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

The Impact of Operative Correction of Equinus in Cerebral Palsy on Gait Patterns

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.

Changes in foot posture evaluated with dynamic pedobarography over the course of childhood in ambulatory youth with cerebral palsy

Purpose

Foot deformities are prevalent in children with cerebral palsy, but there is limited research on the progression of foot posture during growth. Our study aimed to evaluate the change in dynamic foot posture in children with cerebral palsy.

Methods

Children with cerebral palsy, aged 17-40 months, were recruited to participate in this Institutional Review Board-approved prospective longitudinal study by having serial foot posture evaluations. The coronal plane index and foot segmental impulses were measured with dynamic pedobarography. Data were compared between children stratified by Gross Motor Function Classification System level and typically developing children using serial Welch's t-tests across time with Holm correction for multiple comparisons.

Results

In total, 33 children (54 limbs) were included in the analysis (21 bilateral and 12 unilateral; Gross Motor Function Classification System: I-13, II-14, III-4, IV-2. Children completed 16.9 (± 4.4) evaluations (initial age 2.9 (± 0.7) and final age 18.6 (± 1.7) years)). Early valgus foot posture normalizes in children at Gross Motor Function Classification System levels I/II and persists in children at levels III/IV who do not have foot surgery. For most young children, foot posture development is variable.

Conclusion

Foot posture in young children with cerebral palsy begins in valgus and tends to normalize in youth who walk without an assistive device. Conservative management of foot deformity is recommended in early childhood.

Level of evidence

Level II, prognostic study.

Rectus femoris surgery for the correction of stiff knee gait in cerebral palsy: A systematic review and meta-analysis

INTRODUCTION

Rectus femoris (RF) transfer was long the gold-standard treatment for stiff knee gait (SKG), but efficacy now seems less than that of distal RF release. The aim of the present study was to compare efficacy between the two. The study hypothesis was that both significantly improve 4 knee kinematic parameters at 1 year.

PATIENTS AND METHOD

A meta-analysis was performed, using PRISMA criteria, on the Medline, Science Direct, Cochrane Registry, Scopus and Pascal databases. Search was conducted up to March 1, 2020 by two authors (A.J & M.T). Study methodology was assessed on MINORS index. Inclusion criteria comprised patients with SKG, treated by RF transfer or distal release. Endpoints comprised: Peak Knee Flexion in swing phase (PKFSW), Knee Range of Motion (KROM), time to Peak Knee Flexion (t-PKFGC), and Maximum Knee Extension in stance phase (MKEST). Effect size was assessed on Standard Mean Deviation (SMD).

RESULTS

A total of 695 studies were identified, 16 of which were included: 14 transfer, 5 release. Data were analyzed for 1,079 limbs in 768 patients. Only transfer improved PKFSW, with small effect size (SMD=0.29). The other three parameters were improved by both techniques, with moderate effect size.

DISCUSSION

Results showed improved knee kinematics after RF transfer, but with small or moderate effect size. The effect of distal release on PKF could not be assessed, due to publication bias. The heterogeneity of studies and low levels of evidence call for caution in interpreting the present results.

LEVEL OF EVIDENCE

III.

A 10.5-year follow-up of walking with unilateral spastic cerebral palsy

Purpose

The purpose of this study was to describe gait evolution in patients with unilateral spastic cerebral palsy (USCP) using modified Gait Profile Score (mGPS without hip rotation), Gait Variable Score (GVS), walking speed, and the observed effects of single-level surgery (SLS) after 10 years.

Methods

Fifty-two patients with USCP (Gross Motor Function Classification System I) and data from two Clinical Gait Analyses (CGAs) were included. The evolution of patients' mGPS, GVS, and walking speed were calculated. Two "no surgery" and "single-level surgery" patient categories were analyzed. Paired t-tests were used to compare the data between CGAs and as a function of treatment category. Pearson's correlations were used to examine relationships between baseline values and evolutions in mGPS and walking speed.

Results

Mean ages (SD) at first and last CGAs were 9.3 (3.2) and 19.7 (6.0) years old, respectively, with an average follow-up of 10.5 (5.6) years. Mean mGPS for the patients' affected side was significantly lower at the last CGA for the full cohort: baseline = 8.5° (2.1) versus follow-up = 7.2° (1.6), effect size = 0.73, p < 0.001. Significant improvements in mGPS and GVS for ankle and foot progression were found for the SLS group. The mGPS change and mGPS at baseline (r = -0.79, p < 0.001) were negatively correlated.

Conclusions

SLS patients demonstrated a positive long-term change in gait pattern over time. The group that had undergone surgery had worse gait scores at baseline than the group that had not, but the SLS group's last CGA scores were relatively closer to those of the "no surgery" group.

Level of evidence

This was a retrospective comparative therapeutic study (level III).

Foot drop after gastrocsoleus lengthening for equinus deformity in children with cerebral palsy

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SIGNIFICANCE

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

The Effects of Prolonged Vibrotactile EMG-Based Biofeedback on Ankle Joint Range of Motion During Gait in Children with Spastic Cerebral Palsy: A Case Series

AIMS

The objective of this case series was to examine the feasibility of vibrotactile EMG-based biofeedback (BF) as a home-based intervention tool to enhance sensory information during everyday motor activities and to explore its effectiveness to induce changes in active ankle range of motion during gait in children with spastic cerebral palsy (CP).

