Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery

The effects of muscle-tendon surgery on dynamic electromyographic patterns and muscle tone in children with cerebral palsy

During multilevel surgery, muscle-tendon lengthening (MTL) is commonly carried out in children with cerebral palsy. However, it is unclear if MTL also modifies increased muscle tone and if pathologic activation patterns are changed as an indirect effect of the biomechanical changes. Since investigations addressing this issue are limited, this study aimed at evaluating the effects of MTL on muscle tone and activation pattern. Forty-two children with spastic diplegia who were treated by MTL underwent standardized muscle tone testing (modified Ashworth and Tardieu test), dynamic EMG and three-dimensional gait analysis before, one and three years after MTL. For the evaluation of muscle activation patterns the norm-distance of dynamic EMG data was analyzed. Range of motion and joint alignment in clinical examination were found to be significantly improved one year after MTL. However, deterioration of these parameters was noted after three years. Muscle tone was significantly reduced one year postoperatively but showed an increase after three years. Joint kinematics were found significantly closer to reference data of age matched controls initially after surgery, but deteriorated until three years postoperatively. However, the EMG patterns of the muscles which were surgically addressed were found to be unchanged in either follow-up. These findings suggest that despite the influence of MTS on biomechanics and physiology (muscle tone reduction and improvements of joint mobility and gait pattern) MTS does not change abnormal patterns of muscle activation. Recurrence of increased muscle tone and deterioration of kinematic parameters three years after surgery may be attributed to these persistent pathologic activation patterns.

Multilevel surgery for equinus gait in children with spastic diplegic cerebral palsy: medium-term follow-up with gait analysis

BACKGROUND

In children with spastic diplegia, surgery for ankle equinus contracture is associated with a high prevalence of both overcorrection, which may result in a calcaneal deformity and crouch gait, and recurrent equinus contracture, which may require revision surgery. We sought to determine if conservative surgery for equinus gait, in the context of multilevel surgery, could result in the avoidance of overcorrection and crouch gait as well as an acceptable rate of recurrent equinus contracture at the time of medium-term follow-up.

METHODS

This was a retrospective, consecutive cohort study of children with spastic diplegia who had had surgery for equinus gait between 1996 and 2006. All children had distal gastrocnemius recession or differential gastrocnemius-soleus complex lengthening, on one or both sides, as part of single-event multilevel surgery. The primary outcome measures were the Gait Variable Scores (GVS) and Gait Profile Score (GPS) at two time points after surgery.

RESULTS

Forty children with spastic diplegia, Gross Motor Function Classification System (GMFCS) level II or III, were included in this study. There were twenty-five boys and fifteen girls. The mean age was ten years at the time of surgery and seventeen years at the time of final follow-up. The mean postoperative follow-up period was 7.5 years. The mean ankle GVS improved from 18.5° before surgery to 8.7° at the time of short-term follow-up (p < 0.005) and 7.8° at the time of medium-term follow-up. The equinus gait was successfully corrected in the majority of children, with a low rate of overcorrection (2.5%) and a high rate of recurrent equinus (35%), as determined by sagittal ankle kinematics. Mild recurrent equinus was usually well tolerated and conferred some advantages, including contributing to strong coupling at the knee and independence from using an ankle-foot orthosis.

CONCLUSIONS

Surgical treatment for equinus gait in children with spastic diplegia was successful, at a mean of seven years, in the majority of cases when combined with multilevel surgery, orthoses, and rehabilitation. No patient developed crouch gait, and the rate of revision surgery for recurrent equinus was 12.5%.

Gait patterns in twins with cerebral palsy: similarities and development over time after multilevel surgery

To examine gait patterns and gait quality, 7 twins with cerebral palsy were measured preoperatively and after surgical intervention. The aim was to study differences and/or similarities in gait between twins, the influence of personal characteristics and birth conditions, and to describe the development of gait over time after single event multilevel surgery. A standardized clinical exam and a three-dimensional gait analysis were performed. Gait patterns were classified according to Sutherland and Davids, and the Gillette Gait Index was calculated as a global measure of the gait impairment. Next to subject characteristics at time of first measurement, and at time of birth, birth conditions were collected. Gait patterns were determined as crouch gait in 13 legs, as stiff gait in 6 legs and as jump gait in 8 legs. One leg showed a normal gait pattern. The knee flexion-extension angle correlated most constant with the knee flexion-extension angle of the contralateral leg (range 0.91-0.99). Correlations with the legs of the sibling showed variable correlations (range 0.44-0.99); with all other legs medium to high correlations of 0.73-0.91 were found. The Gillette Gait Index was found to initially decrease after surgical intervention. Similar correlations were found between twins or between legs for the gait pattern expressed by the knee flexion-extension angle, and the Gillette Gait Index improved after surgery. It seems that gait quality in twins with cerebral palsy is characterized predominantly by the traumatic disorder: genetic dispositions and personal characteristics only play a negligible role.

Are results after single-event multilevel surgery in cerebral palsy durable?

BACKGROUND

Gait and function may deteriorate with time in patients with spastic diplegia. Single-event multilevel surgery often is performed to either improve gait or prevent deterioration. However it is unclear whether the presumed gait improvements are durable.

QUESTIONS/PURPOSES

We therefore determined whether (1) single-event multilevel surgery improves gait in patients with spastic diplegia and (2) whether the improved function is durable.

METHODS

We retrospectively reviewed the data of 14 patients with spastic diplegia. At the time of surgery, one patient had gross motor Level I function, 10 patients had Level II function, and three patients had Level III function. There were four females and 10 males with a mean age of 13 years (range, 7-18 years). The mean number of orthopaedic procedures per single-event multilevel surgery session was 7.4 ± 2.8 (median, 6.5; range, 4-15). We used instrumented gait analysis to determine joint ROM, movement analysis profiles, and the gait profile score. The minimum followup was 1 year (mean, 2 years; range, 1-3 years).

