Comprehensive Rehabilitation of Charcot Foot With Equinovarus Deformity: A Case Report.

Charcot neuroarthropathy is the destruction of the bones and joints caused by underlying neuropathy, trauma, and disturbances in bone metabolism. Modern health care and surgical options now include limb salvage. An acquired or congenital foot deformity is the equinovarus deformity, also known as clubfoot or talipes equinovarus. The foot is fixed in plantarflexion (equinus), deviates toward its center (varus), and is rotated upward so that it rests on its outside (supination) in this condition. In another way, the foot turns axially outward while pointing downward and inward. Charcot neuroarthropathy generally occurs due to diabetes, but in this case, it occurs due to trauma and leads to a traumatic congenital talipes equinovarus deformity. A 38-year-old male patient complained of right foot pain and an inability to walk. Two years ago, he was involved in an accident that left him with a right leg injury. He was eventually diagnosed with a mid-shaft tibia-fibula fracture and underwent surgery with nailing. But one month ago, he again met with an accident and was diagnosed with Charcot's foot and equinovarus deformity. He returned to Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi, Wardha, Maharashtra, for further management. K-wire was applied for the fixation of Charcot foot with equinovarus deformity. Further on, rehabilitation was started to restore mobility, regain full range of motion and develop muscle strength.

Conventional Versus Accelerated Ponseti in the Management of Cases of Idiopathic Clubfoot: A Systematic Review and Meta-Analysis.

This study aimed to compare the outcomes of the accelerated and standard Ponseti method for clubfoot pathology by constructing a systematic review and meta-analysis of relevant randomized controlled trials and nonrandomized comparative studies. A systematic search was conducted to identify the relevant studies through PubMed, Google Scholar, and Cochrane depending on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The keywords used included "accelerated" AND "standard" AND "Ponseti" AND "clubfoot" AND "Congenital Talipes Equinovarus" AND "CTEV" AND "prospective comparative design" AND "randomized trial." We conducted this analysis among 13 studies that met the criteria adopted in this review where eight studies were prospective comparative studies, and five studies were randomized prospective comparative studies which were published in the period between 2015 and 2022. Statistically, accelerated Ponseti showed superior impact over standard Ponseti considering the duration of treatment (22.53 days vs. 40.61 days, p<0.001). No significant difference was reported between the two methods considering final Pirani score (0.64 vs. 0.56, p=0.194), number of casts (5.23 vs. 5.25, p=0.425), rate of tenotomy (66.2% vs. 63.1%, OR=1.246, 95% CI: 0.86-1.80, p=0.245), relapse rate (9.51% vs. 8.54%, OR=1.126, 95% CI: 0.68-1.86, p=0.642) and complication rate (14.4% vs. 13.1%, OR=1.130, 95% CI: 0.58-2.19, p=0.717). We concluded that the accelerated Ponseti method could achieve comparable efficacy to the standard method in terms of post-procedure Pirani score, tenotomy rate, relapse rate, complications rate, and number of casts needed by the patients with advantage of requiring shorter duration of treatment which is associated with more patient's compliance.

Case report: Multiple gastrointestinal perforations in a rare musculocontractural Ehlers-Danlos syndrome with multiple organ dysfunction.

A 36-year-old male with congenital equinovarus deformity was admitted to the hospital due to worsen deformity. He was known to have ear perforation in childhood. After hospitalization, he received equinovarus correction surgery, fourth toe osteotomy, and external fixation for right foot during the procedure. During his hospital stay, the patient has been treated with multiple gastrointestinal perorations, accompanied with multiple organ dysfunction and fragile soft tissues. During his in-hospital stay, multiple organ dysfunctions were observed, including the heart, kidney, liver, and intestines. In order to identify the mutation site, whole-exome sequencing (WES) was performed, and further verified with Sanger sequencing analysis in this patient. One-site mutation located at CHST14 [c.883_884del, p (Phe295Cysfs*5)] was identified in this patient, whereas this mutation was not observed in other 100 healthy controls. Also, this variant has not been reported in public databases (ExAC and gnomAD). Our report showed that unanticipated multiple tissue deformation observed the musculocontractural EDS patient was caused by mutation located at CHST14 [c.883_884del, p (Phe295Cysfs*5)] induced truncated CHST14 protein.

