Isolated calf lengthening in cerebral palsy

The impact of hamstring lengthening on stance knee flexion at skeletal maturity in ambulatory cerebral palsy

This study reports the long-term outcomes of hamstring lengthening to treat flexed knee gait in children with ambulatory cerebral palsy (CP) after skeletal maturity. This retrospective longitudinal observational study used instrumented gait analysis (GA) <8 and >15 years old in children with bilateral CP. The primary variable was knee flexion in stance phase. Eighty children (160 limbs) were included; 49% were male, 51% female. Mean age at first GA was 6.0 (SD: 1.2) years and 19.6 (SD: 4.5) years at final GA. Mean follow-up was 13.7 (SD: 4.7) years. Children were classified as Gross Motor Function Classification System I-8, II-46 and III-26. Average Gross Motor Function Measure Dimension D was 72% (SD: 20%). Hamstring lengthenings occurred once in 82, twice in 54 and three times in 10 limbs. From initial to final GA, average knee flexion in stance was unchanged, 27.8° (SD: 14.8°) to final 27.0° (SD: 11.2°; P = 0.54). Knee flexion at foot contact was 39.6° (SD: 13.0°), improving to final GA of 30.7° (SD: 10.6°; P < 0.001). Initial gait deviation index was 65.8 (SD: 31.9), improving to final 78.9 (SD: 28.2; P < 0.001). Older age, males and concomitant plantar flexor lengthening predicted change toward more flexed knee gait. Hamstring lengthening did not lead to back-kneeing gait at maturity while maintaining childhood stance phase knee flexion. A subgroup still developed significant flexed knee gait posture and may have benefited from more aggressive treatment options. This outcome may also be impacted by diverse functional levels, etiologies and treatments of flexed knee gait.

A PRISMA-IPD systematic review and meta-analysis: does age and follow-up improve active range of motion of the wrist and forearm following pediatric upper extremity cerebral palsy surgery?

Purpose

Surgical treatments such as tendon transfers and muscle lengthening play a significant role in cerebral palsy management,but timing of upper extremity cerebral palsy surgery remains controversial. This study systematically reviews the current literature and investigates the correlation between age at surgery and follow-up time with surgical outcomes in pediatric upper extremity cerebral palsy patients.

Methods

A comprehensive search of PubMed, Cochrane, Web of Science, and CINAHL databases was performed from inception to July 2020 and articles were screened using PRISMA guidelines to include full-text, English papers. Data analysis was performed using itemized data points for age at surgery, follow-up length, and surgery outcomes, reported as changes in active forearm and wrist motion. A 3D linear model was performed, to analyze the relationship between age, follow-up length, and surgery outcomes.

Results

A total of 3,855 papers were identified using the search terms and a total of 8 studies with itemized patient data (n=126) were included in the study. The studies overall possessed moderate bias according to the ROBINS-I scale. Regression analysis showed that age is a significant predictor of change (|t| > 2) in active forearm supination (Estimate = -2.3465, Std. Error = 1.0938, t-value= -2.145) and wrist flexion (Estimate = -2.8474, Std. Error = 1.0771, t-value = -2.643) post-intervention, with older individuals showing lesser improvements. The duration of follow-up is a significant predictor of improvement in forearm supination (Estimate = 0.3664, Std. Error = 0.1797, t-value = 2.039) and wrist extension (Estimate = 0.7747, Std. Error = 0.2750, t-value = 2.817). In contrast, forearm pronation (Estimate = -0.23756, Std. Error = 0.09648, t-value = -2.462) and wrist flexion (Estimate = -0.4243, Std. Error=0.1859, t-value = -2.282) have a significant negative association with follow-up time.

Conclusion

These results suggest that there is significant correlation between the age and follow up after surgery with range of motion gains. Most notably, increased age at surgery had a significant negative correlation with select active range of motion postoperative outcomes. Future research should focus on identifying other factors that could affect results of surgical treatment in upper extremity.

Single-Event Multi-Level Surgery in Cerebral Palsy: A Bibliometric Analysis

Background and Objectives: Single-Event Multi-Level Surgery (SEMLS) is a complex surgical programme in which soft tissue contractures and bony torsional deformities at the ankle, knee and hip, in both lower limbs are surgically corrected during a single operative session, requiring one hospital admission and one period of rehabilitation. The aim of SEMLS is to improve gait and function in ambulant children with cerebral palsy. Utilisation of the SEMLS concept can reduce the number of surgical events, hospital inpatient stays and reduce rehabilitation requirements to a single intensive episode. Three-dimensional gait analysis is a pre-requisite to plan intervention at multiple anatomic levels to correct fixed deformities and to improve gait and function. Materials and Methods: This study was a bibliometric analysis of SEMLS in cerebral palsy using the Clarivate Web of Science Core Collection database from 1900 to 29 May 2023. Results: A total of 84 studies met the inclusion criteria. The most highly cited article was "Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery" by Rodda et al. (2006) with 141 citations. The most productive institutions by number of articles were the Royal Children's Hospital Melbourne (Australia), Murdoch Children's Research Institute (Australia) and University of Melbourne (Australia). The most productive author by number of citations was HK Graham (Australia). Conclusions: The literature base for SEMLS consists largely of retrospective cohort studies. The aforementioned three institutes in Melbourne, Australia, which frequently collaborate together, have contributed the greatest number of studies in this field.

Surgical Management of Severe Equinus Deformity in Ambulatory Children With Cerebral Palsy

BACKGROUND

Tendo Achilles lengthening (TAL) for the management of equinus contractures in ambulatory children with cerebral palsy (CP) is generally not recommended due to concerns of over-lengthening, resulting in weakness and plantar flexor insufficiency. However, in some cases, surgical correction of severe equinus deformities can only be achieved by TAL. The goal of this study is to assess the outcomes following TAL in these cases.

METHODS

A retrospective cohort study of children with CP with severe equinus contractures (ankle dorsiflexion with the knee extended of -20 degrees or worse) who underwent TAL as part of a single event multilevel surgery, with preoperative and postoperative gait analysis studies. Continuous data were analyzed by paired t test, and categorical data by McNemar Test.

RESULTS

There were 60 subjects: 42 unilateral, 18 bilateral CP; 41 GMFCS II, 17 GMFCS I; mean age at surgery was 10.6 years, mean follow-up was 1.3 years. Ankle dorsiflexion with the knee extended improved from -28 to 5 degrees (P<0.001). The ankle Gait Variable Score improved from 34.4 to 8.6 (P<0.001). The ankle moment in terminal stance improved from 0.43 to 0.97 Nm/kg (P<0.001). Significant improvements (P<0.001) were seen in radiographic measures of foot alignment following surgery. There were few significant differences in the outcome parameters between subjects with unilateral versus bilateral CP (eg, only the bilateral group showed improved but persistent increased knee flexion in mid-stance).

CONCLUSIONS

The outcomes following TAL for the management of severe equinus deformity in ambulatory children with CP were favorable 1 year after surgery, with significant improvements in all domains measured.

SIGNIFICANCE

This study does not advocate for the widespread use of TAL to correct equinus deformity in children with CP. However, it does show that good short-term outcomes following TAL are possible in properly selected subjects with severe contractures when the dosing of the surgery is optimal (correction of contracture to between 0 and 5 degrees of dorsiflexion with the knee extended) and the procedure is performed in the setting of single event multilevel surgery with subsequent proper orthotic management and rehabilitation.

Overlapping repair and epitenon healing are more stable biomechanically than side to side repair and endotenon healing in achilles tendon lengthening with Z plasty

BACKGROUND

The current study aimed to compare biomechanical stability and healing process of side-to-side repair with overlapping repair after Achilles tendon lengthening with Z-plasty.

