SLR - March 2021 - Milad Kashani
References: Westberry DE, Carpenter AM, Brandt A, et al. Surgical Outcomes for Severe Idiopathic Toe Walkers. J Pediatr Orthop. 2021;41(2):e116-e124. doi:10.1097/BPO.0000000000001677Level of Evidence: Level III, Case series
Scientific Literature Review
Reviewed By: Milad Kashani, DPM
Residency Program: Swedish Medical Center – Seattle, WA
Podiatric Relevance: It is imperative for every foot and ankle specialist to be familiar with pediatric orthopedic issues, especially the ones with low occurrence like idiopathic toe walking that can be extremely concerning for parents. Various conservative treatment options have been described for idiopathic toe walking such as serial casting, physical therapy, and bracing. Surgical options are usually considered after failure of conservative treatments. The authors tried to evaluate the outcomes of surgical intervention for patients with severe idiopathic toe walking, some of whom have failed conservative treatment. They also tried to compare the outcomes of different lengthening procedures.
Methods: In this retrospective study all patients from 2002 to 2017 with idiopathic toe walking that underwent gastrocnemius recession or tendo-Achilles lengthening surgery with pre-operative and one-year post-operative motion analysis were included. Any patient with a known etiology of toe walking or botulinum toxin treatment 6 months prior to surgery was excluded. Using Alvarez classification system, only patients with severe toe walking (Type 3) were included in this study. All surgeries were performed by five surgeons in a single surgical institution. In most cases, surgeons either performed gastrocnemius/soleus fascia recession for plantarflexion contracture of <15 degrees or tendo-Achilles lengthening (either open or closed) for plantar flexion contracture of >15 degrees. All patients were placed in a short leg cast following surgery. Physical, clinical, kinematic, and radiographic outcomes were evaluated for both groups post-operatively.
Results: Forty-six extremities from 26 patients were included in this study. Gastrocnemius recession was performed on 25 extremities and tendo-Achilles lengthening on 21 extremities. For physical outcome, ankle dorsiflexion in both groups was similar and had statistically significant improvement post operatively, although ankle dorsiflexion was still below normal values in both groups. For kinematic outcomes, although not fully normalized, dorsiflexion at initial contact phase and swing phase improved in both surgical groups. No significant radiographic changes noted postoperatively in both groups. Of the 46 extremities in this study, 40 extremities required no further treatment with no recurrence or complications. Six extremities, all of which had received gastrocnemius recession required further surgical treatment due to recurrence. In term of Alvarez classification, nine extremities improved from Alvarez type 3 to Alvarez type 1, while 34 extremities improved from Alvarez type 3 to Alvarez type 2, and 3 extremities remained Alvarez type 3. Both surgical interventions were similar in terms of these improvements.
Conclusions: Surgical approaches for treatment of this condition has led to improvements and sustained toe walking resolution in this study. Subjects receiving tendo-Achilles lengthening had better outcomes than the group receiving gastrocnemius recession procedure. One risk associated with surgical approach is Achilles tendon over lengthening which was not observed in this study. The other risk associated with surgical intervention which was observed in this study is the unmasking of other anatomical abnormalities such as external foot progression angle once toe walking has resolved. Some of the weaknesses of the current study are lack of a control group that received conservative treatment and a relatively short follow up period.