Equinus Foot Research Articles

脳性麻ひに対する尖足矯正術の成績

We reviewed the results of 32 equinus feet of 21 patients with cerebral palsy who were treated with selective posterior release between 1991 and 1996. The mean age at surgery was 14.1 years and the postoperative follow-up period averaged 32.5 months. In addition to the selective posterior release, 24 feet of 14 patients received plantar release, and 7 patients with severe equinus deformities received Achilles tendon lengthening using White's method. Four feet of two patients showed recurrence (recurrence rate, 12.5%).Locomotion was improved in eight patients, unchanged in 13 patients, and worse in none. No patients newly developed a crouching posture after surgery. Selective posterior release and plantar release are sufficent procedures for correction of equinus deformity caused by cerebral palsy.

Walking ability of stroke patients: Efficacy of tibial nerve blocking and a polypropylene ankle-foot orthosis

Objective: To investigate the efficacy of tibial nerve blocking by percutaneous radiofrequency thermocoagulation and an ankle-foot orthosis on the walking ability of stroke patients with a spastic equinus or equinovarus foot. Design: A placebo-controlled randomized clinical trial with a 2 × 2 factorial design and with a 3-month follow-up. Setting: Outpatient clinic of a department of rehabilitation medicine. Subjects: Sixty stroke patients (17 women, 43 men) with a median age of 58 years and a median period of 34 months poststroke were allocated to one of four treatment groups. Main Outcome Measures: Changes in walking ability (measured with the Sickness Impact Profile category “ambulation”; possible score range, 0% to 100%) and walking speed after 3 months. Results: With respect to walking ability, the efficacy of thermocoagulation as compared with placebo thermocoagulation was .56% (95% confidence interval [CI]−3.01% to 4.13%), whereas the efficacy of the ankle-foot orthosis as compared with the placebo ankle-foot orthosis was 2.72% (95% CI −.94% to 6.38%). To study the potential synergistic effect of both treatments, a multivariate model was used; interaction between both treatments was small, .83% (95% CI −6.73% to 8.40%). Analysis restricted to the compliers ( n = 30) showed an increased efficacy of thermocoagulation and a decreased efficacy of the ankle-foot orthosis. The changes in comfortable and maximal safe walking speed were less than .10m/sec and were neither clinically nor statistically significant (the median baseline values for the total group were .42m/sec and .56m/sec, respectively). Conclusion: No support was found for the beneficial effects of either thermocoagulation of the tibial nerve or a polypropylene ankle-foot orthosis in 5 degrees of dorsiflexion on the walking ability of stroke patients.

The efficacy of thermocoagulation of the tibial nerve and a polypropylene ankle-foot orthosis on spasticity of the leg in stroke patients: results of a randomized clinical trial

Objective: To investigate the efficacy of thermocoagulation of the tibial nerve and a polypropylene ankle-foot orthosis (AFO) on spasticity of the leg in stroke patients with a spastic equinus or equinovarus foot. Design: A placebo-controlled randomized clinical trial with a 2 x 2 factorial design. Setting: Outpatient clinic, Department of Rehabilitation Medicine, Academisch Ziekenhuis Vrije Universiteit Amsterdam. Subjects: 60 stroke patients (17 women, 43 men), with a median age of 58 years and a median period of 34 months poststroke, with at least independent walking capacities at home. Main outcome measures: Change in spasticity, muscle tone, ankle clonus, Achilles tendon reflex, ankle range of motion (ROM), motor function of the leg, and balance, measured six and 15 weeks after randomization. Results: Thermocoagulation, rather than the AFO, reduced spasticity, muscle tone, Achilles tendon hyperexcitability, and ankle clonus. At six-week follow- up, the effects on Achilles tendon reflex and ankle clonus were the most pronounced; reflex excitability was reduced in 59% of the patients treated with thermocoagulation, as compared to 14% of the placebo-treated patients, whereas ankle clonus was reduced in 55% and 0% of the patients, respectively. Reduced spasticity was found in 35% of the actively treated, as compared to 10% of the placebo-treated patients. For muscle tone, the percentages of improved patients in each group were 45% and 24%, respectively. After 15 weeks the differences between the groups were smaller. No clinically relevant improvement was found with regard to ROM, the Fugl-Meyer lower extremity and balance scores, walking ability and walking speed. Conclusion: Thermocoagulation is effective for the reduction of spasticity in stroke patients with a spastic equinus or equinovarus foot. No effect on spasticity of the AFO could be demonstrated. When the efficacy of thermocoagulation and the AFO are judged in terms of functional abilities, however, the effects seem of little value.