METHODS

In our study, 22 Sprague Dawley male rats were used. Side-to-side repairs were classified as group 1 and overlapping repairs as group 2. The left and right legs of seven rats were used to compare early group 1 and early group 2 biomechanical test results at day 0. Seven rats were used to compare late group 1 and late group 2 biomechanical test results at day 28. Both the right and left tendons were tested from the four rats examined in the biomechanically in the untreated control group. The last remaining four rats were used for histopathological evaluation of tendon repair, at 28-days from the index procedure.The ultimate load to failure was compared between groups.

RESULTS

At time 0, there were no measurable differences between group 1 (3.8 ± 1.4 N) and group 2 (3.7 ± 1.1 N), and both could endure less than one-tenth of the untreated control (49 ± 12). At 28 days, ultimate load to failure improved significantly in both group 1 (16.2 ± 3.5 N) and even more in group 2 (36 ± 8.1 N). While there was a significant difference between group 1 and group 2, neither were able to meet the untreated control (49 ± 12). Histopathological evaluation in the post-healing period showed that fibrosis, neovascularization, and inflammation increased in both groups.

CONCLUSION

The overlapping suture technique and epitenon healing have more stability compared to side-to-side suture technique and endotenon healing. Human population trials may or may not exist, our study suggests it should be considered and further investigation needed before actual clinical application.

Robot-Assisted Ankle Rehabilitation Using the Hybrid Assistive Limb for Children after Equinus Surgery: A Report of Two Cases

After equinus corrective surgery, repetitive exercises for ankle dorsiflexion and plantar flexion are crucial during rehabilitation. The single-joint Hybrid Assistive Limb (HAL-SJ) is an advanced exoskeletal robotic device with a control system that uses bioelectrical signals to assist joint motion in real time and demonstrates joint torque assistance with the wearer's voluntary movement. We present two cases of robot-assisted ankle rehabilitation after equinus surgery using the HAL-SJ in children. Case 1 was an 8-year-old boy, whereas case 2 was a 6-year-old boy. When they were allowed to walk without braces, training with the HAL-SJ was performed postoperatively for 20 min per session a total of eight times (2-4 sessions per week). Assessments were performed before and after HAL-SJ training. During gait analysis, case 1 had improved joint angles during the stance phase on the operated side; however, case 2 had improved joint angles during the stance and swing phases. The co-activation index values of the medial gastrocnemius and tibialis anterior muscles, which were high before training, decreased after training and approached the standard value. The HAL-SJ may provide systematic feedback regarding voluntary ankle dorsiflexion and plantar flexion and is considered to have motor learning effects.

Ankle Dorsiflexor Function after Gastrocsoleus Lengthening in Children with Cerebral Palsy: A Literature Review

Background and Objectives: Ambulant children with cerebral palsy can demonstrate persistent “foot drop” after successful gastrocsoleus lengthening (GSL) surgery for equinus deformity. This may be due to inadequate strength and/or selective motor control of the ankle dorsiflexor muscles. A procedure has been developed to reduce foot drop—Tibialis Anterior Tendon Shortening (TATS), to be performed in conjunction with GSL. However, it is currently unclear how ankle dorsiflexor function changes after surgery and which children could benefit from TATS. This review summarises changes in ankle dorsiflexor function after GSL for equinus, as reported in the literature. Methods: A search was performed of the Medline, Embase and PubMed databases from 1980 to 5 March 2021. Keywords included “cerebral palsy”, “equinus deformity”, “orthopedic procedures” and “gait analysis”. The search identified 1974 studies. Thirty-three cohort studies met the inclusion criteria for this review. Results: Twenty-two studies reported improvement in swing phase ankle dorsiflexion kinematics, after GSL. There was also evidence that clinical measures of ankle dorsiflexor strength improved after surgery. Four studies reported changes in selective motor control, with mixed results across the studies. Conclusions: There is good evidence that swing phase ankle dorsiflexion improves after GSL surgery. Although, there is limited evidence that this correlates with reduced foot drop or diminished need for an ankle-foot orthosis. Future research should be prospective, randomised, include a large sample size, and should focus on identifying the optimal candidates for TATS.

Recurrence of Equinus Foot in Cerebral Palsy following Its Correction-A Meta-Analysis

Background: Recurrence in cerebral palsy (CP) patients who have undergone operative or non-operative correction varies greatly from one study to another. Therefore, we conducted this meta-analysis to determine the pooled rate of equinus recurrence following its correction either surgically or non-surgically. Methods: Nine electronic databases were searched from inception to 6 May 2021, and the search was updated on 13 August 2021. We included all studies that reported the recurrence rate of equinus following its correction among CP patients. The primary outcome was recurrence, where data were reported as a pooled event (PE) rate and its corresponding 95% confidence interval (CI). We used the Cochrane’s risk of bias (RoB-II) tool and ROBINS-I tool to assess the quality of included randomized and non-randomized trials, respectively. We conducted subgroup analyses to identify the sources of heterogeneity. Results: The overall rate of recurrence was 0.15 (95% CI: 0.05−0.18; I2 = 88%; p < 0.01). Subgroup analyses indicated that the laterality of CP, study design, and intervention type were significant contributors to heterogeneity. The recurrence rate of equinus differed among interventions; it was highest in the multilevel surgery group (PE = 0.27; 95% CI: 0.19−0.38) and lowest in the Ilizarov procedure group (PE = 0.10; 95% CI: 0.04−0.24). Twelve studies had a low risk of bias, eight had a moderate risk, and nine had a serious risk of bias. Conclusion: The recurrence of equinus following its correction, either surgically or non-surgically, in CP patients is notably high. However, due to the poor quality of available evidence, our findings should be interpreted with caution. Future studies are still warranted to determine the actual risk of equinus recurrence in CP.

Continuous Wear of Night and Day Orthosis Is a Key Factor for Improvement of Fixed Equinus Deformity after the Transverse Vulpius Procedure

Background: Equinus foot deformity is secondary to either spasticity or contracture of the gastrocnemius–soleus complex. The plantar flexion is basically treated conservatively; several different surgical methods have been discussed. This paper focuses on the improvement of passive ankle dorsiflexion after a transverse Vulpius procedure in equinus foot deformity. Additionally, the influence of consequent postoperative wear of orthosis on the improvement of ankle range of motion was investigated. Methods: In total, 41 patients with neuromuscular impairment and 59 equinus feet deformities were surgically treated by using a transverse Vulpius procedure. A total of 19 female patients and 22 male patients with a mean age at surgery of 10.18 years (2 to 31) were included. Mean follow-up took place 12.26 ± 7.95 months after surgery. Passive ankle dorsiflexion was measured and subjective patients’ satisfaction was assessed. Results: Range of motion, measured as the maximum of passive ankle joint dorsiflexion, improved significantly from −8° ± 5.9° to 11.1° ± 6.7° directly after surgery to 16.2° ± 10.7° at follow-up. The improvement of passive ankle dorsiflexion was significantly associated with the continuous wearing of night and day orthosis (p = 0.0045). Patient subjective satisfaction was very high. Conclusion: A transverse Vulpius procedure for aponeurotic gastrocnemius and soleus muscle lengthening of equinus foot deformity resulted in a significant improvement of passive ankle dorsiflexion. Positive surgical results correlated to a continuous use of orthotic devices.

Outcome of Gastrocnemius Soleus Facial Lengthening in Ambulatory Patients With Cerebral Palsy

BACKGROUND

Treatment of equinus contractures in children with cerebral palsy (CP) varies across centers. Existing literature utilizes mixed study populations with a variety of procedures. As such, there is limited knowledge regarding recurrence rates and efficacy of a single procedure performed on a homogenous cohort. Here we retrospectively evaluate outcomes from gastroc soleus fascial lengthenings (GSFL) performed at 2 centers with consistent approaches in both patient selection and operative technique.

