Ultrasound (US) measurement of the distance between the Achilles tendon and the posterior tibial neurovascular bundle in equinus infantile deformity

OBJECTIVE

To study the distance between the Achilles tendon and the posterior tibial neurovascular bundle via ultrasound (US) - Doppler, with the goal of preventing neurovascular bundle injuries.

METHODS

We studied 36 feet with equinus deformity (18 cases on the right and left side) in children with a mean age of 20.9 months. The distance between the Achilles tendon and the posterior tibial artery was intraoperatively measured using linear US at 10 MHz with Doppler. The measurement was made 1 cm proximal to the calcaneus insertion of the Achilles, where we planned to perform the tenotomy. The patient's weight and height were also recorded. Kolmogorov-Smirnov, t test, and Pearson correlation analyses were applied. Statistical significance was defined as p < 0.05.

RESULTS

Mean distance between Achilles tendon and posterior neurovascular tibial bundle was 7.3 mm, and no differences between sexes or sides were observed. The distance was significantly correlated with weight (r = 0.54, p = 0.01) but not height or age.

CONCLUSIONS

The distance between the Achilles tendon and the tibialis posterior neurovascular bundle is small, and there is a risk of surgical injury during tenotomy of the Achilles tendon.

Relationship between ultrasonographic, electromyographic, and clinical parameters in adult stroke patients with spastic equinus: an observational study

OBJECTIVE

To find more accurate indices that could affect decisions in spasticity treatment by investigating the relation between ultrasonographic, electromyographic, and clinical parameters of the gastrocnemius muscle in adults with spastic equinus after stroke.

DESIGN

Observational study.

SETTING

University hospitals.

PARTICIPANTS

Chronic patients with stroke with spastic equinus (N=43).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Ultrasonographic features were spastic gastrocnemius muscle echo intensity, muscle thickness, and posterior pennation angle of the gastrocnemius medialis (GM) and gastrocnemius lateralis (GL) in both legs. Electromyographic evaluation included compound muscle action potentials (CMAPs) recorded from the GM and GL of both legs. Clinical assessment of the spastic gastrocnemius muscle was performed with the Modified Ashworth Scale (MAS) and by measuring ankle dorsiflexion passive range of motion (PROM).

RESULTS

Spastic muscle echo intensity was inversely associated with proximal (GM and GL: P=.002) and distal (GM and GL: P=.001) muscle thickness, pennation angle (GM: P< .001; GL: P=.01), CMAP (GM: P=.014; GL: P=.026), and ankle PROM (GM: P=.038; GL: P=.024). The pennation angle was directly associated with the proximal (GM and GL: P< .001) and distal (GM: P=.001; GL: P< .001) muscle thickness of the spastic gastrocnemius muscle. The MAS score was directly associated with muscle echo intensity (GM: P=.039; GL: P=.027) and inversely related to the pennation angle (GM and GL: P=.001) and proximal (GM: P=.016; GL: P=.009) and distal (GL: P=.006) muscle thickness of the spastic gastrocnemius.

CONCLUSIONS

Increased spastic muscle echo intensity was associated with reduced muscle thickness, posterior pennation angle, and CMAP amplitude in the gastrocnemius muscle. Building on previous evidence that these instrumental features are related to botulinum toxin response, these new findings may usefully inform spasticity treatment decisions.

Deep calf cavernous haemangioma in a 10 year- old girl: a case report

Haemangiomas are abnormal proliferation of blood vessels in any vascularised tissue. They can be capillary or cavernous varieties. Cavernous are either of cutaneous or deep types. Cavernous when compared with the capillary haemangioma is rare. Rarer still is the deep type of cavernous haemangioma. This is a report of a 10 year old Nigerian girl who presented with a right posterior leg swelling of 8 year duration, size initially was that of a peanut but increased to fill the entire calf region causing pain to the patient as well as cosmetic and anxiety concern to the parents. No preceding history of trauma, no associated systematic symptoms. She had exploratory laparatomy at 1 year of age at a private hospital for an abdominal mass which was excised. Pre-operative plain radiograph, Magnetic Resonance Imaging(MRI), Abdominopelvic ultrasound scan (USS) were done, fine needle aspiration cytology (FNAC) though done was not helpful. Histo-pathology result of excised leg mass confirmed diagnosis; there was a free margin of excision. Post-operatively, clinical improvement was marked.

New technique of arthroscopic triple arthrodesis

Triple arthrodesis is a common procedure in foot and ankle surgery. It has a significant role in treating hind foot osteoarthrosis and deformity. We describe a new arthroscopic approach of triple arthrodesis. Through carefully planned portal placement of midtarsal joint arthroscopy, together with subtalar arthroscopy, we can denude articular cartilage of the 3 joints with minimal resection of subchondral bone. The 3 joints are put into the desired position and fixed with cannulated screws. This has the potential advantage of minimal bone removal and better fusion surface preparation, especially of the talonavicular joint.

Achilles tendon lengthening for ankle equinus deformity in hemophiliacs: 23 patients followed for 1-24 years

BACKGROUND

Bleeding in the calf or ankle joint may lead to ankle equinus deformity, particularly in childhood and during adolescence. We assessed the long-term functional and radiographic results after Achilles tendon lengthening for ankle equinus deformity in hemophiliacs.

