Gait analysis in hemiplegic patients after gait training or surgery of a foot deformity

The change of gait in stroke patients after gait training or surgery for foot deformity was analyzed according to walking cycle and gait speed and cadence by means of the accelorometer or the large force plate. The results were summarized as follows. Twenty patients receiving gait training. Variation of the stride duration decreased gradually on both sides. The stance phase and the double support phase had the tendency to demonstrate equal percentage on both sides, decreasing in the unaffected side. The percentage values were higher than those in the normal person except a few cases. The cadence increased in all cases except one. Twenty-two patients following surgery for foot deformities. Walking cycle revealed almost the same result as that of cases receiving gait training. The percentage of the double support phase in the unaffected side characteristically approached that of the affected side after surgery, suggesting surgical benefits. Cadence decreased in 7 cases, while gait speed increased in all cases. It may come from the wider stride length after surgery.     

Electric excitability of the peroneal muscles in congenital equinovarus deformity

Irritability of the peroneal muscles by stimuli of the rectangular current in infants with congenital club foot was examined. Examinations were performed immediately before surgery in patients in general Ketamine anesthesia. The first group contained children with unilateral congenital club foot and the normal extremity was examined for comparison. In the group of children with bilateral club foot, one of the feet was examined twice about 4 months apart. A decrease of irritability of the peroneal muscles was found before operation. After operation this irritability reached the proper values. The authors think that the peroneal muscles in congenital club foot are stretched and that after correction of deformation their length and tension become normal.     

Electromyographic analysis of equinovarus following stroke

The pattern of muscle activity was determined in 40 hemiplegic stroke patients with equinus, equinovarus or varus deformities. Although the exact pattern of muscle activity varied with each patient, the following general conclusions are possible. Premature firing of the triceps surae due to release of primitive locomotor control mechanisms and a hyperactive stretch response during limb loading are important causes of equinus. Prolonged firing of the tibialis anterior during stance and inactivity of the peroneus brevis are the principal factors responsible for varus.     

Long-term follow-up of surgery for equinovarus foot deformity in children with cerebral palsy

The factors associated with failed operative intervention in the treatment of equinovarus foot deformity in children with cerebral palsy (CP) were evaluated after long-term follow-up. One hundred eight children with CP who had surgery on the posterior tibialis tendon (split tendon transfer, intramuscular lengthening, or Z-lengthening) on 140 feet were reviewed at a mean age of 16.8 years with 7.3 years of follow-up. The surgery was considered a failure when a 10 degrees or greater varus or valgus hindfoot deformity was present or if an additional operative intervention was required or planned. Involvement of CP, age at operation, and preoperative status of ambulation were significant factors in the outcome of the surgery. Hemiplegic patients demonstrated the best results, regardless of age or surgical procedure. Seventy-five percent of diplegic and quadriplegic patients who were younger than 8 years or who were not capable of community ambulation failed operative intervention, and surgery on the posterior tibialis tendon is not recommended in this group of patients.     

Anterior transfer of the toe flexors for equinovarus deformity of the foot

Summary Anterior transfer of the long toe flexors was carried out for the treatment of spastic equinovarus foot deformity in both adults and children. Adults included those with hemiplegia subsequent to a stroke, spastic hemiplegia due to cerebral palsy and spastic spinal paraplegia. Most of the children had cerebral palsy. The transfer was indicated for an equinovarus foot with persistent activity of the toe flexors, which produced curling of the toes in the swing phase of the gait or a fixed hammer toe deformity.Fifty six patients were followed up for more than four years. In all cases correction of the equinovarus deformity was achieved and maintained. With satisfactory correction stability of the ankle improved, postural abnormalities during gait decreased and bracing was not required.This study demonstrates the advantage of the long toe flexors for muscle transfer in these patients. The length of tendon available permitted easy transfer to the metatarsal. The defunctioning of the spastic muscles allowed gait improvement and function of the tibialis posterior and tibialis anterior was preserved.

