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AIM: The aim of the study was to investigate the relationship between the clinical evidence of foot deformities in spina bifida occulta and the associated neurophysio-logical damage.
METHODS: The authors studied 47 patients with foot deformities (37 flat foot, 10 pes cavus) and vertebral cleft, variably associated with enuresis, midline cutaneous lesions, and further orthopaedic deformities. An electrophysiological evaluation was performed in an attempt to investigate the peripheral nervous system in greater detail, including conventional motor and sensory nerve conduction, F-wave recording and electromyogram (EMG) testing.
RESULTS: The peroneal nerve F wave latency was longer in patients with pes cavus than in those with flat foot (P<0.04). Conversely, the posterior tibial nerve F-wave latency was longer in patients with flat foot than in those with pes cavus (P<0.02). Needle EMG showed large amplitude motor unit potentials during voluntary recruitment in all patients, suggesting a neurogenic origin of these EMG changes. Neurophysiological study makes it possible to distinguish between myogenic and lower motor neuron involvement. The existence of some degree of spinal cord dysraphism may be pathophysiologically associated with foot deformities.
CONCLUSION: Children with foot deformities and clinical evidence of occult spinal dysraphism should have a neuro-physiological assessment in order to obtain an early diagnosis and avoid ineffective foot surgery.
OBJECTIVE: To analyze the incidence, clinical features, deformity categories and orthopedic treatment of foot and ankle deformities caused by spinal bifida.
METHODS: The charts of the patients received surgical treatment between January 1990 and July 2009 were studied retrospectively, and the data were analyzed.
RESULTS: One hundred and seven cases of foot and ankle deformities caused by spinal bifida received surgical treatment and were included. There were 44 male and 63 female patients. The average age was 17.7 years (range, 1.3 - 52.0 years). And 50.5% (54/107) of cases were over 18 years old and had spinal bifida occulta, and the other 49.5% had spinal bifida manifesta. There was only one case of thoracic spinal bifida (T(3-8)), while the other 106 cases had lumbosacral vertebrae cleft (mainly L(3) to Sacrum). Among a total of 165 feet, unilateral involvement was found in 49 cases (22 cases on the left side, 27 cases on the right side), bilateral involvement in 58 cases. Combined ankle-foot deformities included 76 varus talipes, 23 talipes valgus, 15 flail feet, and 51 other foot deformities. Other site deformities, as a result of spinal bifida, included knee flexion or hyperextension deformity in 4 cases, hip deformity (hip adduction, flexion, or hip dislocation, pelvic tilt, lower extremity discrepancy, etc.) in 17 cases, and urinatory dysfunction and defecation in 30 cases. Twenty-nine of 54 cases with spinal bifida occulta failed to be diagnosed in other hospitals and the misdiagnosed rate reached 53.7% (29/54). Corrective surgery was performed in only 26 patients. And 50.5% (54/107) of patients (over 18 years old) had severe foot and ankle deformities due to a failure of prior surgical treatment.
CONCLUSIONS: Spinal bifida is the most commonly found in the lumbosacral vertebrae. Although the main pathogenesis is developmental abnormalities of spinal cord and nerve, the secondary deformity is usually located on the foot and ankle. Some young orthopedic surgeons may not have enough awareness and treatment experience about this disease due to over-specialty of the orthopaedics, so the delay of early diagnosis and treatment is often found and many severe foot and ankle deformities occur.
To study surgical strategies for ankle and foot deformities secondary to spina bifida and treatment methods for different types of deformities.
From January 1990 and July 2009, 107 patients with ankle and foot deformities secondary to spina bifida were retrospectively analyzed. There were 44 males and 63 females, with an average age of 17.7 years (rangd from 1.3 to 52 years). Among the patients, 58 patients had double ankle deformities, 49 patients had unilateral deformities (22 cases on the left side, 27 cases on the right). Ninety-nine patients with equinus deformities were treated by achilles tendon lengthening and tendon transfering; 25 patients with talipes were treated by release of anterior tendon of ankle and tendon transfer; 17 patients with valgus and varus deformities were treated by tendon transfer and calcaneal osteotomy; 15 patients with flail deformities were managed treated by bone fusion between calcaneus and talus and shortening of achilles tendon; 9 patients with claw toe deformities were treated by bone fusion of interphalangeal joint or Ilizarovs distraction. AOFAS (American Orthopaedic Foot & Ankle Society) comprehensive scoring system was used to evaluate subjective pain and objective functional.
Seventy-nine (127 feet) of 107 patients were followed up, and the duration ranged from 48 to 180 months (averaged, 64 months). According to AOFAS scoring system, the results were rated as excellent in 89 feet, good in 26 feet, moderate in 9 feet and poor in 3 feet.
Treatment strategies for ankle-foot deformities mainly included four principles, deformity correction, muscular balance, joint stability and reservation of foot elasticity. Different combined procedure was applied for different foot deformities and received good therapeutic effects.
