Treatment of spastic diplegia in patients with cerebral palsy: Part II

Simultaneous subtalar arthroeresis, midfoot soft tissue release, and talo-navicular arthrodesis in children with planovalgus neurologic foot

PURPOSE

Planovalgus foot deformity (PVFD) is common in children with neuromuscular conditions and severe deformity may require surgical correction. This study aims to assess clinical and radiological outcomes of PVFD secondary to neuromuscular disease managed by subtalar arthroeresis (SuAE), midfoot soft tissue release and talo-navicular arthrodesis (TNA).

METHODS

A retrospective analysis of children with neuromuscular disease and nonreducible PVFD who underwent SuAE, midfoot soft tissue release, and TNA and with a minimum follow-up of 5 years was performed. A total of 60 patients with neuromuscular disease (108 feet) including cerebral palsy were reviewed. Mean age at surgery was 12.7 ± 4.6 years (6-17). Mean follow-up was 7 ± 2.9 years (5-10). Clinical outcomes and radiologic correction at final follow-up were compared with preoperative values. Statistical analysis was performed and significance was set at P < 0.01.

RESULTS

Statistically significant radiological improvements between pre- and postoperative values were found for all angle values. At final follow-up, there was a significant improvement in VAS score (4.8 vs. 2; P < 0.01). There was also a positive trend in the improvement of walking ability. No cases of pseudoarthrosis were reported at final follow-up. Screw removal was required in 5 out of 108 feet (4.6%) and 2 feet (3.3%) had delayed medial wound healing.

CONCLUSIONS

SuAE combined with TNA and midfoot soft tissue is a safe and feasible procedure that can provide good clinical and radiologic results in patients with neuromuscular disease and nonreducible PVFD; the procedure can improve foot stability, and has a limited number of complications.

LEVEL OF EVIDENCE

IV.

Systematic review: exercise training for equinus deformity in children with cerebral palsy

Background

Children with spastic cerebral palsy have motor deficits that can lead to joint contractures. Ankle equinus deformity is the most common foot deformity among children with CP. It is caused by spasticity and muscular imbalance in the gastrocnemius-soleus complex. Exercise enhances ankle function, improves gait in children with CP, and prevents permanent impairment. Therefore, there is a need to investigate the effectiveness of different types of exercise used in equine management. The aim of this review is to assess the evidence of the effectiveness of exercise training on equinus deformity in children with cerebral palsy.

Methodology

The American Academy for Cerebral Palsy and Developmental Medicine and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology were used to conduct this systematic review. Four databases (PubMed, Cochrane Library, Physiotherapy Evidence Database (PEDro), and Google Scholar) were searched till January 2022 using predefined terms by two independent reviewers. Randomized controlled trials published in English were included. This review included seven studies with 203 participants ranging in age from 5 to 18 years. Methodological quality was assessed using AACPDM, PEDro scale; also, levels of evidence adopted from modified Sacket’s scale were used for each study. Primary outcomes were dorsiflexion angle, plantar flexion angle, and plantar flexors strength.

Results

The quality of studies ranged from good (six studies) to fair (one study). The level of evidence was level 1 (six studies) and level 2 (one study) on modified Sacket’s scale. There is a low risk of bias in the included studies. Meta-analysis revealed a non-significant difference in plantar flexor strength, plantar flexion angle, and dorsiflexion angle between the study and control group.

Conclusions

There is a need for high-quality studies to draw a clear conclusion as the current level of evidence supporting the effectiveness of various types of exercises on equinus deformity in children with cerebral palsy is still weak.