METHODS

Subjects meeting inclusion criteria including CP diagnosis, ambulation status, and minimum follow-up criteria were identified. Revision rate was reported based on need for additional calf lengthening procedures. Functional outcomes were evaluated using physical exam measures and selected variables from computational gait analysis. Outcomes factors were identified by comparing revised subjects to unrevised. Longitudinal outcomes of index surgeries were assessed by comparing preoperative functional data to short-term, mid-term, and long-term data.

RESULTS

A total of 64 subjects with 87 limbs met inclusion criteria. In all, 25% of subjects and 21% of limbs went on to revision. Factors influencing revision were age at index surgery and gross motor function classification system (GMFCS) level. More than half of revised limbs had index surgery before age 7. Revision rates for subjects less than 7 were 44% compared with a 17% revision rate for ages 7 to 12, and a 4% revision rate on children older than 12. GMFCSIII subjects had significantly higher revision rates (43%) compared with GMFCSII (18%) and GMFCSI (11%) subjects. Ankle range of motion measures improved significantly with GSFL and most maintained improvements at all time periods. GSFL did not lead to significant calcaneal gait or crouch.

CONCLUSIONS

This study evaluates long term efficacy of GSFL to address equinus in ambulatory children with CP. Overall revision rates are similar to previous reports for GSFL and other calf lengthening procedures. This information may be useful in setting expectations and counselling families. Younger subjects and those with more severe involvement are more likely to need revision surgery, with these factors compounding the likelihood in the younger GMFCSIII child.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Surgical Management of Foot and Ankle Deformities in Cerebral Palsy

Children with cerebral palsy (CP) are at a high risk of developing foot and ankle deformities that can impact function, brace/shoe fit, and seating. The 3 commonly observed foot and ankle segmental malalignment patterns include equinus, planovalgus, and equinovarus. Assessment of foot deformities is multifaceted, requiring the collection and integration of data from a combination of sources that include the clinical history, standardized physical examination, observational and quantitative gait analysis, GMFCS classification, and radiographic findings. Surgical procedures are determined by identifying all segmental malalignments and assessing the contribution of dynamic or flexible soft-tissue imbalance, fixed soft-tissue imbalance, and skeletal deformities.

The Pediatric Foot in Neurologic Disorders

Every child with a neuromotor disorder is at risk for the development or a deterioration of foot deformities. This relates to central and peripheral diseases. Almost any kind of deformity may occur. As the basic problems mostly remain, a multidisciplinary team care program is necessary in addition to surgical management of the feet. Surgery must respect any muscle imbalance as well as joint deformities and instabilities. Postoperative orthotic support supplements most treatments. Long-term follow-ups are strongly advised to detect any recurrences or overcorrections.

Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery.

Motion analysis and surgical results of anterior transfer of flexor hallucis longus for equinovarus gait in children with hemiplegia

BACKGROUND

Rigid equinovarus foot deformities are seen in patients with cerebral palsy (CP). This retrospective study was undertaken to evaluate flexor hallucis longus tendon (FHL) transfer with gastrocsoleus recession (GSR) using motion analyses and quantitative measurement, and to investigate postoperative complications.

METHODS

This study included 10 hemiplegic CP patients who underwent FHL transfer with GSR, and were evaluated by motion analyses consisting of weight distribution in static standing position and three-dimensional gait analysis, both pre and post-operatively. They were assessed in terms of kinematic data, Gait Variable Scores (GVS), and Gait Profile Score (GPS).

RESULTS

The mean age at operation was 7.3 years (range, 4-13 years), and mean follow-up duration was 35 months (range, 25-64 months) post-operatively. Weight distribution at surgical site significantly rose from 34.3% pre-operatively to 47.3% post-operatively, and abnormal asymmetry of weight distribution between surgical site and contralateral site disappeared post-operatively. Maximum ankle dorsiflexion (ADF) at initial contact rose from -20.9° to -6.28°. Similarly, Maximum ADF at both stance and swing phase rose from -13.8° to 17.7° (P = 0.0003), and from -19.5° to 1.35° (P = 0.001), respectively. Although mean GPS decreased from 15.6° pre-operatively to 11.8°, which corresponded to 2.38 times the minimal clinically important difference (MCID = 1.6°), three cases manifested talipes calcaneus at final follow-up.

CONCLUSION

Although quantitative assessment showed that the potential value of FHL transfer with GSR was to obtain initial heel contact and maintain sufficient clearance from the ground in swing, it also revealed a risk of leading to talipes calcaneus. In the near future, we should establish accurate criteria for determination of transfer site, and consider the possibility of modification of this procedure in order to balance between recurrent equinus and significant talipes calcaneus.

STUDY DESIGN

Clinical comparison between preoperative and postoperative.

Postoperative changes in vertical ground reaction forces, walking barefoot and with ankle-foot orthoses in children with Cerebral Palsy

BACKGROUND

Children with cerebral palsy often have problems to support the body centre of mass, seen as increased ratio between excessive vertical ground reaction forces during weight acceptance and decreased forces below bodyweight in late stance. We aimed to examine whether increasing ankle range of motion through surgery and restraining motion with ankle-foot orthoses postoperatively would have impact on the vertical ground reaction force in weight acceptance and late stance.

METHODS

Ground reaction forces were recorded from 24 children with bilateral and 32 children with unilateral cerebral palsy, each measured walking barefoot before and after triceps surae lengthening. Postoperatively, the children were also measured walking with ankle-foot orthoses. Changes in vertical ground reaction forces between the three conditions were evaluated with functional curve and descriptive peak analyses; accounting for repeated measures and within-subject correlation.

FINDINGS

After surgery, there were decreased vertical ground reaction forces in weight acceptance and increased forces in late stance. Additional significant changes with ankle-foot orthoses involved increased vertical forces in weight acceptance, and in late stance corresponding to bodyweight (bilateral, from 92% to 98% bodyweight; unilateral, from 94% to 103% bodyweight) postoperatively.

INTERPRETATION

Our findings confirmed that surgery affected vertical ground reaction forces to approach more normative patterns. Additional changes with ankle-foot orthoses indicated further improved ability to support bodyweight and decelerate centre of mass in late stance.

Musculoskeletal Pathology in Cerebral Palsy: A Classification System and Reliability Study

This article presents a classification of lower limb musculoskeletal pathology (MSP) for ambulant children with cerebral palsy (CP) to identify key features from infancy to adulthood. The classification aims to improve communication, and to guide referral for interventions, which if timed appropriately, may optimise long-term musculoskeletal health and function. Consensus was achieved by discussion between staff in a Motion Analysis Laboratory (MAL). A four-stage classification system was developed: Stage 1: Hypertonia: Abnormal postures are dynamic. Stage 2: Contracture: Fixed shortening of one or more muscle-tendon units. Stage 3: Bone and joint deformity: Torsional deformities and/or joint instability (e.g., hip displacement or pes valgus), usually accompanied by contractures. Stage 4: Decompensation: Severe pathology where restoration of optimal joint and muscle-tendon function is not possible. Reliability of the classification was tested using the presentation of 16 clinical cases to a group of experienced observers, on two occasions, two weeks apart. Reliability was found to be very good to excellent, with mean Fleiss' kappa ranging from 0.72 to 0.84. Four-stages are proposed to classify lower limb MSP in children with CP. The classification was reliable in a group of clinicians who work together. We emphasise the features of decompensated MSP in the lower limb, which may not always benefit from reconstructive surgery and which can be avoided by timely intervention.

