Renders A, Detrembleur C, Rossillon R, Lejeune T, Rombouts J J
Service de médecine Physique et Réadaptation, Cliniques Universitaries Saint-Luc, Bruxelles, Belgique.
Rev Chir Orthop Reparatrice Appar Mot. 1997;83(3):259-64.
This preliminary study describes the methodology and the results of gait analysis in cases of equinus and equino-varus deformity of the foot in cerebral palsy children. The ultimate goal was to establish an aid to decision in spastic foot surgical management.
A prospective series of 12 walking children (16 feet) with cerebral palsy has been evaluated prior to surgical correction of equinus or equino-varus deformity of the foot. The mean age was 8 years (range 4 to 11 years of age).
The pattern of muscle activity during gait cycle has been recorded by surface electrodes for the tibialis anterior, the triceps and the peroneae and by implanted electrodes for the tibialis posterior. Foot switches have been used to differentiate swing and stance gait phases. The results were compared with these of a series of normal children previously published.
In four cases, the dynamic equinus was due to an extended or continuous contraction of the triceps surae. The varus deformity appeared to originate from two muscles: the tibialis posterior in 9 cases and the tibialis anterior in 1 case. Both muscles were responsible for the deformity in 2 cases. Two muscular activation patterns were observed in the tibialis posterior: inverted (2 feet) or permanent (9 feet). From the main muscle which was responsible for deformity, we have determined the surgical technique which was most appropriate to restore the muscular balance.
Our observations confirm Perry's hypothesis, namely that selective and phasic control during the walking cycle does not occur for patients suffering from cerebral palsy. Different surgical procedures were chosen according to the literature on this subject. In the treatment of equinus deformity, lengthening of the Achilles tendon is a satisfactory technique for hemiplegic patients. But we prefer gastrocnemius recession described by Vulpius in spastic diplegia in order to avoid over-lengthening or calcanal gait. If it can be shown that posterior tibial muscle overactivity is the cause of equinovarus, we perform a posterior tibial tendon lengthening, as proposed by Ruda and Frost, or a split posterior tibial tendon transfer as developed by Green. If the posterior tibial muscle is active only during the swing phase, we accomplish a split posterior tibial tendon transfer through the interosseus membrane as advocated by Saji. If the anterior tibial muscle is continuously active, a split anterior tibial tendon transfer to the cuboid described by Hoffer is performed. If the activity is continuous in both the tibial posterior and the tibial anterior muscles, we add a posterior tibial myotendinous lengthening to the split anterior tibial tendon transfer.
Since 1992, we have developed in our institution a gait analysis laboratory in order to bring objective data in the process of decision making for tendon transfer surgery. With 4 years experience, this objective support now seems to us compulsory in decision of type of transfer. The goal of this preliminary study was to explain how we use the data and match these to our experience and literature.
本初步研究描述了脑性瘫痪儿童马蹄足和马蹄内翻足畸形病例的步态分析方法及结果。最终目标是为痉挛性足部手术治疗提供决策辅助。
对12名步行的脑性瘫痪儿童（16只脚）进行前瞻性研究，这些儿童在接受足部马蹄足或马蹄内翻足畸形手术矫正之前接受了评估。平均年龄为8岁（范围为4至11岁）。
通过表面电极记录胫前肌、三头肌和腓骨肌在步态周期中的肌肉活动模式，通过植入电极记录胫后肌的活动模式。使用足部开关区分摆动期和站立期步态阶段。将结果与先前发表的一系列正常儿童的结果进行比较。
在4例中，动态马蹄足是由于小腿三头肌的持续收缩所致。内翻畸形似乎源于两块肌肉：9例为胫后肌，1例为胫前肌。2例中两块肌肉均导致畸形。在胫后肌中观察到两种肌肉激活模式：反向（2只脚）或持续（9只脚）。从导致畸形的主要肌肉中，我们确定了最适合恢复肌肉平衡的手术技术。
我们的观察结果证实了佩里的假设，即脑性瘫痪患者在步行周期中不存在选择性和阶段性控制。根据关于该主题的文献选择了不同的手术方法。在治疗马蹄足畸形时，跟腱延长术对偏瘫患者是一种令人满意的技术。但对于痉挛性双侧瘫患者，我们更喜欢武尔皮乌斯描述的腓肠肌松解术，以避免过度延长或跟骨步态。如果能证明胫后肌过度活动是马蹄内翻足的原因，我们会按照鲁达和弗罗斯特的建议进行胫后肌腱延长术，或按照格林开发的方法进行胫后肌腱劈开转移术。如果胫后肌仅在摆动期活跃，我们会按照佐治的主张通过骨间膜进行胫后肌腱劈开转移术。如果胫前肌持续活跃，则进行霍弗描述的胫前肌腱劈开转移至骰骨的手术。如果胫后肌和胫前肌均持续活跃，我们会在胫前肌腱劈开转移术的基础上增加胫后肌腱肌腹延长术。
自1992年以来，我们在本机构建立了一个步态分析实验室，以便在肌腱转移手术的决策过程中提供客观数据。经过4年的经验，现在我们认为这种客观支持在决定转移类型时是必不可少的。本初步研究的目的是解释我们如何使用这些数据，并将其与我们的经验和文献相匹配。