Added Value of Dynamic EMG in the Assessment of the Equinus and the Equinovarus Foot Deviation in Stroke Patients and Barriers Limiting Its Usage.

Equinus (EFD) and equinovarus foot deviation (EVFD) are the most frequent lower limb deformities in stroke survivors. The equinus component can be triggered by a combination of dorsiflexor deficits, plantar flexor overactivity, muscle stiffness, and contractures. The varus component is typically due to an imbalance between invertor and evertor muscle actions. An improvement in identifying its causes leads to a more targeted treatment. These deformities are typically assessed via a thorough clinical evaluation including the assessment of range of motions, force, spasticity, pain, and observational gait analysis. Diagnostic nerve blocks are also being increasingly used. An advantage of dynamic electromyography (dEMG) is the possibility of measuring muscle activity, overactivity or lack thereof, during specific movements, e.g., activity of both ankle plantar flexors and dorsiflexors during the swing phase of gait. Moreover, fine-wire electrodes can be used to measure the activity of deep muscles, e.g., the tibialis posterior. An impediment to systematic use of dEMG in the assessment of EFD and EVFD, as a complimentary tool to the clinical evaluation, is a lack of evidence of its usefulness. Unfortunately, there are few studies found in literature. In order to fill this void, we studied three pairs of patients suffering from chronic hemiparesis consequent to a stroke, with EFD or EVFD. At the initial evaluation they all displayed the same clinical traits, very similar walking patterns, and an overlapping gait kinematics. However, the patterns of muscle activity differed considerably. dEMG data acquired during walking provided information that was not available from the sole clinical assessment. The contribution of this information to the subsequent clinical and rehabilitation process was discusses along with the barriers that limit the use of dEMG as a routine tool in neurorehabilitation.

Medial Swivel Peritalar Fracture Dislocation: A Case Report.

A medial swivel peritalar fracture-dislocation is a rare and disabling foot injury. The terminology describes a peritalar dislocation as the direction of peritalar foot displacement. Medial dislocation is the most frequent type. A rare variant involves talonavicular joint dislocation, subtalar joint fracture-dislocation, and calcaneocuboid fracture-dislocation. The clinical position of the foot resembles an equinovarus deformity. A computed tomography (CT) scan is necessary to obtain a diagnosis and formulate a surgical plan. A medial swivel peritalar fracture-dislocation is a challenging injury, and because there have been few reported cases in the literature, an optimal treatment protocol has not yet been established. We present a case of an unusual fracture-dislocation pattern of the hind and midfoot causing a complex talonavicular fracture-dislocation, subtalar fracture dislocation, and calcaneocuboid fracture-dislocation. The injury was successfully treated with open reduction and internal fixation.

Novel mutations in SLC6A5 with benign course in hyperekplexia.

Infants suffering from life-threatening apnea, stridor, cyanosis, and increased muscle tone may often be misdiagnosed with infantile seizures and inappropriately treated because of lack and delay in genetic diagnosis. Here, we report a patient with increased muscle tone after birth and hypertonic attacks with life-threatening apnea but no epileptiform patterns in EEG recordings. We identified novel compound heterozygous variants in SLC6A5 (NM_004211.4:c.[1429T > C];[1430delC]) by trio whole-exome sequencing, containing a base deletion inherited by the asymptomatic mother leading to a frameshift (c.1430delC, p.Ser477PhefsTer9) and a de novo base exchange leading to an amino acid change (c.1429T > C, p.Ser477Pro). To date, there are four known disease-associated genes for primary hyperekplexia, all of which are involved in the functioning of glycinergic synapses. SLC6A5 encodes the sodium- and chloride-dependent glycine transporter 2 (GlyT2), which recaptures glycine, a major inhibitory transmitter in the brainstem and spinal cord. The diagnosis altered the patient's medical care to his benefit because SLC6A5 mutations with rather benign courses of hyperekplexia may be spared of needless pharmacotherapy. Symptoms eventually decreased in frequency until about once in 2 mo at 2 yr age. We present the first report of halting hyperekplexia episodes by maternal soothing in multiple instances. We highlight the importance of clarifying the genetic diagnosis by rapid next-generation sequencing techniques in this group of infantile apneic attacks with hyperekplexia due to the broad differential diagnoses.