Effectiveness of a Blend of Pelvic Proprioceptive Neuromuscular Facilitation, Task-Oriented Approach, and Rood's Approach in a Three-Year-Old Child With Spastic Diplegia: A Case Report

As a result of non-progressive brain damage, cerebral palsy (CP) has traditionally been seen as a disorder of movement and posture; however, more recent classifications enable clinicians to understand more than just the movement issue. Research has evolved with the accurate categorization of cerebral palsy into distribution, motor type, and functional level. Children with spastic diplegia usually have pelvic asymmetry, which affects the child's functional abilities, including their ability to balance and walk independently. Physical therapists currently treat this illness using a variety of treatments, each of which is significant in its own way. A model for enhancing organizational capabilities is clinical management in physical therapy, which incorporates effective practices supported by research and improves outcomes. This case study demonstrates the efficiency of a deliberate physical therapy strategy to enhance functional independence in a three-year-old male child with spastic diplegia. The young patient complained of difficulties with balance and toe-walking and a delay in reaching age-appropriate milestones when seen in the neuro physiotherapy outpatient department. History demonstrated that a delayed cry occurred with an abrupt onset of fever, foaming at the mouth, and other symptoms described.

Creating and developing a comprehensive pediatric physical medicine program: A 10-year experience

PURPOSE

A multi-institutional and multidisciplinary pediatric physical medicine rehabilitation healthcare system was developed to meet regional patient needs.

METHODS

A ten-year experience meeting regional patient care needs in northeast Florida and southern Georgia is described.

RESULTS

A collaborative effort of multiple institutions resulted in the recruitment of a pediatric physical medicine and rehabilitation physician in June 2009, followed by planning stages that included initiation, development, and structuring of the program.

PHASE I

selection of clinic spaces, training of existing staff, creating specialized programs.

PHASE II

recruitment of an additional physician and dedicated advanced practice registered nurse, hospital nursing and radiology personnel training, development of protocols for specific disease entities, formulating a team approach for patient care, development of dedicated clinics for disease processes. Phase III: incorporating care into existing multidisciplinary clinics, education of existing physical, occupational, and speech therapists in dedicated remote clinics on early detection and management of specialty issues. Phase IV: ongoing education provided by rehabilitation faculty. Quality improvement aspects included outcome studies, coordinating with the Cerebral Palsy Research Network databank, and others. All phases overlapped in time and are ongoing, adapting to new needs.

CONCLUSION

A collaborative program can be created to provide comprehensive pediatric physical medicine and rehabilitation in regions lacking such a system.

Study protocol: functioning curves and trajectories for children and adolescents with cerebral palsy in Brazil - PartiCipa Brazil

Background

Gross motor development curves for children with Cerebral Palsy (CP), grouped by Gross Motor Function Classification System (GMFCS) levels, help health care professionals and parents to understand children’s motor function prognosis. Although these curves are widely used in Brazil to guide clinical decision-making, they were developed with Canadian children with CP. Little is known about how these patterns evolve in children and adolescents with CP in low-income countries like Brazil. The PARTICIPA BRAZIL aims to: (i) to identify and draw a profile of functioning and disability of Brazilian children and adolescents with CP by classifying them, for descriptive purposes, with all five valid and reliable functional classifications systems (gross motor function, manual ability, communication function, visual and eating and drinking abilities); (ii) to create longitudinal trajectories capturing the mobility capacity of Brazilian children and adolescents with CP for each level of the GMFCS; (iii) to document longitudinal trajectories in the performance of activities and participation of Brazilian children and adolescents with CP across two functional classification systems: GMFCS and MACS (Manual Abilities Classification System); (iv) to document longitudinal trajectories of neuromusculoskeletal and movement-related functions and exercise tolerance functions of Brazilian children and adolescents with CP for each level of the GMFCS; and (v) to explore interrelationships among all ICF framework components and the five functional classification systems in Brazilian children and adolescents with CP.

Methods

We propose a multi-center, longitudinal, prospective cohort study with 750 Brazilian children and adolescents with CP from across the country. Participants will be classified according to five functional classification systems. Contextual factors, activity and participation, and body functions will be evaluated longitudinally and prospectively for four years. Nonlinear mixed-effects models for each of the five GMFCS and MACS levels will be created using test scores over time to create prognosis curves. To explore the interrelationships among ICF components, a multiple linear regression will be performed.

Discussion

The findings from this study will describe the level and nature of activities and levels of participation of children and youth with CP in Brazil. This will support evidence-based public policies to improve care to this population from childhood to adulthood, based on their prognosis.

