Equinovarus Foot Research Articles

Unsuspected tarsal coalitions in equinus and varus foot deformities.

Tarsal coalitions have been reported in the setting of equinovarus foot deformities, but only as rare isolated findings. Failure to recognize this diagnosis may inhibit successful equinovarus correction. Here, we review a series of tarsal coalitions seen in congenital and neuropathic equinovarus deformity at two institutions, to report the breakdown of types of coalitions encountered, and to suggest methodology to facilitate earlier diagnosis. The records of all patients treated by two of the authors for bilateral equinovarus deformities and found to have either a unilateral or bilateral tarsal coalition between 2006 and 2016 were reviewed. Nine feet with tarsal coalition (calcaneonavicular n = 7 and talocalcaneal n = 2) were reviewed. Five of these cases occurred in patients with idiopathic equinovarus and four cases in patients with equinovarus related to a neurologic disease. All patients were definitively diagnosed by computed tomography scans with 3D reconstruction. In 56% of cases, the patient had previously undergone at least one open procedure before the coalition was recognized. The mean age at diagnosis of the coalition was 11.4 years. Our experience suggests that tarsal coalitions, particularly calcaneonavicular coalitions, may occur more frequently in equinovarus deformities than previously reported. Upon recognition and removal of these coalitions, we were able to achieve improved correction of the equinovarus deformities and improved range of motion. We recommend that surgeons maintain an awareness of this potential concomitant problem in all equinovarus foot deformities and consider advanced imaging in cases which fail to respond to traditional treatment.

Long-term effects on body functions, activity and participation of hemiplegic patients in equino varus foot deformity surgical correction followed by immediate rehabilitation. A prospective observational study

ABSTRACTBackground: Functional surgery is an effective approach in the treatment of the rigid equinovarus foot deformity (EVFD). This must be associated with early rehabilitation treatments (ERTs) to prevent muscle rearrangements due to immobilization.Objectives: To assess the effects of EVFD surgical correction in adult stroke patients, when assessed according to the ICF domains.Methods: Variables from 24 adult chronic stroke survivors with EVFD surgical correction followed by ERT, age 55 ± 13 years, affected side 12L/12R, time from lesion 5 ± 4 years were analyzed. Body function domain: pain (NPRS), walking speed, clinical global impression of change (cGIC). Activity domain: Rivermead Mobility Index (RMI), FAC, and 6 min walking test (6MWT). Participation domain: Walking Handicap Scale (WHS). Patients were assessed before (T0), one (T1), three (T2) and twelve (T3) months after surgery by a single assessor.Results: All variables but the 6MWT significantly improved (Wilcoxon test, p < .05) at T1 or T2 and this remained until the 12-months mark. Since T1, all patients reached and maintained a supervised independent walking (FAC≥3) and all those wearing an AFO stopped using it. The median cGCI was “much improved” at T1, with a “further minimal improvement” at T3. This was not associated with the improvement measured by both FAC, and WHS (Chi-square test, p = .20 and p = .36, respectively).Conclusions: Functional surgery combined with ERT is effective in improving the patients’ condition according to all ICF domains. Both subjective and objective assessments have to be used when assessing these patients.

P87-F Severe congenital myopathy related to a novel mutation in the titin gene. A case report

Mutations in the titin gene (TTN) are related to a wide spectrum of disease. In recent years, congenital titinopathy has emerged as a cause of severe early onset myopathy. A case of two female sisters born at 32 weeks of gestation by cesarean section, from a non-consanguineous, healthy couple. They had normal prenatal ultrasounds except from equinovarus foot in one twin. Apgar score was low at birth (6–10 at 1 and 5 min in both). Both girls needed ventilator support because of respiratory insufficiency, severe axial hypotonia, multiple joint contractures distal and proximal and multiple long bone fractures. Chromosomopathy and osteogenesis imperfect were ruled out in the Genetic unit of our institution. Cardiological studies were normal. The neurographic study performed at two months of life showed extremely low amplitudes of the CMAPs with normal conduction velocities and relative preservation of the SNAPs, without clear myopathic features or spontaneous activity in the needle EMG. The whole exome sequencing (GenExComplete) revealed two extremely rare mutations in the titin gene, only expressed in the fetal skeletal transcript of TTN. One of the twins died at 8 months of age from pneumonia and the other baby needs mechanical ventilation for life support to date. In a case of severe congenital myopathy without cardiac involvement, it is essential to consider the global clinical context. Although very rare, mutations in the fetal skeletal transcript of TTN should be excluded.

