Double hindfoot arthrodesis technique for the treatment of severe equino-plano-valgus foot deformity in cerebral palsy: long-term results and radiological evaluation.

The aim of this study was to evaluate the clinical and radiological results of a double arthrodesis technique for the treatment of equino-plano-valgus foot deformity in pediatric patients affected by cerebral palsy. A retrospective evaluation was performed on 175 feet surgically treated with a talonavicular and calcaneocuboid joint fusion technique. The average age at surgery was 14.7 years (range: 12-20 years). Visual analogue scale for pain score, Gross Motor Function Classification System scale, talonavicular angle, Costa-Bertani angle, and Kite's angle on standard weight bearing radiographs were evaluated preoperatively and postoperatively. The mean clinical follow-up was 62.4 months (range: 12-112 months). The mid Gross Motor Function Classification System scale value did not show a significant improvement in any of the subgroups considered. A significant improvement in the visual analogue scale for pain score value was evident 6 months after surgery. Radiological examination showed a statistically significant improvement in the talonavicular angle (average 7.4°) and the Costa-Bertani angle (average 128.5°). Complications occurred in 8.6% of cases. The described surgical technique is safe and efficacious, and could represent a useful option of treatment of equino-plano-valgus severe deformity in cerebral palsy patients older than 12 years of age.

Surgical Correction of the Achilles Tendon for Diabetic Foot Ulcerations and Charcot Neuroarthropathy.

Achilles tendon pathologic conditions are implicated in contributing to the development of many diabetic foot complications including diabetic foot ulceration and Charcot neuroarthropathy. Surgical correction of the diabetic equinus deformity has been studied as an isolated or adjunctive treatment when dealing with difficult-to-close diabetic foot ulcerations or when surgically addressing the diabetic Charcot neuroarthropathy foot or ankle. This article reviews the most common indications, complications, and surgical procedures for equinus correction by either a tendo-Achilles lengthening or gastrocnemius recession for the management of diabetic foot conditions.

Riesgos ortopédicos en los niños andadores de puntillas de edad preescolar / Orthopedic risks in preschool idiopathic toe-walkers

Introducción: La marcha de puntillas idiopática, considerada un diagnóstico de exclusión de alteraciones neurológicas y ortopédicas, se ha relacionado con diversas alteraciones ortopédicas del pie y del tobillo. Aunque la limitación en la movilidad del tobillo resulta el criterio de valoración e indicación terapéutica más empleado, su evaluación en edades tempranas y la comparación con valores de normalidad no han sido apenas estudiadas. El objetivo de este trabajo es verificar si la evaluación precoz de los niños andadores de puntillas (AP) pone de manifiesto características clínicas diferenciales que indiquen riesgos ortopédicos. Pacientes y métodos: Mediante un estudio descriptivo transversal se ha comparado la estática y la movilidad de rodilla, tobillo y pie de un grupo de 56 AP de 3-6 años de edad con un grupo de 40 niños de un grupo control (GC). Resultados: Se descartó en los AP (el 69,6% varones; p= 0,008) un flexo de rodilla, pero presentaron una menor movilidad pasiva del tobillo con la rodilla flexionada (p <0,05) y una mayor disminución del apoyo del talón en bipedestación que los niños del GC (p= 0,000). Los AP mostraron también una mayor pronación del pie, corroborada en un mayor valgo de calcáneo, ángulo de pronación, caída del navicular y pico de pronación en la huella plantar (p <0,05). Conclusiones: La evaluación clínica de los AP en edad preescolar mediante pruebas específicas facilita la detección de riesgos ortopédicos, lo que podría permitir establecer medidas específicas para evitar su posible evolución negativa (AU)

Introduction: Idiopathic tiptoe gait, considered as a diagnosis of exclusion of neurological and orthopedical diseases, has been related to various foot and ankle orthopedic alterations. The limitation of the ankle movement range is the main guideline for evaluation and therapeutical indication. However, its early assessment and its comparison with normality values have been seldom studied. The aim of the present work is to verify if the early evaluation of toe walkers (TW) reveals specific clinical characteristics denoting orthopedical risks. Patients and methods: A cross-sectional study was conducted to compare the posture and the movement of knee, ankle and foot of a group of 56 TW and a group of 40 controls (CG), aged 3 to 6 years old. Results: TW children, 69.6% of them boys (p= 0.008), did not suffer a knee flexum, but they demonstrated a lower passive ankle mobility measured with the knee flexed (p <0.05) and a diminution of the heel support while standing than CG children (p= 0.000). TW also showed more pronation of the foot, objectified in a higher calcaneus valgus, pronation angle, navicular drop and pronation peak observed in the footprint (p <0.05). Conclusions: Clinical evaluation in preschool ITW by means of specific measures helps detecting orthopedical risks. It could allow to set particular strategies to prevent their possible negative evolution (AU)

Prevalence of equinus in diabetic versus nondiabetic patients.

