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Horsch A, Petzinger L, Deisenhofer J, Ghandour M, Klotz M, Renkawitz T, Putz C. The Impact of Operative Correction of Equinus in Cerebral Palsy on Gait Patterns. Foot Ankle Int 2024; 45:130-140. [PMID: 38156624 DOI: 10.1177/10711007231217273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND This study aimed to evaluate gait outcomes and strength following the surgical correction of equinus in cerebral palsy (CP) based on different surgical procedures. We included the Baumann and Strayer procedures, as well as the Achilles tendon lengthening (ATL). METHODS A retrospective analysis was performed in patients with infantile, bilateral CP who received instrumental 3D gait analysis before and after surgical correction (18.66 months postoperatively). Patients were divided into 3 groups: Strayer surgery, Baumann surgery, and ATL. Gait performance and muscle strengths were compared between studied surgeries. RESULTS A total population of 204 patients (15.43 years) with 341 operated lower limbs (LLs) was analyzed. Dorsiflexion in swing and stance phases significantly improved in all groups postoperatively. The Strayer and the ATL group showed higher postoperative dorsiflexion than the Baumann group. However, no loss of strength was observed with the Baumann method. Maximum power improved in this group postoperatively. An 8.2% loss in calf muscle strength was recorded in the Strayer group. CONCLUSION Operative pes equinus treatment successfully improved the gait of children and adults with CP postoperatively. There were differences in postoperative results between studied operative techniques regarding range of motion and power. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Axel Horsch
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Lara Petzinger
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Julian Deisenhofer
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Maher Ghandour
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Klotz
- Orthopedics and Trauma Surgery, Marienkrankenhaus Soest, Soest, Germany
| | - Tobias Renkawitz
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelia Putz
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
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Kindred KB, Kapsalis AP, Adams WJE, Miller JM, Blacklidge DK, Elliott BG, Hoffman SM. The Role of the Plantaris in Intramuscular Gastrocnemius Equinus Correction. J Foot Ankle Surg 2023; 62:272-274. [PMID: 36096902 DOI: 10.1053/j.jfas.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 02/03/2023]
Abstract
Equinus deformity is a common cause of foot and ankle pathology. The purpose of our study was to evaluate the role of the plantaris in equinus. Secondary aims were to describe the role of the plantaris in intramuscular gastrocnemius recession and to determine the prevalence of the plantaris in our patient population. We measured ankle dorsiflexion during the steps of a Baumann-type intramuscular gastrocnemius recession. Eighty-nine patients were enrolled in our study. Fourteen of 89 (15.7%) patients did not have a plantaris. A mean dorsiflexion of 9 (interquartile range 6-12)° was obtained after transection of the plantaris tendon and an additional mean 8 (interquartile range 5-10)° was obtained after recession of the gastrocnemius aponeurosis. There was a strong positive correlation (rs = 0.842) of dorsiflexion increase after plantaris transection and dorsiflexion increase after gastrocnemius recession (p < .00). Linear regression showed that for every one-degree of dorsiflexion increase with plantaris transection, there was a predicted dorsiflexion increase of 0.69° with gastrocnemius recession. These results indicate that the plantaris is a component of equinus deformity.
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Affiliation(s)
- Kristin B Kindred
- Postgraduate Fellow, American Health Network Foot and Ankle Reconstructive Surgery Fellowship, Carmel, IN.