Botulinum Toxin Type A Injection for Spastic Equinovarus Foot in Children with Spastic Cerebral Palsy: Effects on Gait and Foot Pressure Distribution.

PURPOSE: To investigate the effect of intramuscular Botulinum toxin type A (BoNT-A) injection on gait and dynamic foot pressure distribution in children with spastic cerebral palsy (CP) with dynamic equinovarus foot. MATERIALS AND METHODS: Twenty-five legs of 25 children with CP were investigated in this study. BoNT-A was injected into the gastrocnemius (GCM) and tibialis posterior (TP) muscles under the guidance of ultrasonography. The effects of the toxin were clinically assessed using the modified Ashworth scale (MAS) and modified Tardieu scale (MTS), and a computerized gait analysis and dynamic foot pressure measurements using the F-scan system were also performed before injection and at 1 and 4 months after injection. RESULTS: Spasticity of the ankle plantar-flexor in both the MAS and MTS was significantly reduced at both 1 and 4 months after injection. On dynamic foot pressure measurements, the center of pressure index and coronal index, which represent the asymmetrical weight-bearing of the medial and lateral columns of the foot, significantly improved at both 1 and 4 months after injection. The dynamic foot pressure index, total contact area, contact length and hind foot contact width all increased at 1 month after injection, suggesting better heel contact. Ankle kinematic data were significantly improved at both 1 and 4 months after injection, and ankle power generation was significantly increased at 4 months after injection compared to baseline data. CONCLUSION: Using a computerized gait analysis and foot scan, this study revealed significant benefits of BoNT-A injection into the GCM and TP muscles for dynamic equinovarus foot in children with spastic CP.

Tibialis Anterior Tendon Transfer.

Tendon transfer procedures are used commonly for the correction of soft tissue imbalances and instabilities. The complete transfer and the split transfer of the tibialis anterior tendon are well-accepted methods for the treatment of idiopathic equinovarus deformity in children and adults. Throughout the literature, complete and split transfer have been shown to yield significant improvements in ankle and foot range of motion and muscle function. At present, there is insufficient evidence to recommend one procedure over the other, although the split procedure has been advocated for consistently achieving inversion to eversion muscle balance without overcorrection.

Botulinum Toxin Type A Injection for Spastic Equinovarus Foot in Children with Spastic Cerebral Palsy: Effects on Gait and Foot Pressure Distribution

PURPOSE: To investigate the effect of intramuscular Botulinum toxin type A (BoNT-A) injection on gait and dynamic foot pressure distribution in children with spastic cerebral palsy (CP) with dynamic equinovarus foot. MATERIALS AND METHODS: Twenty-five legs of 25 children with CP were investigated in this study. BoNT-A was injected into the gastrocnemius (GCM) and tibialis posterior (TP) muscles under the guidance of ultrasonography. The effects of the toxin were clinically assessed using the modified Ashworth scale (MAS) and modified Tardieu scale (MTS), and a computerized gait analysis and dynamic foot pressure measurements using the F-scan system were also performed before injection and at 1 and 4 months after injection. RESULTS: Spasticity of the ankle plantar-flexor in both the MAS and MTS was significantly reduced at both 1 and 4 months after injection. On dynamic foot pressure measurements, the center of pressure index and coronal index, which represent the asymmetrical weight-bearing of the medial and lateral columns of the foot, significantly improved at both 1 and 4 months after injection. The dynamic foot pressure index, total contact area, contact length and hind foot contact width all increased at 1 month after injection, suggesting better heel contact. Ankle kinematic data were significantly improved at both 1 and 4 months after injection, and ankle power generation was significantly increased at 4 months after injection compared to baseline data. CONCLUSION: Using a computerized gait analysis and foot scan, this study revealed significant benefits of BoNT-A injection into the GCM and TP muscles for dynamic equinovarus foot in children with spastic CP.

Midterm Follow-Up of Talectomy for Severe Rigid Equinovarus Feet.