RESULTS

At last followup, movement analysis profiles for knee flexion, for ankle dorsiflexion, and for foot progression improved as did the gait profile score. Additional surgery after the index procedure was performed in nine of the 14 patients because of relapse of the original or new gait problems. Major surgical adverse events occurred in one of the 14 patients.

CONCLUSIONS

Severe gait dysfunction in patients with spastic diplegia can be improved short-term in one operative session by single-event multilevel surgery, but to preserve the early improvements many patients require additional surgery. It is unknown whether the improvements will last for decades.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Single Event Multilevel Surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study

BACKGROUND

Single Event Multilevel Surgery (SEMLS) is considered the standard of care to improve gait and function in children with bilateral spastic cerebral palsy (BSCP). We have demonstrated in a randomized controlled trial (RCT) of SEMLS, that gait was improved at 12 months after surgery and gross motor function at 24 months after surgery. The question addressed in this study, was to determine if improvements in gait and function, would be maintained at 5 year follow-up.

METHODS

Nineteen children with BSCP, GMFCS levels II (14 children) and III (5 children), mean age 9.7 years (range 7.7-12.2 years) participated in a prospective cohort study following participation in a RCT, with follow-up to 5 years. Outcome measures were Gait Profile Score (GPS), Gillette Gait Index (GGI), Gait Deviation Index (GDI), Gross Motor Function Measure (GMFM66) and Functional Mobility Scale (FMS).

RESULTS

Eighteen children have completed follow-up, with interval analysis at 1, 2 and 5 years post SEMLS. One child was excluded because of neurological deterioration and his diagnosis was revised to Hereditary Spastic Paraparesis (HSP). GPS improved by 5.29° and GMFM66 by 3.3% at 5 years post SEMLS. Differences between outcome measures at 1 versus 5 years and 2 versus 5 years (except GMFM66) were not significant, indicating that improvements in gait and gross motor function were stable over time.

CONCLUSIONS

SEMLS results in clinically and statistically significant improvements in gait and function, in children with BSCP, which were maintained at 5 years after surgery.

Stability of the Gross Motor Function Classification System after single-event multilevel surgery in children with cerebral palsy

AIM

There are conflicting reports about the stability of the Gross Motor Function Classification System (GMFCS) in children with cerebral palsy (CP) after orthopaedic surgery. We studied the stability of the GMFCS in children with bilateral spastic CP after single-event multilevel surgery, using the Gait Profile Score (GPS) as the primary outcome measure.

METHOD

This was a retrospective cohort study of 107 children (46 females, 61 males) with bilateral spastic CP, classified as GMFCS level II or III, who underwent surgery at a single tertiary institution between 1997 and 2008. The mean age at surgery was 10 years 7 months (SD 2 y 8 mo). The primary outcome measure was the GPS. Changes in GMFCS level were studied at multiple time points before and after intervention.

RESULTS

Gait dysfunction was partially corrected, with a mean improvement of 28% in the GPS. The GMFCS remained stable and unchanged in 95% of children and improved by one level in 5% of children. The improvement in GPS was three times the minimal clinically important difference. The mean age at final postoperative GPS assessment was 11 years 10 months (SD 2 y 10 mo) and at final GMFCS assessment was 15 years 7 months (SD 3 y 9 mo).

INTERPRETATION

Stability of the GMFCS was confirmed in the majority of children with bilateral spastic CP after single-event multilevel surgery, despite statistically and clinically significant improvements in gait dysfunction and functional mobility. This information is important in realistic goal-setting and in counselling families.

Orthopedic surgery and mobility goals for children with cerebral palsy GMFCS level IV: what are we setting out to achieve?

BACKGROUND

Multilevel orthopedic surgery is considered to be the gold standard treatment for ambulatory children with cerebral palsy (CP), classified at levels I, II, or III according to the Gross Motor Function Classification System (GMFCS). Hip enlocation and stability are the main goals of orthopedic intervention in the GMFCS level IV subgroup and are well researched; however, there is no evidence to date to support or challenge the effectiveness of orthopedic treatment to preserve functional mobility in this patient group. The aim of this study was to evaluate the results of orthopedic surgery to maintain or restore standing transfers and supported walking in children with CP at GMFCS level IV.

METHODS

Twenty-two children with CP GMFCS level IV who underwent orthopedic surgery to improve mobility between the years 2004 and 2008 were included in this study. A retrospective chart review was performed and a satisfaction questionnaire sent to all patients. The primary outcome measure was the attainment and maintenance of mobility goals 2 years post-surgery. The secondary outcome measures were family/patient satisfaction, Functional Mobility Scale (FMS), and complications.

RESULTS

The two goals identified by the patients and carers were standing transfers and supported walking. At the 2-year post-surgery assessment, 14 children (63.6 %) did not reach their pre-determined goals. In the questionnaire, 21.4 % of the families reported that surgery was not beneficial. The FMS score remained unchanged in 95.4 % of the patients. Fourteen patients (63.6 %) had at least one complication that prolonged their post-operative rehabilitation (e.g., neuropraxia).

CONCLUSION

This study suggests that orthopedic surgery in children with CP at GMFCS level IV is unlikely to maintain or restore mobility. Furthermore, it carries a significant risk of complications.

LEVEL OF EVIDENCE

Case series, Level IV.