Three-Dimensional Gait Analysis in Children Undergoing Gastrocsoleus Lengthening for Equinus Secondary to Cerebral Palsy

Background and Objectives: Equinus is the most common deformity in children with cerebral palsy, and surgical lengthening of the gastrocsoleus muscle-tendon unit is the most commonly performed operation for children with cerebral palsy. Treatment outcomes of orthopaedic surgery can be measured objectively with three-dimensional gait analysis. This study examined the quality of evidence for gastrocsoleus lengthening surgery based on objective measures. Materials and Methods: A search was performed with Medline, Embase and PubMed from 1990 to 25 August 2020 using the keywords "cerebral palsy", "equinus", "surgery" and "gait analysis". Only studies of gastrocsoleus lengthening surgery using three-dimensional gait analysis were included, yielding 34 studies. Results: Fourteen studies reported swing phase kinematics and all studies reported a significant improvement. Rates of recurrent equinus and calcaneus were reported in 21 studies and varied widely based on follow-up period and surgical technique. Conclusions: Poor study quality and marked variability in study samples and interventions made comparison difficult. Future studies should consider prospective design, controls or comparison groups and more detailed breakdowns of outcomes by cerebral palsy subtype, sagittal gait pattern, and equinus type in order to allow more rigorous treatment recommendations to be made.

Is shortening of Tibialis Anterior in addition to calf muscle lengthening required to improve the active dorsal extension of the ankle joint in patients with Cerebral Palsy?

INTRODUCTION

Shortening of the tibialis anterior tendon (TATS) has been shown to improve the ankle dorsiflexion in swing following the calf muscle lengthening procedure (CMLP) in patients with cerebral palsy (CP). Others have reported the similar improvements following CMLP but without TATS. However there are no studies comparing both procedures. Therefore the purpose of the study was to compare the ankle dorsiflexion in swing and foot position in the sagittal plane during gait following TATS and CMLP to that of CMLP alone.

MATERIALS AND METHODS

A retrospective study was carried out in CP patients who presented with fixed equinus deformity. They were grouped into unilateral CP and bilateral CP. Depending on the procedures, each group was again subdivided into subgroup CMLP only and subgroup CMLP and TATS (CMLPTATS). All patients were subjected to pre and postoperative clinical and gait analysis.

RESULTS

44 feet in 44 patients were included in the study. Of these, 24 feet (24 patients) belonged to unilateral and 20 feet (20 patients) to bilateral CP group. The mean age of the patients at surgery was 11.5 years (6.0 - 29.0) in the unilateral CP group and 10.5 years (5.0-34.0) in the bilateral CP group. In the unilateral CP group, 12 feet belonged to subgroup CMLP and 12 to subgroup CMLPTATS with a mean equinus contracture of 7.5° in both subgroups. In bilateral CP group, 11 feet belonged to subgroup CMLP with a mean equinus contracture of 5° and 9 to subgroup CMLPTATS, with a mean equinus contracture of 10°. The subgroups did not vary significantly in the demographics, anthropometry, kinematics and kinetics of ankle joint preoperatively. The mean follow up time was 19.7 months. The surgery produced significant changes in both groups and subgroups. However, none of the relevant gait parameters were significantly different between groups and subgroups.

SIGNIFICANCE

Adding TATS to CMLP, compared to CMLP alone did not improve ankle dorsiflexion in swing and the foot position more than CMLP alone.

Association of age in motor function outcomes after multilevel myofascial release in children with cerebral palsy

BACKGROUND

Many recommend deferring orthopedic surgery for cerebral palsy-related disorders in young children. However, age is correlated with musculoskeletal deterioration, and deferral may affect surgical outcomes. We aimed to clarify the relationships among age, degree of musculoskeletal disorder, and postoperative motor function change in children with cerebral palsy.

METHODS

We prospectively evaluated children with cerebral palsy and a knee flexion gait disorder who underwent multilevel myofascial release between June 2010 and July 2014. The children were divided into younger (<10 years of age) and older (>10 years of age) groups. Outcome measures included the Gross Motor Function Measure (GMFM), range of motion, spasticity, and physical capacity. Preoperative factors and postoperative changes were compared between the groups using the chi-squared, independent t-, and Mann-Whitney tests. Significant factors were plotted by participant age to identify the relationships between age and other variables.

RESULTS

We analyzed 20 patients who underwent multilevel myofascial release (12 and 8 in the younger and older groups, respectively). Whereas most preoperative factors were comparable between the two groups, the older group had a higher range of motion limitation score (44.4 vs. 36.1, p < 0.05). The older group also showed less improvement in the GMFM (-0.3 vs. +3.0, p < 0.05) and physical capacity (+0 vs. +1, p < 0.05) scores after 6 months of postoperative rehabilitation.

CONCLUSIONS

Age was positively correlated with the range of motion limitation and negatively correlated with postoperative GMFM improvement. The less favored postoperative rehabilitation course in older children needs to be considered for parents whose children are amenable to surgeries.

Cognitive behavioral therapy for the treatment of chronic pelvic pain

Chronic pelvic pain (CPP) in women is defined as noncyclical and persistent pain lasting more than six months perceived to be related to the pelvis. There are many etiologies that can cause CPP, including gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and psychosocial. There is a strong association between psychological factors and CPP. It has been noted that almost half of women being treated for CPP report a history of sexual, physical, or emotional trauma. Women with CPP have been noted to have higher rates of psychological disorders in comparison to their peers. For men, the most common etiology for CPP is chronic prostatitis and there are also correlations with psychological disorders. There are many different treatment options for CPP: surgical, pharmacological, and non-pharmacological (alternative therapies). Cognitive-behavioral therapy may be another option when treating chronic pelvic pain syndrome and should be considered.

Pre-operative gastrocnemius lengths in gait predict outcomes following gastrocnemius lengthening surgery in children with cerebral palsy

Equinus deformity is one of the most common gait deformities in children with cerebral palsy. We examined whether estimates of gastrocnemius length in gait could identify limbs likely to have short-term and long-term improvements in ankle kinematics following gastrocnemius lengthening surgery to correct equinus. We retrospectively analyzed data of 891 limbs that underwent a single-event multi-level surgery (SEMLS), and categorized outcomes based on the normalcy of ankle kinematics. Limbs with short gastrocnemius lengths that received a gastrocnemius lengthening surgery as part of a SEMLS (case limbs) were 2.2 times more likely than overtreated limbs (i.e., limbs who did not have short lengths, but still received a lengthening surgery) to have a good surgical outcome at the follow-up gait visit (good outcome rate of 71% vs. 33%). Case limbs were 1.2 times more likely than control limbs (i.e., limbs that had short gastrocnemius lengths but no lengthening surgery) to have a good outcome (71% vs. 59%). Three-fourths of the case limbs with a good outcome at the follow-up gait visit maintained this outcome over time, compared to only one-half of the overtreated limbs. Our results caution against over-prescription of gastrocnemius lengthening surgery and suggest gastrocnemius lengths can be used to identify good surgical candidates.

Safety and immediate effects of Hybrid Assistive Limb in children with cerebral palsy: A pilot study

PURPOSE

Early intervention is effective for developing motor ability and preventing contractures and deformities in patients with cerebral palsy (CP). Gait training using the newly developed Hybrid Assistive Limb (HAL) shows promise as an intervention to prevent deterioration in walking ability and deformities in pediatric CP patients. The purpose of this pilot study was to examine the safety and immediate effects on walking ability after gait training using the HAL in pediatric CP patients.

METHODS

Nineteen patients (six females, 13 males; mean age 8.5 years; mean height 120.5 cm; mean weight 23.2 kg) were enrolled. The Gross Motor Functional Classification Scale level was I in two patients, II in two, III in eight, and IV in seven. The HAL was used for a single session of gait training. The primary outcome was safety of the HAL for use in pediatric CP patients. The secondary outcome was the immediate effect after gait training with HAL, evaluated by passive range of motion (ROM) and gait parameters, including gait speed (m/s), step length (cm), and cadence (step/min).