METHODS

Ten children ages 6 to 13 years with spastic CP were recruited. Participants wore two EMG-based vibro-tactile BF devices for at least 4 hours per day for 1-month on the ankle and knee joints muscles. The device computed the amplitude of the EMG signal of the target muscle and actuated a silent vibration motor proportional to the magnitude of the EMG.

RESULTS

Our results demonstrated the feasibility of the augmented sensory information of muscle activity to induce changes of the active ankle range of motion during gait for 6 children with an increase ranging from 8.9 to 51.6% compared to a one-month period without treatment.

CONCLUSIONS

Preliminary findings of this case series demonstrate the feasibility of vibrotactile EMG-based BF and suggest potential effectiveness to increase active ankle range of motion, therefore serving as a promising therapeutic tool to improve gait in children with spastic CP.

The Medial Gastrocnemius Recession, an Alternative Surgical Treatment for Isolated Gastrocnemius Contracture: A Cadaver Study With Discussion Emphasizing Variable Conjoint Tendon Anatomy

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.

Reliability and Reference Norms of Single Heel-Rise Test Among Children: A Cross-sectional Study

There is a lack of data regarding the single heel-rise test (SHRT) among children. Hence, we aimed to establish reliability and reference norms of SHRT among children aged 8 to 12 years. About 500 healthy children were randomly selected from the recognized school and community settings. After demographic measurements, SHRT was conducted to evaluate the strength of each plantar flexors. SHRT repetitions were assessed by the same rater on 2 occasions for intrarater (on the same day) and test-retest reliability (on different days) and by 2 raters for inter-rater reliability. Relative reliability was described in terms of the intraclass correlation coefficient (ICC) and Pearson correlation coefficient (r). Absolute reliability was indicated by the standard error of measurement (SEm), minimal detectable change (MDC), and Bland-Altman graph. The mean of the number of repetitions of SHRT was calculated to derive the reference norm of SHRT. The anthropometric parameters were correlated with SHRT for multiple regression analysis. Intrarater, test-retest, and inter-rater reliability of SHRT were, ICC = 0.81, ICC = 0.70, and ICC = 0.57, respectively. The Bland-Altman graph confirmed limits of agreement for intrarater, test-retest, and inter-rater reliability. The reference norm of SHRT is documented to be 20.6 ± 4.8. SEm and MDC are found to be 2 and 3, respectively. Multiple regression analysis predicted a correlation of age, weight, and calf muscle girth with SHRT. SHRT is moderate to good reliable in assessing the strength of plantar flexors. The reference norms of SHRT have been derived for healthy children aged 8 to 12 years.

Mid-Term Results of Distal Femoral Extension and Shortening Osteotomy in Treating Flexed Knee Gait in Children with Cerebral Palsy

Background: Distal femoral extension and shortening osteotomy (DFESO) seems to be an effective method for the treatment of flexed knee gait in children with cerebral palsy. Nevertheless, studies investigating the mid- and long-term outcomes after such procedures are lacking in the literature. Therefore, the purpose of this study was to assess the mid-term outcomes regarding sagittal plane kinematics of the knee after DFESO with or without concomitant patella advancement. Furthermore, an evaluation of the postoperative course and possible recurrence of flexed knee gait was planned. Methods: In a prospective observational study, 19 patients (28 limbs; mean age 11.8 years (6.7–16.0 years)) were examined using 3-D gait analysis and clinical exam before (E₀) and at a mean of 38 months (E₂: 24–55 months) after surgery. Fifteen patients (22 limbs) had an additional first postoperative gait analysis (E₁) after a mean of 14 (10–20) months after surgery. In these patients, the postoperative changes between the short-term and mid-term gait analyses were evaluated. Results: DFESO led to a significant decrease in flexed knee gait with an improvement in sagittal plane kinematics during the stance phase. In addition, a slightly increased anterior pelvic tilt was observed at E₁, and we found a tendency towards stiff knee gait with a decrease in mean knee flexion in swing at E₂. Conclusions: DFESO led to a significant improvement in flexed knee gait in children with cerebral palsy. The therapeutic effect seems to be lasting on mid-term follow-up with a slight overall tendency to recurrence.

Rehabilitation After Single-Event Multilevel Surgery for Children and Young Adults With Cerebral Palsy: A Systematic Review

ABSTRACT

This review sought to describe and analyze published protocols for rehabilitation after single-event multilevel surgery for people with cerebral palsy, to identify their differences and limits, and to introduce a common step-by-step framework for future descriptions and assessments of postoperative rehabilitation protocols.The MEDLINE, Embase, CINAHL, and the Cochrane Library databases were searched. Inclusion criteria were as follows: (1) single-event multilevel surgery, (2) full-text reports published after 1985, and (3) articles with a method section describing the rehabilitation protocol. Interventions were coded using the Oxford Levels of Evidence and the Methodological Index for Non-Randomized Studies Index.Twenty-four articles were included in the review. Studies included patients aged 4-30 yrs with spastic cerebral palsy (hemiplegia, diplegia, and quadriplegia). The mean postoperative rehabilitation duration was 4.5 mos, with 4 sessions per week, and rehabilitation took place in a rehabilitation center. This review provides relevant information about the modalities, contents, limits, and difficulties associated with the post-SEMS rehabilitation protocol reported in the literature. Pain was identified as a major problem.A more precise and comprehensive description of post-SEMS rehabilitation protocols would be useful. The proposed five-step framework could be used by future studies to standardize their protocol description in terms of objective, content, and intensity.