Vasculo-Behçet disease complicated by conversion disorder diagnosed with &lt;sup&gt;18&lt;/sup&gt;F-fluoro-deoxy-glucose positron emission tomography combined with computed tomography (PET/CT)

Vasculitis in Behçet's disease, termed "vasculo-Behçet's disease," is a major cause of mortality and morbidity. We report a case of vasculo-Behçet's disease complicated by conversion disorder, in which 18F-fluoro-deoxy-glucose positron emission tomography combined with computed tomography (FDG PET/CT) was useful for the diagnosis. A twenty-two-year-old woman recently diagnosed with tonsillitis presented with fever, right foot pain, left equinovarus foot, and numbness in both hands and feet. Laboratory data showed elevated levels of c-reactive protein (CRP). The patient was positive for HLA B51; pathergy testing was also positive. Nerve conduction velocity and electromyography were normal. MRI showed swelling of the left crural muscle group. PET/CT showed intense FDG uptake in the left popliteal artery, demonstrating active vasculitis. The patient was diagnosed with vasculo-Behçet's disease and treated with corticosteroids, colchicine, and infliximab, which led to obvious improvement of the MRI findings and reduction in CRP. However, left equinovarus foot and numbness in the extremities persisted. She also developed aphonia. They were attributed to psychogenic dystonia and conversion disorder, and psychiatric treatment was effective in relieving those symptoms. We suggest that PET/CT may be useful for the early diagnosis of medium-sized vessel vasculitis in patients with Behçet's disease.

Anatomical landmarks for tibial nerve motor branches in the management of spastic equinovarus foot after stroke: An ultrasonographic study

To identify the anatomical landmarks of tibial motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles for selective motor nerve blocks in the management of spastic equinovarus foot. Observational study. Twenty-five chronic stroke patients with spastic equinovarus foot. Motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were tracked in the affected leg, using ultrasonography, and located in the space (vertical, horizontal and deep) according to the position of the fibular head (proximal/distal) and a virtual line from the middle of the popliteal fossa to the Achilles tendon insertion (medial/lateral). Mean coordinates for the gastrocnemius medialis motor branch were: 1.5 cm (standard deviation (SD) 2.7) vertical (proximal), 1.7 cm (SD 1.3) horizontal (medial), 1.1 cm (SD 0.4) deep; for the gastrocnemius lateralis motor branch: 0.9 cm (SD 2.2) vertical (proximal), 1.8 cm (SD 1.7) horizontal (lateral), 1.0 cm (SD 0.3) deep; for the soleus motor branch: 1.4 cm (SD 1.1) vertical (distal), 1.6 cm (SD 0.7) horizontal (lateral), 2.8 cm (SD 0.7) deep; and for the tibialis posterior motor branch: 4.3 cm (SD 1.5) vertical (distal), 1.9 cm (SD 0.9) horizontal (lateral), 4.2 cm (SD 0.8) deep. These findings may help in the identification of tibial motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles for selective motor nerve blocks in the management of spastic equinovarus foot.

Assessment of the Anterior Talofibular Ligament(ATFL) Thickness in Chronic Stroke Patients by Ultrasound

Stroke is one of the commonest diseases affecting people world-wide. Spastic equino varus foot is one of most common disabling deformities observed among hemiparesis patients. The aim of the study is to compare ATFL thickness on the affected and unaffected sides of chronic stroke patients with that of healthy individuals using ultrasonography.

