction of cavus foot was analyzed based on the current research and our own experience. At the same time, 3D models were used to simulate different surgical methods for cavus foot correction. Results: A total of 575 papers were identified and subsequently evaluated based on the title, abstract, and full text. A total of 84 articles were finally included in the review. The deformities involved in cavus foot are complex. Neuromuscular disorders are the main etiologies of cavus foot. Clinical evaluations including biomechanics, etiology, classification, pathophysiology and physical and radiological examinations should be conducted carefully in order to acquire a full understanding of cavus deformities. Soft-tissue release, tendon-transfer, and bony reconstruction are commonly used to correct cavus foot. Surgical plans need to be customized for different patients and usually involve a combination of multiple surgical procedures. A 3D simulation is helpful in that it allows us to gain a more intuitive understanding of various osteotomy methods. Conclusion: The treatment of cavus foot requires us to make personalized operation plans according to different patients based on the comprehensive evaluation of their deformities. A combination of soft-tissue and bony procedures is required. Bony procedures are indispensable for cavus correction. With the promotion of digital orthopedics around the world, we can use computer technology to design and implement cavus foot operations in the future.

Foot Assessment Clinical Scales in Charcot-Marie-Tooth Patients: A Scoping Review

Introduction

Charcot-Marie-Tooth disease (CMT) is a slow and progressive peripheral motor sensory neuropathy frequently associated with the cavo-varus foot deformity. We conducted a scoping review on the clinical scales used to assess foot deviations in CMT patients and analyzed their metric properties.

Evidence Acquisition

A first search was conducted to retrieve all scales used to assess foot characteristics in CMT patients from the Medline, Web of Science, Google Scholar, Cochrane, and PEDro databases. A second search was conducted to include all studies that evaluated the metric properties of such identified scales from the same databases. We followed the methodologic guidelines specific for scoping reviews and used the PICO framework to set the eligibility criteria. Two independent investigators screened all papers.

Evidence Synthesis

The first search found 724 papers. Of these, 41 were included, using six different scales: “Foot Posture Index” (FPI), “Foot Function Index”, “Maryland Foot Score”, “American Orthopedic Foot & Ankle Society's Hindfoot Evaluation Scale”, “Foot Health Status Questionnaire”, Wicart-Seringe grade. The second search produced 259 papers. Of these, 49 regarding the metric properties of these scales were included. We presented and analyzed the properties of all identified scales in terms of developmental history, clinical characteristics (domains, items, scores), metric characteristics (uni-dimensionality, inter- and intra-rater reliability, concurrent validity, responsiveness), and operational characteristics (normative values, manual availability, learning time and assessors' characteristics).

Conclusions

Our results suggested the adoption of the six-item version of the FPI scale (FPI-6) for foot assessment in the CMT population, with scoring provided by Rasch Analysis. This scale has demonstrated high applicability in different cohorts after a short training period for clinicians, along with good psychometric properties. FPI-6 can help health professionals to assess foot deformity in CMT patients over the years.

Posterior Tibial Tendon Transfer for the Correction of Drop Foot

BACKGROUND

Drop foot is a crippling condition that often requires surgical intervention to restore functional dorsiflexion. Although transfer of the posterior tibial (PT) tendon has been well described for the treatment of drop foot, there is no consensus on whether tendon transfers affecting the ankle joint sufficiently restore functional status for daily activities. In addition, most studies have focused on drop foot caused by peripheral nerve disorders. The purpose of this study was to evaluate the functional outcomes and patient satisfaction following PT tendon transfer for the correction of drop foot resulting from both peripheral and central neurologic causes.

METHODS

Patients with drop foot who underwent a PT tendon transfer were followed for a minimum of 1 year and investigated retrospectively. Outcome measures included the American Orthopaedic Foot & Ankle Society ankle and hindfoot scoring system, a patient satisfaction questionnaire, postoperative ankle range of motion, and postoperative ambulatory status.

RESULTS

We evaluated 15 feet in 14 patients at a median follow-up of 50 months. The median postoperative American Orthopaedic Foot & Ankle Society ankle and hindfoot score was 85.0. Thirteen patients (92.9%) reported that they would undergo the procedure again. The median postoperative passive ankle dorsiflexion was 5.0°, and the median postoperative passive ankle plantarflexion was 30.0°. Thirteen patients (92.9%) were able to ambulate postoperatively. Ten (71.4%) ambulated without the use of an ankle-foot orthosis (AFO), and three (21.4%) ambulated with the use of an AFO. Overall, orthoses were able to be discontinued in 73.3% of the cases.

CONCLUSIONS

Our results suggest that the PT tendon transfer is an effective procedure for the treatment of drop foot that can improve the patient's functional status and ability to ambulate. The majority of patients were able to discontinue the use of their AFO postoperatively.

Transfer of the Posterior Tibial Tendon for Chronic Peroneal Nerve Palsy

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The common peroneal nerve (CPN) is one of the most frequently injured nerves of the lower extremity.