Valgus foot is a common foot deformity in spina bifida. The most popular operation for the valgus deformity has been the Grice talocalcaneal blocking. It has not been studied primarily in children with spina bifida. We report a prospective series, we present the results of hind foot valgus deformity of children with spina bifida, using Grice talocalcaneal arthrodesis with a tricortical iliac bone graft.
MATERIALS AND METHODS:
Between May 2000 and December 2003, 21 patients with bilateral (42 feet) valgus deformity of feet underwent surgery. There were 7 males and 14 females. The mean age of patients was 67.7 months (range 50-108 months).
The total number of feet that had nonunion was 11, in 7 of them the grafts were completely reabsorbed and the outcome of all these feet was unsatisfactory. Four feet had partial union of which three had unsatisfactory and one had satisfactory outcome. Sixteen feet had residual valgus deformity at the last followup visit, 10 patients had nonunion, and 6 had inadequate correction. Mean preoperative talocalcaneal and calcaneal pitch angles were 48.5° and 31.9°, respectively, which decreased to 38.5° and 29.1°, respectively, postoperatively. The decrease in talocalcaneal angle and calcaneal pitch was significant between preoperative and postoperative measurements (P<0.05).
Grice subtalar arthrodesis technique is still a valuable option for valgus foot in patients with spina bifida. In this study, we found more encouraging results in older patients.
Both congenital and acquired orthopaedic deformities are common in patients with spina bifida. Examples of congenital deformities, which are present at birth, include clubfoot and vertical talus. Acquired developmental deformities are related to the level of neurologic involvement and include calcaneus and cavovarus. Orthopaedic deformities may also result from postoperative tethered cord syndrome. The previously published Part I reviewed the overall orthopaedic care of a patient with spina bifida, with a focused review of hip, knee, and rotational deformities. This paper will cover foot and ankle deformities associated with spina bifida, including clubfoot, equinus, vertical talus, calcaneus and calcaneovalgus, ankle and hindfoot valgus, and cavovarus. In addition, this paper will address the issues surrounding skin breakdown in patients with spina bifida.
Effect of Pulsed Nd:YAG Laser in the Treatment of Neuropathic Foot Ulcers in Children with Spina Bifida: A Randomized Controlled Study.
Ebid AA, Abd El-Kafy EM, Alayat MS. Photomed Laser Surg. 2013 Oct 25.
Objective: This study assessed the effects of pulsed Nd:YAG laser treatment of neuropathic foot ulcers in children with spina bifida.
Background data: Children with spina bifida face increased risk for developing neuropathic foot ulcers.
Methods: In a randomized controlled trial, 39 children and adolescents (ages 6-15 years) with spina bifida and stage III neuropathic foot ulcers were randomly assigned to the laser group or the placebo laser group. The former received pulsed Nd:YAG laser treatments (i.e., total energy of 300-350 J during three sessions/week) plus standard wound care, and the latter received sham laser treatments plus standard wound care. Wound size and wound appearance were assessed for all patients at the beginning of the treatment, after 5 weeks, and after 10 weeks.
Results: The decrease in wound surface area at 5 and 10 weeks post- treatment was significantly greater in the laser group (i.e., 2.44±0.33 and 0.29±0.25 cm2, respectively) than in the placebo group (i.e., 3.81±0.18 and 3.24±0.44 cm2, respectively). Also, the decrease in the total score for the Pressure Sore Status Tool (PSST) at 5 and 10 weeks post-treatment was significantly different for the laser group (i.e., 32.76±2.30 and 17.52±1.66, respectively) than for the placebo group (i.e., 46.50±2.12 and 38.11±3.17, respectively).
Conclusions: Treatment with pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laser combined with standard wound care decreases wound size and improves wound appearance for stage III neuropathic foot ulcers in children with spina bifida.
The effects of orthoses, footwear, and walking aids on the walking ability of children and adolescents with spina bifida: A systematic review using International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) as a reference framework
Barbara Ivanyi et al Prosthet Orthot Int August 8, 2014
Background: To date no review has been published that analyzes the efficacy of assistive devices on the walking ability of ambulant children and adolescents with spina bifida and, differentiates between the effects of treatment on gait parameters, walking capacity, and walking performance.
Objectives: To review the literature for evidence of the efficacy of orthotic management, footwear, and walking aids on gait and walking outcomes in ambulant children and adolescents with spina bifida.
Study design: Systematic literature review.
Methods: A systematic literature search was performed to identify studies that evaluated the effect of any type of lower limb orthoses, orthopedic footwear, or walking aids in ambulant children (≤18 years old) with spina bifida. Outcome measures and treatment results for gait parameters, walking capacity, and walking performance were identified using International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) as the reference framework.
Results: Six case-crossover studies met the criteria and were included in this systematic review. Four studies provided indications of the efficacy of the ankle–foot orthosis in improving a number of kinematic and kinetic properties of gait, stride characteristics, and the oxygen cost of walking. Two studies indicated that walking with forearm crutches may have a favorable effect on gait. The evidence level of these studies was low, and none of the studies assessed the efficacy of the intervention on walking capacity and walking performance.