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Résumé Le transfert antérieur des longs fléchisseurs des orteils a été utilisé pour corriger la déformation en varus équin du pied spastique, tant chez l'adulte que chez l'enfant. Chez l'adulte, il s'agissait d'hémiplégies secondaires à un accident vasculaire cérébral, d'hémiplégies spastiques dues à une paralysie cérébrale, et de paraplégies médullaires spastiques. La plupart des enfants étaient atteints de paralysie cérébrale. Le transfert a paru indiqué en présence d'un pied varus équin avec fléchisseurs des orteils actifs, entraînant soit une griffe des orteils au cours de la phase pendulaire de la marche, soit une attitude en marteau irréductible.Cinquante-six malades ont été suivis plus de quatre ans. Dans tous les cas la correction du varus équin a été obtenue et s'est maintenue. Grâce à une correction satisfaisante, la stabilité de la cheville a été améliorée, les anomalies posturales au cours de la marche ont diminué et l'appareillage est devenu inutile.Ce travail démontre la supériorité du transfert des longs fléchisseurs des orteils chez de tels malades. La longueur des tendons utilisables permet de les transposer aisément sur la face dorsale du métatarse. La suppression de l'activité de muscles spastiques entraîne une amélioration de la marche et préserve la fonction des muscles jambiers antérieur et postérieur.

     

Selective fasicular neurotomy for spastic equinovarus foot deformity in cerebral palsy children

Spasticity is usually treated by rehabilitation, orthosis, chemical denervations, orthopaedic surgery and neurosurgery. Selective fascicular neurotomy is a neurosurgical procedure consisting in partial section of selected motor nerves innervating spastic muscles. Neurotomy is indicated in cases of localised disabling spasticity without musculotendinous shortening, resistant to chemical denervation and for which a motor nerve block with anaesthetic has given a good functional result. Neurotomy includes division of the afferent Ia and Ib fibers, unable to recover, leading to permanent disappearance of the spasticity. Neurotomy also includes section of the motor efferent fibers with transient paresis as a result. In adults, neurotomy provides functional improvement in 81 to 97% of cases. In case of posterior tibial neurotomy, improved walking stability and a decrease in foot equinus and knee recurvatum is observed. In children, the risk of deformity recurrence seems higher because of motor axonal reinnervation: indications must therefore be carefully considered and rehabilitation provided after surgery.     

Ilizarov技术联合Ponseti方法治疗儿童僵硬性马蹄内翻足的临床研究

目的 探讨Ilizarov技术联合Ponseti方法治疗大龄儿童僵硬性马蹄内翻足畸形的临床疗效.方法 回顾性分析2012年7月至2016年7月玉林桂南医院收治的36例(49足)儿童僵硬性马蹄内翻足病例的临床资料,术前均行负重位踝关节正侧位X线检查,根据安装Ilizarov外固定架治疗前是否进行Ponseti石膏矫正分为...     

Correlation of foot bimalleolar angle with Pirani score to assess the severity of congenital talipes equinovarus deformity

Various reported scores for congenital talipes equinovarus are presented with observer variations and lack in objective evidence of severity of deformity. Anteromedial foot bimalleolar angle (FBM), an objective assessment of deformity and correction, was correlated and compared with Pirani scores 0.5-2, 2.5-4, 4.5-6 as grouped I to III for mean and SD in 244 club feet in 137 children. The mean FBM angles of groups I to III were 79.72°, 68.4°, and 53.27°, respectively. The FBM angle gives an objective assessment of the severity of deformity and can be used as objective evidence of improvement/deterioration of deformity.     

Electromyographic analysis of muscles across the elbow joint

An electromyographic (EMG) technique was developed to study simultaneously the eight major elbow muscles in five normal subjects. Recordings of EMG activity in elbow muscles were obtained while the elbow joint was subjected to resisted flexion, extension, abduction, and adduction functions. The results indicate that activity in the major elbow muscles is determined by the size of the resultant flexion and extension moments created about the elbow joint, but not by varus and valgus moments. These results support the hypothesis that determination of muscle force about a joint depends on joint constraint, namely, the degree of freedom, the resultant joint forces and moments due to externally applied load, and also the function of the muscle, i.e., the line of action of the muscle that crosses the joint. The data may be used to further refine the calculation of muscle force distribution across the elbow joint.     