| | - Andrew P Kapsalis
- Postgraduate Fellow, American Health Network Foot and Ankle Reconstructive Surgery Fellowship, Carmel, IN
| | - William J E Adams
- Postgraduate Fellow, American Health Network Foot and Ankle Reconstructive Surgery Fellowship, Carmel, IN
| | - J Michael Miller
- Surgeon, American Health Network, Avon, Carmel, Kokomo, Muncie, IN
| | | | - Brian G Elliott
- Surgeon, Major Health Partners ReNovo Orthopedics, Shelbyville, IN
| | - Scott M Hoffman
- Surgeon, American Health Network, Avon, Carmel, Kokomo, Muncie, IN
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Sclavos N, Thomason P, Passmore E, Graham K, Rutz E. Foot drop after gastrocsoleus lengthening for equinus deformity in children with cerebral palsy. Gait Posture 2023; 100:254-260. [PMID: 36682318 DOI: 10.1016/j.gaitpost.2023.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Gastrocsoleus lengthening (GSL) is the most common surgical procedure to treat equinus deformity in ambulant children with cerebral palsy (CP). Foot drop, where the ankle remains in plantarflexion during swing phase, can persist in some children post-operatively. There is currently limited understanding of which children will demonstrate persistent foot drop after GSL. RESEARCH QUESTION Which children develop persistent foot drop after GSL surgery for equinus? METHODS We conducted a retrospective cohort study on ambulant children with CP who had GSL surgery for fixed equinus deformity. The aims of the study were: to determine the frequency of persistent foot drop post-operatively and to compare outcome parameters from physical examination and three-dimensional gait analysis for children with hemiplegia or diplegia. RESULTS One hundred and ten children functioning at GMFCS Levels I/II/III of 28/75/7 met the inclusion criteria for this study. There were 71 boys and mean age was 9.1 years at time of GSL surgery. The overall frequency of persistent foot drop was 25%, with a higher frequency of persistent foot drop in children with hemiplegia (42%) than children with diplegia (19%). There were significant improvements in dorsiflexor strength and in selective motor control in children with diplegia but not in children with hemiplegia. Mean (SD) pre-operative mid-swing ankle dorsiflexion for children with hemiplegia was - 14.0° (9.9°) and improved post-operatively to - 1.6° (5.5°). For children with diplegia, the pre-operative mid-swing ankle dorsiflexion was - 12.1° (12.9°) and improved post-operatively to + 4.2° (6.9°). SIGNIFICANCE Foot drop is present following GSL surgery for fixed equinus deformity in a significant number of children with hemiplegia and to a lesser extent in children with diplegia, which may reflect a difference in the central nervous system lesion between these groups. New management approaches are required for this important and unsolved problem.
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Affiliation(s)
- Nicholas Sclavos
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria 3052, Australia; Hugh Williamson Gait Analysis Laboratory, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Pam Thomason
- Hugh Williamson Gait Analysis Laboratory, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Elyse Passmore
- Hugh Williamson Gait Analysis Laboratory, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department Biomedical Engineering, The University of Melbourne, Parkville, Victoria 3052, Australia
| | - Kerr Graham
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria 3052, Australia; Hugh Williamson Gait Analysis Laboratory, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Orthopaedics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Erich Rutz
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria 3052, Australia; Hugh Williamson Gait Analysis Laboratory, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Orthopaedics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Medical Faculty, The University of Basel, Basel 4001, Switzerland.
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Bull PE, Thompson MJ, McGann M, Mendez G, Berlet GC, Olaniyan A. The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy. Foot Ankle Spec 2022:19386400221133410. [PMID: 36330662 DOI: 10.1177/19386400221133410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Gastrocnemius recession is a popular procedure utilized to treat chronic conditions related to isolated gastrocnemius contracture (IGC). Recent anatomical research detailing variable gastrocsoleus tendon morphology has raised important questions regarding the safety of some traditional recession procedures. Alternative gastrocnemius recession strategies may produce comparable dorsiflexion improvement results while avoiding the surgical risk related to conjoint tendon anatomical variability. METHODS Ten matched cadaver pairs were randomized to receive either a medial gastrocnemius recession (MGR) procedure or a gastrocnemius intramuscular recession "Baumann" procedure. Postoperative dorsiflexion improvement was measured and then compared between groups. Detailed postoperative surgical dissections were performed to assess structures at risk, conjoint tendon morphology, and anatomical symmetry. RESULTS Medial gastrocnemius recession and Baumann procedures were equally effective at producing significant increases in passive ankle dorsiflexion. No sural nerve injuries were observed. Thirty-five percent of specimens showed direct muscular fusion of at least a portion of the distal gastrocnemius muscular tissue to the adjacent soleus. CONCLUSION The MGR procedure produced comparable dorsiflexion improvement results to the Baumann procedure in our cadaver model. Surgeons must account for certain conjoint tendon anatomical variants when surgically treating IGC as traditional recession methods risk tendo-Achilles overlengthening. LEVELS OF EVIDENCE Level V: Cadaver Study.