An Evaluation of the Posterior Leaf Spring Orthosis Using Joint Kinematics and Kinetics

Summary The primary function of the posterior leaf spring orthosis (PLS) is to prevent excessive equinus or drop foot in swing. The name of the orthosis, posterior leaf “spring,” suggests that it also mechanically augments push-off in stance. The purpose of this study was to determine the effect of the PLS on ankle function by using computerized gait-analysis techniques. Multiple barefoot versus brace walks were compared in 31 children with cerebral palsy. Results indicate that the PLS reduces excessive equinus in swing and is sufficiently flexible to allow ankle dorsiflexion in midstance. In terminal stance, the peak power-generating capabilities of the ankle were reduced when the child was wearing the PLS. Energy results indicate that more mechanical energy was absorbed during midstance and less produced during terminal stance with the PLS. Therefore, the PLS improved ankle function but did not augment ankle function through storage and return of mechanical, or spring, energy.

Surgical treatment for equinus feet deformity in pre-school children with infantile cerebral paralysis

The treatment results of 184 children under school age with infantile cerebral paralysis and equinus deformity were analysed. There were 268 feet with equinus deformity. Out of 312 operations 137 (44%) Str operations, 63 (20,3%) aponeurotic elongation of gastrocnemical muscle, 56 (18,1%) Z-shape elongation of gastrocnemical muscle and 14 (4,5%) achilloplasty by Hoke-method were performed. The indications to apply the surgical management depending on the orthopedic and neurologic status as well as the methods of aponeurotic elongation of gastrocnemical muscle are presented. Excellent and good results were achieved in 86% of cases, recurrence of deformity was observed in 8% of cases. Minimum trauma, high efficiency, organ-sparing pattern of aponeurotic elongation of gastrocnemical muscle makes this procedure the method of choice in children under school age.

Different mechanisms may underlie spastic diplegic gait

One of the treatment option to reduce spasticity in cerebral palsy children is selective dorsal rhizotomy. Several studies have demonstrated short and long term improvements in gait and other activities after rhizotomy but this surgery still remains a controversial procedure and patient outcome indicators measures are not uniform.To describe our assessment and outcome evaluation protocol and to verify by this protocol short term results of rhizotomy.We recruited 9 cerebral palsy children (mean age 7.9 years ± 3.2) affected by mild to moderate spastic diplegia and operated by rhizotomy. Patients were studied preoperatively and at 12 months after surgery by the following clinical and instrumental measures correlated to the International Classification of Functioning: modified Ashworth Scale, passive Range of Motion, Medical Research Council Scale, Selective Motor Control Scale, 3D-motion analysis and energy cost of locomotion measurements (indicators of “body functions”); Gross Motor Functional Measure and Motor Functional Independence Measure (indicators of “activities and participation”).Our data showed, after rhizotomy, reduction of spasticity specially in plantarflexors muscles (p < 0.01), increase of strength of knee flexors/extensors and foot plantar/dorsiflexion muscles (p < 0.01), improvement of selective motor control (p < 0.05), more similar spatio-temporal parameters of gait analysis to healthy subjects, reduced equinus foot and knees hyperflexion as energy cost.The complementary use of multiple indicators may improve the evaluation of the results of dorsal rhizotomy. A beneficial outcome measured by these indicators has been found in our spastic diplegic children one year after rhizotomy.

