Efficacy of conservative treatment for spastic cerebral palsy children with equinus gait: a systematic review and meta-analysis.

BACKGROUND: Comparisons between various conservative managements of spastic equinus deformity in cerebral palsy demonstrated limited evidences, to evaluate the efficacy of conservative treatment among cerebral palsy children with spastic equinus foot regarding gait and ankle motion. METHODS: Studies were identified from PubMed and Scopus up to February 2022. Inclusion criteria were randomized controlled trial (RCT), conducted in spastic cerebral palsy children with equinus deformity, aged less than 18 years, compared any conservative treatments (Botulinum toxin A; BoNT-A, casting, physical therapy, and orthosis), and evaluated gait improvement (Physician Rating Scale or Video Gait Analysis), Observational Gait Scale, Clinical Gait Assessment Score, ankle dorsiflexion (ankle dorsiflexion at initial contact, and passive ankle dorsiflexion), or Gross Motor Function Measure. Any study with the participants who recently underwent surgery or received BoNT-A or insufficient data was excluded. Two authors were independently selected and extracted data. Risk of bias was assessed using a revised Cochrane risk-of-bias tool for randomized trials. I2 was performed to evaluate heterogeneity. Risk ratio (RR), the unstandardized mean difference (USMD), and the standardized mean difference were used to estimate treatment effects with 95% confidence interval (CI). RESULTS: From 20 included studies (716 children), 15 RCTs were eligible for meta-analysis (35% had low risk of bias). BoNT-A had higher number of gait improvements than placebo (RR 2.64, 95% CI 1.71, 4.07, I2 = 0). Its combination with physical therapy yielded better passive ankle dorsiflexion at knee extension than physical therapy alone (USMD = 4.16 degrees; 95% CI 1.54, 6.78, I2 = 36%). Casting with or without BoNT-A had no different gait improvement and ankle dorsiflexion at knee extension when compared to BoNT-A. Orthosis significantly increased ankle dorsiflexion at initial contact comparing to control (USMD 10.22 degrees, 95 CI% 5.13, 15.31, I2 = 87%). CONCLUSION: BoNT-A and casting contribute to gait improvement and ankle dorsiflexion at knee extension. BoNT-A specifically provided gait improvement over the placebo and additive effect to physical therapy for passive ankle dorsiflexion. Orthosis would be useful for ankle dorsiflexion at initial contact. Trial registration PROSPERO number CRD42019146373.

Correction of Recurrent Equinus Deformity in Surgically Treated Clubfeet by Anterior Distal Tibial Hemiepiphysiodesis.

BACKGROUND: Residual or recurrent equinus deformity is a common problem in surgically treated clubfeet. This deformity may occur due to soft tissue-related reasons or due to bony deformity. An increased anterior distal tibial angle (ADTA) was previously found in 48% of the operated clubfeet. This study aimed to determine the efficacy and safety of anterior distal tibial hemiepiphysiodesis (ADTE) in the treatment of recurrent equinus deformity in patients with an increased ADTA. METHODS: Eighteen children (23 feet) treated by ADTE to correct recurrent equinus deformity in surgically treated clubfeet were included in this retrospective, single-center study. ADTE using 8 plates was performed in children with an increased ADTA (>82 degrees) and inability to dorsiflex the ankle (≤0 degree of dorsiflexion). The mean patient age was 11.3 years (range: 10.2 to 12.9 y). All patients had completed treatment with implant removal after an average of 20.3 months (range: 9 to 37 mo). RESULTS: The mean preoperative ankle dorsiflexion significantly improved from -3.3 degrees (range: -20 to -0 degrees) to 6.1 degrees (range: -15 to 10 degrees) at the time of 8-plate removal (correction rate: 9.4 degrees; P<0.0001). The ADTA was a mean of 87.5 degrees (range: 83 to 110 degrees) before surgery and significantly improved to 75.8 degrees (range: 63 to 106 degrees) at the time of implant removal (correction rate: 11.7 degrees; P<0.0001). Average follow-up was 43.9 months (range: 10 to 76 mo). Follow-up examinations were continued in 11 patients (13 feet) after implant removal. Changes of ankle dorsiflexion (mean: -2.5 degrees) and ADTA (mean: 3.6 degrees) occurred in this group. CONCLUSIONS: ADTE was safe and effective in the treatment of recurrent equinus deformity in surgically treated clubfeet with increased ADTA. Deterioration of ankle dorsiflexion and ADTA occurred after implant removal in some cases. The results of this study have to be analyzed with caution due to the limited number of included patients and its retrospective nature. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Serial Casting of the Ankle and Knee in a Child With Vascular Anomaly of the Calf Musculature: A Case Report.

