See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/236912065

Multilevel Surgery for Equinus Gait in Children

with Spastic Diplegic Cerebral Palsy: Medium-
Term Follow-up with Gait...

Article in The Journal of Bone and Joint Surgery · May 2013

DOI: 10.2106/JBJS.K.01542 · Source: PubMed

CITATIONS READS

27 223

8 authors, including:

Gregory B. Firth Elyse Passmore

University of the Witwatersrand The Royal Children's Hospital
25 PUBLICATIONS 101 CITATIONS 13 PUBLICATIONS 67 CITATIONS

SEE PROFILE SEE PROFILE

Morgan Sangeux Susan Donath

Murdoch Childrens Research Institute University of Melbourne
84 PUBLICATIONS 466 CITATIONS 179 PUBLICATIONS 6,467 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Processing data from gait analysis View project

CRIB - Comparison of Rehydration methods in Infants with Bronchiolitis View project

All content following this page was uploaded by Elyse Passmore on 22 May 2014.

The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document
and are linked to publications on ResearchGate, letting you access and read them immediately.
 931
C OPYRIGHT Ó 2013 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Multilevel Surgery for Equinus Gait in Children

with Spastic Diplegic Cerebral Palsy
Medium-Term Follow-up with Gait Analysis
Gregory B. Firth, MBBCh, FCS(Orth)SA, MMed(Orth), Elyse Passmore, BEng, MEng, Morgan Sangeux, MSc, PhD,
Pam Thomason, BPhty, MPT, Jill Rodda, BAppSc(PT), PhD, Susan Donath, MA, BSc, Paulo Selber, MD, FRACS,
and H. Kerr Graham, MD, FRCS(Ed), FRACS

Investigation performed at the Orthopaedic Department, The Royal Children’s Hospital, Parkville, Victoria, Australia

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.

W
hen children with spastic diplegia begin walking, of the gastrocnemius-soleus complex, especially percutaneous
they usually walk on tiptoe with an equinus gait1. lengthening of the Achilles tendon4-9. The standard of care for
Older children and adolescents more often have the management of gait dysfunction in children with spastic
flexed-knee patterns and crouch gait1-3. Crouch gait may be diplegia is single-event multilevel surgery in which all con-
part of the natural history of gait evolution in children with tractures and osseous deformities are dealt with during a single
spastic diplegia but may be precipitated by isolated lengthening operative session, commonly on the basis of three-dimensional

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2013;95:931-8 d http://dx.doi.org/10.2106/JBJS.K.01542

 932
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
M U LT I L E V E L S U R G E RY F O R E Q U I N U S G A I T IN CHILDREN
V O L U M E 95-A N U M B E R 10 M AY 15, 2 013
d d
W I T H S PA S T I C D I P L E G I C C E R E B R A L P A L S Y

gait analysis10-23. In this context, the correction of equinus de- The inclusion criteria were (1) a diagnosis of cerebral palsy according to
formity is important to the overall outcome because of its the 2005 international definition and registration in the Statewide Cerebral
43,44
Palsy Register ; (2) a spastic movement disorder with bilateral involvement
contribution to sagittal plane balance24.
(spastic diplegia) and Gross Motor Function Classification System (GMFCS)
Many procedures for the correction of equinus deformity 45
level II or III ; (3) single-event multilevel surgery between 1996 and 2006 ; (4)
46

in children with spastic cerebral palsy have been reported25-39. 9

Zone-1 surgery for equinus gait on one or both sides (Fig. 1) and no prior calf
The outcomes of ten different procedures were summarized surgery; and (5) preoperative three-dimensional gait analysis in the six months
and grouped by anatomic zone in a recent systematic review9. before surgery (Time 1), between twelve and eighteen months after surgery
Zone 1 extends from the origin of the gastrocnemius to the (Time 2), and at a minimum of four years after surgery (Time 3).
most distal fibers of the medial gastrocnemius muscle belly. The indication for single-event multilevel surgery was progressive im-
pairment of gait secondary to fixed musculoskeletal pathology despite non-
Zone-1 procedures include proximal gastrocnemius recession as
operative management, including injections of Botox (botulinum toxin A) and
described by Silfverskiöld31, intramuscular lengthening of the the use of ankle-foot orthoses
25,46
. The selection of procedures for each child
gastrocnemius and soleus as described by Baumann and Koch32, was based on evaluation of all components of the diagnostic matrix and fol-
and distal gastrocnemius recession as described by Strayer33. lowed published guidelines
46-49
.
Zone 2 extends from the termination of the medial gastrocne-
mius muscle belly to the most distal extent of the soleus fibers. Surgery for Equinus
Zone-2 procedures include recession of the gastrocnemius- The indications for surgery included tripping, falling, forefoot pain, and poor
soleus complex as described by Vulpius and Stoffel34 and balance combined with functional impairment
13,14,22,25
. Objective criteria in-
by Baker35. Zone 3 is the Achilles tendon, and procedures cluded an equinus position in late stance more than two standard deviations
within this zone include Achilles tendon lengthening and below the laboratory mean and the presence of a fixed equinus contracture
translocation36-38. at the ankle, with dorsiflexion to less than neutral, on examination with the
46,47,50,51
patient under anesthesia immediately prior to surgery . The principle
The gastrocnemius muscle spans two joints and has been governing the surgery was to use the most conservative gastrocnemius length-
implicated as a more important contributor to equinus gait in ening procedure possible to achieve 5° of dorsiflexion with the knee extended .
51