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

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

The Foot in Cerebral Palsy

Children with cerebral palsy frequently develop foot deformities, most commonly equinus contractures, which can be managed with orthotics up to age 5 to 7 years. Plantar flexor lengthening, typically around this age, should be restricted to the offending muscle only, usually with a fascia release of the gastrocnemius. Equinovarus, mainly a problem in children with unilateral cerebral palsy, often responds to plantar flexor lengthening. If further tendon transfers are needed, they should be done when the child is older to avoid overcorrection. Planovalgus mostly improves spontaneously up to age 5 years. Surgical correction is best done in adolescence.

The Pediatric Foot in Neurologic Disorders

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

Is the Prevalence of Equinus Foot in Cerebral Palsy Overestimated? Results from a Meta-Analysis of 4814 Feet

Background: Equinus is a common foot deformity in patients with cerebral palsy (CP). However, its prevalence is scarcely reported in the literature. Therefore, we conducted this review to estimate the prevalence of equinus foot in CP. Methods: Eight databases were searched. Our primary outcome was the prevalence of equinus foot in CP patients. Subgroup analysis was conducted based on study design, the laterality of CP, and whether equinus foot was defined or not. Results: The prevalence of equinus foot in CP was 93% (95% CI: 71–99). The prevalence was 99% (95% CI: 55–100), 96% (95% CI: 57–100), and 65% (95% CI: 37–86) in unilateral, both, and bilateral CP, respectively. Based on study design, equinus foot prevalence was 92% (95% CI: 34–100) in case series and 62% (95% CI: 47–74) in cohort studies. Four studies reported definition criteria for equinus foot, with a pooled prevalence rate of equinus foot of 99% (95% CI: 36–100) compared to a rate of 89% (95% CI: 59–98) among studies that lacked a definition criterion. Conclusions: This is the first meta-analysis to address the prevalence of equinus foot in CP patients. Although its prevalence is very high, our findings should be interpreted with caution due to the presence of multiple limitations, such as the lack of standardized definition criteria for equinus foot, the inappropriate study design, the wide confidence interval of equinus foot rate, and the small number of studies investigating it as a primary outcome.

Gastrocnemius Recession as an Alternative to Midfoot Arthrodesis for Painful Midfoot Arthritis

Arthrodesis has been described as the gold standard of treatment for midfoot degenerative joint disease (DJD) but has also been associated with nonunion, increased tourniquet times, technical difficulty, and a long postoperative non-weightbearing period. Although it is postulated that a contracted gastrocnemius may cause midfoot pain, there are no reports of using the procedure as a primary treatment for midfoot DJD. The purpose of this study was to determine whether gastrocnemius recession resolved midfoot pain from osteoarthritis and eliminated the need for midfoot arthrodesis. Eleven patients with symptomatic midfoot osteoarthritis and gastrocnemius equinus elected to have a modified Baker gastrocnemius recession as an alternative to a recommended midfoot arthrodesis. Patients were kept non-weightbearing for 2 weeks, transitioned to protected weightbearing in a controlled ankle motion walking boot at weeks 3 to 4, and were allowed to ambulate without restriction in regular shoes at 4 weeks. Preoperative American Orthopedic Foot & Ankle Society (AOFAS) midfoot scores were compared with postoperative scores. Eight (72.7%) of the 11 patients responded to the postoperative survey (n = 8). The mean AOFAS midfoot score improved by 44.63 ± 20.9 points (mean ± standard deviation) (range 18 to 76) or 107% (p < .01). All subjects reported sustained improvement since the preoperative evaluation, with a mean time to follow-up of 28 ± 9.9 months (range 12 to 40). None of the patients surveyed underwent subsequent arthrodesis of the midfoot. The results of this investigation indicate that gastrocnemius recession is an effective treatment to relive symptomatic midfoot osteoarthritis. Foot and ankle surgeons may consider this procedure before performing midfoot arthrodesis to treat this pathology.

