Review of ankle rehabilitation devices for treatment of equinus contracture.

INTRODUCTION: Equinus contracture is a serious disability and attention should be paid to proper and effective treatment. Most attention is given to neurologically impaired patients, but the incidence of equinus contracture is much higher, for example, in post-traumatic patients. In addition to conventional physical therapy, robotic rehabilitation treatment is one of the promising procedures to precede severe contraction cases and the need for surgery. AREAS COVERED: This study aims to cover the description of different types of stationary and wearable ankle rehabilitation devices suitable for the treatment of equinus contracture and point to deficiency in research, clinical trials, and launch of the market. EXPERT OPINION: This review provides insight into ankle rehabilitation devices with a focus on equinus contracture. Due to the fact that robotic devices successfully restore the condition of patients, attention should not be paid only to those with neurological impairments. This paper points that future research should be effectively linked to clinical practice with the aim of covering a wider range of disabilities and make an effort to successfully introduce devices from development into the practice.

Is shortening of Tibialis Anterior in addition to calf muscle lengthening required to improve the active dorsal extension of the ankle joint in patients with Cerebral Palsy?

INTRODUCTION: Shortening of the tibialis anterior tendon (TATS) has been shown to improve the ankle dorsiflexion in swing following the calf muscle lengthening procedure (CMLP) in patients with cerebral palsy (CP). Others have reported the similar improvements following CMLP but without TATS. However there are no studies comparing both procedures. Therefore the purpose of the study was to compare the ankle dorsiflexion in swing and foot position in the sagittal plane during gait following TATS and CMLP to that of CMLP alone. MATERIALS AND METHODS: A retrospective study was carried out in CP patients who presented with fixed equinus deformity. They were grouped into unilateral CP and bilateral CP. Depending on the procedures, each group was again subdivided into subgroup CMLP only and subgroup CMLP and TATS (CMLPTATS). All patients were subjected to pre and postoperative clinical and gait analysis. RESULTS: 44 feet in 44 patients were included in the study. Of these, 24 feet (24 patients) belonged to unilateral and 20 feet (20 patients) to bilateral CP group. The mean age of the patients at surgery was 11.5 years (6.0 - 29.0) in the unilateral CP group and 10.5 years (5.0-34.0) in the bilateral CP group. In the unilateral CP group, 12 feet belonged to subgroup CMLP and 12 to subgroup CMLPTATS with a mean equinus contracture of 7.5° in both subgroups. In bilateral CP group, 11 feet belonged to subgroup CMLP with a mean equinus contracture of 5° and 9 to subgroup CMLPTATS, with a mean equinus contracture of 10°. The subgroups did not vary significantly in the demographics, anthropometry, kinematics and kinetics of ankle joint preoperatively. The mean follow up time was 19.7 months. The surgery produced significant changes in both groups and subgroups. However, none of the relevant gait parameters were significantly different between groups and subgroups. SIGNIFICANCE: Adding TATS to CMLP, compared to CMLP alone did not improve ankle dorsiflexion in swing and the foot position more than CMLP alone.

Modified Extended External Fixator Frame for Leg Elevation in Trauma.

Lower extremity trauma is very often managed by applying an external fixator to stabilize the fracture site. These limbs very frequently require multiple surgeries, which predisposes them to problems like heel pressure sore, equinus deformity and limb edema. These complications prolong the healing time and create obstacles in rehabilitation. Our aim was to modify the usual uniplanar external fixator in such a way that it is able to provide stable limb elevation and also keep the leg and the foot in such a position, so as to avoid the above-mentioned complications. We used our frame in 10 patients and none of our patients developed heel ulceration or equinus deformity. We found that the frame enables easier daily examination of the wound and improves patient comfort during dressing changes.

Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot.

BACKGROUND: Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity. METHODS: We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications. RESULTS: Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems. CONCLUSIONS: Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Achilles tendoscopy.

Endoscopic surgery provides a minimally invasive approach to visualize and treat several pathologic conditions of the Achilles tendon. Open surgery on the Achilles tendon is notorious for wound complications, whereas endoscopic procedures have been recognized for less scaring, less perioperative pain, fewer wound complications, and faster recovery. This article reviews various endoscopic techniques for the treatment of equinus contracture, Achilles rupture, Haglund's deformity, and noninsertional Achilles tendinopathy.

Endoscopic gastrocnemius release.

Endoscopic gastrocnemius release (EGR) is a recently developed procedure that is a reliable option for surgical management of ankle equinus contracture. Comfort with endoscopic equipment and surgical anatomy, especially the sural nerve, is of paramount importance for performing the procedure safely, effectively, and efficiently. The primary advantage of the procedure is improved cosmesis and decreased wound complications of the smaller surgical scars. The current body of literature of clinical outcomes for EGR consists of limited level IV case series with broad variations in study rigor, author training background, and the surgical technique itself.

Silfverskiold's test in total ankle replacement with gastrocnemius recession.

BACKGROUND: For patients undergoing primary total ankle replacement (TAR) with an equinus contracture, gastrocnemius recession may be performed to increase dorsiflexion. We examined whether gastrocnemius recession would significantly increase dorsiflexion even with a negative Silfverskiöld test. METHODS: Data were prospectively collected on a consecutive series of 29 patients who underwent TAR. All were deemed to require lengthening of the posterior soft tissue structures for unacceptable equinus contracture. Once each patient was under anesthesia, Silfverskiöld's test was performed. A digital photograph was taken with the ankle at maximum passive dorsiflexion with the knee at 0 degrees of flexion and again with the knee at 30 degrees of flexion. Strayer gastrocnemius recession was then performed in standard fashion in every patient. After recession, Silfverskiöld's test was again performed with photographs obtained in the same manner. The digital photographs demonstrating the results of the preoperative and postoperative Silfverskiöld's tests in both knee positions were analyzed and the degree of ankle dorsiflexion measured. RESULTS: Regardless of the results of Silfverskiöld's test, after gastrocnemius recession, patients had an average increase of 12.6 ± 1.6 degrees of dorsiflexion with the knee extended compared to the same position preoperatively (P < .0001) and an increase of 10.1 ± 2.0 degrees with the knee flexed (P < .001). In 6 patients Silfverskiöld's test was markedly positive preoperatively; in this group, recession resulted in an average increase of dorsiflexion of 17.8 ± 3.6 degrees with the knee extended (P = .004) and 13.4 ± 5.4 degrees with the knee flexed (P = .055). For the remaining 23 patients with a negative preoperative Silfverskiöld's test, dorsiflexion increased by 11.3 ± 1.6 (P < .0001) and 9.3 ± 2.2 degrees (P = .0003) with the knee extended and flexed, respectively. CONCLUSION: Our data show that a gastrocnemius recession resulted in a significant, reproducible increase in dorsiflexion regardless of the results of the Silfverskiöld test while avoiding potential push-off and plantarflexion weakness associated with an Achilles lengthening. LEVEL OF EVIDENCE: Level IV, case series.