RU2712951C2 - Method for determining severity of equinus foot deformation in children with infantile cerebral paralysis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to orthopaedics, and is intended for use in determining the severity of equinus deformation of feet in children with infantile cerebral paralysis. A child is laid horizontally on the inspection table and an individual bucket of polymer hardening material is made, which follows the outlines of the deformed foot. On the edges of the basement at the level of heads I and V of the metatarsal bones and Shoparov's joint, four holes are formed - a groove through which metal ropes of identical length are drawn and fixed. Cables are connected to each other in the form of pyramid and mechanical spring dynamometer is fixed at their connection point. Then, a manual tie-rod is made behind the dynamometer ring in the direction of dorsiflexion of the foot with a straight knee joint and the force of exposure required to eliminate equinus deformation is measured.

EFFECT: method enables determining the surgical exposure on the gastrocnemius muscle to achieve a stable correction position.

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Description

The invention relates to medicine, namely to orthopedics, and can be used to determine the severity of equinus deformity of the feet in children with cerebral palsy (cerebral palsy).

Cerebral palsy is one of the most severe disabling diseases of the nervous system and musculoskeletal system, which is a consequence of brain damage that occurs in the prenatal, intrapartum and postnatal periods. A characteristic feature of cerebral palsy is a violation of the motor development of the child, due primarily to the abnormal distribution of muscle tone and impaired coordination of movements (Badalyan L.O. Pediatric Neurology. - M .: Medicine, 1984. - 576 p.). One of the main syndromes leading to disability of patients is muscle spasticity. It is accompanied by a limitation in the volume of active and passive movements, which subsequently leads to the formation of myogenic and then fixed contractures (Krasnov A.S. Surgical treatment of equine foot deformity in children with cerebral palsy // Saratov Journal of Medical Scientific Research. - 2011. - T. 7 - No. 3. - S. 700-703).

The lower limb is the most distal part of the human body and, in terms of functionality, is central to the musculoskeletal system (Research on the Performance of the Spastic Calf Muscle of Young Adults With CerebralPalsy // JClinMedResHYPERLINKhttp: //www.ncbi.nlm.nih .gov / pmc / issues / 201174 / "v.3 (1); Feb 2011). Of the total number of patients with cerebral palsy, foot deformities occur on average in 60% of cases, with at least 40% of patients with foot deformities requiring surgical treatment ( Ryzhikov D.V. Surgical correction of equino-valgus deformity of the feet in children with cerebral palsy Alich // Genius of Orthopedics. - 2010. - No. 3. P. 95-100). The knowledge of the origin of spastic contraction of the calf muscles gives a general idea of the spastic gait model, and is also useful in deciding the treatment tactics. According to many scientists it is the calf muscle that is of key importance in the occurrence of equinus deformity of the foot and the complex effect on it with conservative and operative methods can lead to normalization of the foot position and restoration of the walking function (Strayer LM Recession of gastrocnemius. J. Bone it Surg. 1950 .-- 32-A, Vol. 5, p. 651-676; Pat. 2254086 RF, IPC A61B 17/56. A method for correcting equinus foot contracture in children with cerebral palsy / Umnov V.V. - Publ. 06/20/2005; Pat. 1477391 USSR, IPC A61B 17/56. A method for the treatment of cerebral palsy with equinus deformity of the foot / Umkhanov H.A., Khaviko T.N. - Publ. 05/07/1989; RF patent 2332180, IPC АВВ 17/56. A method for the surgical treatment of equinus foot deformity in children with cerebral palsy / Shamik VB, Dyakova VN - Publ. 08/27/2008). However, to select the optimal method and tactics for the treatment of equinus foot deformity of spastic origin, it is necessary to determine the severity of ankle joint contracture in patients with cerebral palsy, which would have specific quantitative expressions.