Single-event multilevel surgery in cerebral palsy: Value added by a co-surgeon

ABSTRACT

The aim of this study was to compare outcomes for single-event multilevel surgery (SEMLS) in cerebral palsy (CP) performed by 1 or 2 attending surgeons.A retrospective review of patients with CP undergoing SEMLS was performed. Patients undergoing SEMLS performed by a single senior surgeon were compared with patients undergoing SEMLS by the same senior surgeon and a consistent second attending surgeon. Due to heterogeneity of the type and quantity of SEMLS procedures included in this study, a scoring system was utilized to stratify patients to low and high surgical burden. The SEMLS events scoring less than 18 points were categorized as low burden surgery and SEMLS scoring 18 or more points were categorized as high burden surgery. Operative time, estimated blood loss, hospital length of stay, and operating room (OR) utilization costs were compared.In low burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 8 patients had SEMLS performed by 2 surgeons. In high burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 12 patients had SEMLS performed by 2 surgeons. For high burden SEMLS, operative time was decreased by a mean of 69 minutes in cases performed by 2 co-surgeons (P = 0.03). Decreased operative time was associated with an estimated savings of $2484 per SEMLS case. In low burden SEMLS, a trend toward decreased operative time was associated for cases performed by 2 co-surgeons (182 vs 221 minutes, P = 0.11). Decreased operative time was associated with an estimated savings of $1404 per low burden SEMLS case. No difference was found for estimated blood loss or hospital length of stay between groups in high and low burden SEMLS.Employing 2 attending surgeons in SEMLS decreased operative time and OR utilization cost, particularly in patients with a high surgical burden. These findings support the practice of utilizing 2 attending surgeons for SEMLS in patients with CP.Level of Evidence: Level III.

Nonsurgical Treatment Options for Muscle Contractures in Individuals With Neurologic Disorders: A Systematic Review With Meta-Analysis

OBJECTIVE

To investigate whether nonsurgical treatment can reduce muscle contractures in individuals with neurologic disorders. The primary outcome measure was muscle contractures measured as joint mobility or passive stiffness.

DATA SOURCES

Embase, MEDLINE, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database in June-July 2019 and again in July 2020.

STUDY SELECTION

The search resulted in 8020 records, which were screened by 2 authors based on our patient, intervention, comparison, outcome criteria. We included controlled trials of nonsurgical interventions administered to treat muscle contractures in individuals with neurologic disorders.

DATA EXTRACTION

Authors, participant characteristics, intervention details, and joint mobility/passive stiffness before and after intervention were extracted. We assessed trials for risk of bias using the Downs and Black checklist. We conducted meta-analyses investigating the short-term effect on joint mobility using a random-effects model with the pooled effect from randomized controlled trials (RCTs) as the primary outcome. The minimal clinically important effect was set at 5°.

DATA SYNTHESIS

A total of 70 trials (57 RCTs) were eligible for inclusion. Stretch had a pooled effect of 3° (95% CI, 1-4°; prediction interval (PI)=-2 to 7°; I 2=66%; P<.001), and robot-assisted rehabilitation had an effect of 1 (95% CI, 0-2; PI=-8 to 9; I 2=73%; P=.03). We found no effect of shockwave therapy (P=.56), physical activity (P=.27), electrical stimulation (P=.11), or botulinum toxin (P=.13). Although trials were generally of moderate to high quality according to the Downs and Black checklist, only 18 of the 70 trials used objective measures of muscle contractures. In 23 trials, nonobjective measures were used without use of assessor-blinding.

CONCLUSIONS

We did not find convincing evidence supporting the use of any nonsurgical treatment option. We recommend that controlled trials using objective measures of muscle contractures and a sufficiently large number of participants be performed.

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

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

SIGNIFICANCE

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

Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study

PURPOSE

Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP.

METHODS

A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process.

RESULTS

Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS).

CONCLUSIONS

The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research.

LEVEL OF EVIDENCE

V.

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.

Conference report on contractures in musculoskeletal and neurological conditions

Limb contractures are debilitating complications associated with various muscle and nervous system disorders. This report summarizes presentations at a conference at the Shirley Ryan AbilityLab in Chicago, Illinois, on April 19-20, 2018, involving researchers and physicians from diverse disciplines who convened to discuss current clinical and preclinical understanding of contractures in Duchenne muscular dystrophy, stroke, cerebral palsy, and other conditions. Presenters described changes in muscle architecture, activation, extracellular matrix, satellite cells, and muscle fiber sarcomeric structure that accompany or predispose muscles to contracture. Participants identified ongoing and future research directions that may lead to understanding of the intersecting factors that trigger contractures. These include additional studies of changes in muscle, tendon, joint, and neuronal tissues during contracture development with imaging, molecular, and physiologic approaches. Participants identified the requirement for improved biomarkers and outcome measures to identify patients likely to develop contractures and to accurately measure efficacy of treatments currently available and under development.

Surgical outcomes after single event multilevel surgery in cerebral palsy patients with mid-stance knee hyperextension

BACKGROUND

Some patients with cerebral palsy (CP) exhibit excessive knee flexion at initial contact followed by knee hyperextension (KE) in mid-stance.

RESEARCH QUESTION

This study investigated the change in sagittal kinematics after distal hamstring lengthening (DHL) and triceps surae lengthening procedures in CP patients with KE, and compared it to those without KE. In addition, the risk factors for the worsening of postoperative KE were analyzed.

METHODS

Consecutive 312 patients (596 limbs) with CP who underwent DHL and triceps surae lengthening were included. All patients underwent preoperative and 1-year postoperative three-dimensional gait analysis. Patients' limbs were divided into the KE and knee flexion (KF) groups, according to preoperative minimum knee flexion in stance. KE was defined as minimum knee flexion in stance less than 0°.

