Clinical Features
- Spasticity with equinovarus foot and flexed elbow, wrist and fingers
- Hemiplegic shoulder pain from subluxation, adhesive capsulitis and cuff disease
- Falls and hip fractures on the weak side, worsened by disuse osteoporosis
- Stroke is a leading cause of adult disability in Australia
- Contractures of the hip adductors and knee flexors in non-walkers
- Heterotopic ossification is uncommon after stroke compared with brain injury
- Complex regional pain syndrome of the hemiplegic arm (shoulder hand syndrome)
Management
- Physiotherapy, splinting and serial casting
- Botulinum toxin for focal spasticity
- Surgery once neurological recovery plateaus, about 6 months or more after stroke
- Achilles lengthening and split anterior tibial tendon transfer (SPLATT) for equinovarus
- Release of finger and wrist flexors for hygiene in a non-functional hand
- Hip fracture surgery should account for weakness and rehabilitation potential
- Shoulder subluxation is managed with positioning and slings, avoiding overhead pulley exercises
- Arthroplasty on the hemiplegic side has higher dislocation risk, with dual mobility or constrained options considered
- Assessment by a rehabilitation physician guides goals
Perioperative Considerations
- Timing of surgery after a recent stroke
- Anticoagulation for atrial fibrillation
- Elective surgery is usually deferred for at least 3 to 6 months after stroke
- Dysphagia raises aspiration risk
- Check skin over pressure areas and the insensate limb
- Plan rehabilitation and discharge destination before surgery
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.