The high incidence of foot deformity in patients with high-level spina bifida

In a consecutive series of 124 children with spina bifida we found that 220 (89%) of the 248 feet were deformed: 70 had a calcaneus deformity; 126 were in equinus; 16 were in valgus; 3 were in varus; and 5 had convex pes valgus. Operations were performed on 171 (78%) of the deformed feet. Spasticity of the muscles controlling the foot was detected in 36 (51%) of the 70 calcaneus feet and in 22 (17%) of the 126 equinus feet. The deformities were symmetrical in 94 children. There is a high incidence of foot deformity in patients with spina bifida who have no voluntary activity in the motors of the feet.

The distal course of the sural nerve and its significance for incisions around the lateral hindfoot.

Twenty preserved cadaver limbs were dissected to show the distal course of the sural nerve and the number and site of origin of its branches. The mean position of the main nerve trunk was calculated at various points related to bony landmarks of the fibula and the fifth metatarsal base. Ninety-five percent confidence limits for the course of the main nerve trunk could be described. A fibula incision may damage the nerve if it extends more than 7 mm inferior to the lateral malleolar tip with the foot in equinus. Dorsolateral foot incisions may damage both the main trunk and the major anterior branch.

Diagnostic blocks of the tibial nerve in spastic hemiparesis. Effects on clinical, electrophysiological and gait parameters

The value of a diagnostic block (DB) of the tibial nerve in 17 hemiparetic patients with gait disturbances was investigated. The purpose of this study was to find instruments that help to select patients who will benefit from a long lasting peripheral nerve block. The manually elicited ankle clonus and its abolition after injection of a local anaesthetic appeared to be a useful clinical test for the efficacy of DB. Electrophysiological tests proved valuable when DB failed to produce clinical effects. With a substantial number of blocked nerve fibres walking velocity did not deteriorate. Transient disturbances in sensation can be regarded as unwanted side effects that might adversely affect the walking ability. From the different aspects of gait an improved heelcontact demonstrated the functional gain in patients with a dynamic equinus foot. To differentiate between a dynamic equinus foot and fixed contractures, we recommend the use of a fast acting local anaesthetic for diagnostic nerve blocks.

Anterior Transfer of the Long Toe Flexors for the Treatment of Spastic Equinovarus and Equinus Foot in Cerebral Palsy

Anterior transfer of the long toe flexors combined with the Baker procedure, or heel cord lengthening was used to correct equinus foot deformity in 21 patients with cerebral palsy. In more than two-thirds of the cases, heel-to-ball gait became possible. There were no significant recurrences that required re-operation. There were no complications caused by loss of original function in the long toe flexors even in younger patients. Excellent and good results were seen in 57.1% of the patients according to the overall results.

Anterior Transfer of the Long Toe Flexors for the Treatment of Spastic Equinovarus and Equinus Foot in Cerebral Palsy

Summary: Anterior transfer of the long toe flexors combined with the Baker procedure, or heel cord lengthening was used to correct equinus foot deformity in 21 patients with cerebral palsy. In more than two-thirds of the cases, heel-to-ball gait became possible. There were no significant recurrences that required re-operation. There were no complications caused by loss of original function in the long toe flexors even in younger patients. Excellent and good results were seen in 57.1% of the patients according to the overall results.

Popliteal Pterygium Syndrome

Popliteal pterygium syndrome is rare, with 50 cases described in the literature. Three additional cases are reported. The syndrome includes a popliteal web extending from the ischium to the heel associated with toenail dysplasia, eventual deformities of the foot and toes, and oral cavity abnormalities, such as cleft palate or lip pits. The main orthopedic problem is a severe flexion contracture of the knee and an equinus foot. Surgical treatment consists of resection of the web. A technical problem emerges on liberating or reconstructing the sciatic nerve or its branches, which are sometimes included within the contracted cord.