Conclusions: Some data support the efficacy of using ankle–foot orthosis and crutches for gait and walking outcomes at the body functions and structures level of the ICF-CY. Potential benefits at the activities and participation level have not been investigated.
Clinical relevance This is the first evidence-based systematic review of the efficacy of assistive devices for gait and walking outcomes for children with spina bifida. The ICF-CY is used as a reference framework to differentiate the effects of treatment on gait parameters, walking capacity, and walking performance.
The previously suggested association between the incidence of high-level foot deformity and muscle imbalance is no longer supported, when evaluated independent from motor and sensory loss and level of lesion, by current studies. The purpose of this study was to evaluate the association between level of lesion and foot deformity.
Of 545 patients, a total of 136 (272 feet) patients admitted to the spina bifida clinic between 2010 and 2014 were included in this study. Levels of all lesions were evaluated using initial operation data, the motor-sensory exams, and direct radiography. All patients were categorized into four different groups: Thoracic region (group 1), high-level lumbar-L1-2 region (group 2), mild and lower lumbar regions (L3-4-5) (group 3), and Sacral region (group 4).
The mean follow-up time was 34.9 months (range 8-176 months). Group 1, group 2, group 3, and group 4 included 24 (17.6 %), 14 (10.3 %), 19 (14 %), and 79 (58.1 %) patients with regards to level of lesion, respectively. The incidences of foot deformity were 85.4, 85.7, 81.5, and 50.6 % in groups 1, 2, 3, and 4, respectively. Of all patients, 22 % (61 feet) had clubfoot, 16 % (44 feet) pes cavus, 10 % (26 feet) pes valgus, 6 % (17 feet) isolated equinus, 6 % (17 feet) pes calcaneus, and 5 % (13 feet) metatarsus adductus. Patients without a foot deformity (81 % of normal feet) usually had a lesion at the sacral level (p ≤ 0.05). On the other hand, isolated equinus (70 %) and clubfoot (49 %) deformities were mostly observed in spinal lesions (p > 0.05). The incidence of pes calcaneus, pes valgus, and adductus deformities inclined as the lesion level decreased (p > 0.05).
In this study, it was concluded that foot deformities were directly related to the level of lesion. The comparison of higher and lower level lesions revealed that the types of foot deformity differed significantly. The muscle imbalance due to spina bifida was not sufficient to explain the pathology. On the other hand, the level of spinal lesion is an important factor for the type of deformity.
PUBLIC RELEASE: 14-MAR-2016 Excessive fat in legs of children with spina bifida suggests risk for metabolic disorders
Children with a severe type of spina bifida called myelomeningocele have a high prevalence of obesity and excess fat accumulation in their lower extremities. In a study designed to assess bone, muscle and fat tissue distribution in the lower legs of children with this disease, researchers at Children's Hospital Los Angeles determined that this excess fat tissue is within the muscle boundary (muscle-associated) rather than subcutaneous. These findings are significant as muscle-associated fat tissue has been linked to insulin resistance and metabolic disorders. The study is published online in the Journal of Child Neurology.
Myelomeningocele is the most severe type of spina bifida and the impact on patients' health goes beyond the characteristic nerve damage and other neurologic disabilities. The condition is estimated to affect 3.4 per 10,000 live births in the United States and the incidence is even higher among certain populations, including Hispanic Americans. In addition to direct neurologic deficits, affected patients also have higher incidence of other adverse health outcomes including osteopenia, pathologic fractures and obesity.
The team of investigators studied the lower leg bone, muscle and adipose tissue volume in children with myelomeningocele to classify the fat accumulated as either subcutaneous (more commonly found just under the skin) or muscle-associated (where the fat tissue in embedded within the muscle tissue and between muscles). Using computed tomography scans, they saw that increases in lower leg adiposity in children with the disorder are primarily attributable to accumulation of muscle-associated adipose, which may signify increased risk for metabolic disorders such as diabetes.
"We found that children with high level myelomeningocele have more adipose tissue, subcutaneous and muscle-associated, as well as less muscle and bone compared with typically developing children," said Tishya Wren, PhD, of the Children's Orthopaedic Center of Children's Hospital Los Angeles. "These children tend to have mobility limitations and as a result they don't walk and are inclined to gain weight."
The distinction is important because the specific health risks of adiposity depend largely on its location. While total leg fat content has been linked with favorable insulin sensitivity, adipose tissue within the deep fascia of leg muscles has been associated with insulin resistance. This previously unknown finding may impact our understanding of long-term health risks in this population.
"Our findings may also have important implications for long-term health management in children with myelomeningocele," adds Wren. "They may be at increased risk for type 2 diabetes which, to our knowledge, has not been studied in the spina bifida population."
The study also found that higher BMI was a significant predictor of more muscle-associated fat, which suggests that lowering BMI through diet and exercise may have a positive effect on intramuscular fat and associated disease risks.