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One-third of patients who develop CPN palsy proceed to chronic impairment without signs of recovery.

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Ankle-foot orthoses can provide improvement with respect to gait dysfunction and are useful as a nonsurgical treatment option.

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Severe cases of CPN palsy demonstrating no signs of recovery may require operative intervention with tendon transfer.

Management of Midfoot Cavus

There is a deficiency in publications on the topic of midfoot cavus. The limited research available does not have a standard definition for the diagnosis of this deformity and lacks a reliable algorithm for its surgical management. The authors performed an extensive review of the literature that found a majority of patients are satisfied with the Cole osteotomy and the dorsiflexory first metatarsal osteotomy for treatment of this condition. High patient satisfaction has been observed with lateralizing calcaneal osteotomies in the setting of midfoot cavus with a secondary rigid rearfoot deformity. Further research on this topic is encouraged.

Anterior Tibial Tendon Side-to-Side Tenorrhaphy after Posterior Tibial Tendon Transfer: A Technique to Improve Reliability in Drop Foot after Common Peroneal Nerve Injury

Common peroneal nerve injury is present in 40% of knee dislocations, and foot drop is the principal complication. Posterior tibial tendon transfer is a viable solution to replace the function of the anterior tibial tendon (ATT) in the mid-foot. Several techniques for posterior tibial tendon transfer exist today, with variable results reported. However, adding augmentation with side-to-side tenorrhaphy of ATT to the transferred posterior tibial tendon (PTT) enhances anterior tissue balance and load sharing stress between native ATT enthesis and PTT tenodesis, allowing early rehabilitation and improving functional outcomes. Side-to-side tenorrhaphy is performed after PTT tenodesis in the lateral cuneiform to improve reliability in foot drop. This technique allows shorter immobilization time (from 6 to 2 weeks), earlier rehabilitation, sooner weight-bearing, and decreased risk of arthrofibrosis, scar formation, and muscle atrophy.

Management of flexible cavovarus foot in patients with Charcot-Marie-Tooth disease: midterm results

INTRODUCTION

Charcot-Marie-Tooth disease (CMT) is a hereditary motor sensory neuropathy that frequently results in a cavovarus foot in the adult. Surgical treatment allows correction of the deformity while preserving an adequate range of motion.

OBJECTIVE

The objective of this study was to assess the result of posterior tibial tendon transfer, first metatarsal ascent osteotomy, and calcaneal valgus osteotomy in the treatment of cavovarus foot secondary to CMT.

MATERIAL AND METHODS

Retrospective cohort of CMT patients who received surgical treatment of their cavovarus foot. Collected data included demographics, CMT genetic variant, neurologic involvement, surgical technique, range of motion, functionality, radiology, and postoperative satisfaction.

RESULTS

16 patients met the inclusion criteria, mostly women (62.5%) with the CMT1A variant (62.5%), and a mean age of 39.5 years. 13 patients required additional surgical techniques: lengthening of the Achilles tendon, interphalangeal arthrodesis and/or plantar fascia section. 2 patients underwent a secondary procedure: subtalar arthrodesis due to persistence of the varus deformity, and a lengthening of the extensor hallux longus due to initial undercorrection. The mean follow-up was 42 months. Significant differences (p = 0.003) were observed between the pre-surgical AOFAS and at 12 months postoperatively (37.25 vs. 86.5). 75% of the patients reported «excellent» or «good» satisfaction after surgery. All radiographic parameters showed significant improvement.

CONCLUSIONS

The combination of the aforementioned surgical techniques for the cavovarus foot in CMT results in adequate functionality, good radiological correction and a high degree of satisfaction, avoiding primary arthrodescent surgery.

Validation of a new hand function outcome measure in individuals with Charcot-Marie-Tooth disease

The symptomatology of Charcot-Marie-Tooth (CMT) disease mainly involves the feet and the hands. To date, there is no consensus on how to evaluate hand function in CMT. The aim of this study is to correlate the data of the engineered glove Hand Test System (HTS) with specific tests and the CMT examination score (CMTES). We analyzed 45 patients with the diagnosis of CMT using HTS, which measures the hand dexterity by specific sequences performed at maximum velocity. We completed the evaluation with the CMTES, tripod pinch and hand grip strength tested by a dynamometer, thumb opposition test (TOT), and Sollerman Hand function test (SHFT), and we conducted a test-retest with 20 normal subjects. Finger tapping (FT) and index-medium-ring-little (IMRL) sequence showed a significant correlation with CMTES (FT: dominant hand (DH): P = .036; non-dominant hand (NDH): P = .033; IMRL: DH: P = .009; NDH: P = .046). TOT correlated with CMTES significantly in both hands (P < .0001). tripod pinch showed a statistically significant correlation with CMTES (DH: P = .002; NDH: P = .005). Correlation between the hand grip and CMTES was significant only in DH (DH: P = .002). SHFT had a significant correlation with the CMTES (DH: P = .002). Test-retest showed a good reliability. HTS parameters correlate with CMTES confirming that this tool is sensitive to the hand deficits. In conclusion, we can state that HTS is a good, simple to use, and objective instrument to evaluate the hand function of CMT patients, but more studies on responsiveness and sensitivity are needed.