spastic diplegia than the soleus, which spans just one joint31,39,40. Three different ‘‘surgical doses’’ for equinus were utilized according to the severity
Given the importance of the soleus muscle in maintaining of the equinus contracture as described in the following sections.
plantar flexion-knee extension coupling with gait, intramus- Distal Gastrocnemius Recession: Strayer Procedure (Fig. 1): The distal
cular gastrocnemius lengthening or gastrocnemius recession limit of the gastrocnemius was identified by inspection and palpation. The
junction of the gastrocnemius aponeurosis with the soleus fascia was explored
might be preferable to more commonly used procedures in
from a 2 to 3-cm vertically oriented posteromedial skin incision. The interval
which both the gastrocnemius and the soleus are length- between the gastrocnemius and soleus fascia was identified and was opened by
ened9,32,33. Some studies suggest that calcaneal gait leading to blunt dissection on the medial side. The sural nerve was protected. The gas-
crouch gait in spastic diplegia is more common after Achilles trocnemius aponeurosis was divided transversely from medial to lateral and
tendon lengthening than after gastrocnemius recession4,5,9.
However, some short-term studies demonstrated no difference
based on the surgical procedure or the zone of the procedure9,17.
Biomechanical studies of human cadavers have provided evi-
dence to suggest that procedures performed proximally in a
muscle-tendon unit, where the cross-sectional area is greater,
may provide more biomechanically stable results than distal
procedures41. Given that both calcaneus/crouch gait and re-
current equinus may not be apparent for many years after
surgery, studies with long-term follow-up and objective out-
come measures may be superior to randomized trials to in-
vestigate these important outcomes4,5,9,30. The purpose of this
study was to report the medium-term outcomes of conserva-
tive (mainly Zone-1) surgery for the management of equinus
gait in the context of single-event multilevel surgery in children
with spastic diplegia. Specifically, we wanted to determine if
conservative surgery resulted in the avoidance of crouch gait at
the expense of recurrent equinus and the need for revision
surgery.
Fig. 1
Gastrocnemius recession with the Strayer procedure (Fig. 1-A) and the
Materials and Methods modified Strayer procedure, which combines distal gastrocnemius re-

T his was a retrospective, consecutive cohort study of data that were pro-
spectively gathered according to standardized gait laboratory protocols,
42
which have good reliability . The study was approved under the audit provi-
cession with soleal fascial lengthening (S.F.L.) (Fig. 1-B). Both are Zone-
1 procedures. Recurrent equinus was managed with lengthening of the
sions of our institution’s Ethics in Human Research Committee. Parents pro- gastrocnemius-soleus complex fascia, according to the method described
34
vided written informed consent for the children to undergo the surgery. by Vulpius and Stoffel (Zone-2 procedure) (Fig. 1-C).
 933
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
M U LT I L E V E L S U R G E RY F O R E Q U I N U S G A I T IN CHILDREN
V O L U M E 95-A N U M B E R 10 M AY 15, 2 013
d d
W I T H S PA S T I C D I P L E G I C C E R E B R A L P A L S Y

TABLE I Study Population Characteristics at Time 1, Time 2, and Time 3*

Time 1 Time 2 Time 3

Age† (yr) 9.3 (4.8-15.1) 11.1 (7.6-17.7) 16.8 (11.7-26.1)

Height† (cm) 129.4 (101.4-160.8) 138.2 (119.8-169.6) 161.9 (146.7-182.5)
Weight† (kg) 29.9 (16.1-54.0) 37.3 (24.0-60.3) 59.4 (41.3-85.8)
Body mass index† (kg/m2) 17.6 (13.7-24.3) 19.3 (13.9-26.8) 22.7 (17.0-34.4)
GMFCS level (no.) I = 0, II = 27, III = 13 I = 0, II = 30, III = 10 I = 1, II = 27, III = 12
Ankle-foot orthoses (no. [%]) 23 (58%) 39 (98%) 14 (35%)

*There were forty patients (twenty-five boys and fifteen girls). The mean interval between Time 1 and Time 3 was 7.5 years (range, 4.4 to 14.6
years). †The values are given as the mean with the range in parentheses.

