Jan 25, 1994 - to that of arthrogryposis. Most of the equinovarus feet which were deformed at birth were rigid and difficultto treat (Fig. 1), whereas calcaneus.
THE
HIGH
INCIDENCE
PATIENTS NIGEL
From
WITH
S. BROUGHTON,
the Royal
FOOT
HIGH-LEVEL
GEOFFREY
Children
OF
GRAHAM,
‘s Hospital,
SPINA MALCOLM
Melbourne,
DEFORMITY
B.
Received
Surg
[Br]
25 January
1994; 1994;
76-B:548-50. Accepted
17 February
1994
AND
METhODS
Beginning in 1960, a consecutive series of 124 children (248 feet) born with thoracic, Li, L2 or L3 spina bifida was assessed yearly for the presence of foot deformity. Children who died in the first year of life were excluded from the study. All the other children were followed up
N. S. Broughton, Surgeon M. B. Menelaus, Royal Children’s Australia.
FRCS
Ed,
MD, FRCS, Hospital,
FRCS, FRACS, Remington
FRACS,
Consultant
Senior Orthopaedic Road, Parkville,
G. Graham, FRCS, Consultant Orthopaedic Surgeon Cardiff Royal Infirmary, Newport Road, Cardiff CF2 Correspondence ©1994 British 0301-620X/94/4827
548
should Editorial
be sent
Society $2.00
1SZ,
to Dr N. S. Broughton. of Bone
and
Joint
Surgery
MENELAUS
from birth for a minimum of three years or until the deformity required an operation. The state of the foot immediately before surgery was recorded and subsequent changes
Orthopaedic Consultant Victoria
UK.
3052,
were
ignored,
to exclude
iatrogenic
deformities.
None of the children had voluntary activity in the motors of the foot, but some had spasticity. Data were collected every six months for the first two years of life and then annually and were recorded on the Patient Data Management System (IBM PC compatible software standardised by the International Myelodysplasia Study Group). They included muscle power (graded 0 to 5), spasticity in muscles and the level of the lesion, using a modification of the method described by Sharrard (1964). This information was collected either by the surgeon treating the patient or by one of several research assistants
It has for long been believed that foot deformity in patients with spina bifida usually results from muscle imbalance and that children without activity in the motors of the foot would therefore have no deformities (Sharrard 1967; Sharrard and Grosfield 1968). Surgeons who treat children with high-level spina bifida, however, are often faced with foot deformities in patients who have either no muscle activity in any of the motors of the foot, or spasticity in some of them. We report the incidence of foot deformities in patients with high-level spina bifida.
PATIENTS
BIFIDA
Australia
In a consecutive series of 124 children with spina bifida we found that 220 (89%) ofthe 248 feet were deformed: 70 had a calcaneus deformity; 126 were in equinus; 16 were in valgus; 3 were in varus; and 5 had convex pes valgus. Operations were performed on 171 (78%) of the deformed feet. Spasticity of the muscles controlling the foot was detected in 36 (51%) ofthe 70 calcaneus feet and in 22 (17%) of the 126 equinus feet. The deformities were symmetrical in 94 children. There is a high incidence of foot deformity in patients with spina bifida who have no voluntary activity in the motors of the feet. J Bonefoint
IN
who
had
been
trained
in Seattle
and
had
carried
out interand intraobserver error tests to prove the reliability of their data collection (Broughton et al 1993). One orthopaedic surgeon (MBM) had managed all but four of the patients considered in this series and his notes were available.
RESULTS The neurosegmental 74 children, at Li Table
lesions were at the thoracic level in 14, at L2 in 9 and at U in 27. I. Foot
deformities
in 248
feet
Deformity
Number
Percentage
Equinus
Equinovarus Equinovalgus
70 47 9
51
j
Calcaneus Calcaneovarus Calcaneovalgus
18 6 46
J
Valgus Varus Convex
16 3 pes valgus
No deformity
5
28
in
28
10
J 11
Of the 248 feet, 220 had marked deformities (Table I), the range of which was similar at all neurosegmental levels. The severity of the deformity led to surgical correction of 171 feet. Two feet were not corrected because of parental refusal, and two patients died. The rest were not operated upon as it was felt to be THE JOURNAL
OF BONE
AND JOINT
SURGERY
THE
inappropriate
because
HIGH
INCIDENCE
OF FOOT
of the severity
DEFORMITY
IN PATIENTS
prediction asymmetrical
and the requirements
of the patient. Spasticity
of the
muscles
present in 59 of the feet those with no deformity. deformity had
(with
or without
spasticity,
tertius equinus
usually
or extensors deformity
(17%) nemius.