BACKGROUND AND PURPOSE: Contracture and toe-walking in children due to vascular anomaly of the calf musculature is rarely described, and there is limited evidence regarding treatment. The purpose of this case is to describe the novel use of serial casting, combining the knee and ankle, to reduce contracture in a child with hemangioma of the calf. CASE DESCRIPTION: An 11-year-old girl received 12 casts of the ankle and knee, followed by custom orthotics, to address chronic contracture and gait impairments caused by a vascular anomaly in the posterior compartment of the lower extremity. OUTCOMES: After casting, the patient had fully restored knee range of motion and improved ankle range of motion by 45 degrees. She received custom orthotics and maintained her range of motion 4 months after casting. DISCUSSION: Serial casting of the knee and ankle may be a useful alternative to surgical lengthenings in patients with chronic contractures caused by vascular anomalies of the lower extremity.

Electrical stimulation of antagonist muscles after botulinum toxin type A for post-stroke spastic equinus foot. A randomized single-blind pilot study.

BACKGROUND: Botulinum toxin type A (BoNT-A) injection is an effective treatment for lower-limb spasticity and should be offered as first-line treatment for focal manifestations. Although its possible role has been hypothesized, the efficacy of electrical stimulation (ES) of antagonists of the injected muscles for improving clinical outcome after BoNT-A injection remains to be established. OBJECTIVES: This randomized single-blind pilot study aimed to investigate the efficacy of ES of antagonist muscles as adjunct treatment after BoNT-A injection to plantar flexor muscles in hemiplegic patients with spastic equinus foot. METHODS: After BoNT-A injection at triceps surae, patients were randomly allocated to 2 groups: group 1, single ES session on injected muscles plus 5 sessions of ES on antagonist muscles, and group 2, single ES session on injected muscles alone. Both groups underwent daily physical therapy for 60min for 2 weeks (5 days/week). Assessments were performed before treatment (T0) and at 10 days (T1), 20 days (T2), and 90 days (T3) after treatment. Our primary outcome was gait velocity at a comfortable speed at T2 (10-m walk test [10MWT]). The following were secondary outcomes: triceps surae spasticity (Modified Ashworth Scale), ankle passive range of motion (pROM), strength of tibialis anterior muscle, and 2-min walk test (2MWT). RESULTS: The 30 patients enrolled were randomly allocated to the 2 groups: 15 in group 1 and 15 in group 2. At T1, T2 and T3, both groups showed a significant reduction in muscle tone and an increase in ankle pROM (P<0.05). At T2 and T3, both groups showed a significant increase in 10MWT and 2MWT. The groups did not significantly differ in tibialis anterior strength or primary or secondary outcome measures. CONCLUSIONS: ES of antagonist muscles does not improve clinical outcomes in the post-stroke spastic equinus foot after BoNT-A injection.

Casting Protocols Following BoNT-A Injections to Treat Spastic Hypertonia of the Triceps Surae in Children with Cerebral Palsy and Equinus Gait: A Randomized Controlled Trial.