allowed to retract proximally. The Silfverskiöld test was performed and if 5° of length and strength. Repeat three-dimensional gait analysis was performed at
ankle dorsiflexion with the knee extended was achieved no additional surgery twelve to eighteen months after surgery (prior to removal of implants [Time 2])
was performed. The gastrocnemius aponeurosis was sutured distally to the and again at four to fourteen years after surgery (Time 3).
52
soleus fascia at the level at which it rested when the knee was in full extension GMFCS level, Functional Mobility Scale (FMS) score , height, weight,
33,51
and the foot was at 90° to the leg . and body mass index (BMI) were all available at Time 1 (in the six months
Distal Gastrocnemius Recession Plus Soleal Fascial Lengthening: Modified before surgery), Time 2, and Time 3 (Table I). Physical examination was per-
Strayer Procedure (Fig. 1): When the Silfverskiöld test revealed residual soleus formed by an experienced physical therapist using standardized protocols,
22,42,52,53
contracture after the Strayer procedure, a single transverse stripe/division of the which have good reliability . Quantitative three-dimensional gait-
51
soleus fascia was performed . The Silfverskiöld test was repeated to confirm 5° analysis data were collected with a state-of-the-art Vicon system (Oxford
of dorsiflexion with the knee extended. The combination of distal gastrocne- Metrics Group, Oxford, United Kingdom) and two AMTI force plates
mius recession and soleal fascial lengthening is called a modified Strayer (Watertown, Massachusetts). Reflective markers were applied to the osseous
51
procedure . landmarks with use of a standardized procedure. Kinematic data were cal-
White Slide Lengthening of the Achilles Tendon: Lengthening of the culated with use of Plug In Gait (Oxford Metrics Group) and uploaded to
54
Achilles tendon was used only when there was a contracture of both the gas- GaitaBase, a web-interfaced repository for gait data .
28
trocnemius and the soleus of >30° and no improvement with knee flexion . The Gait Profile Score (GPS) as well as the Gait Variable Scores (GVS)
In children with symmetric equinus deformities, both sides were treated for nine kinematic parameters (pelvic tilt, pelvic obliquity, pelvic rotation, hip
with either a Strayer procedure or a modified Strayer procedure. Asymmetric flexion, hip abduction, hip rotation, knee flexion, ankle dorsiflexion, and foot
equinus contractures were managed with various combinations, including the progression) were calculated for each child. The nine GVS values and the GPS
Strayer procedure on one side plus Botox injection on the contralateral side, the value formed the Movement Analysis Profile (MAP), which is a graphical
55
Strayer procedure plus the modified Strayer procedure, or slide lengthening of representation of these data (Fig. 2). The GVS was also calculated for
the Achilles tendon by double hemisection (White slide procedure) accom- two kinetic parameters: sagittal ankle moment and ankle power. Each GVS is
28,51
panied by a contralateral Strayer or modified Strayer procedure . The final a measure of the distance of the patient’s curve from the corresponding
47,50,51
choice was always based on an intraoperative Silfverskiöld test .
Recurrent equinus was corrected with a Vulpius gastrocnemius-soleus
complex recession with use of a single transverse division of both the gas-
34,51
trocnemius aponeurosis and the soleus fascia, in Zone 2 (Fig. 1). Indica-
tions for revision surgery were identical to those for the index surgery.
Postoperative management was uniform for all of the equinus surgical
procedures. A below-the-knee plaster cast was applied with the foot in a neutral
position of dorsiflexion. Concomitant hamstring surgery was protected by knee
immobilizers. The children were discharged from the hospital four to seven
days after surgery, at which time they used knee immobilizers with elevating
22,46
footrests on their wheelchair . Unrestricted weight-bearing beginning the
first postoperative day was prescribed for children who had had soft-tissue
surgery only. Children treated with osteotomies were encouraged to begin full
weight-bearing at one to three weeks after surgery, according to the surgeon’s
46
assessment of the stability of fixation and osteotomy site healing .
Casts were removed after three weeks to check healing and to cast molds
for ankle-foot orthoses. The standard postoperative ankle-foot orthosis was
46
solid with hinges inserted but not activated . Fiberglass casts were applied and Fig. 2
worn for an additional three weeks. These were removed at six weeks after The Movement Analysis Profile (MAP) for nine kinematic Gait Variable
surgery and replaced by ankle-foot orthoses. Gait and function were checked in Scores (GVS) at Time 1 (T1), Time 2 (T2), and Time 3 (T3) in comparison
the gait laboratory with use of a standardized protocol for two-dimensional with laboratory normal values. In addition, the Gait Profile Scores (GPS) at
22,46
video-based gait analysis at three, six, and nine months after surgery . The
decision to activate the ankle-foot-orthosis hinges was contingent on stable Time 1, Time 2, and Time 3 are shown, also with reference to the laboratory
plantar flexion-knee extension coupling, full knee extension in stance phase, normal range. Mean values with standard deviation (error bars) are shown.
and a clinical assessment showing sufficient gastrocnemius-soleus complex The units of the y axis are degrees for each of the parameters.
 934
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
M U LT I L E V E L S U R G E RY F O R E Q U I N U S G A I T IN CHILDREN
V O L U M E 95-A N U M B E R 10 M AY 15, 2 013
d d
W I T H S PA S T I C D I P L E G I C C E R E B R A L P A L S Y

normative curve. The GPS is a composite measure of gait quality or summary

statistic of gait. It is calculated as the root mean square of the nine kinematic
GVS. The GPS and kinematic GVS units are degrees, and the larger the value the
more abnormal is the subject’s gait.
The MAP provides a graphical display of the subject’s specific gait de-
viations giving rise to the overall GPS. The GVS and GPS were calculated for
both lower limbs during four individual gait cycles. The median GPS was
54
calculated for each child by an independent assessor using GaitaBase . The
minimum clinically important difference for the GPS has recently been re-
56
ported to be 1.6° .
Kinematic and kinetic data were captured during barefoot walking,
without external support whenever possible. The need for assistive devices was
recorded for every subject at each assessment. All forty patients had kinematic
data at Time 1 and Time 3, and thirty-nine patients had kinematic data at Time
2. Twenty-seven patients had kinetic data at Time 1 and Time 3, and twenty-five Fig. 3
patients had kinetic data at Time 2. Box-and-whisker plot of maximum ankle dorsiflexion in late stance at Time
Recurrent equinus was defined as maximum dorsiflexion more than two
4,30 1 (T1), Time 2 (T2), and Time 3 (T3). The horizontal line within each box is
standard deviations below the normal range in late stance on gait analysis .
Overlengthening was defined as maximum dorsiflexion more than two standard the median, the top and bottom of each box is the interquartile range, the
4,30
deviations above the normal range in late stance on gait analysis . The need for upper whisker extends to the highest data value within the upper limit, the
revision surgery for recurrent equinus deformity was also recorded. lower whisker extends to the lowest value within the lower limit, the as-
terisks indicate outliers, the horizontal solid line across the figure is the
Ankle First Rocker normal mean range, and the dashed lines indicate one or two standard
A qualitative assessment of initial contact was made from ankle kinematic traces deviations (SD) above and below the normal mean.
at each of the three assessments. If initial contact was made by the heel and the
first ankle movement was into plantar flexion, first ankle rocker was deemed to
57
be present (see Appendix) . in six, peroneus brevis in three, and gastrocnemius-soleus
complex in seventy-four (fifty-six Strayer procedures, fifteen
Statistical Methods modified Strayer procedures, and three White slide proce-
Paired t tests were used to assess change in GPS over time (Time 1 versus Time dures). Botox injections were performed in the gastrocnemius-
2, Time 1 versus Time 3, and Time 2 versus Time 3). The GVS were assessed soleus complex unilaterally in six cases. Thirty-four patients
separately for the right and left lower limb for each child, so each child con- had a bilateral calf-lengthening procedure, and six patients had
tributed two measurements to each GVS at each time point. Since these two
a calf-lengthening procedure with a Botox injection on the
measurements could not be assumed to be independent of each other, linear
regression estimation with robust standard errors to allow for clustering of
contralateral side. Tendon transfers included semitendinosus
measurements within patients was used to assess the change in GVS over time. to the adductor tubercle (seven), split tibialis anterior (three),
and rectus femoris (forty-two). The osseous surgical procedures
Source of Funding included femoral derotation osteotomy (seventy-four), tibial
Funding in the form of salary support for two of the authors was provided by a derotation osteotomy (four), calcaneus lengthening (eleven),
philanthropic organization (The Hugh Williamson Foundation), which had no and subtalar fusion (five).
direct role in the conduct of the research. The changes in gait parameters among Time 1, Time 2, and
Time 3 are summarized in Figure 2 and the Appendix. Ankle
Results kinematics, moments, and powers all demonstrated clinically

