Heel Cord Lengthening Research Articles

Continuum of reflex excitability in hemiplegia: influence of muscle length and muscular transformation after heel-cord lengthening and immobilization on the pathophysiology of spasticity and clonus.

The electromyographic (EMG) responses to tendon taps at the ankle and ensuing muscular twitch forces and temporal parameters were studied at varying angles across the joint range in 18 children, aged 3 to 14.9 years, with congenital hemiparetic cerebral palsy and 22 healthy (control) children, aged 3 to 13.6 years. Those subjects with hemiparesis were community ambulators without assistance. In all subjects, passive muscle stretch caused a waxing of the reflex EMG and twitch force near neutral (with the sole of the foot at right angles to the tibia) and a diminution of these with further dorsiflexion. Twitch times increased with each dorsiflexing increment, being slowest at maximum dorsiflexion and fastest at the resting plantarflexion angle. Heterogeneity of the hemiparetic-limb data is evident when compared with data of non-paretic and unaffected limbs, with clear differences in the clonic (fast twitch) as opposed to non-clonic (slow twitch) muscles. In four cases with clinical clonus, clonus frequency was reduced by passive dorsiflexion. Plaster immobilization for 1 month produced clonus which was previously absent in one subject, and caused a fast-twitch phenotype to emerge in two subjects. Follow-up after heel-cord lengthening in one subject showed that clonus frequency diminished from 9 to 3 Hz with slowing and strengthening of muscle-twitch phenotype. Short- and long-term peripheral manipulations appear to regulate neuromuscular excitability according to whether muscles are loaded or unloaded. Although damage to the nervous system provides the setting for reflex excitability, the data suggest that the muscle length (which specifies the joint angle) and the muscle-twitch phenotype of any given limb for any given case appear to dictate the actual speed and strength of reflex muscle-twitch and clonus profiles. This study illustrates how peripheral manipulations of muscles and tendons may alter the expression of what have hitherto been considered as exclusively central phenomena.

Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome.

The intermediate outcome of patients who underwent a triple arthrodesis for the treatment of adult foot disorders was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 63 feet in 57 patients who underwent a triple arthrodesis using rigid internal fixation for the treatment of hindfoot deformities associated with symptomatic arthrosis. Twenty-four men and thirty-three women, with an average age of 54 years, were evaluated. The average follow-up was 30 months. Multiple diagnoses contributed to hindfoot deformities with secondary arthrosis. Iliac crest bone graft was used in 56 of 63 cases (89%). Percutaneous heel cord lengthening was done in 53 of 63 cases (84%). Twenty-four of the thirty patients (80%) returned to work. Twenty-five patients were retired and two were unemployed before surgery. All patients except two (97%) were satisfied with the surgery and would have the surgery again. The average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot preoperative score was 28 points, and the average postoperative score was 81 points (P < 0.0001). In the radiographic measurements, there was an average improvement of 12 degrees in the lateral talometatarsal angle, 7 degrees in the lateral talocalcaneal angle, and 10 degrees in the AP talometatarsal angle (P < 0.0001). Complications experienced included two varus malunions, two valgus malunions, two nonunions, two deep vein thromboses, one distal fibula stress fracture, and one wound infection. Of the 26 feet in 22 patients with mortise views available, 10 feet (38%) had evidence of ankle arthrosis and 19 feet (73%) had some degree of talar tilt postoperatively.

Posterior tibial tendon insufficiency: diagnosis and treatment.

Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and evidence of local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal anti-inflammatory drug, and perhaps an orthotic device. Corticosteroid injections continue to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease.