AIM: To study the effects of single versus serial casting post-Botulinum toxin A (BoNT-A) injections on hypoextensibility of triceps surae in children, 2-7 years old, with cerebral palsy and equinus gait. METHODS: A randomized, stratified, parallel, two-group trial was conducted at a pediatric health center with assessments at baseline, precast, postcast and, 1-, 2-, and 6-month follow-ups. One week following BoNT-A injections into triceps surae muscle, a single below-knee cast (n = 10) or 3 serial casts (n = 10) were applied for 3 weeks. Primary outcome measure was the Modified Tardieu Scale (MTS), secondary outcome measures were Modified Ashworth Scale (MAS), GAITRite™, Gross Motor Function Measure-66 (GMFM-66), and Pediatric Evaluation of Disability Inventory (PEDI). RESULTS: Significant effects of time, but not group-by-time, were found for MTS R1 (P < 0.001), MTS R2 (P < 0.001), MAS (P = 0.001), GMFM-66 (P = 0.002), and PEDI (P < 0.001-0.009). One participant who received a single cast did not complete the 6-month assessment. CONCLUSIONS: Magnitudes of improvements were similar using single or serial casting. If these findings are corroborated in a larger scale study, the recommendation of a single cast may be appropriate due to its greater convenience for families and clinicians.

Conservative treatment for equinus deformity in children with cerebral palsy using an adjustable splint-assisted ankle-foot orthosis.

BACKGROUND: A novel splint, the assisting ankle-foot orthoses (AFO), was developed to provide adjustable sustained stretching to improve conservative treatment for equinus deformities in children with cerebral palsy (CP). The treatment effect was validated by follow-up visits. METHODS: This study involved subjects between 2 and 12 years old, including 28 CP children treated with splint-assisted AFO correction, 30 CP children treated with static AFO correction, and 30 normal children with typical development (TD). Quantitative pedobarographic measurements were taken to evaluate the effect of splint-assisted AFO correction. The heel/forefoot ratio was introduced to indicate the degree of the equinus deformity during treatment. RESULTS: The results showed that the heel/forefoot ratios were 1.41 ±â€Š0.26 for the TD children; 0.65 ±â€Š0.41, 1.02 ±â€Š0.44, and 1.24 ±â€Š0.51 for the splint-assisted AFO correction before and after 6-month and 12-month treatments; 0.59 ±â€Š0.37, 0.67 ±â€Š0.44, and 0.66 ±â€Š0.42 for the static AFO correction before and after 6-month and 12-month treatments. CONCLUSIONS: This study suggests that correction with the adjustable splint-assisted AFO is an effective treatment for equinus deformity in CP Children.

Tratamiento del pie equino espástico con la técnica de Hsu: estudio de tres años / Treatment of the equine spastic foot with the technique of Hsu: study of three years

Fundamento: la parálisis cerebral es un motivo de gran preocupación para los familiares, constituye la discapacidad física más frecuente de la niñez y es la causa más usual de consulta en Ortopedia Infantil por trastorno neurológico.Objetivo: evaluar la técnica de Hsu en el tratamiento del pie equino espástico en paciente con parálisis cerebral.Métodos: se realizó un estudio longitudinal y descriptivo en 29 pacientes con el diagnóstico de pie equino espástico tratados con la técnica de Hsu en el servicio de Ortopedia y Traumatología del Hospital Pediátrico Universitario Eduardo Agramonte Piña desde mayo 2011 hasta mayo 2014, para evaluar los resultados obtenidos con esta técnica.Resultados: predominaron los pacientes del sexo masculino, la deformidad bilateral, los menores de cinco años de edad y la causa perinatal. Los resultados fueron satisfactorios en la mayoría de los casos y las complicaciones todas menores.Conclusiones: la técnica de Hsu es una buena opción terapéutica en pacientes con pie equino espástico y parálisis cerebral, por ser un procedimiento sencillo, por sus escasas complicaciones y buenos resultados quirúrgicos(AU)