F orty children, twenty-five boys and fifteen girls with a mean

age at surgery of ten years (range, 5.5 to 16.7 years), were
included in the study. No patient had had a prior selective
relevant and statistically significant improvements at Time 2
compared with Time 1 and at Time 3 compared with Time 1. The
mean ankle dorsiflexion kinematic in late stance was 4.9° at Time
dorsal rhizotomy or gastrocnemius-soleus complex lengthen- 1. This increased to 10.7° at Time 2 and stabilized at 8.6° at Time
ing, but twenty-two patients had had one or more injections of 3. The GPS also demonstrated clinically relevant and statistically
Botox at a minimum of twelve months prior to the multilevel significant improvement at both Time 2 and Time 3 compared
surgery. The mean duration of follow-up between Time 1 and with Time 1. The mean decrease in GPS was 5.9° between Time
Time 3 was 7.5 years (range, 4.4 to 14.6 years). Changes in 1 and Time 2 and 6.6° between Time 1 and Time 3.
height, weight, BMI, GMFCS level, and use of ankle-foot or-
thoses are summarized in Table I. The ankle physical exami- Maximum Ankle Dorsiflexion in Late Stance (Fig. 3)
nation measures (Silfverskiöld test) are summarized in Table II. Figure 3 summarizes the data for maximum ankle dorsiflexion
The single-event multilevel surgery included 271 soft- at Time 1, Time 2, and Time 3 with the use of a box-and-
tissue procedures and ninety-four osseous procedures, for a whisker plot showing the median and interquartile ranges. At
mean of 9.1 procedures (range, five to eighteen) per child. The Time 3, the rate of overcorrection was 2.5% and the rate of
sites of muscle-tendon lengthening included the psoas at the recurrent equinus was 35%, according to sagittal ankle kinematic
brim of the pelvis in twenty-three cases, hip adductors in criteria described above. Revision calf surgery was performed
thirty-four, medial hamstrings in sixty-six, tibialis posterior in five patients (13%), bilaterally in two and unilaterally in
 935
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
M U LT I L E V E L S U R G E RY F O R E Q U I N U S G A I T IN CHILDREN
V O L U M E 95-A N U M B E R 10 M AY 15, 2 013
d d
W I T H S PA S T I C D I P L E G I C C E R E B R A L P A L S Y

TABLE II Physical Examination Results of Silfverskiöld Test at Time 1, Time 2, and Time 3

Time 1 Time 2 Time 3

Dorsiflexion of right ankle (deg)

With knee extended 27 (240 to 112) 2 (215 to 120) 3 (212 to 128)
With knee flexed 6 (222 to 135) 17 (25 to 145) 17 (24 to 145)
Dorsiflexion of left ankle (deg)
With knee extended 26 (232 to 115) 3 (220 to 120) 2 (212 to 126)
With knee flexed 7 (212 to 135) 18 (25 to 145) 16 (26 to 140)

three, for recurrent equinus deformity before Time 3. The re- the mean height increased from 129 to 162 cm, the mean
vision lengthenings were performed at a mean of 3.7 years weight increased from 30 to 59 kg, and the mean BMI increased
(range, 1.7 to 5.6 years) after the initial surgery. The indications from 17.6 to 22.7 kg/m2 between Time 1 and Time 3 (Table I).
for revision surgery were identical to those for the index sur- By Time 3, the majority of adolescents had reached skeletal
gery. The mean age at the index surgery for those who required maturity.
revision surgery was 8.5 years compared with 10.2 years for The results of equinus contracture surgery may dete-
those who did not. riorate with time, and long-term follow-up with objective
measures offers the best opportunity to report meaningful
Movement Analysis Profile (MAP) (Fig. 2 and Appendix) outcomes4,5,9,30,59. To the best of our knowledge, the present
The MAP improved significantly between Time 1 and Time 2 study has the second longest follow-up among studies in which
and between Time 1 and Time 3 for six five of the nine GVS gait analysis has been utilized9,30. It is relatively easy to deter-
(sagittal hip, sagittal knee, sagittal ankle, coronal pelvis, trans- mine the rate of recurrent equinus requiring revision surgery
verse hip, and transverse foot progression). The mean sagittal from a chart review27,59. However, only three-dimensional
ankle GVS was 18.5° at Time 1 and decreased to 8.7° at Time 2 gait analysis permits precise documentation of more minor
and 7.8° at Time 3. The sagittal ankle GVS improved for 81% of degrees of both overcorrection and undercorrection and re-
the subjects at Time 2, and this percentage increased to 92% of current equinus deformity4,30.
the subjects at Time 3 (see Appendix). Significant improvements In this study, we report the outcomes of a conservative
in the ankle moment and power GVS were also noted (see approach to equinus contracture surgery in the context of
Appendix). single-event multilevel surgery, with the aim being to preserve
Mean gait parameters do not reveal individual patterns of strong coupling between the ankle and knee and to prevent the
outcomes. Three cases are illustrated with serial sagittal ankle cascade of events that can lead to progressive crouch gait4,5,7,8.
and knee kinematics at Time 1, Time 2, and Time 3 in the The potential danger of this approach is undercorrection, re-
Appendix. current deformity, and the need for repeat surgery30,59. This
study demonstrated satisfactory correction at the ankle level in
First Ankle Rocker most children as well as a clinically relevant and statistically
At Time 1, first rocker was not present at either ankle in any significant correction of the overall gait pattern. The im-
subject. At Time 2, first rocker was present on one or both sides provement in GPS was clinically relevant and statistically sig-
in seven subjects and this increased to ten subjects at Time 3. nificant, equating to a 38% improvement in gait function
between Time 1 and Time 3—more than four times the min-
Discussion imum clinically important difference56. The ankle also showed