Rigid equinovarus foot is a challenging problem. Talectomy has been advocated as a salvage procedure to achieve a plantigrade painless foot in the treatment of rigid equinovarus deformity. The present prospective observational study evaluated the effectiveness of talectomy in the treatment of Dimeglio grade IV rigid equinovarus feet. Nineteen feet in 13 patients were treated by talectomy from September 2001 through January 2012 (10-year, 2-month period). Of the 13 patients, 9 (69.23%) had a foot deformity due to arthrogryposis multiplex congenita and 1 (7.69%) each due to sacral agenesis, spastic cerebral palsy, neglected congenital talipes equinovarus, and post-traumatic contracture. Of the 13 patients, 9 (69.23%) were male and 4 (30.77%) were female. Their mean age was 7.7 (range 3 to 26) years. The mean follow-up duration was 6.4 (range 2 to 11) years. Along with talectomy, excision of the navicular was performed in 8 feet (42.11%), calcaneal osteotomy with a laterally based wedge in 8 (42.11%), and calcaneocuboid fusion in 3 feet (15.79%). Postoperatively, all the feet improved to Dimeglio grade II and were painless, and 16 feet (84.22%) were plantigrade; 1 foot (5.26%) had residual equinus resulting from incomplete removal of the talus and 2 (10.53%) had residual varus. Also, 3 feet (15.79%) had forefoot adduction (2 residual and 1 recurrent) that required a second surgery to correct the deformity. From our experience, talectomy is an effective procedure for correction of severe rigid equinovarus feet, provided that the talus is completely removed and the calcaneus is positioned correctly in the ankle mortise.

Effects of Ankle Kinesio Taping on Postural Control in Stroke Patients.

BACKGROUND: To investigate the effects of kinesio taping on postural control in stroke patients. MATERIALS AND METHODS: Forty stroke patients aged 30 to 60 years were randomly divided into an experimental and a control group. In the experimental group, kinesio tape (KT) was applied directly on the skin over the affected ankle in the direction of dorsiflexion and eversion to correct the equinovarus deformity. The tape was kept on the ankle for 1 day. The results were measured with the forward reach test, lateral reach test, Berg Balance Scale (BBS), and timed up and go test. Center of pressure (COP) displacement and velocity were also measured while the patients stood on a force plate. All variables were measured on the first day immediately after taping and 24 hours later in the KT group, and on the first day and also 24 hours later in the control group. RESULTS: There was a statistically significant difference in BBS between the first day and 24 hours later in the KT group (P = .01). The forward reach test and mediolateral displacement of the COP differed significantly after taping in the experimental group compared to the control group (P = .04). Immediately after taping, BBS improved significantly in the KT group (P = .02). CONCLUSIONS: The application of KT improved forward reach test results and displacement of the COP in stroke patients.

Post-activation depression of the lower extremities in stroke patients with spasticity and spastic equinovarus deformity / Depressão pós-ativação das extremidades inferiores de pacientes com acidente vascular cerebral que apresentam espasticidade e deformidade equinovarus por espasticidade

This study aimed to investigate changes of post-activation depression in two groups of patients with or without spastic equinovarus deformity (SED). Paired and independent t-tests were used to compare post-activation depression within and between the groups, respectively. There was a significant positive correlation between diminished post-activation depression and spasticity severity. The soleus and tibialis anterior (TA) post-activation depression values were significantly decreased on the affected sides of patients with SED compared to those without. In patients without SED, the soleus post-activation depression was significantly decreased on the affected side; however, TA post-activation depression was higher on the affected side. Both the soleus and TA become active, but the onset time may be different. The imbalanced muscle tone between the soleus and TA in the early stage after stroke may be related to equinus deformity.

O principal objetivo deste estudo é a investigação da depressão pós-ativação em pacientes com deformidade equinovarus espástica (DEE). Os pacientes foram divididos em dois grupos. Student-t testes pareados e independentes foram utilizados para comparar a depressão pós-ativação intra- e inter-grupos, respectivamente. Houve uma correlação positiva significativa entre a diminuição da depressão pós-ativação e a gravidade da espasticidade. A depressão pós-ativação dos músculos sóleo e tibial anterior (TA) estavam significativamente diminuídas no lado afetado dos pacientes com SEE em relação aos membros sem SEE. Em pacientes sem SEE, a depressão pós-ativação do músculo sóleo encontrava-se significativamente diminuída do lado afetado. No entanto, a depressão pós-ativação do músculo TA era maior no lado afetado que no lado não afetado. Tanto o sóleo quanto o TA serão ativados, mas o tempo para isso pode ser diferente. O desequilíbrio entre o tônus dos músculos sóleo e TA nos estágios iniciais pode estar relacionado à deformidade equina.