Comparison of mid-term efficacy of spastic flatfoot in ambulant children with cerebral palsy by 2 different methods

To compare the treatment efficacy of spastic flatfoot surgery by 2 different surgical methods: nonfusion subtalar arthroereisis using subtalar joint stabilizer (SJS) and Dennyson-Fulford subtalar arthrodesis (D-FSA).A total of 26 cases of ambulant children with cerebral palsy diagnosed as spastic flatfoot were surgically treated from January 2011 to December 2014. Preoperative and postoperative American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) scores, anteroposterior-talocalcaneal angles (ATAs), and lateral talar-first metatarsal angles (Meary angles) of the affected foot were recorded.Among 12 children in the SJS group, the AOFAS-AH scores were median preoperative score of 61 (58-64) versus median postoperative score of 83 (75-92), with significant difference (P < .05). Of the 20 feet treated, only 1 foot developed occasional pain. Postoperative ATA was decreased from preoperative 35° (20°-50°) to 19° (12°-25°); lateral X-ray films showed that the Meary angle was decreased from preoperative 20° (15°-40°) to postoperative 0° (0°-3°). The differences in both findings were statistically significant (P < .05). Fourteen children (22 treated feet) formed the D-FSA group; all demonstrated fusion of the talocalcaneal joint; AOFAS-AH scores were median preoperative score of 61 (58-64) versus median postoperative score of 83 (75-92), with significant difference (P < .05). Only 1 foot had occasional pain. Postoperative ATA was decreased from preoperative 35° (20°-45°) to 16° (12°-25°); lateral X-ray films showed that the Meary angle was decreased from preoperative 19° (10°-40°) to postoperative 2° (0°-5°); the differences in both findings were statistically significant (P < .05).Both nonfusion subtalar arthroereisis using SJS and D-FSA were effective for the surgical treatment of spastic flatfoot, with similar clinical outcomes.

Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow-up

BACKGROUND

Overactivity or contractures of the hamstring muscles in ambulatory children with cerebral palsy (CP) can lead to either a jump gait (knee flexion associated with ankle plantar flexion) or a crouch gait (knee flexion associated with ankle dorsiflexion). Hamstring lengthening is performed to decrease stance knee flexion. However, this procedure carries the potential risk of weakening hip extension power as well as recurrence over time; therefore, surgeons have adopted a modified procedure wherein the semitendinosus and gracilis are transferred above the knee joint, along with lengthening of the semimembranosus and biceps femoris.

PURPOSE

The purpose of our study is to evaluate the differences between hamstring lengthening alone (HSL group) and hamstring lengthening plus transfer (HST group) in the treatment of flexed knee gait in ambulatory children with CP. We hypothesized that recurrence of increased knee flexion in the stance phase will be less in the HST group at long-term follow-up, and hip extensor power will be better preserved.

METHODS

Fifty children with CP who underwent hamstring surgery for flexed knee gait were retrospectively reviewed. All subjects underwent a pre-operative gait study, a follow-up post-operative gait study, and a long-term gait study. The subjects were divided into two groups; HSL group (18 subjects) or HST group (32 subjects). The mean age at surgery was 9.9 ± 3.3 years. The mean follow-up time was 4.4 ± 0.9 (2.7-6.3) years.

RESULTS

On physical examination, both groups showed improvement in straight leg raise, knee extension, popliteal angle, and maximum knee extension in stance at the first post-op study, and maintained this improvement at the long-term follow-up, with the exception of straight leg raise, which slightly worsened in both groups at the final follow-up. Both groups improved maximum knee extension in stance at the initial follow-up, and maintained this at the long-term follow-up. Only the HST group showed significant (p < 0.05) improvement in the peak hip extension power in stance at the first post-op study, and this increased further at the final follow-up. In the HSL group, there was an initial slight decrease in the hip extension power, which subsequently increased to pre-operative values at the long-term study. Only the HST group showed increase of the average anterior pelvic tilt at the long-term follow-up study, although this was small in magnitude. There were two subjects who developed knee recurvatum at the post-op study, and both were in the HST group.

