Factors Related to Combined Orthopedic Surgery

Table 4.2: Modified Ashworth scale

Normal muscle tone

Mild increase in muscle tone is manifested by sudden onset of resistance, or mild resistance during urgent examination or

stretch

Mild increase in muscle tone is manifested by a sudden onset of resistance followed by a mild resistance that is no longer exceeded.

range of motion of joint

Increased muscle tone clearly limits the range of motion of the joint, however, passive flexion and extension of the joint can be easily examined.

The muscle tone is so strong that passive flexion and extension of the joint becomes difficult.

Fixed joints cannot be flexed, extended or passively adducted.

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Because the study was conducted in many neurosurgery departments at People's Hospital 115, People's Hospital Gia Dinh and Children's Hospital II, we decided not to apply this scale but to use the scale in Table 2.3, which is similar to the Tardieu scale [95] (Table 4.3) which is mainly evaluated based on the speed of stretching during examination, not based on the angle at which the reflex appears because this angle is very difficult to evaluate.

Table 4.3: Diversity assessment table

No clonus
1	Has slight mobility
2	Polymorphism appears and disappears on its own.
3	Continuous motion without stopping
4	Continuous movement without stopping even when pulling the limb at slow speed

During the stretch reflex examination, an antagonistic reaction to the traction force will appear, the most difficult thing to know is to distinguish at this time between reflex muscle contraction and increased muscle stiffness, in other words, true stiffness. This is the key point in indicating the opening of the CTKCL because according to the theory of nerve opening has no effect on reflex muscle stiffness. It is very interesting to note that in our study, the expression of muscle stiffness is not constant because the passive dorsiflexion movement in the straight knee position is improved statistically significantly after surgery. The disappearance of stiffness after surgery helps improve joint mobility, over time helping to reduce stiffness. In the series of studies, we always performed the stretch reflex examination in the same position. The simple scale to evaluate the stretch reflex that we applied proved to be very convenient in clinical practice [8].

Table 4.4: Held-Tardieu scale

Characteristics of muscle contraction reaction (X)

0	No resistance on passive motion examination
1	Mild increase in resistance during passive range of motion examination without feel any clearness of the joint
2	Sudden resistance appears to clearly impede passive movement. joint movement at a certain angle, then the joint softens again
3	Multi-motion appears at a certain angle, lasts < 10 seconds and then disappears automatically. all the way while keeping the instep flexed
4	Multi-motion appears at a certain angle, lasting continuously >10 seconds while still flexing the instep
Angle of muscle contraction (Y)
	Measure the angle of the joint at the position where the muscle contraction reflex begins to appear.

4.1.3. Motor and sensory examination

Proprioceptive or motor paralysis combined with spasticity limits the outcome after neurotomy. For example, paralysis of the muscles that raise the foot can be masked by preoperative spasticity, and this often prevents patients from using a post-operative ankle brace. In our study, one patient had this problem. Postoperatively, the patient showed severe paralysis of the muscles that raise the foot, and although the factors causing spasticity were completely resolved after surgery, the patient still felt difficulty wearing shoes and did not see a clear effect after surgery. This shows that it is necessary to evaluate the quality and quantity of motor function before surgery. Applying the method of alcohol block injection into the nerve branches innervating the triceps muscle of the lower leg causes motor impairment

Temporary paralysis of these muscles in some cases allows the detection of latent paralysis of some muscle groups that are obscured by spasticity [20], [21], [91].

Evaluation of sensory disturbances is equally important. We performed a deep sensory examination of the thumb position and vibration sensation, and in cases of severe sensory damage, the indication for CTKCL surgery should be carefully considered [20].

Clinical assessment is necessary to set appropriate treatment goals for each patient.

4.1.4. Functional table

Walking studies in the same patients with shoes and bare feet have shown preoperative differences. These differences disappeared after CTKCL surgery. This means that wearing shoes helps the patient to partially control the factors that cause foot deformity. Therefore, it is necessary to carefully examine the patient's walking in both states to clearly determine whether the patient has a real functional impediment (barefoot) or an impediment that the patient can partially control (thanks to wearing shoes) in daily activities. This walking study also allows for an objective assessment of the effectiveness of antispasmodic treatment. Our study showed a statistically significant increase in normal walking speed after surgery compared to normal walking speed before surgery regardless of whether the patient wore shoes or went barefoot.

Spastic foot deformity causes effects on the knee (postflexion of the knee) and on the skin (lesions of the toes). Sixty-one percent of the patients in our series had postflexion of the knee and about 50% had skin lesions of the foot. Open treatment of spasticity with CTKCL resulted in a statistically significant improvement in these parameters.

Comfort in normal footwear is also a common factor in patients with foot contractures. In our study, improvement in comfort in footwear was achieved in 85%, with 8 patients (26%) wearing modified footwear all experiencing increased comfort postoperatively, and this was a very important factor in assessing patient satisfaction, increasing from 6.1 preoperatively to 7.9 postoperatively.

4.2. POST-SURGICAL RESULTS:

4.2.1. Treatment goals

Until now, there has been no radical treatment for the cause of spasticity, so open surgery for CTKCL in particular and combined orthopedic surgeries aim to correct local deformities on the paralyzed limbs to help patients walk more comfortably. This is the goal of treatment that surgeons need to emphasize and explain clearly to patients and their families to avoid misunderstandings that after surgery the paralyzed limb will return to normal, causing disappointment after treatment.

