International Orthopaedics (SICOT) (1988) 12:57-59
Orthopaedics
Transfer of half the calcaneal tendon to the dorsum of the foot for
paralytic equinus deformity
F. Fernfindez-Palazzi, J. R. Medina, and N. Marcano
Service C Orthopaedics and Physical Medicine, Hospital San Juan de Dios, Caracas, Venezuela
Summary. Transfer of half of the calcaneal tendon
to the dorsum of the foot will maintain correction o f
a paralytic equinus deformity. We have used this
procedure on 9 7 f e e t since 1967. Seventy-six were
reviewed and the overall results were excellent or
good in 69%. The outcome was better in children
with cerebral palsy (85% excellent or good) than in
those with poliomyelitis (only 13% excellent or
good).
Rbsum& La dkformation en bquin du pied est l'ano-
malie la plus frbquente chez les enfants prksentant
diffbrents types de paralysies. L'allongement du
tendon d'Achille est insuffisante dans la plupart des
cas, en l'absence d'un moteur actif En 1957 Cald-
well a dkcrit le transfert d'un hkmi-tendon d'Achille
sur la face antkrieure du pied. Depuis 1967 nous
avons pratiqub cette intervention 97 fois sur 88 ma-
lades. Nous avons revu 76 pieds et bvaluk les r~sul-
tats en fonction de la correction, de la flexion dor-
sale active du pied, et de la marche. Ils ont btb di-
vis~s en excellents, bons, passables et mauvais. Les
rbsultats btaient excellents et bons dans 53 cas
(69%), passables 14 fois et mauvais 9 fois. Les meil-
leurs rksultats ont btk obtenus dans les paralysies
cbrbbrales (85% excellents ou bons). Les indications
de cete opbration sont: pied ~quin paralytique avec
ou sans varus ou valgus, marche possible sans or-
th~se, fort triceps sural et absence de dkformation
osseuse.
Key words: Paralytic equinus deformity, Calcaneal
tendon transfer, Dorsum o f foot
Offprint requests to: F. Fern{mdez-Palazzi, PO Box 66473, Pla-
za Las Americas, Caracas 1061 A, Venezuela
International
© Springer-Verlag 1988
Introduction
An equinus deformity of the foot is a common af-
ter paralysis, whatever the cause. It results from
muscle imbalance when the dorsiflexors are weak
and the calf muscles are strong. Elongation of the
calcaneal tendon may correct the fixed deformity,
but this will recur unless the patient wears a suit-
able orthosis or a tendon transfer is carried out to
restore the power of dorsiflexion.
Caldwell described the transfer of half of the
calcaneal tendon to the dorsum of the foot in
cases of paralysis after poliomyelitis [2], and other
surgeons have experienced good results with this
operation in myelodysplasia [7, 8] and in one case
of Charcot-Marie-Tooth disease [3]. We have re-
ported our experience of the operation in children
with a spastic equinus deformity [4].
The result depends on various factors which
should be born in mind when considering the in-
dications for the operation. In cerebral palsy there
is spasticity of the calf with primary or secondary
weakness of the dorsiflexors. In myelodysplasia,
we found that the calcaneal tendon was very tight
with associated spasticity which is sometimes
overlooked; the dorsiflexors are paralysed and
there is loss of sensation. In poliomyelitis, there is
paralysis of the dorsiflexors, but no sensory loss.
Materials and Methods
We have performed anterior transfer of half the calcanealten-
don on 97 feet in 88 patients. The disorders treated were:
Cerebral palsy 68
Poliomyelitis 19
Club foot 3
Lateral popliteal nerve lesion 3
Guillain Barrie disease 1
Charcot-Marie-Tooth disease 1
Unknown cause 2
58 F. Fernandez-Palazzi et al.: Treatment of the paralytic equinus deformity

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Fig. 1. Skin incision medial to the calcaneal tendon

Fig. 2. The dissection is carried proximally to the muscle belly of gastrocnemius. A Z-lengthening of the remaining part of the
calcaneal tendon is carried out, if necessary
Fig. 3. The part of the tendon to be transferred is dissected out and detached from the calcaneum
Fig. 4. The front of the leg with the transferred tendon passed through a window cut in the interosseous membrane, the incision
over the middle cuneiform is shown
Fig. 5. The transferred tendon is attached to the middle cuneiform with a pull-out stitch

Fig. 6a, b. The photographs show an excellent result 3 years after operation (a) the range of plantarflexion. (b) active dorsiflexion
by the transferred tendon

