The analysis of equinus deformity caused by intramuscular venous malformation onset posterior muscles of leg and the treatment of surgery / 中华整形外科杂志

Objective@#To analyze the causes of equinus deformity caused by intramuscular venous malformation onset posterior muscles of leg, and discuss the corresponding treatment methods.@*Methods@#A retrospective study was conducted on 69 cases of intramuscular venous malformations with equinus deformity from January 2012 to December 2017. Based on patient's main complain, physical examination and imaging data, the causes were divided into two categories: pain disorder and contracture disorder. Classification was on the basis of definite diagnosis of MRI. When the main complaint of medical history and physical examination indicated pain relief or passivity of the affected limb, and when the back extension of ankle joint was greater than 75 degrees, it was a pain disorder; when the medical history and physical examination indicated pain relief or passivity of the affected limb, the back extension of ankle joint was less than 15 degrees, it was a contracture disorder. Therapeutic methods included drug conservative treatment and surgical treatment. For the patients with pain disorder, the first choice was drug conservative treatment, and for the patients with contracture disorder, the first choice was surgery. Operative methods include simple venous malformation resection, venous malformation resection and Z-type Achilles tendon anastomosis lengthening. After operation patients received systematic functional rehabilitation exercise and calculated the satisfaction rate.@*Results@#13 cases of painful disorders were firstly treated by conservative medicine, but 4 cases were treated by operation after series of conservative treatments, satisfaction rate was 69.2%(9/13). 56 contracture cases were treated by operation, including 11 cases of simple venous malformation resection, 45 cases resection and Z-type anastomosis lengthening of Achilles tendon. All the patients were followed up for 6 months to 2 years after operation. 53 patients recovered to normal walking after operation, and 3 patients had mild limp, satisfaction rate was 94.6%(53/56). Patient satisfaction was 100%.@*Conclusions@#The equinus deformity caused by intramuscular venous malformation onset posterior muscles of leg affect the quality of life. Muscle/tendon contracture was the main cause. Correct surgical treatment combined with early rehabilitation exercise post operation can restore normal walking posture.

Effects of eccentric exercise in pressure pain threshold in subjects with functional ankle equinus condition

SUMMARY Stretching exercises are widely used by the population before sporting activities. One of the most common technique is eccentric exercise. Here, we made a clinical examination of 98 subjects with equinus condition before activity and after 30 min of running (49 participants with previous eccentric exercise and 49 with no previously eccentric exercise). The clinical assessment of the Achilles tendon was based on the pressure pain threshold (PPT). We identified significant PPT changes between the previous eccentric stretching and the non-previous eccentric stretching group in the Achilles tendon evaluations. Based on our findings, we propose that subjects with equinus condition could use eccentric stretching in order to improve the Achilles tendon status.

RESUMO Exercícios de alongamento são amplamente utilizados pela população antes da atividade esportiva. Uma das técnicas mais comuns é o exercício excêntrico. Aqui, fizemos um exame clínico de 98 indivíduos com condição de pé equino antes da atividade e após 30 minutos de corrida (49 corredores com exercício excêntrico anterior e 49 sem exercício excêntrico anterior). A avaliação clínica do tendão de Aquiles foi baseada no limiar de dor à pressão (PPT). Identificamos modificações significativas no PPT entre alongamentos prévios excêntricos e nenhum exercício anterior excêntrico de alongamento para as avaliações do tendão de Aquiles. Com base em nossos achados, propomos que sujeitos com condição de pé equino poderiam fazer alongamentos com exercícios excêntricos para melhorar o status do tendão de Aquiles.