Potential of lower-limb muscles to accelerate the body during cerebral palsy gait

Two of the most common gait patterns in children with spastic diplegic cerebral palsy (CP) are termed 'crouch gait' and 'jump gait'. While outcomes of surgical interventions designed to improve functional mobility are generally positive, many children displaying these gait patterns show minimal or no improvement post-surgery. A poor response to treatment may be partially attributable to incorrect interpretations of muscle function. Computational techniques that assess muscle function may help address this issue, but before studying specific surgeries, the gait patterns themselves must be better understood. The aim of this study was to identify differences in lower-limb muscle function when comparing crouch, jump and able-bodied gait patterns by quantifying the potential of lower-limb muscles to accelerate the body's center of mass. A muscle's potential acceleration was defined as the acceleration induced by a unit of muscle force. Dynamic simulations of walking using musculoskeletal models were developed for eight children with crouch gait, ten with jump gait, and ten controls. There were significant differences (p<0.05) in muscle potential accelerations between crouch and able-bodied gait patterns, and between jump and able-bodied gait patterns, for most of the major muscles of the hip, knee, and ankle. One important outcome was the identification of the significantly reduced potential of gluteus medius to extend the hip in both crouch gait and jump gait. Potential acceleration analyses appear to be suitable for evaluating differences between common gait patterns and may also be applied to study the effects of surgical treatments. The results of such studies may lead to improved treatment outcomes for individuals with impaired mobility.

Kinematic determinants of anterior knee pain in cerebral palsy: a case-control study

OBJECTIVE

To quantify the role patellofemoral and tibiofemoral kinematics may play in development of anterior knee pain (AKP) in individuals with cerebral palsy (CP).

DESIGN

Case-control.

SETTING

Clinical research center.

PARTICIPANTS

Knees from individuals with diagnosed CP (n=20) and control knees (n=40) were evaluated. Controls were matched for sex and age based on the group average. Matching by height and weight was a secondary priority. Subjects in the control cohort were asymptomatic with no history of lower leg abnormalities, surgery, or major injury. Only individuals who were physically capable of sustaining slow, cyclic knee flexion-extension for 2.5 minutes and had no contraindications to magnetic resonance imaging were enrolled. Both groups were samples of convenience.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Three-dimensional patellofemoral and tibiofemoral joint kinematics, acquired during active leg extension, under volitional control.

RESULTS

Participants with CP and AKP (n=8) demonstrated significantly greater patellofemoral extension, valgus rotation, and superior and posterior displacement relative to controls and to the subgroup of participants with CP and no AKP (n=12). Patellofemoral extension discriminated AKP in individuals with CP with 100% accuracy.

CONCLUSIONS

In quantifying the 3-dimensional, in vivo knee joint kinematics during a volitional extension task, kinematic markers that discriminate AKP in individuals with CP were identified. This provides an ability to predict which individuals with CP are most likely to develop AKP and could enable aggressive conservative treatment, aimed at reducing patella alta and excessive patellofemoral extension, to be prescribed before considering surgical options. The current findings will likely lead to improved clinical diagnostics and interventions for individuals with CP, with the ultimate goal of helping maintain, if not improve, functional mobility throughout the lifespan.

Single-event multilevel surgery for children with cerebral palsy: a systematic review

AIM

To conduct a systematic review of single-event multilevel surgery (SEMLS) for children with cerebral palsy, with the aim of evaluating the quality of the evidence and developing recommendations for future research.

METHOD

The systematic review was conducted using standard search and extraction methods in Medline, EMBASE, CINAHL, and Cochrane electronic databases. For the purposes of this review, SEMLS was defined as two or more soft-tissue or bony surgical procedures at two or more anatomical levels during one operative procedure, requiring only one hospital admission and one period of rehabilitation. Studies were included if: (1) the primary focus was to examine the effect of SEMLS in children with cerebral palsy; (2) the results focused on multiple anatomic levels and reported findings of one or more World Health Organization International Classification of Functioning, Disability and Health (ICF) domains. Studies that focused on a single intervention or level, or on the utility of a specific outcome measure were excluded. Study quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) and the Oxford Centre for Evidence-Based Medicine scale. The review also examined the reporting of surgery, adverse events, and rehabilitation.

RESULTS

Thirty-one studies fulfilled the criteria for inclusion, over the period 1985 to October 2010. The MINORS score for these studies varied from 4 to 19, with marked variation in the quality of reporting. Study quality has improved over recent years. Valid measures of gait and function have been introduced and several of the most recent studies have addressed multiple dimensions of the ICF. A statistical synthesis of the outcome data was not conducted, although a trend towards favourable outcomes in gait was evident. Caution is advised with interpretation owing to the variable study quality. Uncontrolled studies may have resulted in an overestimation of treatment efficacy.

INTERPRETATION

The design and reporting of studies of SEMLS are improving with the development of multidisciplinary teamwork and frameworks such as the ICF. However, the evidence base is limited by the lack of randomized clinical trials, especially when compared with other surgical interventions such as selective dorsal rhizotomy.

Development of knee function after hamstring lengthening as a part of multilevel surgery in children with spastic diplegia: a long-term outcome study

BACKGROUND

Hamstring lengthening commonly is performed for the treatment of flexed knee gait in patients with spastic diplegic cerebral palsy. Satisfactory short-term results after hamstring lengthening have been demonstrated in various studies. However, evidence for the effectiveness of hamstring lengthening to correct flexed knee gait is scant because of small and inhomogeneous case series, different surgical techniques, and short follow-up.

METHODS

The long-term results for thirty-nine patients with spastic diplegia and flexed knee gait who were managed with intramuscular hamstring lengthening as a part of multilevel surgery are presented. Standardized three-dimensional gait analyses and clinical examinations were performed for all patients preoperatively and at one, three, and six to twelve years postoperatively.

RESULTS

Significant improvements in kinematic parameters and the popliteal angle were noted at short-term follow-up (p < 0.01), supporting the results of previous studies. Long-term results showed significant deterioration of minimum knee flexion in stance and the popliteal angle (p < 0.01), whereas the improvements in the Gross Motor Function Classification System and Gillette Gait Index were maintained. This recurrence of flexed knee gait is partial and measurable. Increased pelvic tilt was found in 49% of the limbs postoperatively, which may represent one factor leading to recurrence of flexed knee gait. Genu recurvatum was seen in eighteen patients (twenty-seven limbs; 35%) one year postoperatively, especially in the patients with a jump knee gait pattern preoperatively. At long-term follow-up, genu recurvatum resolved in many limbs, but 12% of the limbs showed residual genu recurvatum, indicating that overcorrection represents a problem following hamstring lengthening.