Congenital Tibial Deficiency.

Congenital tibial deficiency is a rare condition characterized by partial to complete absence of the tibia, an intact but frequently overgrown fibula, variable degrees of knee deformity and function, and an abnormal equinovarus foot. It can occur in isolation but also presents concurrently with other orthopaedic anomalies and syndromic conditions. Among these, congenital abnormalities of the hand and femur are most commonly observed. Many theories exist regarding its etiology and some genetic mutations have been identified; however, the underlying mechanism remains unknown. The prognosis and treatment differ based on the clinical severity. The goal of treatment is always to create a stable, functional limb, most commonly with amputation and use of prosthetics. Controversy exists over the level of amputation and the usefulness of reconstructive procedures to preserve the foot and limb length. Current investigation on this complex disorder is focused on identifying its origins and further developing a classification-based treatment algorithm to improve patient outcomes.

Data analysis of 8 113 cases of limb deformities corrected by external fixation

To analyze the data of external fixation instruments (including Ilizarov instruments) used by QIN Sihe orthopaedic surgical team in the treatment of limb deformities in the past 30 years, and to explore the indications for the application of modern external fixation techniques in the correction of limb deformities and individual device configuration selection strategy. According to QIN Sihe orthopaedic surgical team, the use of external fixator between January 1988 and December 2017 was analyzed retrospectively. The total use of external fixation and the proportion of different external fixators were analyzed in gender, different operation time, different age, different parts, and different diseases. External fixators were used in 8 113 patients, 69 of them were used simultaneously in both lower extremity surgery, so 8 182 external fixators were used. Among them, there were 4 725 (57.74%) combined external fixators, 3 388 (41.41%) Ilizarov circle fixators, 64 (0.78%) single arm external fixators (including Orthofix), 5 (0.06%) Taylor space external fixators. There were 4 487 males (55.31%) and 3 626 females (44.69%). According to the analysis of different time periods, the number of external fixators increased year by year, and the number of applications increased after 2000. The main age of the patients was 11-30 years old, of which 1 819 sets (22.23%) were used at the age of 21-25 years. The use of the external fixator covered almost all parts of the limbs, with the ankle and toe areas being the most common, reaching 4 664 sets (57.00%), and the upper extremities the least, with 152 sets (1.86%). The 8 113 cases covered more than a dozen disciplines and more than 150 kinds of diseases. The top 5 diseases were poliomyelitis sequelae, cerebral palsy, deformity of lower extremity after spina bifida, traumatic sequelae, and congenital equinovarus foot. Ilizarov technique has been widely used in extremity deformity, disability, and complicated orthopedic diseases caused by vascular, lymphoid, nerve, skin, endocrine, and other diseases. The indication of operation is far beyond the scope of orthopedics. The domestic external fixator and its mounting tools can basically meet the requirements of various treatments. The technique of external fixation has entered a new era of tension tissue regeneration under stress control, natural repair of tissue trauma and deformity, and reconstruction of limb function.

Safety and long-term effects on gait of hemiplegic patients in equinovarus foot deformity surgical correction followed by immediate rehabilitation: a prospective observational study.

