Hyperselective Neurectomy versus Tendo-Achilles Lengthening for Pediatric Spastic Equinus: A Comparative Cohort Study.

Abstract

Spastic equinus is a common gait-limiting deformity in children with upper motor neuron disorders, particularly cerebral palsy. Surgical management has traditionally emphasized tendon-lengthening procedures such as tendo-Achilles lengthening (TAL), which correct structural shortening but do not address the neural mechanisms underlying spasticity. Hyperselective neurectomy (HSN) of tibial motor branches has emerged as a targeted approach to reduce focal spastic overactivity. To describe two sequential treatment-era cohorts managed with TAL or HSN for pediatric spastic equinus and to examine whether the observed clinical and reintervention patterns support further prospective evaluation of mechanism-based surgical selection. Retrospective comparative cohort study (Level III). Two sequential treatment eras (2021-2023) from a single surgeon's practice were analyzed. The earlier cohort underwent TAL, whereas the later cohort underwent HSN of tibial motor branches to the gastrocnemius-soleus complex. Treatment selection emphasized clinical differentiation between dynamic and fixed equinus using passive ankle dorsiflexion, clonus assessment, and gait evaluation. Demographic variables, follow-up duration, and need for additional procedures were recorded. Eight patients underwent TAL and ten underwent HSN. Mean age at surgery was 8.1 and 9.5 years, with mean follow-up of 26 and 23 months, respectively. Additional procedures were performed in 2 of 8 patients after TAL and 2 of 10 patients after HSN. Secondary procedures after HSN reflected staged correction of residual contracture. Clinical records documented qualitative reduction in clonus following HSN, but standardized between-group comparison was not possible. These preliminary findings suggest that distinguishing dynamic neural overactivity from fixed contracture may assist surgical selection and sequencing; they do not establish superiority or equivalence between HSN and TAL.