{"id":2564,"date":"2010-09-11T12:42:39","date_gmt":"2010-09-11T12:42:39","guid":{"rendered":"http:\/\/snpcar.ro"},"modified":"2018-09-11T12:42:52","modified_gmt":"2018-09-11T12:42:52","slug":"piciorul-varus-equin-spastic","status":"publish","type":"post","link":"https:\/\/snpcar.ro\/en\/piciorul-varus-equin-spastic\/","title":{"rendered":"SPASTIC EQUINOVARUS CLUB FOOT"},"content":{"rendered":"

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ABSTRACT:<\/strong><\/p>\n

Within the general frame of child cerebral palsy, the attention to the legs is compulsory. Since the resulted leg is curved, when it grows, the difficulties of the affected child amplify with dramatic consequences, both while standing and in walking; sometimes the child experiences problems of psycho\/social integration.<\/p>\n

The aim of this study is to draw the attention of all the specialists, who are treating such cases: neuropsychiatrist, physical therapist, pediatric surgeon, that , without team work and collaboration, the results are modest.<\/p>\n

The study takes into consideration 57 cases treated at \u201cThe Paediatric Surgery Clinic\u201d in Timisoara between 2000-2010. The patients\u2019 family history, hereditary-collateral antecedents and family environment factors have been recorded. Particular stress has been placed on the existence, or not, of interactive cooperation among the specialists involved in the treatment, and, at the same time, on a good collaboration with the family.<\/p>\n

The results of the study show that these deformities imply hard work for a very long time, on the part of complex multidisciplinary medical teams.<\/p>\n

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INTRODUCTION<\/strong><\/p>\n

A short history of walking research<\/strong><\/p>\n

Through the ages, walking research has been approached by numerous scholars from different specialties (9).<\/p>\n

\u201cHuman walking has the general characteristic of the quadrupeds, which move their limbs cross like. When a man walks, he moves his four limbs like a horse, cross like; first stepping with the right foot and outstretching the opposite arm at the same time\u201c said Leonardo Da Vinci (1).<\/p>\n

Descartes, the philosopher and physicist studied walking, making notes about it.<\/p>\n

Borelli (1682), whose major scientific achievements are focused around his investigation into biomechanics, is better known for determining the position of the body\u2019s center of gravity (9).<\/p>\n

Demeny and Carlet (1891) introduced in the pressure control on the soil as well as chromatography (9).<\/p>\n

Braune and Fischer (1885) offered a mathematic approach to walking (9).<\/p>\n

The walking manner of ailing human beings arouse the interest of Gheorghe Marinescu (1910), Joel Herrley (1943) , Grossiord (1965), Al. Radulescu, Cl. Baciu, Ducroquet (1965).<\/p>\n

The treatment of the club foot associated with paediatric cerebral palsy, require the cooperation of a large number of specialists such as: neurologist, kinesipathist, pediatric surgeon. Without this cooperation, the therapeutic results are poor (10).<\/p>\n

The central lesions which characterize this type of pathology are usually mixed, pyramidal, with secondary spasticity , or the extra pyramidal lesions, involving coordination disorders and muscular tonicity. Leg distortion happens due to a muscular disorder that includes the contraction of the more spastic and hypertone muscular groups (4).<\/p>\n

The outcome of the vicious attitude is exaggerated and it becomes inreductible by secondary bone form alteration. (see Wolf \u2013 Delpeche law).<\/p>\n

The club foot is the most frequent deformity and it is due to the hypertonicity of the triceps sural muscle (2).<\/p>\n

The club foot is characterized by spasm and hypertonicity of the pronator muscles.<\/p>\n

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Fig. 1.\u00a0<\/strong>Equinovarus club foot<\/p>\n

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Often, the deformity of the foot occurs in combination with spastic equinovarus. In cerebral paralyses, the main treatment consists in early psychomotor reeducation (2).<\/p>\n

When the neurological disorders and leg distortion are in an advanced stage, walking becomes difficult or even impossible. The therapeutic results are satisfactory in children with a normal level of understanding and sensitiveness, their cooperation being an important part of the treatment (3).<\/p>\n

The orthopaedic and surgical treatment of the deformities is advisable only in children who can stand and have not mastered the walking ability yet. Only<\/p>\n

the predominantly pyramidal forms are fit for surgery, and, rarely, the spastic types, too, being associated with other medical therapies: neurological and kinetotherapy (5).<\/p>\n

The therapeutic indications are according to the prevalence of the lesions (7,8):<\/p>\n

in equine club foot we recommend, a moderate linear extension of the achillion tendon (Staryer-Vulpius method), the duble arthrodesis Lambrinudi operation for toddlers.<\/p>\n

in equinovarus club foot we perform the Codivilla operation and after the age of 12 the double arthrodesis Ducroquet- Launay is used.<\/p>\n

The lenghtening of the Achilles\u2019 tendon in these cases is a very useful procedure, when a correct therapeutic plan has been established (6).<\/p>\n

The following operations are performed:<\/p>\n

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Fig 2.\u00a0<\/strong>Slightly curved incision with medial concavity along the lateral aspect of the Achilles\u2019s tendon relief<\/p>\n

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Fig. 3<\/strong>. The tendon is dissected and guided by locating the route of the future tenotomy<\/p>\n

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A.\u00a0<\/strong>in equine club foot the Achilles\u2019 tendon tenotomy is performed in a frontal \u201cZ\u201d incision.<\/p>\n

B<\/strong>. in equinovarus club foot the Achilles\u2019 tendon tenotomy is performed in a sagittal \u201cZ\u201d incision.<\/p>\n

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Fig. 4.\u00a0<\/strong>The foot is guided to so as to form a 90 degrees position in relation to the ankle, suturing the tendon with the leg in slight hypercorrection<\/p>\n

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Fig. 5.\u00a0<\/strong>Postoperatory, a cast holds the clubfoot still for 30 days, while it heals<\/p>\n

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Postoperatory, after the removal of the plaster cast, kinetotherapy is required in order to gain full recovery. Applying stress on the damaged foot, together with progressive walking, are allowed after 45 days.<\/p>\n

Sometimes after surgery, in certain cases with pronounced spasticity, ankle braces are necessary. A close cooperaration with the neurologist is required, the specific treatment being controlled according to the future evolution of the patient (8).<\/p>\n

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MATERIAL AND METHOD<\/strong><\/p>\n

The study included 57 patients with the ages between 4 and 12 years, hospitalized at \u201cThe Paedia-tric Surgery Clinic\u201d in Timisoara between 2000-2010 with spastic equine clubfoot, associated to child cerebral palsy.<\/p>\n

After the surgery, these patients have been re-evaluated from the surgical point of view taking into consideration the two compulsory criteria of the normal locomotion: stability and motility.<\/p>\n

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DISCUSSION<\/strong><\/p>\n

Out of the 57 patients, 6 of them have shown absolute surgical contraindications, since they could not walk. A number of 8 patients have presented different degrees of psychic retardation, and in such cases cooperation pre and post surgery is difficult; that was why, the therapeutic results were modest.<\/p>\n

We have to say that in this group, 7 operated patients have not been present to the subsequent controls, due to a weak cooperation with their families. In such cases by lack of a sound collaboration of all the entities involved and within medical team (the neurologist, physical therapist, surgeon), the initial good results, can be compromised.<\/p>\n

The therapeutic evaluation was done according to a few criteria concerning the mobility and stability of the locomotion, which were clasified as:<\/p>\n