Equinovarus foot deformity (EVFD) is the most common lower limb deformity in stroke patients. Immobilization following EVFD surgical correction is known to have a negative impact on muscle rearrangement with possible loss of walking ability in stroke patients. In a previous study, safe and positive effects at one-month follow-up after surgery were obtained with an early rehabilitation treatment (ERT) characterized by immediate walking and training. To determine long-term safety and efficacy of functional surgery followed by early rehabilitation (FSER). A 12 months prospective observational study. Outpatients clinic, Gait and Motion Laboratory, Sol et Salus Hospital, Rimini, Italy. Twenty-four adult chronic stroke survivors with EVFD surgical correction followed by ERT, age 55±13 years, affected side 12L/12R, time from lesion 5±4 years. Patients received clinical and instrumental evaluation by gait analysis (GA) before (T0), one, three and twelve months after surgery. Safety was defined as the absence of any complication consequent to FSER. Efficacy was assessed by the recovery in ankle kinematics, walking speed and space-time parameters. No clinical complication (thrombosis, surgical wound infection, muscle or tendon injury, muscle hematoma) arose in the sample during the follow-up year. Variables relating to ankle kinematics improved towards their normal values at one month after surgery. These were maintained at 3 and 12 months, with a significant difference between follow-ups and pre-surgical values (Durbin-Conover Test, P<0.01). Gait speed, cadence, anterior step length and stride length of the affected side showed a statistical improvement at 3 and 12 months (Wilcoxon test, P=0.012 and P=0.001, respectively). Stride width decreased at 1 month after surgery and showed a further stable reduction at 3 months (P=0.008). The ERT protocol with immediate rehabilitation starting on the first day after surgical correction was safe and effective in providing a long-term correction of EVFD. Ankle dorsiflexion improved both in stance and swing, allowing for a significative improvement in walking speed. FSER can be considered an encouraging approach in the management of EVFD, with durable results.

A Review of Extensor Hallucis Longus Variants Featuring a Novel Extensor Primi Internodii Hallucis Muscle Merging With Extensor Hallucis Brevis

The extensor hallucis longus (EHL) muscle/tendon complex has been used in a variety of tendon transfer and tenodesis surgeries to correct iatrogenic hallux varus deformity, equinovarus foot deformity, clawed hallux associated with a cavus foot, and dynamic hyperextension of the hallux and, even, to prevent pedal imbalance after transmetatarsal amputation. Although it is usually considered a unipennate muscle inserting into the dorsum of the base of the distal phalanx of the hallux, a vast majority of EHL muscles possess ≥1 accessory tendinous slips that insert into other neighboring bones, muscles, or tendons, which can complicate these surgeries. The present report reviewed the reported data on EHL variants and describe a new variant, in which the tendons of the extensor primi internodii hallucis muscle of Wood and extensor hallucis brevis muscle merged together proximal to the tarsometatarsal (Lisfranc) joint, a site of rupture for extensor tendons of the foot. The reported variant might have contributed to the development of the clawed hallux seen in our patient and could complicate its operative management by mimicking the normal extensor digitorum longus tendon. Knowledge of the EHL variants and the particular muscular pattern described in the present review could improve the diagnosis and tendon transfer and tenodesis operative planning and outcomes.

An examination of real-world onabotulinumtoxina utilization for the treatment of lower limb spasticity: The Adult Spasticity International Registry (ASPIRE) study

OnabotulinumtoxinA treatment for spasticity is variable as treatment is individualized and dependent on numerous factors. Here, we explore real-world patterns of onabotulinumtoxinA utilization in patients with lower limb spasticity over 2 years. Multicenter, international, prospective, observational study ( NCT01930786 ), examining adult patients with focal spasticity across multiple etiologies treated with onabotulinumtoxinA at their physician's discretion. Assessments include utilization (each treatment visit) and patient/physician satisfaction (5 ± 1 weeks post-treatment). Patients ( n = 731) were on average 53.6 years of age (18.5–93.2 years), 52% female, and predominantly Caucasian (77%). Stroke was the most frequently reported etiology (56%). The most commonly treated lower limb spasticity presentation was equinovarus foot (59%). Across all equinovarus foot treatment sessions ( n = 1609), percentage injected and dose (mode) injected into each muscle are as follows: gastrocnemius (79%, 100 U), soleus (70%, 100 U), tibialis posterior (48%, 50 U), flexor digitorum longus (21%, 50 U), flexor hallucis longus (8%, 50 U) and other muscle (13%, 50 U). EMG was frequently used to localize the muscles to treat equinovarus foot (>40%). Across all treatment sessions, 95% of physicians and 85% of patients reported being satisfied/extremely satisfied that treatment helped manage spasticity, 89% of physicians and 76% of patients reported treatment benefit was sustained, and 98% of physicians and 92% of patients would definitely/probably continue treatment with onabotulinumtoxin A. 261 patients (36%) reported 831 adverse events (AEs); 23 AEs in 20 patients (3%) were considered treatment-related. 94 patients (13%) reported 195 serious AEs; 3 serious AEs in 2 patients (0.3%) were considered treatment-related. No new safety signals were identified. ASPIRE provides valuable, real-world data on dosing, injection guidance, and muscle targeting over 2 years, that may help guide clinical strategies. The study captured the individualized nature of onabotulinumtoxin A utilization for spasticity, while demonstrating consistently high satisfaction. These results add to the body of evidence on the safety and effectiveness of onabotulinumtoxin A for spasticity.