A Consensus Statement on the Surgical Treatment of Charcot-Marie-Tooth Disease

BACKGROUND

Charcot-Marie-Tooth (CMT) disease is a hereditary motor-sensory neuropathy that is often associated with a cavovarus foot deformity. Limited evidence exists for the orthopedic management of these patients. Our goal was to develop consensus guidelines based upon the clinical experiences and practices of an expert group of foot and ankle surgeons.

METHODS

Thirteen experienced, board-certified orthopedic foot and ankle surgeons and a neurologist specializing in CMT disease convened at a 1-day meeting. The group discussed clinical and surgical considerations based upon existing literature and individual experience. After extensive debate, conclusion statements were deemed "consensus" if 85% of the group were in agreement and "unanimous" if 100% were in support.

CONCLUSIONS

The group defined consensus terminology, agreed upon standardized templates for history and physical examination, and recommended a comprehensive approach to surgery. Early in the course of the disease, an orthopedic foot and ankle surgeon should be part of the care team. This consensus statement by a team of experienced orthopedic foot and ankle surgeons provides a comprehensive approach to the management of CMT cavovarus deformity.

LEVEL OF EVIDENCE

Level V, expert opinion.

[Effectiveness of tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy]

Objective

To investigate the effectiveness of tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy.

Methods

The clinical data of 21 patients with unilateral foot drop secondary to peroneal nerve palsy between October 2009 and September 2016 was retrospectively analyzed. There were 12 males and 9 females with an average age of 32.1 years (range, 23-47 years). The causes of peroneal nerve injury were iatrogenic injury in 7 cases, tibiofibular fractures combined with compartment syndrome in 5 cases, nerve exploration surgery after stab or cut injury in 3 cases, direct violence in 4 cases, and the fibular head fracture in 2 cases. The average time from injury to operation was 5.6 years (range, 2-8 years). There was 1 case of hallux valgus and 5 cases of toe flexion contracture. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, Foot and Ankle Ability Measure (FAAM) scores, range of motion (ROM), and dorsiflexion strength of ankle joint were used to evaluated the ankle function. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, and hindfoot alignment angle.

Results

All incisions healed by first intention. All patients were followed up 18-42 months (mean, 30.2 months). The dorsiflexion strength of ankle joint recovered from grade 0 to grade 3-4 after operation. There was no patient with a postoperative flat foot deformity and claw toe during follow-up. There was no significant difference in Meary angle, calcaneal pitch angle, and hindfoot alignment angle between pre- and post-operation ( P>0.05). The AOFAS score, FAAM score, and ROM of dorsiflexion significantly improved at last follow-up when compared with preoperative values ( P<0.05); while there was no significant difference in ROM of plantar-flexion between pre- and post-operation ( t=4.239, P=0.158). There were significant differences in AOFAS score, FAAM score, and ROM of dorsiflexion between affected and healthy sides ( P<0.05); but no significant difference in ROM of plantar-flexion was found ( t=2.319, P=0.538).

Conclusion

Tibialis posterior tendon transfer is an effective surgical option for foot drop secondary to peroneal nerve palsy. And no postoperative flat foot deformity occurred at short-term follow-up.

Failure of Surgical Treatment in Patients with Cavovarus Deformity: Why Does This Happen and How Do We Approach Treatment?

Recurrent deformity after surgical treatment of the cavus foot occurs because a procedure is not performed at the apex of the deformity. In many instances there are multiple apices and, in addition to hindfoot osteotomy or arthrodesis, the midfoot must be corrected. There is not much of a role for the Coleman block test to determine flexibility of the foot, and this has led to many failures where the foot was believed flexible and an osteotomy was insufficient treatment. Skeletal correction, even if perfect, does not last unless the foot is balanced with appropriate tendon transfers.

Cavus Foot: Deciding Between Osteotomy and Arthrodesis

Mild to moderate cavus deformity creates a dilemma in terms of surgical decision-making. The decision to pursue osteotomy or arthrodesis is not always clear. This article provides a framework for guiding management of these deformities, followed by a detailed surgical approach to correcting moderate cavus deformities, which emphasizes the use of a midfoot osteotomy-arthrodesis.

Updates in Pediatric Cavovarus Deformity

The treatment goal for pediatric cavovarus deformities is to neutralize plantar pressure distribution, reduce hindfoot varus deformity, and avoid or postpone ankle, midfoot, and hindfoot arthritis. If nonoperative treatment is not sufficient, surgical realignment must be discussed. Promising improvements in decision making and operative techniques have been published. To avoid disappointment owing to recurrence or failures of operative procedures, selection of the appropriate and preferably single operative procedure remains the most crucial factor for success. This article focuses on current treatment options depending on the localization of the anatomic pathology. Outcomes of nonoperative and operative treatments are presented.