Duration of Immobilization After Percutaneous Sliding Heel-Cord Lengthening

Heel-cord lengthening is commonly performed for contractures in neuromuscular disease. Immobilization after this procedure has ranged from 3 to 8 weeks. A three-part study was performed to determine adequate length of immobilization. Sixteen rabbits had surgical transection of the right gastrocsoleus tendon in phase 1. Healing was allowed for 1, 3, 5, or 7 weeks. Tendons were then studied by magnetic resonance imaging (MRI), mechanical testing, or histologic section. A marker for healing was determined by MRI. Seven children underwent percutaneous sliding heel-cord lengthening (PSHCL) in phase 2. Healing was studied by MRI. Based on the marker from phase 1, adequate healing occurred at 3 weeks. Thirty-one children underwent PSHCL for neuromuscular contracture in phase 3. Cast immobilization was maintained for 3 weeks (group 1) and for >3 weeks (group 2). There was no evidence of rupture or progressive lengthening after cast removal in either group.

Crouch gait in spastic diplegia after heel cord lengthening

Crouch gait in spastic diplegia after heel cord lengthening

Split Posterior Tibial Tendon Transfer for Varus Deformity of Hindfoot

Sixteen patients (23 feet) who underwent split posterior tibial tendon transfers were evaluated. The patients were seen on a followup basis for a minimum of 1 year postoperatively. The causes were spastic cerebral palsy in 13 feet, spastic-athetoid cerebral palsy in 3 feet, hydrocephalus in 3 feet, and other diseases in 4 feet. The indication for surgery was varus deformity during the stance phase of gait and increased varus deformity during the swing phase of gait because of spasticity of the posterior tibial muscle. Heel cord lengthening was done on 17 feet. Preoperative and postoperative gaits were evaluated while the patients were walking. Axial radiographs of the calcaneus and the tibia were taken of all patients while they were weightbearing. There were 15 excellent, 6 good, and 2 poor results. The poor ratings were assigned to patients who had recurrence of varus deformity; there were no cases of overcorrection. Split posterior tibial tendon transfer was effective for treating spastic varus deformity of the hind part of the foot. This treatment also could be considered for a patient with spastic-athetoid cerebral palsy, if the deformity was determined to be caused by overactivity of the tibialis posterior muscle.

Kinematic and kinetic effects of heel cord lengthening in gait of children with spastic hemiplegic cerebral palsy

Kinematic and kinetic effects of heel cord lengthening in gait of children with spastic hemiplegic cerebral palsy

Biomechanical analysis of the effects of heel cord lengthening on gait in a child with cerebral palsy: A case study

β-Blocking agents reduce cardiovascular mortality in patients with heart disease, but their potential benefit in dialysis patients is unclear. We aimed to determine the feasibility of a randomized controlled trial (RCT).Pilot RCT.Patients who received dialysis for 3 or more months and were 50 years or older (or ≥18 years with diabetes or cardiovascular disease) were recruited from 11 sites in Australia and New Zealand. We aimed to recruit 150 participants.After a 6-week run-in with the β-blocker carvedilol, we randomly assigned participants to treatment with carvedilol or placebo for 12 months.The prespecified primary outcome was the proportion of participants who tolerated carvedilol, 6.25 mg, twice daily during the run-in period. After randomization, we report participant withdrawal and the incidence of intradialytic hypotension (IDH).Of 1,443 patients screened, 354 were eligible, 91 consented, and 72 entered the run-in stage. 49 of 72 run-in participants (68%; 95% CI, 57%-79%) achieved the primary outcome. 5 of the 23 withdrawals from run-in were attributable to bradycardia or hypotension. After randomization, 10 of 26 allocated to carvedilol and 4 of 23 allocated to placebo withdrew. 4 participants randomly assigned to carvedilol withdrew because of bradycardia or hypotension. Overall, there were 4 IDH events per 100 hemodialysis sessions; in participants allocated to carvedilol versus placebo, respectively, there were 7 versus 2 IDH events per 100 hemodialysis sessions (P = 0.1) in the 2 weeks immediately following a dose increase and 4 versus 3 IDH events per 100 hemodialysis sessions after no dose increase (P = 0.7).Unable to recruit planned sample size.Recruiting patients receiving dialysis to an RCT of β-blocker versus placebo will prove challenging. Possible solutions include international collaboration and exploring novel trial designs such as a registry-based RCT.

