- Orthopaedic Implications:
- it is estimated that 50% of hemiplegics can be improved by surgical interventions and can achieve brace free function;
- pts who have had a stroke may cont to improve upto 6 months after their vascular event;
- pts w/ traumatic brain injury may improve upto 18 mo after injury
- to walk independently, the hemiplegic requires:
- adequate balance to stand independently;
- hip flexion to advance the limb;
- normal strength of uninvolved side;
- normal proprioception;
- if the patient does not have these requirements, walking may not be a realistic goal;
-
CVA and hip fracture: (see
femoral neck and
intertroch fractures);
- in the report by T. Youm et al (JTO Vol 14, No 5 p 329), the authors evaluated 829 patients who sustained a hip fracture;
- of these patients 7.3% had a history ov a CVA;
- the fracture was on the hemiplegic side in 87%;
- the authors theorized that due to gluteus medius weakness, patients lean toward the hemiplegic side,
increasing the likehood of fracture;
- 89% of patients had a CVA one year or more before hip fracture;
- one year mortality was 11%;
- there was an equal predominance of left and right hemiplegia (ie, there was no evidence that
left sided strokes increased risk of hip fracture due to possible spacial disorientation);
- Managment of Upper Extremity Deformities:
-
flexor origin slide:
- indicated for patients w/ finger flexion contracture but maintenance of active grasp;
- about 4-5 cm of excursion in flexor tendons is determined by the wrist motion;
- if the fingers are contracted into the palm w/ wrist extension but are relaxed when the
wrist is is flexed, then about 4-5 cm in length are required to release the contracture;
- this can be accomplished by the flexor origin release or the flexor slide;
-
intramuscular injection of botulinum toxin:
- ref:
Intramuscular Injection of Botulinum Toxin for the Treatment of Wrist and Finger Spasticity after a Stroke.
- references:
-
Results of transfer of the flexor digitorum superficialis tendons to the flexor digitorum profundus tendons in adults with acquired spasticity of the hand.
- Management of Lower Extremity Deformities:
-
knee:
- w/ the hemiplegic, the knee and ankle can be immobilized w/ an AKFO and can still ambulate,
but they need some hip flexion to clear the leg during ambulation;
-
foot:
-
ankle equinus may cause
hallux valgus deformity;
- the underlying equinus deformity should be corrected before an attempted correction of bunion (
MTP fusion);
- AFO w/ a wire spring orthosis;
- biomechanics: a mild dorsiflexion assist device and mild medial and lateral control;
- useful in the stroke pt with weak dorsiflexors of foot and unable to keep his foot up to clear the ground in swing;
-
equinovarus deformity
- references:
-
Surgical correction of foot deformities after stroke.
- Orthopaeidc management of the stroke patient.
Part II. Treating deformities of the upper and lower extremities.
Botte MJ et al.
Orthop Rev. Vol 17. 1988. p 891-910.
-
Combined split anterior tibial-tendon
transfer and intramuscular lengthening of the posterior tibial tendon. Results in patients who have a varus deformity of the foot due to spastic cerebral palsy.
- Surgical correction of gait abnormalities following stroke.
Waters RL et al.
CORR. Vol 131. 1978. p 54-63.
The Orthopedic Management of the Stroke Patient.
Preliminary report of the Stroke Prevention in Atrial Fibrillation Study.
The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators;
Adult-onset hemiplegia: changes in gait after muscle-balancing procedures to correct the equinus deformity.
Split posterior tibial tendon transfer for spastic equinovarus foot deformity.
Anterior transfer of the toe flexors for equinovarus deformity due to hemiplegia. S. Morita.
JBJS. 76-B. 1994. p 447-449.
Anterior transfer of the toe flexors for equinovarus deformity of the foot. Ono, K. et al.
Int Orthop. Vol 4. 1980. p 225-229.
The treatment of spastic planovalgus foot deformity in the neurologically impaired adult.
Intrinsic toe flexion deformity following correction of spastic equinovarus deformity in adults.
Adult-onset hemiplegia: changes in gait after muscle-b
The results of tenodesis of the tendo achillis to the fibula for paralytic pes calcaneus.
Perioperative Stroke.
