[Palliative surgical treatment of spastic paralysis in the lower extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades inferiores.

AIMS: The purpose of this paper is to describe our experience with and to review the best results in the surgical treatment of patients suffering from spastic paralysis of the lower limbs. DEVELOPMENT: To enable a correct indication of the techniques to be employed the authors recommend a thorough examination of the types of deformity (fixed, dynamic or mixed) and the use of specific tests for exploring the different deformities. These are necessary steps to be able to interpret the different disorders in a global manner and thus reach diagnostics that provide us with a proper surgical therapeutic orientation about the spastic hip, knee, ankle and foot. Due to the importance of the overall problem, it is becoming increasingly more frequent to advise multidisciplinary work involving the collaboration of different specialists (neurologists, rehabilitators, physiotherapists, psychologists, paediatricians, neurophysiologists and orthopaedic surgeons). Spasticity is as heterogeneous as the results of the different treatment projects. The techniques used must allow the rehabilitation therapy to be continued. Surgical intervention is recommended when the damage to the CNS has stabilised and the patient is over 4 years old. The psychic state of the patient and the family must also be evaluated. CONCLUSIONS: The objective of the treatment in patients who can walk is to improve motor functioning, the type of gait and to prevent fixed deformities from developing. In patients who do not walk, the aim is to improve their hygiene and their capacity to sit and to walk. These indications are indispensable to be able to successfully perform a little-known area of orthopaedic surgery which does not respond to the techniques used in flaccid paralysis surgery.

[Palliative surgical treatment of spastic paralysis in the upper extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades superiores.

AIMS: In this paper we review the main studies conducted on therapy applied to the bony and soft parts in spastic paralysis of the upper extremity. DEVELOPMENT: Spasticity presents muscular hypertonia and hyperexcitability of the stretch reflex, which are typical of upper motoneuron syndrome. Physiopathologically, spasticity is due to the medullar and supramedullar alteration of the afferent and efferent pathways. Treatment is multidisciplinary and involves the collaboration of rehabilitators, neurophysiologists, neurologists, paediatricians, orthopaedic surgeons and psychologists, who all contribute with their different therapeutic aspects and characteristics (which can be pharmacological, peripheral neurological blockages, surgical, etc.). The characteristic posture of the upper extremities in spastic cerebral palsy is the inward rotation of the shoulder, flexion of the elbow and pronated forearm, and the deformity of the fingers (swan-neck and thumbs-in-palm). The primary objectives in these patients will be to improve communication with their surroundings, perform activities of daily living, increase mobility and walking. CONCLUSIONS: The surgical treatment applied by orthopaedic surgeons in the upper extremities are aimed at achieving an enhanced adaptive functionality rather than morphological normality. Factors to be taken into account include age, voluntary control over muscles and joints, level of severity of the spasticity (Ashworth scale) and stereognostic sensitivity. In general, on soft parts we will use procedures such as dehiscence or lengthening of the flexor muscles of the shoulder and elbow or of the adductor of the thumb; transfer of the pronators in order to adopt the supinating function or of the flexors so as to reinforce the extensors of the forearm, and capsulodesis or tenodesis in the hand. The bony procedures will consist in derotational osteotomies of the humerus and radius and arthrodesis in the wrist or in the metacarpophalangeal joints of the thumb, depending on whether there is greater rigidity or age in the former cases or instability in the latter.