Spasm or contracture of the gastrocnemius muscle is predominantly responsible for the equinus deformity of the foot in cerebral palsy. Its release is therefore logical in the treatment of all cases which do not respond to conservative measures. The authors have demonstrated, by the use of metal markers and radiographic control at operation, that adequate release cannot be achieved by severance of the calcaneal tendon alone, and that in order to ensure relaxation of the gastrocnemius muscle, the operation of choice is gastrocnemius recession by the method of Strayer, coupled with lengthening of the calcaneal tendon to deal with such degree of the deformity as may be attributable to shortening of the soleus. A survey of 100 limbs treated by this method revealed a recurrence rate of equinus of 9% and a degree of calcaneus deformity resulting in inadequate push-off in 3% of cases after an average follow-up period of six years.
J Pediatr Orthop. ;30 (3):240-3 20357589
Development of calcaneal gait without prior triceps surae lengthening: an examination of predictive factors.
Childrens Orthopaedic Center, Childrens Hospital, Los Angeles, CA, USA.
BACKGROUND Although equinus is more common in cerebral palsy (CP), the prevalence of calcaneal gait (CG) has been reported at more than 30% among patients with CP, even in the absence of prior surgical intervention. The goal of this study was to identify patient characteristics predictive of the development of CG in patients without prior triceps surae lengthening. METHODS Gait data were reviewed for 58 participants with bilateral involvement owing to CP (116 limbs) who had 2 gait analysis tests with no triceps surae lengthening between tests. None of the patients exhibited CG at the initial gait study. Patients were grouped according to whether or not they exhibited CG patterns at the second test. Factors potentially predictive of calcaneal gait patterns were compared statistically between groups. RESULTS CG was shown by 24/116 extremities (21%) at the second study. The CG group experienced greater increase in body weight and body mass index between tests (P=0.006 and 0.03 respectively). Passive dorsiflexion range with the knee flexed was significantly greater in the CG group (P=0.008). The CG group also showed a tendency toward greater plantarflexor weakness, although this only approached statistical significance (P=0.08) likely owing to small sample size. Age, CP subtype, time to follow-up, hamstring range, selective motor control, and gross motor functional level were not predictive. CONCLUSIONS Patients who undergo (or have potential to undergo) significant weight gain, and have tendencies toward excessive passive dorsiflexion with the knee flexed may be at risk for development of CG over time. In such patients, treatment regimens should include therapy to maintain or improve plantarflexor strength, and methods to prevent overstretching the plantarflexors. Nonsurgical treatments for triceps surae contractures, such as serial casting, may be preferable, to avoid hastening development of calcaneal crouch gait over time. LEVEL OF EVIDENCE Prognostic study---Level III (case-control).
Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing: a prospective cohort study.
Department of Orthopaedics, University of Geneva Hospitals, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland. firstname.lastname@example.org
We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5 degrees with the knee extended, a Strayer-type gastrocnemius recession was performed. The mean duration of chronic ulceration despite a minimum of six months' conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal. We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.
The gastrocnemius intramuscular aponeurotic recession: a simplified method of gastrocnemius recession.
Kaiser North Bay Consortium Residency Program, Department of Orthopedics and Foot & Ankle urgery, Kaiser Permanente Medical Centers, CA, USA.
High recurrence after calf lengthening with the Ilizarov apparatus for treatment of spastic equinus foot deformity.
Department of Orthopaedics, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria. email@example.com
Both gastrocnemius recession and Achilles tendon lengthening lead to scarring in the calf and have high reported recurrence rates when performed under the age of 8 years. Triceps surae lengthening by external fixation seemed to be a valuable alternative. Twelve calf lengthenings have been performed with an Ilizarov device with a mean correction of 27 degrees. No calcaneal gait was observed, but there was a slow continuous loss of dorsiflexion over the observation period. The Ilizarov technique has a higher recurrence rate than most operative procedures for calf lengthening, but carries virtually no risk in producing calcaneus. The technique cannot be recommended for routine clinical use and may only be an alternative for selected cases.
Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, 1425 South Main St, Walnut Creek, CA 94526, USA. firstname.lastname@example.org
To evaluate morbidity associated with surgical lengthening of the gastrocnemius, medical records were reviewed retrospectively for 126 patients (mean age, 49.7 years; range, 8-78 years) who had undergone open gastrocnemius recession. Ten patients had isolated recession; 116 had gastrocnemius recession with an additional foot or ankle procedure on the ipsilateral limb. During a mean follow-up period of 19 months (range, 6-50 months), all patients were examined for any postoperative complications associated with the recession. Complications were defined as the presence of postoperative infection, wound dehiscence, nerve problems, decreased muscle strength, scar problems, or calcaneus gait (overlengthening). Uncomplicated outcome was defined as absence of all these complications and return to regular activity, both occurring during a follow-up of at least 6 months. Postsurgical complications developed in 9 (6%) of the 126 patients: 6 (4%) had scar problems, 2 (1.33%) had wound dehiscence, 2 (1.33%) had infection, 3 (2%) had nerve problems, and 1 (0.67%) developed complex regional pain syndrome. No patient complained of either a limp or gait disturbance. Neither persistent decrease in muscle strength nor calcaneus gait was seen. These data suggest that the open gastrocnemius recession procedure has low associated morbidity.
One Small Step Gait Laboratory, Guy's Hospital, St Thomas Street, London SE1 9RT, UK. email@example.com
We assessed the architecture of the medial gastrocnemius in nine children (five males, four females; age range 6 to 15 years; mean 10 years 10 months, SD 3 years 6 months) with spastic diplegia by ultrasound imaging before and after a gastrocnemius recession. The children were ambulant (seven independent, one with a posterior walker, one using crutches) before and after surgical intervention. We compared values for fascicle lengths and deep fascicular-aponeurosis angles with those from a group of normally developing children (five males, five females; age range 6 to 11 years; mean 8 years 4 months, SD 1 year 4 months). Despite a variable interval between assessments (from 56 to 610 days), fascicles were shorter (p=0.00226) and the deep fascicular-aponeurosis angle increased (p=0.0152) after intervention. Fascicle lengths of patients were similar to those in the group of normally developing children before surgery. After surgery, fascicles in the group of children with spastic diplegia were shorter than in their normally developing peers (p=0.00109). The gastrocnemius recession procedure alters muscle architecture, though the degree of fascicular shortening varied, with four of the participants in our study losing less than 10% of their original fascicular length at maximum dorsiflexion. Increases in ankle-joint power in walking, observed after surgical intervention in children with spastic diplegia, may be due to a more normal ankle position rather than to improvements in the active mechanical performance of the gastrocnemius.
Rehabilitation Research and Development, Center of Excellence in Limb Loss Prevention and Prosthetic Engineering, Seattle VA Medical Center, WA 98108, USA. firstname.lastname@example.org
To achieve more objective and repeatable measurements of equinus contracture, we developed the equinometer, a device that allows the measurement of ankle range of motion under controlled torque conditions. This study assessed its accuracy across different subjects and examiners. Two examiners used the equinometer to measure the angle of ankle dorsiflexion at 15 N x m torque on five subjects. Accounting for variation in measurements because of subjects, examiners, and placement of device, we used linear mixed-effects models. Accounting for the variation because of subject, different placements of the equinometer within each subject and the adjustment for the effects of examiner and trial sequence, the standard deviation was 0.94 degrees, 95% confidence interval (0.79 degrees, 1.13 degrees). An upper standard deviation of 1.36 degrees is felt to be acceptable for clinical investigation.
Christopher W DiGiovanni, Roderick Kuo, Nirmal Tejwani, Robert Price, Sigvard T Hansen Jr, Joseph Cziernecki, Bruce J Sangeorzan
Department of Orthopaedics, Harborview Medical Center and the Veterans Affairs Medical Center, Seattle, Washington, USA.
