Sobel E, Caselli MA, Velez Z.

New York College of Podiatric Medicine, New York, USA.
Abstract

Sixty idiopathic toe walkers (age range 1 to 15 years) were evaluated to determine the natural history of toe-to-toe gait and the relationship between the range of ankle dorsiflexion and increasing age. The majority of toe walkers had a normal birth weight (average 7.06 pounds), walked on time (average 11.14 months), began toe walking immediately (87%), stood plantigrade (90%), were able to demonstrate a heel-toe gait (88%), and toe walked intermittently (68%). Forty-six percent of all toe walkers were found to have 0 degree or less of passive ankle dorsiflexion. Equinus toe walkers (mean dorsiflexion -5.2 degrees) had significantly less dorsiflexion than the remaining toe walkers (mean dorsiflexion 16.9 degrees; p < 0.01). An average of 12 degrees of dorsiflexion was resent in the 1-to 2-year age group, which gradually diminished to -4 degrees in the 6- to 15-year age group. It appears that there may be a relationship between persistent toe walking and the development of ankle equinus in some children and therefore interventions should be considered to inhibit the toe walking progression.

The article concludes that toe walkers where there is equinus deformity need treatment to improve dorsiflexion

2. What are the results of conservative treatment and serial casting?

Acta Paediatr. 2004 Feb;93(2):196-9.
The natural history of idiopathic toe-walking: a long-term follow-up of fourteen conservatively treated children.
Hirsch G, Wagner B.

Department of Paediatric Orthopaedics, Astrid Lindgren’s Children’s Hospital, Karolinska sjukhuset, Stockholm, Sweden. georg.hirsch@ks.se
Abstract

AIM: To determine the long-term results after conservative treatment (physiotherapy, casting, orthoses, or a combination of these) of idiopathic toe-walking (ITW). METHODS: Tiptoe-walking is diagnosed as idiopathic (habitual) if no signs of neurological, orthopaedic, or psychiatric disease are detected. The diagnosis is one of exclusion. Sixteen former patients with ITW, all now at least 13 y old, were asked to participate in a follow-up investigation 7-21 y after being first diagnosed. Two cases were excluded because heel-cord lengthening had been performed later on in other hospitals. The remaining 14 patients completed a questionnaire. Eleven patients consented to a clinical examination, during which they were videotaped and their active and passive ankle-joint dorsiflexion measured. These data were compared with the assessment at the initial evaluation. In one instance, the toe-walking ceased after conservative treatment (plaster cast). In all other cases the toe-walking pattern recurred. RESULTS: At follow-up three patients showed some toe-walking when they were unobtrusively observed. When videotaped, they did not toe-walk, although a distinct heel-strike was missing. The remaining eight patients all walked with a heel-strike. Two patients had slight symptoms possibly related to toe-walking. No fixed contracture was present at the first evaluation, and none was found at follow-up. There was no systematic change in ankle-joint dorsiflexion from initial assessment to follow-up examination. CONCLUSION: Non-surgical treatment of ITW does not have a lasting effect and the long-term results in this study are considered to reflect the natural history, i.e. the toe-walking pattern eventually resolves spontaneously in the majority of children. Surgical treatment of ITW should be reserved for the few cases with a fixed ankle-joint contracture.

The article concludes that toe walkers where there is equinus deformity need treatment to improve dorsiflexion

Acta Orthop Belg.  2006 Dec;72(6):722-30.
Serial casting in the treatment of idiopathic toe-walkers and review of the literature.

Fox A, Deakin S, Pettigrew G, Paton R.

Blackburn Royal Infirmary, Blackburn, United Kingdom. annafox2k@btopenworld.com
Abstract

Idiopathic toe-walking is defined as persistent toe-walking in a normal child in the absence of developmental, neurological or neuromuscular conditions. True idiopathic toe-walking is a rare referral, representing approximately 1:100 new patients seen in the Paediatric Orthopaedic Clinic. A prospective study of idiopathic toe-walking (ITW) was organised between 1999 and 2003. Patients underwent full history, neurological examination and assessment of ankle dorsiflexion, followed by below-knee weight-bearing casting. Forty four developmentally normal children with no delay in walking age were in this study. There was an age range on presentation from 2 years to 14 years 4 months, with median 60.5 months. Sixty eight percent were male. Thirty four percent had a family history of the condition. Following casting, 66% of patients had improved gait on patient and clinician determined outcomes, with the majority of children ceasing to toe-walk. Ankle dorsiflexion significantly improved in those children who were successfully treated (p = 0.001).

The article conclused that in one third of patients the serial casting did not work these are likely to be patients with ankle equinus

3. What is the outcome of surgery for ITW

J Pediatr Orthop.  2006 May-Jun;26(3):336-40.
Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking.

Hemo Y, Macdessi SJ, Pierce RA, Aiona MD, Sussman MD.