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Affiliation(s)
| | | | - Maria McGann
- Romano Orthopaedic Center, River Forest, Illinois
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Ankle Dorsiflexor Function after Gastrocsoleus Lengthening in Children with Cerebral Palsy: A Literature Review. Medicina (B Aires) 2022; 58:medicina58030375. [PMID: 35334551 PMCID: PMC8955202 DOI: 10.3390/medicina58030375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/20/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Recurrence of Equinus Foot in Cerebral Palsy following Its Correction-A Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030339. [PMID: 35327713 PMCID: PMC8947726 DOI: 10.3390/children9030339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/21/2022] [Accepted: 02/26/2022] [Indexed: 11/23/2022]
Abstract
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.
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Manzi G, Bernasconi A, Lopez J, Brilhault J. Ankle dorsiflexion after isolated medial versus complete proximal gastrocnemius recession: A cadaveric study. Foot (Edinb) 2021; 49:101842. [PMID: 34687979 DOI: 10.1016/j.foot.2021.101842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 06/02/2021] [Accepted: 06/09/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Gastrocnemius recession has been described in the treatment of gastrocnemius contracture. The aims of this study were: (1) to assess the change in ankle dorsiflexion after isolated medial gastrocnemius recession performed according to L.S. Barouk's technique; (2) to compare ankle dorsiflexion after isolated medial head with complete proximal gastrocnemius recession. METHODS A cadaveric study was performed on 15 lower limb adult specimens. Isolated medial gastrocnemius head recession was initially performed, followed by an additional recession of the lateral gastrocnemius head. Ankle dorsiflexion torque was applied with 2 and 4 kg forces on second metatarsal head. Ankle dorsiflexion was measured with the knee both in extension and at 90° of flexion and values were recorded before surgery (T0), after medial head recession (T1) and after both heads recession (T2). Normality of data was assessed using the Shapiro-Wilk test, then measurements were compared in the three conditions with appropriate statistical tests. RESULTS After isolated medial gastrocnemius recession (Δ = T1-T0), ankle dorsiflexion assessed with the knee in extension significantly increased by 5° ± 3 (range, -2 to 10) with a 2-kg torque (p = 0.02) and by 4.5° ± 3 (range, -4 to 10) with a 4-kg torque (p = 0.04). No significant difference was observed with the knee flexed at 90° (p > 0.05 for all measurements). After both gastrocnemius heads recession (Δ = T2-T1), although a further increase in dorsiflexion was noticed, statistical significance was not reached neither with the knee in extension nor at 90° of flexion (p > 0.05 for all measurements). CONCLUSION In this study, isolated medial gastrocnemius head recession performed according to LS Barouk's technique was effective in improving ankle dorsiflexion, whereas the additional release of the lateral head did not produce any significant change. LEVEL OF EVIDENCE Level V, cadaveric study.
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Affiliation(s)
- Giovanni Manzi
- Service de Chirurgie Orthopédique, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France.
| | - Alessio Bernasconi
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, London, United Kingdom; Orthopaedic and Traumatology Unit, Department of Public Health, "Federico II" Naples University, Naples, Italy
| | | | - Jean Brilhault
- Centre de Chirurgie Orthopédique & Traumatologique, C.H.R.U Tours, 37044, Tours Cedex, France; Faculté de Médecine de Tours, 10, Boulevard Tonnelé, 37032 Tours Cedex 1, France
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Stief F, Holder J, Böhm H, Meurer A. [Dynamic analysis of joint loading due to leg axis deformity in the frontal plane : Relevance of instrumented gait analysis]. DER ORTHOPADE 2021; 50:528-537. [PMID: 34156498 DOI: 10.1007/s00132-021-04121-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Instrumented 3D gait analysis (IGA) has been established for the functional evaluation of orthopedic diseases. It can provide valuable additional information beyond conventional static radiographic diagnostics and, thus, contributes to treatment decisions and a successful surgical outcome. Regarding the assessment of leg axis deformities IGA is currently only used in a few specialized centers. PRACTICE This article describes the methods used by IGA and shows its benefit for the treatment of leg axis deformities of the knee in the frontal plane. In particular, the calculation of dynamic joint loads provides important insights regarding the development of degenerative joint deformities in the knee joint and, thus, complements the static assessment of the leg axis. A new treatment algorithm for guided growth intervention in children and adolescents by temporary epiphysiodesis is presented. IGA can be particularly useful for clinical decision-making in borderline cases. If there is a discrepancy between the static leg axis and dynamic knee joint loading, IGA can reveal potential compensatory mechanisms during walking.
