Feet

Foot deformities are fairly common in children with spina bifida. In fact, it is felt that almost 90% have some abnormality. Foot management is based on developing a plantar-grade foot and to protect vulnerable soft tissues.

Serial casting is often not effective, and surgical intervention is often required. Timing for surgery is before age 2 years. Complex tendon releases and bony interventions are done. Salvage procedures include tri­ple arthrodesis and the Grise procedure. Calcaneus deformities occur when the anterior tibialis, toe exten­sors, and peroneal muscles are unopposed. This is seen in those with L4-level spina bifida. The calcaneal defor­mities affect the gait pattern and can cause the skin over the heel to break down. Stretching is not effective, and surgery is indicated. This includes tendon transfers of the anterior tibialis and anterior capsule release. Even though some power can be generated in plantarflexion, this is generally not enough to walk without braces. Equinus deformities generally require an Achilles lengthening procedure. Cavus foot deformity is found in sacral-level injuries. Intrinsic muscle abnormalities lead to high arches and toe clawing. These deformities can cause areas of increased pressure and the risk for skin breakdown. Orthotics and extra-depth shoes may reduce pressure points. Surgery is indicated if these measures fail. Plantar fascial release and multiple bony surgeries can be done. Toe deformities such as hammer toes often require tendon procedures and fascial release.

Clinical Case: JR is an L3 level, which means he has strong hip flexors, quadriceps, and adductors. We know this places him in Group 2 related to risk of spi­nal deformities. This suggests he has a medium risk for developing scoliosis and lordosis. His level places him in a very high risk for hip subluxation/disloca- tion (36%), and we know that he may develop knee contractures. Leg length problems will be based on dislocations. He will not have any foot control and could have congenital foot abnormalities.