I n patients with cerebral palsy, ‘‘a little equinus is better than

calcaneus’’ because overcorrection may set in motion a
cascade of events that result in a severe crouch gait and loss of
major improvements in terms of both the kinematic GVS and
the kinetic GVS (ankle moments and powers; see Appendix).
A previous study of gastrocnemius-soleus complex length-
walking ability5,10,30. If it is not feasible to achieve and maintain ening for equinus contracture, in which the investigators used the
perfect length and strength of the gastrocnemius-soleus com- same criteria as we used in this study, showed that 40% of
plex in every case, it is better to err on the side of under- children with spastic diplegia developed calcaneal deformity,
correction10. The correct surgical ‘‘dose’’ for equinus deformity crouch gait, and increased dependence on aids and ankle-foot
must not only achieve adequate length of the gastrocnemius- orthoses after a mean duration of follow-up of seven years4. The
soleus complex for dorsiflexion in stance phase, but also pre- rate of recurrent equinus was 16%4. In comparison, the current
serve adequate strength and moment generation to control series showed a major decrease in calcaneal gait, to 2.5%, but
advancement of the tibia over the foot during the stance phase an increase in the prevalence of equinus, to 35%. Dietz and
of gait (second rocker)40,57,58. The ankle moment must be ade- colleagues reported the outcomes of Zone-3 surgery, as part
quate not only in the short term but also in the long term, when of multilevel surgery, for equinus deformity in children with
the child with spastic diplegia becomes mature. In this study, spastic diplegia and quadriplegia5. Forty-one percent of patients
 936
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
M U LT I L E V E L S U R G E RY F O R E Q U I N U S G A I T IN CHILDREN
V O L U M E 95-A N U M B E R 10 M AY 15, 2 013
d d
W I T H S PA S T I C D I P L E G I C C E R E B R A L P A L S Y