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Affiliation(s)
- Felix Stief
- Klinik für Orthopädie (Friedrichsheim), Universitätsklinikum Frankfurt, Marienburgstraße 2, 60528, Frankfurt am Main, Deutschland.
| | - Jana Holder
- Klinik für Orthopädie (Friedrichsheim), Universitätsklinikum Frankfurt, Marienburgstraße 2, 60528, Frankfurt am Main, Deutschland
| | - Harald Böhm
- Orthopädische Kinderklinik, Aschau im Chiemgau, Deutschland
- PFH Private Hochschule, Göttingen, Deutschland
| | - Andrea Meurer
- Klinik für Orthopädie (Friedrichsheim), Universitätsklinikum Frankfurt, Marienburgstraße 2, 60528, Frankfurt am Main, Deutschland
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Ma N, Sclavos N, Passmore E, Thomason P, Graham K, Rutz E. Three-Dimensional Gait Analysis in Children Undergoing Gastrocsoleus Lengthening for Equinus Secondary to Cerebral Palsy. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:98. [PMID: 33499373 PMCID: PMC7911110 DOI: 10.3390/medicina57020098] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Norine Ma
- Australia and Hugh Williamson Gait Laboratory, Pediatric Orthopedic Department, The Royal Children’s Hospital, Parkville, Melbourne, VIC 3052, Australia; (N.M.); (N.S.); (E.P.); (P.T.); (K.G.)
| | - Nicholas Sclavos
- Australia and Hugh Williamson Gait Laboratory, Pediatric Orthopedic Department, The Royal Children’s Hospital, Parkville, Melbourne, VIC 3052, Australia; (N.M.); (N.S.); (E.P.); (P.T.); (K.G.)
| | - Elyse Passmore
- Australia and Hugh Williamson Gait Laboratory, Pediatric Orthopedic Department, The Royal Children’s Hospital, Parkville, Melbourne, VIC 3052, Australia; (N.M.); (N.S.); (E.P.); (P.T.); (K.G.)
- Murdoch Children’s Research Institute, Melbourne, VIC 3052, Australia
- Faculty of Engineering and Information Technology, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Pam Thomason
- Australia and Hugh Williamson Gait Laboratory, Pediatric Orthopedic Department, The Royal Children’s Hospital, Parkville, Melbourne, VIC 3052, Australia; (N.M.); (N.S.); (E.P.); (P.T.); (K.G.)
- Murdoch Children’s Research Institute, Melbourne, VIC 3052, Australia
| | - Kerr Graham
- Australia and Hugh Williamson Gait Laboratory, Pediatric Orthopedic Department, The Royal Children’s Hospital, Parkville, Melbourne, VIC 3052, Australia; (N.M.); (N.S.); (E.P.); (P.T.); (K.G.)
- Murdoch Children’s Research Institute, Melbourne, VIC 3052, Australia
- Department of Pediatrics, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Erich Rutz
- Australia and Hugh Williamson Gait Laboratory, Pediatric Orthopedic Department, The Royal Children’s Hospital, Parkville, Melbourne, VIC 3052, Australia; (N.M.); (N.S.); (E.P.); (P.T.); (K.G.)
