Ortesis pasiva tobillo-pie de uso nocturno en la prevención del pie equino en la parálisis cerebral / Nocturnal use of an ankle-foot orthosis in the prevention of equinuus in cerebral palsy

Introducción. El equinismo, que es la deformidad más frecuente en los pacientes con parálisis cerebral, aumenta la inestabilidad, dificulta la marcha y la adaptación a la silla de ruedas. La corrección del equinismo beneficia al niño deambulador, facilita la adecuada colocación del pie en el reposapiés de la silla de ruedas y la posibilidad de usar un calzado convencional en el niño que no tiene capacidad de marcha. El objetivo de este estudio es valorar si el uso nocturno de ortesis de tobillo-pie en ortoposición permite prevenir o diferir la aparición de equinismo y así evitar o retrasar la cirugía de alargamiento tendinoso. Material y método. Se ha realizado un estudio observacional descriptivo retrospectivo, revisando el historial clínico de pacientes diagnosticados de parálisis cerebral, tratados mediante ortesis de tobillo-pie nocturnas en la Unidad de Rehabilitación Infantil del Hospital Virgen Macarena. Resultados. De los 90 pacientes tratados con la ortesis de tobillo-pie nocturna, el 88,9% consiguió el rango de flexión dorsal necesario para la deambulación (≥ 10°) o la correcta adaptación a la silla de ruedas y al calzado (≥ 0°). Únicamente en 9 pacientes (10% de los casos) no se alcanzaron los objetivos pretendidos. Conclusión. El tratamiento preventivo con ortesis rígidas constituye una opción de primera línea en el tratamiento de la parálisis cerebral. El uso reglado y mantenido de las ortesis de tobillo-pie nocturnas puede retrasar la aparición del equinismo en la parálisis cerebral y permite diferir o evitar la cirugía con un beneficio funcional evidente (AU)

Introduction. Equinus, the most common deformity in patients with cerebral palsy, increases instability and impairs gait and adaptation to a wheelchair. Correction of equinus benefits walking children and aids proper placement of the foot on the footrest of a wheelchair. It also allows the possibility of using conventional footwear in children with no ability to walk. The aim of this study was to assess whether the use of an ankle-foot orthosis at night, keeping the foot in orthoposition, can prevent or delay the onset of equinus and thus prevent or delay tendon lengthening surgery. Material and methods. We performed a retrospective observational study based on a chart review of 90 patients diagnosed with cerebral palsy treated with a nocturnal ankle-foot orthosis in the Children's Rehabilitation Unit at Hospital Virgen Macarena in Spain. Results. Of the 90 patients treated with nocturnal ankle-foot orthosis, 88.9% achieved the dorsiflexion necessary for ambulation (≥ 10°) or adequate adaptation to a wheelchair and footwear (≥ 0°). Only 9 patients (10%) did not achieve the intended objectives with the use of the splint. Conclusion. Preventive treatment with a rigid ankle-foot orthosis is a widely accepted practice that constitutes a first-line option in the treatment of cerebral palsy. Systematic and persistent use of a nocturnal ankle-foot orthosis can delay the onset of equinus in cerebral palsy and can delay or avoid surgery, with a clear functional benefit (AU)

A randomized controlled trial studying efficacy and tolerance of a knee-ankle-foot orthosis used to prevent equinus in children with spastic cerebral palsy.

