Kinematic and Kinetic Outcomes After Identical Multilevel Soft Tissue Surgery in Children With Cerebral Palsy

Abstract

This study evaluates the outcomes of multilevel soft tissue surgery in 31 ambulatory children (n = 39 sides) with cerebral palsy. All children had undergone rectus femoris transfer, hamstring lengthening, and gastrosoleus lengthening for the purpose of correcting sagittal plane abnormalities. There were no simultaneous bony surgeries. Preoperative and postoperative evaluation consisted of clinical assessment and gait analysis, including 3-dimensional kinematics and kinetics. Results demonstrated improvements in knee and ankle function. At the knee, there was a decrease in mean flexion at initial contact (from 31 degrees [SD, +/-8 degrees] to 21 degrees [SD, +/-10 degrees]) and in stance (mean stance, 22 degrees [SD, +/-12 degrees] to 16 degrees [SD, +/-11 degrees]) associated with a decreased mean internal extensor moment in stance (from 0.09 Nm/kg [SD, +/-0.24 Nm/kg] to -0.03 [SD, +/-0.22 Nm/kg]). At the same time, knee flexion was preserved in swing and occurred earlier. At the ankle, mean dorsiflexion improved at the time of examination (from 8 degrees [SD, +/-9 degrees] to 14 degrees [SD, +/-11 degrees] with the knee in extension), in terminal stance (peak from 7 degrees [SD, +/-9 degrees] to 12 degrees [SD, +/-8 degrees]), and in swing. Peak ankle power generation in stance was preserved and shifted later in stance toward push-off, with no functional weakening of the ankle plantar flexors. A longer-term assessment of a subset of patients with a second postoperative gait analysis at a mean of 4 years after surgery showed that gains measured at 1 year were maintained during the longer term. A subgroup demonstrating a jump knee gait pattern (as defined by excessive knee flexion at initial contact followed by rapid knee extension to full knee extension in midstance) had a tendency to go into knee hyperextension in stance with resultant net knee flexor moment after surgery. This raises concern about the indications for hamstring lengthening in this patient group.

Surgical correction of equinus deformity in children with cerebral palsy: A systematic review

“…Some studies focused on a single operative procedure [25,30,37], others on a comparison of multiple procedures [17,33,40], and some in the setting of SEMLS [2,11,14,20,23,24,27,29,35,37,38,41,45]. The reason for the choice of various procedures was often surgeon preference or frequently not clearly stated.…”

“…The outcome measures reported included clinical examination and rating scales [2,11,, gait rating scales [2, 14, 16-18, 20-22, 24, 25, 27, 29, 30, 32, 33, 36, 39, 42], goniometry [2,14,17,21,25,36,44], three-dimensional gait analysis [2, 11, 14, 15, 17, 21-24, 28, 29, 31, 32, 35, 37-39, 41, 44, 46], the modified Ashworth scale (spasticity) [2,11,36,37], radiographs [17,32,45], electromyography [11,15,23,24,35,38], the Gross Motor Function Measure (GMFM) [14,21] and the need for floor reaction AFOs to manage crouch gait [20,26]. Such measures were used to derive an outcome scale, which rated the overall result from good to poor.…”

“…These were examined in depth. After applying inclusion and exclusion criteria, 35 studies were included (Table 1) [2,11,.…”

“…Historically, studies on equinus surgery have grouped heterogenous patients together, thus, compromising the conclusions of equinus surgery. Single-event multi-level gait improvement surgery (SEMLS) has become the standard of care in many institutions for the treatment of walking children with cerebral palsy [8][9][10][11]. In this era of SEMLS surgery, equinus surgery is rarely performed in isolation and more commonly performed in concert with other surgical procedures designed to correct lever arm dysfunction, improve the biomechanics of the plantar flexion/knee extension couple and correct fixed musculoskeletal contractures.…”

Mechanical effect of rat flexor carpi ulnaris muscle after tendon transfer: does it generate a wrist extension moment?

“…It is important to note that Riewald and Delp (26) measured the RF moment in only one configuration of the leg: with the knee joint flexed at 90°and the hip joint flexed at 40 -45°. During walking, however, these joints are more extended (1). Different joint angles involve different muscle-tendon complex lengths and different relative positions of transferred RF and neighboring knee flexors and extensors (for a schematic illustration, see Ref.…”