with spastic diplegia and 50% of patients with quadriplegia We believe that we are the first to report on the presence
developed crouch gait and required bracing5. Dietz et al. also of first rocker at the time of medium-term follow-up after
noted that ground-reaction ankle-foot orthoses were difficult surgery for equinus gait. First rocker is a hallmark of normal
to don and doff, were poorly tolerated, and were relatively gait and is rarely present in children with cerebral palsy57. The
ineffective5. presence of first rocker is associated with a gait pattern that
In contrast, Dreher and colleagues recently reported ex- appears more ‘‘normal.’’ Conversely, the absence of first rocker,
cellent long-term results after gastrocnemius-soleus intramus- even when equinus has been corrected, is associated with an
cular aponeurotic recession as part of multilevel surgery in abnormal appearance of gait, or ‘‘limping.’’ In this study, no
patients with spastic diplegic cerebral palsy30. The patients in patient had first rocker before surgery and 25% had first rocker
their study had less severe cerebral palsy than the patients in our at Time 3. Equinus deformity precludes first rocker in children
study, according to the GMFCS levels, and the equinus con- with cerebral palsy. Effective surgery for equinus gait may re-
tracture was less severe. The mean ages of the patients (9.8 years store first rocker but only when the correction is precise and
versus ten years), the concomitant procedures in the multilevel underlying strength and selective motor control are adequate5
surgery (both osseous and soft-tissue), and the changes in the (see Appendix).
height, weight, and BMI of the patients during the follow-up Five children had surgery for recurrent equinus con-
period were similar30. Dreher et al. used the same kinematic tracture between Time 2 and Time 3. No overcorrection or
criteria for overcorrection and undercorrection as were utilized recurrent equinus had been recorded in these children at
in our study, permitting a direct comparison between the Time 3, at a mean of 4.8 years (range, 1.1 to 10.0 years). Two
studies. In their study, fixed equinus was corrected by intra- children were offered additional surgery and declined. The
muscular aponeurotic recession of the gastrocnemius or in- equinus in the remaining nineteen adolescents was asymp-
tramuscular aponeurotic recession of the gastrocnemius and tomatic and well tolerated at the time of writing. The equinus
soleus, with three legs (in the group of forty-four patients) not could be considered to be an advantage for some in that it
requiring a lengthening procedure. The Baumann procedure preserved extension at the knee and allowed them to walk
consists of intramuscular aponeurotic lengthening of the gas- without the need for ankle-foot orthoses5,10 (see Appendix).
trocnemius (and soleus when indicated) and is performed in The results of the medium-term gait analysis (Time 3) were
Zone 113. In the current study, distal gastrocnemius recession used to determine which children and adolescents could safely
(the Strayer procedure) or distal gastrocnemius recession with discontinue the use of ankle-foot orthoses; it was possible for
soleal fascial lengthening (the modified Strayer procedure) 65% to do so.
were the principal procedures utilized, and they are Zone-1 The strengths of this study were a standardized approach
surgical procedures that yield stable results. An important to surgery, rehabilitation and orthotic prescription, and long-
difference between the two studies was the intraoperative goal. term follow-up with objective outcome measures. A rigorous
Dreher et al. aimed for 15° to 20° of dorsiflexion with knee kinematic definition of both overcorrection (calcaneus gait)
extension and knee flexion whereas our goal was 5° of dorsi- and undercorrection/recurrence (recurrent equinus) was uti-
flexion with the knee extended. Overcorrection with calcaneal lized, allowing for direct comparison with previous studies in
gait and severe crouch gait was more common in their study30. which the same outcome criteria had been used4,30,61. The
It would seem that both Zone-1 procedures are associated with weaknesses of the study were variability in the single-event
a significant rate of recurrent equinus, as determined by kine- multilevel surgery prescription and in the duration of follow-
matics, and a relatively low rate of overcorrection. However, up. In addition, the variable surgical prescription, including
aiming for 15° to 20° of dorsiflexion intraoperatively may be both soft-tissue and osseous procedures at multiple levels, has
overly aggressive, and our data suggest that a more conservative both known and unknown impacts on the ankle level and
goal of 5° may be better. dynamic ankle function. However, given the documented
The categorical classification of dynamic gastrocnemius- poor results of single-level surgery for equinus, it is likely
soleus complex length is a useful method for summarizing that a multilevel surgical approach will remain the treatment
outcomes and comparing results between series4,9,30. How- paradigm for the foreseeable future4,30,61. Clinical researchers
ever, dichotomous outcomes that are quantitatively similar and surgeons will continue to have to grapple with the
are not of equal clinical relevance. A gastrocnemius-soleus complexity of the local and distant effects of multilevel sur-
complex length that is two standard deviations above the gical procedures when they evaluate outcomes. In addition,
mean may, in the long term, result in severe crouch gait with given that patients cannot ethically remain in randomized
severe disability10,30. There are currently no reliable methods trials for long periods of time, prospective studies with long-
with which to shorten an overlengthened gastrocnemius- term objective outcome measures are likely to offer the best
soleus complex. Surgery for severe crouch gait is invasive and opportunity for meaningful clinical research in this complex
requires prolonged rehabilitation7,8. In contrast, recurrent area9,30,61.
equinus can be easily managed with revision surgery59. Most
cases of equinus gait at Time 3 in our study were the result of Appendix
recurrent equinus deformity and not undercorrection at the A table showing comparisons of GPS and GVS among
index surgery59,60. the evaluation times and figures demonstrating sagittal
 937
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
M U LT I L E V E L S U R G E RY F O R E Q U I N U S G A I T IN CHILDREN
V O L U M E 95-A N U M B E R 10 M AY 15, 2 013
d d
W I T H S PA S T I C D I P L E G I C C E R E B R A L P A L S Y

kinematic traces of the knee and ankle of specific patients are Elyse Passmore, BEng, MEng
available with the online version of this article as a data sup- Morgan Sangeux, MSc, PhD
plement at jbjs.org. n Pam Thomason, BPhty, MPT
Jill Rodda, BAppSc(PT), PhD
Hugh Williamson Gait Laboratory,
The Royal Children’s Hospital,
Gregory B. Firth, MBBCh, FCS(Orth)SA, MMed(Orth) Parkville, Victoria 3052, Australia
Paulo Selber, MD, FRACS
H. Kerr Graham, MD, FRCS(Ed), FRACS Susan Donath, MA, BSc
Orthopaedic Department, The University of Melbourne,
The Royal Children’s Hospital, Flemington Road, Parkville, Grattan Street, Parkville,
Victoria 3052, Australia Victoria 3010, Australia