affecting
foot
with deformity Of the 70 feet valgus
in the
posture
was
and in none of with a calcaneus
or varus),
tibialis
36
anterior,
WITH
(5 1%)
peroneus
of the toes. Of the 126 feet with (with or without varus or valgus),
an 22
SPINA
BIFIDA
549
of foot deformity. In view of the number deformities many of which could not
explained assumed of foot
HIGH-LEVEL
by spasticity, posture deformity.
of some
of the
it seems
is the main Intrauterine
unlikely
of be
that habitually
reason for the development position may be the cause
deformities,
and
some
children
have
an
appearance similar to that of arthrogryposis. Most of the equinovarus feet which were deformed at birth were rigid and difficultto treat (Fig. 1), whereas calcaneus presenting
had spasticity of the foot motors, usually gastrocOf the other 24 feet with deformities (valgus, and paralytic convex pes valgus), only 1 (4%) had
varus
Spasticity. Ninety-four patients had symmetrical deformities both limbs. Fifteen of the patients who had asymmetrical
in
deformities had valgus or varus)
a calcaneus deformity (with on one side and an equinus
or without deformity
(with
valgus
in only
or without
of these asymmetry.
was
valgus, two with a varus
or varus)
spasticity Of the five
on the other;
thought feet with
were bilateral and the other was foot on the other side; no spasticity
The other combinations.
asymmetrical
six
to account for paralytic convex
deformities
had
this pes
combined was seen.
a variety
of
Fig. Bilateral mental
rigid lesion.
equinovarus
1
deformities
in a neonate
with
a T12
neuroseg-
DISCUSSION We
have
shown
a high
incidence
of foot
high-level spina bifida. In most patients were severe enough to require surgical were
not
due
to voluntary
the patients reviewed Previous reports of foot included
Dow
(1964)
described
with
spina
calcaneus
reported in patients
296
with
activity
most spina
in 161
at all levels; Sharrard
of which
neurosegmental
levels
motor activity. Lindseth (1976)
according bifida the
none
bifida
and
of
reported
to neurosegmental incidence of club
had
no deformity,
cases
of convex pes valgus. The incidence which
9%
had
not
350
(1968)
operated
dependent
on
children,
and
there
2
Right fixed calcaneus deformity, year-old child with no voluntary spasticity in tibialis anterior.
present motor
at
2).
at birth activity
and increasing, below Li,
but
in a 1some
volun-
separated spina of feet were
two
birth
is
pliant
(Fig.
associated with Menelaus 1986). In summary,
spasticity
patients
conjectural,
remains
tary
muscle
ities
can no longer
1994
of deformity
Fig.
in feet
76-B, No. 4, JULY
report
They
the cause of the stimulation of the of deformity. Dias had foot deformity was similar for all
with no voluntary motor activity is high. Some deformities were clearly due to spasticity and some may have been due to spasticity which we have been unable to detect. We have had no success with Faradic stimulation in the
VOL.
we
upon,
levels.
level. In high-level foot was 53%; 37% calcaneus
in 100
19 of them
and Grosfield
at all segmental
was
feet
only
had been
implied that muscle imbalance was deformity and reported that Faradic motors to the foot was a good predictor (i983) described 246 feet, 220 ofwhich and stated that the type of deformity tary
since
bifida but they have usually levels. Hayes, Gross and
deformities bifida
deformities. feet,
in
had any such muscle activity. have also shown a high incidence
deformity in spina all neurosegmental
children were
motor
deformities
the deformities correction. They
No benefits commercial
the
imbalance
in any form party related
Many
calcaneus
(Menelaus
cause
of deformity but
is responsible
feet
1971;
the
Bliss
in many concept for
of our
that
all foot
are and
volundeform-
be accepted.
have been received directly or indirectly
or will be received to the subject of this
from article.
a
550
N.
5.
BROUGHTON,
G.
GRAHAM,
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OF BONE
AND JOINT
SURGERY
in
