Paralytic Foot Research Articles

Improvement in clinical outcome and quality of life after arthroscopic ankle arthrodesis in paralytic foot drop

BackgroundParalytic foot-drop is a disabling deformity that results from nerve or direct muscle injuries. Palliative surgeries such as tendon transfer and ankle arthrodesis are reserved for permanent deformity, with the arthroscopic technique had not been widely studied before. This study aims to evaluate the clinical outcome and quality of life after arthroscopic ankle fusion of paralytic foot-drop deformity.Materials and MethodsThe patients who were retrospectively enrolled in this study underwent arthroscopic ankle fusion for paralytic foot-drop deformity between March 2017 and December 2021. The American Orthopedic Foot and Ankle Society (AOFAS) ankle–hindfoot score and Cumberland Ankle Instability Tool (CAIT) were the measures used for clinical assessment. To judge the union, serial plain radiographs of the ankle were obtained. The preoperative and postoperative means were analyzed utilizing a two-tailed paired t-test, with a p value of less than 0.05 indicating statistical significance.ResultsThis study included 21 consecutive patients with a mean follow-up of 35.09 ± 4.5 months and a mean age of 41.5 ± 6.1 years. Highly significant improvements were observed between the preoperative and final follow-up means of the AOFAS score (from 57.6 ± 4.6 to 88.3 ± 2.7) and CAIT (from 12.1 ± 2.2 to 28.9 ± 1.01; p ˂ 0.00001 for both). All patients attained radiographic union and resumed their previous occupations without reporting serious adverse effects.ConclusionsArthroscopic ankle fusion is an effective, minimally invasive palliative surgery for patients suffering from permanent paralytic foot-drop deformity. This technique was shown to provide good functional and radiologic outcomes without significant complications.Level of evidenceRetrospective cohort; level of evidence (IV).

Post Injection Sciatic Neuritis: A Case Report

For administration of certain drugs, intramuscular injections are used in children. The dorsogluteal area between the iliac crest and the greater trochanter is the most suitable site for intramuscular injection. Due to the poor co-operation of children/wrong technique/lack of trained personnel, there may be a risk of damage to sciatic nerve. A four-year-old boy presented with four day history of left foot drop. He had history of fever for which he consulted a local untrained medical practitioner and received an intramuscular injection at left gluteal region. Magnetic Resonance Imaging (MRI) of pelvis and proximal thigh was performed and showed thickened and increased T2W signal of left sciatic nerve with perineural T2W hyperintensities suggestive of Sciatic Neuritis. Sciatic nerve injury can be potentially devastating, resulting in foot drop due to loss of dorsiflexion of the foot. The most common presentation is a paralytic foot drop that is caused due to involvement of the peroneal division of the sciatic nerve. Imaging of the sciatic nerve by MRI helps in early diagnosis and can assess the extent of involvement.

Post Injection Sciatic Neuritis: A Case Report

For administration of certain drugs, intramuscular injections are used in children. The dorsogluteal area between the iliac crest and the greater trochanter is the most suitable site for intramuscular injection. Due to the poor co-operation of children/wrong technique/lack of trained personnel, there may be a risk of damage to sciatic nerve. A four-year-old boy presented with four day history of left foot drop. He had history of fever for which he consulted a local untrained medical practitioner and received an intramuscular injection at left gluteal region. Magnetic Resonance Imaging (MRI) of pelvis and proximal thigh was performed and showed thickened and increased T2W signal of left sciatic nerve with perineural T2W hyperintensities suggestive of Sciatic Neuritis. Sciatic nerve injury can be potentially devastating, resulting in foot drop due to loss of dorsiflexion of the foot. The most common presentation is a paralytic foot drop that is caused due to involvement of the peroneal division of the sciatic nerve. Imaging of the sciatic nerve by MRI helps in early diagnosis and can assess the extent of involvement.