RESULTS

The KE and KF groups included 130 and 466 limbs, respectively. Knee and ankle sagittal kinematics significantly improved after surgery in both groups. Minimum knee flexion in stance significantly increased from -6.6˚ to 0.5˚ in the KE group, but decreased from 14.6˚ to 7.8˚ in the KF group. Among the KE group, minimum knee flexion in stance improved in 103 limbs (79.2 %), but worsened in 27 limbs (20.8 %). Degree of preoperative KE was the only factor significantly associated with postoperative worsening of KE (p=0.002). The cutoff value for the worsening of KE was -5.8˚ of preoperative minimum knee flexion in stance.

SIGNIFICANCE

This study demonstrated that the sagittal kinematics of the knee and ankle joints improved after DHL and triceps surae lengthening procedures in CP patients with and without KE. Preoperative degree of KE was a risk factor for the worsening of KE after surgery. Therefore, careful selection for indication of DHL is required to prevent postoperative KE due to overlengthening of the hamstrings, particularly in patients with severe preoperative KE.

Follow-up of walking quality after end of growth in 28 children with bilateral cerebral palsy

PURPOSE

Assessment of surgical treatments on gait in patients with bilateral cerebral palsy (CP) is often performed in short-term studies. The purpose of this study was to analyze the influence of single-event multilevel surgery (SEMLS) on long-term evolution of gait using gait deviation index (GDI) and walking speed.

METHODS

In all, 28 patients with bilateral CP (Gross Motor Function Classification System I to III) with two clinical gait analyses (CGA) were included (mean age: 9.0 years (sd 2.9) at the first CGA, 19.6 years (sd 4.1) at the last, all of them at skeletal maturity). GDI, walking speed and their changes were calculated. Statistical analysis was performed to observe differences between baseline and follow-up CGA. Pearson's correlations were conducted to evaluate the associations between GDI and walking speed changes with: GDI at baseline and walking speed at baseline. GDI and walking speed evolution have been analyzed for two groups of patients: with and without SEMLS.

RESULTS

Regardless of the treatment, GDI was significantly higher at follow-up CGA (baseline: 73.1 (sd 13.1) versus follow-up: 80.1 (sd 13.2); p = 0.014). Significant negative correlations were found between GDI change and GDI at baseline (r = -0.52; p = 0.004) and between walking speed change and walking speed at the baseline (r = -0.70; p < 0.001). Regarding the group of patients with or without SEMLS, only significant improvement of GDI was found for patients with SEMLS (at baseline: 69.0 (sd 12.1) versus follow-up: 77.8 (sd 11.2); p < 0.05).

CONCLUSION

Analysis at skeletal maturity showed a gait quality maintained for patients without SEMLS and an improvement for patients with SEMLS.

LEVEL OF EVIDENCE

Level III.

Functional outcomes after selective dorsal rhizotomy followed by minimally invasive tendon lengthening procedures in children with spastic cerebral palsy

Many surgical options have been proposed to improve the ambulatory status of children with spastic cerebral palsy (CP), but none have focused on addressing both spasticity and lower extremity tendon contractures. The purpose of this study is to evaluate the results of selective dorsal rhizotomy (SDR) followed by minimally invasive tendon lengthening allowing immediate return to ambulation. Two hundred fifty-five spastic CP patients (who received SDR procedure at an average age of 6.9±2.6  years and tendon lengthening procedure at an average age of 7.2±2.5  years) were retrospectively reviewed. Patients were grouped by the gross motor function classification system (GMFCS) 1-3 and 4-5. Kaplan-Meier analysis and Cox proportional hazard model using a requirement for additional tendon lengthening as an end point were conducted. Tendon lengthening followed SDR at an average of 4.3±10.7  months. On an average of 4.9±1.2  years after tendon lengthening, GMFCS was improved in 28 and maintained in 213 patients, respectively. There was no difference of variables and joint angles between the two GMFCS groups. A repeat tendon lengthening was required in 19 patients. The Kaplan-Meier analysis showed 81% success rate. Cox proportional hazard model identified age at tendon lengthening [hazards ratio (HR), 0.53; 95% confidence interval (CI), 0.37-0.76] and duration between SDR and tendon lengthening of more than 6  months (HR, 2.96; 95% CI, 1.05-8.33) associated with need for a repeat tendon lengthening procedure. Our novel approach of SDR/tendon lengthening results in improved joint angles as well as stable or improved GMFCS. Longer follow-up is necessary to determine if this approach could prolong ambulatory ability and reduced need for more invasive orthopedic surgeries.