BACKGROUND Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed. METHODS This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed). RESULTS With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group. CONCLUSIONS On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present. Clinical Relevance: These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.
Length and force of the gastrocnemius and soleus during gait following tendo Achilles lengthenings in children with equinus.
Motion Analysis Laboratory, Shriners Hospital for Children, Portland, OR, USA. email@example.com
Nine subjects (12 sides) with cerebral palsy who walked in equnius were evaluated prior to and 1 year after surgical tendo Achilles lengthening. Gastrocnemius and soleus length [Gait Posture, 6 (1997) 9] and plantarflexor force [Gait Posture, 6 (1997) 9; J Biomech, 23 (1990) 495] were calculated. The length of the gastrocnemius and soleus increased significantly (P<0.01) following the intervention. Force output of the triceps surae during push-off increased significantly (13.95 N/kg body weight (BW) preop to 30.31 N/kg BW postop; P<0.01). Assessment of the force-length capacity of the triceps surae in candidates for tendo Achilles lengthenings may identify individuals at risk of residual weakness and iatrogenic crouch.
Other papers by authors:
Folic acid use and major congenital malformations in offspring of women with epilepsy: a prospective study from the UK Epilepsy and Pregnancy Register.
J I Morrow, S J Hunt, A J Russell, W H Smithson, L Parsons, I Robertson, R Waddell, B Irwin, P J Morrison, J J Craig
Department of Neurology, Royal Group of Hospitals, Belfast, UK. firstname.lastname@example.org
OBJECTIVE In the general population, folic acid supplementation during pregnancy has been demonstrated to reduce the frequency of neural tube defects (NTDs) and other major congenital malformations (MCMs). It is recommended that women with epilepsy contemplating pregnancy take supplemental folic acid because of the known antifolate effect of some antiepileptic drugs (AEDs). Here the aim was to determine the effectiveness of this practice. METHODS This study is part of a prospective, observational, registration and follow-up study. Suitable cases are women with epilepsy who become pregnant and who are referred before outcome of the pregnancy is known. The main outcome measure is the MCM rate. Outcomes were analysed against folic acid exposure, malformation type and drug group for the most commonly used monotherapy AEDs. RESULTS In 1935 cases reported to have received preconceptual folic acid, 76 MCMs (3.9%; 95% CI 3.1 to 4.9) and eight NTDs (0.4%; 95% CI 0.2 to 0.8) were identified. For 2375 women who were reported to have received folic acid but not until later in the pregnancy (n = 1825) or not at all (n = 550), there were 53 outcomes with an MCM (2.2%; 95% CI 1.7 to 2.9) and eight NTDs (0.34%; 95% CI 0.2 to 0.7). CONCLUSIONS The study supports the view that extrapolation from studies carried out in the general population to groups of women with epilepsy may be questionable. It may be that the increased risk of MCM recorded in this group occurs through mechanisms other than that of folic acid metabolism.
Idiopathic intracranial hypertension; incidence, presenting features and outcome in Northern Ireland (1991-1995).
Department of Neurology, Royal Victoria Hospital, Grosvenor Road, Belfast.
OBJECTIVES To determine the age and sex specific incidence rates, presenting features, and visual outcome of idiopathic intracranial hypertension in Northern Ireland. METHODS A case-note review of all patients with idiopathic intracranial hypertension, diagnosed at the Royal Victoria Hospital, Belfast between 1991 and 1995. RESULTS Forty-two patients were identified corresponding to an average annual incidence rate per 100,000 persons of 0.5 for the total and 0.9 for the female population. The commonest presenting symptoms were headache (84%), transient visual obscurations (61%) and sustained visual loss (34%). Impaired Snellen visual acuity and visual field loss were documented in 21% and 62% of patients respectively at presentation, and in 24% and 39% at last follow-up. One patient suffered deterioration in visual functioning sufficient to interfere with normal daily activities. CONCLUSIONS The age and sex specific incidence rates of IIH in Northern Ireland are lower than have been reported in previous population-based series. Disabling visual loss occurs in a small number of patients despite all interventions.
