Dia SOFMER 2015 Pied Neuro - Cofemer SOFMER 2015 Pied Neuro.pdf · • A program of functional surgery of the limbs is ... effect and tibialis anterior tenodesis or ... Analytic and

10/07/2016

Paralytic deformities of the foot and ankle

Bertrand COULET MD PhD,

Service de Chirurgiedela Main et du Membre SupérieurChirurgiedes Paralysies

CHRUMontpellier

Movement to Health (M2H) - EuroMov

Montpellier 1 University

MontpellierFrance

[email protected]

Introduction0

Strategy in cases of limb palsy

• TWO STAGES :

1. Neurological surgical procedures : Initial stage• Only in cases of LOWERMOTONEURON PALSIES

• Respecting:

• Muscle denervation delay

• Nerve injury type

• Patient’s intrinsic factors: age, tabac

2. Palliative technique : tendon transfers and joint

stabilization

Introduction0

Palliative techniques : tendon transfers and joint stabilization

• A program of functional surgery of the limbs is builded according to:

Programof

functional surgery

Extent of palsy

Musclesremainedfunctionaland usable

Usefull functions to

restore

Introduction0

The aimsof this lecture

• To set out surgeon state of mind face to lower limb palsy.

• To remind the great biomecanic principles of the gait.

• To decribe to the different lower limb palsies.

• To understand the main surgical techniques and indications.

• To report results and complications.

1

mailto:[email protected]
























10/07/2016

Anatomy and Biomecanics of foot and anckle1

Gait

• Gait :

• Essentiel human function

• Semi-automatic sequences of muscle activation

• Permanent retro-control necessary


Gait

• 2 muscular systems

• 3 Fonctions:

• Propulsion

• Stabilization

• Swing phase

• 2 essential joints motio

• Knee

• Ankle

• Coordination

n:


Options

OBJECTIVES OF FOOT AND ANKLE ACTIVATION :• Floor adaptation

• 3D activation• Stabilization

FIRST SOLUTION :

• Poly-articular chain

• One muscle for each degree of freedom• Problem: major difficulties to stabilize this system


Options

Solution:• Slight rotation of muscle insertions

• Each muscle is in charge of two degrees of freedom

2

10/07/2016


Options

• Eachmuscle has two degreesof freedom:easierto stabilize

• Triceps:Flexion / eversion• Tibialposterior :Flexion /inversion

• Tibialanterior :Extension / Inversion

• Fibular:Eversion / Extension


Innervation

Triceps SuralTibial Ant.

Fibulaires

N. Tibial Post.

Stance Phase

Tibial Post.

N. Fibulaire commun

As always , we note a strict correlation between function and troncular innervation

Swing Phase


Innervation and coordination

Central Coordination :

Motor schedule

Fibulaires

Triceps SuralTibial Ant.

Tibial Post.

Classification of lower limb palsies2

Lower limb palsies

Lower Motorneuron damaged

Commun Fibular nerve palsy

Sciatic nerve palsy

Upper Motorneuron damaged

Equinovarus deformity

Vascular hemiplegia+/- Tramatic

Equinovarus deformity+intrinsic Muscles spasticity

Traumatic

Valgus Flat footCerebralpalsy

/tramatic

3

10/07/2016

Palsies with lower motorneuron damaged3

Common Fibular nerve palsies

TricepsFibulars

Ant. Tib ialis

Tib ial Post.

Coordination centrale:

Moteur schedule

What is happening ?


Commun Fibular nerve palsies

What is happening ? •Muscular imbalance from fibular and anteriortib ialis palsies

• Normal proprioceptive and Plantar sensitivity• No spasticity

Consequences:

• Steppage – drop foot• Instability• With time anckle stiffness - Equin



What to do? Only one muscle to be transfered the

POSTERIOR TIBIALIS to the front of foot



What to do? Only one muscle to be transfered the

Posterior tib ialis to the front of foot

4

10/07/2016



Why this option is not satisfactory?

Because:

1. After removing the Posterior tib ialis the

medial arch of the foot collapse.

2. Only two muscles are unable to stabilise

the poly-articular chain of the foot in

lateral and frontal p lane.



What solution offer ?

The poly-articular chain of the foot seems to the horses team of a

carriage. The coachman has only two reins to drive only the first horses

row.

Talonavicular +/- sub-talar arthrodesis

5

10/07/2016


Common Fibular and tibial posterior nerves palsies

TricepsFibulars

Ant. Tib ialis

Tib ial Post.

Coordination centrale:

Moteur scheme

What is happening ?