Innovative treatment for pes cavovarus: a pilot study of 13 children

Background and purpose - Pes cavovarus (PCV) is a complex deformity, frequently related to neurological conditions and associated with foot pain, callosities, and walking instability. The deformity has the tendency to increase during growth. Orthotic treatment is ineffective and surgery may be troublesome. We present the preliminary results of a new mini-invasive surgical technique for correction of this foot deformity. Patients and methods - We operated on 13 children (24 feet), age 7-13 years. In 7 children the deformity was neurological in origin. The surgical technique included a dorsal hemiepiphysiodesis of the 1st metatarsal, and a plantar fascia release. The clinical deformity, hindfoot flexibility, and foot callosities, together with a radiological assessment (Meary angle, calcaneal pitch, and talo-calcaneal angle), was done pre- and postoperatively. At final check-up, after a median of 28 months (12-40), the Oxford Ankle Foot Questionnaire for children (OXAFQ-C) was used to assess patient satisfaction. The primary outcome was the hindfoot varus correction. Results - All the operated feet improved clinically and radiologically. Heel varus improved from a mean 6° preoperatively to 5° valgus postoperatively. In those children where treatment was initiated at a younger age, full correction was achieved. Footwear always improved. Interpretation - This treatment may offer a less aggressive alternative in the treatment of PCV in young children and may eventually reduce the amount of surgery needed in the future.

Biomechanical Evaluation of Circumtibial and Transmembranous Routes for Posterior Tibial Tendon Transfer for Dropfoot

BACKGROUND

Tibialis posterior tendon transfer is performed when loss of dorsiflexion has to be compensated. We evaluated the circumtibial (CT), above-retinaculum transmembranous (TMAR), and under-retinaculum transmembranous (TMUR) transfer gliding resistance and foot kinematics in a cadaveric foot model during ankle range of motion (ROM).

METHODS

Eight cadaveric foot-ankle distal tibia specimens were dissected free of soft tissues on the proximal end, applying an equivalent force to 50% of the stance phase to every tendon, except for the Achilles tendon. Dorsiflexion was tested with all of the tibialis posterior tendon transfer methods (CT, TMAR, and TMUR) using a tension tensile machine. A 10-repetition cycle of dorsiflexion and plantarflexion was performed for each transfer. Foot motion and the force needed to achieve dorsiflexion were recorded.

RESULTS

The CT transfer showed the highest gliding resistance ( P < .01). Regarding kinematics, all transfers decreased ankle ROM, with the CT transfer being the condition with less dorsiflexion compared with the control group (6.8 vs 15 degrees, P < .05). TMUR transfer did perform better than TMAR with regard to ankle dorsiflexion, but no difference was shown in gliding resistance. The CT produced a supination moment on the forefoot.

CONCLUSION

The CT transfer had the highest tendon gliding resistance, achieved less dorsiflexion and had a supination moment. Clinical Relevance We suggest that the transmembranous tibialis posterior tendon transfer should be the transfer of choice. The potential bowstringing effect when performing a tibialis posterior tendon transfer subcutaneously (TMAR) could be avoided if the transfer is routed under the retinaculum, without significant compromise of the final function and even with a possible better ankle range of motion.

Strength of Interference Screw Fixation to Cuboid vs Pulvertaft Weave to Peroneus Brevis for Tibialis Posterior Tendon Transfer for Foot Drop

BACKGROUND

Tibialis posterior (TP) tendon transfer is an effective treatment for foot drop. Currently, standard practice is to immobilize the ankle in a cast for 6 weeks nonweightbearing, risking postoperative stiffness. To assess whether early active dorsiflexion and protected weightbearing could be safe, the current study assessed tendon displacement under cyclic loading and load to failure, comparing the Pulvertaft weave (PW) to interference screw fixation (ISF) in a cadaveric foot model.

METHODS

Twenty-four cadaveric ankles had TP tendon transfer performed, 12 with the PW technique and 12 with ISF to the cuboid. The TP tendon was cycled 1000 times at 50 to 150 N and then loaded to failure in a materials testing machine. Tendon displacement at the insertion site was recorded every 100 cycles. An independent t test and 2-way analysis of variance were performed to compare techniques, with a significance level of P < .05.

RESULTS

Mean tendon displacement was similar in the PW group (2.9 ± 2.5 mm [mean ± SD]) compared with the ISF group (2.4 ± 1.1 mm), P = .35. One specimen in the ISF group failed early by tendon pullout. None of the PW group failed early, although displacement of 8.9 mm was observed in 1 specimen. Mean load to failure was 419.1 ± 82.6 N in the PW group in comparison to 499.4 ± 109.6 N in the ISF group, P = .06.

CONCLUSION

For TP tendon transfer, ISF and PW techniques were comparable, with no differences in tendon displacement after cyclical loading or load to failure. Greater variability was observed in the PW group, suggesting it may be a less reliable technique.