Ilizarov method combined with reversed sural or saphenous neurocutaneous island flaps transfer for posttraumatic equinus with soft tissue defects on ankle and foot / 中华骨科杂志

Objective To evaluate the clinical effects of the Ilizarov method combined with two kinds of reversed neurocutaneous island flaps transfer for posttraumatic equinus with soft tissue defects on ankle and foot.Methods Data of 21 cases of posttraumatic equinus with soft tissue defects on ankle and foot who were treated with the Ilizarov external fixation combined with the two kinds of reversed neurocutaneous island flaps transfer from June 2006 to January 2018 were retrospectively analyzed.There were 17 males and 4 females,aged from 26 to 65 years,with an average age of 43.9 years.The soft tissue defect dimensions ranged from 6 cm×5 cm to 10 cm×9 cm,and the time from the initial trauma to the operation ranged from 2.5 to 240.0 months.The mean preoperative equinus contracture was-38.9° (range,-25° to-66°),and total ankle range of motion (ROM) was 7.1° (range,0°-18°).All cases were treated with the Ilizarov external fixation combined with the two kinds of reversed neurocutaneous island flaps transfer.Two weeks after the flap transfer,distraction of the Ilizarov fixator was initiated to gradually correct the equinus foot.The flap survival was observed in the postoperative period,and the International Club Foot Study Group (ICFSG) score was collected at the latest follow-up.The criteria were used to assess the morphological and functional outcome.Results A total of 21 resversed flaps were transferred,including 15 sural neurocutaneous flaps and 6 saphenous neurocutaneous flaps.The sizes of flaps were from 7 cm±6 cm to 11 cm± 10 cm.Among them,17 patients underwent primary flap transfer,and 4 patients underwent a delayed second-stage procedure 2 weeks after primary surgery.The 4 delayed flaps contain 3 sural neurocutaneous flaps and 1 saphenous neurocutaneous flap.All 21 patients were followed up and the average periodof follow-up was 20.3 months (range,8-96 months).Among the 21 flaps,19 survived completely.Although marginal necrosis was observed in 2 cases,these wounds healed after subsequent debridement and dressing change treatment.No major complication was seen,but superficial pin tract infection was present in 4 cases who then received dressing change and oral antibiotic.Deformities were corrected,and ankle motion had increased significantly.The mean ankle activity at the latest follow up was 22° (range,8°-38°),and postoperative ICFSG score at the latest follow-up was 5.67±3.09,which significantly reduced compared with preoperative one (30.81 ±3.63).The difference was statistically significant (t=32.815,P=0.035).The results were excellent in 13 feet,good in 7,and fair in 1,with the excellent and good rate of 95.24％ (20/21).The local infections were cured without recurrence at operative site.Equinus deformities were corrected,and the latest follow-up results showed that all patients walked normally without recurrence.Conclusion Ilizarov method combined with reversed sural and saphenous neurocutaneous island flap can improve the limb function and the flap can survival with good clinical effect.

Avaliação crítica das técnicas cirúrgicas de correção do equino / Critical evaluation of the surgical techniques to correct the equinus deformity

RESUMO A deformidade em equino leva a diversos transtornos da marcha, ao causar alterações no apoio do pé e afetar regiões anatômicas mais distantes, como o joelho, quadril e tronco. Geralmente é secundária à retração, encurtamento ou espasticidade do tríceps sural, de modo que algumas intervenções cirúrgicas podem ser necessárias para corrigi-la. Trata-se de um dos procedimentos mais antigos da Ortopedia, antes realizado apenas no tendão calcâneo e que, ao longo do tempo, evoluiu com técnicas diferentes de acordo com o grau de deformidade, doença de base e perfil do paciente. Busca-se corrigir a deformidade, com a menor interferência possível na força muscular e, com isso, diminuir a incidência de complicações, como marcha agachada, arrastada e pé calcâneo. Do ponto de vista anatômico, o tríceps sural apresenta cinco regiões que podem ser abordadas cirurgicamente para correção do equino. Em virtude da complexidade do paciente com equino, os ortopedistas devem ter experiência com ao menos uma técnica em cada zona. Neste texto são abordadas e analisadas criticamente as técnicas mais importantes para correção do equino, principalmente de modo a evitar complicações. Foi realizada uma busca sobre técnicas cirúrgicas mais comuns de correção do equino em livros clássicos e identificação e consulta aos artigos originais. Em seguida, fez-se uma busca em bases de dados nos últimos dez anos.