In the scientific literature there is a classification of I.S. Perkhurova, V.M. Luzinovich, E.G. Sologubova for patients with cerebral palsy according to the severity of a motor defect (I.S. Perkhurova, V.M. Luzinovich, E.G. Sologubov / Regulation of posture and walking with cerebral palsy and some correction methods Moscow, 1996, 242 s). According to this classification, the following degrees of severity are distinguished: I degree light: independent movement, standing and walking altered, there are no fixed contractures of the joints, the cervical-tonic and labyrinth-tonic reflex prevail; II average degree: walks and sits with additional support, there are fixed deformations of the joints; Severe III: patients do not move, but have the potential to walk. There are passive fixed deformations of the joints. According to the authors, the proposed classification reflects the severity of a motor defect and locomotor dysfunction, determined by subjective clinical examination. According to the authors, this classification of patients makes it possible to determine the objectives and tactics of orthopedic surgical treatment. However, this separation of patients into groups does not specify the severity of muscle contractures of the joints and does not make it possible to determine a specific treatment method.

Classical in determining the severity of motor disorders are a large number of rating scales for patients with cerebral palsy - the modified Ashworth scale, the Gross Motor Function Classification System, the Edinburgh visual scale, etc. (Union of Russian Pediatricians. Federal Clinical Guidelines for the provision of medical care for children with cerebral palsy . - M .: 2013. - 28 p .; Aranovich AM, Popkov A.V., Schukin A.A. Results of multilevel simultaneous surgical interventions in patients with cerebral palsy // Genius Orthopedics. - 2013. - No. 4. - FROM. 53-60 .; Kurenkov A.L., Batysheva T.T., Vinogradov A.V. Zyuzyaeva E.K. Spasticity in cerebral palsy: diagnosis and treatment strategies // Journal of Neurology and Psychiatry. - 2012 - No. 7. - Issue 2. - P. 24-28.) These scales are generalizing and carry a certain share of subjectivity, do not contain specific quantitative diagnostic criteria, including for equinus deformity of the feet.

When assessing legal capacity in the bodies of medical and social expertise, clinical and functional signs of foot dysfunction, proposed by R.V., are widely used. Latypov, I.I. Nikitchenko, N.N. Lebedeva, on the basis of which the degrees of dysfunction are determined according to the diagnostic tables for assessing disorders of the motor functions of the lower extremities (Medical and Social Expertise [Electronic resource] // Congenital deformities of the foot. URL: http://www.invalidnost.com/index/3_3_3_vrozhdennye_deformacii_stopy/0- 294). However, these criteria relate mainly to congenital clubfoot and do not take into account the spastic nature of the equinus component in cerebral palsy. In addition, the objective of these criteria is to determine the degree of dysfunction and the level of self-care of the person being tested, and not the choice of therapeutic tactics.

RF patent No. 2294178 (2007) protects the invention of a stop-holder for compensating for shortening of the limb and holding the foot, the essence of which is to use a stop-holder with a fixed load cell, with which you can dose the load on the foot. In this invention, quantitative indicators of the degree of load on the foot are determined using a strain gauge.

RF patent No. 2301039, IPC АВВ 17/56, A61F 5/14 (2008) protected a method for creating shoes for the correction of foot deformation elements. The impact occurs on the anchor points using a device that ensures during the operation of the foot the torsion of the foot itself or its individual parts relative to the sagittal, frontal, horizontal planes. Torsion is aimed at bringing the foot to its normal physiological form. A well-known patent has solved the problem of manufacturing a foot support platform and its effect on the foot support points.

