• Cerebral Palsy General 
  • There are many gait disorders described in cerebral palsy and they tend to be author dependent.  For simplification purposes, we will use the standard:
    • Equinus gait
    • Jump gait
    • Crouched gait
    • Stiff-knee gait
  • Gait analysis has helped identify distinct problems and guide orthopaedic treatment 
  • Gait developmental milestones
    • independent gait expected between 12 to 18 months old in non-CP children 
  • Introduction 
    • common in hemiplegics 
  • Treatment
    •  ankle foot orthosis
      • indications
        • flexible deformities - ankle is passively correctable to neutral while maintaining a subtalar neutral position
      • technique
        • posterior leaf-spring orthoses used in presence of excessive ankle plantar flexion in the swing phase
    • tendo-achilles lengthening
      • indications
        • rigid deformities - ankle is not passively correctable to neutral
        • CAUTION - isolated heel cord lengthening in the presence of tight hamstrings and hip flexors will lead to progressive flexion at the hips and knees, thus worsening the crouched gait 
      • technique
        • gastrocnemius recession vs tendo-achilles lengthening
        • Silfverskiöld test distinguishes between contracture of gastrocnemius only versus combined gastrocnemius and soleus
        • intra-operative goal is to obtain 10 degrees of dorsiflexion
Jump Gait
  • Introduction
    • deformity includes hip flexion, knee flexion, and equinus ankle deformity
  • Treatment
    • chemodenervation
      • injections of botulinum neurotoxin A for hamstring spasticity without fixed deformity
    • soft tissue lengthenings
      • medial hamstring lengthening for mild knee dysfunction, usually younger patients with less than 5 degrees knee flexion deformity
      • medial hamstring lengthening combined with semitendinosus transfer to the adductor tubercle for knee flexion deformities of 5-15 degrees
      • transfer of the semitendinosus combined with growth plate surgery for severe flexed knee gait, combined with knee flexion deformities of 10-25 degrees in the patients with at least two years of growth remaining
    • osteotomy with tendon advancement or shortening 
      • supracondylar extension osteotomy combined with patellar tendon advancement or shortening for knee flexion deformities of 10-30 degrees, with severe quadriceps lag close to or already at skeletal maturity
Crouched Gait 
  • Introduction 
    • common in diplegic CP
    • a combination of hip flexion, knee flexion, and ankle dorsiflexion
  • Treatment (dependent on severity on patient symptoms, physical exam measures, gait analysis and radiographic findings). 
    • multiple simultaneous soft tissue releases 
      • complications
        • hamstring contracture most likely to recur
        • elongated patellar tendon (patellar alta) is another complication of this condition that is difficult to treat
Stiff-Knee Gait
  • Introduction
    • common in spastic diplegic CP
    • characterized by limited knee flexion in swing phase due to rectus femoris firing out of phase (seen on EMG)
  • Evaluation 
    • instrumented gait analysis shows quadriceps activity from terminal stance throughout swing phase
  • Treatment
    • transfer of distal rectus femoris tendon 

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(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


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




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




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




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




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



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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.


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