Every patient had an equinus deformity which was associated
with varus in 24 and valgus in 12. Some of the patients wore
an orthosis or had to use crutches before operation.
The mean age at operation was 8 years 6 months (range
21A-20 years).
The mean follow-up was 1 year 9 months (range 4 months
- 6 years). There was sufficient information available to evalu-
ate the results in 76 feet. There were 52 spastic feet in 45 pa-
tients, 16 feet in 15 patients with poliomyelitis, and 8 with
other conditions.
In 61 cases the medial half of the tendon was transferred
and in 15 the lateral. In 60 the t e n d o n was inserted into the
middle cuneiform bone, in 8 into the lateral and into the medi-
al cuneiform in 8.
Operative technique. A posteromedial incision is made to ex-
pose the calcaneal tendon and the lower part of the gastrocne-
mius muscle (Fig. 1). The tendon is then split longitudinally
from the lower third of its muscular part to its insertion into
the calcaneum (Fig. 2). The medial part is detached from the
bone, but if there is a tendency to valgus it is better to use the
lateral half. If the calcaneal tendon is tight and prevents dor-
siflexion of the foot, a Z-lengthening of the remaining tendon
should be carried out (Fig. 3). A small incision is now made
over the lower part of the leg and the detached part of the ten-
don is passed through a window cut in the interosseous mem-
b r a n e (Fig. 4). A third incision overlies the middle cuneiform
bone and the tendon is passed to it through a subcutaneous
tunnel. Finally, the tendon is inserted through a drill-hole in
the bone and fixed with a pull-out suture (Fig. 5).
Postoperative management. A below-knee plaster cast is appli-
ed with the foot in 10-15 degrees of dorsiflexion. After three
weeks this is changed to a posterior splint, and active and pas-
F. Fernandez-Palazzi et al. : Treatment of the paralytic equinus deformity
sive movements are begun. If a bony operation has been carri-
ed out at the same time, plaster immobilisation is continued
until the fusion is solid. After a further three weeks, weight-
bearing is allowed. In some cases, especially in small children,
an orthosis with a posterior block is used for six months.
Results
We classified our results as follows:
Excellent Active dorsiflexion of more than 20
degrees w a s achieved. The drop foot
gait disappeared and an orthosis was
no longer necessary. The patient was
satisfied.
Good The transfer acted as a tenodesis or a
few degrees of active dorsiflexion
was possible. The gait was improved,
the patient was satisfied and did not
need to wear an orthosis.
Fair The transfer did not work as a teno-
desis and the equinus persisted. The
drop foot gait was improved.
Poor The foot was the same, or worse,
than before operation.
Overall there were 53 (69%) excellent or good, 14
(19%) fair and 9 (12%) bad results.
The best results were in children with cerebral
palsy (Fig. 6); 44 (85%) were excellent or good, 4
were fair and 4 poor.
In poliomyelitis, however, only 2 were excel-
lent or good and both these were relatively mild
cases. There were 14 (87%) fair or poor results.
In the remaining cases due to other causes, 7
(87%) were excellent or good. The one poor result
was in a foot with a congenital equinovarus defor-
mity.
Discussion
In our experience the operation of transfer of half
of the calcaneal tendon to the dorsum of the foot
gives good results in a wide variety of conditions.
The main indications are:
1. An equinus deformity due to paralysis. A varus
or valgus deformity may also be present.
2. The ability to walk without using an orthosis.
3. A strong calf muscle.
59
4. Absence of bony deformities which might pre-
vent correction.
Additional operative procedures can be done at
the same time, but if bony operations are neces-
sary they should be carried out at a previous
stage. Overlengthening of the calcaneal tendon
must be avoided.
Although the operation was first used in pa-
tients with poliomyelitis, our results in this group
were disappointing, except when the paralysis
was confined to below the knee and there were no
gross deformities. The results were especially
good in patients with spastic equinus. If there is a
primary paresis with absence or weakness of dor-
siflexion due to insufficient contraction of the
muscles producing that movement, the transfer
acts as a dynamic tenodesis which stabilises the
foot in a neutral position. In secondary paresis,
where there is hyperactivity of the antagonists op-
posing dorsiflexion [1], the transfer weakens the
calf and the dynamic tenodesis prevents recur-
rence of the deformity in spite of persistent spastic-
ity, and so gives an excellent result.
We are now carrying out further studies using
electromyography to determine the behaviour of
the transfer during walking.
References
1. Bastos-Mora F, Gonzales Aguilar J (1965) Cirufga de las
Paralisis. Ed Jims, Barcelona, pp 11-18
2. Caldwell GD (1958) Correction of Paralytic Foot-drop by
Hemigastrosoleus Transplant. Clin Orthop 11:81-84
3. Clippelle H de (1973) H6mitransplantation du tendon
d'Achille chez un myopathique. Acta Orthop Belg 39:
734-737
4. Fernandez-Palazzi F, Guerra-Mas JB, Damas A (1974)
Hemitransplante du Aquiles en el Tratiemento Pie Equino
Espastico. Rev Soc Med Quir 9 : 3 3 - 4 1
5. Jolson (1977) Split Triceps Transfer for Recurrent Equinus.
In: McLaurin (ed) Meningomyelocoele pp 427-436. Grune
& Stratton, New York
6. Palazzi AS, Madrigal JJ, Xicoy J, Palazzi-Coll (1966) Pie
Paralytico. Rev Orthop Traumatol (Iberica) 10:66-67
7. Sharrard WJW (1967) Paralytic Deformity of the Lower
Limb. J Bone Joint Surg 49-B: 731
8. Sharrard WJW (1979) Paediatric Orthopaedics and Frac-
tures. (2rid Ed). Blackwell Scientific Publications, pp
1154-1155