Predicting gait adaptations due to ankle plantarflexor muscle weakness and contracture using physics-based musculoskeletal simulations

Deficits in the ankle plantarflexor muscles, such as weakness and contracture, occur commonly in conditions such as cerebral palsy, stroke, muscular dystrophy, Charcot-Marie-Tooth disease, and sarcopenia. While these deficits likely contribute to observed gait pathologies, determining cause-effect relationships is difficult due to the often co-occurring biomechanical and neural deficits. To elucidate the effects of weakness and contracture, we systematically introduced isolated deficits into a musculoskeletal model and generated simulations of walking to predict gait adaptations due to these deficits. We trained a planar model containing 9 degrees of freedom and 18 musculotendon actuators to walk using a custom optimization framework through which we imposed simple objectives, such as minimizing cost of transport while avoiding falling and injury, and maintaining head stability. We first generated gaits at prescribed speeds between 0.50 m/s and 2.00 m/s that reproduced experimentally observed kinematic, kinetic, and metabolic trends for walking. We then generated a gait at self-selected walking speed; quantitative comparisons between our simulation and experimental data for joint angles, joint moments, and ground reaction forces showed root-mean-squared errors of less than 1.6 standard deviations and normalized cross-correlations above 0.8 except for knee joint moment trajectories. Finally, we applied mild, moderate, and severe levels of muscle weakness or contracture to either the soleus (SOL) or gastrocnemius (GAS) or both of these major plantarflexors (PF) and retrained the model to walk at a self-selected speed. The model was robust to all deficits, finding a stable gait in all cases. Severe PF weakness caused the model to adopt a slower, "heel-walking" gait. Severe contracture of only SOL or both PF yielded similar results: the model adopted a "toe-walking" gait with excessive hip and knee flexion during stance. These results highlight how plantarflexor weakness and contracture may contribute to observed gait patterns.

Multilevel Surgery for Children With Cerebral Palsy: A Meta-analysis

CONTEXT

Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP).

OBJECTIVE

To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched.

STUDY SELECTION

Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected.

DATA EXTRACTION

Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events.

RESULTS

Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: -0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: -0.01 to 0.25) but did improve gait (SMD: -0.80; 95% CI: -0.95 to -0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies.

LIMITATIONS

Data were largely from cohort studies.

CONCLUSIONS

Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.

Current practice and preferences to management of equinus in children with ambulatory cerebral palsy: A survey of orthopedic surgeons

Introduction: The consensus among orthopedic surgeons on the management of equinus deformity in cerebral palsy (CP) children has not been reported previously despite being a prevalent deformity. The goals of this study were to examine the orthopedic surgeons’ current practice regarding the management of equinus deformity in children with ambulatory CP, and analyze variations in current practice between general orthopedic and pediatric orthopedic surgeons.

Methods: We implemented a brief cross-sectional self-reported questionnaire that addressed the areas of clinical examination and decision-making skills of management of equinus deformity in CP children. We targeted a convenience sample of 400 participants. Surgeons that provided complete responses to the questionnaire were 223 with a response rate of 56%, of which 123 (55%) were general orthopedic surgeons, whereas 100 (45%) were pediatric orthopedic surgeons. The target population consisted of orthopedic surgeons who were further sub-classified in accordance with practice age, general versus pediatric, and exposure to children’s orthopedics during the last three years of their practice. For analytical statistics, the Chi-Square test and Fisher’s exact test were used to examine the relationship between two qualitative variables.

Results: The overall clinical practice preferences of all survey participants were unimpressive with discordant survey responses. Pediatric orthopedic surgeons generally demonstrated a statistically significant difference regarding clinical assessment skill items of the survey, in contrast to general orthopedic surgeons. However, we found no differences between pediatric orthopedic and general orthopedic surgeons regarding most of the decision-making/knowledge items.

Discussion: Generally, there are insufficient clinical practice trends of both general and pediatric orthopedic surgeons regarding equinus treatment in CP children. This may indicate a knowledge–practice gap with potential risks to CP children undergoing surgery for equinus. There is a need for a more competent exposure to CP in orthopedic surgeons’ educational curricula and an updated health referral system.

Estimating the effect size of surgery to improve walking in children with cerebral palsy from retrospective observational clinical data

Single-event multilevel surgery (SEMLS) is a standard treatment approach aimed at improving gait for patients with cerebral palsy, but the effect of this approach compared to natural progression without surgical intervention is unclear. In this study, we used retrospective patient history, physical exam, and three-dimensional gait analysis data from 2,333 limbs to build regression models estimating the effect of SEMLS on gait, while controlling for expected natural progression. Post-hoc classifications using the regression model results identified which limbs would exhibit gait within two standard deviations of typical gait at the follow-up visit with or without a SEMLS with 73% and 77% accuracy, respectively. Using these models, we found that, while surgery was expected to have a positive effect on 93% of limbs compared to natural progression, in only 37% of limbs was this expected effect a clinically meaningful improvement. We identified 26% of the non-surgically treated limbs that may have shown a clinically meaningful improvement in gait had they received surgery. Our models suggest that pre-operative physical therapy focused on improving biomechanical characteristics, such as walking speed and strength, may improve likelihood of positive surgical outcomes. These models are shared with the community to use as an evaluation tool when considering whether or not a patient should undergo a SEMLS.

