A multimodal approach to the correction of equinovarus foot deformity in patients following focal lesions of the brain and spinal cord: integration of local botulinum therapy and surgical interventions on the capsuloligamentous and musculotendinous apparatus

Equinovarus foot deformity is one of the most common orthopaedic sequelae/patterns in patients with spastic paresis of the lower limb following focal lesions of the brain and spinal cord. The effectiveness of comprehensive rehabilitation for patients with spastic paresis of the lower limb and equinovarus foot, incorporating local administration of botulinum toxin type A (BTA) and surgical intervention on the capsuloligamentous and musculotendinous apparatus, has been little studied.

Objective: to develop and evaluate the effectiveness of rehabilitation programmes for patients with spastic paresis of the lower limb following focal lesions of the brain and spinal cord (ischaemic and haemorrhagic strokes and trauma) and equinovarus foot deformity, incorporating intramuscular administration of BTA and minimally invasive surgical correction of the capsuloligamentous and musculotendinous apparatus.

Material and methods. This prospective study included four patients (one man and three women aged between 20 and 63) with spastic paresis of the lower limb resulting from ischaemic and haemorrhagic stroke (two patients) and spinal cord injury (two patients), and with equinovarus deformity of the foot.

Results. A combined rehabilitation strategy for patients, incorporating intramuscular BTA injections and minimally invasive surgical correction of the capsuloligamentous and musculotendinous apparatus, resulted in a statistically significant increase in dorsiflexion of the foot and walking speed, as well as a reduction in foot pronation and toe flexion, in all patients. In all cases, it was possible to reduce muscle tone and spasticity, improve the foot’s weight-bearing capacity, and enhance the functional outcomes of rehabilitation. Two patients were able to completely discontinue the use of assistive devices and restore a virtually normal gait pattern, which made walking safer, reduced the risk of falls, and improved their quality of life.

Conclusion. The use of minimally invasive surgical correction of the capsuloligamentous and musculotendinous apparatus in patients with spastic paresis of the lower limb following focal lesions of the brain and spinal cord, resulting in equinovarus deformity of the foot, and where previous courses of rehabilitation involving botulinum toxin therapy have proved insufficiently effective, represents an effective and safe innovative strategy. It improves the functional outcomes of rehabilitation.

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