Dana Children’s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.
Abstract

Fifteen children who were diagnosed with idiopathic toe walking that cannot be corrected by nonoperative treatment were assessed by clinical examination and computer-based gait analysis preoperatively and approximately 1 year after Achilles tendon lengthening. Passive dorsiflexion improved from a mean plantarflexion contracture of 8 degrees to dorsiflexion of 12 degrees after surgery. Ankle kinematics normalized, with mean ankle dorsiflexion in stance improving from -8 to 12 degrees and maximum swing phase dorsiflexion improving from -20 to 2 degrees. Peak ankle power generation increased from 2.05 to 2.37 W/kg but did not reach values of population norms. No patient demonstrated clinically relevant triceps surae weakness or a calcaneal gait pattern. Seven patients had a stance phase knee hyperextension preoperatively, and 6 of these corrected after surgery. Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery.

The article conclused that surgery in selected cases who do not improve with conservative treatment improves ankle dorsiflexion and way the child walks inclusing the energy efficiency. There may be calf weakness post operatively which corrects in one year time

J Pediatr Orthop.  2001 Nov-Dec;21(6):790-1.
Simplified approach to idiopathic toe-walking.

Kogan M, Smith J.

Primary Children’s Medical Center, Salt Lake City, Utah, USA.
Abstract

Controversy exists as to the treatment of idiopathic toe-walking (ITW). Since 1993, the authors have managed children with ITW using an outpatient percutaneous lengthening of the Achilles tendon, followed by placement of below-knee walking casts for 4 weeks. The authors reviewed 15 children who were treated for ITW with percutaneous Achilles tendon lengthening between 1993 and 1999. Ten of the 15 patients could be contacted for a follow-up survey. None of the parents stated that their child’s toe-walking had recurred. There were no painful scars. All of the children were able to keep up with other children and did not notice any calf weakness. Two children had occasional Achilles tendinitis, which was relieved with antiinflammatory medications. All parents were satisfied with their child’s outcome. The authors believe that percutaneous tendo-Achilles lengthening in ITW greatly simplifies the management of ITW.

Indications

• Correcting angular deformity in a growing child with open physis
  

• Any age/ Size
• Any accessible physis
• Any diagnosis including sick physis
• 1 year of growth remaining
• Any plane frontal sagital oblique

Contraindications

• Closed Physis
• Skeletal Maturity
• Physiological Deformities

Equipments needed

• C ARM
• Radiolucent table
• 1mm and 1.5 mm guide wires
• E plate
• 4.5mm self tapping cannulated screws (15-30mm)
• Stop Drill

Surgical steps

Step 1 : LOCALIZATION OF PHYSIS

• Under image intensifier 1.5 mm guide wire is passed at the center of physis
• Confirmed in both AP & Lat views

Step 2: SKIN INCISION

• About 1.5 cm centered over guide wire
• The incision is deepened till perichomdrium
• E plate is positioned with its central hole sliding over the guide wire over the perichondrium
• The plate should be along the midline of the bone axis on lateral view

Step 3 GUIDE WIRES

• 2 guide wires are passed  through the holes on either sides of the physis
• They  need not be parallel but  care should be taken is not to violate the physis

Step 4 SELF TAPPING CANNULATED SCREWS

• Screw length is measured
• Should not be too short
• Generally 15-30 mm screws are sufficient
• Cortex is drilled
• Self tapping screws are passed

Step 5 Closure and Dressing

The closure is done in layers and compression dressing is applied.

No cast or immobilization is needed

Full weight bearing supported walking and knee mobilization are started the next day

Post op Protocol

• Day care surgery
• No immobilisation
• Immediate mobilisation
• Xrays once in 3 months
• Implant removal once the deformity is corrected

Case report-

8 yr old girl with renal osteodystrophy with genu valgum

Immediate post op xray

3 month follow up

6 month follow up

Advantages of E plate over staples

• Flexibility
• Unconstrained implant
• Load sharing
• One plate per physis
• Fully threaded cannulated screws resist pull-out forces
• Diverging screws function like a hinge to gently guide natural growth
• Easy to remove

preoperative picture the child has varus and inernal rotation

3 year old child with tibia vara  The child has varus and internal rotation deformity not correcting on serial follow up.

Proximal  Block is made with 2 K wires inserted parallel to knee joint and perpendicular to the tibia.

Distal block is made with 2 K wires inserted inserted parallel to ankle and perpendicular to distal tibia.

In the transverse plane the proximal wires are in axis of the knee joint ( inter epicondylar axis) and the distal wires 15 degrees internal to bimalleolar axis

The osteotomy is made at CORA with multiple drill holes made in transverse plane and completed with 5 mm osteotome

When the wires are braught parallel the varus and the rotational deformities are corrected

The wires are connected  with miniexternal fixation clamps

An antero posterior anti toggle wire is added to proximal and distal blocks

The fixator is removed once the osteotomy heals generally 6 weeks post op

Step 1

Step 2