Isolated calf lengthening in cerebral palsy. Outcome analysis of risk factors

Quantifying the effects of achilles tendon lengthening surgery: An intraoperative approach

Achilles tendon lengthening (ATL) is frequently used in the treatment of foot deformities. However, there is currently no objective method to determine the optimal muscle length during surgery. We developed an intraoperative approach to evaluate the passive and active forces of the triceps surae muscle group before and after ATL and aimed to test the following hypotheses: 1) the ankle passive range of motion (ROM) increases, 2) passive muscle forces decrease post-ATL, and 3) forces measured from patients with non-neurological and neurological conditions demonstrate different characteristics. Passive forces at various ankle joint positions were measured in ten patients (11.3 ± 3.0 years old) pre- and post-ATL using a force transducer attached to the Achilles tendon. In six patients, active isometric forces were measured by stimulating the triceps surae supramaximally. Passive forces decreased by 94.3% (p < 0.0001), and ROM increased by 89.4% (p < 0.0001) post-ATL. The pre-ATL passive forces were 70.8% ± 15.1% lower in patients with idiopathic foot deformities than in patients with neurological conditions (p < 0.001). The peak active force of 209.8 ± 114.3 N was achieved at an ankle angle of 38.3° ± 16.0°, where the passive force was 6.3 ± 6.7 N. The inter-individual variability was substantial in both groups. In conclusion, the hypotheses posed were supported. The present findings suggest that muscle passive and active force production as well as the inter-individual variability should be considered when planning further treatment.

Pendulum test in chronic hemiplegic stroke population: additional ambulatory information beyond spasticity

Spasticity measured by manual tests, such as modified Ashworth scale (MAS), may not sufficiently reflect mobility function in stroke survivors. This study aims to identify additional ambulatory information provided by the pendulum test. Clinical assessments including Brünnstrom recovery stage, manual muscle test, MAS, Tinetti test (TT), Timed up and go test, 10-m walk test (10-MWT), and Barthel index were applied to 40 ambulant chronic stroke patients. The pendular parameters, first swing excursion (FSE) and relaxation index (RI), were extracted by an electrogoniometer. The correlations among these variables were analyzed by the Spearman and Pearson partial correlation tests. After controlling the factor of motor recovery (Brünnstrom recovery stage), the MAS of paretic knee extensor was negatively correlated with the gait score of TT (r =  − 0.355, p = 0.027), while the FSE revealed positive correlations to the balance score of TT (r = 0.378, p = 0.018). RI were associated with the comfortable speed of 10-MWT (r = 0.367, p = 0.022). These results suggest a decrease of knee extensor spasticity links to a better gait and balance in chronic stroke patients. The pendular parameters can provide additional ambulatory information, as complementary to the MAS. The pendulum test can be a potential tool for patient selection and outcome assessment after spasticity treatments in chronic stroke population.

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.

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.

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.

Cerebral Palsy. Considerations Upon 249 Consecutive Patients and Review of Literature

Aim: to determine the prevalence of cerebral palsy (C.P.) among children and to describe its main characteristics (clinical forms, treatment plan, and results). Material and Methods: 249 C.P were studied (120 boys and 129 girls, aged between 0 and 12 years) during 2,321 consecutive clinic visits (incidence 10.7%) to a private pediatric orthopedic clinic in Jeddah, Saudi Arabia, between 2011 and 2016. Spastic type was the main clinical form (231=92.8%), spastic diplegia being the most frequent (166=71.9%). The treatment was complex: conservative only in 42.2%; surgery indicated in 149 (59.8%) cases was performed only in 81 cases, by means of muscle and/or bone procedures, depending on the lesion balance. Results. The postoperative results were excellent in 2.4% of cases, acceptable to some extent in 93.8% and poor in 3.8%. We registered a recurrence rate of 14.8%, a postoperative morbidity rate of 6.17% with a postoperative mortality rate of 0. Treatment results could not be assessed in 129 (51.9%) cases due to lack of follow up. Conclusion: 1. C.P. represents the third most common diagnosis in pediatric orthopedic private practice. 2. The treatment results were acceptable in most cases, but not optimal. 3. Gait analysis using in the preoperative planning could improve significantly the outcome, especially in complicated cases.

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.

Use of 3D gait analysis as predictor of Achilles tendon lengthening surgery outcomes in children with cerebral palsy

BACKGROUND

In children with spastic cerebral palsy (CP), the treatment of equinus foot with Achilles tendon lengthening (ATL) surgery is associated with high incidence of overcorrection, which may result in crouch gait.

AIM

We aimed to assess if gait pattern in preoperative time could be a predictor of the surgery outcome.

DESIGN

Cross-sectional retrospective study.

SETTING

Movement Analysis Lab of IRCCS San Raffaele Pisana Hospital in Rome (Italy).

POPULATION

Eighteen children (mean age 9.6±4.7 years) with spastic diplegia CP who underwent bilateral ATL surgery to correct equinus foot were involved.

