Functional surgery and early rehabilitation treatment in hemiplegic patients

Advances in the therapy of patients with neurological disorders have resulted in a large and growing population of subjects with dysfunction and deformity of the extremities secondary to a central nervous system lesion (upper motor neuron syndrome, UMNS). Traumatic brain injuries (TBIs) and cerebral vascular accidents (CVAs), or strokes, can have profound effects both on the patient and on society. Stroke is currently the third leading cause of mortality and is a common cause of long-term disability, generating increasing annual healthcare costs. Approximately 60% of these patients survive, and half of them may have residual hemiparesis. Due to the central nervous system damage, stroke patients show muscle weakness, abnormal muscle tone, and disorders of balance and posture control, which lead to difficulty controlling movements, limb spasticity and limb deformities (Keenan et al. in J Neuro Rehabil I2:119–143, 1999 [1]; Banks in Clin Orthop Relat Res 122:70–76, 1977 [2]). Limb deformities are commonly the result of both static and dynamic phenomena. The former include heterotopic ossification, fracture malunion and soft tissue contractures, and the latter weakness, spasticity, rigidity and impaired motor control. In more than 80% of hemiplegic patients, equinovarus foot deformity (EVFD), resulting in abnormal walking patterns, is the main factor limiting post-stroke gait (Lin et al. in Arch Phys Med Rehabil 87:562–568, 2006 [3]). It usually results from spasticity of the plantar flexor and invertor muscles, associated with a deficit of the dorsiflexors, their antagonists. Specifically, deformity of the foot can be seen in the presence of combined spasticity of several different muscles, including the gastrocnemius, soleus, tibialis anterior (TA), tibialis posterior (TP), flexor hallucis longus (FHL), and flexor digitorum longus (FDL), while associated weakness can be recorded in the peroneal muscles. Foot deformities interfere with toe clearance in the swing phase, with correct pre-positioning of the foot at the end of the swing phase, with loading of the stance leg, and with ankle stability during the stance phase (Keenan et al. in J Neuro Rehabil I2:119–143, 1999 [1]). Consequently, neurological patients with EVFD are often unable to walk unassisted, requiring either an orthotic device or crutches (Keenan et al. in Foot Ankle 5:35–41, 1984 [4]).