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.

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.

Double arthrodèse de l'arrière pied associée à la libération postéro-médiale des parties molles dans le pied varus équin invétéré

Introduction : Les méthodes chirurgicales du pied varus équinirréductible sont variées. Le but de cette étude était d'évaluer les résultats de ce traitement par l'association simultanée de la double arthrodèse sous talienne et médio-tarsienne et la libération postéro-interne du pied. Patients et méthodes : Il s'agissait d'une étude rétrospective de 19 patients (19 pieds) opérés pour pied varus équins invétérés entre janvier 1990 et décembre 2002. L'âge moyen des patients était de 21 ans (13-38). La cause de la déformation était l'injection intra fessière avec déficit du grand nerf sciatique (n=15), la poliomyélite (n= 2), et le traumatisme(n=2). Le délai moyen entre le début de la lésion initiale et l'opération était 11ans (2 -26). Le tendon d'Achille était allongé. La désinsertion distale du muscle tibial postérieur était réalisée. Toutes les arthrodèses étaient fixées par des agrafes. La greffe osseuse n'a pas été réaliséeLes résultats étaient appréciés selon les critères de Angus et Cowell. Résultats : Le recul moyen était de 4,8 ans (2-10). Tous les patients ont été revus. La consolidation a été obtenue chez tous les patients dans un délai de trois mois. Les résultats globaux étaient bons (n=12), moyen (n=6), et mauvais (n=1). Il n'y avait ni échec de l'arthrodèse, ni nécrose du talus. Conclusion : La double arthrodèse associée à la libération postéro-interne dans le même temps opératoire permet une correction des déformations. Cette technique est fiable et ses résultats se maintiennent dans le temps

Surgical Results of Limb Lengthening at the Femur, Tibia, and Humerus in Patients with Achondroplasia

BACKGROUND: Results of limb lengthening in patients with achondroplasia were previously reported in many studies. However, the reports of comparison among the three long bones (femur, tibia, and humerus) are rare, especially for the results of crossed lengthening (lengthening of one femur and contralateral tibia followed by that of the opposite side) for the lower limbs. The purpose of this study was to report the surgical results of a series of limb lengthening in achondroplastic or hypochondroplasia patients at our institution. METHODS: Fifteen patients (14 with achondroplasia and 1 with hypochondroplasia) underwent lower limb lengthening of the femur (n = 32) and tibia (n = 28), and 12 of them underwent crossed lengthening. Humeral lengthening was performed in 14 patients (n = 28). The mean age at the first operation was 11.7 years, and the mean follow-up duration was 66.7 months. The healing index, consolidation period index (duration of consolidation period/gained length), and other radiographic indices were analyzed. Limb length discrepancy and hip-knee-ankle alignment in lower limbs, and the occurrence of difficulties were assessed. RESULTS: The average gain in length for the femur, tibia, and humerus was 8.3 cm, 8.5 cm, and 7.4 cm, respectively. The mean healing index was 29.6 days/cm for the femur, 29.0 days/cm for the tibia, and 27.2 days/cm for the humerus. The mean consolidation period index was 14.7 days/cm for the humerus, which was significantly lower than that in the lower limb (17.3 days/cm for the femur and 17.8 days/cm for the tibia). Of the 12 who underwent crossed lengthening, five showed limb length discrepancy ≥ 1.0 cm. Among their 24 lower limbs, three showed valgus alignment ≥ 5° and one showed varus alignment ≥ 5°. Thirty-two pin site infections and three fractures were conservatively managed. Three femoral fractures, eight equinus deformities, and four cases with premature consolidation of the fibula were surgically treated. Obstacle and true complication related to humeral lengthening were not observed. CONCLUSIONS: Humeral lengthening was relatively effective and safe. Careful attention will be needed to avoid the occurrence of limb length discrepancy or malalignment in crossed lengthening.

Propuesta de un nuevo diseño de órtesis post-tratamiento de pie equino varo congénito / Proposal for a new design of post-treatment congenital club foot orthosis

La investigación tuvo como objetivo rediseñar la órtesis utilizada post-tratamiento Ponseti, en niños con pie equino varo congénito, de forma tal que permita la reducción de rechazo a su uso. Método: Se identificaron las necesidades de los niños con pie equino varo congénito, para verificar los inconvenientes con respecto a la funcionalidad, diseño y adaptabilidad a la órtesis dado que si la férula no se usa adecuadamente el riesgo de recidiva es de 80 %, por el contrario con el uso de la férula el riesgo es de 4 %. Se realizó un estudio biomecánico del movimiento de un paciente durante el gateo, con y sin la órtesis. Resultados: Se elaboró un modelo 3D de la propuesta, para simular el diseño sometido a las fuerzas generadas por los bebés durante el pataleo en posición supina. Se evaluó experimentalmente el desempeño del prototipo alfa, para determinar si cumplía con la meta prevista. Se obtuvo la fabricación y pruebas de la órtesis en plataforma virtual y físico. Acorde al alcance del proyecto, se determinó que es probable que se reduzca el rechazo al uso y por consiguiente la formación de recidiva, al reducir los factores determinantes propios de la férula del mercado, que propiciaban el mal uso de esta en el tratamiento. La velocidad promedio de gateo es de 0.48 m/s y con la férula se reduce a 0.37 m/s. Discusión: La férula del mercado pesa 304.07 g y la propuesta pesa 209.26 g. Se sugiere que se continúe la investigación en el estudio biomecánico.