METHODS

Participants underwent 3D gait analysis before and approximately 12 months after surgery. Primary measures were spatiotemporal, kinematic (summarized by Gait Variable Scores, GVSs) and kinetic parameters. The gait patterns for each leg was defined from kinematic data, using a quantitative classification: plantar flexor knee extension (PFKE) index. The CP group was split into true equinus and jump gait.

RESULTS

The equinus foot was successfully corrected as demonstrated by the improvement of GVS ankle dorsi-plantarflexion. However, there was a high rate of overcorrection in the true equinus, characterized by increases in knee flexion-extension GVS (8.7° pre vs. 16.7° post P<0.05) and knee flexion angle at initial contact (5.2° vs. 20.6° P<0.05) and by a decrease in the maximum ankle power generated at push-off (1.49 vs. 0.83 W/kg P<0.05).

CONCLUSIONS

Assessment of motor phenotype in preoperative time are good predictors of the results of ATL surgery. In children with true equinus gait, the increase of knee flexion subsequent to ATL is an early indicator that this technique will lead to crouch gait. These results show the influence of true equinus and jump gait patterns on the outcomes of the ATL.

CLINICAL REHABILITATION IMPACT

Therefore, we propose that this approach could have clinical value to evaluate and prescribe rehabilitation in children with CP disease, proposing different solutions depending on motor phenotype.

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.

Resistance Training Combined With Stretching Increases Tendon Stiffness and Is More Effective Than Stretching Alone in Children With Cerebral Palsy: A Randomized Controlled Trial

Aim: Stretching is often used to increase/maintain muscle length and improve joint range of motion (ROM) in children with cerebral palsy (CP). However, outcomes at the muscle (remodeling) and resulting function appear to be highly variable and often unsatisfactory. During passive joint rotation, the Achilles tendon lengthens more than the in-series medial gastrocnemius muscle in children with CP, which might explain the limited effectiveness of stretching interventions. We aimed to ascertain whether increasing tendon stiffness, by performing resistance training, improves the effectiveness of passive stretching, indicated by an increase in medial gastrocnemius fascicle length. Methods: Sixteen children with CP (Age median [IQR]: 9.6 [8.6, 10.5]) completed the study. Children were randomly assigned to a combined intervention of stretching and strengthening of the calf muscles (n = 9) or a control (stretching-only) group (n = 7). Medial gastrocnemius fascicle length at a resting ankle angle, lengthening during passive joint rotations, and tendon stiffness were assessed by combining dynamometry and ultrasound imaging. The study was registered on clinicaltrials.gov (NCT02766491). Results: Resting fascicle length and tendon stiffness increased more in the intervention group compared to the control group (median [95% CI] increase fascicle length: 2.2 [1.3, 4.3] mm; stiffness: 13.6 [9.9, 17.7] N/mm) Maximum dorsiflexion angle increased equally in both groups. Conclusion: This study provides proof of principle that a combined resistance and stretching intervention can increase tendon stiffness and muscle fascicle length in children with CP. This demonstrates that remodeling of muscle structure is possible with non-invasive interventions in spastic CP.

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.

Aponeurosis influences the relationship between muscle gearing and force

Aponeuroses are connective tissues found on the surface of pennate muscles and are in close association with muscle fascicles. In addition to transmitting muscle forces to the external tendon, aponeurosis has been hypothesized to influence the direction of muscle shape change during a contraction. Muscle shape changes affect muscle contractile force and velocity because they influence the gear ratio with which muscle fascicles transmit force and velocity to the tendon. If aponeurosis modulates muscle shape changes, altering the aponeurosis' radial integrity with incisions should alter gearing. We tested the hypothesis that incising the aponeurosis would lead to decreased gearing across force conditions with an in situ preparation of the turkey lateral gastrocnemius muscle. We found that multiple full-length incisions in the aponeurosis altered the relationship between gearing and force relative to the intact aponeurosis condition. Specifically, after multiple aponeurosis incisions, gear ratio decreased by 19% in the high-force contractions compared with the intact condition. These results suggest that aponeuroses influence muscle shape change and can alter muscle contractile force and speed through their effect on muscle gearing. NEW & NOTEWORTHY Muscle gearing is determined by muscle shape change during a contraction and varies with the force of contraction. Variable gearing influences muscle force and speed, but how gearing is modulated is not well understood. Incising the aponeurosis before and after contractions demonstrates that aponeurosis plays a role in modulating gearing.

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.

Screening and referral for children with physical disabilities

The clinical care of children with physical disabilities is a major priority for paediatricians and paediatric orthopaedic surgeons. Cerebral palsy (CP) is the prototypical condition and remains the most common cause of physical disability in developed countries. The incidence is approximately 2 per 1000 live births, translating to between 600 and 700 new children per annum in Australia, with approximately 34 000 children and adults currently living with CP. This figure is predicted to rise inexorably over the next 20 years. The care of children with physical disabilities, including those with CP, is usually coordinated by paediatricians, general practitioners and allied health teams including physiotherapists, with input from paediatric orthopaedic surgeons when appropriate. The emphasis in care for children with CP has moved from 'reactive' to 'proactive'. In the past, children are often referred when symptomatic, for example when a hip dislocation had occurred and became painful. The emphasis now is on coordinated, multidisciplinary care in which musculoskeletal manifestations of disability are identified by screening programmes. Systematic screening, especially when population-based and linked to a register, avoids children getting 'lost in the system'. Early and more effective interventions may be offered for the prevention of contractures, dislocation of the hip and spinal deformities. In this review, we will focus on the assessment of gait in children with physical disabilities, and monitoring for hip and spine deformity.

