Is there still a place for Achilles tendon lengthening?

Patients with diabetes and ankle equinus are at particularly high risk for forefoot ulceration because of the development of high forefoot pressures. Stiffness in the triceps surae muscles and tendons are thought to be largely responsible for equinus in patients with diabetes and underpins the surgical rationale for Achilles tendon lengthening (ATL) procedures to alleviate this deformity and reduce ulcer risk. The established/traditional surgical approach is the triple hemisection along the length of the Achilles tendon. Although the percutaneous approach has been successful in achieving increases in ankle dorsiflexion >30°, the tendon rupture risk has led to some surgeons looking at alternative approaches. The gastrocnemius aponeurosis may be considered as an alternative because of the Achilles tendon's poor blood supply. ATL procedures are a balance between achieving adequate tendon lengthening and minimizing tendon rupture risk during or after surgery. After ATL surgery, the first 7 days should involve reduced loading and protected range of motion to avoid rupture, after which gradual reintroduction to loading should be encouraged to increase tendon strength. In summary, there is a moderate level of evidence to support surgical intervention for ankle joint equinus in patients with diabetes and forefoot ulceration that is non-responsive to other conservative treatments. Areas of caution for ATL procedures include the risk for overcorrection, tendon rupture and the tendon's poor blood supply. Further prospective randomized control trials are required to confirm the benefits of ATL procedures over conservative care and the most optimal anatomical sites for surgical intervention.

Technique, indications, and results of proximal medial gastrocnemius lengthening

Gastrocnemius proximal lengthening was first performed to correct spasticity in children, and was adapted for the patient with no neuromuscular condition in the late 1990s. Since then, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. The indications for performing this procedure are a clinically demonstrable gastrocnemius contracture that influences a variety of clinical conditions in the forefoot, hindfoot, and ankle. It is a safe and easy procedure that can be performed bilaterally simultaneously, and does not require immobilization of the ankle after surgery.

Biofeedback baropodometry training evaluation: a study with children with equinus foot deformity

The lack of perception in the hindfoot increases the plantar flexion, causing irregular posture due to the foot position, a disability known as equinus foot deformity. A portable device, named baropodometer, that measures the pressure at the forefoot and hindfoot regions was built to help this population in terms of balance and posture correction. Ten hemiparetic teenager volunteers with equinus foot participated in the experiments. The results demonstrated that the proposed device increased the weight-bearing in upright stance in the paretic side, decreasing the weight in the non-paretic side. After 10 experimental sessions, performed along 6 months, the distribution of the pressure in the lower limbs was very similar. The baropodometer facilitates the rehabilitation, by biofeedbacking the pressure of the calcaneus, using the volunteer's audiovisual system. The rehabilitation using the proposed device was able to recover the balance by posture correction, facilitating future gait training of these volunteers.

Equinus foot classification in cerebral palsy: an agreement study between clinical and gait analysis assessment

BACKGROUND

Excessive ankle plantar flexion (equinus foot) is a common problem in cerebral palsy (CP) and several treatment options can be considered depending on the equinus type. Few attempts have been made to classify different forms of equinus foot for specific treatment.

AIM

This study is aimed at defining equinus foot types in CP patients according to the Ferrari classification, integrating clinical and instrumental assessments. The hypothesis is that clinical differentiation of equinus foot can be evidenced by recurrent anomalies identifiable through gait analysis (GA), which can make the assessment, usually based only on clinician semeiotics, more objective.

DESIGN

Clinical and instrumental assessments were performed separately by a senior CP physiatrist and a senior GA physiatrist, the latter was blind to the clinical diagnosis of equinus type.

SETTING

Outpatients

POPULATION

Twenty patients, 16 diplegics and 4 hemiplegics (mean age 11 years, SD 4 years 11 months).

METHODS

Clinical assessment by means of Modified Ashworth Scale, Gross Motor Function Measure (GMFM), Observational Gait Analysis (OGA), and measurement of lower limb muscle strength by dynamometer were used to classify the equinus type. Gait analysis assessed the kinematics and EMG of affected lower limbs.

RESULTS

Ten different equinus types were identified. Since various forms of equinus can be present in the same patient, we were able to classify a total of 61 types of equinus in 36 feet. Substantial agreement was found between Clinical and Gait Analysis equinus assignment matched in 50 out of 61 types (Index of agreement with Fleiss' Kappa 79.3 % ). In some case only Gait Analysis was able to identify the equinus type, while in others it did not confirm clinical assignment.

CONCLUSION

Gait analysis is able to distinguish different equinus types according to Ferrari classification, making the clinical decision less arbitrary.