The silver test (method) of Silverskjöld (triceps-test), which consists in determining the amount of passive movements in the ankle joint (Dyakova V.N. Optimization of orthopedic and surgical treatment of equine foot deformity in children with cerebral palsy, is widely covered and used in practice in the scientific literature: Abstract of thesis of the Candidate of Medical Sciences: special code 14.00.35 / RostSMU. - Rostov-on-Don, 2007. - 23 p .; Foot and Ankle Exam [Electronic resource] // URL: http: / /www.boneschool.com/examinations/lower-limb/foot-ankle-exam). The test is carried out as follows: a patient with cerebral palsy with equinus deformity of the foot (for example, the right) is placed on the couch, on the back. The doctor's face is turned to the patient. With the left hand, the doctor holds the knee joint in an unbent position, with the right hand grabs the foot from the inside (the palm and first finger are on the plantar surface of the foot, and 2-3-4-5 fingers are on the back surface) and performs passive back flexion of the foot - displays the foot in the average physiological position (the angle in the ankle joint is 90 °). At the maximum possible back flexion with an extended knee joint, the doctor loosens the fixation of the knee joint with his left hand and performs its passive flexion. If contracture persists when the foot is removed, the knee joint is bent, then the soleus and calf muscles are involved in the process. If the back flexion is limited with a straight knee, but not in a bent position, then it is regarded as a pathology exclusively of the calf muscle. Given the results of the test, determine the severity of ankle joint contracture and the method of treatment of equinus foot deformity in cerebral palsy. The test is of great practical importance, it helps to determine the leading role in the occurrence of equinus deformation of the foot in cerebral palsy of the affected calf muscle, and helps determine the operational tactics. However, the test is based on the manual subjective sensations of the doctor and does not give a quantitative result in assessing the degree of equinus deformation. This method of Silverscheld (triceps-test) is the closest to the proposed method for determining the severity of equinus deformation of the foot in cerebral palsy.

Also known is low-temperature plastic (NTP) for the manufacture of orthopedic orthoses. NTPP is a material that heats up (becomes plastic) in water at a temperature of 60 to 75 degrees Celsius. After the material is removed from the water, its surface temperature drops to 35-40 ° C (surface cooling takes only a few seconds), while the material remains plastic. This temperature is acceptable for direct modeling of plastic along the contours of the patient's body. Most NTTPs also have a “working memory” effect, which makes it possible to repeatedly remodel the finished product ([Electronic document] The use of low-temperature thermoplastics in orthosis of the upper limbs. - URL: turbocast.com.ua> docs / Turbocast_instructions).

The objective of the proposed method is to determine the magnitude of the force on the foot in patients with cerebral palsy for the correction of equinus deformity. The technical result of the invention is the ability to further determine the amount of surgical exposure to the calf muscle to achieve a stable correction position.

The task is achieved by the fact that the child is placed in a horizontal position on the viewing table. An individual footplate is made from a polymer hardening material that repeats the contours of the deformed foot, at the edges of which four groove holes are formed at the level of the heads of I and V metatarsal bones and Shoparov’s joint, through which metal cables of the same length are held and fixed. The cables are interconnected in the form of a "pyramid", after which the mechanical spring dynamometer is fixed at the connection point of the cables. A manual traction is performed for the dynamometer ring in the direction of the back flexion of the foot with the straight knee joint, while measuring the force of the action necessary to eliminate the equinus deformation.

The inventive method for determining the severity of equinus deformity of the feet in children with cerebral palsy is illustrated in the drawings, where in FIG. 1 schematically depicts a modeling step of a footplate, and FIG. 2 - the stage of determining the severity of equinus deformation. In FIG. 1 are conventionally marked: 1 - an individual foot rail, 2 - metal cables, 3 - a mechanical spring dynamometer.

The method is as follows.

The patient is laid on a couch while lying on his back. Polymer hardening material, for example, turbocast, preheated in water up to 70 ° C, is applied to the plantar surface of the deformed foot, and modeling by foot with hands is performed. Along the edges of the manufactured individual crib -1 (Fig. 1) in the projection of the heads I and V of the metatarsal bones and tarsal bones (Chopar joint of the foot) holes form grooves through which metal cables are passed and fixed - 2 of the same length (from 10 to 15 cm ) The ends of the latter are connected at the “top of the formed pyramid”, as shown in FIG. 1. A measuring device is attached to the junction of metal cables, for example, a mechanical spring dynamometer - 3. The assistant holds the knee joint of the studied limb with one hand in an unbent position to an angle of 180 °, and with the other hand holds the heel in the middle position between eversion and iversion (sagittal plane ) The doctor pulls the ring of the measuring device in the direction of the back flexion of the foot (Fig. 2). As a result, when the foot is brought into the correction position, a quantitative expression of the force necessary to eliminate the deformation is obtained. Having the results of this measurement, they conclude that the severity of the equinus deformity of the foot during cerebral palsy.

