Aims

To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

Aims

The purpose of this study was to evaluate the long-term outcome of adolescents with cerebral palsy who have undergone single-event multilevel surgery for a flexed-knee gait, followed into young adulthood using 3D motion analysis.

Aims

A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood.

The natural history of gait pattern change in children with spastic diplegia is a transition from toe walking to progressive hip and knee flexion with eventual crouch gait. This has been attributed to the adolescent growth spurt, progressive lever arm dysfunction, and iatrogenic weakening of the soleus with isolated tendo achilles lengthening (TAL). The relative contribution of TAL to the development of crouch gait is uncertain. The purpose of this study was to identify the frequency of crouch gait in spastic diplegic patients with and without history of prior TAL. Patients with spastic diplegia greater than 10 years of age with instrumented gait analysis were reviewed. Exclusion criteria included diagnosis other than cerebral palsy, prior dorsal root rhizotomy, or incomplete past surgical history. Patients were divided into three groups: Group 1, no prior orthopaedic surgical intervention; Group 2, prior orthopaedic surgery without TAL; Group 3, prior orthopaedic surgery with TAL. Instrumented gait analysis data was analysed. Gait data were analysed using a single randomised limb from each patient. One hundred and seventy-eight patients were identified: 39 in Group 1, 49 in Group 2, and 90 in Group 3. Mean time from TAL to gait analysis was 7.5 years (range 1.0–14.6 years). Mean age at TAL was 6.3 years (range 1.2–17.5 years). There was no significant difference in age, BMI, walking speed, or cadence between groups. Kinematic analysis showed no significant difference in mean stance phase maximum knee or ankle flexion between groups. There was no significant difference in frequency of increased mid stance knee flexion between groups (Group 1, 53.8%; Group 2 46.9%; Group 3, 43.3%, p=0.546). There was a trend towards increased frequency in excessive stance phase ankle dorsiflexion in Group 3 (60% Group 3 vs 46.2% Group 1, and 40% Group 2, p=0.071). Crouch gait (stance minimum hip flexion > 30, mid stance minimum knee flexion > 200, and stance maximum ankle dorsiflexion > 150) was seen with similar frequency in all groups (Group 1, 23.1%; Group 2, 18.4%; Group 3, 26.7%; p=0.544). There is a trend towards increased frequency of excessive stance phase ankle dorsiflexion in spastic diplegic patients with prior TAL. However, no significant difference in frequency of crouch gait between patients with and without history of TAL was identified. Crouch gait is part of the natural history of gait pattern change in spastic diplegic patients independent of prior surgical intervention

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

Cite this article: Bone Joint J 2015;97-B:564–71.

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

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

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

The August 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: a multilevel approach to equinus gait; whether screening leads to needless intervention; salvage of subcapital slipped epiphysis; growing prostheses for children’s oncology; flexible nailing revisited; ultrasound and the pink pulseless hand; and slipping forearm fractures.

Purpose of Study. In children with spastic diplegia, surgery for equinus has a high incidence of both over and under correction. We wished to determine if conservative (mainly Zone 1) surgery for equinus gait, in the context of multilevel surgery, could result in the avoidance of calcaneus and crouch gait as well as an acceptable rate of recurrent equinus, at medium term follow-up. Description of Methods. This was a retrospective, consecutive cohort study of children with spastic diplegia, between 1996 and 2006. All children had distal gastrocnemius recession or differential gastrocsoleus lengthening, on one or both sides, as part of Single Event Multilevel Surgery. The primary outcome measures were the Gait Variable Scores (GVS) and Gait Profile Score (GPS) at two time points after surgery. Summary of Results. Forty children with spastic diplegia, GMFCS Level II and III were eligible for inclusion in this study. There were 25 boys and 15 girls, mean age 10 years at surgery. The mean age at final follow-up was 17 years and the mean postoperative follow-up period was seven years. The mean ankle GVS improved from 18.5° before surgery to 8.7° at short term follow-up (P<0.005) and 7.8° at medium term follow-up. Equinus gait was successfully corrected in the majority of children with a low rate of over-correction (2.5%) but a high rate of recurrent equinus (35.0%), as determined by sagittal ankle kinematics. Conclusion. Surgery for equinus gait, in children with spastic diplegia, was successful in the majority of children, at a mean follow-up of seven years, when combined with multilevel surgery, orthoses and rehabilitation. No patients developed crouch gait and the rate of revision surgery for recurrent equinus was 12.5%. NO DISCLOSURES