Department of Neurology, Royal Victoria Hospital, Belfast, UK.
We report the case of a man with an acute cervical cord lesion which was diagnosed after a teleconsultation with a neurologist at a distant neurological centre. We show that the ability to assess patients clinically using real-time videolinks is also of use in detecting those patients who would benefit from specialist neurosurgical intervention, but who might otherwise be denied it because of their location.
Prevalence of the Chiari/hydrosyringomyelia complex in adults with spina bifida: preliminary results.
Clinic for Adults with Spina Bifida and Hydrocephalus, Musgrave Park Hospital, Belfast, Northern Ireland, UK.
AIM To establish the prevalence of Chiari malformations and hydrocephalus (HS) in adults with spina bifida (SB). INTRODUCTION Adults with SB have recently been shown to be at risk from significant deterioration arising from the C/HS complex. Little is known about the prevalence of these malformations in adulthood, their natural history, risk factors for deterioration and optimum management. MATERIALS AND METHODS Patients are recruited from a clinic for adults with SB and hydrocephalus, routinely questioned about recent changes in neurological symptoms and a full neurological examination performed. Functional assessments include: Barthel Index; Nottingham EADL; Nine Hole Peg Test; 10 metre timed walk test. Sagittal T1 and TSE (turbo spin-echo) magnetic resonance images (MRI) of the cranio-cervical junction and spinal cord are obtained using a 1.0-T MRI system with a phased-array surface coil. Scans are reported blindly. RESULTS 76 patients have been assessed, 40 female, 36 male, mean age 27.5 years. Of these, 48 (63.2%) have symptoms +/- signs compatible with C/HS, but only 18 (23.7%) have reported new, potentially relevant, neurological symptoms over the previous 12 months. Of 25 patients undergoing MRI so far, 19 (76%) have had Chiari malformations and 12 (48%) have had HS. None of those with a negative scan have had signs/symptoms suggestive of the C/HS complex but a negative clinical evaluation has been unable to exclude such pathology. CONCLUSIONS These early results suggest that the prevalence of the C/HS complex is high in adults with SB and cannot be predicted by neurological examination alone. Given past experience, the need for continued neurological follow up in a large proportion of the SB population throughout adulthood is likely to be essential.
Vagal nerve stimulation in patients with refractory epilepsy. Effect on seizure frequency, severity and quality of life.
Directorate of Neurosciences, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK.
Vagal nerve stimulation using an NCP (Cyberonics) device has been suggested as a potential treatment for patients with epilepsy that has previously proven refractory. Ten patients in Northern Ireland have had this device implanted and been fully audited pre- and post-operatively. Twelve months post-implantation, five patients have demonstrated a greater than 50% reduction in seizure frequency. A statistical reduction in seizure severity of the ictal phase of the major seizures has also been shown. Improvement in the patients' overall quality of life has, however, not been demonstrated in parallel to seizure reduction.
Department of Neurology, Royal Victoria Hospital, Belfast, Northern Ireland, UK.
Confusion occurring in pituitary apoplexy is well described. We describe a case of pituitary apoplexy associated with confusion, occurring as a result of non-convulsive status epilepticus. Electroencephalography should be performed in pituitary apoplexy associated with confusion if this treatable and potentially serious complication is not to be missed.
Department of Neuroradiology, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK.
Astrocytomas involving the limbic system are usually unilateral in nature. We report a very unusual case where a low-grade astrocytoma originating in the left temporal lobe spread to the right hippocampus through the hippocampal commissure to cause disabling amnesia and seizures. Some improvement in the memory deficit was facilitated by identification of complex partial status epilepticus. EEG should be performed in all patients with lesions of the limbic system and neuropsychological problems if ongoing seizure activity is not to be missed.
Department of Neurology, Royal Victoria Hospital, Belfast BT12 6BA, UK.
Institute of Telemedicine and Telecare, Queen's University of Belfast, UK.