Outcomes of equinus/varus foot surgery in patients with spastic paresis: A retrospective study on 126 patients

Equinovarus foot is the most frequent complication in patients suffering from spastic paresis. Surgical treatment of equinovarus spastic foot includes different kinds of surgery, such as: selective tibial neurotomy, lengthening of the gastrocnemii, soleus, or Achilles tendon, tendon transfer, or rear- and midfoot arthrodesis. So far, there is a lack of precise guidelines about the surgery to consider, for these patients according to their clinical situation. To describe the outcome and complications of equinovarus foot surgery. We performed an analytic, retrospective, single centre study. We included all patients with spastic paresis acquired after 18 years who were operated for an equinovarus foot, on a 12-year period. Four time points were studied: the preoperative situation, postoperative at 3 and 12 months, and the last assessment during follow-up. Considering three main clinical situations (dynamic equinus, fixed equinus and fixed rear and midfoot deformities), we described the surgical procedures and their outcomes. From 200 patients who underwent surgery, 126 feet were included. Forty-eight percent of patients presented with a dynamic equinus foot and had a neurotomy; in such cases 10% of surgery failed, whereas only 6% failed in fixed equinus. The rate of subjective success (assessed by the patients) was 86%. Thirty percent of patients experienced a revision surgery, and 15% presented with complications. Fifteen percent of patients had claw toes after surgery in each group. Five patients had bone surgery because of a fixed varus. The occurrence of postoperative neuropathic pain, was associated with neurotomy of the plantar nerve ( P < 0.01). Equinus/equinovarus foot is a complex situation in patients with spastic paresis. Several clinical pictures can be identified. An important variety of surgical procedures is performed in these patients. The predictive factors of failure and complications of such surgeries can be suggested from this study.

Ultrasonographic Evaluation of Botulinum Toxin Injection Site for the Medial Approach to Tibialis Posterior Muscle in Chronic Stroke Patients with Spastic Equinovarus Foot: An Observational Study.

The tibialis posterior muscle is a frequent target for injection of botulinum toxin during the management of spastic equinovarus foot in adults with post-stroke spasticity. Although it is deep-seated, the needle insertion into the tibialis posterior muscle is usually performed using anatomical landmarks and safety information obtained from healthy subjects and cadavers. Our aim was to evaluate the botulinum toxin injection site for the medial approach to the tibialis posterior muscle in chronic stroke patients with spastic equinovarus foot. Forty-six patients were evaluated at the affected middle lower leg medial surface with ultrasonography according to the following parameters: tibialis posterior muscle depth, thickness, and echo intensity. As to the spastic tibialis posterior, we found a mean muscle depth of 26.5 mm and a mean muscle thickness of 10.1 mm. Furthermore we observed a median tibialis posterior muscle echo intensity of 3.00 on the Heckmatt scale. The tibialis posterior muscle thickness was found to be inversely associated with its depth (p < 0.001) and echo intensity (p = 0.006). Furthermore, tibialis posterior muscle depth was found to be directly associated with its echo intensity (p = 0.004). Our findings may usefully inform manual needle placement into the tibialis posterior for the botulinum toxin treatment of spastic equinovarus foot in chronic stroke patients.