OBJECTIVE: To examine whether using a knee-ankle-foot orthosis helps maintain ankle-foot dorsiflexion range of motion over time. DESIGN: A multicentre randomized controlled trial. SETTING: Two hospitals and one rehabilitation centre in the Netherlands and the USA. SUBJECTS: Children (4-16 years old) with spastic cerebral palsy who were able to walk. INTERVENTION: Use of a knee-ankle-foot orthosis, equipped with an Ultraflex ankle power unit, for at least 6 hours every other night for one year. PRIMARY OUTCOME MEASURE: ankle-foot dorsiflexion range of motion. SECONDARY OUTCOME MEASURES: ankle-foot and knee angle in gait and gross motor function. Wearing time was also measured. Measurements were taken at baseline and at 3, 6, 9 and 12 months. RESULTS: 28 children (experimental group: n=15, control group: n=13) participated in the study. 11 participants (experimental: n=4, control: n=7) did not complete all five measurements, as they needed additional treatment. No significant difference was found in the decrease of ankle-foot dorsiflexion range of motion between the experimental and control groups (difference: -1.05°, 95% confidence interval: -4.71° - 2.61°). In addition, secondary outcome measures did not show differences between groups. Despite good motivation, knee-ankle-foot orthosis wearing time was limited to a mean±SD of 3.2±1.9 hours per prescribed night due to discomfort. CONCLUSIONS: Knee-ankle-foot orthosis with dynamic ankle and fixed knee are poorly tolerated and are not beneficial in preventing a reduction in ankle-foot dorsiflexion range of motion in children with spastic cerebral palsy, at least with limited use.

Splint: the efficacy of orthotic management in rest to prevent equinus in children with cerebral palsy, a randomised controlled trial.

BACKGROUND: Range of motion deficits of the lower extremity occur in about the half of the children with spastic cerebral palsy (CP). Over time, these impairments can cause joint deformities and deviations in the children's gait pattern, leading to limitations in moblity. Preventing a loss of range of motion is important in order to reduce secondary activity limitations and joint deformities. Sustained muscle stretch, imposed by orthotic management in rest, might be an effective method of preventing a decrease in range of motion. However, no controlled study has been performed. METHODS: A single blind randomised controlled trial will be performed in 66 children with spastic CP, divided over three groups with each 22 participants. Two groups will be treated for 1 year with orthoses to prevent a decrease in range of motion in the ankle (either with static or dynamic knee-ankle-foot-orthoses) and a third group will be included as a control group and will receive usual care (physical therapy, manual stretching). Measurements will be performed at baseline and at 3, 6, 9 and 12 months after treatment allocation. The primary outcome measure will be ankle dorsiflexion at full knee extension, measured with a custom designed hand held dynamometer. Secondary outcome measures will be i) ankle and knee flexion during gait and ii) gross motor function. Furthermore, to gain more insight in the working mechanism of the orthotic management in rest, morphological parameters like achilles tendon length, muscle belly length, muscle fascicle length, muscle physiological cross sectional area length and fascicle pennation angle will be measured in a subgroup of 18 participants using a 3D imaging technique. DISCUSSION: This randomised controlled trial will provide more insight into the efficacy of orthotic management in rest and the working mechanisms behind this treatment. The results of this study could lead to improved treatments. TRIAL REGISTRATION NUMBER: Nederlands Trial Register NTR2091.

Equinus deformity during tibial lengthening with ankle orthoses for equalization of leg-length discrepancies.

BACKGROUND: Although it is known that equinus deformity develops at a high rate during tibial lengthening, the efficacy of ankle orthoses for preventing equinus deformity and the etiology of equinus deformity remain unknown. The purpose of this study was to clarify the incidence and causes of equinus deformity in tibial lengthening with ankle orthoses worn for 16 h a day. METHODS: 102 patients who had tibial lengthening were included in this study. There were 80 males and 22 females with ages at surgery from 6 to 70 years. Tibial lengthening was performed at the proximal tibia using an Ilizarov fixator. During limb lengthening, an ankle orthosis was used for more than 16 h a day to prevent equinus deformity. The rates and the causes of equinus deformity were investigated. RESULTS: Equinus deformity was observed for eight cases (7.8%). Among these, the final gain in length was less than 5 cm in 6 patients. There were no significant differences between final gain in length, average lengthening rate, and final percentage gain of tibial length in the group with occurrence of equinus deformity and that without. CONCLUSIONS: The incidence of equinus deformity was 7.8% during tibial lengthening wearing ankle orthoses.

Extra-articular ankle stabilization: a case series.

