Treatment of Severe Rigid Posttraumatic Equinus Deformity With Gradual Deformity Correction and Arthroscopic Ankle Arthrodesis.

BACKGROUND: Posttraumatic ankle equinus is associated with rigid deformity, poor skin condition, and multiple prior surgeries. Open acute correction has been described using osteotomies, talectomy, and arthrodesis, but concerns exist about skin complications, neurologic alterations, secondary limb discrepancy, and bone loss. Gradual correction using a multiplanar ring fixator and arthroscopic ankle arthrodesis (AAA) may decrease these complications. METHODS: We retrospectively reviewed patients undergoing correction of posttraumatic rigid equinus with at least 1 year of follow-up after frame removal. The procedure consisted of percutaneous Achilles lengthening, gradual equinus correction using a multiplanar ring fixator, and AAA retaining the fixator in compression with screw augmentation. Frame removal depended on signs of union on the computed tomography scan. Visual analog scale (VAS) and Foot Function Index (FFI) scores were assessed as well as preoperative and postoperative x-rays. Complications were noted throughout the follow-up period. RESULTS: Five patients were treated with a mean age of 35 years and mean follow-up of 31 months. Deformities were gradually corrected into a plantigrade foot over an average duration of 6 weeks. Union was achieved in all patients with a mean time of an additional 25 weeks, for a mean total frame time of 31 weeks. The mean preoperative tibiotalar angle was 151 degrees and was corrected to 115 degrees. FFI score improved from a mean of 87 to 24 and VAS from 8 to 2. CONCLUSION: Posttraumatic rigid equinus can be treated effectively using gradual correction followed by integrated AAA in a safe and reproducible manner. Patients in this series had excellent functional, radiological, and satisfaction results. LEVEL OF EVIDENCE: Level IV, retrospective case series.

[Analysis to determine optimal age for surgical management of equinus foot in patients with childhood cerebral palsy]. / Análisis para determinar la edad óptima para el manejo quirúrgico del pie equino en pacientes con parálisis cerebral infantil.

INTRODUCTION: Childhood cerebral palsy, a non-progressive brain injury, occurs before, during or after delivery, with variable neurological damage from mild to disabling. The deformity in equine is treated conservatively at an early age, but when is surgical management indicated? OBJECTIVE: Our goal was to determine the optimal age for surgical management of the equine foot in CCP patients. MATERIAL AND METHODS: Retrospective study, in patients diagnosed with CCP (all types), treated surgically with open or percutaneous Achilles tendon elongation, assessed with external consultation notes, in patients aged 1-16 years, and average follow-up of 6 years, evaluating progress with relapse of deformity and gait with plantigrade support. RESULTS: 55 patients, 74 equinus feet (29 in girls, 45 in boys) were analyzed with surgical treatment. Those treated before six years old presented relapses, with vulnerable period in 4-6 years. Monoplegia presented 100% relapses, and triplegia presented 0%. Open surgery presented 50% recurrence and percutaneous technique only 19%. CONCLUSION: In our institution, the optimal age is suggested in 6-12 years. Percutaneous technique over the open, should be preferred, and greater attention should be paid to monitoring monoplexy.

INTRODUCCIÓN: La parálisis cerebral infantil es una lesión cerebral no progresiva que ocurre antes, durante o después del parto y provoca daño neurológico variable que oscila de leve hasta discapacitante. La deformidad en el pie equino se trata conservadoramente en edades tempranas, pero ¿cuándo está indicado el manejo quirúrgico? OBJETIVO: Determinar la edad óptima para el manejo quirúrgico del pie equino en pacientes con PCI. MATERIAL Y MÉTODOS: Estudio retrospectivo realizado en pacientes con diagnóstico de PCI (todos los tipos), tratados quirúrgicamente con alargamiento del tendón de Aquiles abierto o percutáneo y valorados con notas de la consulta externa; los pacientes tuvieron de 1-16 años y un seguimiento promedio de seis años, valorándose la marcha con recidiva de deformidad y la marcha plantígrada. RESULTADOS: Se analizaron 55 pacientes, 74 con pie equino (29 niñas y 45 niños); de éstos, presentaron más recidivas los operados antes de los seis años de edad, con un período vulnerable entre los cuatro y seis años. La monoplejía registró 100% de recidivas, mientras que la triplejía 0%. La cirugía abierta se asoció con recurrencia en 50% y la cirugía percutánea sólo en 19%. CONCLUSIONES: En nuestra institución, se sugiere que la edad óptima de la cirugía esté entre los 6-12 años. Es preferible la técnica percutánea sobre la abierta, debiendo poner mayor atención en el seguimiento de la monoplejía.

