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A Case of Lipomyelomeningocele causing
Equinovarus is Reported
Guanghui Zhang
Jining Medical College: Jining Medical University
hui han
Zaozhuang MUNICIPAL HOSIPITAL https://orcid.org/0000-0002-0925-1389
Chengcai Hou ( houchengcai333@163.com )
Zaozhuang Municipal Hospital https://orcid.org/0000-0002-5996-0458
Case Report
Keywords: Lipomyelomeningocele, Equinovarus, high arched foot, osteotomy correction, Soft tissue
loosening, calcaneocubic joint fusion
DOI: https://doi.org/10.21203/rs.3.rs-112889/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
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Abstract
Background Lipomyelomeningocele ( LMM) is a congenital factor that causes clubfoot. This disease
often develops into adulthood and often has rigid deformities. This is the most dicult orthopedic and
functional reconstruction surgery.
Case presentation We reporta case of stiff clubfoot caused by LipomyelomeningoceleLMM. Through
osteotomy correction and Soft tissue loosening, clubfoot deformity was corrected and good results were
achieved.
ConclusionThe use of osteotomy correction technology combined with Soft tissue loosening to treat
adult stiff clubfoot can correct the deformity and restore the shape of the foot and ankle. The effect is
denite and it is worthy of popularization and application.
Background
Equinovarus is one of the most common malformations in the motor system [1], and adult rigid
equinovarus is the most dicult category of surgical orthotics and functional reconstruction [2].
Equinovarus occurrence reason is caused by innate or acquired a variety of factors, congenital lesions in
fetal period of primary development is mainly due to the limb, evolved into the Equinovarus deformity, the
day after tomorrow is mainly due to the nervus peroneus communis injury sequela, foot ankle trauma
sequela, stroke and cerebral hemorrhage sequelae, lesions caused by polio.This case is a congenital
Equinovarus deformity due to lipomyelomeningocele ,which is reported as follows.
Case Presentation
A 20-year-old male patient was diagnosed with congenital neural tube malformation-
Lipomyelomeningocele (LMM) 10years ago when he was found to have bipedal varus and decreased
muscle strength(Fig.1). He underwent spinal cord surgery at that time. Six years after the operation, the
left foot varus was signicantly worsened, the left ankle exion and extension was limited, the ankle joint
plantar exion was 70°, and the average range of motion was 10°(plantar exion 10°-back extension 0°);
tibialis anterior muscle and bulamuscle strength level 0, tibialis posterior muscle strength level 2, Raise
the medial longitudinal arch, plantar ulceration, sphincter bladder function paralysis, and catheterization
bag for 5 yearsFig.2.
Use general anesthesia.Patient in supine position.First, a small longitudinal incision was made on the
medial side of the Achilles tendon, and a sharp knife was used to cut the tendon vertically. The Achilles
tendon was released in the shape of "Z". After proper pulling, the arteries and veins and nerves of the
posterior tibial were separated for protection, and the soft tissue and the posterior tibial joint capsule were
released.The insertion point of the posterior tibial tendon was cut through the medial foot incision, and
the tendon was extracted before the ankle to prepare for the external displacement of the posterior tibial
tendon.The plantar medial incision was made to expose the plantar aponeurosis, and "Z" was released to
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suture the skin.The dorsal incision of the rst metatarsal was made, the skin was cut subcutaneously, the
rst metatarsal base was exposed, and the rst metatarsal base was cuneate osteotomy, xed with 6-
hole "T" type plate and screw, and the internal arch of the foot was reduced.Make an incision at the
calcaneocuboid joint on the dorsolateral side of the foot, cut the skin subcutaneously, expose the
calcaneocuboid joint, remove the cartilage surface, expose the fresh bone surface, "X" x with steel plate
and screw to correct the foot adduction;The lateral incision of the calcaneus was made, the skin was cut
subcutaneously, the external side of the calcaneus was exposed, the bone knife was osteotomized and
externally removed, and xed with a 4.5mm hollow screw to correct the calcaneal varus.Intraoperative
uoroscopy showed that the position of steel plate, screw and hollow screw was good and the length was
appropriate.The incision was made at the lateral calcaneus, the skin was cut subcutaneously, the
peroneus brevis was separated, the tendons of the anterior ankle and the posterior tibial tendon were
moved and sutured to strengthen the eversion force, the muscle balance was observed during the
operation, the varus of the foot, high arch and plantarsal exion were corrected, the wound was rinsed,
the layer by layer was sutured, and the back extension was xed with plaster.The operation was
successful, the anesthesia was satisfactory, and the patient was returned to the ward after the
operation(Fig.3).
