Neuro-orthopaedic Surgery in the Treatment of the Spastic Equinovarus Foot
Condition: Spasticity; Spastic Foot; Stroke
MeSH terms: Muscle Spasticity; Clubfoot; Talipes; Equinus Deformity
Study type: Observational

Summary: 
      Spastic equinovarus foot (SEF) is a major cause of disability in stroke patients. Treatments
      may include physical therapy, orthosis, botulinum toxin (BTX) injections, selective tibial
      neurotomy and tendon lengthening and/or transfer.

      Until now, no study has been conducted to assess the result of neuro-orthopaedic surgery in
      the treatment of SEF.

      The aim of this study is to evaluate the benefit of neuro-orthopaedic surgery (selective
      neurotomy and/or Achilles tendon lengthening and/or tibialis anterior transfer) in case of
      SEF according to the 3 domains of the International Classification of Functioning, Disability
      and Health (ICF)of the World Health organisation (WHO)
    

Detailed description: 
      INTRODUCTION

      Stroke is the third cause of death and the leading cause of handicap among industrialized
      countries (1). Spasticity following stroke is responsible for spastic equinovarus foot (SEF)
      in 18% of cases (2). Spastic equinovarus foot is due to spasticity (muscle hypertonia) of the
      calf muscles (soleus, gastrocnemius and tibialis posterior), often complicated by contracture
      and by the weakness of peroneus longus and peroneus brevis muscles (3). Therefore, stroke
      patients walk slowly, and often require assistive device as orthosis or canes. This
      disability limits their social participation and their quality of life.

      Spastic equinovarus foot treatments include oral medications, physical therapy, orthosis,
      chemical denervations (botulinum toxin, alcohol or phenol injections), selective neurotomy
      and orthopedic surgery (3). Selective neurotomy is a neurosurgical procedure consisting in
      partially and selectively cutting motor branches innervating the spastic muscles providing a
      permanent treatment of the spasticity (3). Orthopaedic surgery consists in Achilles tendon
      lengthening and tibialis anterior transfer (3). The efficacy of mixed neur-orthopaedic
      surgery has never been prospectively assess according to the ICF classification.

      OBJECTIVES

      The aim of the present project is to study the effectiveness of neuro-orthopaedic surgery
      (neurotomy and tendon surgery) in the treatment of SEF.

      The functional assessment will explore the three ICF domains.

      METHODS

      The investigators will recruit 50 chronic spastic patients presenting with SEF. The surgical
      treatment will be decided according to the improvement obtained by an anaesthetic diagnostic
      tibial motor nerve branches block (5) followed by an interdisciplinary discussion.

      Patients will be assessed before treatment, 2 months, 1 year and 2 years after treatment
      among the 3 ICF domains. Impairments will be assessed by the Stoke Impairment Assessment Set
      (SIAS), the Ashworth and Tardieu scales (spasticity) and the MRC scale (muscle strength).
      Gait disorders will be evaluated by a video analysis. Disability will be evaluated by the
      ABILOCO scale (6) and the participation (quality of life) by the SATIS-Stroke questionnaire
      (7) and the SF-36 questionnaire.

      The patients selection, the lidocaine hyperselective diagnostic blocks, the selective
      neurotomy and the tendon surgery will be achieved by the medical doctors participants to the
      spasticity group. The functional assessment will be achieved by the physical therapists of
      the PMR department (blinded assessor).

      PERSPECTIVE

      The investigators hope to demonstrate the benefit of neuro-orthopaedic surgery in case of SEF
      according to the 3 domains of the ICF (8)
    

Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Patients with central neurological disease (stroke, traumatic brain injury, spinal cord
        injury, multiple sclerosis) suffering from a spastic equinovarus foot referred to an
        interdisciplinary spasticity group in a University Hospital
      
Keywords: Spastic equinovarus foot; Stroke; Neurotomy; Tendon surgery