Análisis para determinar la edad óptima para el manejo quirúrgico del pie equino en pacientes con parálisis cerebral infantil / Analysis to determine optimal age for surgical management of equinus foot in patients with childhood cerebral palsy

Resumen: Introducción: La parálisis cerebral infantil es una lesión cerebral no progresiva que ocurre antes, durante o después del parto y provoca daño neurológico variable que oscila de leve hasta discapacitante. La deformidad en el pie equino se trata conservadoramente en edades tempranas, pero ¿cuándo está indicado el manejo quirúrgico? Objetivo: Determinar la edad óptima para el manejo quirúrgico del pie equino en pacientes con PCI. Material y métodos: Estudio retrospectivo realizado en pacientes con diagnóstico de PCI (todos los tipos), tratados quirúrgicamente con alargamiento del tendón de Aquiles abierto o percutáneo y valorados con notas de la consulta externa; los pacientes tuvieron de 1-16 años y un seguimiento promedio de seis años, valorándose la marcha con recidiva de deformidad y la marcha plantígrada. Resultados: Se analizaron 55 pacientes, 74 con pie equino (29 niñas y 45 niños); de éstos, presentaron más recidivas los operados antes de los seis años de edad, con un período vulnerable entre los cuatro y seis años. La monoplejía registró 100% de recidivas, mientras que la triplejía 0%. La cirugía abierta se asoció con recurrencia en 50% y la cirugía percutánea sólo en 19%. Conclusiones: En nuestra institución, se sugiere que la edad óptima de la cirugía esté entre los 6-12 años. Es preferible la técnica percutánea sobre la abierta, debiendo poner mayor atención en el seguimiento de la monoplejía.

Abstract: Introduction: Childhood cerebral palsy, a non-progressive brain injury, occurs before, during or after delivery, with variable neurological damage from mild to disabling. The deformity in equine is treated conservatively at an early age, but when is surgical management indicated? Objective: Our goal was to determine the optimal age for surgical management of the equine foot in CCP patients. Material and methods: Retrospective study, in patients diagnosed with CCP (all types), treated surgically with open or percutaneous Achilles tendon elongation, assessed with external consultation notes, in patients aged 1-16 years, and average follow-up of 6 years, evaluating progress with relapse of deformity and gait with plantigrade support. Results: 55 patients, 74 equinus feet (29 in girls, 45 in boys) were analyzed with surgical treatment. Those treated before six years old presented relapses, with vulnerable period in 4-6 years. Monoplegia presented 100% relapses, and triplegia presented 0%. Open surgery presented 50% recurrence and percutaneous technique only 19%. Conclusion: In our institution, the optimal age is suggested in 6-12 years. Percutaneous technique over the open, should be preferred, and greater attention should be paid to monitoring monoplexy.

Post-activation depression of the lower extremities in stroke patients with spasticity and spastic equinovarus deformity.

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.

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.

Tratamento cirúrgico do pé eqüino na paralisia cerebral: uma revisão sistemática e quantitativa da literatura / Surgical treatment of equinus varus deformity of the foot in cerebral palsy: a systematic and quantitative review of the literature

OBJETIVO: Realizar uma revisão sistemática e quantitativa da literatura que versa sobre o tratamento cirúrgico do pé eqüino na paralisia cerebral, submetendo os resultados à apreciação estatística, caracterizando-se assim uma metanálise, cujo propósito é esclarecer qual a técnica cirúrgica que apresenta o menor risco de recidiva da deformidade em eqüino e quando devemos operar. MÉTODOS: Revisão sistemática e quantitativa da literatura entre 1966 e 2007. A seleção dos artigos seguiu critérios de inclusão e exclusão preestabelecidos. Os estudos foram identificados e escolhidos utilizando como estratégia de busca os bancos de dados computadorizados da Internet (Medline, Embase, Lilacs e Biblioteca Virtual Cochrane). Também foi realizada a busca manual de estudos em periódicos e livros. Os dados de cada estudo foram coletados conforme formulário preestabelecido. Foi avaliada a qualidade metodológica de cada estudo. Calculou-se para cada estudo selecionado a estimativa do efeito do tratamento (risco relativo de recidivas). Os dados foram submetidos à apreciação estatística específica direcionada para revisões sistemáticas. Os estudos e dados obtidos foram submetidos à análise clínica e estatística de heterogeneidade por meio da análise de subgrupos (média de idade, tempo de seguimento e técnica cirúrgica utilizada). RESULTADOS: Do total de 70 publicações encontradas, foram selecionados 20 estudos observacionais retrospectivos. A análise dos estudos com seguimento médio acima de cinco anos mostra que as taxas de recidiva se tornam de maior valor absoluto quanto maior o tempo de seguimento. Os estudos em que a média de idade dos pacientes no momento da cirurgia foi superior aos sete anos mostram menor soma dos riscos relativos, quando comparados ao grupo com média de idade inferior aos sete anos, evidenciando diminuição significativa do risco absoluto. A análise comparativa dos estudos que citam alongamentos realizados no tendão calcâneo mostra...