References
1. Rab GT. Diplegic gait: Is there more than spasticity? In: Sussman MD, editor The 21. Thompson N, Stebbins J, Seniorou M, Wainwright AM, Newham DJ, Theologis
diplegic child. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1992. TN. The use of minimally invasive techniques in multi-level surgery for children with
p 99-110. cerebral palsy: preliminary results. J Bone Joint Surg Br. 2010;92(10):1442-8.
2. Rodda J, Graham HK. Classification of gait patterns in spastic hemiplegia and 22. Thomason P, Baker R, Dodd K, Taylor N, Selber P, Wolfe R, Graham HK. Single-
spastic diplegia: a basis for a management algorithm. Eur J Neurol. 2001;8(Suppl event multilevel surgery in children with spastic diplegia: a pilot randomized con-
5):98-108. trolled trial. J Bone Joint Surg Am. 2011;93(5):451-60.
3. Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R. Sagittal gait patterns in 23. McGinley JL, Dobson F, Ganeshalingam R, Shore BJ, Rutz E, Graham HK. Single-
spastic diplegia. J Bone Joint Surg Br. 2004;86(2):251-8. event multilevel surgery for children with cerebral palsy: a systematic review. Dev
4. Borton DC, Walker K, Pirpiris M, Nattrass GR, Graham HK. Isolated calf length- Med Child Neurol. 2012;54(2):117-28.
ening in cerebral palsy. Outcome analysis of risk factors. J Bone Joint Surg Br. 2001; 24. Silver RL, de la Garza J, Rang M. The myth of muscle balance. A study of relative
83(3):364-70. strengths and excursions of normal muscles about the foot and ankle. J Bone Joint
5. Dietz FR, Albright JC, Dolan L. Medium-term follow-up of Achilles tendon length- Surg Br. 1985;67(3):432-7.
ening in the treatment of ankle equinus in cerebral palsy. Iowa Orthop J. 2006;26: 25. Davids JR. The foot and ankle in cerebral palsy. Orthop Clin North Am. 2010;41(4):
27-32. 579-93.
6. Segal LS, Thomas SE, Mazur JM, Mauterer M. Calcaneal gait in spastic diplegia 26. Sharrard WJW, Bernstein S. Equinus deformity in cerebral palsy. A comparison
after heel cord lengthening: a study with gait analysis. J Pediatr Orthop. 1989; between elongation of the tendo calcaneus and gastrocnemius recession. J Bone
9(6):697-701. Joint Surg Br. 1972;54(2):272-6.
7. Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. Correction of 27. Olney BW, Williams PF, Menelaus MB. Treatment of spastic equinus by apo-
severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic neurosis lengthening. J Pediatr Orthop. 1988;8(4):422-5.
surgery. J Bone Joint Surg Am. 2006;88(12):2653-64. 28. Graham HK, Fixsen JA. Lengthening of the calcaneal tendon in spastic hemi-
8. Stout JL, Gage JR, Schwartz MH, Novacheck TF. Distal femoral extension oste- plegia by the White slide technique. A long-term review. J Bone Joint Surg Br.
otomy and patellar tendon advancement to treat persistent crouch gait in cerebral 1988;70(3):472-5.
palsy. J Bone Joint Surg Am. 2008;90(11):2470-84.
29. Lyon R, Liu X, Schwab J, Harris G. Kinematic and kinetic evaluation of the ankle
9. Shore BJ, White N, Kerr Graham H. Surgical correction of equinus deformity in joint before and after tendo achilles lengthening in patients with spastic diplegia.
children with cerebral palsy: a systematic review. J Child Orthop. 2010;4(4):277-90. J Pediatr Orthop. 2005;25(4):479-83.
10. Rang M, Silver R, de la Garza J. Cerebral palsy. In: Lovell WW, Winter RB, editors. 30. Dreher T, Buccoliero T, Wolf SI, Heitzmann D, Gantz S, Braatz F, Wenz W. Long-
Pediatric orthopaedics. 2nd ed. Philadelphia: Lippincott; 1986. p 345-96.
term results after gastrocnemius-soleus intramuscular aponeurotic recession as a
11. Gage JR. The role of gait analysis in the treatment of cerebral palsy. J Pediatr part of multilevel surgery in spastic diplegic cerebral palsy. J Bone Joint Surg Am.
Orthop. 1994;14(6):701-2. 2012;94(7):627-37.
12. Abel MF, Damiano DL, Pannunzio M, Bush J. Muscle-tendon surgery in diplegic 31. Silfverskiöld N. Reduction of the uncrossed two-joints muscles of the leg to one-
cerebral palsy: functional and mechanical changes. J Pediatr Orthop. 1999;19(3):
joint muscles in spastic conditions. Acta Chir Scand. 1924;56:315-30.
366-75.
32. Baumann JU, Koch HG. Lengthening of the anterior aponeurosis of the gas-
13. Saraph V, Zwick EB, Uitz C, Linhart W, Steinwender G. The Baumann procedure
trocnemius muscle. Oper Orthop Traumatol. 1989;1:254.
for fixed contracture of the gastrosoleus in cerebral palsy. Evaluation of function of
33. Strayer LM Jr. Recession of the gastrocnemius; an operation to relieve spastic
the ankle after multilevel surgery. J Bone Joint Surg Br. 2000;82(4):535-40.
contracture of the calf muscles. J Bone Joint Surg Am. 1950;32-A(3):671-6.
14. Steinwender G, Saraph V, Zwick EB, Uitz C, Linhart W. Fixed and dynamic
34. Vulpius O, Stoffel A. Orthopaedische Operationslehre 1920. Tenotomie der end
equinus in cerebral palsy: evaluation of ankle function after multilevel surgery.
J Pediatr Orthop. 2001;21(1):102-7. schen der mm. Gastrocnemius el soleus mittels rutschenlassens nach. p 29-31.
15. Saraph V, Zwick EB, Zwick G, Steinwender C, Steinwender G, Linhart W. Multi- 35. Baker LD. Triceps surae syndrome in cerebral palsy; an operation to aid in its
level surgery in spastic diplegia: evaluation by physical examination and gait analysis relief. AMA Arch Surg. 1954;68(2):216-21.
in 25 children. J Pediatr Orthop. 2002;22(2):150-7. 36. Hoke M. An operation for stabilizing paralytic feet. J Bone Joint Surg Am. 1921;
16. Schwartz MH, Viehweger E, Stout J, Novacheck TF, Gage JR. Comprehensive 3(10):494-507.
treatment of ambulatory children with cerebral palsy: an outcome assessment. 37. White JW. Torsion of the Achilles tendon: its surgical significance. Arch Surg.
J Pediatr Orthop. 2004;24(1):45-53. 1943;46(5):748-87.
17. Kay RM, Rethlefsen SA, Ryan JA, Wren TA. Outcome of gastrocnemius recession 38. Pierrot AH, Murphy OB, Albert E. Klinkicht Award, 1972. Heel cord advancement.
and tendo-achilles lengthening in ambulatory children with cerebral palsy. J Pediatr A new approach to the spastic equinus deformity. Orthop Clin North Am. 1974;
Orthop B. 2004;13(2):92-8. 5(1):117-26.
18. Adolfsen SE, Ounpuu S, Bell KJ, DeLuca PA. Kinematic and kinetic outcomes 39. Craig JJ, van Vuren J. The importance of gastrocnemius recession in the cor-
after identical multilevel soft tissue surgery in children with cerebral palsy. J Pediatr rection of equinus deformity in cerebral palsy. J Bone Joint Surg Br. 1976;58(1):
Orthop. 2007;27(6):658-67. 84-7.
19. Gough M, Schneider P, Shortland AP. The outcome of surgical intervention for 40. Delp SL, Zajac FE. Force- and moment-generating capacity of lower-extremity
early deformity in young ambulant children with bilateral spastic cerebral palsy. muscles before and after tendon lengthening. Clin Orthop Relat Res. 1992;
J Bone Joint Surg Br. 2008;90(7):946-51. 284(284):247-59.
20. Gorton GE 3rd, Abel MF, Oeffinger DJ, Bagley A, Rogers SP, Damiano D, 41. Altuntas AO, Dagge B, Chin TYP, Palamara JEA, Eizenberg N, Wolfe R, Graham
Romness M, Tylkowski C. A prospective cohort study of the effects of lower extremity HK. The effects of intramuscular tenotomy on the lengthening characteristics of
orthopaedic surgery on outcome measures in ambulatory children with cerebral tibialis posterior: high versus low intramuscular tenotomy. J Child Orthop. 2011;
palsy. J Pediatr Orthop. 2009;29(8):903-9. 5(3):225-30.
 938
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
M U LT I L E V E L S U R G E RY F O R E Q U I N U S G A I T IN CHILDREN
V O L U M E 95-A N U M B E R 10 M AY 15, 2 013
d d
W I T H S PA S T I C D I P L E G I C C E R E B R A L P A L S Y