The role of tibialis posterior tendon transfer in foot drop by circumtibial route and evaluation of the results according to criteria

Background: The transfer of the tibialis posterior tendon to the anterior aspect of the ankle not only replaces the function of the paralyzed muscles, but also removes the deforming force on the medial aspect of the foot. This study was conducted to find the role of tibialis posterior tendon transfer in foot drop by circumtibial route and with evaluation of the results according to criteria.Methods: This study was conducted in MLB Medical College and Hospital, Jhansi. Patients of paralytic foot drop due to leprosy with a moderately strong tibialis posterior muscle were selected from the outpatient department of Orthopaedics and Leprosy reconstructive surgery units. After taking informed consent, detailed history was taken. Data was analyzed using Microsoft Excel and the difference was considered to be significant if ‘p’ value was <0.05.Results: Eleven patients were operated. Majority were males (82%). Eight patients (73%) had excellent and good results which were aged less than forty years. Two cases showed excellent results after corrective surgery that had deformities from 31 to 36 months before operation. Out of six patients who were taking antileprotic treatment, one (9.1%) showed excellent and three (27.3%) showed good results.Conclusions: Method of anterior transfer of tibialis posterior for correction of foot drop has given encouraging results in a fairly large percentage of cases. The greatest utility of such a transfer is that of allowing the freedom of normal mobility in comparison to bony stabilization. After correction of deformity and disability the patient’s mental health is improved.

Triple Arthrodesis for Adult-Acquired Flatfoot Deformity.

Originally described as a means to address fixed deformities or uncontrolled movement of the hindfoot observed in paralytic foot deformities, triple arthrodesis has evolved into a powerful procedure for the correction of a variety of foot deformities. Over the past decade, multiple advances have been made with respect to diagnostic imaging, fixation options, bone graft substitutes, and postoperative regimens. While this operation requires experience and skill to execute, when properly performed, it allows for correction of deformity and a plantigrade and ideally pain-free foot for ambulation. The purpose of this review is to highlight advances in the procedure and its application to the rigid planovalgus foot.Level of Evidence:Level V, review.

Functional Outcomes Following Anterior Transfer of the Tibialis Posterior Tendon for Foot Drop Secondary to Peroneal Nerve Palsy.

This retrospective comparative study reports the practical function in daily and sports activities after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Seventeen patients were followed for a minimum of 3 years after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Matched controls were used to evaluate the level of functional restoration. Functional evaluations included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) scores, and isokinetic muscle strength test. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, hindfoot alignment angle, and navicular height. Mean AOFAS, FAOS, and FAAM scores significantly improved from 65.1 to 86.2, 55.6 to 87.8, and 45.7 to 84.4 points at final follow-up, respectively. However, all functional evaluation scores were significantly lower as compared to the control group ( P < .001). Mean peak torque (60 degrees/sec) of ankle dorsiflexors, plantarflexors, invertors, and evertors at final follow-up were 7.1 (deficit ratio of 65.4%), 39.2, 9.8, and 7.3 Nm, respectively. These muscle strengths were significantly lower compared to the control group ( P < .001). No significant differences in radiographic measurements were found, and no patients presented with a postoperative flat foot deformity. One patient (5.9%) needed an ankle-foot orthosis for occupational activity. Anterior transfer of the tibialis posterior tendon appears to be an effective surgical option for paralytic foot drop secondary to peroneal nerve palsy. Although restoration of dorsiflexion strength postoperatively was about 33% of the normal ankle, function in daily activities and gait ability were satisfactorily improved. In addition, tibialis posterior tendon transfer demonstrated no definitive radiographic or clinical progression to postoperative flat foot deformity at intermediate-term follow-up. Level IV, retrospective case series.

Tomasz Drobnik (1858-1901).

Tomasz Drobnik (1858-1901).

The Adult Paralytic Foot

The adult paralytic foot is a common clinical entity. It has numerous neurologic, systemic, and traumatic causes that result in muscle imbalance and foot deformity. A thorough physical examination and diagnostic work-up, as well as an understanding of the relevant functional anatomy, are essential to proper management. Treatment goals include the establishment of a plantigrade foot, elimination of deforming forces, and, when possible, restoration of active motor control.