CONCLUSIONS

The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning.

Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy

BACKGROUND

Severe crouch gait in adolescent cerebral palsy is a difficult problem to manage. The patients develop loading of patellofemoral joint, leading to pain, gait deviation, excessive energy expenditure and progressive loss of function. Patella alta and avulsion of patella are the other complications. Different treatment options have been described in the literature to deal with this difficult problem. We evaluated outcome of supracondylar femoral extension osteotomy (SCFEO) and patellar tendon advancement (PTA) in the treatment of crouch gait in patients with cerebral palsy.

MATERIALS AND METHODS

Fourteen adolescents with crouch gait were operated by SCFEO and PTA. All subjects were evaluated pre and postoperatively. Clinical, radiographic, observational gait analysis and functional measures were included to assess the changes in knee function.

RESULTS

Cases were followed up to 3 years. The patients walked with increased knee extension and improvement in quadriceps muscle strength. Knee pain was decreased and improvements in functional mobility and radiologic improvement were found.

CONCLUSION

SCFEO and PTA for adolescent crouch gait is effective in improving knee extensor strength, reducing knee pain and improving function.

Characteristics associated with improved knee extension after strength training for individuals with cerebral palsy and crouch gait

Muscle weakness may contribute to crouch gait in individuals with cerebral palsy, and some individuals participate in strength training programs to improve crouch gait. Unfortunately, improvements in muscle strength and gait are inconsistent after completing strength training programs. The purpose of this study was to examine changes in knee extensor strength and knee extension angle during walking after strength training in individuals with cerebral palsy who walk in crouch gait and to determine subject characteristics associated with these changes. A literature review was performed of studies published since January 2000 that included strength training, three-dimensional motion analysis, and knee extensor strength measurements for individuals with cerebral palsy. Three studies met these criteria and individual subject data was obtained from the authors for thirty crouch gait subjects. Univariate regression analyses were performed to determine which of ten physical examination and motor performance variables were associated with changes in strength and knee extension during gait. Change in knee extensor strength ranged from a 25% decrease to a 215% increase, and change in minimum knee flexion angle during gait ranged from an improvement of 9° more knee extension to 15° more knee flexion. Individuals without hamstring spasticity had greater improvement in knee extension after strength training. Hamstring spasticity was associated with an undesired increase in knee flexion during walking. Subject-specific factors such as hamstring spasticity may be useful for predicting which subjects will benefit from strength training to improve crouch gait.

Severe crouch gait in spastic diplegia can be prevented

We studied the prevalence of severe crouch gait over a 15-year period in a defined population of children with spastic diplegia and Gross Motor Function Classification System levels II and III, to determine if there had been a decrease following changes to the management of equinus gait. These changes were replacing observational with three-dimensional gait analysis, replacing single level with multilevel surgery, and replacing gastrocsoleus lengthening with gastrocnemius recession. Of 464 children and adolescents with spastic diplegia who underwent three-dimensional gait analysis, 27 had severe crouch gait. Seventeen of these had been managed by isolated lengthening of the gastrocsoleus. Following changes in the management of equinus gait, the prevalence of severe crouch gait decreased from 25% and stabilised at a significantly lower rate, fluctuating between 0% and 4% annually (p < 0.001).

We conclude that severe crouch gait in this population was precipitated by isolated lengthening of the gastrocsoleus. These findings may be relevant to other surgical populations, as severe crouch gait may be a useful way to monitor the quality of the surgical management of abnormal gait in children with cerebral palsy and spastic diplegia.

The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait

AIM

Information on the timing and long-term outcome of single-event multilevel surgery in children with bilateral spastic cerebral palsy (CP) walking with flexed knee gait is limited. Based on our clinical experience, we hypothesized that older children with bilateral spastic CP would benefit more from single-event multilevel surgery than younger children. Moreover, any improvement in older children could be maintained with fewer additional surgery events.

METHOD

We performed a retrospective analysis of the long-term outcomes of single-event multilevel surgery. Thirty-two children (17 males, 15 females) who had received single-event multilevel surgery between 1995 and 2000 with a mean age at the time of surgery of 10 years 6 months (range 5y 8mo-15y 6mo; SD 3y 1mo) and in Gross Motor Function Classification System level II (n=12) or III (n=20) were included in the study. The inclusion criteria required that all children were ambulatory with spastic bilateral CP, had a flexed knee gait, had a full set of data for single-event multilevel surgery preoperatively and at 1 year and 10 years postoperatively, had not had previous surgery on their lower limbs, had not had any treatment with botulinum toxin A before gait assessment, and had not received intrathecal baclofen medication. The follow-up time lasted for over 10 years until the participants reached adulthood (mean age at the last follow-up 21 years 4 months, SD 3y 4mo). Data were collected on six separate occasions: preoperatively, at 1 year, at 2 to 3 years, at 5 years, at 7 to 8 years, and at 10 or more years postoperatively. The primary outcome was the Gait Deviation Index, and the secondary outcomes were the number and type of initial and additional surgeries. A linear mixed model and Spearman's rank correlation coefficient were used to prove the hypothesis.

RESULTS

The older the child was at the time of the surgery, the better the long-term result ((Age,Time) =0.15; p=0.03). We did not find any correlation between age at the time of surgery and the number of bony or soft-tissue procedures performed initially as well as during the 10 years of follow-up.

INTERPRETATION

Children with CP who require single-event multilevel surgery at an older age fare better in the long term than those who are younger at the time of surgery. The pubertal growth spurt is discussed as a contributing factor to gait deterioration.