Depending on the data obtained, the tactics of surgical treatment are determined.

Example 1. Patient C., age 10 years (clinical observation No. 45). Diagnosis: cerebral palsy,

spastic tetraparesis, equinus deformity of both feet. On clinical examination: the patient moves without additional support, loading the forefoot. The right foot is in the equinus position, there is no roll when walking. Equinus - 115 °. Muscle tone on the Ashworth scale of 1 point, I level of motor skills on the GMFMC scale. In a gypsum cabinet in the shape of the right foot, a footplate is made of a polymer hardening material - turbocast. In the grooves made, metal cables are fixed, interconnected. A spring dynamometer is fixed to the connection. The girl is laid on the couch. The assistant, holding the right knee joint in the maximum extension position, fixed the right heel in the sagittal plane with the other hand. The doctor performed the back flexion of the foot by pulling on the dynamometer ring. It was possible to bring the foot to the mid-physiological position (90 °) with the application of a force of 5 kg / cm ² , which corresponds to the first degree of severity of deformation according to the conditionally proposed classification.

Example 2. Patient C., age 5 years (clinical observation No. 48). Diagnosis: cerebral palsy, spastic right-sided hemiparesis, equinus deformity of the foot. On clinical examination: the patient moves without additional support, loading the forefoot. The right foot is in the equinus position, there is no roll when walking. Equinus - 120 °. Muscle tone on the Ashworth scale 2 points, II level of motor skills on the GMFMC scale. In a gypsum cabinet in the shape of the right foot, a footplate is made of a polymer hardening material - turbocast. In the grooves made, metal cables are fixed, interconnected. A spring dynamometer is fixed to the connection. The girl is laid on the couch. The assistant, holding the right knee joint in the maximum extension position, fixed the right heel in the sagittal plane with the other hand. The doctor performed the back flexion of the foot by pulling on the dynamometer ring. It was possible to bring the foot to the mid-physiological position (90 °) with the application of a force of 9 kg / cm ² , which corresponds to the second degree of severity of deformation according to the conditionally proposed classification.

Example 3. Patient M., age 5 years 8 months (clinical observation No. 49). Diagnosis: cerebral palsy, spastic left-side hemiparesis, equinus deformity of the foot. On clinical examination: the patient moves without additional support, loading the forefoot. The left foot is in the equinus position, there is no roll when walking. Equinus - 35 °. Muscle tone on the Ashworth scale 3 points, II level of motor skills on the GMFMC scale. In a gypsum cabinet in the shape of the left foot, a footplate is made of a polymer hardening material - turbocast. In the grooves made, metal cables are fixed, interconnected. In place

connections fixed spring dynamometer. The girl is laid on the couch. The assistant, holding the left knee joint in the maximum extension position, fixed the right heel in the sagittal plane with the other hand. The doctor performed the back flexion of the foot by pulling on the dynamometer ring. Feet brought up to an angle of 95 ° with the application of a force of 12 kg / cm ² , which corresponds to the third degree of severity of deformation according to the conditionally proposed classification.

Claims (1)

A method for determining the severity of equinus deformity of the feet in children with cerebral palsy, characterized in that the child is placed in a horizontal position on the examination table, an individual foot is made of polymer hardening material, repeating the contours of the deformed foot, at the edges of which at the level of the heads I and V of the metatarsal bones and Shoparov’s joints form four groove holes through which metal cables of the same length are held and fixed, connect them together in the form of “pyramids” s ”, after that the mechanical spring dynamometer is fixed at the connection point of the cables, then manual traction is performed for the dynamometer ring in the direction of back flexion of the foot with the straight knee joint, while measuring the force necessary to eliminate the equine deformation.

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