The Role of Pantalar Arthrodesis in the Treatment of Paralytic Foot Deformities

Pantalar arthrodesis is considered by many to be the final operative option before amputation for the treatment of paralytic foot deformities. The aim of the present study was to evaluate the long-term results of pantalar arthrodesis with regard to its impact on the adjacent joints and the walking ability of patients with paralytic foot deformities. Twenty-four patients (seventeen men and seven women) who underwent a one-stage pantalar arthrodesis between 1953 and 1973 for the treatment of sequelae of poliomyelitis were reevaluated. All patients underwent a physical and radiographic examination, and all completed the Short Form-36 questionnaire and a pantalar arthrodesis specific questionnaire. The average age of the patients was twenty years at the time of the operation and 57.2 years at the time of the latest evaluation. The average duration of follow-up was 37.2 years. Eleven patients had development of immediate postoperative complications, including wound-healing problems (nine) and infections (two). The long-term results,however, were good (mean Short Form-36 scores, 73 of 100 points [overall], 51.5 points [physical functioning], and >70 points [all other domains]). Sixteen patients experienced repeated episodes of ipsilateral knee pain; most (fifteen) of these patients experienced a gradual onset of this pain, starting at an average of 20.8 years (range, fifteen to thirty years) postoperatively. The position of the fused ankle did not appear to have a significant impact on the development of ipsilateral knee pain or the time interval between the pantalar arthrodesis and the onset of ipsilateral knee pain. Pantalar arthrodesis effectively stabilizes the ankle, hindfoot, and midfoot in patients with severe paralytic deformities. Even though most patients can be expected to have development of osteoarthritis of the ipsilateral knee, it seems that a successfully performed pantalar arthrodesis in carefully selected cases is a reliable operative option offering a strong and stable foot that will function well for many years.

Thalo Navicular Arthrodesis Of Steinhaeuser In Senegal

Thalo Navicular Arthrodesis Of Steinhaeuser In Senegal

Osteotomies of the Foot for Cavus Deformities in Children

The cavovarus foot has been defined as plantar flexion of the first ray. The usual cause is due to a muscle imbalance. The purpose of this study was to report our experience with selective, joint-sparing osteotomies of the foot that address each deformity in the cavovarus foot in a stepwise fashion. Most bony procedures for correction of cavus feet have centered on osteotomies across multiple joints or fusions. We report on stepwise osteotomies: (1) closing wedge to the first metatarsal, (2) opening plantar wedge of the medial cuneiform, (3) cuboid closing wedge, (4) and as needed second and third metatarsal osteotomies, calcaneal sliding osteotomies, and plantar fasciotomy and peroneus longus-to-brevis transfer. We measured all feet radiographically and clinically. We studied 20 feet in 13 patients with multiple etiologies. Nearly all feet were graded good to excellent on our outcome scale. Correction in Meary and Hibb angles was observed. There were no significant complications. By performing a double osteotomy on the first ray (cuneiform and metatarsal), the cavus can be nearly fully corrected. The cuboid osteotomy provides increased mobility of the forefoot. The sliding calcaneal osteotomy should be used to improve any residual hindfoot varus. We recommend transferring the peroneus longus to brevis to balance the paralytic foot. The cavus foot needs to be addressed at the apex, while sparing the midtarsal joints and avoiding fusion. This sequence of osteotomies addresses all of the components of a cavus foot. Therapeutic study-level IV.

The Role of Pantalar Arthrodesis in the Treatment of Paralytic Foot Deformities

Pantalar arthrodesis is considered by many to be the final operative option before amputation for the treatment of paralytic foot deformities. The aim of the present study was to evaluate the long-term results of pantalar arthrodesis with regard to its impact on the adjacent joints and the walking ability of patients with paralytic foot deformities. Twenty-four patients (seventeen men and seven women) who underwent a one-stage pantalar arthrodesis between 1953 and 1973 for the treatment of sequelae of poliomyelitis were reevaluated. All patients underwent a physical and radiographic examination, and all completed the Short Form-36 questionnaire and a pantalar arthrodesis-specific questionnaire. The average age of the patients was twenty years at the time of the operation and 57.2 years at the time of the latest evaluation. The average duration of follow-up was 37.2 years. Eleven patients had development of immediate postoperative complications, including wound-healing problems (nine) and infections (two). The long-term results, however, were good (mean Short Form-36 scores, 73 of 100 points [overall], 51.5 points [physical functioning], and >70 points [all other domains]). Sixteen patients experienced repeated episodes of ipsilateral knee pain; most (fifteen) of these patients experienced a gradual onset of this pain, starting at an average of 20.8 years (range, fifteen to thirty years) postoperatively. The position of the fused ankle did not appear to have a significant impact on the development of ipsilateral knee pain or the time interval between the pantalar arthrodesis and the onset of ipsilateral knee pain. Pantalar arthrodesis effectively stabilizes the ankle, hindfoot, and midfoot in patients with severe paralytic deformities. Even though most patients can be expected to have development of osteoarthritis of the ipsilateral knee, it seems that a successfully performed pantalar arthrodesis in carefully selected cases is a reliable operative option offering a strong and stable foot that will function well for many years.