CONCLUSIONS

There is no clear benefit in regards to recurrence when comparing HST to HSL in the long term. In both HSL and HST, there was reduction of stance phase knee flexion in the long term, with no clear advantage in either group. Longer follow-up is needed for additional recurrence information. There was greater improvement of hip extension power in the HST group, which may justify the additional operative time of the transfer.

SIGNIFICANCE

This study helps pediatric orthopedic surgeons choose between two different techniques to treat flexed knee gait in patients with CP by showing the long-term outcome of both procedures.

Does proximal rectus femoris release influence kinematics in patients with cerebral palsy and stiff knee gait?

BACKGROUND

Stiff gait resulting from rectus femoris dysfunction in cerebral palsy commonly is treated by distal rectus femoris transfer (DRFT), but varying outcomes have been reported. Proximal rectus femoris release was found to be less effective compared with DRFT. No study to our knowledge has investigated the effects of the combination of both procedures on gait.

QUESTIONS/PURPOSES

We sought to determine whether an additional proximal rectus release affects knee and pelvic kinematics when done in combination with DRFT; specifically, we sought to compare outcomes using the (1) range of knee flexion in swing phase, (2) knee flexion velocity and (3) peak knee flexion in swing phase, and (4) spatiotemporal parameters between patients treated with DRFT, with or without proximal rectus release. Furthermore the effects on (5) anterior pelvic tilt in both groups were compared.

METHODS

Twenty patients with spastic bilateral cerebral palsy treated with DRFT and proximal rectus femoris release were matched with 20 patients in whom only DRFT was performed. Standardized three-dimensional gait analysis was done before surgery, at 1 year after surgery, and at a mean of 9 years after surgery. Basic statistics were done to compare the outcome of both groups.

RESULTS

The peak knee flexion in swing was slightly increased in both groups 1 year after surgery, but was not different between groups. Although there was a slight but not significant decrease found the group with DRFT only, there was no significant difference at long-term followup between the groups. Timing of peak knee flexion, range of knee flexion, and knee flexion velocity improved significantly in both groups, and in both groups a slight deterioration was seen with time; there were no differences in these parameters between the groups at any point, however. There were no group differences in spatiotemporal parameters at any time. There were no significant differences in the long-term development of anterior pelvic tilt between the groups.

CONCLUSIONS

The results of our study indicate that the short- and long-term influences of adding proximal rectus femoris release on the kinematic effects of DRFT and on pelvic tilt in children with cerebral palsy are negligible.

LEVEL OF EVIDENCE

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

The influence of botulinum toxin A injections into the calf muscles on genu recurvatum in children with cerebral palsy

BACKGROUND

With cerebral palsy (CP), an equinus deformity may lead to genu recurvatum. Botulinum toxin A (BtA) injection into the calf muscles is a well-accepted treatment for dynamic equinus deformity.

QUESTIONS/PURPOSES

The purpose of this study was to determine whether BtA injections into the calf muscles to decrease equinus would decrease coexisting genu recurvatum in children with diplegic CP.

METHODS

In a retrospective study, 13 children (mean age, 5 years) with spastic diplegic CP showing equinus and coexisting primary genu recurvatum, who were treated with BtA injections into the calf muscles, were included. Evaluations were done before and 6 and 18 weeks after intervention using three-dimensional gait analysis and clinical examinations according to a standardized protocol. Basic statistical analyses (power analysis, ANOVA) were performed to compare genu recurvatum before treatment and at 6 and 18 weeks after injection with BtA.

RESULTS

During stance phase, maximum ankle dorsiflexion was increased substantially from -3.0° ± 14.3° before to 6.2° ± 14.2° 6 weeks after the injections. Despite this, with the numbers available, the amount of recurvatum in stance did not improve with treatment at either 6 or 18 weeks. There was significant improvement of knee hyperextension during stance phase of 6.2° between baseline and 18 weeks after BtA injection, but a genu recurvatum was still present in most patients.

CONCLUSIONS

Despite improvement of ankle dorsiflexion after injection with BtA, genu recurvatum did not show relevant improvement at 6 or 18 weeks after injection with the numbers available. Because knee hyperextension remained in most patients, other factors leading to genu recurvatum should be taken into consideration. In addition, a botulinum toxin-induced weakness of the gastrocnemius may explain why recurvatum gait was not significantly reduced.