Efficacy and Safety of Letibotulinum Toxin A for the Treatment of Dynamic Equinus Foot Deformity in Children with Cerebral Palsy: A Randomized Controlled Trial

The objective of this clinical trial was to compare the efficacy and safety of letibotulinum toxin A and onabotulinum toxin A for improving dynamic equinus foot deformity in children with cerebral palsy (CP). In total, 144 children with spastic CP who had dynamic equinus foot deformity were assigned randomly to the Botulax group (injection of letibotulinum toxin A) or the Botox group (injection of onabotulinum toxin A). The Physician’s Rating Scale (PRS), ankle plantar flexor spasticity using the Modified Tardieu Scale, the Gross Motor Function Measure (GMFM)-88, and the GMFM-66 were completed before injection and at 6, 12, and 24 weeks after injection. The PRS responder rate was 60.27% in the Botulax group and 61.43% in the Botox group at 12 weeks after treatment, and the lower limit of the 95% confidence interval for the between-group difference in responder rates was −17.16%, higher than the non-inferiority margin of −24.00%. The clinical efficacy and the safety profiles of the groups did not significantly differ. The results suggest that injection of letibotulinum toxin A is as effective and safe as that of onabotulinum toxin A for the treatment of dynamic equinus foot deformity in children with spastic CP.

A cohort study of tibialis anterior tendon shortening in combination with calf muscle lengthening in spastic equinus in cerebral palsy

The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (±5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15°, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p=0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP.

Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial

AIM

We compared two botulinum toxin A (BoNT-A) injection frequency regimens, 12-monthly versus 4-monthly, for spastic equinus in a randomized clinical trial. The primary outcome measure was passive ankle dorsiflexion.

METHOD

Forty-two ambulant children with spastic equinus, secondary to cerebral palsy (23 males and 19 females; mean age 3y 6mo, SD 13mo; GMFCS levels I [n=20], II [n=19], III [n=3]) were randomized to receive either 12-monthly or 4-monthly BoNT-A injections to the calf, over a 26-month period. Twenty-one children had spastic hemiplegia, 21 children had spastic diplegia. A fixed 6U/kg dose of Botox was injected into the gastrocnemius muscle of both limbs in children with diplegia and the gastrocsoleus of the affected limb in children with hemiplegia, under mask anaesthesia.

RESULTS

Forty-two children entered the trial with 21 participants randomized to each group. There were three withdrawals and two children received serial casting midway through the trial. There was no significant difference in passive dorsiflexion between 12-monthly and 4-monthly regimens (p=0.41). There were also no significant between group differences on secondary outcome measures. There were no serious adverse events - the rate was 1.2 adverse events per child per year in the 12-monthly group and 2.2 adverse events per child per year in the 4-monthly group. Subgroup analysis revealed a significant difference in passive dorsiflexion between children with hemiplegia and diplegia (p=0.01).

INTERPRETATION

There was no significant difference between 12-monthly and 4-monthly injection regimens on passive dorsiflexion or secondary outcome measures. BoNT-A injections for spastic equinus may be recommended on a 12-monthly basis.

Neuromuscular Foot: Spastic Cerebral Palsy

Foot and ankle deformities in cerebral palsy can be effectively treated with surgery. Surgery should be considered in patients with significant deformity and those who have pain or difficulty with orthotic and shoe wear. Equinus contracture of both gastrocnemius and soleus can be treated with open tendoachilles lengthening; ankle valgus with medial epiphysiodesis. Equinovarus is more commonly seen in hemiplegic patients and this deformity can usually be treated with tendon transfers. Triple arthrodesis is an option in children with severe degenerative changes. It is important to address all aspects of the child's pathology at the time of surgical correction.

Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot

BACKGROUND

Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity.

METHODS

We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications.

RESULTS

Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems.

CONCLUSIONS

Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Effectiveness of Posterolateral Lumbar Fusion Varies with the Physical Properties of Demineralized Bone Matrix Strip

STUDY DESIGN

A randomized, controlled animal study.

PURPOSE

To investigate the effectiveness of fusion and new bone formation induced by demineralized bone matrix (DBM) strips with jelly strengths.

OVERVIEW OF LITERATURE

The form of the DBM can make a difference to the outcome. The effect of different jelly strengths on the ability of DBM to form new bone is not known.