RESULTS

All 19 patients were able to carry out the gait training without any severe adverse events. Significant improvements were observed for mean internal/external rotation and abduction angles of the hip joint, and ankle dorsiflexion angles (n = 19). Significant improvements were observed for mean gait speed and step length based on expansion of the hip flexion-extension range (n = 11).

CONCLUSION

Gait training using the HAL is safe and can produce immediate improvements in ROM and walking ability in pediatric patients with CP.

Comparison of two different methods in preoperative planning of the amount of lengthening in Z achilloplasty technique

Achilles tendon lengthening (ATL) surgery is a technique that is frequently used in the surgical treatment of contracture of the Achilles tendon seen in many pediatric orthopedic problems such as cerebral palsy, clubfoot, pes planovalgus and myelomeningocele. It is important to appropriately adjust the amount of ATL. However, the literature on the preoperative calculation of the required amount of tendon lengthening is limited. The aim of the study was to compare the reliability of the two different methods of predicting the amount of ATL. Eighteen feet of 16 patients who underwent ATL with Z-plasty technique were included in the study. The required amount of ATL was calculated as double blind according to the Cosine theorem and a method that was described by Garbarino et al. in 1985 and compared with the amounts of ATL applied during the operation. The mean amount of lengthening was 25.24 mm during surgery. The required amount of lengthening was 41.55 ± 11.0 mm, according to the Garbarino's method. The required amount of lengthening was 23.93 ± 9.03 mm, according to the Cosine theorem. The quantities calculated according to the Cosine theorem showed excellent agreement with the amount of lengthening during surgery. The quantities calculated according to the Garbarino's method showed poor agreement with the amount of lengthening during surgery. The calculation of the amount of ATL required in the treatment of the equinus deformity before surgery is possible by Cosine Theorem. The method of Cosine theorem is more reliable than the previous method described by Garbarino et al.

Botulinum Toxin in the Management of Children with Cerebral Palsy

During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.

Comparison of gait with and without ankle-foot orthoses after lower limb surgery in children with unilateral cerebral palsy

PURPOSE

Children with spastic unilateral cerebral palsy (SUCP) frequently undergo lower limb surgery to improve gait. Postoperatively, ankle-foot orthoses (AFOs) are used to maintain the surgical corrections and provide adequate mechanical support. Our aim was to evaluate changes in gait and impacts of AFOs one-year postoperatively.

METHODS

In all, 33 children with SUCP, 17 girls and 16 boys, mean age 9.2 years (5 to 16.5) were measured by 3D gait analysis walking barefoot preoperatively and walking barefoot and with AFOs one-year postoperatively. Changes in Gait Profile Scores (GPS), kinematic, kinetic and temporal spatial variables were examined using linear mixed models, with gender, gross motor function and AFO type as fixed effects.

RESULTS

The results confirm significant gait improvements in the GPS, kinematics and kinetics walking barefoot one year after surgery. Comparing AFOs with barefoot walking postoperatively, there was additionally reduced ankle plantarflexion by an average of 5.1° and knee flexion by 4.7° at initial contact, enhanced ankle moments during loading response, increased velocity, longer steps and inhibited push-off power generation. Stance and swing phase dorsiflexion increased in children walking with hinged AFOs versus children walking with ground reaction AFOs. Changes in the non-affected limbs indicated less compensatory gait postoperatively.

CONCLUSION

Major changes were found between pre- and postoperative barefoot conditions. The main impact of AFOs was correction of residual drop foot and improved prepositioning for initial contact, which could be considered as indications for continued use after the one-year follow-up.

LEVEL OF EVIDENCE

Level II - Therapeutic.

Impact of ankle-foot orthoses on gait 1 year after lower limb surgery in children with bilateral cerebral palsy

BACKGROUND:

Different types of ankle-foot orthoses are commonly used following lower limb surgery in children with bilateral spastic cerebral palsy. After three-dimensional gait analysis 1 year postoperatively, many children are recommended continued use of ankle-foot orthoses.

OBJECTIVES:

Our aims were to quantify the impact of ankle-foot orthoses on gait 1 year postoperatively and evaluate predictors for clinically important improvement.

STUDY DESIGN:

Prospective cohort study.

METHODS:

A total of 34 ambulating children with bilateral cerebral palsy, with mean age 11 years (range 6-17), comprising 12 girls and 22 boys, were measured with three-dimensional gait analysis preoperatively (barefoot) and 1 year postoperatively (barefoot and with ankle-foot orthoses). Outcome was evaluated using gait profile score, key kinematic, kinetic and temporal-spatial variables in paired sample comparisons. Logistic regression was used to evaluate predictors for clinically important improvement with orthoses (⩾1.6° change in gait profile score).

RESULTS:

Walking barefoot 1 year postoperatively, major improvements were seen in gait profile score and key variables. With ankle-foot orthoses, there were significantly improved step length and velocity, additional moderate reduction/improvement in gait profile score and knee moments and decreased stance ankle dorsiflexion compared to barefoot. Children using ground reaction ankle-foot orthoses ( n = 14) decreased stance knee flexion from 13.9° walking barefoot to 8.2° with orthoses. High gait profile score and more gait dysfunction preoperatively were significant predictors of clinically important improvement walking with orthoses.

CONCLUSION:

The results indicate improved gait function walking with ankle-foot orthoses versus barefoot 1 year after lower limb surgery. Stronger impact of ankle-foot orthoses was found in children with more pronounced gait dysfunction preoperatively.

CLINICAL RELEVANCE

The 1-year postoperative three-dimensional gait analysis is a useful method to assess treatment outcome after lower limb surgery in children with bilateral cerebral palsy and could also guide clinicians whether further treatment with ankle-foot orthoses is indicated, using clinically important differences as thresholds to evaluate their impact on gait.

Selective dorsal rhizotomy in ambulant children with cerebral palsy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a surgical procedure for treating spasticity in ambulant children with cerebral palsy (CP). However, controversies remain regarding indications, techniques and outcomes.

CURRENT EVIDENCE SUMMARY

Because SDR is an irreversible procedure, careful patient selection, a multi-disciplinary approach in assessment and management and division of the appropriate proportion of dorsal rootlets are felt to be paramount for maximizing safety. Reliable evidence exists that SDR consistently reduces spasticity, in a predictable manner and to a substantial degree. However, functional improvements are small in the short-term with long-term benefits difficult to assess.

FUTURE OUTLOOK

There is a need for high-quality studies utilizing long-term functional outcomes and well-matched control groups. Collaborative, multicentre efforts are required to further define the role of SDR as part of the management paradigm in maximizing physical function in spastic CP.

Onabotulinum toxin-A (Botox) for spastic equinus in cerebral palsy: a prospective kinematic study

PURPOSE

Botulinum toxin-A (or Botox) is widely used for the management of equinus gait in children with cerebral palsy but few recent studies have included instrumented gait analysis.

METHODS

This was a prospective cohort study. Gait analysis was performed four weeks before and four weeks after Botulinum toxin-A injection for spastic equinus to detect the maximum effects on gait kinematics. Outcome measures included the Gait Profile Score (GPS), the Gait Variable Score (GVS) for the ankle, maximal ankle dorsiflexion and maximal knee extension at midstance.

