Therapeutic efficacy and safety of various botulinum toxin A doses and concentrations in spastic foot after stroke: a randomized controlled trial

No recommended guidelines currently exist for the therapeutic concentration or dose of botulinum toxin type A(BTXA) injected into the muscle to treat limb spasticity. Therefore, in this randomized controlled trial, we explored the safety and efficacy of two concentrations and two doses of BTXA in the treatment of spastic foot after stroke to optimize this treatment in these patients. Eligible patients(n = 104) were randomized into four groups. The triceps surae and tibialis posterior on the affected side were injected with BTXA at one of two doses(200 U or 400 U) and two concentrations(50 U/m L or 100 U/m L). The following assessments were conducted before as well as 4 days and 1, 2, 4, and 12 weeks after treatment: spasticity, assessed using the modified Ashworth scale; basic functional mobility, assessed using a timed up and go test; pace, assessed using a 10-meter timed walking test; and the ability to walk, assessed using Holden's graded scale and a visual analog scale. The reported results are based on the 89 patients that completed the study. We found significant differences for the two doses and concentrations of BTXA to improve the ability of patients to walk independently, with the high-dose/low-concentration combination providing the best effect. Onset and duration of the ameliorating effects of BTXA were 4–7 days and 12 weeks, respectively. Thus, BTXA effectively treated foot spasms after stroke at an optimal dose of 400 U and concentration of 50 U/m L.     

Biomechanics of first ray hypermobility: An investigation on joint force during walking using finite element analysis

Hypermobility of the first ray is suggested to contribute to hallux valgus. The investigation of first ray hypermobility focused on the mobility and range of motion that based on manual examination. The load transfer mechanism of the first ray is important to understand the development and pathomechanism of hallux valgus. In this study, we investigated the immediate effect of the joint hypermobility on the metatarsocuneiform and metatarsophalangeal joint loading through a reduction of the stiffness of the foot ligaments.A three-dimensional foot model was constructed from a female aged 28 via MRI. All foot and ankle bones, including two sesamoids and the encapsulated bulk tissue were modeled as 3D solid parts, linking with ligaments of shell elements and muscles connectors. The stance phase of walking was simulated by the boundary and loading conditions obtained from gait analysis of the same subject.Compared with the normal foot, the hypermobile foot had higher resultant metatarsocuneiform and metatarsophalangeal joint forces. The increases accounted for 18.6% and 3.9% body weight. There was also an abrupt change of metatarsocuneiform joint force in the medial–lateral direction. The predicted results represented possible risk of joint problems and metatarsus primus varus.     

内侧撑开胫骨高位截骨Tomofix内固定治疗膝内翻的初步观察

目的探讨内侧撑开胫骨高位截骨结合Tomofix内固定治疗膝内翻畸形的手术方法及短期疗效.方法 2009年10月至2010年8月,采用内侧撑开胫骨高位截骨(open wedge high tibial osteotomy,OWHTO)结合Tomofix锁定钢板内固定治疗膝内翻9例10个膝关节.术前、术后、术后2个月、6个月行X线片检查测量胫骨平台后倾角、胫骨股骨角、Insall-Salvati指数、并行Lysholm功能评分.结果患者术后随访2-10个月,平均6.2个月.胫股角从术前185.8°±2.5°降至 174.4°±2.7°,术前与术后胫骨平台后倾角、Insall-Salvati指数、Lysholm评分无明显差异,患者术后3-4周基本恢复负重行走,术后6个月截骨处均一期愈合,无感染、骨不愈合、膝关节不稳及神经损伤等并发症,终末随访无膝内翻复发,术后疼痛及行走功能改善显著.结论内侧撑开胫骨高位截骨Tomofix内固定操作较简单,创伤小,并发症少,对关节正常解剖影响较小,可作为治疗膝内翻畸形和单间室骨关节炎的有效方法之一.     

儿童肱骨髁上骨折肘内翻机理研究进展

肱骨髁上骨折在小儿肘部骨折中最为多见,发病率占肘部骨折50%～60%,虽然儿童肱骨髁上的治疗方法较多,但是均不能有效避免肘内翻的形成.本文从解剖和生物力学对儿童肱骨髁上骨折肘内翻发生机理的进展作一综述.     