This research was developed with the objective of redesigning the orthosis used in the post- Ponseti treatment in children with clubfoot, with the intention of reducing the rejection to its use. Method: A research on the needs of children with congenital clubfoot was conducted to identify the disadvantages on functionality, design and adaptability of the orthosis if the splint is not used appropriately, the risk of relapse is 80 %, whereas using the splint, the risk is 4 %. A biomechanical study of a patient's movement during the crawl was performed with and without the orthosis. Results: A 3D model of the design was developed to simulate computationally its performance under the forces generated by the babies during the kick in supine position. Finally, an experimental evaluation of the alpha prototype performance was made to determine whether it met the intended goal. Thus, the manufacturing and testing of the orthosis on virtual and in physical platform took place. Taking in account the goal of this project, it 3 was determined that it is possible to reduce the reject to the use and therefore the formation of relapse by reducing the determinant factors of the common market splint, which promotes its incorrect use of this in the treatment. The average crawl speed is 0.48 m/s and with the splint, it decreases to 0.37 m/s. Discussion: The weight of the common market splint is 304.07 g and the weight of the one designed in the study is 209.26 g. Further biomechanical research is suggested to get conclusive results

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>

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.

Funcionamiento normal y aumentado de la glándula tiroides en equinos / Normal and ncreaased functioning of thyroid gland in equines

Objetivo: Describir y analizar el funcionamiento normal de la glándula tiroides en equinos y los factores que aumentan en ellos los niveles de hormonas tiroideas. Materiales y métodos: Mediante la revisión de la literatura disponible de los últimos 50 años en las bases de datos BBCS-LILACS, fuente académica, IB-PsycINFO, IB-SSCI, IB-SciELO, Scopus y Scirus, al igual que artículos históricos, textos y referencias citadas en trabajos publicados. Resultados: la información obtenida relacionada con los objetivos propuestos en la presente revisión, permite clasificar en 4 secciones a saber: síntesis y secreción de hormonas tiroideas; transporte y metabolismo; funciones; hipertiroidismo en los equinos. Conclusión: La glándula tiroides juega un papel importante, como productora de hormonas tiroideas, las cuales son necesarias para la diferenciación celular y crecimiento del organismo. El buen funcionamiento de las vías metabólicas depende de estas hormonas, las que tienen efectos específicos sobre diferentes órganos, manteniendo la homeostasis en todos los tejidos.

Objective: to describe and analyze the normal functioning of the thyroid gland in equines and the factors which increase the thyroid hormone levels. Materials and methods: information from the last 50 years included in the BBCS-LILACS, Fuente Académica, IB-PsycINFO, IB-SSCI, IB-SciELO, Scopus and Scirus, data bases as well as historical articles, texts and references cited in work published to date were analyzed. Results: important information related to the objectives proposed in the present review was found and analyzed. It was then divided into two sections as follow: synthesis, liberation and metabolism of thyroid hormones; factors that modify the thyroid hormone levels. Conclusion: the thyroid gland plays an important role producing thyroid hormones which are necessary for cellular differentiation and organic growth. The adequate functioning of metabolic ways depends on these hormones, which have specific effects on different organs maintaining homeostasis between all the tissues.

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.

Vascular Malformation of Flexor Hallucis Longus Muscle Associated with a Flexion Deformities of Toes: A Case Report / 대한골관절종양학회지

Vascular malformations may typically present with palpable mass that can be either asymptomatic or can present with symptoms including swelling and pain. On rare occasions, vascular malformation of muscle may produce joint deformities caused by contracture of the involved muscle. When vascular malformation involves the flexor muscle of the leg, ankle equinus deformity may occur. However, there are no reports of toe deformities secondary to intermuscular or intramuscular vascular malformations of flexor muscles of toe. Thus, we report a case of vascular malformation of flexor hallucis longus muscle with flexion contracture of toes in a 40-years-old woman who was treated with surgical excision.

Technique Tip: Percutaneous Gastrocnemius Aponeurosis Recession - A Modified Minimal Invasive Technique / 대한족부족관절학회지

Equinus contracture of the gastrocnemius-soleus complex is associated with many foot and ankle diseases. We introduce a new simple technique that can be performed using a minimal incision with simple devices. Briefly, 0.5 cm sized medial and lateral longitudinal skin incisions are made at the level of the distal one third of the calf. The musculotendinous junction of the gastrocnemius is gently transected using an Arachnoid blade. The skin is, then, closed with non-absorbable sutures.