CLINICAL REHABILITATION IMPACT

Correct objective diagnosis of equinus foot in CP patients is of paramount importance when choosing suitable rehabilitative interventions.

Gait recovery in a distal spinal muscular atrophy patient wearing a patellar tendon-bearing orthosis and orthopaedic shoes

OBJECTIVE

To illustrate that a patient with distal spinal muscular atrophy can recover gait with a combination of orthoses and orthopaedic shoes.

SUBJECT

A 28-year-old man with distal spinal muscular atrophy affecting only the distal muscles of the lower limbs. Clinical examination showed a bilateral pes cavus with a varus and a 90 degrees equinus of the ankle joint.

METHODS

The patient was fitted with orthopaedic shoes and a patellar tendon-bearing orthosis. In order to assess the clinical effects of this fitting, a complete physical examination was performed and the patient's temporo-spatial gait parameters were assessed quantitatively using gait analysis tools (Gaitrite) both prior to treatment and after one month.

RESULTS

Before the fitting, the patient was not able to walk alone or to maintain an upright position and he suffered from foot pain. One month after the fitting was applied, the patient was able to walk alone and to maintain an upright position for 1 hour. His pain disappeared. Quantified study of the patient's gait parameters shows that the temporo-spatial parameters are close to normal with fitting.

CONCLUSION

Clinical and quantitative data both confirm the subjective improvements reported by the patient.

DOES FASCICULAR NEUROTOMY HAVE LONG-LASTING EFFECTS?

OBJECTIVE

To determine whether fascicular neurotomy has long-lasting effects on spasticity.

DESIGN

We present 4 clinical cases and a critical analysis of the literature.

PATIENTS

This is a retrospective study on 4 patients referred to our department for spastic equinovarus foot deformity. For all 4, neurotomy was successful not long after surgery, but spasticity reappeared after a few months.

METHODS

We compared our results with those in the PubMed database.

RESULTS

Most publications acknowledge the immediate effectiveness of this surgery, but do not study the long-term effects of neurotomy. No publication proved long-lasting effects of neurotomy for spastic equinovarus foot deformity. The only long-term follow-up with a sufficient population is the one of Berard et al. who reported 61% recurrence.

CONCLUSION

There is no study showing that tibial nerve neurotomy has long-lasting effects. The 4 cases reported are an illustration that recurrence of spasticity may occur after neurotomy. These findings have to be taken into account for treatment decision-making and for provision of information to patients.

Spastic equinus foot: multicenter study of the long-term results of tibial neurotomy

OBJECTIVE

Tibial neurotomy is a surgical technique widely used for the treatment of spastic equinus foot, but it has rarely been evaluated. The primary objective of this prospective study was to provide an objective quantification of the long-term results of tibial neurotomy.

METHODS

This multicenter prospective study was conducted from 1999 to 2003. Fifty-five patients with spastic equinus foot were treated in five neurosurgical centers. Preoperative and postoperative clinical evaluation comprised description of the foot deformity, study of stretch reflexes, evaluation of the repercussions of the deformity, and gait analysis. Selective neurotomy was performed in all patients.

RESULTS

No postoperative complications were observed. The mean postoperative follow-up was 10 months. Tibial neurotomy improved the appearance of the foot (equinus and varus deformities, claw toes); the equinus score decreased from 1.54 to 0.273 after the operation. Stretch reflex scores were decreased significantly and for a long term after surgery; the mean triceps surae stretch reflex score decreased from 2.46 to 0.47. The angle of passive dorsiflexion of the ankle increased significantly (from -0.56 degrees to +6.85 degrees). Gait analysis demonstrated a statistically significant increase in the speed of the patient's gait after surgical treatment; the time taken by the patient to walk 10 m at a normal speed in shoes decreased from a mean of 55 seconds to 35.16 seconds. Postoperatively, 92.7% of preoperative objectives had been achieved.

CONCLUSION

Tibial neurotomy ensures long-term functional improvement of patients with spastic equinus foot. It provides a lasting response for these patients compared with other, more transient treatments.

Selective blocks of the motor nerve branches to the soleus and tibialis posterior muscles in the management of the spastic equinovarus foot11No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit on the author(s) or on any organization with which the author(s) is/are associated

OBJECTIVE

To identify the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor nerve blocks in the management of the spastic equinovarus foot.

DESIGN

Descriptive study by computed tomography (CT) scan of 12 hemiplegic legs.

SETTING

Spasticity group at a university hospital.

PARTICIPANTS

Twelve patients with hemiplegia (6 men, 6 women) with spastic equinovarus foot.

