Surgical Treatments

OBJETIVES of the surgical procedure:

  • Reduce spasticity.
  • Correct osteoarticular side effects.

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SURGERY FOR UPPER LIMB SPASTICITY

Prior assessment: degree of sensory, motor and cognitive involvement and passive and active joint balance.

  • Surgical treatment of shoulder spasticity: Tenotomy or lengthening of subscapularis and pectoralis major.
  • Surgical treatment of elbow flexion: Lengthening of biceps by Z-plasty, resection of aponeurosis expansion and fasciotomy of the brachialis anticus. In non-functional patients, complete tenotomy of the biceps or neurotomy of the cutaneous nerve of forearm may be assessed.

    Codo FlexoInicio Tenotomía Bíceps Alargamiento Bíceps
  • The most common deformity is in the flexion of the wrist and triphalangeal fingers and inclusion of the thumb-in-palm.
  • In the non-functional hand: lengthening or detachment of flexors.
  • Lengthening of flexor pollicis longus, detachment of intrinsic musculature or cubital neurotomy.

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LOWER LIMB SPASTICITY SURGICAL TREATMENTS

Prior assessment:

  • Whether the patient is able to walk or not.
  • Whether the deformity is unilateral or bilateral.
  • Whether the deformity is singular or combined.

Surgical treatment of hip spasticity:

  • Hip flexor:
  1. In patients who are able to walk, Z-plasty of the iliopsoas tendon, tenectomy of the anterior rectus. 
  2. In patients who are unable to walk, complete tenectomy of the iliopsoas tendon and/or anterior rectus tendon.

    Deformidad combinada caderas y rodillas flexas bilaterales
  • Hip abduction.
  1. This is normally proposed in cases with bilateral involvement.
  2. With tenectomy of the long and short abductors, neurectomy of the obturator nerve.
  • Hip luxation. 
  1. Patients unable to walk: Resection arthroplasty (Girdlestone procedure).
  2. Patients able to walk: Re-centring femoral osteotomy, resection arthroplasty (Girdlestone procedure).

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Surgical treatment of knee flexor muscles:

  • The most common deformity in patients with spasticity. In patients able to walk with unilateral involvement, it may be associated with a compensated equinus foot.
  1. In patients who are able to walk, selective tenectomy of the hamstring.
  2. In patients who are unable to walk: Egger’s procedure.
  • Knee extensor: tenotomy of the anterior rectus and vastus intermedius.

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Surgical treatment of foot spasticity:

Foot deformities most frequently require a surgical solution. Equinus foot, in its different forms, is the most prevalent deformity.

  • Equinus foot: Z-plasty of the Achilles tendon, proximal detachment of the gastrocnemius musculature. (Link to: Equinus Foot)

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  • Equinovarus foot: lengthening of Achilles tendon, associated to lengthening of the tibialis posterior in moderate and non-walking cases, or tibialis posterior transfer in patients who are able to walk and do not have active dorsiflexion. If it is due to tibialis anterior involvement, it is associated to transferring half of this muscle.

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  • Planovalgus foot: Normally reducible in children, it is indicated when the purpose is to improve the gait. The surgical technique consists of the placement of a subtalar endoprosthesis.
  • Talipes valgus foot: These are normally very structured cases.  Surgery is indicated when the aim is to improve plantigrade support and achieve a standing position. Astragalectomy, triple arthrodesis or astragalotibial pantalar arthrodesis are performed.

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DEFORMITIES

  • Claw-toe: proximal tenotomy (myotendinous attachment of the flexor digitorum longus and flexor hallucis longus muscles).
  • Intrinsic foot deformity: flexion of metatarsophalangeal joints and extension of distal and proximal metacarpophalangeal joints due to hypertonia of the lumbricals and dorsal interossei. Treatment consists of neurectomy of the external plantar nerve, posterior tibial nerve branch.

    Dedos en garraNeurectomía del plantar externo

  • Combined deformities:
  1. In case of combined hip-knee flexion, the joint most affected is operated on first.
  2. If equinus is associated, the treatment differs.

Neurectomia del nervio obturador