A cohort study of tibialis anterior tendon shortening in combination with calf muscle lengthening in spastic equinus in cerebral palsy

Abstract

The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (±5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15°, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p=0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP.

Equinus Correction During Multilevel Surgery in Adults With Cerebral Palsy

“…12,13,29,33 The main goal in children with CP is to avoid a decrease of muscle strength of the triceps surae resulting in calcaneal gait and to strengthen the antagonists (eg, tibialis anterior muscle). 37 It is not clear, so far, if adults with CP show similar results after correction of equinus. Furthermore, compared with children, further growth cannot influence the postoperative course of rehabilitation.…”

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

“…The overall number of included patients with CP in our study is 3595 patients and 4814 limbs/feet, ranging from 7 patients in the study of Goncalves et al [ 22 ] to 1147 patients in the study of Naidu et al [ 28 ]. Most of the included studies reported the data of patients with the spastic type of CP (15 studies) [ 6 , 7 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 30 , 31 , 35 ]. The age of CP patients among included studies ranged from a mean of 3.8 years (with SD of 2) in the study of Boulay et al [ 17 ] to 18.2 years (with SD of 9.9) in the study of Horsch et al [ 6 ].…”

“…The overall number of included patients was 3595, with 4814 affected limbs being analyzed. The prevalence of equinus foot among patients with cerebral palsy varied substantially among included individual studies, ranging from 10.9% [ 35 ] to 100% [ 7 , 17 , 18 , 19 , 20 , 23 , 26 , 27 , 29 , 31 ]. A total of 22 studies were included in the meta-analysis with an overall prevalence rate of equinus foot of 93% (95% CI: 71–99%; I 2 = 100%, p < 0.01) ( Figure 2 ).…”

“…Certain designs had only one study, and therefore, they were not reliable in estimating the overall prevalence rate of equinus foot in CP. Meanwhile, 14 studies were cohort in design, and they had an overall prevalence rate of 62% (95% CI: 47–74%; I 2 = 98%, p < 0.01) [ 6 , 17 , 20 , 24 , 25 , 27 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. On the other hand, 4 studies were case series in design, with an overall prevalence rate of 92% (95% CI: 34–100%; I 2 = 84%, p < 0.01) [ 18 , 19 , 21 , 29 ].…”

“…Quality assessment of the included studies was conducted by the NIH quality assessment tool for each distinctive study design. A total of 16 studies were of fair quality (moderate risk of bias) [ 6 , 7 , 17 , 20 , 22 , 24 , 25 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ], 4 studies were of poor quality (high risk of bias) [ 18 , 19 , 21 , 29 ], and 2 studies were of good quality (low risk of bias) [ 23 , 26 ].…”