Background: cerebral palsy is a major concern for family, is the most common physical disability in childhood and is the most common cause of consultation in pediatric orthopedics by neurological disorder.Objective: to evaluate the technique of Hsu in the treatment of the equine spastic foot of patient with cerebral paralysis. Methods: was carried out a longitudinal and descriptive study in 29 patients with the diagnosis of foot spastic equine treaties with the technique of Hsu in the service of Orthopedics and Traumatologic of the Pediatric University Hospital Eduardo Agramonte Piña, from May 2011 until May 2014 to evaluate the results obtained with this technique.Results prevailed the patients of the masculine sex with bilateral deformity, smaller than five years and perinatal etiologic. The results were satisfactory in most of the cases and the complications were all smaller.Conclusions: the technique of Hus is a therapeutic good option in patient with equine spastic foot with cerebral paralysis, to be a simple procedure, for its scarce complications and surgical good results(AU)

Dynamic pedobarographic classification of idiopathic toe-walkers for therapeutical indication / Clasificación baropodométrica dinámica de los andadores de puntillas para la indicación terapéutica

Idiopathic toe-walkers (ITWs) pedobarographic analysis has not been described yet nor its possible relationship with orthopedical and developmental characteristics. The objective of this research is to develop a dynamic pedobarographic classification of ITWs to propose a specific therapeutical approach. Through an observational study, 56 ITWs aged 3-6 years were classified by their initial foot contact; differences between idiopatic toe-walking (ITW) types and with respect to 40 control children were calculated by means of ANOVA and Student t-tests. The results show that the three ITW types displayed different step models for pressure and impulse distribution and also for temporal development (p<.05). They also showed different orthopedic and developmental characteristics (p<.05). As a whole, they demonstrated different severity levels, which suggest different therapeutical indications. This study confirms the convenience of a specific orthopedic, developmental, and gait assessment in ITW to clarify therapeutical indication

El análisis baropodométrico de la marcha de los andadores de puntillas (AP) no ha sido aún descrito en la literatura, ni tampoco su posible relación con sus características ortopédicas y neuromadurativas. El objetivo de este trabajo es desarrollar una clasificación baropodométrica dinámica de los AP para proponer un abordaje terapéutico específico. En un estudio observacional, 56 AP de 3 a 6 años han sido clasificados por su contacto inicial del pie, calculándose las diferencias entre los diferentes tipos de AP y con respecto a 40 niños que conformaron el grupo control, mediante los tests ANOVA y t de Student. Los resultados demostraron que los tres tipos de AP tenían diferentes modelos de paso en cuanto a la distribución de presiones e impulsos y también en su desarrollo temporal (p<.05). También se encontraron diferencias significativas en sus características ortopédicas y neuromadurativas (p<.05). En conjunto, los tres grupos de AP demostraron diferentes niveles de severidad que sugieren la indicación de abordajes terapéuticos diversos. Este estudio confirma la necesidad de una valoración específica de la marcha ortopédica y neuromadurativa en los AP para clarificar la indicación terapéutica

Is there still a place for Achilles tendon lengthening?

Patients with diabetes and ankle equinus are at particularly high risk for forefoot ulceration because of the development of high forefoot pressures. Stiffness in the triceps surae muscles and tendons are thought to be largely responsible for equinus in patients with diabetes and underpins the surgical rationale for Achilles tendon lengthening (ATL) procedures to alleviate this deformity and reduce ulcer risk. The established/traditional surgical approach is the triple hemisection along the length of the Achilles tendon. Although the percutaneous approach has been successful in achieving increases in ankle dorsiflexion >30°, the tendon rupture risk has led to some surgeons looking at alternative approaches. The gastrocnemius aponeurosis may be considered as an alternative because of the Achilles tendon's poor blood supply. ATL procedures are a balance between achieving adequate tendon lengthening and minimizing tendon rupture risk during or after surgery. After ATL surgery, the first 7 days should involve reduced loading and protected range of motion to avoid rupture, after which gradual reintroduction to loading should be encouraged to increase tendon strength. In summary, there is a moderate level of evidence to support surgical intervention for ankle joint equinus in patients with diabetes and forefoot ulceration that is non-responsive to other conservative treatments. Areas of caution for ATL procedures include the risk for overcorrection, tendon rupture and the tendon's poor blood supply. Further prospective randomized control trials are required to confirm the benefits of ATL procedures over conservative care and the most optimal anatomical sites for surgical intervention.