Talectomy and tibiocalcaneal arthrodesis with intramedullary nail fixation for treatment of equinus deformity in adults.

BACKGROUND: Severe equinovarus foot deformity in adults is a challenging problem. Conservative treatment rarely is effective, and operative options are limited. The aim of this study was to evaluate the results of talectomy and tibiocalcaneal arthrodesis with intramedullary nail fixation for the treatment of severe equinovarus deformity in adults. METHODS: Twelve patients (average age 39 years, range 15-70 years) with severe equinovarus deformities of the foot were treated with talectomy and tibiocalcaneal arthrodesis with intramedullary nail fixation between March 2010 and February 2013. Average follow-up was 20 months (range 10-37 months). RESULTS: Tibiocalcaneal fusion was achieved in all patients at an average of 12 weeks (range 8-17 weeks). Preoperatively, all patients had severe, irreducible equinovarus deformities; at last follow-up, almost all feet had mild residual deformity, but were plantigrade and did not require a brace or orthosis. The average AOFAS ankle score improved from 41.1 (range 8-66) preoperatively to 78.4 (range 67-86) postoperatively (P = .02). There was a similar improvement in the average VAS score from 6.3 (range 2-10) preoperatively to 0.8 (range 0-4) postoperatively (P = .02). CONCLUSION: The combination of talectomy and tibiocalcaneal arthrodesis was effective in correcting severe rigid equinovarus deformity in adults. Removal of the talus resulted in laxity of the soft tissues, making correction of the deformity easier. Tibiocalcaneal arthrodesis achieved a stable foot without the problems associated with talectomy alone. LEVEL OF EVIDENCE: Level IV, case series.

Treatment of Calcaneovalgus Deformity Following Operative Treatment of Diplegic Equinovarus Deformity in Cerebral Palsy Patient: A Case Report / 대한족부족관절학회지

Calcaneal or calcaneovalgus deformity can occur after surgical treatment of equinus or eguinovarus deformity in cerebral palsy patient. It is a serious complication and the results of many conservative and operative treatments are reported unsatisfactory. We experienced one case of both calcaneovalgus deformity following operative treatment of diplegic equinovarus deformity in a spastic cerebral palsy patient and report about the result of the treatment.

Teatment of severe rigid talipes equinovarus deformity with Ilizarov technique / 中国矫形外科杂志

[Objective]To study the results of Ilizarov technique in treatment of the severe rigid talipes equinovarus deformity.[Method]The Ilizarov technique was used in 9 patients(11 feet)with the severe rigid talipes equinovarus deformity,in which one patient with syringomyelia,and the orthers with congenital club foot.[Result]Prospective goals of correction were made in all the cases.The results were assessed by Garceau criterion.For 9 patients(11 feet),6 feets achieved excellent result,4 feets good and 1 foot poor results respectively.[Conclusion]Ilizarov technique in treatment of the severe rigid talipes equinovarus deformity achieves a good clinical result.

Progressive Dynamic Equinovarus Deformity in Hereditary Spastic Paraplegia: A Case Report / 대한족부족관절학회지

In neurogenic equinovarus deformity, surgical intervention such as tendon transfer or osteotomy can be expected to improve symptoms. However, in rare cases of hereditary spastic paraplegia, the deformity and paralysis gradually progress. So limited operation and early post-operative rehabilitation are preferred to aggressive operation. We would like to report our clinical experience with one case of hereditary spastic paraplegia patient with reference review. A 40 year-old male, given tendon transfer of ankle and foot and tendo achilles lengthening 10 years ago, complained about aggravated spastic paraplegia which resulted in dynamic equinovarus and limited walking ability since his operation. Family history showed limited walking ability of his father with gradually progressing spastic paralysis and he was diagnosed as hereditary spastic paraplegia type I. We had performed a limited operation such as tendo achilles and tibialis posterior lengthening to induce plantigrade standing and walking with crutch. As a result, the patient was able to maintain a stabilized standing posture and walk after the operation. Hereditary spastic paraplegia presents with a progressive paralysis which limits rehabilitation after tendon transfer, and the symptoms can be aggravated. Therefore, considering potential hereditary neurogenic disorders in paients with equinovarus deformity and performing limited operative procedures seem to be important.