LEVEL OF EVIDENCE

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

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.

Initiating a pediatric spasticity program with multispecialty and multi-institutional support: a preliminary report

We describe the initiation and development of a comprehensive multidisciplinary and multi-institutional program for the evaluation and management of youth with spasticity. A descriptive step-by-step process of the administrative and organizational sequence of the development of the program is delineated. The Spasticity Clinic now meets regularly, and multiple diagnostic and treatment modalities are performed. This experience may assist those that wish to initiate a similar venue for youth with spasticity.

A prospective cohort study of the effects of lower extremity orthopaedic surgery on outcome measures in ambulatory children with cerebral palsy

BACKGROUND

Lower-extremity musculotendinous surgery is standard treatment for ambulatory children with deformities such as joint contractures and bony torsions resulting from cerebral palsy (CP). However, evidence of efficacy is limited to retrospective, uncontrolled studies with small sample sizes focusing on gait variables and clinical examination measures. The aim of this study was to prospectively examine whether lower-extremity musculotendinous surgery in ambulatory children with CP improves impairments and function measured by gait and clinical outcome tools beyond changes found in a concurrent matched control group.

METHODS

Seventy-five children with spastic CP (Gross Motor Function Classification System levels I to III, age 4 to 18 y) that underwent surgery to improve gait were individually matched on the basis of sex, Gross Motor Function Classification System level, and CP subtype to a nonsurgical cohort, minimizing differences in age and Gross Motor Function Measure Dimension E. At baseline and at least 12 months after baseline or surgery, participants completed gait analysis and Gross Motor Function Measure, and parents completed outcome questionnaires. Mean changes at follow-up were compared using analysis of covariance adjusted for baseline differences.

RESULTS

Surgery ranged from single-level soft tissue release to multilevel bony and/or soft tissue procedures. At follow-up, after correcting for baseline differences, Gillette Gait Index, Pediatric Outcomes Data Collection Instrument Expectations, and Pediatric Quality of Life Inventory (PedsQL) Physical Functioning improved significantly for the surgical group compared with the nonsurgical group, which showed minimal change.

CONCLUSIONS

On the basis of a matched concurrent data set, there was significant improvement in function after 1 year for a surgical group compared with a nonsurgical group as measured by the Gillette Gait Index, with few significant changes noted in outcome measures. Changes over 1 year are minimal in the nonsurgical group, supporting the possibility of ethically performing a randomized controlled trial using nonsurgical controls.

LEVEL OF EVIDENCE

Therapeutic level 2. Prospective comparative study.

Cerebral palsy: orthopedic aspects and rehabilitation

Cerebral palsy is the most common chronic disability of childhood today. The concept of management rather than cure forms the basis of intervention. Therapy programs should be integrated with summer camps, home activities, and school, enabling the child and the family to live as close to normal as possible. Successful rehabilitation should prevent additional problems, minimize disability, and create a happy child.

The outcome of surgical intervention for early deformity in young ambulant children with bilateral spastic cerebral palsy

We reviewed the outcome in 24 children with bilateral spastic cerebral palsy aged seven years or younger for whom surgery was recommended between 1999 and 2005 following gait analysis. A total of 13 children (operative group) had surgery and the remaining 11 (control group) did not, for family or administrative reasons. The operative group had at least two post-operative gait analyses at yearly intervals, with eight children having a third and six children a fourth. The control group had a second analysis after a mean interval of 1.5 years (95% confidence interval 1.1 to 1.9). In the operative group, the Gillette gait index, the ranges of movement in the lower limb joint and knee extension in stance improved following surgery, and this was maintained overall at the second post-operative analysis. The minimum knee flexion in stance in the control group increased between analyses.

These results suggest that surgical intervention in selected children can result in improvements in gait and function in the short to medium term compared with non-operative management.

Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy

PURPOSE

The purpose of this study was to evaluate the results of distal femur extension osteotomy and medial hamstring lengthening in the treatment of fixed knee flexion deformity in patients with spastic diparetic cerebral palsy.

