Results of combined split transfer of tibialis anterior tendon and intramuscular lengthening of tibialis posterior tendon for foot varus deformity because of cerabral palsy

Öz

Results of combined split transfer of tibialis anterior tendon and intramuscular lengthening of tibialisposterior tendon for foot varus deformity because of cerabral palsyAim: The aim of the study is represent 3 years follow-up results after split transfer of tibialis anterior tendonand intramuscular lengthening of tibialis posterior tendon together for foot varus deformity due to cerabralpalsy. Patients and Method: Twelve patients who have foot varus deformity due to cerebral palsy wereincluded in the study between 2008-2012 prospectively. Mean age was 8.1. Secondary to combined splittransfer of tibialis anterior tendon and intramuscular lengthening of tibialis posterior tendon percutaneousachilles lengthening for 9 patients and open achilles lengthening for 2 patients were applied simultaneously.Functions and clinical results were evaluated according to AOFAS (American Orthopaedic Foot and AnkleSociety) score and Kling et al scoring system respectively. Results: Mean follow-up was 29.3 months. Accordingto Kling et al score 7 patients were excellent, 4 were good and 1 were poor. Patients with excelent and goodresults had platigrade posture. Operated 17 feet at 12 patients had mean preop and last follow-up AOFASscore were 35.8 and 81.4 respectively. The diffence was statistically significant (p=0.023). Discussion: Combined split transfer of tibialis anterior tendon and intramuscular lengthening of tibialis posterior tendon methodhas found as an effective technique for dynamic varus foot deformity of cerebral palsy during both stanceand swing phase of gait

Anahtar Kelimeler

• Cerebral palsy
• tibialis anterior tendon
• tibialis posterior tendon
• split transfer

SEREBRAL PALSİ'YE BAĞLI AYAK VARUS DEFORMİTELERİNDE KOMBİNE TİBİALİS ANTERİOR TENDONU SPLİT TRANSFERİ VE TİBİALİS POSTERİOR TENDONU'NUN İNTRAMUSKÜLER UZATILMASI SONUÇLARI

Öz

Amaç: Bu çalışmanın amacı Serebral Palsi'ye bağlı gelişen ayak varus deformitelerinin tedavisinde kombine olarak Tibialis Anterior Tendonu split transferin ve Tibialis Posterior Tendonu İntramüsküler uzatma yönteminin 3 yıllık takip sonuçlarını bildirmektir. Hastalar ve Yöntem: 2008-2012 arasında serebral palsi'ye bağlı ayak varus deformitesi olan 12 hasta prospektif olarak değerlendirildi. Hastaların ortalama yaşı 8,1 idi. Kombine anterior tibial tendon split transferi ve posterior tibial tendonun intramüsküler uzamasına ek olarak aynı seansta 11 hastanın, 9'una aşil tendona perkütan , 2'sine açık uzatma uygulandı. Ayrıca 4 hastada harmstring ve 1 hastada fleksör hallucis longus ve fleksör digitorum longus uzatıldı. Hastaların fonksiyonları operasyon öncesi ve sonrası AOFAS (American Orthopaedic Foot and Ankle Society) skorları ile değerlendirildi. Klinik sonuçların değerlendirilmesinde Kling ve ark. tariflediği sınıflandırma kullanıldı. Sonuçlar: Hastalar ortalama 29.3 ay takip edildi. Kling sınıflamasına göre 12 hastanın 7'sinde mükemmel, 4'ünde iyi, 1'inde sonuçlar kötü olarak değerlendirildi. Mükemmel ve iyi sonuç elde edilen hastalarda plantigrad basma elde edildi. Oniki hastanın cerrahi uyguladığımız 17 ayağının işlem öncesi ortalama AOFAS skoru 35.8 iken son takiplerinde ortalama 81.4 olarak bulundu. Aradaki fark istatistiksel olarak anlamlı bulundu (p=0.023). Tartışma: Yürümenin hem duruş, hem salınım fazında serebral palsi'ye bağlı dinamik varus deformitesi olanlarında kombine olarak tibialis anterior split transferi ve tibialis posteriorun intramüsküler uzatılması tekniği literatürde belirtildiği gibi çalışmamızda da efektif bir metod olarak bulunmuştur.