Effect of postural insoles on gait pattern in individuals with hemiparesis: A randomized controlled clinical trial

IntroductionRecovering the ability to walk is an important goal of physical therapy for patients who have survived cerebrovascular accident (stroke). Orthotics can provide a reduction in plantar flexion of the ankle, leading to greater stability in the stance phase of the gait cycle. Postural insoles can be used to reorganize the tone of muscle chains, which exerts an influence on postural control through correction reflexes. The aim of the present study was to perform kinematic and spatiotemporal analyses of gait in stroke survivors with hemiparesis during postural insole usage. Material and MethodsTwenty stroke victims were randomly divided into two groups: 12 in the experimental group, who used insoles with corrective elements specifically designed for equinovarus foot, and eight in the control group, who used placebo insoles with no corrective elements. Both groups were also submitted to conventional physical therapy. The subjects were analyzed immediately following insole placement and after three months of insole usage. The SMART-D 140® system (BTS Engineering) with eight cameras sensitive to infrared light and the 32-channel SMART-D INTEGRATED WORKSTATION® were used for the three-dimensional gait evaluation. ResultsSignificant improvements were found in kinematic range of movement in the ankle and knee as well as gains in ankle dorsiflexion and knee flexion in the experimental group in comparison to the control group after three months of using the insoles. ConclusionPostural insoles offer significant benefits to stroke survivors regarding the kinematics of gait, as evidenced by gains in ankle dorsiflexion and knee flexion after three months of usage in combination with conventional physical therapy.

OnabotulinumtoxinA for Lower Limb Spasticity: Guidance From a Delphi Panel Approach

BackgroundOnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established. ObjectiveTo define a clinically recommended treatment paradigm for the use of onabotulinumtoxinA for each common posture among patients with poststroke lower limb spasticity (PSLLS) and to identify the most common PSLLS aggregate postures. DesignClinical experts provided insight regarding onabotulinumtoxinA treatment for PSLLS using an adaptation of the Delphi consensus process. SettingDelphi panel. ParticipantsTen expert clinicians in neurology and physical medicine and rehabilitation who treat PSLLS. MethodsA minimum of 2 rounds of anonymous voting occurred for each recommendation until consensus was reached (≥66% agreement). The first round was conducted via a survey; the second round was an in-person meeting. Main Outcome MeasurementsReached consensus on muscle selection for injection, overall and per-muscle dose of onabotulinumtoxinA, number of injection sites/muscle, onabotulinumtoxinA dilution, and use of localization techniques. The most common PSLLS postures were reviewed. Recommendations were tailored toward injectors with less experience. ResultsConsensus was reached on targeted subsets of muscles for each posture. Doses ranged from 20 to 150 U for individual muscles and 50 to 300 U for limb postures. OnabotulinumtoxinA dilution 50 U/mL (2:1 ratio) was considered most appropriate but varied based on muscles selected (range, 2:1-4:1). Experts agreed that localization techniques for muscle identification during injection for all postures would be useful. For suboptimal response to injection, all panel members would increase the dose, and the majority (89%) would increase the number of treated muscles. The panel identified 3 common aggregating lower limb postures: (1) equinovarus foot and flexed toes; (2) extended knee and plantar flexed foot/ankle; and (3) plantar flexed foot/ankle and flexed toes. The recommended starting doses for each aggregate posture were 400 U, 400 U, and 300 U, respectively. ConclusionThe modified Delphi panel process provided consensus on common muscles and corresponding onabotulinumtoxinA treatment paradigms for postures associated with PSLLS that can be used for guidance in optimizing care delivery. Level of EvidenceV

Management of foot deformity in children.