Kinematic analysis of gait before and after heel cord lengthening for idiopathic toe walking

Idiopathic toe walking is a diagnosis of exclusion characterized by a persistent toe–toe gait pattern after three years of age. Treatment for toe walking includes physical therapy, orthotics, casting, Botulinum Toxin A injection into gastrocnemius/soleus muscles, and/or surgery; yet, little evidence exists regarding long-term treatment effects.The objective of this study was to explore the differences in longer-term gait outcomes and severity of idiopathic toe walking between children treated actively with casting or inactively following recommendations for stretching.Forty-three adolescents and young adults (14.3–28.8 years; 21 females, 22 males) who had participated in an idiopathic toe walking classification study as children, returned for repeat physical examination and three-dimensional computerized gait analysis (13.4 years follow-up, range 9.4–17.8 years); 23 participants had received active treatment with casting and ankle foot orthotics ± Botulinum Toxin A injection as children and 20 participants had received inactive treatment with recommended stretching exercises. Gait analysis data were compared retrospectively from baseline to follow-up using analysis of variance; toe walking severity was compared using a Wilcoxin Signed-Rank Sums test.Ankle angle at initial contact, peak dorsiflexion in stance, and toe walking severity improved significantly in the active treatment group only at follow-up. Significant improvement in peak ankle power and timing of ankle kinematics and kinetics in the gait cycle were found in both groups; however, greater changes occurred in the active treatment group. Both groups showed significantly improved internal plantar flexor moments, whereas knee extension increased in stance and passive ankle dorsiflexion decreased in both groups at follow-up (p = 0.001). Intermittent toe walking was reported in 49% (21/43) of participants at follow-up.The results of this study suggest that improvement in ankle kinematic timing and ankle kinetic gait analysis variables is sustainable, independent of conservative treatment for idiopathic toe walking in childhood.

Chopart Amputation With Percutaneous Heel Cord Lengthening

When amputation becomes necessary in a patient with peripheral vascular disease, it is important to preserve as much tissue as possible to preserve maximum function. This is especially important because the other extremity may have similar involvement in the future. With appropriate care, an amputation at the Chopart (calcaneocuboid-talonavicular) level can give a good functional result.

Results of Grice operation in cerebral palsy patients

In the Department of Orthopaedic Surgery and Traumatology, Ege University, Medical Faculty, 45 Grice-Green operations and adjuvant operations were performed to correct planovalgus deformity in 45 cerebral palsy patients. They were 14 males and 13 females, with minimum age 4, maximum age 11 , average age: 7, mean age 8. Follow-up period changed between 3 months and six years, with average one year. Grice procedure were perfomed on 12 feet alone, on 8 feet with heel cord lengthening, on 8 feet with peroneal lengthening, on 9 feet with heel cord lengthening and peroneal lengthening, on 6 feet with peroneal re-routing and 2 feet with heel cord lengthening and peroneal re-routing. Original technique with tibial graft and-wire insertion were used for stabilization. The results were excellent in 43 feet (%55.6), good in 18 feet (%40), poor in 2 feet (%4.4) High rate of satisfactory results were attributed to the preoperative good assessment and the combination of Grice procedure with the soft tissue operations.

Calcaneal Gait in spastic Diplegia After Heel Cord Lemgthening

Calcaneal gait or deformity can be a significant complication after heel cord lengthening. After heel cord lengthening, 20 children with spastic diplegia were evaluated by gait analysis to define calcaneal gait objectively and describe associated morbidity. Mean age was 5 years 2 months (range 2 years 7 months to 8 years 2 months), and mean length of follow-up was 5 years 8 months (range 1 years 1 month 11 year 3 months). Calcaneal gait was defined as dorsiflexion 1 SD beyond the mean in the sagittal plane for all phases of stance. Increased ankle dorsiflexion during mid-stance most accurately predicts calcaneal gait. Through gait analysis, a 30% (6 of 20) prevalence of calcaneal gait suggests that an increased incidence of calcaneal gait may be present after heel cord lengthening.