- Murdoch Children’s Research Institute, Melbourne, VIC 3052, Australia
- Department of Pediatrics, The University of Melbourne, Melbourne, VIC 3052, Australia
- Medical Faculty, The University of Basel, 4001 Basel, Switzerland
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Mu X, Deng B, Zeng J, Zhang H, Zhao Y, Sun Q, Xu J, Wang L, Xu L. Orthopedic treatment of the lower limbs in spastic paralysis. BRAIN SCIENCE ADVANCES 2020. [DOI: 10.26599/bsa.2020.9050001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Spastic paralysis of the limb mainly results from the central lesion, in which spastic cerebral palsy is the common cause. Due to durative muscle spasm in spastic cerebral palsy, it is often accompanied by the formation of secondary musculoskeletal deformities, resulting in limb motor disability. Based on its pathogenesis, surgical treatment is currently applied: selective posterior rhizotomy (SPR) or orthopedic surgery. The primary purpose of early orthopedic surgery was simply to correct limb deformities, which usually led to the recurrence of deformity as a result of the presence of spasticity. With the application of SPR, high muscle tone was successfully relieved, but limb deformity was still present postoperatively. Therefore, this study aimed to elaborate on the management of orthopedic surgery, common deformities of the lower limb, and orthopedic operative methods; discuss the relationship between SPR and orthopedic procedure for limb deformity; and focus on the indications, timing of intervention, and postoperative outcome of different surgical methods.
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Affiliation(s)
- Xiaohong Mu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Bowen Deng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Jie Zeng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Houjun Zhang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Yi Zhao
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Jie Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Le Wang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Lin Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
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Putz C, Mertens EM, Wolf SI, Geisbüsch A, Niklasch M, Gantz S, Döderlein L, Dreher T, Klotz MC. Equinus Correction During Multilevel Surgery in Adults With Cerebral Palsy. Foot Ankle Int 2018; 39:812-820. [PMID: 29606023 DOI: 10.1177/1071100718765161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Equinus foot deformity constitutes a common gait disorder in ambulatory adults with bilateral spastic cerebral palsy (BSCP). The outcome after intramuscular aponeurotic lengthening in the context of single-event multilevel surgery (SEMLS) in adulthood has not been investigated. METHODS We followed a group of 31 ambulatory adults with BSCP and equinus who underwent SEMLS including gastrocnemius-soleus intramuscular aponeurotic recession or Achilles tendon lengthening. All patients were analyzed preoperatively and at least 1 year (mean follow-up period: 1.6 years) postoperatively by clinical examination and 3-dimensional instrumented gait analysis including the Gait Profile Score (GPS). RESULTS Clinical examination showed no significant improvement of ankle dorsiflexion ( P = .5) and an unchanged plantarflexion ( P = .7) with knee extended but a significant postoperative reduction of spasticity in the calf muscle ( P = .0001) as measured by clinical examination following the modified Ashworth scale. Significant improvement of mean ankle dorsiflexion in stance and swing ( P = .0001) was found. The GPS decreased and improved significantly (15.9 ± 4.6 to 11.4 ± 3.1; P = .0001). Persistence of equinus and calcaneal gait indicating under- and overcorrection at follow-up was found in 1 patient (3%), respectively. CONCLUSION Intramuscular gastrocnemius-soleus aponeurotic recession is part of multilevel surgery corrected equinus deformity in adults. The increase in muscle length led to significant improvement of kinetic and kinematic parameters during walking without a loss of muscle strength and push-off capacity. The risk of overcorrection after equinus correction in adults with BSCP was found to be relatively low. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Cornelia Putz
- 1 Pediatric Orthopedics and Foot Surgery, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Eva Maria Mertens
- 1 Pediatric Orthopedics and Foot Surgery, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian I Wolf
- 1 Pediatric Orthopedics and Foot Surgery, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Geisbüsch