OBJECTIVE: To perform an systematic and quantitative review of the literature dealing with the surgical treatment of equinus foot in cerebral palsy, to perform a statistical analysis of the results in order to characterize a meta-analysis, the purpose of which is to clarify which of the surgical techniques has the lesser risk of recurrence of the equinus deformity, and when to operate on. METHODS: Systematic and quantitative review of the literature between 1966 and 2007. The selection of articles followed a pre-established inclusion and exclusion criteria. The studies were identified and chosen using the computer databases in the Internet as the search strategy (Medline, Embase, Lilacs, and Cochrane Virtual Library). A manual search in journals and books was also done. The data of each study were collected in a pre-established form. The methodological quality of each study was evaluated. For each study selected an estimate was made of the effects of the treatment (relative risk of recurrence). The data were submitted to clinical analysis and to statistical heterogeneity appreciation by analyzing subgroups (mean age, duration of follow-up, and surgical technique used). RESULTS: From the 70 publications found, 20 observational, retrospective studies were selected. Analysis of the studies with mean follow-up longer than five years shows that the rate of recurrence are of higher absolute value in proportion with the longer duration of the follow-up. The studies in which the mean age of patients at the time of surgery was older than seven years show a smaller sum total of relative risks when compared to the group with mean ager younger than seven years, showing a significant reduction of the absolute risk. The comparative analysis of studies that mention performance of lengthening of the calcaneus tendon shows a lower sum total of risks when compared to studies that mention lengthening in the muscle-tendon junction, but with a small reduction...

Botulinum toxin type A for the treatment of the spastic equinus foot in cerebral palsy.

Muscle overactivity, one of the cardinal features of spasticity, is a common sequel of cerebral palsy. In this group of patients spasticity is responsible for several limitations that interfere with gait, causing variable functional disability. Drugs such as baclofen, tizanidine, or benzodiazepines, or even definitive treatments such as orthopedics or neurosurgeries are generally prescribed with uncertain results. The use of botulinum toxin type A has been frequently suggested for the treatment of spastic equinus foot in cerebral palsy, but few studies with adequate methodology support this idea. The present paper reviews and summarizes the data of published double-blind, randomized clinical trials to assess, with a meta-analysis, if botulinum toxin type A is an adequate treatment for spasticity caused by cerebral palsy. The results reveal a statistical superiority of botulinum toxin type A over placebo on gait improvement, tested using the Physician Rating Scale and Video Gait Analysis (Peto odds ratio = 3.99, 95% confidence interval = 2.20-7.22) in patients with spastic equinus foot. The botulinum toxin group also presented better results in the subjective assessment than the placebo group (Peto odds ratio = 3.49, 95% confidence interval = 1.50-8.12). Adverse events were more frequently observed after the use of botulinum toxin type A, but they were considered mild and self-limited.

Resultados y evolución del tratamiento quirúrgico del pie equino varo congénito, en el Hospital Escuela Oscar Danilo Rosales Argüello del 01 de enero de 1997 al 15 de febrero de 1999 / Results and evaluation of the treatment of surgical congenital equinovarus foot (Clubfoot) in the Hospital Escuela Oscar Danilo Rosales foom january 1 of 1997 - to 15 th of february of 1999

Se realizó un estudio descriptivo de serie de casos a pacientes atendidos en el departamento de Ortopedía y Traumatología del Hospital Escuela Oscar Danilo Rosales Argüello, durante el período del primero de enero de 1997 al 15 de febrero de 1999. El universo de estudio serán los pacientes afectados por la enfermedades pie equino varo congenito, ingresados en el departamentode Ortopedía. Según el estudio el sexo masculino fué el más afectado, las intervenciones quirúrgicas se realizán un poco más tarde, ya que la mayoría de pacientes, se operan después del primer año. El tipo de tratamiento utilizado es el tratamiento conservador a base de yeso se prolonga por mucho tiempo

Cirugia de Evans I / Evans I surgery

Como manifiesta el Dr. Evans en su articulo original la operacion descrita tiene dos propositos que son: Primero, el proveer un metodo satisfactorio para manejar la recidiva del pie equino varo congenito y ofrecer una evidencia experimental de la validez de la teoria que cualquiera que sea la etiologia del pie equino varo congenito, la deformidad esencial es el desplazamiento medial o una rotacion del escafoides sobre el astragalo. La recidiva se presenta en la recurrencia de este desplazamiento, o mas probablemente de fallas al corregirlo completamente en las manipulaciones previas. Es asi como se debe encaminar la correccion del pie equino varo congenito a reducir el escafoides sobre la cabeza del astragalo y una vez hecho lo anterior, el cuboides habra sido empujado lateralmente y habra tapado con la parte anterior y final del calcaneo, el cual quedara libre de la parte anterior y final del astragalo; el talon se movera al valgo y se habra aclarado el camino para la correccion del equino. Por lo tanto, si llega a ser evidente que el pie esta recidivado, el tratamiento debe comenzar de nuevo, pero es obvio que en esta etapa la resistencia ofrecida por el pie ha llegado a ser muy grande y la correccion completa es a menudo imposible. Existe aqui un fenomeno de sobrecrecimiento relativo de la columna lateral del pie que impide una correccion satisfactoria de la deformidad primaria y es aqui donde el autor se detiene y hace un analisis cuidadoso de lo que ofrece la reseccion de una cuna en la articulacion calcaneo-cuboidea. Se concluye por su trabajo, por los autores (pocos) y por el presente, el buen resultado, ...