Philippe De Cloedt

Assessment and treatment of spastic equinovarus foot after stroke: Guidance from the Mont-Godinne interdisciplinary group.

OBJECTIVE To present interdisciplinary practical guidance for the assessment and treatment of spastic equinovarus foot after stroke. RESULTS Clinical examination and diagnostic nerve block with anaesthetics determine the relative role of the factors leading to spastic equinovarus foot after stroke: calf spasticity, triceps surae - Achilles tendon complex shortening and dorsiflexor muscles weakness and/or imbalance. Diagnostic nerve block is a mandatory step in determining the cause(s) of, and the most appropriate treatment(s) for, spastic equinovarus foot. Based on interdisciplinary discussion, and according to a patient-oriented goal approach, a medical and/or surgical treatment plan is proposed in association with a rehabilitation programme. Spasticity is treated with botulinum toxin or phenol-alcohol chemodenervation and neurotomy, shortening is treated by stretching and muscle-tendon lengthening, and weakness is treated by ankle-foot orthosis, functional electrical stimulation and tendon transfer. These treatments are frequently combined. CONCLUSION Based on 20 years of interdisciplinary expertise of management of the spastic foot, guidance was established to clarify a complex problem in order to help clinicians treat spastic equinovarus foot. This work should be the first step in a more global international consensus.

Neurologic Hip Disorders Treated By Femoral Shortening and Lesser Trochanter Detachment

In a group of 40 children with cerebral palsy (CP), myelomeningocele, or sequelae of previous tenotomy and neurotomy, a specific surgical approach was used to correct various type of hip disorders: migrating hip, subluxated or luxated hip, compressed hip, and wind-blown hip, especially in quadriplegia. Osteotomy is performed at the intertrochanteric area, where a segment of femur (3-5 cm) is removed and the lesser trochanter is released, allowing the psoas muscle to reinsert in a more proximal position. Based on the concept of imbalance between predetermined bone growth and passive adaptation of muscles, we postulated in 1982 that a reduction in bone length should have an effect on surrounding muscles, allowing them the possibility of working in better anatomic conditions. With our procedure, we obtain major release of muscle tension around the hip-release of hamstring, psoas, and tensor of fascia lata-and consequently a wide range of passive motion of the hips as well as the knees. Long-lasting effects are preserved only by use of regular splinting for a prolonged time. In hip luxation, reduction can be obtained by this extraarticular approach, without need to open the joint. A pelvic procedure is performed only when the acetabulum shows marked changes. In five children with CP, the procedure was combined with shortening of the patellar tendon to reactivate the extensor mechanism of the knees. We consider this specific approach a safe procedure that leaves the neural anatomy undisturbed and allows early ambulation, usually at 4 weeks. It may be used as a salvage procedure and as the initial treatment step for various neurologic hip disorders.