METHODS

Forty-eight rabbits were randomized into a control group and two experimental groups. In the control group (group 1), 1.4 g of autologous iliac crest bone was placed bilaterally. In the experimental groups, a high jelly strength DBM-hyaluronic acid (HA)-gelatin strip (group 2) and a low jelly strength DBM-HA-gelatin strip (group 3) were used. The fusion was assessed with manual manipulation and radiographs. The volume of the fusion mass was determined from computed tomographic images.

RESULTS

The fusion rates as determined by manual palpation were 37.5%, 93.8% and 50.0% in group 1, group 2, and group 3, respectively (p<0.05). By radiography, the fusion rate of High jelly strength DBM strip was statistically significantly greater than that of the other alternatives (p<0.05). The mean bone volume of the fusion mass as determined by computed tomography was 2,142.2±318.5 mm(3), 3,132.9±632.1 mm(3), and 2,741.5±380.4 mm(3) in group 1, group 2, and group 3, respectively (p<0.05).

CONCLUSIONS

These results indicate that differences in the structural and mechanical properties of gelatin that are associated with jelly strength influenced cellular responses such as cell viability and bony tissue ingrowth, facilitating greater bone fusion around high jelly strength implants.

Reported outcomes of lower limb orthopaedic surgery in children and adolescents with cerebral palsy: a mapping review

AIM

Lower limb surgery is often performed in ambulatory children with cerebral palsy (CP) to improve walking ability. This mapping review reports on outcome measures used in the published literature to assess surgical results, determine range and frequency of use, and map each measure to the International Classification of Functioning, Disability and Health.

METHOD

A mapped review of literature published between 1990 and 2011 was carried out to identify papers reporting the outcomes of lower limb orthopaedic surgery in ambulatory children with CP, aged 0 to 20 years.

RESULTS

A total of 229 published papers met the inclusion criteria. Thirty-two outcome measures with known psychometric properties were reported in the 229 papers. Twenty measures assess impairments in body structure and function and were used in 91% of studies. Ten measures assess restrictions in activity and participation and were used in 9% of papers. Two measures assessed quality of life. Since 1997, 29% of papers have used the Gross Motor Function Classification System to describe participants.

INTERPRETATION

The body of literature evaluating outcomes of lower limb orthopaedic surgery in CP is small but increasing. There is a need to develop a suite of outcome measures that better reflect outcomes across the International Classification of Functioning, Disability and Health, including activity and participation.

Assessment and treatment of children with cerebral palsy

Children with cerebral palsy are prone to development of musculoskeletal deformities. The underlying neurlogic insult may results in a loss of selective motor control, an increase in underlying muscle tone, and muscle imbalance, which can lead to abnormal deforming forces acting on the immature skeleton. The severely involved child is one who is at increased risk for developing progressive musculoskeletal deformities. Close surveillance and evaluation are key to addressing the underlying deformity and improving and maintaining overall function.

Spinal fusion in the next generation: gene and cell therapy approaches

Bone fusion represents a challenge in the orthopedics practice, being especially indicated for spine disorders. Spinal fusion can be defined as the bony union between two vertebral bodies obtained through the surgical introduction of an osteoconductive, osteoinductive, and osteogenic compound. Autogenous bone graft provides all these three qualities and is considered the gold standard. However, a high morbidity is associated with the harvest procedure. Intensive research efforts have been spent during the last decades to develop new approaches and technologies for successful spine fusion. In recent years, cell and gene therapies have attracted great interest from the scientific community. The improved knowledge of both mesenchymal stem cell biology and osteogenic molecules allowed their use in regenerative medicine, representing attractive approaches to achieve bone regeneration also in spinal surgery applications. In this review we aim to describe the developing gene- and cell-based bone regenerative approaches as promising future trends in spine fusion.

[Spastic foot deformities in children: surgical management]

Although the neurological defects associated with cerebral palsy are not progressive, secondary musculoskeletal disorders due to growth and gravity are variable. In the clinical analysis of spastic foot deformities different mechanisms that produce a variety of deformities have to be analyzed. The goals of surgical treatment are correction of the deformity, reestablishment of stability of the foot and preservation of functionally important ranges of motion and muscle strength. The most common spastic foot deformities are equinus, planovalgus, equinovarus and calcaneus. For treatment soft tissue surgery, such as muscle lengthening and transfer together with bone surgery, such as osteotomy or arthrodesis are used and combinations of these methods are often required. Subsequently postoperative plasters are necessary followed by dynamic orthotic management.

Tissue engineering strategies in spinal arthrodesis: the clinical imperative and challenges to clinical translation

Skeletal disorders requiring the regeneration or de novo production of bone present considerable reconstructive challenges and are one of the main driving forces for the development of skeletal tissue engineering strategies. The skeletal or mesenchymal stem cell is a fundamental requirement for osteogenesis and plays a pivotal role in the design and application of these strategies. Research activity has focused on incorporating the biological role of the mesenchymal stem cell with the developing fields of material science and gene therapy in order to create a construct that is not only capable of inducing host osteoblasts to produce bone, but is also osteogenic in its own right. This review explores the clinical need for reparative approaches in spinal arthrodesis, identifying recent tissue engineering strategies employed to promote spinal fusion, and considers the ongoing challenges to successful clinical translation.

