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http://upload.orthobullets.com/topic/4128/images/cp gait.jpg
Introduction
  • Cerebral Palsy General 
  • Overview
    • 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
      • new treatment strategies focus on understanding the
        • underlying pathophysiology (deviations)
        • planes of deformity (sagittal, coronal, transverse)
        • anatomic level (hip, knee, ankle)
      • single-event, multi-level surgery (SEMLS) addresses the multiple planes and levels of deformity during a single surgery to avoid annual surgeries and the prolonged bouts of recovery required after each surgical session
  • Epidemiology
    • gait disorder is the primary reason for orthopaedic consultations in CP patients
      • independent gait expected between 12 to 18 months old in non-CP children 
  • Pathophysiology
    • Divided into:
      • primary deviations
        • those caused by the primary CNS insult including
          • spasticity
          • weakness
          • compromised proprioceptive pathways
      • secondary deviations
        • growth-related deviations that arise due to abnormal loading in the setting of primary gait deviations, including:
          • anatomic shortening of muscle-tendon units (e.g., myotatic contractures)
          • persistent bony deformities (e.g., femoral anteversion)
          • joint subluxations/dislocations  (e.g., hip subluxation or equinoplanovalgus feet)
      • tertiary deviations
        • compensations related to secondary gait deviations
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
  • 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
      • sagittal plane
        • includes:
          • anterior or posterior pelvic tilt
          • hip flexion/extension
          • knee flexion/extension
          • ankle dorsiflexion/plantarflexion
      • coronal plane
        • includes:
          • pelvic elevation/depression
          • hip abduction/adduction
      • transverse plane
        • transverse plane is least reliable plane described in instrumented gait analysis
        • includes:
          • pelvic and hip internal and external rotation deformities, foot progression angle
Comprehensive Gait Analysis
  • Gait analysis
    • has helped identify distinct problems and guide orthopaedic treatment 
      • quantitative gait analysis is more accurate at detecting gait abnormalities than is qualitative assessment alone
    • comprehensive gait analysis may include the following components:
      • physical exam findings
        • spasticity assessment, contractures and torsional abnormalities
      • kinetic analysis
        • forces (procuce linear accelerations) and moments (produce rotational accelerations) acting on and within the body
      • kinematic analysis
        • description of movement, typically described in segments and joints in 3 planes sagittal/coronal/transverse
      • pedobarography
        • special force plate that shows contact pressures through the stance phase
      • dynamic electromyography 
        • muscle activation detected at different (normal or abnormal) start points in gait
      • video
Treatment
  • Nonoperative
    • physical therapy
      • indications
        • plays an important role in both operative an nonoperatively treated patients
    • chemodenervation (botulinum neurotoxin A)
      • may be used to temporize certain muscle groups in order to delay surgical management or as a primary treatment modality
      • indications
        • hamstring spasticity without fixed deformity in ambulatory patient
    • orthoses
      • solid ankle foot orthosis (AFO)
        • indications
          • flexible equinus deformities
            • ankle is passively correctable to neutral while maintaining a subtalar neutral position 
      • posterior leaf-spring (or hinged) orthoses
        • indications
          • used in presence of excessive ankle plantar flexion in the swing phase 
  • Operative
    • single-event, multi-level surgery (SEMLS)
      • overview
        • SEMLS approach has become the gold-standard of CP gait surgery
        • goal is to address all primary (spasticity) and secondary (i.e. contractures) deviations at multiple levels during a single surgery 
          • addressing multiple deviations at once is essential to avoiding iatrogenic worsening of gait
      • procedures used during a SEMLS
        • lever arm dysfunction due to increased femoral anteversion: external rotation proximal femur osteotomy
        • hip flexion contracture: intramuscular psoas lengthening 
        • knee contractures
          • medial hamstring lengthening (lateral may result in excessive weakness) if minimal fixed contracture
          • guided growth
          • distal femur extension osteotomy
          • rectus transfer for stiff knee gait
        • equinus: tendo-achilles lengthening or gastrocnemius recession
        • flatfoot reconstruction
      • rehabilitation
        • AFOs and aggressive physical therapy for re-training and strengthening following releases is an essential component of SEMLS intervention
        • expect one year for recovery
Techniques
  • External rotation proximal femur osteotomy
    • indications
      • femoral anteversion / hip internal rotation deviation
  • Rectus Transfer
    • indications
      • stiff knee gait
    • technique
      • create knee flexion vector with rectus activation by transferring it posterior to the center of rotation of the knee
  • Medial hamstring lengthening 
    • indications
      • for mild knee dysfunction, usually younger patients with less than 5 degrees knee flexion deformity
    • technique
      • fractional lengthening at the myotendinous junction is ideal
    • complications
      • hamstring contractures often recur, especially in jump gait
  • Guided growth surgery
    • indications
      • knee flexion deformities of 10-25 degrees in the patients with at least two years of growth remaining
  • Supracondylar femur extension osteotomy +/- patellar tendon advancement or shortening
    • indications
      • for knee flexion deformities of 10-30 degrees, with severe quadriceps lag close to or already at skeletal maturity
  • Gastrocnemius recession 
    • indications 
      • Silfverskiöld test positive
    • technique
      • horizontal or vertical incision at the level of the myotendinous junction of the gastroc
      • identify and protect the sural nerve (superficial to fascia)
      • sharply divide the tendon only, preserving the muscle fibers not yet joined to the tendon
      • incise all deeper bands that prevent release of contracture (small raphes may be present in the tendon
      • manipulate the ankle
      • goal of treatment is 10 degrees of dorsiflexion
  • Tendo-achilles lengthening
    • indications
      • rigid deformities - ankle is not passively correctable to neutral
      • true equinus
      • Silfverskiöld negative
    • techniques
      • multiple hemi-lengthenings or a Z-lengthening can be performed
      • avoid overlengthning
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
 

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Questions (1)

(OBQ08.184) A posterior leaf spring ankle-foot orthosis would be appropriate for which foot and ankle malalignment pattern in a child with spastic-type cerebral palsy? Review Topic

QID:570
1

Absent heel strike, excessive plantar flexion in the swing phase, and 5 degrees of passive ankle dorsiflexion

60%

(1370/2282)

2

Excessive ankle dorsiflexion in midstance caused by incompetence of the ankle plantar flexors

23%

(533/2282)

3

Crouch gait pattern with excessive ankle dorsiflexion, increased knee flexion, and increased hip flexion in midstance

10%

(232/2282)

4

Excessive supination of the hindfoot during stance, which is passively correctable

5%

(124/2282)

5

Significant knee instability and weakness with stance in a child who is minimally ambulatory

0%

(7/2282)

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PREFERRED RESPONSE 1

Specific indications for the different orthoses used to improve gait in cerebral palsy may vary among providers. Davids et al discuss these indications in their review article. The authors state that the factors that make the posterior leaf spring ankle-foot orthosis (PLSO), shown in Illustration A, most appropriate are the clinical presence of absent heel strike and minimal (but some) dorsiflexion. The PLSO is designed to control excessive ankle plantar flexion in the swing phase and allow ankle dorsiflexion in midstance. A solid AFO(Illustration B) is both a stance and swing-phase control orthosis, which can help with excessive ankle dorsiflexion in midstance. A crouch gait pattern may attempt to be treated with a floor-reaction AFO (Illustration C), and a knee-ankle-foot orthoses(Illustration D) is useful for maintaining knee position and stability in children who primarily stand, and are minimally ambulatory. Supramalleolar orthoses(Illustration E) are used to control flexible coronal plane deformities, such as excessive supination or pronation of the hindfoot.

ILLUSTRATIONS:

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