To compare the reliability of neurological examination performed by telemedicine and face to face, a junior doctor examined 23 patients face to face, these examinations being witnessed either by one or by two telemedicine observers using a telemedicine video-link at 384 kbit/s. The gold standard was a face-to-face examination from a panel of six consultant neurologists. Power, deep tendon reflexes, plantar responses, coordination, sensation, eye movements, facial strength, tongue movements, sitting balance and gait were studied. Seventeen patients satisfied the inclusion criteria, and a total of 1,084 matched pairs of observations were made. The reliability of the telemedicine examination ranged from fair to moderate for deep tendon reflexes, coordination and eye movement, to near perfect for plantar responses. Overall, examination by telemedicine compared favourably with face-to-face examination. Telemedicine examination was more sensitive in detecting abnormalities than face-to-face examination for all the neurological tests studied and more specific for all but one (plantar responses). The study showed that neurological examination using telemedicine is at least as good as face-to-face examination performed by a junior doctor.
Department of Neurology, Royal Victoria Hospital, Belfast, Ireland.
Latest similar papers:
Long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery in spastic diplegic cerebral palsy.
Thomas Dreher, Tanja Buccoliero, Sebastian I Wolf, Daniel Heitzmann, Simone Gantz, Frank Braatz, Wolfram Wenz
Department of Orthopaedic and Trauma Surgery, Paediatric Orthopaedics and Foot Surgery, Heidelberg University Clinics, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany. email@example.com
BACKGROUND Equinus of the foot at the ankle is one of the most common deformities in patients with spastic diplegic cerebral palsy, leading to gait disturbances and secondary deformities. During single-event multilevel surgery, equinus is commonly corrected by calf muscle lengthening, such as gastrocnemius-soleus intramuscular aponeurotic recession. Various studies have described satisfactory short-term results after gastrocnemius-soleus intramuscular aponeurotic recession. However, there is no evidence for maintenance of equinus correction because of the small and heterogeneous case series and short follow-up time previously reported. METHODS The present study provides long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery for the treatment of equinus in forty-four patients with spastic diplegia who were able to walk (forty-eight legs had lengthening of the gastrocnemius and thirty-four legs had lengthening of the gastrocnemius and soleus). Standardized three-dimensional gait analysis and clinical examination were done preoperatively and at one year, a mean (and standard deviation) of 3 ± 1 years, and a mean of 9 ± 2 years after surgery. RESULTS Significant improvements in kinematic and kinetic ankle parameters on gait analysis as well as passive dorsiflexion in clinical examination were found one year after surgery. While there was a significant loss of passive dorsiflexion at the time of long-term follow-up, the improvements in gait analysis parameters were maintained. The endurance of gait improvements was accompanied by a persistent increase of dorsiflexor muscle strength without relevant loss of plantar flexor strength. Although it was not significant, there was a tendency for deterioration of gait analysis parameters over the nine years. The analysis of individual patterns showed recurrence of equinus at the ankle in 24% of the legs. Early-onset calcaneal gait was found one year after surgery in seven legs (9%), but without secondary crouch gait, and there was recovery at the time of the long-term follow-up. Late-onset calcaneal gait was seen at the time of long-term follow-up in eight legs (10%), of which four had an accompanying crouch gait. CONCLUSIONS Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to satisfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession.
Case Rep Med. 2010 ;2010 :417806 20339527
Gait Analysis before and after Gastrocnemius Fascia Lengthening for Spastic Equinus Foot Deformity in a 10-Year-Old Diplegic Child.
Manuela Galli, Veronica Cimolin, Giorgio Cesare Santambrogio, Marcello Crivellini, Giorgio Albertini
Bioengineering Department, Politecnico Di Milano, Piazza Leonardo da Vinci 32, 20133 Milano, Italy.