CLINICAL RELEVANCE

The results indicate that early active dorsiflexion and protected weightbearing may be safe for clinical evaluation, with potential benefits for the patient compared with cast immobilization.

[Components of the joint-sparing, combined bony and soft tissue correction of the cavovarus foot]

OBJECTIVE

Combined bony and soft tissue correction of a mild foot and flexible rearfoot deformity in cavovarus foot.

INDICATIONS

Drop foot during swing phase and muscular imbalance in the stance phase in cavovarus foot, flexible cavovarus foot, accompanying symptoms such as recurrent calluses and ulcerations, compliance.

CONTRAINDICATIONS

Pes cavovarus of spastic genesis, mild deformities, fixed bony deformity, lack of compliance, florid inflammation in the foot area, severe peripheral artery disease (PAD), diabetes mellitus.

SURGICAL TECHNIQUE

Description of the gradual escalation of joint-sparing bony and soft tissue procedures.

POSTOPERATIVE MANAGEMENT

Postoperative lower leg cast. In cases of combined bony and soft tissue correction, first 6 weeks of nonweight-bearing with lower leg cast, then 6 weeks of lower leg walking cast. With adequate bony consolidation, cast removal after a total of 12 weeks. In cases of pure soft-tissue foot correction, 6 weeks of lowerleg walking cast.

RESULTS

It was shown that only 22.5% of the affected feet (40 preoperative patients with cavovarus foot deformity) had a severe hindfoot equinus due to shortened calf muscles. In a study with 14 patients, it was shown that the tibialis posterior tendon transfer corrects the drop foot component and the excessive medial arch of the feet is significantly reduced by combined soft tissue and bony procedures.

Stress Fracture of the Fifth Metatarsal in Foot Deformity Secondary to Neuromuscular Disease: Experiences of Deformity Correction Treatment-A Report of 3 Cases and Review of the Literature

Fractures at the proximal metaphyso-diaphyseal junction of the fifth metatarsal are associated with high rates of delayed union. When these fractures are the result of repeated stress in patients with equinovarus hindfoot, which in turn is caused by neurological disorders, delayed union is the rule. Therefore, in neurological patients with stress fractures, optimal treatment would be to achieve a plantigrade foot enabling them to relieve the fifth metatarsal overload, which prevents the consolidation. We report 3 cases of fifth metatarsal stress fracture resulting from an equinovarus hindfoot deformity caused by a neuromuscular disease. Our surgical indication was to correct the foot deformity with no direct action on the fracture. Once a good alignment (plantigrade foot) was obtained, stress causing the fracture disappeared, and union was achieved with optimal biomechanical function in all 3 fractures. When stress fracture of the fifth metatarsal is caused by a secondary foot deformity, treating the deformity can lead to healing the fracture efficiently and should be considered prior to indicating surgical stabilization of the fracture itself. Primary treatment of the fracture with no correction of the deformity leads to therapeutic failure.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

An Innovative Anchoring Technique for Anterior Transfer of the Tibialis Posterior Tendon

Favorable results have been reported for tibialis posterior tendon transfers, which can effectively restore the dorsiflexion of the ankle and normal heel-to-toe gait. However, the commonly used methods for anchoring the transplanted tendon have some drawbacks. Therefore, we developed a new tendon-anchoring method to improve fixation of the transferred tendon and reduce the related complications. The new method entails tying the anchoring suture to the navicular bone instead of the button on the plantar foot to avoid wound complications. It requires no additional skin incisions or special equipment. We retrospectively evaluated 24 feet of 19 pediatric patients (13 [68.4%] females and 6 [31.6%] males) who had undergone anterior transfer of the tibialis posterior tendon with our new method from 2000 to 2013. All patients were clinically followed up. At the final follow-up visit, they were evaluated while standing and walking, and the range of motion of the foot was evaluated. The mean age at surgery was 7.8 (range 2 to 16) years. At the longest follow-up point, all the patients exhibited improved gait, except for 1 patient who required a secondary procedure. All the transferred tibialis posterior tendons could be palpated with certainty during active dorsiflexion or withdrawal of the foot. No tendon displacements, wound infections, or postoperative complications were observed. Fixation of a transferred tibialis posterior tendon by tying the suture to the navicular bone is simple and reliable. This technique can efficiently prevent the plantar ulcers that can develop with the traditional pull-out button method and provides a solution when appropriate-size bioabsorbable interference screws are unavailable.

[Charcot-Marie-Tooth disease associated with hip dysplasia in an adolescent]

Charcot-Marie-Tooth disease (CMT) is classified into hereditary motor and sensory neuropathy and can induce severe neuro-orthopaedics deformities, disabling at an early age. Hip dysplasia is present in 6% of CMT patients affecting preferentially CMT1 patients and can appear from the age of 8 years. The pathophysiological is paradoxical because we are confronted with proximal osteoarthritis deformations but genetics research brings use new trail. The main functional complaint is a hip joint pain during walking. Four orthopaedics abnormalities can be revealed by physical and radiological exam: acetabular dysplasia, femoral dysplasia, high femoral antetorsion and excentric head of femur. The natural evolution, in the absence of treatment, is an early secondary osteoarthritis. The therapeutic management should be as early as possible with preventive measures and joint health. During the symptomatic phase, the only treatment is a surgical correction. A systematic clinical examination of the hip all CMT children and a radiograph of the pelvis at the slightest clinical suspicion is recommended.

