ANSWERS TO THE REVIEWERS’ REPORTS
Reviewer 1
The cohort of the study consisted of 48 consecutive ambulant or potentially
ambulant patients with spastic paralysis due to cerebral palsy. The majority of
the patients were hemiplegic and diplegic, while only 4 were tetraplegic with
limited ambulation. One of our prerequisite for split tibialis tendon transfers
was the ability of the patients for walking or the potential of standing and
ambulation, as it is unnecessary to restore the muscle balance of feet in nonambulatory patients. In these cases, the deformity can be corrected in a later
stage by performing bone surgery.
The underlying cause of the foot deformity in both groups were the cerebral
palsy, which is a non-progressive neurological condition, justifying thus better
final results than any other progressive one.
Reviewer 2
It was referred that no revisions needed.
Reviewer 3
Major
In the contrary, we mentioned that although the gait analysis and the
dynamic EMG are of a great importance, they are not available in every
Institution. It is suggested not only from us but from the recent literature as
well the use of these tools for diagnostic purposes. For the completion of our
study this was not available.
The overactivity of PT causes not only varus but equinus hind-foot deformity
as well, and the cause of the deformity cannot be clinically identified in some
cases, especially when Achilles shortening co-exists. Under these
circumstances, we can intraoperatively identify the percentage of the equinus
due to Achilles shortening and/or to posterior tibial tendon overactivity.
It is corrected through the whole text that one of the inclusion criteria is the
patients to be ambulant or potentially ambulant.
The equinus position of the hindfoot should be addressed if it is >5°.
The plantar soft tissue release is the Steindler procedure (open release of the
plantar aponeurosis+release of the plantar muscles from their insertion to the
calcaneus).
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We used tables to indicate the results as a percentage according to the
involvement, the supplementary operations performed concomitant with the
main operation (SPLATT) and supplementary operations performed
concomitant and after the main operation (SPOTT). Evaluation of the results
was carried out using the clinical criteria of Hoffer et al in group one and Kling
and Kaufer in group two.
All figures have been re-arranged in a more suitable way so as to be clearer
to the reader.
Minor
All the corrections concerning the English language were addressed.
Additionally:
Line 19: all the deformities were flexible as mentioned concerning the
inclusion criteria
Line 33: the muscle-tendon unit is contracted
Line 40: index operation (main procedure)
Line 58: spasticity of the gastrocnemius-soleus complex which turns into
tightness after a long period of time.
Line 83: a sliding lengthening of the Achilles (Hoke procedure) was
performed.
Reviewer 4
The aim of the study has not been expressed properly as our goal was “to
identify the causative muscle producing the deformity and apply the most
suitable technique”, as the cause of the deformity was the cerebral palsy, a
non-progressive neurological condition. As two different clinical assessments
of outcome between the two groups have been used, our intention was not to
compare against each other, but to identify the muscle causing the deformity
and performing the appropriate technique as the deformity can be clinically
unidentifiable in some cases, when Achilles shortening co-exists producing
foot equinus.
We performed the Hoke procedure (sliding technique) for the Achilles
lengthening in 18 feet.
The cavus component was presented in feet which underwent supplementary
operations performed concomitant with the index operation. The two major
additional operations that have been performed were: the plantar soft tissue
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release, the most common out of these procedures, as it lengthens the
shortened base of the foot, and its contribution to the successful outcome for
the correction of the cavus component cannot be overemphasized, and the
the extensor tendons transfer to the metatarsals which aimed to improve the
metatarsophalangeal dysfunction, to enhance ankle dorsiflexion and in
association with the transcutaneous flexor tenotomies in several toes to
correct the clawing. In complex deformities, other supplementary procedures
may be required to achieve the best possible outcome.
It could be argued that the validity and reliability of our results may have
been affected by the assessors used being closely involved with the design of
the study and measurement of outcomes, thus allowing for a possible
experimenter bias. However, the patients were seen by two independent
orthopaedic surgeons, and the range of objective and subjective outcome
data used led us to conclude that there was sufficient triangulation for the
results to be seen as reliable.
Additional corrections by authors
1. The abbreviations for split anterior and posterior tibial tendons have
been corrected to SPLATT and SPOTT. The purpose of doing split
tendon transfers instead of whole transfers in children with cerebral
palsy has been included to the discussion.
2. It was clarified though the text according to the inclusion criteria that
the children should be ambulators or potentially ambulators. Patient’s
status in Fig 1c was potentially ambulatory becoming full ambulatory
postoperatively. We divided the study groups into those with more
prominent forefoot and midfoot inversion (group I) and those with
more prominent hindfoot varus (group II) and proposed the SATT for
group I and the SPTT for group II. Patient in Figs 1d, 2d was an
isolated forefoot and midfoot inversion and was treated by SPOTT.
3. The split lateral half of the tendon was passed into the holes made in
the cuboid and sutured either to itself under moderate tension
whenever there was sufficient length, or we performed the technique
of anchoring the stump (pull- out wire, suturing to the periosteum etc).
See surgical procedure part.
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