RESULTS

In all, 37 children participated (20 boys); mean age five years seven months (4 years 1 month to 8 years 2 months); 19 with unilateral and 18 bilateral involvement. At a mean four weeks post-injection, the GPS and ankle GVS were unchanged. However maximum ankle dorsiflexion increased for the whole group; median 7.7° (confidence interval (CI) 4° to 10.6°) to 11.5° (CI 7.7° to 12.9°), p = 0.02. Maximum midstance knee extension was unchanged for the whole group, but median knee flexion increased in children with bilateral involvement; 10.9° (CI 7.4° to 20.8°) to 16.5° (CI 8.4° to 19.7°), p = 0.58.

CONCLUSION

Injections of the gastrocsoleus for spastic equinus did not result in objective improvements in overall gait. Improvements in ankle dorsiflexion for children with bilateral involvement may be offset by deterioration at the knee.

LEVEL OF EVIDENCE

II - prospective cohort study, before and after intervention.

The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy

Crouched gait is common in children with cerebral palsy (CP), and there are various treatment options. This study evaluated the effectiveness of single-event multilevel surgery including posterior knee capsulotomy or distal femoral extension osteotomy to correct knee flexion contracture in children with CP. Gait analyses were carried out to evaluate gait preoperatively and postoperatively. Significant improvements were found in physical examination and kinematic measures, which showed that children with CP and crouched gait who develop knee flexion contractures can be treated effectively using single-event multilevel surgery including a posterior knee capsulotomy or distal femoral extension osteotomy.

Predictors of outcome after single-event multilevel surgery in children with cerebral palsy

Aims

Single event multilevel surgery (SEMLS) has been shown to improve gait in children with cerebral palsy (CP). However, there is limited evidence regarding long-term outcomes and factors influencing them.

Methods

In total 39 children (17 females and 22 males; mean age at SEMLS ten years four months, standard deviation 37 months) with bilateral CP (20 Gross Motor Function Classification System (GMFCS) level II and 19 GMFCS level III) treated with SEMLS were included. Children were evaluated using gait analysis and the Gait Deviation Index (GDI) before SEMLS and one, two to three, five and at least ten years after SEMLS. A linear mixed model was used to estimate the effect of age at the surgery, GMFCS and follow-up period on GDI.

Results

There was a mean improvement of 12.1 (-15.3 to 45.1) GDI points one year after SEMLS (p <  0.001) and 10.3 (-23.1 to 44.2) GDI points ten years after SEMLS compared with before SEMLS (p < 0.001). GMFCS level III children aged ten to 12 years had the most improvement. The GMFCS III group had more surgical procedures at the index SEMLS (p < 0.001) and during the follow-up period (p = 0.039). After correcting for other factors, age at surgery was the only factor predictive of long-term results. Our model was able to explain 45% of the variance of the change in GDI at the different time points. Take home message: Children with GMFCS III level aged ten to 12 are the benchmark responders to SEMLS in the long-term. Cite this article: Bone Joint J 2016;98-B:278–81.

Evaluation and management of crouch gait

PURPOSE OF REVIEW

Crouch gait is defined as excessive ankle dorsiflexion, knee and hip flexion during the stance phase. This gait disorder is common among patients with cerebral palsy. The present article brings an up-to-date literature review on the pathoanatomy, natural history, and treatment of this frequent gait abnormality.

RECENT FINDINGS

Hamstrings are often not shortened in patients with crouch. Patella alta must be addressed if surgery is performed. Surgical correction of joint contractures and lever arm dysfunction can be effectively achieved through a single-event multilevel surgery.

SUMMARY

Crouch gait is a common gait deviation, often seen among ambulatory diplegic and quadriplegic patients, once they reach the pubertal spurt, when weak muscles can no longer support a toe walking pattern because of rapidly increased weight. This form of gait is highly ineffective and might compromise walking ability over time. The anterior knee is overloaded; pain, extensor mechanism failure, and arthritis might develop. Its progressive nature often requires surgical intervention. The cause of crouch gait is multifactorial, and surgery should be tailored to meet the individual's specific anatomic and physiologic abnormalities.

Recurrence of equinus foot deformity after tendo-achilles lengthening in patients with cerebral palsy

BACKGROUND

Recurrence of equinus deformity after surgery is common in patients with cerebral palsy. This retrospective study was undertaken to estimate the recurrence rate of the equinus deformity after tendo-Achilles lengthening (TAL) in patients with cerebral palsy and to investigate the risk factors associated with the recurrence.

METHODS

Two-hundred forty three ambulatory patients with cerebral palsy, who underwent TAL for equinus foot deformity since 1995, and had undergone a preoperative and postoperative 3-dimensional gait analysis, were included. Cox proportional hazards model was used to determine the significant contributing factor for the recurrence of equinus foot deformity.

RESULTS

The mean patient age at surgery was 7.8±2.7 years and the mean follow-up duration was 8.1±3.4 years. Equinus deformity recurred in 22 of the 243 patients (9.1%) and the Kaplan-Meier survival estimate was shown to be 89.4% at 10 years not needing repeat surgery. According to the multivariate analysis using the Cox proportional hazard model, preoperative ankle dorsiflexion at initial contact (P=0.016) was the only significant factor for recurrence of equinus deformity after surgery. Age at surgery and the type of limb involvement were not associated with the recurrence (P=0.433 and 0.269). The cutoff values of preoperative gait kinematics between the nonrecurrence and recurrence groups were -19 degrees of ankle dorsiflexion at initial contact (P=0.018).

CONCLUSIONS

This study showed that the severity of preoperative equinus deformity was a risk factor associated with recurrence after TAL in patients with cerebral palsy. Therefore, surgeons should consider the recurrence and later revision surgery for the patients with severe equinus foot deformity.

LEVEL OF EVIDENCE

Therapeutic level III.

The transverse Vulpius gastrocsoleus recession for equinus gait in children with cerebral palsy

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles.

Gastrocsoleus recession techniques

Lengthening of the conjoined tendon of the gastrocnemius aponeurosis and soleus fascia is frequently used in the treatment of equinus deformities in children and adults. The Vulpius procedure as described in most orthopaedic texts is a division of the conjoined tendon in the shape of an inverted V. However, transverse division was also described by Vulpius and Stoffel, and has been reported in some clinical studies.

We studied the anatomy and biomechanics of transverse division of the conjoined tendon in 12 human cadavers (24 legs). Transverse division of the conjoined tendon resulted in predictable, controlled lengthening of the gastrocsoleus muscle-tendon unit. The lengthening achieved was dependent both on the level of the cut in the conjoined tendon and division of the midline raphé. Division at a proximal level resulted in a mean lengthening of 15.2 mm (sd 2.0, (12 to 19), which increased to 17.1 mm (sd 1.8, (14 to 20) after division of the midline raphé. Division at a distal level resulted in a mean lengthening of 21.0 mm (sd 2.0, (18 to 25), which increased to 26.4 mm (sd 1.4, (24 to 29) after division of the raphé. These differences were significant (p < 0.001).

Cite this article: Bone Joint J 2014; 96-B:778–82.

The operative correction of symptomatic flat foot deformities in children: the relationship between static alignment and dynamic loading

At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available. We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group.

Management of children with ambulatory cerebral palsy: an evidence-based review. Commentary by Hugh Williamson Gait Laboratory staff

The evaluation of complex interventions, such as Single Event Multilevel Surgery (SEMLS) requires more than randomized controlled trials. Rehabilitation following SEMLS is prolonged and the outcomes of interest may not be apparent for 5 years or more after the surgery. We suggest long term, prospective cohort studies with objective outcome measures be recognized as of equal importance to randomized controlled trials. The evidence in support of instrumented gait analysis (IGA) is also reviewed. We suggest that clinical levels of evidence are not an appropriate method to evaluate a measurement tool. Specifically, IGA should be evaluated in terms of validity, reliability and cost effectiveness. We demonstrate that the use of IGA has improved medium and long term outcomes in ambulant children with cerebral palsy in a center where IGA has been used routinely both for planning SEMLS and for monitoring outcomes.

