Improving calf muscle strength in patients with spastic equinovarus deformity by transfer of the long toe flexors to the Os calcis.

The split tibialis anterior tendon transfer (SPLATT), Achilles tendon lengthening, and toe flexor release are proven and effective procedures for correcting a spastic equinovarus deformity of the foot. Paresis is a prominent feature of upper motoneuron syndrome. Lengthening the Achilles tendon, although necessary to correct the equinus, further weakens the gastrocnemius-soleus muscle group. The calf paresis commonly results in the need for an ankle-foot orthosis (AFO) during ambulation. Previous studies have shown that despite the correction of the equinovarus deformity, only one third of patients were able to ambulate without an AFO. The need for continued use of an AFO was because of insufficient calf strength to stabilize the tibia during late stance when the body mass is anterior to the ankle joint. This study prospectively evaluated the results of transfer of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) to the os calcis in 30 patients. The transfer was done in an effort to augment the strength of the gastrocnemius-soleus muscle complex. Twenty-five patients in group I (the control group) underwent SPLATT, Achilles tendon lengthening, and toe flexor release. Thirty patients in group II (the study group) underwent the identical procedures plus the additional FHL and FDL transfer to the os calcis. Postoperatively, the varus and toe flexion deformities were corrected in all feet. In group II, two feet had a mild residual equinus that did not interfere with ambulation. Of the 11 patients who were not independent community ambulators in group I, 7 (64%) improved ambulatory status by at least one level after surgery. Of the 15 patients who were not independent community ambulators in group II, 14 (93%) improved ambulatory status by at least one level after surgery. In group I, 10 of 25 (40%) of the patients were brace free at follow-up. In group II, 21 of 30 (70%) were brace free at follow-up (c2, P =.025). These results indicate that the addition of an FHL and FDL transfer to the os calcis at the time of SPLATT, Achilles tendon lengthening, and toe flexor release improves calf strength and allows greater increase in function and less reliance on orthotics.