An Untethered Ankle Exoskeleton Improves Walking Economy in a Pilot Study of Individuals With Cerebral Palsy

The high energy cost of walking in individuals with cerebral palsy (CP) contributes significantly to reduced mobility and quality of life. The purpose of this paper was to develop and clinically evaluate an untethered ankle exoskeleton with the ability to reduce the metabolic cost of walking in children and young adults with gait pathology from CP. We designed a battery-powered device consisting of an actuator-and-control module worn above the waist with a Bowden cable transmission used to provide torque to pulleys aligned with the ankle. Special consideration was made to minimize adding mass to the body, particularly distal portions of the lower-extremity. The exoskeleton provided plantar-flexor assistance during the mid-to-late stance phase, controlled using a real-time control algorithm and embedded sensors. We conducted a device feasibility and a pilot clinical evaluation study with five individuals with CP ages five through thirty years old. Participants completed an average of 130 min of exoskeleton-assisted walking practice. We observed a 19±5% improvement in the metabolic cost of transport (p = 0.011) during walking with untethered exoskeleton assistance compared to how participants walked normally. These preliminary findings support the future investigation of powered ankle assistance for improving mobility in this patient population.

Equinus Correction During Multilevel Surgery in Adults With Cerebral Palsy

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.

Long-term results of multilevel surgery in adults with cerebral palsy

BACKGROUND

Deterioration of gait in adolescent and adult patients with cerebral palsy can be associated with multiple factors. Multilevel surgery (MLS) is one option in adults with cerebral palsy to improve gait function with encouraging short-term results. It is a question whether these improvements are maintained over time.

METHODS

In a retrospective consecutive cohort study, adults with bilateral spastic cerebral palsy (BSCP) treated with MLS between 1995 and 2011 were scanned for potential inclusion. Patients needed to fulfill the following inclusion criteria: age at MLS > 17, standardized three-dimensional gait analysis (3D-GA) including clinical examination at pre-operative (E0), a short-term follow-up (E1) and at least seven years (E2) after the index MLS. Twenty adults (10 women, 10 men) with a Gross Motor Function Classification Level (GMFCS) I-III and a mean age at MLS of 24.8 years were included in this study. The average long-term follow-up was 10.9 years. The Gait Profile Score (GPS) was used as primary outcome measure.

RESULTS

The GPS improved significantly from 13.8° before surgery to 11.2° at short-term (p = 0.007) and to 11.3° at long-term follow-up (p = 0.002). Mean GPS showed a slight deterioration between E1 and E2 due to a minority of six patients (30%) who showed a significant loss of correction.

CONCLUSION

Surgical treatment in adults with BSCP was feasible and effective in the long-term. Significant improvement of gait and function was maintained in the majority of patients, while some patients were prone to develop crouch gait, hip flexion contractures, or pain.

Cadaveric Study of the Junction Point Where the Gastrocnemius Aponeurosis Joins the Soleus Aponeurosis

Purpose

To study the location of the junction point where the gastrocnemius aponeurosis joins the soleus aponeurosis to form the Achilles tendon.

Methods

Twelve lower limb specimens were used. The distance between the medial tibial plateau and the superior border of the posterior calcaneal tubercle (A) was measured and the distances of the junction point to the superior border of the posterior calcaneal tubercle (B) were measured.

Result

The ratio B/A averaged 0.45. The gastrocnemius muscle reached or extended beyond the junction point in eight specimens (67%). The average distance from the lowest border of the muscle to the junction point was 0±12mm (-25-25).

Conclusion

There are great anatomical variations of the gastrocnemius insertion. Resection of muscle bound portion of the gastrocnemius aponeurosis is a more appropriate approach of endoscopic gastrocnemius aponeurosis recession.

Clinical Relevance

This report suggests that resection of muscle bound portion rather than the muscle void portion of the gastrocnemius aponeurosis is a more appropriate approach of endoscopic gastrocnemius aponeurosis recession.

Long-term development of gait after multilevel surgery in children with cerebral palsy: a multicentre cohort study

AIM

We investigated the long-term efficacy and safety of multilevel surgery (MLS) in ambulatory children with bilateral spastic cerebral palsy (CP).

METHOD

Two hundred and thirty-one children were evaluated at short term (1.1y, SD 0.4) and long term (9.1y, SD 3.0) follow-up using clinical examination and gait analysis. MLS was investigated by studying changes in the Gait Profile Score (GPS) referenced to the minimally important clinical difference.

RESULTS

Ambulatory children aged 10 years and 7 months (SD 2y 11mo) at MLS in Gross Motor Function Classification System levels I (19), II (144), and III (68) showed a decrease (improvement) in preoperative GPS from 16.3° (SD 4.8) to 11.3° (SD 3.2) at short-term follow-up, an improvement of 5°. At long-term follow-up, GPS was maintained at 11.4° (SD 3.1). Overall, 177 (76.6%) children maintained their improvement in GPS after 9 years.

INTERPRETATION

Multilevel surgery is a safe and effective surgical intervention, which leads to a significant improvement in gait kinematics in children with bilateral spastic CP. This study improves our understanding of MLS in the long term and will help to inform families and children when planning for MLS.

WHAT THIS PAPER ADDS

Largest study of multilevel surgery (MLS) for children with bilateral spastic cerebral palsy, with longest follow-up. MLS resulted in significant long-term improvements in gait function. Minor adverse events were common, while events requiring intervention were uncommon (4% of children). Thirty-nine per cent of children required additional surgery during follow-up. 'Single-event multilevel surgery' was changed to the more realistic term 'multilevel surgery'.

Long-term follow-up after tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy

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.

