Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKbH4TTImqenVCSTviUIIukZ+Kc6C+XR+Hpix4E/m9lQJq9w8vM2vaCA on 02/16/2019 Correction of Postburn Equinus Deformity Gi-Yeun Hur, MD, Byung-Jun Rhee, MD, Jang-Hyu Ko, MD, Dong-Kook Seo, MD, Jai-Koo Choi, MD, PhD, Young-Chul Jang, MD, PhD, and Jong-Wook Lee, MD, PhD Background: Equinus deformity is characterized by an abnormal tiptoe gait and does not allow normal walking, hence needing correction. Congenital causes of equinus deformity include neurological diseases such as cerebral palsy and poliomyelitis. Acquired causes include injuries such as extensive trauma. We have corrected equinus deformity from extensive lower leg burns by a single op- eration through excisional release of the scar, Achilles lengthening, and radial forearm free flap. Methods: Fifteen patients with postburn equinus deformity who were treated between January 2000 and March 2012 were retrospectively studied. We inves- tigated their age, sex, cause and severity of burn injury, equinus degree, ankle range of motion and the changes in the activity, extent of Achilles lengthening, flap size, complication, and the recurrence in these patients. Results: The average degree of equinus deformity before the operation was 45 degrees. With an average Achilles lengthening of 4.6 cm, all patients achieved neutral position. The patients who had poor activity due to tiptoe gait before the operation showed good to fair levels of walking ability postoperatively. During an average follow-up period of 3 years and 9 months, no patients had a recurrence. Conclusions: Equinus deformity causes significant restrictions to walking and the reconstruction is a challenging problem. Although prevention is more im- portant during the initial stages of treatment, we have successfully corrected patients with existing equinus deformity by scar release, Z-tenoplasty of Achilles, and radial forearm free flap. Key Words: equinus deformity, Achilles tendon, burns, free tissue flaps (Ann Plast Surg 2013;70: 276Y279) I n normal coordinated gait, the ankle joint repeats plantar flexion and dorsiflexion, with the ankle range of motion (ROM) of approx- imately 30 degrees. In severe burns that damage soft tissue, there can be loss of function of the ankle joint, causing significant disability. In equinus deformity, there is no dorsiflexion past plantigrade when the knee is extended and the hindfoot is in neutral position. 1 Equinus disrupts the normal gait cycle by decreasing stability in stance phase and causing inadequate clearance in swing phase. 2 As a result, it leads to tiptoe gait, causing chronic pain, rupture of the skin of the toe tips, and ulceration. 3 The causes of equinus deformity include the aforemen- tioned postburn soft tissue defect, as well as neurological diseases in- cluding cerebral palsy, poliomyelitis, and neuromuscular dystrophy. Other causes include fibromyalgia after compartment syndrome and chronic plantar flexion due to various reasons. 4 For cerebral palsy, which is a common cause of equinus defor- mity, there are many reports on the surgical and nonsurgical treatments. However, the reports on the treatment of postburn equinus deformity are limited, and there are controversies regarding the appropriate treat- ment. It is different to cerebral palsy in that there are comorbid soft tissue injuries. Postburn equinus deformity is also more prone to poor management such as inappropriate joint fixation during the acute burn treatment period and early postburn rehabilitation period. Therefore, the treatment plan for equinus deformity should be different from that for cerebral palsy. According to various literatures, the nonsurgical treatment op- tions for equinus deformity include stretching exercises, splint fixation, orthotics, nerve blocking using substances such as botulinum, alcohol, and phenol; and surgical treatments include nerve blocking, Achilles lengthening, gastrocnemius and/or soleus fascial lengthening, and Ilizarov fixation. 2 However, in many cases, there was a high rate of recurrence and unsatisfactory outcome from several surgical treat- ments. 5 It is not yet known which treatment method is most appro- priate and thus the correct treatment of equinus deformity still remains controversial. The aim of this study is to conduct and prove the effectiveness of reconstructive surgery on patients with postburn equinus deformity by excisional release of scar, Achilles lengthening followed by radial forearm free flap. PATIENTS AND METHODS Subjects The subjects for this study were 15 patients with postburn equinus deformity who were treated by Achilles tendon lengthening and radial forearm free flap between January 2000 and March 2012. The age, sex, cause of injury, length of hospital stay at the time of the initial burn, number of operations, equinus degree presurgery and postsurgery, changes in ankle ROM and activity, length of Achilles lengthening, flap size, complication, and recurrence was investigated in these patients. The indications for surgery included having received at least 6 months of conservative treatment without improvement in symptoms, or if dorsiflexion was not possible, or if there was a tiptoe gait. For patients with equinus deformity due to soft tissue injury, there had to be no severe degenerative changes in the ankle joint. 6 To address this issue, we took x-ray photographs of the patients’ ankles to exclude any degenerative bony changes. Surgical Methods With the patients lying prone under general anesthesia, the scar tissue was removed around the Achilles tendon. Using the calcaneus bony insertion and the calf muscle origin of the Achilles tendon as reference, horizontal incisions were made at these 2 points 5 cm away from the 2 ends of the tendon. A linear incision was then made at the midline of the Achilles tendon to divide the tendon. Hence, the Achilles tendon was completely separated proximally and distally so the inci- sion lines formed a step-ladder shape (Fig. 1). The calcaneus, talus, and the tibia were fixed using Steinmann pins at the plantar surface with the ankle in passive dorsiflexion so that the ankle joint was almost in a vertical position. Such ankle reduction leads to manual capsulotomy of the ankle joint; #3-0 Prolene was used to suture the slid proximal and distal Achilles tendon. The length of the Achilles tendon was decided with the foot in passive dorsiflexion and the foot and the ankle joint forming a vertical angle. After BURN SURGERY AND RESEARCH 276 www.annalsplasticsurgery.com Annals of Plastic Surgery & Volume 70, Number 3, March 2013 Received July 26, 2012, and accepted for publication, after revision, October 18, 2012. From the Department of Plastic and Reconstructive Surgery, Hangang Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea. Conflicts of interest and sources of funding: none declared. Reprints: Jong-Wook Lee, MD, PhD, Department of Plastic and Reconstructive Surgery, Hangang Sacred Heart Hospital, Hallym University Medical Center, 94-200 Youngdeungpo-dong, Youngdeungpo-gu, Seoul 150-719, Korea. E-mail: jwlpsdoc@yahoo.co.kr. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7003-0276 DOI: 10.1097/SAP.0b013e31827a6c83 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.