Isolated calf lengthening in cerebral palsy

Abstract

We assessed the medium-term outcome of three methods of isolated calf lengthening in cerebral palsy by clinical examination, observational gait analysis and, where appropriate, instrumented gait analysis. The procedures used were percutaneous lengthening of tendo Achillis, open Z-lengthening of tendo Achillis and lengthening of the gastrosoleus aponeurosis (Baker's procedure). We reviewed 195 procedures in 134 children; 45 had hemiplegia, 65 diplegia and 24 quadriplegia. We established the incidence of calcaneus and recurrent equinus and identified 'at-risk' groups for each. At follow-up, 42% had satisfactory calf length, 22% had recurrent equinus and 36% calcaneus. The incidence of calcaneus in girls at follow-up was significantly higher (p = 0.002) while boys had an increased rate of recurrent equinus (p = 0.012). Children with diplegia who had surgery when aged eight years or younger had a 44% risk of calcaneus, while those over eight years had a 19% risk (p = 0.046). Percutaneous lengthening of tendo Achillis in diplegia was the least predictable, only 38% having a satisfactory outcome compared with 50% in the other procedures. The incidence of recurrent equinus in hemiplegic patients was 38%. Only 4% developed calcaneus. The type of surgery did not influence the outcome in patients with hemiplegia or quadriplegia. Severity of involvement, female gender, age at operation of less than eight years and percutaneous lengthening of tendo Achillis were 'risk factors' for calcaneus. Hemiplegia, male gender, and an aponeurosis muscle lengthening increased the risk of recurrent equinus.

Factors associated with pelvic retraction during gait in cerebral palsy

“…This finding may be due to excessive retraction being associated with equinus in the hemiplegic population. A study by Borton et al [9] found that males had a significantly increased rate of recurrent equinus following isolated calf lengthening compared to females. It may be that males are more predisposed to equinus in general which in turn means they are more likely to develop pelvic retraction.…”

The management of spastic equinus in cerebral palsy

“…On the other hand, there should be no need to delay until the end of growth, because progression of bone deformities compromises soft tissue procedures. 20,21 Nonoperative treatment aims at functional improvement, postponing surgery to at least the age of 6 years or at avoiding surgery by prevention of a fixed deformity. Additional rationales include improving the patient's ability to wear shoes, the acceptance of orthoses, ease of physical therapy and elimination of disturbances.…”

“…The younger the age of surgical correction, the more likely the recurrence of equinus, due to rapid bone growth that is faster than muscle and tendon growth. 20,28 In diplegia and quadriplegia the timing of surgery is also important. Girls over 7 years old and boys over 8 show much better results, but delayed development of gait or difficulty in predicting the final length and strength of plantarflexors of the foot can be problematic.…”

Tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy

“…Previous studies have reported recurrent equinus in approximately 10-30% of patients with hemiplegia [11,12] and overcorrection with calcaneus foot in 3-30% of patients with spastic diplegia [10,13,14]. In addition Biedermann et al [15] reported in 2007 a high recurrence rate after calf lengthening with the Ilizarov apparatus for treatment of spastic equinus foot deformity.…”