ABSTRACT The equinus deformity causes changes in the foot contact and may affect more proximal anatomical regions, such as the knee, hip and trunk, potentially leading to gait disorders. The equinus is usually secondary to retraction, shortening and/or spasticity of the triceps surae, and it may require surgical correction. Surgery for the correction of equinus is one of the oldest procedures in Orthopedics, and it was initially performed only at the calcaneus tendon. The technique has evolved, so that it could be customized for each patient, depending on the degree of deformity, the underlying disease, and patient´s profile. The aim is to correct the deformity, with minimal interference in muscle strength, thus reducing the incidence of disabling complications such as crouch gait and calcaneus foot. We conducted a literature search for the most common surgical techniques to correct the equinus deformity using classic books and original articles. Further, we performed a database search for articles published in the last ten years. From the anatomical perspective, the triceps surae presents five anatomical regions that can be approached surgically for the equinus correction. Due to the complexity of the equinus, orthopedic surgeons should be experienced with at least one procedure at each region. In this text, we critically approach and analyze the most important techniques for correction of the equinus, mainly to avoid complications.

Clinical observation of osteotomy and fusion for the treatment of severe rigid equinus deformity / 中国骨伤

<p><b>OBJECTIVE</b>To explore clinical efficacy of osteotomy and fusion in treating severe rigid equinus deformity.</p><p><b>METHODS</b>From April 2010 to October 2015, 13 patients(16 feet) with severe rigid equinus deformity were treated with osteotomy and fusion by hollow screw, including 6 males and 7 females aged from 39 to 62 years old with an average of(49.6±5.3) years old;the courses of diseases ranged from 5 to 27 years with an average of (9.0±4.8) years. Six patients (9 feet) were treated with osteotomy and fusion for three joints, 4 patients(4 feet) were treated with osteotomy and fusion for four joints, and 3 patients (3 feet) were treated with osteotomy and fusion for tibiotalar and calcaneal-talar joints. All patients manifested as foot pain, heel could not touch floor and walking before operation. Postoperative complications were observed, AOFAS score were applied to evaluate clinical effect.</p><p><b>RESULTS</b>Thirteen patients were followed up from 18 to 24 months with an average of 20 months. Only one patient occurred local skin necrosis after operation and healed by dressing change and anti-infective therapy. All feet obtained fracture healing, the time ranged from 12 to 16 weeks with an average of 13.2 weeks. AOFAS score were improved from 11.85±10.66 before operation to 81.38±3.69 after operation, and had significant difference(=-25.67, <0.05);15 feet good and 1 foot moderate.</p><p><b>CONCLUSIONS</b>Tibiotalar and calcaneal-talar joint fusion, osteotomy and fusion for three and four joints could treat severe rigid equinus deformity according to patients' individual and could obtain satisfied clinical effects.</p>

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.

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.

Current research of role of Hox genes in pathogenesis of equinus deformity / 天津医药

Congenital clubfoot(CCF), which is also known as equines deformity, is a common congenital malformation that affect children′s life quality. However, its cause is still to be elucidated. Currently, polygenetic and environmental fac?tors are both believed to play important roles in CCF pathogenesis. Several genes including HOX, PITX1, NAT2, P63, DTDS and COL9A were shown to contribute to congenital clubfoot, but which is the most critical gene remains unclear. Several re?ports have revealed that Hox genes are closely related to the cause of CCF. Hox genes are regulators of body morphogenesis, and its mutation result in limbs and trunk deformity in human. Here, we systematically reviewed the latest literature that stud?ied the role of Hox genes in pathogenesis of Congenital clubfoot, with the prospect of laying a foundation for its future clinic treatment.