Functional Outcomes Following Anterior Transfer of the Tibialis Posterior Tendon for Foot Drop Secondary to Peroneal Nerve Palsy

BACKGROUND

This retrospective comparative study reports the practical function in daily and sports activities after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy.

METHODS

Seventeen patients were followed for a minimum of 3 years after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Matched controls were used to evaluate the level of functional restoration. Functional evaluations included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) scores, and isokinetic muscle strength test. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, hindfoot alignment angle, and navicular height.

RESULTS

Mean AOFAS, FAOS, and FAAM scores significantly improved from 65.1 to 86.2, 55.6 to 87.8, and 45.7 to 84.4 points at final follow-up, respectively. However, all functional evaluation scores were significantly lower as compared to the control group ( P < .001). Mean peak torque (60 degrees/sec) of ankle dorsiflexors, plantarflexors, invertors, and evertors at final follow-up were 7.1 (deficit ratio of 65.4%), 39.2, 9.8, and 7.3 Nm, respectively. These muscle strengths were significantly lower compared to the control group ( P < .001). No significant differences in radiographic measurements were found, and no patients presented with a postoperative flat foot deformity. One patient (5.9%) needed an ankle-foot orthosis for occupational activity.

CONCLUSIONS

Anterior transfer of the tibialis posterior tendon appears to be an effective surgical option for paralytic foot drop secondary to peroneal nerve palsy. Although restoration of dorsiflexion strength postoperatively was about 33% of the normal ankle, function in daily activities and gait ability were satisfactorily improved. In addition, tibialis posterior tendon transfer demonstrated no definitive radiographic or clinical progression to postoperative flat foot deformity at intermediate-term follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Peroneal Nerve Dysfunction due to Multiligament Knee Injury: Patient Characteristics and Comparative Outcomes After Posterior Tibial Tendon Transfer

OBJECTIVE

To objectively compare outcomes of nonoperative management and posterior tibial tendon (PTT) transfer for peroneal nerve injury due to multiligament knee injury (MLI).

DESIGN

Retrospective cohort study with prospective follow-up.

SETTING

Tertiary care institution.

PATIENTS

Ten patients with peroneal nerve injury due to MLI (5 managed nonoperatively, 5 with PTT transfer) were evaluated and a control group of 4 patients without peroneal nerve injury.

INTERVENTIONS

Clinical examination, subjective questionnaires, and 3-D motion capture gait analysis during flat-ground walking and stair descent.

MAIN OUTCOME MEASURES

The primary outcome measure was the result of gait analysis. The results of subjective questionnaires were a secondary outcome measure.

RESULTS

Dorsiflexion was significantly reduced at initial contact and mid-late swing phase in the nonoperative cohort. The PTT transfer cohort demonstrated increased dorsiflexion at each of these time intervals compared with patients managed nonoperatively, restoring symmetry between limbs. The PTT transfer cohort demonstrated similar gait patterns to controls but tended to be more everted. Ground reaction force was increased in the uninvolved limb in the PTT transfer group during gait and step down. There were no statistically significant differences in AOFAS, FAAM, IKDC, or Lysholm results.

CONCLUSIONS

Posterior tibial tendon transfer is an option to restore dorsiflexion and eliminate the need for an orthosis in patients with foot drop due to MLI. Gait analysis demonstrates a significant improvement in sagittal plane ankle kinematics after PTT transfer. The trade-off is subtle instability, highlighting the dynamic stability that the PTT provides.

Rehabilitation issues in Charcot-Marie-Tooth disease

Charcot Marie Tooth (CMT) disease is the most common hereditary sensorimotor neuropathy that has a slow onset. It presents usually in childhood, starting distally and from the lower limbs progressing to more proximal muscles. Due to the lack of curative medical treatments and the problematic outcomes of surgical intervention, rehabilitation continues to play a major role in treatment. This paper aims to summarize the rehabilitation approaches like aerobic, stretching and strengthening exercises. Orthotics is another important part of treatment that complete rehabilitative approaches. Orthotic devices that are currently being used and investigated in patients with CMT are also reviewed. The evidence shows that exercise is effective in improving strength and general fitness. Stretching is somewhat effective in maintaining range of motion. Orthotic devices are the mainstay of maintaining mobility and ambulation and upper extremity function.

Cavovarus deformity in Charcot-Marie-Tooth disease: is there a hindfoot equinus deformity that needs treatment?