What's New in the Orthopaedic Treatment of Cerebral Palsy

BACKGROUND

The orthopaedic treatment of the patient with cerebral palsy (CP) is complex and must take into account the heterogeneity and natural history of the condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This update serves to summarize some of the recent publications in the field of pediatric orthopaedics that have made important contributions to our understanding and care of the patient with CP.

METHODS

We searched the PubMed database using the following terms: "cerebral palsy" AND "orthopedic." The results were then filtered to include only review papers or clinical trials published in English from 2010 to 2014. The obtained list of references was then reviewed for publications in the fields of lower extremity muscle imbalance, foot and ankle deformities, hip and acetabular dysplasia, and advances in orthopaedic-related technology.

RESULTS

Updates in the field of pediatric orthopaedics are constant and the current level of evidence for the effectiveness of specific treatment modalities in patients with CP was reviewed. The search method yielded 153 publications, of which 31 papers were identified as having contributed important new findings.

CONCLUSIONS

Our understanding of orthopaedic treatments for children with CP continues to grow and expand. The studies reviewed illustrate just some of the strides we have taken in utilizing evidence-based surgical decision making in practice. Nevertheless, there remains a paucity of randomized controlled trials and higher evidence research, which may contribute to the variability in current practices among providers. By elucidating these gaps we can more purposefully delegate our time and resources into targeted areas of research.

LEVEL OF EVIDENCE

Level 4-literature review.

Children with cerebral palsy have altered oscillatory activity in the motor and visual cortices during a knee motor task

The neuroimaging literature on cerebral palsy (CP) has predominantly focused on identifying structural aberrations within the white matter (e.g., fiber track integrity), with very few studies examining neural activity within the key networks that serve the production of motor actions. The current investigation used high-density magnetoencephalography to begin to fill this knowledge gap by quantifying the temporal dynamics of the alpha and beta cortical oscillations in children with CP (age = 15.5 ± 3 years; GMFCS levels II–III) and typically developing (TD) children (age = 14.1 ± 3 years) during a goal-directed isometric target-matching task using the knee joint. Advanced beamforming methods were used to image the cortical oscillations during the movement planning and execution stages. Compared with the TD children, our results showed that the children with CP had stronger alpha and beta event-related desynchronization (ERD) within the primary motor cortices, premotor area, inferior parietal lobule, and inferior frontal gyrus during the motor planning stage. Differences in beta ERD amplitude extended through the motor execution stage within the supplementary motor area and premotor cortices, and a stronger alpha ERD was detected in the anterior cingulate. Interestingly, our results also indicated that alpha and beta oscillations were weaker in the children with CP within the occipital cortices and visual MT area during movement execution. These altered alpha and beta oscillations were accompanied by slower reaction times and substantial target matching errors in the children with CP. We also identified that the strength of the alpha and beta ERDs during the motor planning and execution stages were correlated with the motor performance. Lastly, our regression analyses suggested that the beta ERD within visual areas during motor execution primarily predicted the amount of motor errors. Overall, these data suggest that uncharacteristic alpha and beta oscillations within visuomotor cortical networks play a prominent role in the atypical motor actions exhibited by children with CP.

•

Children with CP performed an isometric task with the knee joint.

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Children with CP had stronger alpha and beta ERD during motor planning.

•

These ERD differences extended through the motor execution period.

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Occipital cortices and visual MT area alpha and beta ERD were weaker.

•

Altered alpha and beta ERD were accompanied by impaired motor actions.

Equinus and Lengthening Techniques

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.

Weakening iliopsoas muscle in healthy adults may induce stiff knee pattern

Objective

The goal of the present study was to investigate the relationship between iliopsoas muscle group weakness and related hip joint velocity reduction and stiff-knee gait (SKG) during walking in healthy individuals.

Methods

A load of 5% of each individual's body weight was placed on non-dominant thigh of 15 neurologically intact, able-bodied participants (average age: 22.4 ± 0.81 years). For 33 min (135 s × 13 repetitions × 5 s rest), a passive stretch (PS) was applied with the load in place until hip flexor muscle strength dropped from 5/5 to 3+/5 according to manual muscle test. All participants underwent gait analysis before and after PS to compare sagittal plane hip, knee, and ankle kinematics and kinetics and temporo–spatial parameters. Paired t-test was used to compare pre- and post-stretch findings and Pearson correlation coefficient (r) was calculated to determine strength of correlation between SKG parameters and gait parameters of interest (p < 0.05).

Results

Reduced hip flexion velocity (mean: 21.5%; p = 0.005) was a contributor to SKG, decreasing peak knee flexion (PKF) (−20%; p = 0.0008), total knee range (−18.9%; p = 0.003), and range of knee flexion between toe-off and PKF (−26.7%; p = 0.001), and shortening duration between toe-off to PKF (−16.3%; p = 0.0005).

Conclusion

These findings verify that any treatment protocol that slows hip flexion during gait by weakening iliopsoas muscle may have great potential to produce SKG pattern combined with reduced gait velocity.

A Systematic Review of the Effects of Single-Event Multilevel Surgery on Gait Parameters in Children with Spastic Cerebral Palsy

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.