Does gender influence the long-term outcome of single-event multilevel surgery in spastic cerebral palsy?

This study compared the long-term outcome of single-event multilevel surgery in spastic diplegic cerebral palsy (CP) on the basis of sex. We hypothesized that boys would have a worse outcome than girls. Thirty-four children (19 boys and 15 girls) with diplegic spastic CP and a minimal follow-up of 10 years were included. The Gillette Gait Index was the main outcome measure. We found no differences in surgical treatment, and both groups initially benefited from the surgery. However, although girls maintained the enhanced level of walking, walking ability in boys deteriorated constantly. Such a finding suggests that sex might have an important influence on treatment outcomes in children with CP.

The Baumann procedure to correct equinus gait in children with diplegic cerebral palsy

Although equinus gait is the most common abnormality in children with spastic cerebral palsy (CP) there is no consistency in recommendations for treatment, and evidence for best practice is lacking. The Baumann procedure allows selective fractional lengthening of the gastrocnemii and soleus muscles but the long-term outcome is not known. We followed a group of 18 children (21 limbs) with diplegic CP for ten years using three-dimensional instrumented gait analysis. The kinematic parameters of the ankle joint improved significantly following this procedure and were maintained until the end of follow-up. We observed a normalisation of the timing of the key kinematic and kinetic parameters, and an increase in the maximum generation of power of the ankle. There was a low rate of overcorrection (9.5%, n = 2), and a rate of recurrent equinus similar to that found with other techniques (23.8%, n = 5).

As the procedure does not impair the muscle architecture, and allows for selective correction of the contracted gastrocnemii and soleus, it may be recommended as the preferred method for correction of a mild fixed equinus deformity.

Long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery in spastic diplegic cerebral palsy

BACKGROUND

Equinus of the foot at the ankle is one of the most common deformities in patients with spastic diplegic cerebral palsy, leading to gait disturbances and secondary deformities. During single-event multilevel surgery, equinus is commonly corrected by calf muscle lengthening, such as gastrocnemius-soleus intramuscular aponeurotic recession. Various studies have described satisfactory short-term results after gastrocnemius-soleus intramuscular aponeurotic recession. However, there is no evidence for maintenance of equinus correction because of the small and heterogeneous case series and short follow-up time previously reported.

METHODS

The present study provides long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery for the treatment of equinus in forty-four patients with spastic diplegia who were able to walk (forty-eight legs had lengthening of the gastrocnemius and thirty-four legs had lengthening of the gastrocnemius and soleus). Standardized three-dimensional gait analysis and clinical examination were done preoperatively and at one year, a mean (and standard deviation) of 3 ± 1 years, and a mean of 9 ± 2 years after surgery.

RESULTS

Significant improvements in kinematic and kinetic ankle parameters on gait analysis as well as passive dorsiflexion in clinical examination were found one year after surgery. While there was a significant loss of passive dorsiflexion at the time of long-term follow-up, the improvements in gait analysis parameters were maintained. The endurance of gait improvements was accompanied by a persistent increase of dorsiflexor muscle strength without relevant loss of plantar flexor strength. Although it was not significant, there was a tendency for deterioration of gait analysis parameters over the nine years. The analysis of individual patterns showed recurrence of equinus at the ankle in 24% of the legs. Early-onset calcaneal gait was found one year after surgery in seven legs (9%), but without secondary crouch gait, and there was recovery at the time of the long-term follow-up. Late-onset calcaneal gait was seen at the time of long-term follow-up in eight legs (10%), of which four had an accompanying crouch gait.

CONCLUSIONS

Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to satisfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession.

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.

Achilles tendon length and medial gastrocnemius architecture in children with cerebral palsy and equinus gait

BACKGROUND

The aim of this study was to examine both the tendon and muscle components of the medial gastrocnemius muscle-tendon unit in children with cerebral palsy (CP) and equinus gait, with or without contracture. We also examined a small number of children who had undergone prior surgical lengthening of the triceps surae to address equinus contracture.

METHODS

Ultrasound was used to measure Achilles tendon length and muscle-tendon architectural parameters in children of ages 5 to 12 years. Muscle and tendon parameters were compared among 4 groups: Control group (N=40 limbs from 21 typically developing children), Static Equinus group (N=23 limbs from 15 children with CP and equinus contracture), Dynamic Equinus group (N=12 limbs from 7 children with CP and equinus gait without contracture), and Prior Surgery group (N=10 limbs from 6 children with CP who had prior gastrocnemius recession or tendo-achilles lengthening). The groups were compared using analysis of variance and Scheffe post hoc tests.

RESULTS

The CP groups had longer Achilles tendons and shorter muscle bellies than the Control group (P<0.001). Normalized tendon length was also longer in the Prior Surgery group compared with the Static Equinus group (P<0.001). The Prior Surgery group had larger pennation angles than the CP groups (P< or =0.009) and tended to have shorter muscle fascicle lengths (P< or =0.005 compared with Control and Static Equinus, P=0.08 compared with Dynamic Equinus). Similar results were observed for pennation angles and normalized muscle fascicle lengths throughout the range of motion.

CONCLUSIONS

Children with spastic CP and equinus gait have longer-than-normal Achilles tendons and shorter-than-normal muscle bellies. These characteristics are observed even in children with dynamic equinus, before contracture has developed. Surgery further lengthens the tendon, restoring dorsiflexion but not normal muscle-tendon architecture. These architectural features likely affect function, possibly contributing to functional deficits such as plantarflexor weakness after surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Development of calcaneal gait without prior triceps surae lengthening: an examination of predictive factors

BACKGROUND

Although equinus is more common in cerebral palsy (CP), the prevalence of calcaneal gait (CG) has been reported at more than 30% among patients with CP, even in the absence of prior surgical intervention. The goal of this study was to identify patient characteristics predictive of the development of CG in patients without prior triceps surae lengthening.

METHODS

Gait data were reviewed for 58 participants with bilateral involvement owing to CP (116 limbs) who had 2 gait analysis tests with no triceps surae lengthening between tests. None of the patients exhibited CG at the initial gait study. Patients were grouped according to whether or not they exhibited CG patterns at the second test. Factors potentially predictive of calcaneal gait patterns were compared statistically between groups.

RESULTS

CG was shown by 24/116 extremities (21%) at the second study. The CG group experienced greater increase in body weight and body mass index between tests (P=0.006 and 0.03 respectively). Passive dorsiflexion range with the knee flexed was significantly greater in the CG group (P=0.008). The CG group also showed a tendency toward greater plantarflexor weakness, although this only approached statistical significance (P=0.08) likely owing to small sample size. Age, CP subtype, time to follow-up, hamstring range, selective motor control, and gross motor functional level were not predictive.

CONCLUSIONS

Patients who undergo (or have potential to undergo) significant weight gain, and have tendencies toward excessive passive dorsiflexion with the knee flexed may be at risk for development of CG over time. In such patients, treatment regimens should include therapy to maintain or improve plantarflexor strength, and methods to prevent overstretching the plantarflexors. Nonsurgical treatments for triceps surae contractures, such as serial casting, may be preferable, to avoid hastening development of calcaneal crouch gait over time.

LEVEL OF EVIDENCE

Prognostic study---Level III (case-control).

Outcomes of gastrocnemius-soleus complex lengthening for isolated equinus contracture in children with cerebral palsy

BACKGROUND

The goal of the gastrocnemius-soleus complex (GSC) lengthenings in children with cerebral palsy (CP) is to achieve a plantigrade foot and normalize kinematics during gait. The study purpose was to evaluate the results of GSC lengthening for isolated equinus contracture in individuals with CP. It was hypothesized that GSC lengthenings would normalize passive ankle range of motion, kinematic, kinetic, and temporal spatial parameters.