Boot Top Fractures

Low transverse fractures of the tibiofibular complex due to ski injuries were formerly virtually unknown but are now met in ever increasing numbers. A series of 126 such fractures occurring in patients 13 years or older was analyzed. The sex and age distributions of these patients were found to differ significantly from those in skiers with other tibial shaft fractures. Among boot top fractures cases, boys younger than 20 years predominated much more than among patients with other fractures of the tibial shaft. In the boot top fracture there is characteristically a backward angulation, which may be combined with a forward displacement of the distal fragment. A simple technique for reduction of this typical deformity is described. According to this technique the surgeon should take a steady grip on the foot held in extreme plantar flexion. By applying strong traction, disimpaction is achieved after which the distal fragment is forced back into position and the fracture is immobilized with the foot in full equinus. This technique was successfully applied in the majority of our cases (112 of 126). Patients with boot top fractures were hospitalized for shorter periods than were skiers with other tibial fractures, and they were able to resume their normal activities much sooner. This held true even when allowance was made for differences in age. During the last few years a new type of boot top fracture has been observed. In this type there is a forward instead of a backward angulation. Its occurrence is most probably related to the new "scoot foot" or "sitting back" technique in downhill skiing. The appearance of this new type of boot top fracture implies that successful prevention can be achieved only with safety bindings that release not only at rotation but also when the skier falls backward.

Initial management of severe open injuries and traumatic amputations of the foot.

Four years' experience with 410 open traumatic injuries of the foot is reported through the period of initial hospitalization and rehabilitation. Initial management principles include multiple roentgenograms; meticulous periodic assessment of vascularity and sensibility; adequate debridement; fasciotomy for minimal ischemia; delayed wound closure; bulky even-pressure dressings; elevation in functional position; internal fixation of skeletal displacement at time of wound closure; static and dynamic splinting to prevent deformity; early mobility; and stable underloaded weight-bearing. Fasciotomies must be performed whenever circulation is threatened. Traumatic amputations shorten the plantar lever arm for weight-bearing, with resultant disrupted gait. During initial management, the neutral functional position needs exaggeration into dorsiflexion to prevent secondary equinus foot deformity. Elective amputations after severe trauma should be staged to attain the most distal viable level.

The Experience of Tenodesis for Paralytic Equinus Foot

The Experience of Tenodesis for Paralytic Equinus Foot

The ankle joint in relation to arthrodesis of the foot in poliomyelitis.

1. Sixty feet operated upon either by triple or pantalar tarsal fusion for instability after poliomyelitis were re-examined ten to twenty-four years later. 2. After triple fusion with preservation of the ankle joint there was a striking absence of late osteoarthritis of the ankle, and only a low incidence of troublesome lateral instability of the ankle. The results were generally good provided the patient had reasonable power of extension of the knee. 3. Triple arthrodesis for completely flail foot in patients without active muscle control of the knee was often disappointing, so far as the limb as a whole was concerned, because of a persistent flexion deformity of the knee which usually necessitated the wearing of an appliance. 4. The results of pantalar arthrodesis for the flail foot were satisfactory. When this operation was performed (with the foot in slight equinus) in patients who lacked active extension of the knee it helped to stabilise the knee in walking by encouraging hyperextension.

Pressure of Fused Foot

Author examined the human foot pressure in 51 cases of fused feet by means of oppress spur used dental modelling.The feet examined were operated by usual methods of arthrodesis. The preoperative deformities were classified into talipes calcaneus (7 cases), equinus (15 cases), varus (15 cases), planovalgus (one case) and flail feet (13 cases).By this method could be recorded precisely the pre- and postoperative deformities of talipes.According to the records, most excellent results were obtained in equinus deformities, and next in varus deformities but remained slight varus in many cases: in another talipes deformities, some degree of the deformities remained in the usual methods of fusion operations.

INJURIES OF THE LATERAL LIGAMENTS OF THE ANKLE

1. In a series of fifty-one severely "sprained" ankles, twenty-three were shown to be spontaneously reduced and four to be recurrent subluxations of the ankle. Seven of twentyfour stable ankles had persistent disability for as long as five months when treated by itsjection and strapping. 2. By observing the course of the lateral ligaments and the effect on ankle stability of cutting them in various combinations, it is concluded that: A. The anterior talofibular ligament is the important component of the fibular collateral ligament of the ankle. B. Inversion films in severe ankle " sprains" should be taken with the foot in equinus, unless there is tenderness posterior to the fibula (which indicates injury to the posterior talofibular ligament). In this event the foot should be inverted with the ankle at 90 degrees. 3. Unstable ankles should be immobilized in walking plaster for about six weeks and should then be strapped with elastoplast for an additional two or three weeks.