Two Hundred Cases of Paralytic Foot Stabilization after the Method of Hoke

Dr. Oscar Lee Miller was born on a farm in Franklin County, in northeast Georgia [6]. He obtained a teachers’ certificate and taught school several years after high school before he attended the University of Georgia and then graduated from the Atlanta College of Physicians and Surgeons (now Emory University School of Medicine) in 1912. He took postgraduate training in Atlanta, working with Dr. Michael Hoke (whose name is associated with hindfoot arthrodesis). He entered military service in 1917, then returned to private practice after the armistice. As with other first Presidents of the AAOS, foreign experience was important, and in 1921 he visited Sir Robert Jones and other British surgeons. Upon returning he moved to Gastonia, North Carolina and helped develop the North Carolina Orthopaedic Hospital, an institution focusing on crippled children. In 1923, he opened an office which eventually became the Miller Clinic in nearby Charlotte. (The Miller Clinic and Charlotte Orthopedic Specialists merged in 2005 to create OrthoCarolina.)Dr. Miller was active in the AOA as well as the AAOS, and was a member of the Argentine Surgical Association. He became President of the AAOS in January, 1942, only days after the bombing of Pearl Harbor. In his Presidential address he emphasized the importance of the care of crippled children and urged a strong relationship with the Latin American orthopaedic community [1]. He served as Chair of a committee that created the Inter-American Orthopaedic Fellowship Program, for Latin American surgeons to visit training centers in the US. He also urged the AAOS to develop a library “as a repository for all pertinent records.” The Executive Committee outlined a program in June, 1941, to present a “motion picture exhibit,” a feature of the meeting which subsequently became the Instructional Course Lecture [2]. Under his leadership at that meeting, the AAOS passed a resolution regarding support of the country during the war years: “It is the desire of the American Academy of Orthopaedic Surgeons to offer its wholehearted support to our Country in this serious emergency.” A telegram with the resolution was sent to the President of the United States.Miller had a lasting interest in foot surgery, undoubtedly influenced by Hoke. We reprint here Miller’s report of Hoke’s triple arthrodesis for paralytic feet [3]. Astonishingly, Miller states this was the only operation performed for paralytic feet in his clinic over a three-year period, yet he reported 200 cases in this short time; obviously the number of polio patients at the time was devastating. Among these 200 cases, 121 were of the “clubfoot type,” 62 had pes cavus (on which he wrote in 1927 [4]), and 17 pes calcaneus (on which he wrote in 1936 [5]). Miller reports eight cases of flail feet (although it is unclear whether these are additional cases, or fall within one of the three categories since the numbers of those categories add to 200). His focus is to describe the basic operations with indications for supplemental procedures including tendon transfers. As was often common practice in describing procedures at the time, he did not report the followup results and did not provide references [3]. Oscar Lee Miller, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.ReferencesHeck CV. Commemorative Volume 1933–1983 Fifty Years of Progress. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Heck CV. Fifty Years of Progress: In Recognition of the 50th Anniversary of the American Academy of Orthopaedic Surgeons. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.Miller O. Two hundred cases of paralytic foot stabilization after the method of Hoke. J Bone Joint Surg Am. 1925;7:85–97.Miller O. A plastic foot operation. J Bone Joint Surg Am. 1927;9:84–91.Miller O. Surgical management of pes calcaneus. J Bone Joint Surg Am. 1936;18:169–172.Oscar Lee Miller 1887–1970. J Bone Joint Surg Am. 1971;53:400–401.

1E2-05 触覚バイオフィードバックに基づく歩行リハビリ支援システム : 第2報:足圧取得・呈示インタフェースを用いた座位・立位リハビリプログラムの構築(OS 歩行支援システム)

We newly propose a locomotion rehabilitation system for stroke patients based on tactile-biofeedback that provides foot contact pressures on the paralytic side onto the body of their non-paralytic side. The proposed system is composed of two tactile interfaces: one of which enables to detect foot contact pressures on the paralytic side during locomotion and the other provides pushing contact senses onto a non-paralytic body surface, based on the contact pressures detected on the paralytic foot. Clinical testing for three stroke patients indicates this system allows the paralytics to improve the adjusting capability of weight and balance at a balancing training with the interfaces after a short training on its usage. The result confirms that our proposed locomotion rehabilitation system has a high potential to enable paralytics to regain the sense of earthing on the paralytic foot and to promote motor recovery after stroke.

