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DMD: Contractures of the Lower Extremities

- Discussion:
    - contractures and progressive weakness of lower extremities render walking increasingly difficult for patients who have DMD;
    - average patient is unable to walk effectively by the time that he is ten years old, in the absence of treatment;
    - age at which walking ceases, however, is relatively variable, ranging from eight to fourteen years;
    - fixed flexion deformity develops in the knees;
    - this is best treated by prevention, using a KAFO, which is locked into exension for at least one hour per day;
    - flexion-abduction deformity develops in the hips, leading to hyperlordotic, broad-based stance;

- Hip:
    - correction of a flexion deformity of the hip involves release of tight anterior muscles, including the rectus femoris, and fascia;
    - release and lateral transfer of the iliopsoas has been used, but this procedure was abandoned after it was found to provide no benefit;
    - abduction contractures:
          - some think that abduction contractures are beneficial, as they provide a more stable, broad-based gait;
          - abduction contractures can be partially or fully corrected by extensive release of the tensor fasciae latae proximally, w/ use of release 
                 distal lateral aspect of thigh & by complete resection of entire iliotibial band, from iliac crest to knee;

- Knee:
    - posterior releases about the knee, designed to allow the strength of quads to permit full extension of knee, have included tenotomy of 

- Foot:
    - equinus contractures:
    - bracing:
          - AFOs that have a knee-lock can allow patient to walk, but there has been limited acceptance of this device by pts, because of their 
                 fear of falling with both knees locked, which is potentially far more traumatic than simply collapsing due to weak quadriceps

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