Treatment of posttraumatic clubfoot with Ilizarov distraction technique in children / 中华创伤杂志

Objective To investigate the approaches and effect of Ilizarov external fixators combined with limited operation in treatment of posttraumatic clubfoot in children.Methods The study involved 40 cases (43 feet) of posttraumatic clubfoot treated with Ilizarov external fixators combined with limited operation including soft-tissue releases (26 cases,28 feet) or osteotomies (14 cases,15 feet)from January 2006 to June 2012.Scoring system of intemational clubfoot study group (ICFSG) including aspects of functional assessment (36 points),morphology (12 points) and radiological assessment (12points) were employed before and after surgery.Results All the cases were available to the follow-up of 0.5-6 years.ICFSG score was excellent in 28 feet,good in 10,fair in four and poor in one foot,with excellent-good rate of 88％.This suggested the good correction of posttraumatic clubfoot,satisfactory weight-bearing exercise and a low relapse rate.Conclusions Conservative open operation brings large trauma and poor results in treatment of posttraumatic clubfeet in children,while Ilizarov invasive distraction technique is probable to offset those weak points.Therefore,Ilizarov external fixators combined with limited operation is an effective treatment.

Avaliação da marcha em paciente com paralisia cerebral submetido à estimulação elétrica dos compartimentos anterior e lateral da perna / Cerebral palsy gait analysis comparison before and after electrical stimulation of anterior and lateral leg compartments

Crianças com lesão do neurônio motor superior possuem déficits funcionais desafiadores. As alterações de marcha são conseqüências da espasticidade, padrão primitivo locomotor, pobre controle motor central e controle debilitado da propriocepção. O objetivo do presente estudo é mostrar os benefícios da eletro-estimulação no padrão da marcha do paciente com paralisia cerebral através do laboratório de marcha e teste ergoespirométrico. Método: Paciente do grupo de Neuro-ortopedia do IOT HC-FMUSP, sexo feminino, 24 anos, estudante, portadora de paralisia cerebral do tipo diplégico espástico, deambuladora comunitária e pés eqüinos flexíveis. Equipamento de análise de marcha: HAWK, Motion Analysis Corporation. Analisador metabólico CPX-D, Medgraphics, EUA. Estimulador elétrico modelo EEF-4, Lynx Tecnologia. Frequência de estímulo de 20Hz, ON/OFF 5s/10s, 40min, 3X/semana por 1,5 meses nos compartimentos anterior e lateral das pernas. Resultado: dorsiflexão fase de balanço pé direito e esquerdo anterior ao estímulo: 2,12º e -0,17º, respectivamente. Após 1,5 meses do término do protocolo: dorsiflexão pé direito=7,54º, dorsiflexão pé esquerdo=5,31º. Ergoespirometria: Aumento do tempo de tolerância ao exercício (TT) em 194%, PO2 em 50%, VO2 em 17% e economia energética relativa a 22% da FC. Conclusão: a estimulação elétrica da perna pode ser responsável por alterações na cinemática não só do tornozelo, mas de todo o membro inferior, influenciando o padrão da marcha e a condição cardiopulmonar do paciente com paralisia cerebral.

Children with upper motor neuron injuries have challenging functional deficits. Their gait deviations are a consequence of spasticity, persistent primitive locomotor patterns, poor selective motor control and impaired proprioception. The objective of this study is to show the benefits of electrical stimulation on gait patterns of patients with cerebral palsy through gait analysis and cardiopulmonary exercise test. Methods: patient from Neuro-orthopedic group of IOT HC-FMUSP, female, 24 years-old, student, cerebral palsy with spastic diplegia, communitarian ambulation and flaccid bilateral equinus foot. Gait analysis equipment: HAWK, Motion Analysis Corporation. Metabolic analyzer: CPX-D, Medgraphics, USA. Electrical stimulator: EEF-4, Lynx Tecnologia. Electrical stimulation using 20Hz, ON/OFF 5sec/10sec, 40min, 3 times a week for 1.5 months on anterior and lateral leg muscles. Results: in swing phase, before stimulus, right and left ankle dorsiflexion = 2.12º and -0.17º, respectively. 1.5 months after last stimulus, right and left ankle dorsiflexion = 7.54º and 5.31º, respectively. Cardiopulmonary analysis: improvement in exercise tolerance of 194%, 50% in O2P, 17% in VO2 and energetic economy of 22% of HR. Conclusion: leg`s electrical stimulation may be responsible for cinematic improvements not only of the ankles but all lower limbs, influencing gait patterns and cardiopulmonary conditions of patients with cerebral palsy.