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.

Malformaciones congénitas músculo esqueléticas / Congenital ômuscle-skeletalõ malformations

La mayoría de las malformaciones congénitas, son de causa desconocida, y muchas veces se asocian a otras malformaciones orgánicas como malformaciones cardiacas, de vías urinarias o sistema digestivo. Por eso es de suma importancia valorar al paciente en forma integral. Las malformaciones congénitas se presentan en 6 % de los nacidos vivos, y de ellas 1% son múltiples.Las anomalías congénitas se pueden clasificar como; malformativas que es la formación anómala del tejido fetal Deformación que es el tejido fetal alterado por un ambiente perjudicial o como desorganización, que es la degradación del tejido a consecuencia a factores maternos.

Most of these congenital malfornations do not have a known cause and in most cases they are associated to those of other organs like, urinary and gut, heart and great vessels. Due to these facts it is mandatory to assess our patients in an integral manner. Congenital malformations account from a 6% of all live birth and of these 1% are multiple. The congenital anomalies can be classified as: malformation, when the fetal tissues are forwed abnormally. Deformation when the fetal tissues are altered by an hazardous environment and disorganization when fetal tissues are degraded as a consequence of the action of maternal factors. Almost all congenital malformations are a therapeutic challenge, even at the best equipped and specialized medical centers; since they require a ôthoroughõ assessment and an integral therapeutic plan which includes several medical specialties.

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.

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...

Slide lengthening of the heel cord in cerebral palsy

Equinus is the most common deformity in children with spastic cerebral palsy [CP]. [Z] lengthening has a low rate of recurrence, but a significant rate of calcaneus deformity. Slide techniques have a higher rate of recurrence, but no calcaneus deformity. The aim of this study is to repopularize the White sliding technique and re-emphasize its efficacy in correcting equinus while avoiding calcaneus deformity. Thirty five children with CP and equinus deformity underwent [White] slide lengthening of the heel cord. The average improvement in dorsiflexion was 22.8°. Four children had a recurrence that required revision surgery. No patient developed a calcaneus deformity. White slide lengthening is an efficient [low recurrence] and safe [no calcaneus deformity] technique for correcting fixed equinus in CP. Surgical intervention should be postponed till above the age of 4 years. Long term follow up is required to report the true incidence of recurrence

Nuestra experiencia en el tratamiento quirúrgico del pie varo equino congénito (1995-2005) / Our experience in the surgical treatment of the congenital equinovarus foot (1995-2005)

Se revisan las historias clínicas de un total de 71 pacientes tratados quirúrgicamente por presentar pie varo equino congénito en un período de 10 años con el propósito de analizar los resultados obtenidos, siendo 42 de presentación bilateral y 29 unilaterales, de los cuales 18 correspondieron al pie derecho. De las intervenciones quirúrgicas de nuestro servicio el 76 por ciento fueron realizadas en miembros inferiores y de éstos el 41 por ciento correspondió a los pies, ocupando el pie varo equino el segundo lugar en frecuencia. En nuestro servicio se realiza el tratamiento por etapas, necesitando tratamiento quirúrgico el 50 por ciento de los pacientes. En la actualidad llevamos a cabo la cirugía en edades más tempranas que en épocas anteriores, prefiriendo realizarla entre los 6 y 12 meses de edad, decidiéndose la edad de comienzo del tratamiento quirúrgico y la técnica a llevar a cabo teniendo en cuenta las características de cada pie. Se arriba a la conclusión de que el éxito del tratamiento está relacionado con la atención personalizada por parte del médico, la individualización del tratamiento en cada paciente y la realización del tratamiento quirúrgico en el momento preciso. El resultado obtenido de 95 por ciento evaluados de bueno lo consideramos satisfactorio.

We reviewed the records of 71 patients surgically treated for presenting a congenital equinovarus foot during a period of ten years with the purpose of analyzing the obtained results, being 42 of bilateral presentation and 29 unilateral; 18 of them corresponded to the right foot. 76 % of the surgical interventions in our service were made in the low extremities, and 41 % corresponded to the foot, being the equinovarus foot on the second place. The treatment in our service is realized by stages, and 50% of the patients need surgical treatment. Nowadays we make surgeries in earlier ages than before, preferring to make them between the age of 6 and 12 months. We decide the age to begin the surgical treatment and the technique to use, according to the foot characteristics. We arrived to the conclusion that the success of the treatment depends on the personalized attention of the doctor, on the individualization of each patient's treatment and on the realization of the surgical treatment in the precise moment. The 95 % of the patients evaluated as good is considered satisfactory.