The August 2012 Children’s orthopaedics Roundup³⁶⁰ looks at: whether 3D-CT gives a better idea of coverage than plain radiographs; forearm fractures after trampolining accidents; forearm fractures and the Rush pin; the fractured distal radius; elastic stable intramedullary nailing for long-bone fractures; aponeurotic recession for the equinus foot; the torn medial patellofemoral ligament and the adductor tubercle; slipped capital femoral epiphysis; paediatric wrist arthroscopy; and Pirani scores and clubfoot.

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

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

We studied the prevalence of severe crouch gait over a 15-year period in a defined population of children with spastic diplegia and Gross Motor Function Classification System levels II and III, to determine if there had been a decrease following changes to the management of equinus gait. These changes were replacing observational with three-dimensional gait analysis, replacing single level with multilevel surgery, and replacing gastrocsoleus lengthening with gastrocnemius recession. Of 464 children and adolescents with spastic diplegia who underwent three-dimensional gait analysis, 27 had severe crouch gait. Seventeen of these had been managed by isolated lengthening of the gastrocsoleus. Following changes in the management of equinus gait, the prevalence of severe crouch gait decreased from 25% and stabilised at a significantly lower rate, fluctuating between 0% and 4% annually (p < 0.001). . We conclude that severe crouch gait in this population was precipitated by isolated lengthening of the gastrocsoleus. These findings may be relevant to other surgical populations, as severe crouch gait may be a useful way to monitor the quality of the surgical management of abnormal gait in children with cerebral palsy and spastic diplegia

We present an illustrative case using a modification of the Gaines procedure for the surgical management of patients with spondyloptosis. It involves excision of the inferior half of the body of L5 anteriorly combined with posterior reduction and fusion.

We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable.

We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida.

A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.

In cerebral palsy, the site and severity of the brain lesion are directly linked to gross motor function and the development of musculoskeletal deformities. The relationship between walking ability and orthopaedic surgery in children with cerebral palsy is not fully understood. The development of new tools such as the Functional Assessment Questionnaire and the Functional Mobility Scale can be used to give new insights on the functional impact of multilevel surgery. These scales are most useful as part of systematic, long-term follow-up.

Between July 2000 and April 2004, 19 patients with bilateral spastic cerebral palsy who required an assistive device to walk had combined lengthening-transfer of the medial hamstrings as part of multilevel surgery. A standardised physical examination, measurement of the Functional Mobility Scale score and video or instrumented gait analysis were performed pre- and post-operatively. Static parameters (popliteal angle, flexion deformity of the knee) and sagittal knee kinematic parameters (knee flexion at initial contact, minimum knee flexion during stance, mean knee flexion during stance) were recorded. The mean length of follow-up was 25 months (14 to 45).

Statistically significant improvements in static and dynamic outcome parameters were found, corresponding to improvements in gait and functional mobility as determined by the Functional Mobility Scale. Mild hyperextension of the knee during gait developed in two patients and was controlled by adjustment of their ankle-foot orthosis. Residual flexion deformity > 10° occurred in both knees of one patient and was treated by anterior distal femoral physeal stapling. Two children also showed an improvement of one level in the Gross Motor Function Classification System.