Background

Charcot-Marie-Tooth disease (CMT), one of the most common hereditary neurologic disorders, often results in debilitating cavovarus foot deformities. The deformities are still not fully understood, and the treatment recommendations are consequently heterogeneous, often including calf muscle or Achilles tendon lengthening.

Methods

We examined 40 patients (80 feet) with CMT and bilateral cavovarus deformities (19 men and 21 women, mean age 33.6 ± 14.6 years) and the feet of a healthy control population of 13 individuals (7 men and 6 women, mean age 43.9 ± 10.8 years). In all cases 3D instrumented gait analysis results with both conventional Plug-in-Gait analysis and the Heidelberg Foot Measurement Method (HFMM) were used to determine the sagittal plane kinematics, dorsi-plantar flexion (DPF), tibio-talar dorsiflexion (TTDF), and medial arch angle (MAA), and the results of patients and the control group were compared using the 2 methods. Decreased and increased dorsiflexion using TTDF was defined as 1 standard deviation below or above the mean of the control. Comparisons were done using descriptive statistics, the Pearson correlation coefficient and ANOVA.

Results

The TTDF was found to be decreased in 18 of the 80 feet examined (22.5 %), normal in 31 feet (38.75 %), and increased in 31 feet (38.75 %). The Pearson coefficient showed a positive correlation with R = 0.765, p < 0.001 between decreased TTDF values found by HFMM and decreased DPF values found with conventional Plug-in-Gait analysis, but a very weak correlation in patients with normal TTDF (R = -0.118) and increased TTDF (R = 0.078). Also, in patients with decreased TTDF values, there was a weak to moderate correlation with the MAA (R = 0.335), but no correlation between the MAA and DPF (R = 0.023).

Conclusions

The HFMM, unlike the conventional Plug-in-Gait analysis, distinguishes between the segments of the foot in foot deformities and facilitates evaluation of the hindfoot equinus component in patients with CMT and cavovarus deformity. Although there is a significant correlation between decreased TTDF with HFMM and decreased DPF with conventional Plug-in-Gait analysis, this correlation was not seen in patients with normal or increased TTDF values. Conventional Plug-in-Gait analysis alone does not indicate if an increased plantar flexion deformity is the result of either a cavus deformity or hindfoot equinus deformity, which limits its usefulness in assisting in treatment decision making.

Tendon Transfers Around the Foot: When and Where

Tendon transfers are invaluable in the treatment of severe children's foot deformities. They are often preferable to simple releases, lengthening, or fusion in surgical treatment because they provide an active motor function for deformity correction and, when properly selected, the procedures stabilize the foot against progressive deformity. The authors describe 4 commonly used tendon transfer procedures that are useful in children's foot deformity surgeries.

Outcomes of the Bridle Procedure for the Treatment of Foot Drop

BACKGROUND

The purpose of this study was to determine the clinical outcomes and objective measures of function that can be expected for patients following the Bridle procedure (modification of the posterior tibial tendon transfer) for the treatment of foot drop.

METHODS

Nineteen patients treated with a Bridle procedure and 10 matched controls were evaluated. The Bridle group had preoperative and 2-year postoperative radiographic foot alignment measurements and completion of the Foot and Ankle Ability Measure. At follow-up, both groups were tested for standing balance (star excursion test) and for ankle plantarflexion and dorsiflexion isokinetic strength, and the American Orthopaedic Foot & Ankle Society and Stanmore outcome measures were collected only on the Bridle patients.

RESULTS

There was no change in radiographic foot alignment from pre- to postoperative measurement. Foot and Ankle Ability Measure subscales of activities of daily living and sport, American Orthopaedic Foot & Ankle Society, and Stanmore scores were all reduced in Bridle patients as compared with controls. Single-limb standing-balance reaching distance in the anterolateral and posterolateral directions were reduced in Bridle participants as compared with controls (P < .03). Isokinetic ankle dorsiflexion and plantarflexion strength was lower in Bridle participants (2 ± 4 ft·lb, 44 ± 16 ft·lb) as compared with controls (18 ± 13 ft·lb, 65 ± 27 ft·lb, P < .02, respectively). All Bridle participants reported excellent to good outcomes and would repeat the operation. No patient wore an ankle-foot orthosis for everyday activities.

CONCLUSION

The Bridle procedure was a successful surgery that did not restore normal strength and balance to the foot and ankle but allowed individuals with foot drop and a functional tibialis posterior muscle to have significantly improved outcomes and discontinue the use of an ankle-foot orthosis. In addition, there was no indication that loss of the normal function of the tibialis posterior muscle resulted in change in foot alignment 2 years after surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

The genetics of Charcot-Marie-Tooth disease: current trends and future implications for diagnosis and management