Lengthening of the gastrocnemius-soleus complex: an anatomical and biomechanical study in human cadavers

BACKGROUND

Lengthening of the gastrocnemius-soleus complex is frequently performed for equinus deformity. Many techniques have been described, but there is uncertainty regarding the precise details of some surgical procedures.

METHODS

The surgical anatomy of the gastrocnemius-soleus complex was investigated, and standardized approaches were developed for the procedures described by Baumann, Strayer, Vulpius, Baker, Hoke, and White. The biomechanical characteristics of these six procedures were then compared in three randomized trials involving formaldehyde-preserved human cadaveric lower limbs. After one of the lengthening procedures was performed, a measured dorsiflexion force was applied across the metatarsal heads with use of a torque dynamometer. Lengthening of the gastrocnemius-soleus complex was measured directly, by measuring the gap between the ends of the fascia or tendon.

RESULTS

The gastrocnemius-soleus musculotendinous unit was subdivided into three zones. In Zone 1, it was possible to lengthen the gastrocnemius-soleus complex in either a selective or a differential manner-i.e., to lengthen the gastrocnemius alone or to lengthen the gastrocnemius and soleus by different amounts. The procedures performed in this zone (Baumann and Strayer procedures) were very stable but were limited with regard to the amount of lengthening achieved. Zone-2 lengthenings of the conjoined gastrocnemius aponeurosis and soleus fascia (Vulpius and Baker procedures) were not selective but were stable and resulted in significantly greater lengthening than Zone-1 procedures (p < 0.001). In Zone 3 (Hoke and White procedures), lengthenings of the Achilles tendon were neither selective nor stable but resulted in significantly greater lengthening than Zone-1 or 2 procedures (p < 0.001).

CONCLUSIONS

Surgical procedures for the correction of equinus deformity by lengthening of the gastrocnemius-soleus complex vary in terms of selectivity, stability, and range of correction. Procedures for the correction of equinus deformity have different anatomical and biomechanical characteristics. Clinical trials are needed to determine whether these differences are of clinical importance. It may be appropriate for surgeons to select a procedure involving the zone best suited to the clinical needs of a specific patient.

The role of gene therapy in regenerative surgery: updated insights

BACKGROUND

In the past two decades, regenerative surgeons have focused increasing attention on the potential of gene therapy for treatment of local disorders and injuries. Gene transfer techniques may provide an effective local and short-term induction of growth factors without the limits of other topical therapies. In 2002, Tepper and Mehrara accurately reviewed the topic: given the substantial advancement of research on this issue, an updated review is provided.

METHODS

Literature indexed in the National Center for Biotechnology Information database (PubMed) has been reviewed using variable combinations of keywords ("gene therapy," "regenerative medicine," "tissue regeneration," and "gene medicine"). Articles investigating the association between gene therapies and local pathologic conditions have been considered. Attention has been focused on articles published after 2002. Further literature has been obtained by analysis of references listed in reviewed articles.

RESULTS

Gene therapy approaches have been successfully adopted in preclinical models for treatment of a large variety of local diseases affecting almost every type of tissue. Experiences in abnormalities involving skin (e.g., chronic wounds, burn injuries, pathologic scars), bone, cartilage, endothelia, and nerves have been reviewed. In addition, the supporting role of gene therapies to other tissue-engineering approaches has been discussed. Despite initial reports, clinical evidence has been provided only for treatment of diabetic ulcers, rheumatoid arthritis, and osteoarthritis.

CONCLUSIONS

Translation of gene therapy strategies into human clinical trials is still a lengthy, difficult, and expensive process. Even so, cutting-edge gene therapy-based strategies in reconstructive procedures could soon set valuable milestones for development of efficient treatments in a growing number of local diseases and injuries.

Estimates of Gastrocnemius Muscle Length During Simulated Pathological Gait

The purpose of this study was to compare estimates of gastrocnemius muscle length (GML) obtained using a segmented versus straight-line model in children. Kinematic data were acquired on eleven typically developing children as they walked under the following conditions: normal gait, crouch gait, equinus gait, and crouch with equinus gait. Maximum and minimum GML, and GML change were calculated using two models: straight-line and segmented. A two-way RMANOVA was used to compare GML characteristics. Results indicated that maximum GML and GML change during simulated pathological gait patterns were influenced by model used to calculate gastrocnemius muscle length (interaction: P = .004 and P = .026). Maximum GML was lower in the simulated gait patterns compared with normal gait (P < .001). Maximum GML was higher with the segmented model compared with the straight-line model (P = .030). Using either model, GML change in equinus gait and crouch with equinus gait was lower compared with normal gait (P < .001). Overall, minimum GML estimated with the segmented model was higher compared with the straight-line model (P < .01). The key findings of our study indicate that GML is significantly affected by both gait pattern and method of estimation. The GML estimates tended to be lower with the straight-line model versus the segmented model.