On the 7th day after the surgery, after the inammatory swelling subsided, patient is pian to perform
active and passive activity.After the suture removal through the incision on the 14th day after the surgery,
the knee joint exion and extension on the bedside were performed to train muscle strength.On the 35th
day after the operation, patient is required to walk with two crutches or Help line devicewithout weight. 60
days after surgery, partial weight-bearing walking exercise was started.After 90 days of surgery, walk with
full weight and resume daily life.
Discussion
Equinovarus is mainly divided into two types: congenital and acquired;Congenital Equinovarus caused by
bad growth is mainly due to the Achilles tendon and shortening of the triceps surae, acquired the
Equinovarus mainly because the ankle back extensor group, the outer most or complete loss of muscle
strength, Triceps of the lower leg and most of the varus muscles strength is normal, lead to the Achilles
tendon contracture, strephenopodia continuously, which in turn leads to the ankle, talonavicular joint,
subtalar joints, with roll displacement of joints, foot ankle joints, ligaments and other soft tissue
contracture of the joint capsule around, adhesion, secondary deformity.It is mainly caused by the
following reasons, such as congenital musculoskeletal malformation, infection, osteomyelitis [3],
congenital equinovarus failure in treatment, traumatic fracture and other reasons leading to the sequela
of crus osteofascial compartment syndrome [4].Extensive scar on the ankle caused by burns [5], nervus
peroneus communis injury [6], lumbosacral spina bida and poliomyelitis sequela [7].Clinical
manifestations are mainly: the talus pancake, the neck of talus shorter distortion, cartilage degeneration
and the metapedes plantar exion, varus and intorsion [8], navicular bone deformation dislocation after
full high arch, supination deformity, propodeon adduction[9], the medial plantar and back skin,
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subcutaneous tissue, the fascia, tendon, articular capsule, blood vessels, nerves, such as soft tissue
contracture, ankle lateral corresponding soft tissue hypoplasia, relaxation or destroy [10].
At present, the understanding of congenital equinovarus disease is relatively mature, and the therapeutic
effect is remarkable.The case was a equinovarus caused by congenital lipomyelomeningocele.
Lipomyelomeningocele (LMM) is neural tube defects (NTD), the disease is due at 18 ~ 28 d, premature
epithelial ectoderm from neural ectoderm, mesenchymal cells into developing neural tube, the formation
of fat affect the spinal cord, the fat through the catheter into the subcutaneous tissue, the disease often
occurs in women, more than 30% of patients can be characterized by abnormal skin,Such as mass, fur
sinus, vascular malformation, etc., all suggest that the patient may have abnormal neural tube
development such as LMM.It can also be manifested as nerve damage, such as tetheredcord syndrome
(TCS), such as defecation and urination dysfunction, lower limb motor sensation disorder, sexual
dysfunction, etc. [11].Without timely intervention after the diagnosis of LMM, 90% of patients will develop
irreversible progressive nerve damage [12].In many studies, through the inference of the natural history of
this disease, it was believed that: most patients' symptoms gradually aggravated with time, including
lower limb movement disorder, muscle weakness, equinovarus and high arch, and the symptoms
gradually aggravated, and at this time, surgery was the only effective way to treat the symptoms at
present;However, postoperative dysfunction of urine and feces, especially bladder function, cannot be
improved [13].Long-term follow-up observation is needed after LMM operation to monitor the occurrence
of LMM.LMM can occur months to years after surgery, with an incidence of 5% ~ 50%[14], manifested by
gradual aggravation of original symptoms or new symptoms, such as pain, incontinence, sexual
dysfunction, and weakness of both legs.After the postoperative stability of the patient's symptoms, new
neurological symptoms or aggravation of the original symptoms should be evaluated for the presence of
LMM.MRI examination is an important evidence to determine the presence or absence of LMM. Based on
the presence or absence of lower spinal cord, syringomyelia, etc., the patient must be combined with
clinical symptoms to make a correct judgment.