Charcot–Marie–Tooth (CMT) disease is the most common hereditary polyneuropathy and is classically associated with an insidious onset of distal predominant motor and sensory loss, muscle wasting, and pes cavus. Other forms of hereditary neuropathy, including sensory predominant or motor predominant forms, are sometimes included in the general classification of CMT, but for the purpose of this review, we will focus primarily on the forms associated with both sensory and motor deficits. CMT has a great deal of genetic heterogeneity, leading to diagnostic considerations that are still rapidly evolving for this disorder. Clinical features, inheritance pattern, gene mutation frequencies, and electrodiagnostic features all are helpful in formulating targeted testing algorithms in practical clinical settings, but these still have shortcomings. Next-generation sequencing (NGS), combined with multigene testing panels, is increasing the sensitivity and efficiency of genetic testing and is quickly overtaking targeted testing strategies. Currently, multigene panel testing and NGS can be considered first-line in many circumstances, although obtaining initial targeted testing for the PMP22 duplication in CMT patients with demyelinating conduction velocities is still a reasonable strategy. As technology improves and cost continues to fall, targeted testing will be completely replaced by multigene NGS panels that can detect the full spectrum of CMT mutations. Nevertheless, clinical acumen is still necessary given the variants of uncertain significance encountered with NGS. Despite the current limitations, the genetic diagnosis of CMT is critical for accurate prognostication, genetic counseling, and in the future, specific targeted therapies. Although whole exome and whole genome sequencing strategies have the power to further elucidate the genetics of CMT, continued technological advances are needed.

Surgical Treatment of Severe Cavovarus Foot Deformity in Charcot-Marie-Tooth Disease

Introduction

A successful adjusted treatment algorithm for the correction of cavovarus foot deformity requires soft-tissue balancing procedures, in particular total split posterior tibial tendon transfer (T-SPOTT), in combination with adjunctive corrective procedures depending on the degree of deformity.

Step 1: Surgical Preparation

Place the patient in a supine position and follow a standard aseptic surgical disinfection and draping protocol, allowing access to the iliac crest.

Step 2: Steindler Release of the Plantar Aponeurosis

Use a medial approach to access and transect the plantar aponeurosis.

Step 3: Release the Posterior Tibial Tendon at the Foot

Transect the posterior tibial tendon near its insertion point.

Step 4: Retract and Split the Posterior Tibial Tendon at the Calf and Transfer It Through the Interosseous Membrane

Make a medial incision in the distal part of the calf, retract the posterior tibial tendon (and flexor digitorum tendon if necessary), split it longitudinally in half, and pass it through the interosseous space.

Step 5: Reveal the Target Tendons and Pull the Posterior-Tibial-Tendon Halves to These Tendons

Expose the anterior tibial and peroneal tendons and pull the posterior-tibial-tendon halves (and flexor digitorum longus tendon of it is being used) to these tendons.

Step 6: Chopart, or Triple or Lambrinudi, Arthrodesis

Perform a Chopart, or triple or Lambrinudi¹⁶, arthrodesis when osseous correction and stabilization are required for fixed deformities.

Step 7: Modified Jones Procedure

If the cavovarus foot displays flexible clawing of the big toe, carry out a modified Jones procedure.

Step 8: Extension Osteotomy of the First Metatarsal

If the first metatarsal remains in a fixed plantar flexed position and cannot be corrected with the Jones procedure, perform a dorsal-based wedge extension osteotomy.

Step 9: Clawing of the Lesser Toes

Incise the plantar tendons, transect the long flexor tendons, and place a single Hohmann wire through the end of each claw toe.

Step 10: Soft-Tissue Equinus Correction (Rarely Needed)

Depending on the severity of the remaining equinus, correct it with calf muscle or calcaneal tendon lengthening (the more severe the equinus, the more distal the corrective measure).

Step 11: Supramalleolar Varus Derotation Osteotomy

If foot external rotation is increased after foot correction, supramalleolar derotation osteotomy should be added to avoid lever-arm problems postoperatively.

Step 12: Complete the Tendon Transfers

Attach the transferred tendons to their respective target tendons using a Pulvertaft needle with a Pulvertaft weave technique, while keeping the foot in a plantigrade position.

Step 13: Wound Closure

Reevaluate the foot and determine if all corrections have been made, perform necessary final radiographic documentation, release the tourniquet, perform hemostasis, clean the wounds, and close them.

Step 14: Postoperative Management and Aftercare

The achieved operative correction is only as good as the postoperative treatment allows.

Results

Various authors have recommended posterior tibial tendon transfer to the dorsum of the foot to correct foot drop.

Indications

Contraindications

Pitfalls & Challenges

Pediatric Charcot-Marie-Tooth disease

Heritable diseases of the peripheral nerves (Charcot-Marie-Tooth disease [CMT]) affect the motor units and sensory nerves, and they are among the most prevalent genetic conditions in the pediatric patient population. The typical clinical presentation includes distal muscle weakness and atrophy, but the severity and progression are largely variable. Improvements in supportive treatment have led to better preservation of patients' motor functions. More than 80 genes have been associated with CMT. These genetic discoveries, along with the developments of cellular and transgenic disease models, have allowed clinicians to better understand the disease mechanisms, which should lead to more specific treatments.