Two Staged Surgical Treatment of Post-Traumatic Severe Ankle Equinus Deformity: Preliminary Report / 대한족부족관절학회지

PURPOSE: To evaluate the effectiveness as well as correct the post-traumatic severe ankle equinus deformity by conducting the treatment surgery, which is divided into 2 stages, soft tissue adhesiolysis and ankle arthrodesis. MATERIALS AND METHODS: We have conducted the methods, which are Z-plasty Achilles tendon lengthening, multiple capsulotomy and tendon lengthening (flexor hallucis longus muscle, flexor digitorum longus, posterior tibialis tendon) for 10 patients who has shown equinus deformity after post-traumatic compartment syndrome due to the injury. The average age of patients was 33.7 year-old; there were 8 men and 2 women, and the follow up period was 13 months (6~31 mon). Outcomes were rated based on American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Visual Analogue Scale (VAS) and patient's satisfaction after operation. RESULTS: The average degree of preoperative equinus deformity was 64 degree (-60~-70), and we've obtained AOFAS anklehindfoot score that was evaluated after 4 months of 2nd operation which was 76.7 score on average. We've also checked the decreased pain score from all of the patients according to the fact that the average VAS before the surgery was 6 (4~8), but it reduced to 3 (1~4). The patient's satisfaction showed generally great satisfactions which was 5 cases were excellent, 2 cases were good, and 3 cases were fair. CONCLUSION: The two staged surgical treatment of post -traumatic severe ankle equinus deformity, which was conducted of soft tissue adhesiolysis and arthrodesis, could be one of the effective methods to improve patients walking ability.

Alternativa quirúrgica con tutor externo tipo Ilizarov para el tratamiento de pie equino varo hipercorregido / Surgical alternative type Ilizarov external fixator for the treatment of overcorrected clubfoot

Este estudio es un análisis retrospectivo que se realizó a 35 pies de 29 pacientes(11 hembras y 18 varones) con el diagnóstico de pie equino varo congénito hípercorregido, en el hospital ortopédico infantil de Caracas en un period comprendido entre el 03-11-1997 al 26-11-2007, a los cuales se le practicó una cirugía con osteotomías percutáneas supramaleolar de tibia y de medio pie, fijados con un tutor externo multiplanar tipo ilizarov. Se encontró mejoría en los ángulos de kite AP y lateral post-operatorio, promedio pre-operatorio (45,8°) lateral y (43,5°) AP con un post-operatorio de(29,8°) lateral y(28,3°)AP. Tomando en cuenta la disminución del tiempo quirúrgico, días de hospitalización, disminución de la injuria a nivel de los tejidos y reincorporación temprana a las actividades, con un seguimiento promedio de 7 años que al final se mantenía el ángulo de kite del último control con respecto al post-operatorio tardío. Por lo que recomendamos este procedimiento como parte del tratamiento para corrección del pie quino varo congénito hipercorregido.

This study is a retrospective analysis was performed to 35 feet of 29 patients (11 females and 18 males) diagnosed with overcorrected clubfoot in children's orthopedic hospital of Caracas in a period from 11.03.1997 to 26.11.2007, to which she underwent surgery supramalleolar percutaneous tibial osteotomy and mid-foot, fixed with Ilizarov external fixator multiplanar type. There was improvement in kite angles AP and lateral postoperative average pre-operative (45.8 °) and lateral (43.5 °) AP with a post-operative (29.8 °) and lateral (28 , 3 °) AP. Taking into account the reduction of surgical time, hospital stay, decreased level of injury to tissues and early return to activities, with an average follow up of 7 years which ultimately kept the kite angle of ultimate control over the late postoperative period. So we recommend this procedure as a treatment for correction of congenital varus foot overcorrected quino.