Introduction and Aims: We studied the outcome of single event multilevel surgery (SEMLS) for the correction of severe crouch gait in spastic diplegia, over a five-year period. It was unknown if gait correction post-SEMLS could be sustained at skeletal maturity. Method: This was a prospective cohort study, utilising validated outcome measures. Presenting symptoms were increasingly abnormal gait, anterior knee pain, patellar fractures and fatigue. SEMLS was based on pre-operative gait analysis: mean of seven procedures (range 5–10), including lengthening of contracted muscle-tendon units (particularly hamstrings and psoas), as well as rotational osteotomies and bony stabilisation procedures to correct lever arm dysfunction. Post-operatively subjects wore Ground Reaction Ankle Foot Orthoses (GRAFOs) and received a community-based rehabilitation program. Post-operative changes were evaluated at five years: technical outcome by 3D kinematics and functional outcome by mobility status. Outcomes were analysed with linear regression with robust standard errors. Results: Eleven children with spastic diplegic cerebral palsy fulfilled the criteria for ‘severe crouch gait’, defined as knee flexion > 30 degrees and ankle dorsiflexion > 15 degrees throughout stance. Ten of 11 subjects had previous Tendo Achilles lengthening. Mean age pre-operatively was 12 years one month (range 8–16) and at follow-up 17 years 10 months (range 16–21). All subjects regained pre-operative mobility levels with improved gait pattern, relief of knee pain and healing of patellar fractures. There was a significant decrease in dependence on assistive devices. Pre- versus five years post-operative kinematics showed clinically and statistically significant increases in knee extension and decreases in ankle dorsiflexion. Improvements were seen in knee extension initial contact (p< 0.001, 95% CI 15°, 31°); maximum knee extension (p< 0.001, 95% CI 16°, 37°), ankle dorsiflexion (p< 0.001, 95% CI 8°, 18°) and plantarflexion 3rd rocker in stance (p=0.03, 95% CI 1°, 17°); knee excursion (p=0.003, 95% CI –24°, −6°), and peak knee flexion timing (p=0.02, 95% CI 2%, 20%). Conclusion: Multilevel surgery for severe crouch gait in spastic diplegia results in consistently marked improvements in dynamic knee and ankle function, but not at the hip and pelvic levels. The results are durable in most patients, after five years and after reaching skeletal maturity

Introduction and Aims: We present the preliminary results of patellar tendon shortening (PTS), for severe crouch gait in children with spastic cerebral palsy who were household ambulators. Method: We performed bilateral patellar tendon shortening in 15 patients with severe spastic diplegia between May 1996 and January 2002. The majority had acquired crouch gait because of isolated lengthening of the Achilles tendons in childhood and presented with anterior knee pain and rapidly deteriorating gait and function. The PTS procedure included dividing the patellar tendon in its mid portion, and performing an overlapping repair by suturing the distal tendon to the distal pole of the patella and the proximal segment to the tibial tubercle. The corrected position of the patella was maintained by a K-wire passed transversely through the patella and incorporated into a cylinder plaster, with the knee in extension, for a period of six weeks. Correction of knee flexion deformity was achieved by transfer of semitendonosis to the distal femur or extension osteotomy of the distal femur. Results: Rehabilitation was predictably slow but all patients regained their pre-operative mobility status within one year and the majority surpassed their pre-operative functional level by two years after surgery. There were no tendon ruptures or growth disturbance in the proximal tibia. Average age at the time of surgery was 14.2 years (10–19 years). Mean follow-up was 27 months (12–48 months). Pre- and post-operative Insall index in 17 knees was 0.68cm (0.46 to 1.07cm, SD=0.16cm) and 0.85cm (0.56 to 1.08cm, SD=0.20) respectively (p< 0.001 Students-t test). Pre-operatively, only three sides had a normal index, but post-operatively 14 sides had a normal index. Crouch gait improved in all patients who were reclassified as community ambulators. Thirteen patients still needed crutches. One patient continued to complain of bilateral knee pain 12 months after surgery, had insufficient correction according to the Insall index (0.58cm on the left 0.56cm on the right). Conclusion: Severe crouch gait after appropriate surgical and orthotic management, maybe due to patella alta, quadriceps and ankle plantarflexors insufficiency. We present preliminary results of a salvage procedure, patellar tendon shortening, which seems a reasonable option to treat complex crouch gait in selected patients with cerebral palsy