Maintenance of the foot at 90 degrees to the lower leg following posterior calf lengthening or to prevent an equinus contracture in situations in which splint, cast, or external fixation is deemed inappropriate is a challenge. The author presents an observational case series involving 9 extra-articular ankle stabilizations performed in 9 consecutive patients. Each patient underwent his or her index surgery followed by percutaneous placement of 2 smooth 2.8-mm or larger diameter Steinmann pins extra-articular to the ankle joint. There were 6 men and 3 women with a mean age of 56.1 years (range, 31-73 years). Five patients had diabetes with peripheral neuropathy, 2 had critical limb ischemia, 1 had alcohol-induced neuropathy, 1 had lupus, and 1 was an active smoker. Eight patients had posterior calf lengthening, and 1 had open metatarsal fractures with severe soft-tissue disruption with an inability to use splint immobilization. Three patients had a transmetatarsal amputation, 2 patients had Chopart amputations, 2 patients had forefoot plastic surgery reconstructive procedures, 1 had a complex Charcot reconstruction, and 1 had a splittibialis anterior tendon transfer. Extra-articular ankle stabilization fixation was retained for a mean of 5.5 weeks (range, 2-10 weeks). Mean follow-up was 12 months (range, 1-17 months). All extra-articular stabilization procedures were deemed successful. When properly performed, extra-articular stabilization to maintain the foot at 90 degrees to the lower leg represents a safe, simple, reliable, and minimally invasive technique useful in situations in which traditional splint or cast immobilization is not possible and when external fixation is deemed inappropriate.

Management of long-term sequelae of compartment syndrome involving the foot and ankle.

BACKGROUND: Lower leg compartment syndrome can lead to severe sequelae affecting patient autonomy. Ischemic muscle fibrosis and retraction result in foot and ankle deformities ranging from claw toes to complex multiplanar dislocations with soft tissue impairment requiring amputation. Although these deformities have been reported in relation to compartment syndrome, they have rarely been discussed specifically in the light of a long term follow up. MATERIALS AND METHODS: Between 1981 and 2006, 151 patients were treated in our hospital for compartment syndrome of the lower limb. Ten of them later required further surgery to treat sequelae on the foot and ankle and were followed up prospectively. Personal data and surgical events were recorded, as well as potential risk factors for sequelae and functional outcome. The data was analyzed and compared to that available in previous literature. We analyzed and describe the different surgical procedures available for the management of this condition including arthroscopic ankle arthrodesis which could be a less invasive and efficient technique in mild equinus deformities. RESULTS: All ten patients were diagnosed late for compartment syndrome. The anterior and lateral compartments were most often involved but rarely accounted for late sequelae. The deep posterior compartment seems to be the key element in generating after effects. Functional results were good in eight patients. Two required amputation after failed secondary surgery. CONCLUSION: The late, post-compartment syndrome affecting the foot and ankle can be treated efficiently provided surgery is performed acurately, taking into account the multiplanar deformity. However, the best treatment for this condition remains prevention.

Tibial lengthening: extraarticular calcaneotibial screw to prevent ankle equinus.

UNLABELLED: Between 2003 and 2006, we used an extraarticular, cannulated, fully threaded posterior calcaneotibial screw to prevent equinus contracture in 10 patients (four male and six female patients, 14 limbs) undergoing tibial lengthening with the intramedullary skeletal kinetic distractor. Diagnoses were fibular hemimelia (two), mesomelic dwarfism (two), posteromedial bow (one), hemihypertrophy (one), poliomyelitis (one), achondroplasia (one), posttraumatic limb-length discrepancy (one), and hypochondroplasia (one). Average age was 24.5 years (range, 15-54 years). The screw (length, typically 125 mm; diameter, 7 mm) was inserted with the ankle in 10 degrees dorsiflexion. Gastrocnemius soleus recession was performed in two patients to achieve 10 degrees dorsiflexion. Average lengthening was 4.9 cm (range, 3-7 cm). Screws were removed after a mean 3.3 months (range, 2-6 months). Preoperative ankle range of motion was regained within 6 months of screw removal. No neurovascular complications were encountered, and no patients experienced equinus contracture. We also conducted a cadaveric study in which one surgeon inserted screws in eight cadaveric legs under image intensifier control. The flexor hallucis longus muscle belly was the closest anatomic structure noted during dissection. The screw should be inserted obliquely from upper lateral edge of the calcaneus and aimed lateral in the tibia to avoid the flexor hallucis longus muscle. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Efficacy of ankle-foot orthoses on gait of children with cerebral palsy: systematic review of literature.