Talectomy for equinovarus deformity in myelodysplasia

Nine patients with myelomeningocele (seventeen involved feet) had talectomy for the correction of equinovarus deformity. The age at surgery ranged from one year and eight months to seven years and four months old. The length of follow-up averaged seven years and four months and ranged from twenty-two months to twelve years. Fifteen feet had a good and two had a poor correction of the deformity of the hind part of the foot, the result being directly related to the intraoperative correction of the equinus deformity. The correction of the fore part of the foot was rated as good in eight, fair in one, and poor in eight feet. Residual deformity of the fore part of the foot compromised the functional result in six feet that had an acceptable correction of the deformity of the hind part.     

The impact of instrumented gait analysis on surgical planning: treatment of spastic equinovarus deformity of the foot and ankle

BACKGROUND: Despite the logic behind instrumented gait analysis, its specific contribution to clinical and surgical decision making is not well known. Our purpose in this study was to determine the influence of gait analysis with dynamic electromyography upon surgical planning in patients with upper motor neuron syndrome and gait dysfunction. METHODS: Two surgeons prospectively evaluated 36 consecutive adult patients with a spastic equinovarus deformity of the foot and ankle. After an initial history and physical exam, each surgeon independently formulated a surgical plan. Surgical treatment options for each individual muscle/tendon unit crossing the ankle included lengthening, transfer, release or no surgery. After the initial clinical evaluation and surgical planning, all patients then underwent instrumented gait analysis collecting kinetic, kinematic and poly-EMG data using a standard protocol by a single experienced physiatrist. Each surgeon reviewed the gait studies and patients independently and again formulated a surgical plan. The surgical plans were compared for each surgeon before and after gait study. The agreement between the two surgeon's surgical plans was also compared before and after gait study. Each patient was evaluated for the clinical outcome of surgery. RESULTS: Overall a change was made in 64% of the surgical plans after the gait study. The frequency of changing the surgical plan was not significantly different between the more and less experienced surgeons. The agreement between surgeons increased from 0.34 to 0.76 (p=0.009) after the gait study. The number of surgical procedures planned by each surgeon converged after the gait studies. Correction of the varus deformity was seen in all patients that underwent surgical treatment. CONCLUSION: Instrumented gait analysis alters surgical planning for patients with equinovarus deformity of the foot and ankle and can produce higher agreement between surgeons in surgical planning. CLINICAL RELEVANCE: The equinovarus deformity is due to a variety of deforming forces and a single, best operation does not exist to correct all equinovarus deformities. Rather, a muscle specific approach that identifies the deforming forces will produce the best outcomes when treating the spastic equinovarus deformity.     

Benchmark analysis of diabetic patients with neuropathic (Charcot) foot deformity.

During a 10-year period, 237 patients (129 women, 108 men) with a diagnosis of neuropathic (Charcot) arthropathy of the foot and ankle were treated in a tertiary care university hospital medical center. During this period, 115 of the patients (48.5%) were treated nonoperatively as outpatients with local skin and nail care, accommodative shoe wear, and custom foot orthoses. A total of 120 (50.6%) underwent 143 operations. Surgery included 21 major limb amputations, 29 ankle fusions, 26 hindfoot fusions, 23 exostectomies, and 23 debridements for osteomyelitis. It is widely accepted that patients with diabetes are at risk for developing foot ulcers, which can lead to lower extremity amputation. Within the population of diabetic patients, it is widely accepted that patients with neuropathic (Charcot) arthropathy of the foot and ankle have one of the highest likelihoods of having to undergo lower extremity amputation. The current emphasis in care of the foot of a diabetic patient involves a multidisciplinary team approach combining patient education, skin and nail care, and accommodative shoe wear. As data from prophylactic programs become available, resource allocation and cost of care can be compared with this benchmark baseline. This benchmark analysis can be used by those who are responsible for allocating resources and projecting healthcare costs for this "high utilization"/high risk patient population.     

