title: The split anterior tibialis tendon transfer procedure for spastic equinovarus foot in children with cerebral palsy: results and factors associated with a failed outcome.
abstract: OBJECTIVE
  The aims of the study were to evaluate the outcomes and predictive factors of the split anterior tibialis tendon transfer (SPLATT) procedure for the treatment of the spastic equinovarus deformity in children with cerebral palsy (CCP).
  
  
  METHODS
  Forty-five ambulatory CCP with 68 equinovarus feet, positive for the flexor withdrawal reflex test, aged 8.1 ± 2.5 (range four to 15) years were enrolled. All feet underwent a soft tissue release procedure combined with the SPLATT procedure and were followed for at least 12 months after surgery. The functional outcome was rated using the criteria of Kling and co-workers. Pre-treatment gross motor functional classification system (GMFCS) levels were compared to the patients' latest evaluations. Factors associated with outcomes and success rate were assessed.
  
  
  RESULTS
  At an average follow-up of 5.5 ± 3.3 (range 1.1-16) years, feet were rated as excellent in 48 cases (70 %), good in ten (15 %) and poor in ten (15 %), respectively. Thirty-four CCP showed an improvement for the GMFCS level, P < 0.001. The factor that could predict a poor outcome was the pre-treatment GMFCS levels 3-4 with an odds ratio (95 % CI) of 4.92 (0.96-25.2), P = 0.03. The ten years success rate of the SPLATT procedure between CCP with GMFCS levels 1-2 and levels 3-4 were not different with a mean ± SD (95 % CI) of 0.85 ± 0.1 (0.5-0.96) versus 0.6 ± 0.1 (0.3-0.8), P = 0.08, respectively.
  
  
  CONCLUSIONS
  The SPLATT procedure provides a balanced function of the foot, thus improving the ambulatory ability in CCP and should be integrated into the surgical plan. Pre-treatment GMFCS levels 3-4 predicted unfavourable outcomes and should be addressed during pre-operative parental counselling.
authors.affiliation: Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand, Noppachart.L@chula.ac.th.
authors.forename: Noppachart
authors.initials: N
authors.lastname: Limpaphayom
authors.forename: Bancha
authors.initials: B
authors.lastname: Chantarasongsuk
authors.forename: Phatcharapa
authors.initials: P
authors.lastname: Osateerakun
authors.forename: Pairatch
authors.initials: P
authors.lastname: Prasongchin
mesh_terms: D000293:Adolescent; D002547:Cerebral Palsy / Q000150:complications*; D002648:Child; D002675:Child, Preschool; D003025:Clubfoot / Q000150:complications* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D009128:Muscle Spasticity; D013709:Tendon Transfer / Q000379:methods*; D016896:Treatment Outcome