PATIENTS AND METHODS

Between 1975 and 1986, 30 hemophilic patients with pes equinus were surgically managed by Achilles tendon lengthening. Of these, 23 were followed up prospectively twice a year for an average of 13 (1-24) years. The mean age at operation was 29 (12-46) years. The clinical results were documented according to the score of the Advisory Committee of the World Federation of Hemophilia (WFH), while radio-graphs were evaluated using the Pettersson score. On average, preoperative ankle equinus deformity was 21 (5-55) degrees. Mean range of motion was 21 (5-42) degrees prior to surgery.

RESULTS

At the first postoperative examination 1 year after surgery, 21/23 cases were improved, and 9/21 reached dorsiflexion to at least neutral position. At the last follow-up, ankle equinus deformity was 10 (4-20) degrees on average. 20/23 patients still showed significant improvement compared to their condition before surgery. 7 patients still had complete correction of the equinus deformity, while mean range of motion decreased constantly over the observation period. The clinical score was significantly improved 1 year after surgery and diminished only slightly afterwards. Radio-graphic outcome deteriorated, with scores rising from 4.3 (1-10) points preoperatively to 7.3 (3-12) points at last follow-up.

INTERPRETATION

Most patients treated for hemophilic pes equinus by Achilles tendon lengthening experienced long-term benefit concerning the equinus deformity, but gradually lost overall movement of the ankle joint. Progression of the ankle arthropathy cannot be hindered.

Extra-articular subtalar arthrodesis

Of 23 children (35 feet) with cerebral palsy who had undergone a Grice extra-articular subtalar arthrodesis for a valgus hindfoot between 1976 and 1981, we reviewed 17 (26 feet), at a mean of 20 years (17 years 3 months to 22 years 4 months) after operation. Seven were quadriplegic, eight spastic diplegic, and two hemiplegic. They were all able to walk at the time of operation.

Thirteen patients (20 feet) were pleased with the Grice procedure, 13 had no pain and 15 (23 feet) were still able to walk. The clinical results were satisfactory for most feet. Radiography showed that the results had been maintained over time but 14 feet developed a mean ankle valgus of 11° (6 to 18) with a compensatory hindfoot varus in 12 feet. No deformity of the talus or arthritis of adjacent joints was noted.

The Grice procedure gives good long-term results in children with cerebral palsy.

Ilizarov treatment for equinoplanovalgus foot deformity caused by melorheostosis

Melorheostosis often is disabling because of progressive contracture of the joint and soft tissue involved. Operative intervention often is hazardous and patients also have recurrences. A 14-year, 2-month-old boy, who presented with a recurrent equinoplanovalgus deformity of the right foot caused by melorheostosis, was treated successfully using the Ilizarov technique, including distraction osteotomy in the calcaneus. The patient had a painless, plantigrade, and functional foot at age 18 years.

Early mobilization after sliding and Z-lengthening of heel cord: a preliminary experimental study in rabbits

Sliding lengthening and Z-lengthening techniques are widely used in heel cord lengthening. Even though most surgeons performing these procedures apply a short leg cast after surgery, their postoperative immobilization intervals vary from 3 to 7 weeks. Nather et al. showed that there was no need for immobilization after the musculotendinous lengthening of long, deep flexor tendons. In the present study, we aimed to show the healing process of heel cords lengthened by sliding and Z-plasty lengthening in rabbits that did not undergo any postoperative immobilization. We performed sliding lengthening in the right heel cords of the rabbits and Z-lengthening in the left heel cords. We compared these two techniques radiographically, biomechanically, and histopathologically. Even though the biomechanical study showed superior results in the sliding lengthening group on the 7th day, elongation of the tendons at both sites was seen radiographically. There was no statistically significant difference between the sites according to the biomechanical study done on the 28th day. We concluded that the ankle should be immobilized in the early healing phase and that both types of lengthening gain a similar level of strength by the 4th week.

[Corrective soft tissue interventions for equinovarus deformity. Foot deformities after tibial compartment syndrome]

Sixty-three patients with rigid equinovarus contractures of the foot following ischemic episodes in the lower leg were treated at our institute from 1983 to 1994 by lengthening the Achilles tendon and the tendon of the m.tibialis posterior, release of the tendons of the m.flexor digitorum longus and the m.flexor hallucis longus and release of the dorsal capsule of the ankle joint. Patients with an equinus deformity greater than 20 degrees, with an additional hind foot varus deformity of more than 5 degrees and/or malrotation of the midfoot were not eligible for this procedure. The initial equinus deformity ranged from 7 degrees to 20 degrees (mean 14 degrees). The clinical and radiological results of 41 patients were evaluated retrospectively with a minimum follow-up of 1 year (mean 3.4 years). The overall results were evaluated according to a modified score of Angus and Cowell. Results were good in 60.9%, fair in 29.3% and poor in 9.8%. The range of motion of the ankle joint and the subtalar and midtarsal joints could not be improved. Postoperative complications were observed in 8 patients, one intraoperative lesion of the posterior tibial artery occurred, one avulsion fracture of the anterior tibial metaphysis and one compression syndrome of the tibial nerve. One patient had an initially incomplete correction with a remaining equinus deformity of 10 degrees, and two recurrences of the foot deformity after initially correct position were observed. Furthermore, two hematomas and two soft-tissue infections required surgical revision. These complications may have been due to the preoperatively scarred soft tissue at the medial aspect of the hind foot and a residual postoperative soft-tissue defect after the correction of the foot deformity had been achieved. In conclusion, the technique described is effective in correcting mild pes equinovarus deformities after ischemic episodes in the lower leg. If the pes equinus deformity is greater than 20 degrees, corrective osteotomies of the hind foot should be performed instead.