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Multilevel Surgery for Equinus Gait in Children with Spastic Diplegic Cerebral Palsy: Medium-Term Follow-up with Gait Analysis

Firth, Gregory B. MBBCh, FCS(Orth)SA, MMed(Orth); Passmore, Elyse BEng, MEng; Sangeux, Morgan MSc, PhD; Thomason, Pam BPhty, MPT; Rodda, Jill BAppSc(PT), PhD; Donath, Susan MA, BSc; Selber, Paulo MD, FRACS; Graham, H. Kerr MD, FRCS(Ed), FRACS

Journal of Bone & Joint Surgery - American Volume: 15 May 2013 - Volume 95 - Issue 10 - p 931–938
doi: 10.2106/JBJS.K.01542
Scientific Articles
Supplementary Content
Disclosures

Background: In children with spastic diplegia, surgery for ankle equinus contracture is associated with a high prevalence of both overcorrection, which may result in a calcaneal deformity and crouch gait, and recurrent equinus contracture, which may require revision surgery. We sought to determine if conservative surgery for equinus gait, in the context of multilevel surgery, could result in the avoidance of overcorrection and crouch gait as well as an acceptable rate of recurrent equinus contracture at the time of medium-term follow-up.

Methods: This was a retrospective, consecutive cohort study of children with spastic diplegia who had had surgery for equinus gait between 1996 and 2006. All children had distal gastrocnemius recession or differential gastrocnemius-soleus complex 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.

Results: Forty children with spastic diplegia, Gross Motor Function Classification System (GMFCS) level II or III, were included in this study. There were twenty-five boys and fifteen girls. The mean age was ten years at the time of surgery and seventeen years at the time of final follow-up. The mean postoperative follow-up period was 7.5 years. The mean ankle GVS improved from 18.5° before surgery to 8.7° at the time of short-term follow-up (p < 0.005) and 7.8° at the time of medium-term follow-up. The equinus gait was successfully corrected in the majority of children, with a low rate of overcorrection (2.5%) and a high rate of recurrent equinus (35%), as determined by sagittal ankle kinematics. Mild recurrent equinus was usually well tolerated and conferred some advantages, including contributing to strong coupling at the knee and independence from using an ankle-foot orthosis.

Conclusions: Surgical treatment for equinus gait in children with spastic diplegia was successful, at a mean of seven years, in the majority of cases when combined with multilevel surgery, orthoses, and rehabilitation. No patient developed crouch gait, and the rate of revision surgery for recurrent equinus was 12.5%.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

1Orthopaedic Department, The Royal Children’s Hospital, Flemington Road, Parkville, Victoria 3052, Australia

2Hugh Williamson Gait Laboratory, The Royal Children’s Hospital, Parkville, Victoria 3052, Australia

3The University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia

Copyright 2013 by The Journal of Bone and Joint Surgery, Incorporated
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