A previously unreported variation related to the insertion of the tibialis anterior muscle and the superficial fibular (peroneal) nerve

During dissection classes in 2003 in the Department of Anatomy at Ege University Faculty of Medicine, an unexpected variation of the insertion of the tibialis anterior tendon was determined on the right side of a formalin-fixed cadaver of a 40-year-old man without any trace of scars, adhesions or signs of trauma or operation. The insertion of the tibialis anterior tendon was very abnormal, not on the medial side of the foot but on the lateral side. The tibialis anterior is an important muscle because of its function and use in tendon transfer as a treatment of recurrent congenital clubfoot and paralytic equinovarus foot deformities in cerebral palsy and arthroscopy, as discussed herein.

THERMOGRAPHIC STUDY OF LOW LEVEL LASER THERAPY FOR ACUTE-PHASE INJURY

Acute-phase injury is generally treated by localized cooling of the region, and rarely by the active use of low level laser therapy (LLLT) in Japan. Thermographic studies of acutephase injury revealed that circulatory disturbances at the site of trauma occurred due to swelling and edema on the day following the injury, and that skin temperature was high at the site of the trauma and low at the periphery. Following LLLT, circulatory disturbances rapidly improved, while temperature in the high temperature zone around the site of trauma fell by 3 degrees on the average, but at the periphery the low temperature rose by 3 degrees on the average to nearly normal skin temperature. Clinically, swelling and edema improved. LLLT was also useful in treating necrosis of the skin in the wound area and in accelerating healing of surgical wounds of paralytic feet, which are prone to delayed, wound healing and also wounds due to spoke injury. LLLT is useful in treating swelling and edema in acutephase injury and in accelerating healing of surgical wounds.

A fixational method of tendon transfer in foot surgery.

Tendon transfer has been used for correcting foot deformities and improving foot function in paralytic and spastic foot problems. The traditional fixational method by Cole's pull-out button often induces pressure sores which make the button sink and loosens the transferred tendon, leading to poor surgical results. By using a metal eye cover and pull-out wire instead of button and suture material, the transferred tendon can be firmly fixed. Moreover, the concavity of the metal eye cover is suitable for the arch of the foot that provides a large contact surface & even pressure distribution to prevent the most common complications of the pull-out button method, the pressure sore.

PARALYTIC DROP FOOT AND GLUTEAL FIBROSIS AFTER INTRAMUSCULAR INJECTIONS

Eight children with paralytic drop foot after intramuscular injections later developed gluteal fibrosis. Sciatic palsy, presenting as equinovarus or equinus deformity, was diagnosed on average 3.8 months after the intragluteal injections, but gluteal fibrosis was not diagnosed until 5.1 years after the injections. In three patients the equinovarus recurred after surgical correction due to persistent muscle imbalance and the effect of the external rotation contracture of the hip.

Paralytic drop foot and gluteal fibrosis after intramuscular injections

Eight children with paralytic drop foot after intramuscular injections later developed gluteal fibrosis. Sciatic palsy, presenting as equinovarus or equinus deformity, was diagnosed on average 3.8 months after the intragluteal injections, but gluteal fibrosis was not diagnosed until 5.1 years after the injections. In three patients the equinovarus recurred after surgical correction due to persistent muscle imbalance and the effect of the external rotation contracture of the hip.

Occult intraspinal anomalies and congenital scoliosis.

Of 251 patients with congenital scoliosis, occult congenital intraspinal anomalies were diagnosed in forty-six (18.3 per cent). A diastematomyelia was the commonest anomaly (forty-one patients). Other less common anomalies, occurring alone or in association with a diastematomyelia, were: neurenteric, epidermoid, and dermoid cysts; teratoma; lipofibroma; absence of nerve roots; fibrous bands; and a tight filum terminale. Intraspinal anomalies were associated with all types and sites of congenital scoliosis by far the highest incidence (52 per cent) occurred in association with a unilateral unsegmented bar with contralateral hemivertebrae in the lower thoracic or thoracolumbar regions. Thirty of the patients with an intraspinal anomaly had neural abnormalities, which usually affected only one lower extremity, and in twenty-four patients a paralytic foot deformity developed. Neural deterioration occurred in nine of these patients before the age of five years and was halted by excision of the anomaly. An additional twelve patients (4.8 per cent) of the 251 with congenital scoliosis also had a unilateral neural deficit in the lower limb and a paralytic foot deformity, similar to those found in the patients with an intraspinal anomaly, but had no myelographic evidence of a structural anomaly.