summary Gait Disorders in Cerebral Palsy are commonly caused by lower limb spasticity and are the primary reason for orthopaedic consultations in CP patients. Diagnosis is made with quantitative evaluation using kinematic, kinetic and EMG analysis. Treatment is usually physical therapy, orthotics and bracing in patients with mild gait disorders. Single-event, multi-level surgery (SEMLS) has become the gold standard surgical intervention for patients with continued difficulty with gait. Epidemiology Incidence gait disorder is the primary reason for orthopaedic consultations in CP patients login to view 1 more bullet Etiology Cerebral Palsy General Pathophysiology Divided into: login to view 12 more bullets Etiology both qualitative and quantitative analysis has been used to describe gait quantitative evaluation (kinematic/kinetic/EMG analysis) have changed how we understand, classify, and treat this condition login to view 4 more bullets Classification Descriptive (Qualitative) classification useful for simplification, though high variability of segmental deviations in each pattern descriptive classifications have been unsuccessful at classifying up to 40% of CP gait patterns. common descriptive classifications are shown in table below. Descriptive Classification Equinus Gait Term "equinus" used to refer to the isoloated abnormality in foot position relative to the tibia, i.e. a one-level deviation (e.g. no knee/hip involvement) characterized by absence of heal strike during gait isolated equinus gait is common in hemiplegics Equinus is either: true equinus: defined by the foot position in relationship to the tibia being less than plantigrade apparent equinus: defined by a foot position that is normal in relationship to the tibia, however heel strike does not occur due to more proximal deviations (flexion of the knee most common) Jump Gait Deformity includes hip flexion, knee flexion, and equinus ankle deformity ( could result in apparent ankle equinus) Multi-level gait deviations where treatment of underlying spasticity should be considered Crouch Gait A combination of hip flexion, knee flexion, and excessive ankle dorsiflexion (the latter may be represented by flatfoot or calcaneus) Common in diplegic CP Pathophysiology: often an iatrogenic consequence of isolated lengthening the achilles in a jump gait pattern if the other levels of gait deviations are not addressed properly Levels of deviation Calcaneal contact pattern throughout stance phase Increased knee flexion throughout stance phase due to disruption of the ankle plantar flexion-knee extension couple Compensated crouch gait refers to tertiary deviations that allow the knee extensor mechanism to be off-loaded during stance phase (e.g. pelvic or truncal forward tilt) - this may be well-tolerated by younger children with CP and low body mass Uncompensated crouch gait occurs secondary to persistent overloading of the extensor mechanism. This occurs in all crouch eventually, if untreated Stiff Knee Gait Common in spastic diplegic CP Characterized by limited knee flexion in swing phase due to rectus femoris firing out of phase (seen on EMG) note the above gait decriptions are stance phase deviations Evaluation gait analysis reveals quadriceps activity from terminal stance throughout swing phase Complications Stiff knee gait can be a compensation due to deviations at the hip; surgical management will not help this subset of stiff-knee gait Term "equinus" used to refer to the isoloated abnormality in foot position relative to the tibia, i.e. a one-level deviation (e.g. no knee/hip involvement) characterized by absence of heal strike during gait isolated equinus gait is common in hemiplegics Equinus is either: true equinus login to view 1 more bullet apparent equinus login to view 1 more bullet Quantitative classification uses technology to better characterize the pathoanatomy of abnormal gait, particularly when multiple planes and segments of deformity exist characterizes gait into 3 planes of deformity login to view 14 more bullets Comprehensive Gait Analysis Gait analysis has helped identify distinct problems and guide orthopaedic treatment login to view 1 more bullet comprehensive gait analysis may include the following components: login to view 11 more bullets Treatment Nonoperative physical therapy login to view 2 more bullets chemodenervation (botulinum neurotoxin A) login to view 3 more bullets orthoses login to view 7 more bullets Operative single-event, multi-level surgery (SEMLS) login to view 17 more bullets Techniques External rotation proximal femur osteotomy indications login to view 1 more bullet Rectus Transfer indications login to view 1 more bullet technique login to view 1 more bullet Medial hamstring lengthening indications login to view 1 more bullet technique login to view 1 more bullet complications login to view 1 more bullet Guided growth surgery indications login to view 1 more bullet Supracondylar femur extension osteotomy +/- patellar tendon advancement or shortening indications login to view 1 more bullet Gastrocnemius recession indications login to view 1 more bullet technique login to view 6 more bullets Tendo-achilles lengthening indications login to view 3 more bullets contraindications login to view 2 more bullets techniques login to view 2 more bullets Complications Recurrent hamstring contracture Worsening crouch gait secondary to isolated and overlengthening of achilles Patella alta elongated patellar tendon (patellar alta) is another complication of this condition that is difficult to treat Multiple simultaneous soft tissue releases without careful gait analysis Knee pain tendo-achilles lengthening may worsen knee pathology if careful gait analysis isn't performed