This study describes the management of foot deformity in children. Severe congenital clubfeet treated using posteromedial release without talocalcaneal joint release were flexible and functional. Talectomy may be necessary for congenital clubfeet with arthrogryposis multiplex congenita. The diagnosis and severity of vertical talus were defined based on stress radiographs. For the deformity with spina bifida, a combination of talocalcaneal joint fusion and precise correction by soft tissue release and tendon transfer was performed. This combined surgery is effective, particularly in patients with equino-varus feet.

Assessment and treatment of spastic equinovarus foot after stroke: Guidance from the Mont-Godinne interdisciplinary group.

To present interdisciplinary practical guidance for the assessment and treatment of spastic equinovarus foot after stroke. Clinical examination and diagnostic nerve block with anaesthetics determine the relative role of the factors leading to spastic equinovarus foot after stroke: calf spasticity, triceps surae - Achilles tendon complex shortening and dorsiflexor muscles weakness and/or imbalance. Diagnostic nerve block is a mandatory step in determining the cause(s) of, and the most appropriate treatment(s) for, spastic equinovarus foot. Based on interdisciplinary discussion, and according to a patient-oriented goal approach, a medical and/or surgical treatment plan is proposed in association with a rehabilitation programme. Spasticity is treated with botulinum toxin or phenol-alcohol chemodenervation and neurotomy, shortening is treated by stretching and muscle-tendon lengthening, and weakness is treated by ankle-foot orthosis, functional electrical stimulation and tendon transfer. These treatments are frequently combined. Based on 20 years of interdisciplinary expertise of management of the spastic foot, guidance was established to clarify a complex problem in order to help clinicians treat spastic equinovarus foot. This work should be the first step in a more global international consensus.

Larsen syndrome

Larsen syndrome is a rare inherited disorder characterized by congenital dislocation of multiple joints along with other anomalies of heart, face, hands and bones. Larsen syndrome was first described in 1950 by Larsen, Schottstaedt and Bost. In the present report, we describe a 10 year old girl who presented with mid facial hypoplasia with depressed nasal bridge, high arched palate, bilateral talipes equinovarus and high arched feet. On examination, she had short stature (HAZ -3.5 SD) with hyperextension of knee joint, fixed flexion of elbow joint. Awareness of this condition and associated complications may help in management and follow up of these patients.

Effects of tibial nerve neurotomy on posture and gait in stroke patients: A focus on patient-perceived benefits in daily life

ObjectiveTo evaluate the objective and subjective functional effectiveness of tibial nerve neurotomy (TNN) in post-stroke spastic equinovarus foot (SEF). MethodsIn an open study, 23 hemiplegic patients were assessed immediately before TNN and then 5months after TNN. The main outcome measure was the Lower Limb Function Assessment Scale (LL-FAS), which provided an ecologic assessment of impairments in standing and walking (i.e. kinematic abnormalities) and their impacts on activities of daily living. Patients were also assessed for global clinical impression of change, fear of falling, neuromotor impairments, spatiotemporal and video gait parameters and walking capacities. ResultsTNN had a very marked effect on the level of spasticity and the range of motion in dorsiflexion (p<10−3). These changes resulted in better foot positioning when standing and walking (particularly in stance), which was perceived very favorably by the patients. There was a clear, patient-perceived improvement in activities performed when standing and walking (LL-FAS (p<0.01)), the global clinical impression of change (p<10−3) and the fear of falling (p=0.022) that was not revealed by conventional, objective measurements (New Functional Ambulation Classification, Rivermead Mobility Index). ConclusionTNN is an effective treatment for post-stroke SEF; it is associated with a patient-reported improvement in standing and walking abilities during activities of daily living. Further research must now assess the long-term subjective efficacy of TNN.

Update on club foot

Abstract This review outlines the present classification, aetiology, diagnosis and assessment of clubfoot (congenital talipes equinovarus or CTEV foot). It also updates the changes that have occurred with regard to the management emphasising the shift away from routine surgical treatment to the serial casting techniques popularised by Ponseti and reasons for this change.