Recurrence after surgery for equinus foot deformity in children with cerebral palsy: assessment of predisposing factors for recurrence in a long-term follow-up study

BACKGROUND

Despite the large number of studies on the recurrence after surgery for equinus foot deformity in cerebral palsy (CP) patients, only a few investigations have reported long-term recurrence rates. Furthermore, little is known on the interval between the recurrent surgeries and the factors that lead to early recurrence. This study aimed to assess the overall recurrence after surgery for equinus foot deformity in patients with CP and to assess the factors associated with recurrence. We also aimed to determine the predisposing factors for early recurrence.

METHODS

The medical records of 186 patients (308 feet) were reviewed in order to determine the recurrence after surgery for equinus foot deformity. The type of CP, type of surgery, age at surgery, functional mobility, passive dorsiflexion of the ankle at the last follow-up visit, and subsequent treatment were recorded. Kaplan-Meier survival analysis was employed, with the end point defined as reoperation.

RESULTS

The mean age at surgery was 6.8 ± 2.5 years (range, 2.2-13.1). With the mean follow-up period of 11.3 years (range, 7.2-17.7), the overall recurrence rate was 43.8%. The recurrence rate was highest among patients with hemiplegia (62.5%). The Kaplan-Meier survival without repeat surgery estimate was shown to be 88.6% at 5 years and 59.6% at 10 years. Among children with hemiplegia and diplegia, the younger children (≤8 years of age) showed a higher rate of recurrence compared with the older children (P = 0.04 and P = 0.01, respectively). In 41 feet (30.4%), reoperations were performed within 5 years after the primary surgery. Early recurrence was most prevalent among children with hemiplegia (50.0%). In children with diplegia and quadriplegia, the younger children underwent the secondary operation later than the older children (P = 0.04 and P = 0.02, respectively).

CONCLUSION

Recurrence after surgery for equinus foot deformity is common and the age at surgery has a significant influence on recurrence. Recurrence can occur at any age while the child is still growing; therefore, it is advised to follow those patients until they reach skeletal maturity.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Can biomechanical variables predict improvement in crouch gait?

Many patients respond positively to treatments for crouch gait, yet surgical outcomes are inconsistent and unpredictable. In this study, we developed a multivariable regression model to determine if biomechanical variables and other subject characteristics measured during a physical exam and gait analysis can predict which subjects with crouch gait will demonstrate improved knee kinematics on a follow-up gait analysis. We formulated the model and tested its performance by retrospectively analyzing 353 limbs of subjects who walked with crouch gait. The regression model was able to predict which subjects would demonstrate 'Improved' and 'Unimproved' knee kinematics with over 70% accuracy, and was able to explain approximately 49% of the variance in subjects' change in knee flexion between gait analyses. We found that improvement in stance phase knee flexion was positively associated with three variables that were drawn from knowledge about the biomechanical contributors to crouch gait: (i) adequate hamstrings lengths and velocities, possibly achieved via hamstrings lengthening surgery, (ii) normal tibial torsion, possibly achieved via tibial derotation osteotomy, and (iii) sufficient muscle strength.

Transverse plane rotation of the foot and transverse hip and pelvic kinematics in diplegic cerebral palsy

External rotation of the foot associated with mid-foot break is a commonly observed gait abnormality in diplegic CP patients. Previous studies have shown a correlation between equinus and internal hip rotation in hemiplegic patients. This study aimed to determine if there was a correlation between the amount of transverse plane rotation in diplegic CP patients using kinematic data from standardised gait analysis. Lower limb data of 134 ambulant children with diplegic CP was analysed retrospectively determining the maximum change in foot, hip and pelvis rotation during loading response. Highly significant negative correlations (P=<0.001) were found between foot and hip movements and foot and pelvic movements. Equinus at initial contact diminished the foot:hip correlation while it enhanced the foot:pelvic correlation. There was less external rotation of the foot in equinus patients (P=0.012) and more external rotation of the pelvis in the equinus group (P=<0.001). This data reveal a correlation between transverse plane rotation at foot level to that at the hip and pelvis. The likely biomechanical explanation is relatively excessive transverse external rotation of the foot due to abnormalities such as mid-foot break. When under load, where the foot is fixed to the floor, internal rotation of the entire leg occurs. This is due to lever arm disease as a result of the relatively shortened foot and inefficiency of the plantar-flexion knee-extension couple. Equinus modulates the effect. When treating such patients, lever arm deformities at all levels must be considered to result in the best outcome and prevent recurrences.

Retest reliability of measuring hip extensor muscle strength in different testing positions in young people with cerebral palsy

Background

In young people with spastic diplegic cerebral palsy weakness of the hip extensor muscles are associated with limitations in activity. It is important that clinicians can reliably measure hip extensor muscle strength to monitor changes over time and the effects of any interventions. Previous research has demonstrated high reliability for measuring strength of all muscles of the lower limb, with the exception of the hip extensors. Therefore the aim of this study was to examine the retest reliability of measuring hip extensor strength in young people with cerebral palsy.

Methods

Using a test-retest reliability research design, 19 participants with spastic diplegic cerebral palsy (Gross Motor Function Classification System Levels II and III) (mean 19 y 2 mo [S D 2 y 5 mo]) attended two testing sessions held 12 weeks apart. Three trials with a hand-held dynamometer were taken at each testing session in supine, prone and standing. Retest reliability was calculated with Intraclass Correlation Coefficients (ICC_(2,1)) and with units of measurement (kilograms) converted to a percentage strength change.

Results

ICC values ranged from .74 to .78 in supine, .75 to .80 in prone, and .73 to .75 in standing. To be 95% confident that real change had occurred, an individual's strength would need to increase 55 to 60% in supine, 86 to 102% in prone, and 102 to 105% in standing. To be 95% confident that real change had occurred across groups, strength would need to increase 4 to 8% in supine, 22 to 31% in prone, and 32% to 34% in standing. Higher ICC values were observed when three trials were used for testing.