PURPOSE: To perform a literature review evaluating the quality of current research on the influence of ankle-foot orthoses (AFOs) on gait in children with cerebral palsy (CP). METHODS: A qualitative systematic review of intervention studies including the following words/phrases in the title/abstract: children with CP, AFO, gait and inferential statistical analysis, and outcomes related to gait. Databases searched included PubMed, Cochrane Library, PEDro, OTSeeker, Lilacs, and Scielo. Level of evidence was graded using the PEDro Scale. RESULTS: Two between-group and 18 within-group studies met the inclusion criteria indicating a low level of evidence. Between-group studies each scored 4 on the PEDro Scale, and 17 within-group studies scored 3 and 1 scored 2, indicating low quality. Standard terminology for AFOs was not used and only 6 studies described functional status using appropriate instruments. CONCLUSIONS: Studies using high quality methods are still needed to support evidence-based decisions regarding the use of AFOs for this population.

Dokuz Eylül University (DEU) orthosis: an orthotic method of preventing ankle equinus during tibial lengthening.

An orthosis developed in Dokuz Eylül University (DEU) at the School of Physical Therapy and Rehabilitation, Department of Orthotics and Prostheticsis is described. It is applied as a non-invasive device attached to the distal ring of the Ilizarov external fixator to keep the ankle joint in a neutral position and prevent ankle equinus during tibial lengthening with Ilizarov technique. This minimises additional invasive techniques such as heel cord release and prophylactic pinning of the heel and the foot, and manipulation under anaesthesia. It may also be detached by the physiotherapist or patient when physical therapy is needed during the lengthening procedure.

Prevention of equinus deformity during tibial lengthening. Comparison of passive stretching with an orthosis.

We have reviewed 28 tibial lengthenings in 14 patients with achondroplasia at an average age of 15 years, and compared the effectiveness of physiotherapy and an orthosis in preventing an equinus deformity. Physiotherapy of 15 min a day was ineffective even when the patients were able to walk. An orthosis worn for 16 h a day prevented equinus deformity up to at least 50% of lengthening, and the difference from physiotherapy was significant at more than 30% of lengthening.

Preventing and overcoming equinus contractures during lengthening of the tibia.

The new technique of leg lengthening and deformity correction with different types of external fixators has given the orthopedic surgeon a tool that allows correction of very difficult deformities and leg length discrepancies of the lower extremity. Dissemination of this knowledge has demonstrated that there are many associated problems with these techniques: one of which is resulting equinus deformity after correcting the tibia. The shortened soleus-gastrocnemius-achilles tendon complex is the cause of this deformity. Several techniques are suggested on avoiding this complication and how to correct it once it has occurred.

Effect of serial casting for the prevention of equinus in patients with acute head injury.

Ten adults with traumatic head injury received serial casts within 14 days of injury for the prevention or correction of equinus. Eighteen limbs (16 bilateral) with spasticity were involved. An average of five casts for a total duration of four to 64 days were used for each limb. Comparisons of passive dorsiflexion measures before and after casting showed a mean gain of 21 degrees (paired t-test, P less than .05). Of the 18 limbs, 13 reached a passive dorsiflexion of 0 degrees or more (ie, no equinus) which could be maintained without force for at least one hour. The procedures appeared safe and the results of the trial were clinically judged to be favorable. There is a need to further assess the efficacy of serial casting through randomized controlled trials and long-term followups.