Lim mineralization protein 3 induces the osteogenic differentiation of human amniotic fluid stromal cells through Kruppel-like factor-4 downregulation and further bone-specific gene expression

Multipotent mesenchymal stem cells with extensive self-renewal properties can be easily isolated and rapidly expanded in culture from small volumes of amniotic fluid. These cells, namely, amniotic fluid-stromal cells (AFSCs), can be regarded as an attractive source for tissue engineering purposes, being phenotypically and genetically stable, plus overcoming all the safety and ethical issues related to the use of embryonic/fetal cells. LMP3 is a novel osteoinductive molecule acting upstream to the main osteogenic pathways. This study is aimed at delineating the basic molecular events underlying LMP3-induced osteogenesis, using AFSCs as a cellular model to focus on the molecular features underlying the multipotency/differentiation switch. For this purpose, AFSCs were isolated and characterized in vitro and transfected with a defective adenoviral vector expressing the human LMP3. LMP3 induced the successful osteogenic differentiation of AFSC by inducing the expression of osteogenic markers and osteospecific transcription factors. Moreover, LMP3 induced an early repression of the kruppel-like factor-4, implicated in MSC stemness maintenance. KLF4 repression was released upon LMP3 silencing, indicating that this event could be reasonably considered among the basic molecular events that govern the proliferation/differentiation switch during LMP3-induced osteogenic differentiation of AFSC.

Cell-mediated and direct gene therapy for bone regeneration

INTRODUCTION

Bone regeneration is required for the treatment of fracture non/delayed-unions and bone defects. However, most current treatment modalities have limited efficacy, and newer therapeutic strategies, such as gene therapy, have substantial benefit for bone repair and regeneration.

AREAS COVERED

This review discusses experimental and clinical applications of cell-mediated and direct gene therapy for bone regeneration. The review covers literature on this subject from 2000 to February 2012.

EXPERT OPINION

Direct gene therapy using various viral and non-viral vectors of cell-mediated genes has been demonstrated to induce bone regeneration, although use of such vectors has shown some risk in human application. Osteoinductive capability of a number of progenitor cells isolated from bone marrow, fat, muscle and skin tissues, has been demonstrated by genetic modification with osteogenic genes. Cell-mediated gene therapy using such osteogenic gene-expressing progenitor cells has shown promising results in promoting bone regeneration in extensive animal work in recent years.

Cerebral palsy: clinical care and neurological rehabilitation

Cerebral palsy (CP) is defined as motor impairment that limits activity, and is attributed to non-progressive disturbances during brain development in fetuses or infants. The motor disorders of CP are frequently accompanied by impaired cognition, communication, and sensory perception, behavioural abnormalities, seizure disorders, or a combination of these features. CP is thought to affect three to four individuals per 1000 of the general population. The incidence, prevalence, and most common causes of CP have varied over time because of changes in prenatal and paediatric care. Medical management of children and adults involves care from primary-care physicians with input from specialists in neurology, orthopaedics, and rehabilitation medicine. Physicians should also work in conjunction with rehabilitation therapists, educators, nurses, social care providers, and schoolteachers. The focus of rehabilitation treatment has recently shifted to neurological rehabilitation in response to increasing evidence for neuroplasticity. This approach aims to improve development and function by capitalising on the innate capacity of the brain to change and adapt throughout the patient's life. As the life expectancy of individuals with CP approaches that of the general population, therapies must be developed that address the needs of adults ageing with disability.

Recurrent ankle equinus deformity due to intramuscular hemangioma of the gastrocnemius: case report

Level of Evidence: V, Expert Opinion

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Spastic equinus foot]

Pes equinus is the most common deformity in cerebral palsy. A primarily dynamic pes equinus without shortening of the calf muscle in many cases turns into a structural pes equinus. This is due to insufficient linear growth of the calf muscle compared to bone growth. Structural pes equinus has to be distinguished from marked, compensatory and forefoot pes equinus. Conservative as well as operative treatment options are often applied in combination or sequentially. In dynamic pes equinus botulinum toxin A is the therapy of choice. Only slight structural pes equinus may improve under botulinum toxin A injection with and without additional casting. Usually, structural pes equinus requires operative treatment or lengthening of the gastrocnemius and/or soleus muscle (operation according to Baumann). Because of its side effect of inducing loss of power of the calf muscle, lengthening of the Achilles tendon should only be performed with caution. Especially in bilateral spastic cerebral palsy, the increased risk of causing talipes calcaneovalgus and crouch gait has to be considered.

Mesenchymal stem cells at the intersection of cell and gene therapy

IMPORTANCE OF THE FIELD

Mesenchymal stem cells have the ability to differentiate into osteoblasts, chondrocytes and adipocytes. Along with differentiation, MSCs can modulate inflammation, home to damaged tissues and secrete bioactive molecules. These properties can be enhanced through genetic-modification that would combine the best of both cell and gene therapy fields to treat monogenic and multigenic diseases.