Conclusions

The supine testing position was more reliable than the prone or standing testing positions. It is possible to measure hip extensor strength with sufficient reliability to be able monitor change within groups using the supine position provided three trials are used during testing. However, there is insufficient reliability to monitor changes in hip extensor strength in individuals with cerebral palsy unless they exhibit very large strength increases.

Radical posterior capsulectomy improves sagittal knee motion in crouch gait

BACKGROUND

Knee flexion contracture leading to crouch gait is commonly seen in children with myelomeningocele. Progressive increase in knee flexion contracture increases energy cost, which interferes with efficient, functional ambulation. To prevent this, surgical release has been recommended when a knee flexion contracture exceeds 15° to 20°.

QUESTIONS/PURPOSES

We therefore asked whether knee flexion contracture release improved dynamic sagittal motion and walking velocity using computerized gait analysis.

PATIENTS AND METHODS

We retrospectively studied 11 patients (20 knees) with high-sacral-level or low-lumbar-level myelomeningocele and knee flexion contracture of greater than 15°. All patients underwent dynamic gait analysis pre- and postoperatively. Surgery consisted of selective hamstring lengthening (medial and lateral), gastrocnemius release from the femoral condyles, and posterior knee capsulectomy.

RESULTS

We observed improvements postoperatively in clinical measurements and sagittal kinematics. The clinical knee flexion contracture improved from a mean of 24.9° preoperatively to 5.9° postoperatively. The knee flexion at initial contact improved from 37.6° to 9.0°, and minimum knee flexion in single-leg stance improved from 48.2° to 16.4. Walking velocity improved from 72.2% to 80.0% of age-matched normal.

CONCLUSIONS

Surgical treatment of knee flexion contracture in patients with myelomeningocele using radical posterior knee capsulectomy leads to improvement in clinical knee flexion contracture, dynamic sagittal kinematics, and walking velocity.

Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement

Botulinum neurotoxin type-A (BoNT-A) has been used in association with other interventions in the management of spasticity in children with cerebral palsy (CP) for almost two decades. This consensus statement is based on an extensive review of the literature by an invited international committee. The use of BoNT-A in the lower limbs of children with spasticity caused by CP is reported using the American Academy of Neurology Classification of Evidence for therapeutic intervention. Randomized clinical trials have been grouped into five areas of management, and the outcomes are presented as treatment recommendations. The assessment of children with CP and evaluation of outcomes following injection of BoNT-A are complex, and therefore, a range of measures and the involvement of a multidisciplinary team is recommended. The committee concludes that injection of BoNT-A in children with CP is generally safe although systemic adverse events may occur, especially in children with more physical limitations (GMFCS V). The recommended dose levels are intermediate between previous consensus statements. The committee further concludes that injection of BoNT-A is effective in the management of lower limb spasticity in children with CP, and when combined with physiotherapy and the use of orthoses, these interventions may improve gait and goal attainment.

Multilevel orthopedic surgery for crouch gait in cerebral palsy: An evaluation using functional mobility and energy cost

BACKGROUND

The evidence for the effectiveness of orthopaedic surgery to correct crouch gait in cerebral diplegic is insufficient. The crouch gait is defined as walking with knee flexion and ankle dorsiflexion through out the stance phase. Severe crouch gait in patients with spastic diplegia causes excessive loading of the patellofemoral joint and may result in anterior knee pain, gait deterioration, and progressive loss of function. We retrospectively evaluated the effect of surgery on the mobility and energy consumption at one year or more with the help of validated scales and scores.

MATERIALS AND METHODS

18 consecutive patients with mean age of 14.6 years with cerebral diplegia with crouched gait were operated for multilevel orthopaedic surgery. Decisions for surgery were made with the observations on gait analysis and physical examination. The surgical intervention consisted of lengthening of short muscle-tendon units, shortening of long muscles and correction of osseous deformities. The paired samples t test was used to compare values of physical examination findings, walking speed and physiological cost index. Two paired sample Wilcoxon signed rank test was used to compare functional walking scales.

RESULTS

After surgery, improvements in functional mobility, walking speed and physiological cost index were found. No patient was able to walk 500 meters before surgery while all were able to walk after surgery. The improvements that were noted at one year were maintained at two years.

CONCLUSIONS

Multilevel orthopedic surgery for older children and adolescents with crouch gait is effective for improving function and independence.

Modified Goal Attainment Scale outcomes for ambulatory children: with and without orthopedic surgery

AIM

The purpose of this study was to determine if mobility goals were met when set and rated by the family using a modified Goal Attainment Scale following lower extremity orthopedic surgery or on follow-up without surgery.

METHODS

Parents were asked to establish the top three goals for their child's mobility during a visit to the Motion Analysis Laboratory. Three groups of subjects were established: (1) 25 children with CP who had surgery, (2) 13 children with CP who did not have surgery and (3) 13 children without CP who had surgery. Goals were rated at the follow-up visit to the Motion Analysis Laboratory a mean of 12.4 months after initial visit using a non-criterion reference scale. The PODCI, Gait Deviation Index and Gillette FAQ were additional standardized tools used to measure outcomes. Data were reviewed retrospectively.

RESULTS

Both groups that had surgery on average met their goals. The group that did not have surgery did not, on average, meet their goals (overall, no change). Significant improvements were noted in both surgery groups on the PODCI and Gait Deviation Index while no changes were found for the group without surgery.

CONCLUSION

Generally, goals are met following orthopedic surgery when set and rated by the family using a modified Goal Attainment Scale in the Motion Analysis Laboratory. However, goals are not universally met which presents an opportunity to improve the goal setting and evaluation process. Goals identified in this study are specific and unique to the family and agree with other standardized outcome tools.

