Elsevier

Foot and Ankle Surgery

Volume 29, Issue 1, January 2023, Pages 44-49
Foot and Ankle Surgery

Recurrent heel ulcers with calcaneal osteomyelitis in myelomeningocele: Treatment by partial calcanectomy and posterior transfer of tibialis anterior tendon

https://doi.org/10.1016/j.fas.2022.09.002Get rights and content

Abstract

Overview

Calcaneus deformity of the foot is common in patients with myelodysplasia, mainly due to muscle imbalance. This deformity, especially in ambulatory patients, can result in gait problems and development of pressure sores, which can be complicated by calcaneal osteomyelitis.

Material and methods

This retrospective cross-sectional study included 12 patients (18 feet), with calcaneus deformity due to myelomeningocele, and presented with penetrating heel ulcers complicated by calcaneal osteomyelitis. The mean age of the included cases was 11 years. The ulcers were unilateral in six patients and bilateral in six. Sensation was absent on the plantar aspect of the foot in all cases. The treatment was done in two stages; The first stage was eradication of infection and obtaining good soft tissue coverage, and the second stage was obtaining motor balance to achieve a more plantigrade and braceable foot.

Results

The average follow-up period was 19.2 months. In the final follow-up, twelve feet were graded as good, five as fair and one as poor according to Legaspi grading system.

Conclusion

The combination of partial calcanectomy and subsequent transfer of tibialis anterior tendon, to improve the foot position and gait, can efficiently prevent ulcer recurrence in myelomeningocele patients with calcaneal deformity.

Level of clinical evidence: 4

Retrospective case series study.

Introduction

In patients with myelomeningocele, several factors can result in the development of foot deformity, including muscle imbalance, spasticity, and soft tissue contractures. The unopposed action of ankle dorsiflexors, mainly the anterior tibialis, against weak plantar-flexors, results in calcaneus ankle deformity, especially among patients with low lumbar functional level [1]. This deformity can result in difficult bracing, problematic shoes fitting, gait problems and development of pressure sores [2]. It has been described that approximately 19% of myelomeningocele patients develop heel ulcers [3].

Anterior tibialis tendon transfer as a modality for treating calcaneus deformity was originally described by Peabody in 1938 for patients with poliomyelitis [1]. Since then, other techniques were introduced for treating this condition, e.g., Achilles tendon tenodesis to the tibia [4] or fibula [5], [6] and calcaneal osteotomy [7].

Loss of heel sensation and prolonged pressure on the heel due to calcaneus deformity in meningocele patients may result in soft tissue breakdown [8], and when the bony calcaneus is exposed, there will be a high probability for the development of osteomyelitis, which is a potentially devastating condition [9]. The management of such penetrating ulcers necessitates debridement of bone infection [10].

Calcanectomy as a curative procedure reduces the bulkiness of the bony prominence, allowing for a tension-free soft tissue approximation over the bone. This procedure could successfully reduce the need for proximal amputation in those patients [11]. On the other hand, to prevent recurrence of the heel ulcer, the calcaneus foot-deformity needs to be corrected to ensure a plantigrade foot. To achieve this goal, the tibialis anterior needs to be removed as a deforming force to be transferred posteriorly into the Achilles tendon.

To the best of our knowledge, the effect of tendon transfer on preventing the occurrence of ulceration in patients with paralytic conditions has not been discussed before. In this study we present the outcome of the management of persistent heel ulcer with calcaneal osteomyelitis, in children with myelomeningocele, by partial calcanectomy and subsequent posterior transfer of tibialis anterior tendon into the Achilles tendon. We report the effect of tendon transfer on the recurrence of heel ulcers in those patients.

Section snippets

Material and methods

A retrospective study was conducted with the purpose of assessing the effect of tendon transfer on prevention of the recurrence of heel ulcers in myelomeningocele patients with calcaneus ankle deformities. The study was approved by our institutional ethical committee and an informed consent was obtained from patients’ parents/guardians. The study included 12 patients (18 feet) with myelomeningocele and calcaneus foot-deformity, presented to our department in the period from March 2017 to June

Results

The demographic data and the outcome are illustrated in Table 1. This study included four males and eight females (Fig. 3). The mean age of the included cases was 11 years (range from 7 to 18 years). The ulcers were unilateral in six (50%) patients and bilateral in six (50%) patients with a total of 18 feet. The right foot was involved in ten feet (55.6%) and the left side in eight (44.4%). All patients had grade 4 or more ankle dorsiflexion according to the Medical Research Council scale. The

4. Discussion

Foot problems due to myelomeningocele can be attributed to several factors; A biological factor, due to loss of protective sensation rendering the foot susceptible to injury and ulceration, and a mechanical factor, due to motor imbalance between an unopposed tibialis anterior muscle contraction against weak or paralyzed triceps sura and ankle evertors, resulting in calcaneovarus foot deformity. This deformity increases the contact pressure over the heel during walking and lying supine,

5. Conclusion

Posterior transfer of tibialis anterior tendon can improve foot position and gait, and efficiently prevent ulcer recurrence in myelomeningocele patients with calcaneal deformity.

Authors statement

All authors approve the final version of the paper provided.

Financial disclosure

None reported.

Declaration of interest

The authors declare no competing interests.

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