- 1 Pediatric Orthopedics and Foot Surgery, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mirjam Niklasch
- 1 Pediatric Orthopedics and Foot Surgery, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Simone Gantz
- 2 Experimental Orthopedics, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Leonhard Döderlein
- 3 Orthopedic Hospital for Children, Behandlungszentrum Aschau GmbH, Bernauerstrasse 18, 83229 Aschau i. Chiemgau, Germany
| | - Thomas Dreher
- 1 Pediatric Orthopedics and Foot Surgery, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias C Klotz
- 1 Pediatric Orthopedics and Foot Surgery, Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Kläusler M, Speth BM, Brunner R, Tirosh O, Camathias C, Rutz E. Long-term follow-up after tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy. Gait Posture 2017; 58:457-462. [PMID: 28918357 DOI: 10.1016/j.gaitpost.2017.08.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/16/2017] [Accepted: 08/24/2017] [Indexed: 02/02/2023]
Abstract
Using Tibialis Anterior Shortening (TATS) in combination with Achilles Tendon Lengthening (TAL) to treat spastic equinus in children with cerebral palsy (CP) was described in 2011. Short-term results have indicated a good outcome, especially an improvement of the drop foot in swing phase and the correction of equinus in stance phase. The aim of this study was to analyse the results of the long-term follow-up and to determine the relapse rate of TATS and TAL. The kinematics of the sagittal, frontal and transversal planes were measured by using instrumented 3D gait analysis at three defined time points and then described using the Gait Profile Score (GPS) and Movement Analysis Profile (MAP). The data was exported into Gaitabase and then the preoperative (T0), short- term (T1) and long-term (T2) follow-up data was statistically compared. 23 patients (mean age at index-surgery=14.9years) were included, there was a mean follow-up time of 5.8 years. 3 children (13%) have shown a relapse. The data of 12 children with spastic hemiplegia (12 legs), as well as 8 children with spastic diplegia (10 legs) has been analysed. There has been a significant (p<0.05) improvement in GPS and MAP for ankle dorsiflexion (describes equinus and drop foot) of the operated legs versus not operated legs. TATS in combination with TAL shows a satisfactory long-term result after 5.8 years in the correction of fixed equinus and drop foot in children with CP. Postoperatively all subjects were able to walk without an AFO.
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Affiliation(s)
- Michèle Kläusler
- Department of Orthopedic Surgery, University Children's Hospital Basel, Spitalstrasse 33, 4056 Basel, Switzerland; Department of Orthopedic Surgery, University Hospital Basel, Spitalstrasse 21, 4056 Basel, Switzerland
| | - Bernhard Maria Speth
- Department of Orthopedic Surgery, University Children's Hospital Basel, Spitalstrasse 33, 4056 Basel, Switzerland
| | - Reinald Brunner
- Department of Orthopedic Surgery, University Children's Hospital Basel, Spitalstrasse 33, 4056 Basel, Switzerland
| | - Oren Tirosh
- Department of Health & Medical Sciences, Swinburne Univerity of Technology, Melbourne, Australia
| | - Carlo Camathias
- Department of Orthopedic Surgery, University Children's Hospital Basel, Spitalstrasse 33, 4056 Basel, Switzerland
| | - Erich Rutz
- Department of Orthopedic Surgery, University Children's Hospital Basel, Spitalstrasse 33, 4056 Basel, Switzerland.
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Georgiadis AG, Schwartz MH, Walt K, Ward ME, Kim PD, Novacheck TF. Team Approach: Single-Event Multilevel Surgery in Ambulatory Patients with Cerebral Palsy. JBJS Rev 2017; 5:e10. [DOI: 10.2106/jbjs.rvw.16.00101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
Equinus is linked to most lower extremity biomechanically related disorders. Defining equinus as ankle joint dorsiflexion less than 5° of dorsiflexion with the knee extended is the basis for evaluation and management of the deformity. Consistent evaluation methodology using a goniometer with the subtalar joint in neutral position and midtarsal joint supinated while dorsiflexing the ankle with knee extended provides a consistent clinical examination. For equinus deformity with an associated disorder, comprehensive treatment mandates treatment of the equinus deformity. Surgical treatment of equinus offers multiple procedures but the Baumann gastrocnemius recession is preferred based on deformity correction without weakness.