The adult with cerebral palsy

Advances in medical and surgical care over the past 20 years have resulted in children who formerly would have died at birth or infancy now surviving well into adulthood, many with permanent physical disabilities, including those caused by cerebral palsy. Inadequate medical and surgical diagnoses and intervention are prevalent in the adult cerebral palsy population. Decreased physical activity and participation in physical therapy and fitness programs, along with loss of strength, contractures, and pain are common factors in the loss of functional weight bearing, self-care, and daily performance over time. Increased awareness of these problems is needed by adult health care providers who provide care to these individuals and also by pediatric providers who may be able to intervene and prevent some of the long-term problems. Early identification and intervention in the child and younger adult remain the ideal in the pursuit of optimal musculoskeletal function and lifestyle throughout the adult years.

The role of gait analysis in treating gait abnormalities in cerebral palsy

Individuals with cerebral palsy (CP) cannot take a normal activity like walking for granted. CP is the most common pediatric neurologic disorder, with an incidence of 3.6 per 1000 live births. The current trend in the treatment of individuals with CP is to perform a thorough evaluation including a complete patient history from birth to present, a comprehensive physical examination, appropriate radiographs, consultation with other medical specialists, and analysis of gait.

Management of the knee in spastic diplegia: what is the dose?

This article discusses the sagittal gait patterns in children with spastic diplegia, with an emphasis on the knee, as well as the concept of the "dose" of surgery that is required to correct different gait pathologies. The authors list the various interventions in the order of their increasing dose. The concept of dose is useful in the consideration of the management of knee dysfunction.

Preoperative botulinum toxin test injections before muscle lengthening in cerebral palsy

BACKGROUND

Muscle weakening is a well-known side effect of muscle-tendon lengthening. Botulinum toxin A (BTX-A) weakens the muscle temporarily by blocking the neuromuscular junction. Hence application of the drug is a logical step to test whether weakness deteriorates function prior to an operation. In the present study, BTX-A application is used to test preoperatively whether the gait pattern depends on the strength of the tested muscle. Since 1999, instrumented gait analysis, including kinematic, kinetic, and dynamic electromyographic data, is routinely used to define the individual surgical program.

METHODS

In our series of 110 consecutive patients with cerebral palsy (CP) considered for surgical muscle lengthening from 1999 to 2008, BTX-A was applied to identify patients at risk for functional deterioration. Gait analysis was repeated 6 weeks (maximum effect of BTX-A) and 12 weeks (follow-up) after the test injection to check for loss of joint control (excessive ankle dorsiflexion, knee flexion, increased anterior pelvic tilt).

RESULTS

In all, 20.9% (n = 23) showed deterioration in gait after preoperative BTX-A test injections (n = 112, two patients had two test trials) in all muscles considered for lengthening. As a consequence, their lengthening surgery was canceled. A total of 68 patients underwent surgery as planned, and in none of them did gait function deteriorate. These clinical data were compared to those of a historical group (n = 105) before this test, where 18% showed functional deterioration after surgery. The similar percentage of patients filtered out by the test suggests that there could be a context to the number of poor results in the historical group.

CONCLUSIONS

We conclude that preoperative BTX-A test injection is a reliable tool for filtering out patients with risk of deterioration after muscle lengthening surgery in patients with CP and can be helpful to avoid poor outcomes.

Rehabilitation after multilevel surgery in ambulant spastic children with cerebral palsy: children and parent experiences

PURPOSE

This study explores post-operative family situation, rehabilitation and interdisciplinary cooperation for ambulant children with cerebral palsy (CP), after multilevel surgery.

METHODS

Eight ambulant spastic children with varied severity of CP and their parents were included. Qualitative, semi-structured interviews were carried out separately with children and parents.

RESULTS

Children experiencing a low degree of post-operative pain were satisfied due to improved strength and ambulation, leading to increased social participation. A few experienced severe pain and modest physical improvement. Most families experienced a lack of information and communication between rehabilitation levels. Rehabilitation was considered strenuous because of complex and intense training programmes. Schools were mostly responsive to children's extra post-operative needs, but some examples of serious neglect and bullying occurred.

CONCLUSION

Results imply the need for systematic securing of interdisciplinary knowledge transfer regionally and locally by the university hospital, aiming at empowering families and health professionals involved in this complex rehabilitation.

Ambulant children with spastic cerebral palsy and their parents' perceptions and expectations prior to multilevel surgery

PURPOSE

This study explores the pre-operative situation of children accepted for multilevel surgery for cerebral palsy (CP) and their parents.

METHODS

Eight ambulatory children with varied severity of spastic CP and their parents were included. Qualitative, semi-structured interviews were carried out separately with the children and parents.

RESULTS

Everyday life of the children and their parents was vulnerable. The degree to which children strived for social acceptance and normality increased their pain. Deteriorating physical capacity resulted in pain and fatigue and was the parents' and children's main motivation for the operation. Although the parents were ambivalent to the operation they mediated hope and cautious optimism about a better life for their children.

CONCLUSION

Parents' and children's experiences imply the need for improvements to ensure facilitation for disabled children in schools and all levels of the health service, equality of communication and awareness-raising in the pre-operative phase of multilevel surgery.

Gait Analysis before and after Gastrocnemius Fascia Lengthening for Spastic Equinus Foot Deformity in a 10-Year-Old Diplegic Child

Purpose. This case study quantified kinematic and kinetic effects of gastrocnemius lengthening on gait in a Cerebral Palsy child with equinus foot. Methods. A 10-year-old diplegic child with Cerebral Palsy was evaluated with Gait Analysis (GA) before and after gastrocnemius fascia lengthening, investigating the lower limb joints kinematics and kinetics. Results. Kinematics improved at the level of distal joints, which are directly associated to gastrocnemius, and also at the proximal joint (like hip); improvements were found in ankle kinetics, too. Conclusions. This case study highlighted that GA was effective not only to quantify the results of the treatment but also to help preoperative decision making in dealing with CP child.

