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- 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 Youm T, et al, 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%;
                        - 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); 
                  - Effect of previous cerebrovascular accident on outcome after hip fracture.

- Managment of Upper Extremity Deformities: 
    - shoulder:
         - ref: Outcomes of the Biceps Suspension Procedure for Painful Inferior Glenohumeral Subluxation in Hemiplegic Patients
    - 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 fingers are contracted into the palm w/ wrist extension but are relaxed when wrist is is flexed, then about 4-5 cm in length are required to release 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. 
         - Intramuscular botulinum toxin-A reduces hemiplegic shoulder pain: a randomized, double-blind, comparative study versus intraarticular triamcinolone acetonide.

- Management of Lower Extremity Deformities:
    - knee:
         - w/ the hemiplegic, knee and ankle can be immobilized w/ an AKFO and can still ambulate, but they need some hip flexion to clear 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; 
              - reference:
                      - Adult-onset hemiplegia: changes in gait after muscle-balancing procedures to correct the equinus deformity
         - equinovarus deformity 
              - references:
                     - Surgery can reduce the nonoperative care associated with an equinovarus foot deformity.
                     - Split posterior tibial tendon transfer for spastic equinovarus foot deformity
                     - Anterior transfer of the toe flexors for equinovarus deformity due to hemiplegia.  
                     - Anterior transfer of the toe flexors for equinovarus deformity of the foot.  
                     - Intrinsic toe flexion deformity following correction of spastic equinovarus deformity in adults
                     - Combined split TA-tendon transfer and IM lengthening of PT tendon. Results in pts who have a varus deformity of foot due to spastic CP. 
                     - Effect of Age, Sex, and Timing on Correction of Spastic Equinovarus Following Cerebrovascular Accident 



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.

The treatment of spastic planovalgus foot deformity in the neurologically impaired adult.

Adult-onset hemiplegia: changes in gait after muscle-balancing procedures to correct the equinus deformity.

The results of tenodesis of the tendo achillis to the fibula for paralytic pes calcaneus.

Perioperative Stroke. 

Surgical correction of foot deformities after stroke

Approaches to senior care #3. Orthopaedic management of the stroke patient. Part II: Treating deformities of the upper and lower extremities.                 
Surgical correction of gait abnormalities following stroke.  

Images in Clinical Medicine. Clonus after a Stroke.