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Affiliation(s)
- Patrick A DeHeer
- Surgery Department, Indiana University Health North Hospital, Carmel, IN, USA; Surgery Department, Johnson Memorial Hospital, Franklin, IN, USA; Department of Podiatric Medicine and Radiology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
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Lamberts RP, Burger M, du Toit J, Langerak NG. A Systematic Review of the Effects of Single-Event Multilevel Surgery on Gait Parameters in Children with Spastic Cerebral Palsy. PLoS One 2016; 11:e0164686. [PMID: 27755599 PMCID: PMC5068714 DOI: 10.1371/journal.pone.0164686] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/29/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Three-dimensional gait analysis (3DGA) is commonly used to assess the effect of orthopedic single-event multilevel surgery (SEMLS) in children with spastic cerebral palsy (CP). PURPOSE The purpose of this systematic review is to provide an overview of different orthopedic SEMLS interventions and their effects on 3DGA parameters in children with spastic CP. METHODS A comprehensive literature search within six databases revealed 648 records, from which 89 articles were selected for the full-text review and 24 articles (50 studies) included for systematic review. The Oxford Centre for Evidence-Based Medicine Scale and the Methodological Index for Non-Randomized Studies (MINORS) were used to appraise and determine the quality of the studies. RESULTS Except for one level II study, all studies were graded as level III according to the Oxford Centre for Evidence-Based Medicine Scale. The MINORS score for comparative studies (n = 6) was on average 15.7/24, while non-comparative studies (n = 18) scored on average 9.8/16. Nineteen kinematic and temporal-distance gait parameters were selected, and a majority of studies reported improvements after SEMLS interventions. The largest improvements were seen in knee range of motion, knee flexion at initial contact and minimal knee flexion in stance phase, ankle dorsiflexion at initial contact, maximum dorsiflexion in stance and in swing phase, hip rotation and foot progression angles. However, changes in 3DGA parameters varied based on the focus of the SEMLS intervention. DISCUSSION The current article provides a novel overview of a variety of SEMLS interventions within different SEMLS focus areas and the post-operative changes in 3DGA parameters. This overview will assist clinicians and researchers as a potential theoretical framework to further improve SEMLS techniques within different SEMLS focus groups. In addition, it can also be used as a tool to enhance communication with parents, although the results of the studies can't be generalised and a holistic approach is needed when considering SEMLS in a child with spastic CP.
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Affiliation(s)
- Robert P. Lamberts
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Newlands, South Africa
| | - Marlette Burger
- Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jacques du Toit
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Nelleke G. Langerak
- Division of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Division of Neurosurgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Rong K, Ge WT, Li XC, Xu XY. Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot. Foot Ankle Int 2015; 36:1223-8. [PMID: 26041542 DOI: 10.1177/1071100715588994] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Kai Rong
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-tao Ge
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xing-chen Li
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang-yang Xu
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai, China Department of Orthopaedics, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Abstract
BACKGROUND AND PURPOSE Instrumented 3-D gait analyses (GA) in children with cerebral palsy (CP) have shown improved gait function 1 year postoperatively. Using GA, we assessed the outcome after 5 years and evaluated parental satisfaction with the surgery and the need for additional surgery. PATIENTS AND METHODS 34 ambulatory children with spastic diplegia had preoperative GA. Based on this GA, the children underwent 195 orthopedic procedures on their lower limbs at a mean age of 11.6 (6-19) years. On average, 5.7 (1-11) procedures per child were performed. Outcome measures were evaluation of gait quality using the gait profile score (GPS) and selected kinematic parameters, functional level using the functional mobility scale (FMS), and the degree of parental satisfaction. RESULTS The mean GPS improved from 20.7° (95% CI: 19-23) preoperatively to 15.4° (95% CI: 14-17) 5 years postoperatively. There was no significant change in GPS between 1 and 5 years. The individual kinematic parameters at the ankle, knee, and hip improved statistically significantly, as did gait function (FMS). The mean parental satisfaction, on a scale from 0 to 10, was 7.7 (2-10) points. There was a need for additional surgical procedures in 14 children; this was more frequent in those who had the index operation at an early age. INTERPRETATION The main finding was that orthopedic surgery based on preoperative GA gave marked improvements in gait function and quality, which were stable over a 5-year period. Nevertheless, additional orthopedic procedures were necessary in almost half of the children and further follow-up with GA for more than 1 year postoperatively is recommended in children with risk factors for such surgery.