[Measures to improve gait in patients with cerebral palsy]

Gait disorders in patients with cerebral palsy result in excessive energy consumption due to spasticity and faulty biomechanics. Instrumented gait analysis shows these problems best and provides the optimal base for the orthopaedic treatment. Modern therapy options consist of muscle lengthenings, muscle shortenings, corrections of torsions and stabilisations of joints. Especially at the foot level, conservative and operative means can be used depending on the individual situation. The aim is to rebalance muscle strength and length and to restore the lever arms. As many procedures as possible are combined in multilevel corrections in order to keep the total rehabilitation for the patient as short as possible.

Cerebral palsy lifetime care - four musculoskeletal conditions

Cerebral palsy (CP) has always been considered a static condition in the neurological sense. Secondary and associated conditions that occur in the patient with CPcan progress over time and cause unwanted sequelae. This paper discusses four musculoskeletal conditions that present across the lifetime and can lead to progressive loss of function in the patient with CP. Patella alta can be particularly painful in the early adult years, limiting mobility particularly when associated with crouch gait. Adults with lower-extremity weight-bearing status having hip dysplasia, progressive over time, often develop pain and severe degenerative arthritis, with or without arthrodesis. Spondylolysis, particularly at the L5 S1 level, is fairly common in the ambulatory adult with diplegia and may, if not diagnosed early, progress to spondylolisthesis. Cervical stenosis appears to be more prevalent in adults with spastic quadriparesis and dystonia and is often associated with myelomalacia and/or radiculopathy. All four of these conditions may be lessened, or even prevented, with intervention and diagnosis in the younger years. Possible interventions and outcomes over time are discussed in the context of multidisciplinary team management of the individual with CP.

Effects of orthopedic intervention in adolescents and young adults with cerebral palsy

The purpose of this study was to determine the effects of orthopedic procedures performed after skeletal maturity on ambulatory patients with cerebral palsy. Twenty-five patients (46 sides) had pre- and postoperative computerized gait analysis. All patients underwent any one or a combination of the following procedures: hamstring lengthenings, ankle plantar flexor lengthenings, rectus femoris transfers, psoas lengthenings, and femoral derotation osteotomies. Surgical results were similar in this group of older patients to those for younger individuals with cerebral palsy. Surgical procedures were evaluated pre- versus postoperatively within the subgroups of patients that had a particular procedure. Patients experienced the following results 1 year postoperatively: (1) improved knee extension at initial contact following hamstring lengthenings (n=35 sides, preop=32+/-15 degrees, postop=22+/-13 degrees, p<0.01), (2) improved peak dorsiflexion in swing (n=23 sides, preop=-1+/-9 degrees, postop=6+/-8 degrees, p<0.01) and improved modulation with peak dorsiflexion occurring later in stance (preop=31+/-15% of gait cycle, postop=43+/-13% of gait cycle, p<0.01) following ankle plantar flexor lengthenings, (3) improved hip rotation following femoral derotational osteotomies (n=9 sides, preop=19+/-12 degrees internal, postop=0+/-12 degrees, p<0.01), (4) improved peak knee flexion in swing following rectus femoris transfers (n=23 sides, preop=47+/-11 degrees, postop=55+/-13 degrees, p=0.01), (5) a reduction in excessive hip flexion during terminal stance was found in those patients with psoas lengthening (n=8 sides, preop=18+/-21 degrees, postop=9+/-19 degrees, p=0.04).

Single-session reliability of discrete gait parameters in ambulatory children with cerebral palsy based on GMFCS level

The single-session reliability of 28 discrete spatiotemporal and kinematic variables was evaluated from computerized gait analysis (CGA) in 33 ambulatory children with cerebral palsy (CP), subcategorized according to Gross Motor Function Classification System (GMFCS) Levels I (n=11), II (n=12) and III (n=10). Nineteen boys and 14 girls participated, mean age=8 years 1 month (S.D.=3 years 0 month). Intraclass correlation coefficients (ICCs) estimated reliability, and the number of strides required to obtain an ICC of at least 0.90 was determined. The reliability of discrete gait parameters was dependent upon GMFCS level, with children in GMFCS Level I exhibiting the highest reliability (ICC range=0.70-0.96). GMFCS Levels II and III had lower levels of reliability with ICC values varying from 0.54 to 0.95 and 0.45 to 0.98, respectively. With the exclusion of pelvis range of motion (ROM), an average of four strides provided a reliability estimate of at least 0.90 for GMFCS Level I, while six strides were needed for children in Levels II and III. On the basis of the intrasession reliability results from the present study, further work is recommended to examine the test-retest reliability of these gait parameters in children with CP.

Results of treatment when orthopaedic surgeons follow gait-analysis recommendations in children with CP

The aim of the present study was to assess the outcome of orthopaedic surgery in ambulant children with cerebral palsy, when the orthopaedic surgeons followed the recommendations from preoperative three-dimensional gait analysis. 55 children, mean age 10 y 11 mo, were clinically evaluated by orthopaedic surgeons who proposed a surgical treatment plan. After gait analysis and subsequent surgery, three groups were defined. In group A, there was agreement between clinical proposals, gait-analysis recommendations, and subsequent surgery in 128 specific surgical procedures. In group B, 54 procedures were performed based on gait analysis, although these procedures had not been proposed at the clinical examination. In group C, 55 surgical procedures that had been proposed after clinical evaluation were not performed because of the gait-analysis recommendations. The children underwent follow-up gait analysis 1 to 2 years after the initial analysis. The kinematic results were satisfactory, with improvement in most of the gait parameters in children who had undergone surgery and no significant deterioration in those who were not operated. In group A, there were significant improvements in maximum hip extension in stance, minimum knee flexion in stance, timing of maximum knee flexion in swing and knee range of motion, maximum ankle dorsiflexion in stance, and mean femur rotation in stance. In group B, there were significant improvements in maximum hip extension in stance, minimum knee flexion in stance, and knee range of motion. We conclude that gait analysis was useful in confirming clinical indications for surgery, in defining indications for surgery that had not been clinically proposed, and for excluding or delaying surgery that was clinically proposed.