Partial wound closure after surgical correction of equinovarus foot deformity using a synthetic skin substitute

We retrospectively reviewed the results of partial wound closure after surgical release of severe equinovarus deformity in forty-eight (48) feet in thirty-two (32) patients. Epigard^®, a commercially manufactured synthetic skin substitute was used as a temporary coverage medium. The decision to perform synthetic skin substituted partial closure was made intraoperatively, if primary closure with the foot in the corrected position threatened circulatory compromise, or loss of correction. We did not find it necessary to deviate from our usual protocol of 6 weeks of postoperative casting, with one cast change at 3 weeks for hardware removal. There were no infections. No feet required grafting or other secondary procedures, including dressing changes. We conclude that synthetic skin substituted partial wound closure is a viable alternative after surgical correction of the severe equinovarus deformity. This technique avoids the inconvenience of frequent cast changes or uncovered partial wound closure, and the expense and increased surgical risk of skin grafting and rotational flap techniques.     

Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity

We studied 24 children (40 feet) to demonstrate that a physiotherapist-delivered Ponseti service is as successful as a medically-led programme in obtaining correction of an idiopathic congenital talipes equinovarus deformity. The median Pirani score at the start of treatment was 5.5 (mean 4.75; 2 to 6). A Pirani score of > or =5 predicted the need for tenotomy (p < 0.01). Of the 40 feet studied, 39 (97.5%) achieved correction of deformity. The remaining foot required surgical correction. A total of 25 (62.5%) of the feet underwent an Achilles tenotomy, which was performed by a surgeon in the physiotherapy clinic. There was full compliance with the foot abduction orthoses in 36 (90%) feet. Continuity of care was assured, as one practitioner was responsible for all patient contact. This was rated highly by the patient satisfaction survey. We believe that the Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme.     

Electromyographic and force patterns of cerebral palsy patients with windblown hip deformity

The electromyographic activity and the forces around the hip were measured in resting, neutral, and 25 degrees abduction in 13 individuals with spastic quadriplegia and windblown deformity. A direct correlation was found between abduction force and myoelectric activity of the abductors. In the adducted hip, there was sustained activity of the adductors while the activity in the abductors was minimal in all positions. In the abducted hip, there was electrical activity in both abductors and adductors in all positions except 25 degrees abduction when only the adductors were active. The results suggest that early detection of potentially progressive windblown hips in children with cerebral palsy may be achieved by careful assessment of hip range of motion, recognition of spasticity in abductors, and the presence of a "pseudo-Galleazzi sign."     

Electromyographic analysis of the deltoid and rotator cuff muscles in persons with subacromial impingement

The purpose of this study was to compare subjects with subacromial impingement and subjects with normal shoulders with respect to muscle activity. Fifteen subjects in each group were studied by means of fine-wire electromyography. The middle deltoid and rotator cuff muscles were evaluated during isotonic scaption from 30 to 120 degrees. Overall, the impingement group demonstrated decreased mean muscle activity in comparison with the group of normal subjects. The magnitude of diminished activity was statistically significantly different (P < .05) during the 30- to 60-degrees arc for the infraspinatus, subscapularis, and middle deltoid muscles; in addition, the infraspinatus muscle demonstrated significantly depressed activity during the 60- to 90-degrees arc. In the impingement group, the supraspinatus and teres minor revealed a diminution of muscle function in comparison with shoulders in the normal group; the difference was not significant. This study demonstrates that muscle activity in subjects with impingement is most notably decreased in the first arc of motion. Also of clinical relevance is the fact that the inferior force vector (from the infraspinatus and subscapularis) is less functional in subjects with impingement than is the superior compressive vector (from the supraspinatus). Thus, humeral head depression during the critical first portion of elevation may be insufficient in people with subacromial impingement.     

Ilizarov技术矫正儿童僵硬型马蹄内翻足畸形

[目的]探讨Ilizarov技术矫正僵硬性马蹄内翻足畸形的方法和效果。[方法]作者在2000年3月～2005年3月间，使用Ilizarov技术矫正9例11足重度僵硬性马蹄内翻足畸形，将连接于胫骨、跟骨、跖骨的外固定环互相连接、组合成复杂的三维外固定架，通过逐渐调整外固定架矫正畸形，从而使患足达到或接近正常足的外形和功能。[结果]按Garceau标准评定疗效，优6足，良4足，差1足。[结论]Ilizarov外固定架三维矫正马蹄内翻足畸形效果确实，尤其适用于大年龄儿童之僵硬、复发或难治性马蹄内翻足，有一定的临床应用价值。