INTERVENTION

Three-dimensional location of the motor nerve branches to the soleus and tibialis posterior muscles with CT scan, followed by selective motor branch blocks with anesthetics.

MAIN OUTCOME MEASURES

Vertical, horizontal, and deep coordinates determined by CT scan in relation to anatomic surface landmarks (upper extremity of the fibula and vertical metallic element). Soleus and tibialis posterior spasticity (Ashworth Scale), soleus H-wave maximum (Hmax)/M-wave maximum (Mmax) ratio, and sensory testing before and after the blocks.

RESULTS

The mean coordinates +/- standard deviation for the soleus motor branch were 10+/-5 mm (vertical), 17+/-9 mm (horizontal), and 30+/-4 mm (deep); for the tibialis posterior motor branch they were 45+/-6mm (vertical), 17+/-8mm (horizontal), and 47+/-4 mm (deep). Spasticity and Hmax/Mmax ratio decreased after the blocks, confirming their efficiency. No subjects experienced additional sensory deficit.

CONCLUSION

Our study determined the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor branch blocks and neurolytic procedures. These coordinates allow us to perform selective motor blocks without CT scan.

Recurrence of equinus foot deformity in cerebral palsy patients following surgery: a review

Although equinus deformity in children with cerebral palsy is often corrected with surgery, postsurgical recurrence of the deformity is not uncommon. In order to isolate factors that may be related to its recurrence, 31 studies were evaluated. Data from nine articles indicated that children younger than approximately 7 years of age at the time of surgery had a higher risk of recurrence than children who were older at the time of surgery. Recurrence rates may be understated in studies including less than a minimum of 4-5 years of patient follow-up. Lower recurrence rates are documented in diplegic patients compared with hemiplegic patients, and postoperative casting/splinting is stated, but not documented, to reduce recurrence. One study demonstrated that the use of chemodenervation delayed surgery and by inference theoretically would decrease recurrence after surgical release.

A pilot study to investigate the combined use of botulinum neurotoxin type a and functional electrical stimulation, with physiotherapy, in the treatment of spastic dropped foot in subacute stroke

The objective was to inform sample size calculations for a full randomized controlled trial (RCT). The design included an RCT pilot trial with a 16 week study period, including a 4 week baseline phase. The subjects were adults within 1 year of first stroke, ambulant with a spastic dropped foot. Twenty-one participants were recruited from the stroke services of 4 centers. For intervention all participants received physiotherapy; the treatment group also received botulinum neurotoxin Type A (BoNTA) intramuscular injections to triceps surae (800 U Dysport) and functional electrical stimulation (FES) of the common peroneal nerve to assist walking. The main outcome measure was walking speed. The result was a significant upward trend in median walking speed for both the control (p = 0.02) and treatment groups (nonstimulated p = 0.004, stimulated p = 0.042). Trend lines were different in location (p = 0.04 and p = 0.009, respectively). In conclusion, there is evidence of an additional, beneficial effect of BoNTA and FES. Sufficient information has been gained on the variability of the primary outcome measure to inform sample size calculations for a full RCT to quantify the treatment effect with precision.

[Idiopathic toe walker child. Diagnosis and spontaneous evolution]

AIM OF THE STUDY

To analyse the clinical, the aetiological aspects, the evolution without treatment and the age of correction.

MATERIAL

This history of 69 children admitted between 1973 and 1998 was analysed. Forty-one were reviewed during the growth; only 6 were treated.

RESULTS

The toe walking was most often observed at the beginning of the walk between the age of 12 and 18 months. The first examination was made between 1 and 4 year old. The ankle dorsiflexion was the same, knee extended or flexed for 41 children and different in 23 cases. Identical cases were present in the family in 16 of 33 when the history family was analysed. The neurological examination was normal in 46 cases. None of the 69 children had a neurological impairment. In 32 cases, spontaneous correction occurred between 3 and 8 years: all these cases presented an ankle dorsiflexion over 10 degrees knee extended. The toe walking persisted in two cases at 10 years and in two cases at 12 and 13 years: the dorsiflexion was under 10 degrees, knee extended at initial examination in these cases.

DISCUSSION AND CONCLUSION

It is possible to differentiate the toe walkers with more than 10 degrees of ankle dorsiflexion knee extended where the correction is possible without treatment and the cases with triceps contracture and less than 10 degrees of ankle dorsiflexion where the correction without triceps lengthening is questionnable.

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.