Purpose. This case study quantified kinematic and kinetic effects of gastrocnemius lengthening on gait in a Cerebral Palsy child with equinus foot. Methods. A 10-year-old diplegic child with Cerebral Palsy was evaluated with Gait Analysis (GA) before and after gastrocnemius fascia lengthening, investigating the lower limb joints kinematics and kinetics. Results. Kinematics improved at the level of distal joints, which are directly associated to gastrocnemius, and also at the proximal joint (like hip); improvements were found in ankle kinetics, too. Conclusions. This case study highlighted that GA was effective not only to quantify the results of the treatment but also to help preoperative decision making in dealing with CP child.
Iliopsoas tenotomy at the lesser trochanter versus at the pelvic brim in ambulatory children with cerebral palsy.
Sheba Medical Center, Tel Hashomer, Israel. firstname.lastname@example.org
BACKGROUND Progressive hip flexion deformity is a common problem in ambulatory children with spastic cerebral palsy, causing static and dynamic deformity. The iliopsoas muscle is recognized as a major deforming force in the development of this problem. Many clinicians address this problem by lengthening the iliopsoas, either in an intramuscular location at the pelvic brim or by complete tenotomy at the lesser trochanter. The goal of this study was to compare the outcomes of patients with ambulatory cerebral palsy who had intramuscular lengthening at the pelvic brim to those who underwent complete release of the iliopsoas tendon at the level of the lesser trochanter. METHODS Twenty patients were included in the study, 11 of whom had iliopsoas release at the lesser trochanter (group 1) and 9 of whom had intramuscular lengthening at the pelvic brim (group 2). All patients had physical examinations, plus kinematic and kinetic analyses in our gait laboratory before and 1 year after surgery. RESULTS Hip flexion contracture was decreased significantly only in group 1, although there was a trend of decrease in group 2. There was a significant increase in maximum hip extension in terminal stance and a reciprocal decrease in maximum swing phase hip flexion in group 1, with a similar trend that did not reach significance in group 2. Stride length increased significantly in both groups. There was no significant change in power generation of hip flexion during the swing phase in either group. CONCLUSIONS We found improved static and dynamic parameters of hip extension after iliopsoas lengthening and did not detect any adverse kinematic or kinetic change in hip function after surgery. The improvement was more robust in the group who underwent release at the lesser trochanter. Because there are no adverse effects of iliopsoas release from the lesser trochanter and the improvement in hip extension is greater, this approach should be considered in ambulatory patients with spastic diplegia when a hip flexor weakening procedure is considered. LEVEL OF EVIDENCE Comparative cohort study, level III, case-control study.
Department of Surgery, The Western Pennsylvania Hospital, Pittsburgh, PA 15224, USA. email@example.com
Ankle equinus can result from congenital, traumatic, neurological, and pathological etiologies. Corrective methods have been described in the literature using a combination of soft tissue releases or osseous procedures with reported complications. We present a case report of a patient with a post-traumatic fixed equinus deformity of 28 degrees at maximum dorsiflexion, treated successfully through gradual correction using a modified constrained external fixator. The patient maintained a rectus foot and was able to perform all daily activities at the final follow-up. Fixed equinus deformities can be difficult to manage. Gradual correction with an external fixator is a reasonable treatment option. Level of Clinical Evidence: 4.
Brachioradialis re-routing for the restoration of active supination and correction of forearm pronation deformity in cerebral palsy.
Department of Plastic and Reconstructive Surgery, Section of Hand Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey. firstname.lastname@example.org
A brachioradialis muscle rerouting procedure was used to restore active supination in five children with cerebral palsy and a pronation deformity. Following release and lengthening of the pronator quadratus and pronator teres muscles, respectively, the brachioradialis tendon was divided as a Z plasty and the distal part of the tendon was passed through the interosseous space in a dorsal to palmar direction, and then sutured to its proximal end. The procedure resulted in a gain of 81 degrees of active supination.
