Hemiplegic Foot
in Children and Teenagers:
When to consider surgery?
Antoine de Gheldere, MD
Consultant in Children’s Orthopaedics and Trauma
GNCH – Royal Victoria Infirmary
Newcastle upon Tyne, UK
Peacocks meeting, Saturday 9th January 2016
3 principles to remember
1. Nobody can cure Hemiplegia (CP)
2. A “neurological deformity” doesn’t get
better with the growth
3. The foot is in continuity with the leg
Common Hemiplegic
• Walking (GMFCS 1 or 2)
• Distal disorder (hand and foot/ankle)
• Weak ankle extensors (dorsal flexion)
• GCS/S increased tone
Worsen without treatment
Natural History
EQUINUS (Triceps tone ++)
Plano-valgus (Talus subluxation)
Cavovarus (TP/TA tone ++)
Reasons for referral
• Gait difficulty: foot – knee – hip – trunk
• Foot pain/discomfort
– Medial or Lateral
– Fixed deformity
– Bunion (teenagers)
• Instability (teenagers)
2nd Question: How many joints affected?
• Knee, hip, trunk, (upper limb)
• Dynamic deformity (spasticity)
• Video recording or gait analysis
Clinical Assessment (2)
3rd Question: Active foot control?
• Selectivity
• Foot “balance”
• Weak agonist vs. antagonist contracture
Clinical Assessment (3)
Surgical Indications
• Fixed deformity
• Uncomfortable flexible
deformity
• Compensation deformity
• Gait deterioration
“Do not wait the end of the growth”
Type of Foot Deformity
Equinus: 35%
Cavovarus: 35%
Planus: 12%
Valgus: 6%
Bunion: 12%
Planus Valgus
Equinus Cavovarus
Equinus
Normal initial contact
- Foot in neutral position
- 30 degrees with ground
No more Achilles lengthening!
Normal foot
1st Rocker = Heel
Ex moment = PF
Tib Ant
Eccentric
Absorb impact
2nd Rocker = Ankle
Ex moment = DF
Soleus
Eccentric
Ankle trunk forward
3rd Rocker = Toes
Ex moment = DF
GCN
Concentric
Propulsion
Cavovarus
• Triceps (GCN/S) tone ++ or contracture ?
• Weak DF: TA? EDL? EHL?
• TA or TP ?
• Weak Peronei ?
+2 years
AA medial derot. O.
Calcaneus double O.
GCN lengthening
PB lengthening
TP shortening
TN capsule repair
Teenagers Hemiplegic Foot
Problem No.1: Doesn’t like splints
• Stretching self-teaching (gym)
• Shoe compensation
– “high heel”
– Boots
Teenagers Hemiplegic Foot
Problem No.2: Ankle instability
• Bardot procedure if:
– Reasonable TA
– Flexible deformity
– “Tenodesis”
Bunion – Hallux Valgus
• More frequent with planovalus foot
• Osteotomy and ADH release
• Aim M1P1 at 0
• Fusion only if (symptomatic) failure
Take Home Message
• Conservative treatment first
• Don’t wait end of growth for surgery
• Understand the deformity
• Avoid fusion
• Osteotomy(ies) and soft tissues