BACKGROUND: There are no conclusive data to support the contention that diabetic patients have an increased frequency of ankle equinus compared with their nondiabetic counterparts. Additionally, a presumed contributing cause of foot ulceration is ankle joint equinus. Therefore, we sought to determine whether persons with diabetes have a higher prevalence of ankle joint equinus than do nondiabetic persons. METHODS: A prospective pilot survey of 102 outpatients (43 diabetic and 59 nondiabetic) was conducted. Demographic and historical data were obtained. Each patient underwent a standard lower-extremity examination, including the use of a biplane goniometer to measure ankle joint range of motion. RESULTS: Equinus, defined as ankle dorsiflexion measured at 0° or less, was found in 24.5% of the overall population. In the diabetes cohort, 16 of 43 patients (37.2%) were affected compared with 9 of 59 nondiabetic participants (15.3%) (P = .011). There was a threefold risk of equinus in the diabetic population (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.28-8.44; P < .013). The equinus group had a history of ulceration in 52.0% compared with 20.8% of the nonequinus group (P = .003). Equinus, therefore, imparted a fourfold risk of ulceration (OR, 4.13; 95% CI, 1.58-10.77; P < .004). We also found a 2.8 times risk of equinus in patients with peripheral neuropathy (OR, 2.8; 95% CI, 1.11-7.09; P < .029). CONCLUSIONS: Equinus may be more prevalent in diabetic patients than previously reported. Although we cannot prove causality, we found a significant association between equinus and ulceration.

Operative correction of arch collapse with forefoot deformity: a retrospective analysis of outcomes.

BACKGROUND: There are many forefoot deformities, including hallux valgus, forefoot overload, and hammertoe that are treated as unrelated problems with multiple different techniques. Currently, there has been renewed interest in the role of a gastrocnemius contracture on foot deformities. Our objective was to review a specific surgical treatment plan for forefoot deformities classified by us as Type 2 arch collapse and evaluate the outcomes. MATERIALS AND METHODS: We retrospectively reviewed the charts of 374 patients who underwent foot procedures to treat deformity classified as a Type 2 arch collapse. Data was collected regarding complications and need for secondary surgery. A phone survey was performed to assess patient satisfaction, pain level, and Foot Function Index (FFI) scores. RESULTS: Of the 374 patients (412 feet), there was a 96% (357 of 371 feet) union rate at the first tarsometatarsal joint and 98% (227 of 232 feet) union rate at metatarsal shortening osteotomy sites. Recurrence of hallux valgus was 2.7% (7 of 256 feet), while hallux varus occurred in 1.6% (4 of 256 feet). There were 292 patients (78%) available for phone interview. Of those patients, 88% were satisfied with the results of the procedure. The subset of procedures relating to the highest mean FFI was hammertoe correction (22.2) and the highest mean pain score was related to metatarsal shortening osteotomy (2.6). CONCLUSION: Utilizing the arch collapse model, operative treatment of forefoot deformities with a combination of procedures including gastrocnemius recession, first TMT fusion, modified McBride, hammertoe correction, and metatarsal shortening osteotomy can produce good satisfaction rates with low complication rates.

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

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

A systematic review of the effects of casting on equinus in children with cerebral palsy: an evidence report of the AACPDM.

This systematic review examines the effects of casting, either alone or in combination with botulinum toxin type A (BTX-A), on equinus in children with cerebral palsy (CP). Comparisons are made between casting alone and no treatment, between casting alone and BTX-A alone, between combined casting and BTX-A and each treatment by itself, and between casting followed by BTX-A and BTX-A followed by casting. A search of PUBMED, CINAHL, Proquest Health and Medical Complete, Cochrane Database of Systematic reviews, Physiotherapy Evidence Database (PEDro), OTseeker, Database of Reviews of Effectiveness (DARE), and Infotrieve yielded 184 citations. Articles were included in the review if they reported the effects of an intervention using casting for equinus in particpants with CP aged 20 or less, if they appeared in a peer-reviewed scholarly journal in 1970 or later, with no language restriction, and if casting was not used in conjunction with surgery. Twenty-two articles were selected, including seven randomized controlled trials (RCTs). There is little evidence that casting is superior to no casting, but the protocols of casting in current use have not been compared with no treatment in any RCT. There is no strong and consistent evidence that combining casting and BTX-A is superior to using either intervention alone, or that either casting or BTX-A is superior to the other immediately after treatment. Finally, there is no evidence that order of treatment (casting before BTX-A versus BTX-A before casting) affects outcome. Much of the evidence both for and against differences is weak, and results may be explained by methodological limitations. Future research needs to use adequate sample sizes, long-term follow-ups, and broader and more global measures.

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...(AU)

Recurrence rates of burn contracture ankle equinus and other foot deformities in children treated with Ilizarov fixation.

