Managing complex foot deformities in paraplegia: Outcomes of intramedullary hindfoot arthrodesis for spastic pes cavovarus; A case series review

<h2>Abstract</h2><h3>Background</h3> Patients with spinal cord injury (SCI), particularly those with paraplegia, often develop rigid foot deformities such as spastic pes cavovarus due to unopposed muscle activity and chronic spasticity. These deformities compromise seating alignment, hinder passive standing programs, and significantly increase the risk of pressure ulcers (PUs), especially at the heel, lateral border, first metatarsal head, and lateral malleolus. Conservative treatments often fail in severe, fixed deformities, necessitating surgical intervention. This study aimed to evaluate the clinical and radiographic outcomes of hindfoot arthrodesis using intramedullary nail (IMN) fixation in paraplegic patients with spastic foot deformities, focusing on fusion rates, PU recurrence, and improvements in wheelchair positioning. <h3>Methods</h3> This retrospective case series included eight paraplegic patients (mean age: 34 years) with fixed pes cavovarus deformities treated between 2015 and 2019. All underwent percutaneous soft tissue release and open hindfoot joint preparation, followed by IMN fixation using a hindfoot nail. Radiographic fusion was assessed at 3, 6, and 9 months via standard radiographs and selected CT scans. Clinical follow-up lasted at least 12 months. <h3>Results</h3> Radiographic fusion was achieved in 75% of cases. All patients showed clinical improvement in seating alignment and tolerance to gravity-loading protocols. Two patients had asymptomatic non-union. Postoperative complications included two superficial infections, one new PU, and two cases of symptomatic screw protrusion requiring hardware removal. <h3>Conclusion</h3> Hindfoot arthrodesis using IMN offers a promising surgical option for SCI patients with rigid foot deformities. It enables plantigrade alignment, supports pressure redistribution, and improves functional seating. Despite a small sample size, the outcomes justify further prospective studies to confirm its role in this complex, underserved population. <h3>Level of evidence</h3> 4