AREAS COVERED IN THIS REVIEW

Findings demonstrating the immunomodulation, homing and paracrine activities of MSCs followed by a summary of the current research utilizing MSCs as a vector for gene therapy, focusing on skeletal disorders, but also cardiovascular disease, ischemic damage and cancer.

WHAT THE READER WILL GAIN

MSCs are a possible therapy for many diseases, especially those related to the musculoskeletal system, as a standalone treatment, or in combination with factors that enhance the abilities of these cells to migrate, survive or promote healing through anti-inflammatory and immunomodulatory effects, differentiation, angiogenesis or delivery of cytolytic or anabolic agents.

TAKE HOME MESSAGE

Genetically-modified MSCs are a promising area of research that would be improved by focusing on the biology of MSCs that could lead to identification of the natural and engrafting MSC-niche and a consensus on how to isolate and expand MSCs for therapeutic purposes.

Tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy

Equinus is the commonest deformity in cerebral palsy (CP). Many different surgical procedures have been described for the treatment of spastic equinus. In long standing equinus deformities the tibialis anterior muscle becomes elongated which is one reason for muscle weakness. Surgical tendon shortening of the tibialis anterior tendon was therefore introduced to rebalance muscle strength. All patients with CP who had a tibialis anterior tendon shortening (TATS) in combination with a tendo Achilles lengthening (TAL) were included in this study. A total of 29 patients had 30 surgical interventions (21 hemiplegic patients: 14 boys/7 girls, age 9-22 years; mean 15.2 years; 5 diplegics and 3 quadriplegics; 5 boys/3 girls, age 7-37.5 years; mean 14.8 years). Fifteen patients had additional surgery (soft tissue or bony procedures). The TATS was performed at the distal insertion with transosseous tendon fixation in the medial cuneiform bone at the original place. Movement Analysis Profile (MAP) for ankle dorsi-/plantarflexion, Gait Profile Score (GPS), Gait Deviation Index (GDI), and Gillette Gait Index (GGI) improved significantly for all patients compared pre- to postoperatively. In 93% of the patients active dorsiflexion of the ankle was possible postoperatively. We conclude that TATS in combination with TAL in spastic equinus in CP is a safe procedure and improves but not completely corrects foot positioning during gait. For the treatment of spastic equinus in CP we recommend shortening of the elongated antagonist (TATS) in combination with lengthening of the short agonist (TAL) for achieving optimal postoperative function.

Combined VEGF and LMP-1 delivery enhances osteoprogenitor cell differentiation and ectopic bone formation

A novel strategy to enhance bone repair is to combine angiogenic factors and osteogenic factors. We combined vascular endothelial growth factor (VEGF) and LIM mineralization protein-1 (LMP-1) by using an internal ribosome entry site to link the genes within a single plasmid. We then evaluated the effects on osteoblastic differentiation in vitro and ectopic bone formation in vivo with a subcutaneously placed PLAGA scaffold loaded with a cloned mouse osteoprogenitor cell line, D1, transfected with plasmids containing VEGF and LMP-1 genes. The cells expressing both genes elevated mRNA expression of RunX2 and β-catenin and alkaline phosphatase activity compared to cells from other groups. In vivo, X-ray and micro-CT analysis of the retrieved implants revealed more ectopic bone formation at 2 and 3 weeks but not at 4 weeks compared to other groups. The results indicate that the combination of the therapeutic growth factors potentiates cell differentiation and may promote osteogenesis.

Surgical correction of equinus deformity in children with cerebral palsy: a systematic review

PURPOSE

Equinus is the most common deformity in cerebral palsy. However, despite the large volume of published studies, there are poor levels of evidence to support surgical intervention. This study was undertaken to examine the current evidence base for the surgical management of equinus deformity in cerebral palsy.

METHODS

A systematic review of the literature using "equinus deformity", "cerebral palsy" and "orthopaedic surgery" generated 49 articles. After applying inclusion and exclusion criteria, 35 articles remained. The Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence and the Methodological Index for Non-Randomized Studies (MINORS) were used to grade the articles.

RESULTS

Studies ranged in sample size from 9 to 156 subjects, with an average of 38 subjects. The mean age of subjects at index surgery ranged from 5 to 19 years. Nineteen studies used instrumented gait analysis, with an average follow-up of 2.8 years. Seven studies reported that a younger age at index surgery was associated with an increased risk of recurrent equinus. The average rate of calcaneus in hemiplegic children was 1% and it was 15% in those with spastic diplegia. Most studies were level 4 quality of evidence, leading to, at best, only grade C recommendation.

CONCLUSIONS

Cerebral palsy subtype (hemiplegia versus diplegia) and age at index surgery were the two most important variables for determining the outcome of surgery for equinus deformity in cerebral palsy. Despite the great emphasis on differences in surgical procedures, there was less evidence to support the type of operation in relation to outcome.

The use of botulinum toxin A in children with cerebral palsy, with a focus on the lower limb

PURPOSE

The purpose of this review is to clarify the role of botulinum toxin serotype A (BTX-A) in the treatment of children with cerebral palsy (CP), with a special focus on the lower limb.

