- Discussion:
- progressive paralytic equinovarus is an important reason for gait deterioration in pts w/ DMD;
- equinus contracture compensates for incr quadriceps weakness & allows knees to lock by enabling wt line to pass in front of knee joint;
- feet become progressively fixed in equinus & then equinovarus position;
- posterior tibial muscle retains good f(x) despite progression of muscle weakness in other areas;
- Indications for Surgery:
- progressive, rigid equinovarus contractures prevent pt from attaining comfortable position of feet in wheelchair or from wearing shoes;
- surgical correction of equinovarus is indicated in pts who retain ability to ambulate;
- if there are equinus contractures of the ankle but the function of quadriceps is still good, isolated Vulpius heel-cord lengthening is often valuable;
- some authors have performed Z-lengthening but have cautioned about possibility of overcorrection;
- procedure can add an average of 3 yrs of f(x) ambulation;
- Operative Treatment:
- multiple tenotomies of Achilles, posterior tibial, FDL & FHL tendons, followed by use of AFO, has led to improvement in
circulation & in position and comfort of the feet of these patients;
- posterior tibial muscle retains good f(x) despite progression of muscle weakness in other areas;
- its transfer thru interosseous membrane to dorsum of foot (lateral cuneiform) prevents recurrence of equinovarus & actively contributes to dorsiflexion of the foot;
- heel cord lengthening is also performed;
- posterior tibial-tendon transfer thru interosseous membrane onto dorsum of the foot;
- tendon transfer allows this musculotendinous unit to serve as dorsiflexor & evertor rather than as plantar flexor & invertor
Surgical prevention of foot deformity in patients with duchenne muscular dystrophy.