Orthopedic Surgery for Correction of Spastic Disorders
Excess of spasticity generates musculotendinous retraction that must be prevented or at least reduced before it becomes irreducible. In addition, disharmony in the intensity of muscular hypertonia creates an articular imbalance that promotes deformities a
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Excess of spasticity generates musculotendinous retraction that must be prevented or at least reduced before it becomes irreducible. In addition, disharmony in the intensity of muscular hypertonia creates an articular imbalance that promotes deformities and requires compensatory treatment. Therefore, it is mandatory to decrease harmful hypertonia before the appearance of irreducible locomotor disorders and beneficial to restore articular function by rebalancing the tonicity of agonist and antagonist muscles. Neurosurgery is the first-line option when spasticity or dystonia predominates, although orthopedic surgical procedures may reduce per se spasticity through muscle relaxation resulting from tendon release or lengthening. Orthopedic surgery (OS) is indicated primarily or as an adjuvant when contractures and ankyloses are predominant or associated to spasticity, respectively. Table 14.1 lists the different categories of OS for the treatment of spastic disorders or sequelae. Common techniques available for correcting shortness of a muscle–tendon unit are muscle slide (en bloc detachment of muscular origins, mobilized musculotendinous body remains on neurovascular bundle), tenotomy (simple tenotomy allows an extension that does not limit the correction of deformation, but the possibilities of functional muscles are lost), or lengthening tenotomy (at the musculotendinous junction, retaining a bundle of muscle fibers, preserving the functional capacity of muscle; at the tendon level by double or triple hemisection [e.g., medial, lateral, and medial] or by splitting and suturing, i.e., a Z-plasty in sagittal or frontal plane). Tendon transfer has a different goal: It may correct articular misalignment due to muscular imbalance. It may be performed either for active function (attachment to another muscle or tendon to restore the action that muscle has lost) or for passive function (attachment to a bone or ligament for stabilization or fixation; tenodesis). Tendon transfer for the restoration of an action is useful only if the muscular strength of the transferred tendon was scored at least 4 out of 5 (0, no visible motor contraction; 5, normal motor strength). Transfer of spastic muscles must be avoided; suppression of spasticity has to be achieved first by botulinum toxin injections or by neurosurgical procedures if necessary. M. Sindou et al., Neurosurgery for Spasticity, DOI 10.1007/978-3-7091-1771-2_14, © Springer-Verlag Wien 2014
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14 Orthopedic Surgery for Correction of Spastic Disorders
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Table 14.1 Categories of OS methods Method Lengthening of tendon–muscle unit (muscle slide, tenotomy, lengthening tenotomy) Tendon transfer (shift or bifurcation for active or passive function)
Goals and indications Achievement of a more functional position
Potential adverse effects and limitations May reduce muscle power
Correction of articular alignment due to muscular imbalance, compensation for absent antagonist
Difficult to predict whether a spastic muscle is transferred, functional risk to transfer a tendo
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