Equinovarus on the basis of the extent of the ankle joint stiffness is divided into soft and rigid, and the
deformation of different age stages present different properties, Equinovarus deformity can press "qin
SiHe equinovarus parting" description: degrees, with the outside of planta weight; degrees, use the front
edge of the fourth and fth metatarsal of weight; degrees, sucient varus, internal rotation, toes pointing
to the rear foot heart up, walking with foot dorsal weight.The case is rigid type degrees of deformity,
needing delay correction, the correction to correct the strephenopodia inward turning talipes cavus, to
correct the plantar exion.
During the treatment, this case adhered to the principle of moderate weight-bearing walking exercise [15]
and "two lines and three balances along the way"."All the way", that is, walking, walking in the treatment,
walking in the treatment;The "two lines" are the "negative gravity line of the lower extremity" and the "joint
line" of the hip, knee and ankle. The line and correction of other local malformations must nally meet the
requirements of the recovery of the two lines of the lower extremity."Three-balance" is the "static balance
and dynamic balance, the balance between the rigidity of xed apparatus and the strength of bone
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healing, the balance between body and mind" in the process of limb reconstruction.By surgical treatment,
malformations can be corrected, the shape of the ankle can be restored, and the affected foot plantar and
painless weight-bearing walking can be made, so that the patients have high satisfaction [16].
Conclusion
Osteotomy correction technology combined with soft tissue loosening is an effective method for the
treatment of adult stiffness clubfoot. This method can correct the foot shape to the plantar foot and walk
with weight. The effect is positive. At present, there are no large-scale clinical studies, and only few
reports, but the effectiveness of correction methods still needs to be further studied.
Abbreviations
LMM: Lipomyelomeningocele
Declarations
Ethics approval and consent to participate
All patients or their relatives provided informed consent, and the study was
approved by the ethical committee of Zaozhuang Municipal Hospital.
Consent for publication
All authors consent to publication in Military Medical Research.
Availability of data and materials
Not applicable
Competing interests
The authors declare that they have no competing interests
Funding
NO
Authors’ contributions
Chengcai Hou and Hui Han performed the patient surgeries. Guanghui Zhang participated in the design
of the study. Guanghui Zhang carried out the statistical analysis. Chengcai Hou collected the data. They
participated in the design and coordination and helped to draft the manuscript. All authors read and
approved the nal manuscript.
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Acknowledgements
The authors are grateful to the subjects who participated in the study and to the physicians’ assistance in
this study.
Author details
1Department of Hand , foot and ankle surgery, Zaozhuang Municipal Hospital, Zaozhuang 277000,
Shandong, China.
2Department of Hand and foot surgery, Aliated Hospital of Jining Medical university, Jining 272011,
China.
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Figures
Figure 1
Ten years ago, lumbar MRI showed :(A and B) fatty myelomeningocele pressing on the spinal cord.
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Figure 2
Lumbar MRI reexamination after spinal cord related surgery showed :(A and B) left fat mass was found in
the spinal cord;(C and D) X ray of both feet showed: left and right heel pronation, left food plantar exion;
(E) Heel pronation in the left heel loading long axis position;Weight bearing position of left ankle showed
plantar exion of ankle, plantar exion of rst metatarsal;(F) Persistent plantar ulcers
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Figure 3
Intraoperative ndings :(A) Achilles tendon, posterior tibial tendon insertion, plantar aponeurosis incision;
(B) Release of the Achilles tendon "Z", release of the plantar aponeurosis, wedge osteotomy of the base of
the rst metatarsal, and reduction of the medial longitudinal arch;(C) calcaneocuboid joint, peroneal
tendons and anterior ankle incisions;(D) Fusion of calcaneocuboid joint and calcaneal valgus osteotomy
Figure 4
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Postoperative results showed that: (A) the left foot Equinovarus deformity was corrected with A beautiful
appearance, and the right foot deformity was not operated on;(B) Postoperative X-ray examination
Figure 5
(A) Three months after operation, both feet orthotopic lm;(B) the posterior position of both feet was
taken, and Left foot deformity was corrected;(C) Plantar ulcer healing 3 months after surgery;
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