Surgical Management of the Severely Multiply Handicapped Individual

Thirty-four surgical procedures were performed over a 12-year period on a select population of severely multiply handicapped individuals. Heel cord lengthening, hamstring and adductor releases, as well as selected osteotomies, tenotomies, and arthrodeses (both wrist and foot) were performed. The objectives were improvement in sitting posture, care, and comfort. Independent evaluations of active function, passive function, cosmesis, self-esteem, limb posture, and ease of dressing and hygiene were assessed. Significant improvement was generally noted. No patient was made worse. Selected procedures in the severely multiply handicapped individual have a definite place in patient management.

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.

Outpatient percutaneous heel cord lengthening in children.

Outpatient percutaneous tendo Achillis lengthening is a quick, complication-free, inexpensive approach to a common pediatric orthopedic problem. The procedure is a known alternative to conventional open procedures, but it is not widely used. This study outlines the advantage of the percutaneous procedure performed in outpatient surgery with the patient under a general anesthetic. Fifty-five patients were operated on between December 1980 and March 1984. Overall results were excellent, with 97% improvement in gait. There were no infections. Percutaneous heel cord lengthening in children is a safe and simple operation, yielding results equal to those of open procedures. The advantage of outpatient surgery adds a further positive dimension to this procedure.

SPLIT POSTERIOR TIBIAL-TENDON TRANSFERS IN CHILDREN WITH CEREBRAL SPASTIC PARALYSIS AND EQUINOVARUS DEFORMITY

In the treatment of equinovarus deformity of the foot in children with cerebral spastic paralysis, to supplement heel-cord lengthening, we split the posterior tibial tendon and transferred its posterior half laterally into the peroneus brevis tendon. Thirty-seven operations were performed on thirty-one hemiplegic, quadriplegic, and diplegic children who were followed for a mean of eight years postoperatively (range, four to fourteen years), at which time twenty-six of the thirty-one children were skeletally mature. There were thirty excellent, four good, and three poor results. The results did not deteriorate with time. Thirty-two of thirty-four children with good or excellent results had functioning dorsiflexors of the foot and were brace-free postoperatively. The children who had a poor result had recurrent deformity, but none had development of a calcaneal or calcaneovalgus deformity.

Split posterior tibial-tendon transfers in children with cerebral spastic paralysis and equinovarus deformity.

In the treatment of equinovarus deformity of the foot in children with cerebral spastic paralysis, to supplement heel-cord lengthening, we split the posterior tibial tendon and transferred its posterior half laterally into the peroneus brevis tendon. Thirty-seven operations were performed on thirty-one hemiplegic, quadriplegic, and diplegic children who were followed for a mean of eight years postoperatively (range, four to fourteen years), at which time twenty-six of the thirty-one children were skeletally mature. There were thirty excellent, four good, and three poor results. The results did not deteriorate with time. Thirty-two of thirty-four children with good or excellent results had functioning dorsiflexors of the foot and were brace-free postoperatively. The children who had a poor result had recurrent deformity, but none had development of a calcaneal or calcaneovalgus deformity.

CALCANEUS DEFORMITY IN CEREBRAL PALSY

Most but not all calcaneus feet in cerebral palsied patients are iatrogenic. The cause is related to imbalance between plantarflexors and dorsiflexors in most instances. Injudicious heel cord lengthening, inadequate preoperative assessment of anterior tibial power, heel cord lengthening accompanied by gastrocsoleus neurectomy or transposition of peroneal and posterior tibial tendons, anterior to the malleoli, are all potential causes of calcaneus deformity in cerebral palsy.

Calcaneus deformity in cerebral palsy.

Most but not all calcaneus feet in cerebral palsied patients are iatrogenic. The cause is related to imbalance between plantarflexors and dorsiflexors in most instances. Injudicious heel cord lengthening, inadequate preoperative assessment of anterior tibial power, heel cord lengthening accompanied by gastrocsoleus neurectomy or transposition of peroneal and posterior tibial tendons, anterior to the malleoli, are all potential causes of calcaneus deformity in cerebral palsy.