Changes in the Gastrocnemius and Soleus Muscle Length during Gait in CP Patients with an Equinus Deformity / 대한정형외과학회잡지

PURPOSE: To measure the muscle length of the gastrocnemius and soleus during gait in CP patients with an equinus deformity before and after surgery. MATERIALS AND METHODS: Twelve CP patients with an equinus deformity (17 limbs) were examined by gait analysis preoperatively and postoperatively. The patient group was further classified into the TAL and Strayer group according to the surgical technique. The mean age and mean follow-up periods were 14.3 years (5-25 years) and 15.3 months (12.5-18.5 months), respectively. The muscle length of the Gastrocnemius and Soleus was measured during gait using the SIMM program linked to a gait analysis system. RESULTS: The ankle ROM, knee ROM, maximal muscle length and peak-to-peak excursion during gait improved after surgery. There was a significant difference between the preoperative and postoperative measurements (p0.05). The muscle length of the soleus was elongated during gait after the Strayer procedure. CONCLUSION: Patients with an equinus deformity had a contracted triceps muscle, which was elongated after surgery. These changes were quantified by a comparison of the preoperative and postoperative measurements.

Application of Ponseti method in patients older than 6 months with con-genital talipes equinovarus / 北京大学学报(医学版)

Objective:To evaluate the effectiveness of Ponseti method in the treatment of congenital talipes equinovarus (CTE) in children older than 6 months. Methods: Ponseti method was used to treat 157 cases (227 feet) of CTE in children older than 6 months. All cases were classified by age and by the degree of deformity severity. The age group classification was: (1) Ⅰ Group (6 months to 12 months),113 feet in 81 cases; (2) ⅡGroup (1 to 3 years old), 78 feet in 52 cases; (3) Ⅲ Group (>3 years old), 36 feet in 24 cases. The degree of deformity of CTE was evaluated with Pirani scoring system. The cases were classified into three groups according to the deformity degree : (1) Mild Group (scoring 1-2. 5) , 85 feet in 56 cases; (2) Moderate Group (scoring 3-4. 5) , 104 feet in 71 cases; (3) Severe Group (scoring 5-6) , 38 feet in 30 cases. A Pirani score of 0-0. 5 is regarded as an excellent result. For each group, we evaluated the number of casts used, the percentage of excellent result according to the Pirani score, and the percentage of percutaneous achillotenotomy. The result was compared among different groups. Results: The overall percentage of excellent result among all cases was 96.92%. A-mong the age groups, the percentage of excellence was not statistically different between Ⅰ Group and Ⅱ Group (P>0. 05). The percentage of excellence was lower in the Ⅲ group than the other groups (P> 0. 01). Among the groups classified by deformity degree, the percentage of excellence was the lowest in severe group (P<0. 05), and the difference between the mild group and moderate group was not statistically different (P>0. 05). The number of casts used among different groups were different (P<0. 01). Among different groups, the percentages of percutaneous achillotenotomy were significantly different (P<0. 01). 209 feet in 148 caseswere followed up for average time duration of 3 years and 11 months. Re-lapse was observed in 40 feet in 29 cases. The percentages of relapse were not statistically different among different groups (P>0. 05). Conclusion: Using Ponseti method to treat CTE for children older than 6 months can achieve excellent results in this study.

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...