Jayme Augusto Bertelli, Marcos Flávio Ghizoni, Thatiana Rodrigues Frasson, Karla Samara Fernandes Borges
University of the South of Santa Catarina, Unisul, Department of Biological and Health Science, CCBS, Praça Getulio Vargas, 322, Florianópolis, SC 88020030, Brazil. email@example.com
Brachial plexus dorsal rhizotomy releases spasticity, improving the functional use of the hand. Grasping and pinch strength are augmented, together with movement speed and dexterity. Even when four dorsal roots have been sectioned, hand sensibility is largely preserved. Movement control is improved and equally advantageous in athetotic patients. Brachial plexus dorsal rhizotomy does not exclude the use of tendon lengthening or transfer procedures, but it is the authors' opinion that orthopedic procedures should be performed after dorsal rhizotomy. Children aged 5-6 years without muscle contractures are the ideal candidates to benefit fully from dorsal rhizotomy.
Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070, USA.
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.
Follow-up of the isolated medial approach to hallux abducto valgus correction without interspace release.
American Board of Podiatric Surgery, USA.
A retrospective radiographic review was performed of 29 patients (37 feet) who underwent an isolated medial approach for correction of hallux abducto valgus deformity from March 1993 to November 1998. Only those patients who had a traditional Austin-type osteotomy with a reducible first metatarsophalangeal joint and flexible first ray were included in the study. The average follow-up period for the entire study group was 18.4 months, with 13 patients (44.83%; 17 feet) having a follow-up period of longer than 2 years. The average decrease in the intermetatarsal angle was 9.89 degrees, and the average decrease in the hallux abductus angle was 14.0 degrees, results that correlated well with those of other studies on correction of hallux abducto valgus. No clinical or radiographic recurrence of hallux abducto valgus was noted throughout the follow-up period. The authors believe that an isolated medial approach to hallux abducto valgus correction without a lateral interspace release yields predictable results when performed in appropriately selected patients.
Spasm or contracture of gastrocnemius causes an equinus deformity of the ankle in both cerebral palsy and hemiplegia. Its release is therefore required in the treatment of those patients who do not respond to conservative measures. The Vulpius procedure is a simple and effective method for the release of gastrocnemius and is particularly indicated when long periods of immobilisation of the foot and ankle are not desirable. We have used this procedure with good results to correct an equinus deformity in 230 adults with a cerebrovascular accident and various associated medical conditions. It is not only effective in cerebral palsy, but should be considered at an early stage in all adult patients with deformity of the ankle and foot in whom spasm of gastrocnemius is the major cause.
University of California, Davis, Department of Orthopaedic Surgery, Sacramento 95817, USA. firstname.lastname@example.org
Gastrocnemius equinus contracture has been suggested as an etiologic factor in mechanical diseases of the foot and ankle and in ulcer formation in the foot. The purpose of this study is to assess the correction in ankle dorsiflexion that can be achieved with a gastrocnemius recession. An isolated gastrocnemius release (Strayer procedure) was performed on 26 legs, in 20 consecutive patients, for clinically significant gastrocnemius equinus contracture. Ankle dorsiflexion was assessed using a validated electrogoniometer. Ankle dorsiflexion was recorded with the knee straight and with the knee bent. Measurements were recorded preoperatively, and immediately postoperatively. Measurements at an average of 55.0 days postsurgery (range, 37 to 128 days) were performed on 20 legs (15 patients). RESULTS: Average preoperative ankle dorsiflexion with the knee straight was 5.1 degrees. Average preoperative ankle dorsiflexion with the knee bent was 22.8 degrees. Immediately following surgery the average ankle dorsiflexion with the knee straight was 23.2 degrees. The average correction was 18.1 degrees and this increase was significant (p < 0.0001.) In the 15 patients (20 legs) available for follow-up, the increase in ankle dorsiflexion with the knee straight was maintained (average: 24.9 degrees). Patients with gastrocnemius contracture who underwent an isolated gastrocnemius release increased their ankle dorsiflexion (knee straight) by an average of 18.1 degrees with postoperative ankle dorsiflexion (knee straight) being equivalent (23.2 and 22.8 degrees) to preoperative ankle dorsiflexion (knee bent). This correction appears to be maintained (23.2 vs. 24.9 degrees) at short-term follow-up.