METHODS

Gait data from 15 able-bodied participants from the laboratory normal database and passive range of motion, kinematic, kinetic, and temporal spatial gait parameters, and oxygen cost were collected and analyzed for 27 individuals with CP (36 limbs) with isolated equinus contracture who received GSC lengthenings. Data were compared between preoperative and postoperative assessments.

RESULTS

Mean age at baseline was 11.4 years (+/-3.2 y). Mean time between surgery and postoperative gait analysis was 1.3 years (+/-0.3 y). Passive range of motion measurements were obtained. Kinematic and kinetic data for the hip, knee and ankle, and temporal spatial parameters were obtained from a representative gait trial preoperatively and postoperatively. Paired t tests (P<0.05) determined whether preoperative data differed from postoperative data or from able-bodied data. The passive range of motion at the ankle was improved and normalized postoperatively. Ankle kinematics normalized without compensatory changes occurring at the knee or hip kinematics. Ankle moments and powers become more normal but did not completely normalize. Kinematics and kinetics of the hip and knee were not adversely affected. No changes in the temporal spatial data or oxygen cost occurred postoperatively.

CONCLUSIONS

These data support the finding that with appropriate patient selection isolated GSC lengthening does not result in overcorrection.

LEVEL OF EVIDENCE

Retrospective comparative study; level 3.

Static and dynamic gait parameters before and after multilevel soft tissue surgery in ambulating children with cerebral palsy

BACKGROUND

Recent studies have questioned the efficacy of releasing hip flexion contractures and the resulting ankle position after tendoachilles lengthening in ambulating children with cerebral palsy (CP).

METHODS

Twenty-three ambulatory children with CP underwent 96 soft tissue-lengthening procedures without bony surgery. Preoperative and postoperative clinical and computerized gait data were reviewed.

RESULTS

Static contractures improved reliably, with improvements in all areas measured, including hip flexion contracture (14 degree improvement), hip abduction (19 degree improvement), popliteal angle (26 degree improvement), and ankle dorsiflexion (11 degree improvement). The changes in computerized gait data were less uniform. The knees showed significant benefits, as evidenced by improved maximal knee extension in stance phase (37.3 degree preop and 19.9 degree postop) and at initial contact (51.6 degree preop and 34.8 degree postop). At the hip, a statistically significant improvement was only seen in maximum hip extension in stance phase (minimum hip flexion), and the magnitude of this change was only 4.6 degree (15.3 to 10.7 degree). There were no significant changes at the pelvis. At the ankle, the tendency was toward calcaneal gait after Achilles tendon lengthening, with excessive dorsiflexion seen both in stance (17.3 degree) and at toe off (-6.9 degree). Tempero-spatial parameters showed improved stride length, but no significant changes in gait velocity or cadence.

DISCUSSION

The persistence of crouch postoperatively, though improved, likely limited the potential changes in hip kinematics. As this study excluded patients undergoing osseous surgery, it is possible that lever arm dysfunction may have contributed to the ongoing crouch. The results of this study suggest that static contractures and knee kinematics improve reliably after soft tissue surgery in children with CP, but that caution must be exercised when considering heel cord lengthening in these children.

LEVEL OF EVIDENCE

Therapeutic level II. See Instructions to Authors for a complete description of levels of evidence.

Long-term physical therapy management following a single-event multiple level surgery

PURPOSE

This case report provides an overview of surgical procedures, including single-event multiple level surgery (SEMLS) used in the management of secondary conditions in cerebral palsy (CP). Physical therapy (PT) management over 35 months following SEMLS is described for an adolescent (Gross Motor Function Classification System level II) with CP.

SUMMARY OF KEY POINTS

When conservative management is not sufficient to manage secondary complications, SEMLS, combined with PT and family support, may provide the foundation for greater functional improvement than surgical correction of a single impairment. The outcome measures used following SEMLS included the Gross Motor Function Measure-66, Activity Scale for Kidsperformance38, goniometry, manual muscle testing, and Numerical Pain Rating Scale.

STATEMENT OF CONCLUSIONS

Preoperative functional level can be exceeded and sustained beyond 24 months following surgery.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Rehabilitation following a SEMLS requires teamwork and a long-term commitment to maximize outcomes.

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.

Changes in the volume and length of the medial gastrocnemius after surgical recession in children with spastic diplegic cerebral palsy

BACKGROUND

Morphology is an important determinant of muscle force and power generation. Children with spastic diplegic cerebral palsy (SDCP) have reduced muscular strength, which in part is caused by inadequate muscle growth. There is a widespread concern that surgery to correct soft tissue deformities may exacerbate the underlying muscle weakness and further retard muscle growth. In this study, we compared measurements of medial gastrocnemius (MG) muscle morphology in typically developing (TD) children to those in children with SDCP with calf muscle deformities before and after corrective surgery.

METHODS

We measured the length and volume of the MG muscle belly using 3-dimensional ultrasound immediately before and at 7 weeks and 1 year after vulpius procedure (VP) surgery in children with SDCP. We made similar measurements in a group of TD children. The SDCP group consisted of 7 children (6 boys, 1 girls; total of 8 limbs; age range, 6-10 years; mean 8 years 1 month, SD +/- 1 year 11 months) and the TD group consisted of 10 children (4 boys, 6 girls; age range, 6-12 years; mean, 9 years 5 months; SD +/- 2 years 6 months).

RESULTS

The children with SDCP presented with MG muscle bellies both smaller and shorter than the TD children even when normalized to body mass and limb length, respectively. Muscle belly length was reduced by surgery and remained unaltered 1 year later, despite skeletal growth. Muscle volume was not significantly changed 7 weeks after surgery, but increased significantly between 7 weeks and 1 year after surgery.

CONCLUSIONS

Children with SDCP presented with short and small MG when compared with TD children. Our results indicate that gastrocnemius muscle volume recovers within a year of VP surgery.

CLINICAL RELEVANCE

This study is the first to investigate the effects of surgery on muscle belly volume and length in the human subject. The study indicates that VP surgery is not an agent of long-term muscle atrophy in individuals with SDCP with plantarflexion deformities.

Postoperative gait velocity and mean knee flexion in stance of ambulatory children with spastic diplegia four years or more after multilevel surgery

Factors associated with longer-term outcomes of multilevel orthopaedic surgery in ambulatory children with cerebral palsy using a multivariate approach were evaluated using a retrospective pretest-posttest design. The population included 20 ambulatory children with spastic diplegia who had undergone multilevel orthopaedic surgery with a minimum of 4-year interval between a preoperative and a postoperative gait assessment. Multiple regression analysis was used to identify factors associated with postoperative velocity and mean knee flexion in stance. Independent variables included in the regression models were velocity, mean knee flexion in stance, age at preoperative evaluation, Gross Motor Function Classification System level, use of ankle-foot orthoses, leg length, age-adjusted body mass index, number of surgical procedures, and range of motion of hip and knee. Children who demonstrated faster postoperative gait velocity 4 years or more after surgery were younger at the time of initial evaluation, had undergone fewer surgical procedures, had faster preoperative gait velocity, used ankle-foot orthoses postoperatively, and had increased hip extension range of motion postoperatively (R = 0.55). Children who demonstrated greater knee flexion in stance 4 years or more after surgery had undergone more surgical procedures, greater postoperative popliteal angle, and less knee extension range of motion (R = 0.73). This study demonstrates the usefulness of a multivariate approach toward understanding and predicting outcomes. The results of this study will provide clinicians and researchers more information about those factors associated with maintained improvements in the longer term and may be useful for treatment planning.