Treatment of Talipes Equinus Deformity Using Free Radial Forearm Flap and Achilles Tendon Lengthening

PURPOSE: Talipes equinus deformity is defined as impossibility of heel weight-bearing and lacking of improvement of toe-tip gait despite sufficient duration of conservative treatment. The incidence of equinus deformity induces post-traumatic extensive soft tissue defect and subsequently increases it. Severe equinus deformities of the foot associated with extensive scarring of the leg and ankle were corrected using achilles Z-lengthening and free-tissue transfer. METHODS: Free radial forearm flap was done in nine cases of eight patients from January 2000 to November 2006. Causes of deformity were post-traumatic contracture (one patient) and post-burn scar contracture (seven patients). Seven patients were male, one patient was female. Mean age was 32.1 (range, 10-57). Flap donors were covered with artificial dermis (Terudermis(R)) and split thickness skin graft (five cases), and medium thickness skin graft only (four cases). RESULTS: The size of flaps varied from 6x12 to 15 x12cm (average, 12x7.8cm). Achilles tendon was lengthened 4.2cm on average. Free radial forearm flap was satisfactory in all cases. All patients could ambulate normally after the surgery. Cases having donor coverage with Terudermis(R) were aesthetically better than those having skin grafts only. CONCLUSION: This study suggested that severe equinus deformities associated with extensive scarring of the leg and ankle can be corrected effectively free radial forearm flap and Achilles tendon lengthening.

The Changes of Foot Pressure Distribution in Spastic Cerebral Palsy with Equinus Deformity following Corrective Surgery

OBJECTIVE: The aim of this study was to identify the changes of pressure distribution on the foot after orthopaedic surgery for equinus deformity in spastic cerebral palsy using F-scan system. METHOD: Twenty-one children with spastic cerebral palsy were participated in this study. They had equinus deformity on foot and received soft tissue surgery. Pressure distribution on foot was measured before and after operation using F-scan system (Tekscan Inc., USA). Paired t-test was used in comparison of preoperative and postoperative measurements for statistical analysis. RESULTS: Total contact area, contact length, midfoot and hindfoot contact width were significantly increased after operation. Relative impulses of medial and lateral forefoot were significantly decreased and relative impulse of hindfoot significantly increased after operation (p<0.05). Anteroposterior distance of center of pressure (COP) and velocity of COP were significantly increased and mediolateral distance and slope of COP were significantly decreased after operation (p<0.05). CONCLUSION: This study revealed that patterns of foot pressure distribution during walking were significantly improved after operation. Therefore, these findings suggested that F- scan system might be useful for surgical outcome measurement for foot deformities in the children with spastic cerebral palsy.

Application of Ponseti method in patients older than 6 months with congenital talipes equinovarus / 北京大学学报(医学版)

0.01). Among the groups classified by deformity degree,the percentage of excellence was the lowest in severe group (P0.05). The number of casts used among different groups were different (P0.05). Conclusion:Using Ponseti method to treat CTE for children older than 6 months can achieve excellent results in this study.

Kinematic and Kinetic Changes of the Ankle After the Correction of Spastic Equinus Deformity: Z-plastic Lengthening versus Strayer Method / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the post-operative changes and to determine the factors affecting results obtained after surgical correction of spastic equinus deformity. MATERIALS AND METHODS: Among cerebral palsy patients who had received Tendo Achilles Lengthening (TAL) or the Strayer procedure, eighty nine patients (114 cases: TAL, 78 cases and Strayer, 36 cases) were included in this study. We evaluated clinical assessment data, kinematic data, and kinetic data pre- and post-operatively, according to the geographic type of cerebral palsy, age at operation, and sex. RESULTS: Clinically, equinus deformities were corrected with an increased passive range of motion of the ankle in both groups. Accord-ing to the kinematic results, both groups showed a normal ankle motion pattern with an increased dynamic range of motion. Kinetic results revealed that peak plantarflexor moment and power generation (A2) increased in both groups and that this increase was statisti-cal significant in TAL group. CONCLUSION: Both the TAL and Strayer procedures corrected the spasticity and equinus deformity, and resulted in an increased dynam-ic range of motion of the ankle joint without compromising the triceps power. However, care must be taken not to decrease power gen-eration when TAL is performed in diplegic cases older than 13 years of age.