The Baumann procedure for fixed contracture of the gastrosoleus in cerebral palsy. Evaluation of function of the ankle after multilevel surgery

We treated 22 children (28 limbs) with diplegic cerebral palsy who were able to walk by the Baumann procedure for correction of fixed contracture of the gastrosoleus as part of multilevel single-stage surgery to improve gait. The function of the ankle was assessed by clinical examination and gait analysis before and at two years (2.1 to 4.0) after operation. At follow-up the ankle showed an increase in dorsiflexion at initial contact, in single stance and in the swing phase. There was an increase in dorsiflexion at initial push-off without a decrease in the range of movement of the ankle, and a significant improvement in the maximum flexor moment in the ankle in the second half of single stance. There was also a change from abnormal generation of energy in mid-stance to the normal pattern of energy absorption. Positive work during push-off was significantly increased. Lengthening of the gastrocnemius fascia by the Baumann procedure improved the function of the ankle significantly, and did not result in weakening of the triceps surae. We discuss the anatomical and mechanical merits of the procedure.

Toe-walking in children younger than six years with cerebral palsy. The contribution of serial corrective casts

Our aim in this retrospective study was to analyse the value of serial corrective casts in the management of toe-walking in children aged less than six years with cerebral palsy. A total of 20 children (10 hemiplegic and 10 diplegic) had elongation of the triceps surae by serial casting at a mean age of four years and one month. The mean passive dorsiflexion of the foot with the knee in extension was 3 degrees (-10 to +5) and 12 degrees (0 to +15) with the knee in flexion. After removal of the cast passive dorsiflexion was 20 degrees (+10 to +30) with the knee in extension, and 28 (+10 to +35) with the knee in flexion. At a mean follow-up of 3.08 years (2.08 to 4.92), passive dorsiflexion was 9 degrees (-10 to +20) with the knee in extension and 18 degrees (0 to +30) with the knee in flexion. Serial corrective casts are useful for the treatment of equinus in young children as the procedure is simple and the results are at least equal to those of other non-operative techniques. It is a safe alternative to surgical procedures especially in young children. If the equinus recurs operation can be undertaken on a tendon which is not scarred.

Gait assessment of fixed ankle-foot orthoses in children with spastic diplegia

OBJECTIVE

To evaluate the effectiveness of ankle-foot orthoses (AFOs) in spastic diplegic cerebral palsy patients for whom orthoses were indicated to control equinus or pes planovalgus deformities.

DESIGN

A retrospective, cross-sectional assessment was performed on diplegic subjects who had suitable barefoot and AFO gait trials on the same day.

PATIENTS

Thirty-five subjects with a mean age of 8.7 yrs were included. Eighteen wore braces to control equinus and 17 to control pes planovalgus and crouch.

OUTCOME MEASURES

Gait data assessed in all subjects included temporal-distance factors and sagittal kinematics. Force plate data to determine joint moments and powers were obtained in 20. Repeated measures analysis of variance was used to compare across conditions and indications.

RESULTS

The cohort demonstrated increased velocity (10 cm/sec; p < .001), stride length (10 cm; p < .001), and percent single-limb support (1.8%; p < .002) using AFOs compared with barefoot gait. In braces, ankle excursion was reduced (p < .0001), while pelvic, hip, and knee excursions were increased to account for the temporal changes (p < .009). Effects were similar in both indication groups. In neither indication group did the AFO significantly alter knee position in stance. Kinetic analysis showed a reduction of abnormal power burst (p < .05) in early stance and an increase in late stance ankle moment (p < .05) with AFOs. Differences in gait characteristics and bracing effects are shown for both indication groups.

CONCLUSION

Compared with barefoot gait, AFOs enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature plantar flexion and improved progression of foot contact during stance. Effects on proximal joint alignment were not significant.

Managing equinus in a child with cerebral palsy: merits of hinged ankle-foot orthoses

A comparison of hinged versus solid ankle orthoses in a child with moderate spastic diplegia demonstrated that solid ankle braces blocked needed foot and ankle mobility. The loss of movement forced the child to use extraneous movement patterns in order to move the upper body over the foot. These iatrogenically induced deviations were considered reasons for surgery. When ankle and foot mobility were increased by the use of hinged ankle braces, the gait improved and with physical therapy the reasons for surgery were removed. This case study shows that significant biomechanical changes can be achieved by simply switching from solid to articulated or hinged ankle-foot orthoses.

Percutaneous elongation of the Achilles tendon in children with cerebral palsy

From 1987 to 1990, 45 children with cerebral palsy underwent percutaneous elongation of the Achilles tendon (71 ankles); the mean age was 5.7 years. Most suffered from spastic diplegia or hemiplegia. A three-step cut technique was used, the limb immobilised in a long leg fiberglass cast and immediate weightbearing allowed. Follow up was from 2 to 5 years. Satisfactory results were obtained with significant improvement in walking in 89%.