42. Keenan WN, Rodda J, Wolfe R, Roberts S, Borton DC, Graham HK. The static 52. Graham HK, Harvey A, Rodda J, Nattrass GR, Pirpiris M. The Functional Mobility
examination of children and young adults with cerebral palsy in the gait analysis Scale (FMS). J Pediatr Orthop. 2004;24(5):514-20.
laboratory: technique and observer agreement. J Pediatr Orthop B. 2004;13(1):1-8. 53. Harvey AR, Morris ME, Graham HK, Wolfe R, Baker R. Reliability of the functional
43. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, Jacobsson B, mobility scale for children with cerebral palsy. Phys Occup Ther Pediatr. 2010;
Damiano D; Executive Committee for the Definition of Cerebral Palsy. Proposed 30(2):139-49.
definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 54. Tirosh O, Baker R, McGinley J. GaitaBase: Web-based repository system for gait
2005;47(8):571-6. analysis. Comput Biol Med. 2010;40(2):201-7.
44. Howard J, Soo B, Graham HK, Boyd RN, Reid S, Lanigan A, Wolfe R, Reddihough 55. Baker R, McGinley JL, Schwartz MH, Beynon S, Rozumalski A, Graham HK,
DS. Cerebral palsy in Victoria: motor types, topography and gross motor function. Tirosh O. The gait profile score and movement analysis profile. Gait Posture.
J Paediatr Child Health. 2005;41(9-10):479-83. 2009;30(3):265-9.
45. Palisano RJ, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Develop- 56. Baker R, McGinley JL, Schwartz M, Thomason P, Rodda J, Graham HK. The
ment and reliability of a system to classify gross motor function in children with minimal clinically important difference for the Gait Profile Score. Gait Posture.
cerebral palsy. Dev Med Child Neurol. 1997;39(4):214-23. 2012;35(4):612-5.
46. Bache CE, Selber P, Graham HK. Mini-symposium: cerebral palsy: the man- 57. Perry J, Burnfield JM. Ankle-foot complex. In: Gait analysis. Normal and patho-
agement of spastic diplegia. Curr Orthop. 2003;17(2):88-104. logical function. 2nd ed. Chapter 4, p 51-82. Thorofare, NJ: SLACK; 2010.
47. Davids JR, Ounpuu S, DeLuca PA, Davis RB. Optimization of walking ability of 58. Delp SL, Statler K, Carroll NC. Preserving plantar flexion strength after surgical
children with cerebral palsy. J Bone Joint Surg Am. 2003;85(11):2224-34. treatment for contracture of the triceps surae: a computer simulation study. J Orthop
48. Novacheck TF. Orthopaedic treatment of muscle contractures. In: The identifi- Res. 1995;13(1):96-104.
cation and treatment of gait problems in cerebral palsy. 2nd ed. Gage JR, Schwartz 59. Joo SY, Knowtharapu DN, Rogers KJ, Holmes L Jr, Miller F. Recurrence after
MH, Koop SE. Novacheck TF, editors. London: Mac Keith Press; 2009. p 445-72. surgery for equinus foot deformity in children with cerebral palsy: assessment of
49. Gage JR. Orthopaedic treatment of long bone torsions. In: The identification and predisposing factors for recurrence in a long-term follow-up study. J Child Orthop.
treatment of gait problems in cerebral palsy. 2nd ed. Gage JR, Schwartz MH, Koop 2011;5(4):289-96.
SE, Novacheck TF, editors. London: Mac Keith Press; 2009. p 473-91. 60. Truscelli D, Lespargot A, Tardieu G. Variation in the long-term results of elon-
50. Kerr Graham H, Selber P. Musculoskeletal aspects of cerebral palsy. J Bone gation of the tendo Achillis in children with cerebral palsy. J Bone Joint Surg Br.
Joint Surg Br. 2003;85(2):157-66. 1979;61-B(4):466-9.
51. Graham HK. Cerebral palsy. In: Drennan’s the child’s foot and ankle. 2nd ed. 61. Svehlı́k M, Kraus T, Steinwender G, Zwick EB, Saraph V, Linhart WE. The
McCarthy JJ, Drennan JC, editors. Philadelphia: Lippincott, Williams & Wilkins; Baumann procedure to correct equinus gait in children with diplegic cerebral palsy:
2010. p 188-218. long-term results. J Bone Joint Surg Br. 2012;94(8):1143-7.

View publication stats