Common Fibular and t ibial posterior nerves palsies

What is happening ? • No functional muscle under the knee

• No Plantar sensitivity

• No spasticity

Consequences:

• Steppage – drop foot

• Instability

• With time anckle stiffness – Equin

• Often trophic problem of the plantar

• Need orthesis

• Palsies with lower motorneuron damaged• 3

• Common Fibular and t ibial posterior nerves palsies

• What to do?• No muscle to transfer

• Stabilize the anckle and sub talar joint

• Correct the vicious attitudes• Solutions:

• Only Jo int stabilization eventually

tenodesis

• Sub-talar arthrodesis with Lambrinudi

effect and tib ialis anterior tenodesis or

Talo-crural arthrodesis

Palsies with upper motorneuron damaged4

Part icularit iesof the palsy

Triceps SuralFibulars

Tib ial Ant.

Tib ial Post.Tib ial Post.

central command:Motor schedule

Triceps Sural

6

10/07/2016


Part icularit iesof the palsy

3- TROUBLES OF MOTOR SCHEDULE :

- Flexi on o f th eK nee- Stiff K neeGai t

1- MOTOR PALSY :

- Tib i al is an teri o r- Fibu l ar

2- SPASTICITY :

P ostu ral muscl es- Sural Tricep s

- P osteri or Ti b i al is- Flexo rs

- Intri n sics

4- SENSITIVE TROUBLES:

- Cu tan eo u s- P ropri ocep ti ve

TENDINO-MUSCULAR

RETRACTIONS

JOINTS STIFFNESS


Evaluation

Patient evaluation

1. Age

2. Delay after stroke

3. Autonomy

4. Way of life

5. Type of shoes / use of stick

6. Patient’s expectations according to a surgical program

7. Medical team’s expectations


Evaluat ion

Gait evaluation (motor scheme): With or without shoes / With orwithout stick

1. Ga it with or without kneeflexion

2. Heel strike

3. Stabilityat the footflat

4. Residualequino-varus

5. Global stability

6. AutomaticTibialisAnterior


Evaluat ion

LYING CLIN ICAL EXAMINATION

1. Joint passive and active range of motion

2. Spasticity et retractions (Gastronemiens versus soleus)

3. Analytic and automatic testing of the TA et TP

4 . C law toe deformities : extrinsic or intrinsic

5. Sensitive evaluation : cutaneous and proprioceptive

7

10/07/2016


Evaluat ion

PARACLIN ICS EVALUATION

• RX +/- CT scan

• PATIENTHISTORY:Toxin botulinic injection effects

• ANESTHESIC BLOCS:Tibialnerve selective or not

• Aims :

1. to make distinction between spasticity and retraction

2. To wake up a tibialis anterior masked by spasticity

3. To evaluate the potential improvement of the motor schedule

4. To unmask a spasticity of the intrinsic muscles


Treatment

3- TROUBLES OF MOTOR SCHEME :

- Flexi o n o f th eK nee- Stiff K neeGai t

1- MOTOR PALSY:

- Tib i al is an teri o r- Fibu l ar

2- SPASTICITY :

P ostu ral muscl es- Sural Tricep s

- P osteri or Ti b i al is- Flexo rs

- Intri n sics

- Cu

- P r

TENDINO-MUSCULAR

RETRACTIONS

JOINTS STIFFNESS

Tendons lengthening

Tendons transfer

Jo ints stabilization

Neurotomies


Evaluat ion

1 - Equinus

Spasticity without retraction ? Partial Neurotomy of tibial nerve

Retraction ? Triceps tendon Lengthening

2- Varus

Automatic TA? P arti al tran sfer of th eTA to l ateral

p art o f th e foot

No automatic TA? TP tran sfert to d orsal part o f th e foot+ Tal o-n avi cu l ar arthrod esi s

3- Mid foot stabilization

When?

Troubles of

proprioceptive sensitivity

Laxity of Mid foot

How ?Talo-navicular / Sub-talar arthrodesis

4- Claw toes deformities

Lesser toes +/ - Always Flexors tenotomies

Hallux Often IP arthrodesis

Problems Questions Solutions


Technique : ½ TA transfer

8

10/07/2016


Technique : Triceps lengthening


Technique : Toes claw


Cases

9

10/07/2016


Cases


Cases


Cases

10

Documents

Dia SOFMER 2015 Pied Neuro - Cofemer SOFMER 2015 Pied Neuro.pdf · • A program of functional surgery of the limbs is ... effect and tibialis anterior tenodesis or ... Analytic and