Bouchard Marc Daniel, Pow Cameron, Polemidiotis Mark, Slawaska-Eng David, Alahmari Mousa Saeed, Kishta Waleed
Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.
JBJS Rev. 2025 Jun 20;13(6). doi: e25.00064. eCollection 2025 Jun 1.
Cerebral palsy (CP) is the most common motor disability of childhood, predominantly characterized by spasticity. A frequent complication of spastic CP is equinovarus deformity, resulting in pain, instability, and altered gait, significantly affecting ambulation. Surgical intervention, particularly the split posterior tibialis tendon transfer (SPOTT), is often required to correct deformity when conservative management fails. However, the variability in outcomes and recurrence rates across different patient subtypes and surgical techniques remains unclear. This systematic review aimed to evaluate the recurrence rate of equinovarus deformity in children with CP after SPOTT, with a focus on factors such as age, CP subtype, and functional status.
A systematic search of MEDLINE, Embase, and Emcare databases was performed to identify observational studies reporting recurrence rates after SPOTT in pediatric patients with CP (aged ≤18 years). Studies with short follow-up periods (<12 months), non-English articles, conference abstracts, and those involving concomitant bony procedures were excluded. Statistical analyses used random-effects meta-analysis models to calculate pooled recurrence rates. All statistical analyses were performed, and forest plots were generated using R (version 4.3.2).
Nine studies (325 patients, 366 feet) met the inclusion criteria. The mean age at surgery was 10.35 years, with a mean follow-up duration of 76.18 months. The overall pooled recurrence rate of equinovarus deformity after SPOTT was 11.4% (95% confidence interval 5.0-17.8), with substantial heterogeneity (I2 = 71.9%). Subgroup analysis revealed higher failure rates among nonambulatory patients with quadriplegic CP (47.6%) compared with ambulatory hemiplegic patients (6.6%). The optimal age window for SPOTT seemed to be between 6 and 10 years as younger patients demonstrated increased risks of valgus deformity, whereas older patients had higher recurrence rates. Variations in surgical techniques, including interosseous membrane versus circumtibial routing, were identified as potential sources of heterogeneity.
SPOTT seems to be an effective intervention for correcting equinovarus deformity in ambulatory patients with CP, particularly those with hemiplegia or diplegia. However, nonambulatory and quadriplegic patients are at higher risk of recurrence, warranting careful patient selection. These conclusions should be interpreted with caution because of substantial study heterogeneity and the variability in surgical techniques reported. Further high-quality studies with standardized reporting and direct comparisons between surgical techniques are necessary to optimize outcomes and inform clinical practice.
Therapeutic Level IV, systematic review. See Instructions for Authors for a complete description of levels of evidence.
脑瘫（CP）是儿童期最常见的运动障碍，主要特征为痉挛。痉挛型脑瘫的常见并发症是马蹄内翻畸形，会导致疼痛、步态不稳和步态改变，严重影响行走能力。当保守治疗无效时，通常需要手术干预，尤其是胫后肌腱劈开转移术（SPOTT）来纠正畸形。然而，不同患者亚型和手术技术的疗效及复发率差异尚不清楚。本系统评价旨在评估SPOTT术后脑瘫患儿马蹄内翻畸形的复发率，重点关注年龄、脑瘫亚型和功能状态等因素。
对MEDLINE、Embase和Emcare数据库进行系统检索，以确定报告CP患儿（年龄≤18岁）SPOTT术后复发率的观察性研究。排除随访期短（<12个月）的研究、非英文文章、会议摘要以及涉及同期骨手术的研究。统计分析采用随机效应荟萃分析模型计算合并复发率。所有统计分析均进行，并使用R（版本4.3.2）生成森林图。
9项研究（325例患者，366只脚）符合纳入标准。手术时的平均年龄为10.35岁，平均随访时间为76.18个月。SPOTT术后马蹄内翻畸形的总体合并复发率为11.4%（95%置信区间5.0 - 17.8），存在显著异质性（I2 = 71.9%）。亚组分析显示，非行走型四肢瘫患儿的失败率（47.6%）高于行走型偏瘫患儿（6.6%）。SPOTT的最佳年龄窗口似乎在6至10岁之间，因为年龄较小的患者外翻畸形风险增加，而年龄较大的患者复发率较高。手术技术的差异，包括骨间膜与绕胫骨路径，被确定为潜在的异质性来源。
SPOTT似乎是纠正行走型脑瘫患者，尤其是偏瘫或双瘫患者马蹄内翻畸形的有效干预措施。然而，非行走型和四肢瘫患者的复发风险较高，需要谨慎选择患者。由于研究存在显著异质性以及报告的手术技术存在差异，这些结论应谨慎解读。需要进一步开展高质量研究，采用标准化报告并对手术技术进行直接比较，以优化治疗效果并为临床实践提供参考。
治疗性四级，系统评价。有关证据级别的完整描述，请参阅作者指南。