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Affiliation(s)
| | | | - Ingrid Skaaret
- Oslo Movement Laboratory, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Mathewson MA, Ward SR, Chambers HG, Lieber RL. High resolution muscle measurements provide insights into equinus contractures in patients with cerebral palsy. J Orthop Res 2015; 33:33-9. [PMID: 25242618 PMCID: PMC4343320 DOI: 10.1002/jor.22728] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/08/2014] [Indexed: 02/04/2023]
Abstract
Muscle contractures that occur after upper motor neuron lesion are often surgically released or lengthened. However, surgical manipulation of muscle length changes a muscle's sarcomere length (Ls ), which can affect force production. To predict effects of surgery, both macro- (fascicle length (Lf )) and micro- (Ls ) level structural measurements are needed. Therefore, the purpose of this study was to quantify both Ls and Lf in patients with cerebral palsy (CP) as well as typically developing (TD) children. Soleus ultrasound images were obtained from children with CP and TD children. Lf was determined and, with the joint in the same position, CP biopsies were obtained and formalin fixed, and Ls was measured by laser diffraction. Since soleus Ls values were not measurable in TD children, TD Ls values were obtained using three independent methods. While average Lf did not differ between groups (CP=3.6±1.2 cm, TD=3.5±0.9 cm; p>0.6), Ls was dramatically longer in children with CP (4.07±0.45 µm vs. TD=2.17±0.24 µm; p<0.0001). While Lf values were similar between children with CP and TD children, this was due to highly stretched sarcomeres within the soleus muscle. Surgical manipulation of muscle-tendon unit length will thus alter muscle sarcomere length and change force generating capacity of the muscle.
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Affiliation(s)
- Margie A. Mathewson
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0412
| | - Samuel R. Ward
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0412,Department of Orthopaedic Surgery, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0863
| | - Henry G. Chambers
- Department of Orthopaedic Surgery, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0863,Rady Children’s Hospital, San Diego, 3020 Children's Way, San Diego, CA 92123
| | - Richard L. Lieber
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0412,Department of Orthopaedic Surgery, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0863
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Abstract
This article summarizes the various alternatives for direct gastrocnemius lengthening and elucidates the relative strengths and tradeoffs of each as a means of providing balanced perspective in selecting the appropriate procedure for any given patient.
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Affiliation(s)
- Raymond Y Hsu
- Department of Orthopaedic Surgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Scott VanValkenburg
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Altug Tanriover
- Department of Orthopaedic Surgery, Cankaya Hospital, Bulten Street 44, Kavaklıdere, Ankara 06700, Turkey
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Sees JP, Miller F. Overview of foot deformity management in children with cerebral palsy. J Child Orthop 2013; 7:373-7. [PMID: 24432097 PMCID: PMC3838514 DOI: 10.1007/s11832-013-0509-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 06/17/2013] [Indexed: 02/03/2023] Open
Abstract
Foot deformities in children with cerebral palsy are common. The natural history of the deformities of the feet is very variable and very unpredictable in young children less then 5 years old. Treatment for the young children should be primarily with orthotics and manual therapy. Equinus is the most common deformity, with orthotics augmented with botulinum toxin being the primary management in young children. When fixed deformity develops lengthening only the muscle which is contracted is preferred. Varus deformity of the feet is often associated with equinus, and can almost always be managed with orthotics until 8 or 10 years of age. Planovalgus is the most common deformity in children with bilateral lower extremity spasticity. The primary management is orthotics until the child no longer tolerates the orthotic; then surgical management needs to consider all the deformities and all should be corrected. This requires correcting the subtalor subluxation with calcaneal lengthening or fusion, medial midfoot correction with osteotomy or fusion.
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Affiliation(s)
| | - Freeman Miller
- AI DuPont Hospital for Children, Box 269, Wilmington, DE 19899 USA
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