METHODS

A retrospective study was done in a group of 12 diparetic cerebral palsy patients. A distal femur extension osteotomy was performed as part of multilevel surgery on lower limbs. The fixed knee flexion deformity was measured during physical examination, whereas hip and knee flexion in the stance phase and anterior pelvic tilt were both analyzed at kinematics. The pre- and post-surgery results were compared and analyzed statistically. A medical record review was done in order to identify the complications. The mean follow-up was 28 months.

RESULTS

A significant reduction of fixed knee flexion deformity at physical examination and knee flexion in the stance phase at kinematics was observed, but with no decrease in hip flexion. As a non-desired effect, there was an increase in anterior pelvic tilt after surgical procedures. With regard to complications, a single patient had skin breakdown at a calcaneous area on one side and the recurrence of deformity was seen in 27% of cases.

CONCLUSIONS

In this study, in which fixed knee flexion deformity did not exceed 40 degrees before surgery, the distal femur extension osteotomy was effective in increasing knee extension in the stance phase. However, an increase in anterior pelvic tilt, deformity recurrence and necessity for walking aids are possible complications of this procedure.

An electromyographic analysis of obligatory (hemiplegic cerebral palsy) and voluntary (normal) unilateral toe-walking

This study compares lower extremity muscle activation during gait in patients with hemiplegic cerebral palsy (CP) with healthy subjects mimicking the patients. The purpose was to understand the differences between obligatory toe-walking as observed in hemiplegic CP gait and voluntary toe-walking. The results contribute to a better understanding by distinguishing between primary deviations in muscle activity as a direct consequence of the underlying neurological pathology of hemiplegic CP and secondary, compensatory deviations due to the biomechanics of toe-walking. Surface electromyographic (EMG), kinematic and kinetic data were compared between a group of 12 hemiplegic CP patients and a group of 10 healthy subjects walking normally and when mimicking hemiplegic gait. Integrated 3D gait analysis was performed with simultaneous EMG recordings of the medial gastrocnemius, tibialis anterior, rectus femoris, and semitendinosus muscles bilaterally. The EMG pattern of the toe-walking leg in the mimicking subjects was modified in gastrocnemius and tibialis anterior as compared with normal gait. This modified muscle activation pattern showed strong similarities to that of the patients and therefore can be regarded, at least in part, as activity required for toe-walking. A possible primary gait abnormality was observed in the rectus femoris where the patients showed a burst of EMG activity in mid-swing phase in contrast to the mimicking subjects who showed normal EMG during this phase.

Changes in muscle activity in children with hemiplegic cerebral palsy while walking with and without ankle-foot orthoses

We compared the electromyographic (EMG) signals of lower extremity muscle groups in 10 children with hemiplegic cerebral palsy (CP) while walking barefoot and in a hinged ankle-foot orthosis (HAFO). All children had excessive plantarflexion and initial toe-contact on the affected side when walking barefoot, a typical gait pattern for hemiplegic patients. The patients walked with a physiological heel-toe gait pattern when wearing the HAFO. The peak activity of the tibialis anterior muscle was reduced by 36.1% at initial contact and loading response phase and by 57.3% just after toe-off when using a HAFO. The decrease in activity was thought to result from the change in gait pattern from a toe-gait to a heel-toe gait as well as the use of a HAFO. The HAFO also slightly decreased muscle activity in the proximal leg muscles mainly during swing phase, improved stride length, decreased cadence, improved walking speed, increased peak hip flexion, improved kinematics in loading response phase at the knee, and reduced the excessive ankle plantarflexion.

Orthopaedic surgery after selective dorsal rhizotomy

Data were collected on orthopaedic surgical interventions during the 5 years after surgery, for 35 consecutive children undergoing selective dorsal rhizotomy. At follow-up, 15 children had been operated in the lower limb. The most frequent procedures were subtalar arthrodesis, Achilles tendon lengthening and adductor tendon lengthening. Children with walking capacity were mostly operated with foot surgery and children without walking capacity were mostly operated with hip surgery. The need for orthopaedic surgery was highest among children with walking capacity.