Deep calf cavernous haemangioma in a 10 year- old girl: a case report.

Haemangiomas are abnormal proliferation of blood vessels in any vascularised tissue. They can be capillary or cavernous varieties. Cavernous are either of cutaneous or deep types. Cavernous when compared with the capillary haemangioma is rare. Rarer still is the deep type of cavernous haemangioma. This is a report of a 10 year old Nigerian girl who presented with a right posterior leg swelling of 8 year duration, size initially was that of a peanut but increased to fill the entire calf region causing pain to the patient as well as cosmetic and anxiety concern to the parents. No preceding history of trauma, no associated systematic symptoms. She had exploratory laparatomy at 1 year of age at a private hospital for an abdominal mass which was excised. Pre-operative plain radiograph, Magnetic Resonance Imaging(MRI), Abdominopelvic ultrasound scan (USS) were done, fine needle aspiration cytology (FNAC) though done was not helpful. Histo-pathology result of excised leg mass confirmed diagnosis; there was a free margin of excision. Post-operatively, clinical improvement was marked.

The association between premature plantarflexor muscle activity, muscle strength, and equinus gait in patients with various pathologies.

This study provides an overview on the association between premature plantarflexor muscle activity (PPF), muscle strength, and equinus gait in patients with various pathologies. The purpose was to evaluate whether muscular weakness and biomechanical alterations are aetiological factors for PPF during walking, independent of the underlying pathology. In a retrospective design, 716 patients from our clinical database with 46 different pathologies (orthopaedic and neurologic) were evaluated. Gait analysis data of the patients included kinematics, kinetics, electromyographic activity (EMG) data, and manual muscle strength testing. All patients were clustered three times. First, patients were grouped according to their primary pathology. Second, all patients were again clustered, this time according to their impaired joints. Third, groups of patients with normal EMG or PPF, and equinus or normal foot contact were formed to evaluate the association between PPF and equinus gait. The patient groups derived by the first two cluster methods were further subdivided into patients with normal or reduced muscle strength. Additionally, the phi correlation coefficient was calculated between PPF and equinus gait. Independent of the clustering, PPF was present in all patient groups. Weak patients revealed PPF more frequently. The correlations of PPF and equinus gait were lower than expected, due to patients with normal EMG during loading response and equinus. These patients, however, showed higher gastrocnemius activity prior to foot strike together with lower peak tibialis anterior muscle activity in loading response. Patients with PPF and a normal foot contact possibly apply the plantarflexion-knee extension couple during loading response. While increased gastrocnemius activity around foot strike seems essential for equinus gait, premature gastrocnemius activity does not necessarily produce an equinus gait. We conclude that premature gastrocnemius activity is strongly associated with muscle weakness. It helps to control the knee joint under load independent from the underlying disease, and it is therefore a secondary deviation. If treated as primary target, caution should be exercised.

Simulation of unilateral equinus using an adjustable orthosis in children: design, feasibility and biomechanical effects.

BACKGROUND AND AIM: In order to increase understanding of the biomechanical consequences of equinus foot on gait, we developed an orthosis to induce an adjustable degree of unilateral equinus. The aim of this study was to evaluate its feasibility and consequences on 3D ankle kinematics and kinetics. TECHNIQUE: 3D gait analysis was carried out in 10 healthy children without the orthosis, with the non-adjusted orthosis and with the orthosis adjusted to +10°, 0°, -10°, -20° of ankle dorsiflexion and maximum plantarflexion (MP). The amount of dorsiflexion at initial contact was close to the goniometric measurement. Significant kinematic and kinetic changes occurred at -10°, -20° and MP. The mean maximum equinus at initial contact -21.65° ± 4.17 and during stance -11.61° ± 4.82 were larger than those obtained with previous described devices. DISCUSSION: Our device was easy-to-use and induced an adjustable, well tolerated equinus. It provides a new way to simulate equinus and its biomechanical consequences on gait.