Anahtar Kelimeler

• Serebral palsi
• tibialis anterior tendon
• tibialis posterior tendon
• split transfer

Kaynakça

1. Hosalkar H, Babatunde O, Goebel J, Rendon N, Bashyal R, Keenan M.A. Current Orthopaedic Practice 2010. Vol 21 ( 1); Jan/Feb
2. Barnes MJ, Herring JA. Combined split anterior tibial- tendon transfer and intramuscular lengthening of the posterior tibial tendon. Results in patients who have a varus deformity of the foot due to spastic cerebral palsy. 1991 Jun;73(5):734-8.
3. Renshaw TS, Green NE, Griffin PP, Root L. Cerebral palsy: orthopaedic management. Instr Course Lect. 1996;45:475-90.
4. Baker L. D. , Hill L. M. Foot Alignment in the Cerebral Palsy Patient. J. Bone and Joint Surg Am.1964 Jan;46:1- 15
5. Bisla RS, Louis HJ, Albano P Transfer of Tibialis Posterior Tendon in Cerebral Palsy. J. Bone and Joint Surg Am.1976 Jun;58(4):497-500
6. RooT L, Miller SR, Kirz P Posterior Tibial-Tendon Transfer in Patients with Cerebral Palsy. J. Bone and Joint Surg Am. 1987 Oct;69(8):1133-9.
7. Williams PF Restoration of Muscle Balance of the Foot by Transfer of the Tibialis Posterior. J. Bone and Joint Surg Br.1976 May;58(2):217-9
8. Bleck EE. Orthopaedic Management in Cerebral Palsy. Clinics in Developmental Medicine 1987 No. 99/100. Philadelphia, J. B. Lippincott

9. Coleman SS Complex Foot Deformities in Children Philadelphla, Lea and Febiger, 1983; 230.
10. Thomas Dreher, MD and Wolfram Wenz, MD Tendon Transfers for the Balancing of Hind and Mid- footDeformities in Adults and Children Techniques in Foot & Ankle Surgery _ 2009 Dec; Vol 8,(4)
11. Carpenter AR. Tendon transplantation. An end-result study of 485 transplantations. J Bone Joint Surg. 1939;21:920–932.(abstract)
12. Kuo KN, Hennigan SP, Hastings ME. Anterior
13. tibial tendon transfer in residual dynamic clubfoot deformity. J Pediatr Orthop. 2001;21:35–41.
14. Hoffer MM, Reiswig JA, Garrett AM, et al. The split anterior tibial tendon transfer in the treatment of spastic varus hindfoot of childhood. Orthop Clin North Am. 1974;5:31–38
15. Vogt JC. Split anterior tibial transfer for spastic equinovarus foot deformity: retrospective study of 73 operated feet. J Foot Ankle Surg.1998;37:2–7.
16. Kling TF Jr, Kaufer H, Hensinger RN. Split posterior tibial-tendon transfers in children with spastic paralysis and equinovarus deformity. J Bone Joint Surg 1985; 67:186-94.
17. Bennet GC, Rang M, Jones D. Varus and Valgus Deformities of the Foot in Cerebral Palsy Dev Med Child Neurol 1982 Aug 24(4):499-503
18. Perry J, Hoffer MM Preoperative and Postoperative Dynamic Electromyography As an Aid in Planning Tendon Transfer in Children with Cerebral Palsy. J.Bone Joint Surg Am 1977 Jun;59(4):531-7
19. Ruda R Frost HM. Cerebral Palsy. Spastic Varus and Forefoot Adductus,Treated by Intramusculer Posterior Tibial Tendon Lengthening Clin.Orthop1971;79:61- 70
20. Green NE, Griffin PP, Shiavi R Split Posterior Tibial -Tendon Transfer in Spastic Cerebral Palsy. Bone and Joint Surg Am 1983 Jul;65(6):768-54