足背隆凸症

本文报道了一种新发现的足部疾病,并命名为足背隆凸症。典型的卧床表现为单侧足背偏内侧皮下骨性肿块伴有患足程度不一的疼痛。X线切位片显示(口止母)第一或第二跖跗关节背侧缘唇样骨质增生、关节间隙变窄等退行性病变特征。强调本症应与(口止母)长伸肌腱腱鞘炎相鉴别。保守治疗方法简单易行,效果良好。并讨论了发病机制,进行了力学分析,认为本症是一种发生在足结构虚弱基础上,由于积累性劳损所致的足跖跗关节退行性改变。     

The elastic high tibia valgusosteotomy in the varus deformity

The alignment of the lower limb is a fundamental condition for the static and the dynamic load of the joints, especially the knee joint. Medial overload in a varus knee enhances cartilage deterioration and early degenerative changes in the medial compartment, leading to compartmental osteoarthritis. This is even of greater importance if the medial meniscus is altered, torn, or excised. Ligamentous instability such as anterior cruciate ligament (ACL) insufficiency (ACL is an antivarus restraint), posterior cruciate ligament insufficiency, lateral instability, combined posterolateral, or even worse, anteroposterolateral instability, increase the varus load tremendously. Therefore, correction of the alignment is a basic orthopaedic principle of treatment. The "unloader" braces may have a limited effect, but the best unloader is a correct osteotomy (OT). OT is not just an easy procedure. To avoid the many described failures, we developed a new technique that is explained here. Our incomplete OT with elastic deformation of the proximal tibia allows one to chose perioperatively the necessary correction angle and to fix it in any desired position. Also a release for reducing the attained correction is still possible, when perioperative radiographs show too much of correction. This new OT system also creates immediate stability without primary and/or secondary loss of correction. Early partial and full weight bearing is possible. These are the fundamental advantages of this elastic valgus OT of the proximal tibia.     

Articular geometry of the medial tarsometatarsal joint in the foot: Comparison of metatarsus primus adductus and metatarsus primus rectus

The three-dimensional surface geometry of the medial tarsometatarsal joint ("first metatarsocuneiform") of the first ray was analyzed to determine if the shape of the joint is distinct in the medially deviated first metatarsal with metatarsus primus adductus (MPA). Clinical evaluation of 29 cadaver feet identified 13 feet with MPA and 16 with metatarsus primus rectus (MPR). Three-dimensional (3D) coordinates x, y, z of the first metatarsal and medial cuneiform joint facets of the feet were digitized on a Coordinate Measuring Machine (accuracy = 0.01 mm) and the data fitted with B-spline surfaces from which 3D curvature maps were generated. Comparison of means of surface-averaged maximum and minimum principal curvatures and root-mean-square curvatures showed significant (p < .0005) differences between the MPA and MPR subsets, male and female subsets, and metatarsal and cuneiform subsets. These results show that the articular shape of the medial tarsometatarsal joint in feet with MPA is significantly less contoured, or is flatter, than the same joint in normal or MPR feet. Results also showed that the female joints are more curved than male joints, and that metatarsal and cuneiform facets closely conform in shape to each other. These preliminary results may be related to questions concerning the anatomical and functional basis for the first metatarsal deviation, for radiographic presentation of the joint and surgical options in correcting related forefoot deformities.     

A New Surgical Technique for Medial Collateral Ligament Balancing : Multiple Needle Puncturing

In this article, we present our experience with a new technique for medial soft tissue balancing, where we make multiple punctures in the medial collateral ligament (MCL) using a 19-gauge needle, to progressively stretch the MCL until a correct ligament balance is achieved. Ligament status was evaluated both before and after the procedure using computer navigation and mediolateral stress testing. The procedure was considered successful when 2 to 4-mm mediolateral joint line opening was obtained in extension and 2 to 6 mm in flexion. In 34 of 35 cases, a progressive correction of medial tightness was achieved according to the above described criteria. One case was considered overreleased in extension. Needle puncturing is a new, effective, and safe technique for progressive correction of MCL tightness in the varus knee.     

The role for hip surveillance in children with cerebral palsy

Spastic hip displacement is the second most common deformity seen in children with cerebral palsy (CP), and the long-term effects can be debilitating. Progressive hip displacement leading to dislocation can result in severe pain as well as impaired function and quality of life. Recent population-based studies have demonstrated that a child’s Gross Motor Functional Classification System (GMFCS) level is most predictive for identifying hips “at-risk” for progressive lateral displacement. As a result, in many developed countries, hip surveillance has now been adopted as an integral piece of the comprehensive care puzzle for the management of children with spastic hip displacement. This paper reviews the spectrum of treatments available for progressive hip displacement, examines the current literature on the success of hip surveillance, and illustrates an example of a current hip surveillance program stratified by the GMFCS level.