Treatment of Severe Equinus Deformity Associated with Extensive Scarring of the Leg and Ankle with the Hinged Ilizarov and Free Tissue Transfer / 대한정형외과학회잡지

We evaluated the results following the use of hinged Ilizarov and free tissue transfer to correct the eqinus deformity of the foot associated with extensive scarring of the leg and ankle in nine patients. The deformity was secondary to ischemic and neuropathic changes after trauma to the leg, ankle and foot. The average age of the patients was seventeen years (range, thirteen to thirty-four years). The average duration of follow-up was twenty-one months (range, twelve to thirty-eight months). Free tissue transfer was done in all cases, parascapular flap was done in seyen cases, groin flap was done in two cases. Among the nine cases, free tissue transfer and hinged Ilizaov were done at the same time in four cases, The average interval of the other five patients between free tissue transfer and hinged Ilizaov was three months (range, two to four months). The duration of distraction was four to six weeks, and the apparatus was kept in place for an additional two months after the desired position of correction had been achieved. The results were evaluated using two criteria, dorsiflexion and range of motion of ankle joint. Criteria on dorsiflexion of ankle, the results were good in seven cases, fair in two cases. Criteria on range of motion of ankle, one case being performed ankle fusion was not evaluated. Total eight cases were evaluated for range of motion of ankle. The results were good in six cases, fair in two cases. On the basis of our results, we believe that severe eqinus deformities of the foot associated with extensive scarring of the leg and ankle can be corrected with heel cord lengthening, free tissue transfer and hinged Ilizarov.

Ilizarov Technique in the Correction of Equinus Deformity / 대한정형외과학회잡지

The introduction and adaptation of the methods of Ilizarov could be achieved correction of equines in patients with major problems such as posttraumatic equines associated with severe soft tissue injury that would not allow the use of conventional surgical methods. In order to evaluate the factors causing complications and affecting the results, we reviewed 12 cases in which the equines deformity of feet were corrected by the Ilizarov method from May 1991 to August 1995. Mean follow up periods were 18 months. The average age of patients was 28 years(ranged from 8 to 56 years). The causes of equines were posttraumatic 9, Charcot-Marie-Tooth disease 1, residual poliomyelitis 1, and deformity of unknown origin 1, and four cases were associated varus deformity. Correction periods was from 4 to 14 weeks(average 7 weeks), fixation period from 1 to 16 weeks(average 6.2 weeks). The additional immobilization with cast or brace was from 4 to 44 weeks, and then rehabilitation was done. Initial equines deformity was averaged 39.5 degrees (range 20-70 degrees). We obtained average 33 degrees of deformity correction which means the average 6.5 degrees of equines still was remained at the last follow up. Range of motion was improved from preoperative 11 to postoperative 20 degrees. One posttraumatic patient with calcaneal varus and loss of calf muscles, and one residual poliomyelitis patient recurred during follow up. We performed the triple arthrodesis and Achilles lengthening in one case of Charcot-Marie-Tooth disease and one case of equines deformity of unknown origin. Gait pattern and pain was improved in all but 2 cases with mild pain in walking. Complications during or after treatment were recurrence(2), anterior subluxation of talus(5), claw toe(10), partical rupture of Achilles tendon(1), valuges or varus deformity (4), posterior tibial nerve injury(1), rockerbottom deformity(2) and pin tract infection(5). The case of recurrence or second operation coourred in 4 of 12 cases(33%). To prevent the recurrence of equines deformity, we recommend that long period of maintainance, adequate cast immobilization or brace more than 3 months, and continuous rehabilitation. The key to prevent subluxation of talus was a precise hinge placement at the center of talar dome and, if subluxation of talus was occurred, it should be corrected by anterior or posterior translation using olive pin. It should be corrected by flexor tendon lengthening during correction period or after removal of Ilizarov, if claw toew deformity occurred.