It is necessary to clearly determine the time of the stroke that causes spasticity until the time of CTKCL surgery, the time must be long enough for the reorganization and recovery of the nerve after the injury to reach the maximum, rarely less than 12 months. For nerve damage due to trauma, this progression is sometimes very favorable and achieves maximum nerve recovery sooner. For degenerative diseases such as multiple sclerosis, this time period varies greatly, but in general, it is necessary to wait for the patient to be in a stable stage of neurological sequelae. In some clinical cases, it is important to note that the indication for intervention to treat spasticity is relatively early if the progression of spasticity occurs rapidly, and the patient should not progress to the stage of difficult-to-recover orthopedic deformities [90]. In our sample, the earliest surgical intervention was 12 months, the longest was 96 months after the stroke, however, the collected data did not show any correlation between the time of surgery

before or after 5 years with the combination of orthopedic surgery on patients (P= 0.95).

Table 4.5: Factors related to combined orthopedic surgery

Element

Orthopedic surgery

Frequency (%)

Are not

Have

Time of surgery

< 5 years

> 5 years

1.06 (0.16 – 7.06)

P = 0.95

17 (68)

4 (66.7)

8 (32)

2 (33.3)

4.2.2. Open CTKCL surgery / orthopedic surgery

Orthopedic surgeries such as tendon lengthening or transfer also contribute to the treatment of ankle contracture deformity, however the limitation of these surgeries is that they do not address the increased tone of contractures, a factor that plays an important role in foot deformity, so the effectiveness of orthopedic interventions in reducing foot contractures is very limited [55].

In the treatment of spastic foot, the main difficulty lies in the fact that it is more difficult to convince the patient to accept a neurosurgery than an orthopedic surgery because an orthopedic intervention has fewer dangerous complications. Therefore, according to Sindou et al., when the patient clinically shows prominent hypertonia, the first appropriate indication is selective tibial neurectomy. Next, if the muscle tendon contracture does not decrease with limited mobility or stiffness, then we will use additional orthopedic surgeries [89]. Selective tibial neurectomy to treat severe spasticity first will help orthopedic surgeries become more effective later. This view is accepted by many authors and they recommend that orthopedic surgeries such as tendon opening, lengthening or tendon transfer should be performed after surgery.

CTKCL surgery and the recommended time is 6 to 12 months after the patient still has residual contracture deformities [89]. However, this view still has a major limitation that is the patient with an inherently poor general health condition must undergo multiple surgeries, in our opinion this is more difficult for both the surgeon and the patient to accept than the problem of convincing the patient to undergo neurosurgery or orthopedics. According to Lapierre et al., with clinical experience and with the development of stimulating electrodes during surgery, in recent years many authors have combined CTKCL surgery with orthopedics at the same time, still giving optimal results. For example, a patient with long-term foot spasticity with inversion deformity and associated damage to the lateral ankle ligament group, in this case we should perform selective tibial neurectomy to resolve the spasticity combined with peroneal brevis tendon transfer at the same time to resolve the inversion and allow stabilization of the patient's ankle, we should not wait for second-stage orthopedic surgery [20]. On the contrary, when the clinical examination shows the main manifestation is weakness of the muscles innervated by the peroneal nerve and the patient does not show signs of excessive spasticity of the muscles innervated by the tibial nerve, then orthopedic surgery with tendon transfer is more appropriate [20].

With that in mind, our study sample only had 2 cases that underwent long flexor digitorum tenotomy (which could be performed under local anesthesia) 3 months after selective nerve resection, and in 11 cases we performed 2 simultaneous nerve resections combined with flexor digitorum tenotomy, and in 6 cases we combined 3 surgeries at the same time: nerve resection, peroneus brevis tendon transfer, and long flexor digitorum tenotomy. The results in the two groups of patients who combined 2 to 3 interventions at the same time all showed improvement in late postoperative deformity parameters. We believe that:

- It is advisable to proactively cut the flexor digitorum longus tendon when clinical examination before surgery shows obvious crow's foot deformity and during surgery there is no clear dissection of the nerve branch innervating the flexor digitorum longus muscle. In our study, 18.2% (6 cases) had ½ of the fibers of the flexor digitorum longus nerve cut. In addition, according to the experience of many authors, selective cutting of the branch innervating this muscle has the risk of postoperative sensory disturbances in the sole of the foot [55], so instead of selectively cutting this nerve branch, we should replace it with cutting the flexor digitorum longus tendon.

- Nine cases combined with peroneus brevis tendon transfer at the same time because before surgery these patients showed severe inversion (with deformity and patient complaints).

Comparison of our combined orthopedic surgery with that of Lapierre

Table 4.6: Comparison of combined orthopedic surgeries

Type of surgery

F. Lapierre	We
Long flexor tendonectomy	33%	52% (19)
Achilles tendon extension	25%	2.8% (1)
Peroneus brevis tendon transfer	50%	25% (9)

It is easy to see in Table 4.6 that we rarely encountered cases (2.8%) requiring combined surgery to lengthen the Achilles tendon, compared to author Lapierre's rate of 25%. We have not been able to explain this difference, perhaps due to the limited research sample or the different progression of foot contractures after CNS injury between European and Asian patients.

Selective tibial neurectomy has been shown to be very effective in this problem because the equinus deformity and ankle hypermobility originate from the soleus muscle.

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