The purpose of this study was to determine recurrence rates of pediatric foot and ankle burn deformities treated with the Ilizarov method. A total of 19 patients with 29 foot and ankle deformities were studied. The most common deformity treated was equinus (23). Rocker-bottom and cavus foot deformities were each treated three times. The average age of the patient at the time of the burn injury was 3.2 years, and the average age at the time of fixation was 9.4 years. Equinus contractures averaged -34 degrees (34 degrees of plantarflexion) before surgery and +7 degrees (7 degrees of dorsiflexion) after treatment with the Ilizarov fixator. The recurrence rate for all 29 ankles and feet was 69% (20/29). The recurrence rate for equinus contractures was 74% (17/23). The average time to recurrence was 17.3 months. Only short-term follow-up was available on four of the six feet and ankles that did not recur. Deformity correction in burned feet and ankles is difficult to obtain by any means. The authors recommend using the Ilizarov method to obtain correction of moderate to severe foot and ankle deformities in pediatric burn patients, but the correction obtained is not stable and deformity will likely recur. Parents and patients should anticipate adjunctive nonoperative and operative procedures to keep their feet plantigrade as they grow. In young children, the possibility of having additional surgeries, including repeat Ilizarov procedures, should be discussed. Even older children should expect additional surgeries to prevent recurrent deformities.

[Epidemiology of pes varus and/or equinus one year after a first cerebral hemisphere stroke: apropos of a cohort of 86 patients]. / Epidémiologie des pieds varus et/ou équin un an après un premier accident vasculaire cérébral hémisphérique: à propos d'une cohorte de 86 patients.

OBJECTIVE: To determine the frequency and the functional consequences of varus equinus in stabilized vascular hemiplegia. METHODS: Prospective cohort study of 86 hemiplegic patients. All patients consecutively admitted for a first hemispheral stroke between July 2001 and January 2002 were included. The evaluation consisted in a clinical examination and a descriptive study of gait. The functional capacity of patients with and without varus equinus were compared using the Barthel index, the New Functional Ambulation Classification (NFAC), the confortable ten meters gait speed and gait perimeter. RESULTS: The incidence of varus equinus was 18%. There was no difference in gait speed (0.8 m/s), NFAC or Barthel index between patients with or without varus equinus. Patients with varus equinus had had more specialized, intensive and prolonged rehabilitation. The only prognostic factor that could be identified was the motor impairment and the existence of spasticity. DISCUSSION: The mechanism of varus equinus is thought to be mainly the over-activity of gastrocnemius and solaris compared to that of the tibialis anterior, associated to the weakness of fibular muscles. The role of tibialis posterior is thought to be less important. The frequency of varus equinus after a first hemispheral stroke was low and the consequences were limited. This could be in part explained by the access of these patients to early, specialized and prolonged rehabilitation care.

Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus.

The authors undertook a study to evaluate the prevalence of ankle equinus and its potential relationship to high plantar pressure in a large, urban population with diabetes mellitus. The first 1,666 consecutive people with diabetes (50.3% male; mean [+/-SD] age, 69.1 +/- 11.1 years) presenting to a large, urban, managed-care outpatient clinic were enrolled in this longitudinal, 2-year outcomes study. Patients received a standardized medical and musculoskeletal assessment at the time of enrollment, including evaluation at an onsite gait laboratory. Equinus was defined as less than 0 degrees of dorsiflexion at the ankle. The overall prevalence of equinus in this population was 10.3%. Patients with equinus had significantly higher peak plantar pressures than those without the deformity and were at nearly three times greater risk for presenting with elevated plantar pressures. There were no significant differences in age, weight, or sex between the two groups. However, patients with equinus had a significantly longer duration of diabetes than those without equinus. Having a high index of suspicion for this deformity and subsequently addressing it through conservative or surgical means may help to reduce the risk of foot ulceration and amputation.

Estudo da tendência de malformaçöes ortopédicas em uma maternidade assistencial (1.000 recém-nascidos avaliados) / Study of the trends of orthopedic malformations in a assistential maternity (evaluated newborn 1.000)

Estudamos 1.000 recém-nascidos vivos em uma maternidade (Instituição Amparo Maternal) voltada para a população carente no período de setembro de 1997 a julho de 1998. Nesse período catalogamos os recém-nascidos por meio de um protocolo que constou dos antecedentes pré-natal e natal e do exame de seis horas. Nossa intenção foi a de analisar o número de recém-nascidos que apresentaram alguma alteracão fenotípica ao nascimento bem como correlacionar os achados com as alterações observadas no exame físico. Catalogamos os recém-nascidos conforme a anomalia encontrada e outros fatores os quais julgamos relevantes, como idade materna, Apgar, peso ao nascimento, idade gestacional, sexo do recém-nascido, peso ao nascimento, tipo do parto e apresentação.Selecionamos 265 recém-nascidos que foram submetidos ao exame físico ortopédico. Encontramos 14 recém-nascidos com algum tipo de malformação entre os 1.000 catalogados, apresentando um total de 16 malformações. Cinco (0,5 por cento) recém-nascidos apresentaram polidactilia, dois (0,2 por cento) pé equino-cavo-varo não-sindrômico, dois (0,2 por cento) pé-equino-cavo-varo sindrômico, dois (0,2 por cento) pé calcâneo valgo, um (0,1 por cento) metatarso adulto, dois (0,2 por cento) artrogripose e dois (0,2 por cento) dedos sobrepostos.

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, ...