BACKGROUND

The treatment of spasticity is central in the clinical management of children with CP. BTX-A blocks the release of acetylcholine at the motor end plate, causing a temporary muscular denervation and, in an indirect way, a reduced spasticity. Children with increased tone develop secondary problems over time, such as muscle contractures and bony deformities, which impair their function and which need orthopaedic surgery. However in these younger children, delaying surgery is crucial because the results of early surgical interventions are less predictable and have a higher risk of failure and relapse. As BTX-A treatment reduces tone in a selective way, it allows a better motor control and muscle balance across joints, resulting in an improved range of motion and potential to strengthen antagonist muscles, when started at a young age. The effects are even more obvious when the correct BTX-A application is combined with other conservative therapies, such as physiotherapy, orthotic management and casts. There is now clear evidence that the consequences of persistent increased muscle tone can be limited by applying an integrated multi-level BTX-A treatment approach. Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, "reflection is more important than injection" remains an actual statement.

Achilles lengthening procedures

Contracture of the gastrocnemius-soleus complex with equinus deformity is a common hindfoot condition. In children, it is frequently associated with neuromuscular conditions such as cerebral palsy. In the adult population, it is linked to numerous pathologies such as adult-acquired flatfoot, diabetic neuropathic ulcers, and plantar fasciitis. With the medial column reduced, failure to achieve 10 degrees of passive ankle dorsiflexion with the knee flexed and extended suggests a contracture. This article reviews the anatomical and evolutionary basis for human foot structure, implications of tight gastrocnemius, and specific disease states. Operative releases for lengthening, including proximal gastrocnemius recession, tendo-Achilles lengthening, and endoscopic recession, are detailed.

Can persistent drop foot after calf muscle lengthening be predicted preoperatively?

Calf muscle lengthening usually corrects equinus gait satisfactorily in stance. While in swing, the foot remains in drop foot in approximately half the limbs. The aim of this study was to evaluate if any preoperative clinical findings or kinematic and kinetic data could predict the outcome regarding drop foot. The study included 34 children with cerebral palsy. The average age was 9.3 years. Only children with preoperative maximum ankle dorsiflexion in stance and maximum ankle dorsiflexion in swing more than 2 standard deviations below the normal mean were included. The children underwent preoperative and postoperative clinical examination and gait analysis. Forty calf muscle lengthenings were performed (26 tendo-achilles lengthenings, 14 gastrocnemius recessions). Nineteen of 40 limbs remained in drop foot despite satisfactory correction in stance. There was a significant association between postoperative drop foot and increased preoperative maximum plantar flexion in initial swing (P = .004; odds ratio, 0.906). A limited number of tests of preoperative selective motor control of dorsiflexion of the ankle indicated that normal function is strongly indicative of postoperative normal swing phase. There were no significant associations between postoperative drop foot and preoperative clinical findings, gait function, type of gait pattern, type of cerebral palsy, and type of operation. Preoperative maximum plantar flexion in an initial swing of less than -42 degrees and a preoperative normal selective motor control of dorsiflexion of the ankle are strongly indicative of postoperative normal swing phase. A lower selective motor control score rather than normal function is not predictive of either normal swing or drop foot.

LEVEL OF EVIDENCE

2.

Adductor release and chemodenervation in children with cerebral palsy: a pilot study in 16 children

PURPOSE

A pilot study with short-term outcomes of a combined surgical and medical intervention for management of generalized lower limb spasticity, hip displacement and contractures of adductors in children with bilateral spastic cerebral palsy.

METHODS

A prospective cohort study of 16 children (9 boys and 7 girls) aged 2-6 years with bilateral spastic cerebral palsy was performed. At entry, 5 were classified as level III and 11 as level IV, according to the Gross Motor Function Classification System (GMFCS). The intervention consisted of surgical lengthening of adductor longus and gracilis combined with the phenolization of the anterior branch of the obturator nerve, using 1 ml of 6% phenol, applied under direct vision at the time of lengthening of adductor longus. The hamstring and calf muscles were each injected with Botulinum neurotoxin A at a dose of 4 U/kg/muscle. Serial clinical (hip, knee, ankle joint range of motion), radiographic (migration percentage) and functional data-taken from a functional mobility scale (FMS) or GMFCS-were collected at 3, 6, 12 and 24 months post-operatively.

RESULTS

There was a significant increase in hip abduction, knee extension (popliteal angle) and ankle dorsiflexion, maintained for 24 months; mean hip migration percentage decreased from 29 to 21% (P < 0.001). Using a validated mobility scale, significant improvements were noted in gross motor function. There were no complications related to the intervention.

CONCLUSIONS

The combined surgical-medical intervention resulted in a reduction of spastic hip subluxation and improvements in gross motor function, as determined by the FMS. The combined intervention is, thus, useful as a temporizing measure, before definitive decisions are made considering such interventions as dorsal rhizotomy, intrathecal baclofen and single-event, multilevel surgery.