Casting, taping or stretching after botulinum toxin type A for spastic equinus foot: a single-blind randomized trial on adult stroke patients.

OBJECTIVE: To investigate the effect of different adjunctive treatments after botulinum toxin type A. DESIGN: Single-blind, randomized trial, with three-month follow-up. SETTING: Secondary rehabilitative care. SUBJECTS: Convenience sample of 69 chronic hemiplegic adult patients with spastic equinus foot. INTERVENTIONS: Following botulinum toxin type A injection at the plantar flexors, patients were randomly assigned to three groups and treated with either taping, casting or stretching for one week, and with stretching and gait training for the next week. OUTCOME MEASURES: Modified Ashworth Scale at plantar flexors, passive range of motion at the ankle, six-minute walking test, 10-metre walking test, Functional Ambulation Categories, ankle dorsiflexor strength were evaluated before treatment (t(0)) at 20 days (t(1)) and 90 days (t(2)) after treatment. RESULTS: At t(1) only the taping and casting groups showed significant improvements in Modified Ashworth Scale, six-minute walking test, 10-metre walking test and passive range of motion (P < 0.02). At t(2), while the results were maintained in the casting group, only six-minute walking test and Modified Ashworth Scale were still significantly improved in the taping group. Ankle dorsiflexor strength and Functional Ambulation Categories did not change in any of the groups at any time. At t(2) the casting group performed better than the taping and stretching groups at Modified Ashworth Scale and passive range of motion, and better than the stretching group at six-minute walking test (P < 0.02). CONCLUSIONS: Combining botulinum toxin type A to the ankle plantar flexors with casting or taping gives better and longer lasting results than with stretching alone.

El pie plano; las recomendaciones del traumatólogo infantil al pediatra / Flat feet; recommendations from the pediatric orthopaedic surgeon to the pediatician

El pie plano es una situación clínica caracterizada por la desaparición o no formación del arco plantar. Sus formas pueden ser variadas y fundamentalmente banales, pero algunas pueden requerir un tratamiento quirúrgico. La forma más frecuente es el pie plano flexible, que es difícil de diferenciar de un pie normal, y que mejora espontáneamente con el crecimiento. Otras formas de pie plano deben diferenciarse y evaluarse adecuadamente, ya que pueden llegar a requerir tratamientos quirúrgicos. Se proponen algunas recomendaciones prácticas desde la perspectiva del traumatólogo infantil (AU)

Flat feet is the result of the disappearance or lack of formation of the arch of the feet. It has varied shapes and are mainly commonplace, but some may require surgery. The most frequent is flexible flat feet, which is difficult to differentiate from a normal foot, and which improves spontaneously with growth. Other types of flat feet should be differentiated and evaluated properly, as they might require surgical treatment. There are several practical recommendations from the perspective of pediatric orthopedists (AU)

Equino bilateral de tobillo: tratamiento mediante soporte plantar / No disponible

En el presente trabajo se realiza una recopilación bibliográfica sobre la patología del pie equino y sus diferentes tratamientos. Esta patología repercute directamente en toda la estructura anatómica del pie, alterando el apoyo del retropié, provocando mecanismos compensatorios en mediopié y en antepié, modificando las fases normales de la marcha. Es necesario por tanto, realizar una buena valoración del paciente para poder realizar el tratamiento adecuado evitando todos los posibles mecanismos compensatorios. A continuación, se expone un caso clínico de una persona joven que padece esta patología(AU)

In this work, is performed a recopilation of bibliography about equinus foot and their differents treatments. It has a direct effect on the anatomical and functional structure of the foot, alterating the normal heal of the rearfoot, and making compensatory mechanisms in both midfoot and forefoot as consequence. It can modify normal gait phases too. By this reason, it’s therefore necessary to do a good evaluation of the patient to perform adequate treatment to avoid any potential compensatory mechanisms. We present a clinical report of a young person suffering from this pathology(AU)