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Introduction
  • Cerebral Palsy General 
  • Definitions
    • many gait disorders described in cerebral palsy
    • no universally accepted classification system
    • strict definitions have been unsuccessful at classifying up to 40% of CP gait patterns.   
  • Epidemiology
    • gait disorder are the primary reason for orthopaedic consultations in CP patients
      • independent gait expected between 12 to 18 months old in non-CP children 
  • Pathophysiology
    • can be broken into
      • primary deviations
        • those caused by the primary CNS insult including
          • spasticity
          • weakness
          • compromised proprioceptive pathways
        • treatment
          • best treated by pharmacological or neurosurgical 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 (myotatic contractures)
          • persistent bony deformities, i.e. femoral anteversion
          • joint subluxations/dislocations, i.e. hip subluxation or equinoplanovalgus feet
        • treatment
          • treated with primarily orthopaedic surgery
      • tertiatry deviations
        • compensations related to secondary gait deviations
        • treatment 
          • address primary or secondary deviations
Classification
  • Plane of deformity
    • breaks into
      • sagittal plane conditions
      • transverse plan conditions
    • breaking down gait into planes of deformity allows the practicioner to better plan multiple-level interventions when they are indicated
  • Eponym (Sagittal Plane Patterns)
    • useful for simplification purposes and helpful to describe overall pattern even given high variability of segmental deviations in each pattern 
      • Equinus gait 
        • definition
          • term "equinus" may be used to refer to the foot position relative to the tibia, an achilles contracture, or a toe-walking pattern with a one-level deviation (e.g. no knee/hip involvement)
          • absence of heal strike during gait is the most common meaning of the term when referring to CP patients
          • isolated equinus gait is common in hemiplegics
        • equinus may be a
          • 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 multilevel changes (flexion of the knee most common)
      • Jump gait
        • deformity includes hip flexion, knee flexion, and equinus ankle spastic deformity (may be 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 flatfoot or calcaneal contact pattern
        • common in diplegic CP
        • pathophysiology
          • may be an iatrogenic consequence of lengthening the achilles in a jump gait pattern if the other levels of gait deviations are not addressed proprely
        • 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 when there is persistent overloading of the extensor mechanism, and this will occur for all children with CP at some point
      • 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 that all other named gaits are stance phase deviations
        • Evaluation 
          • instrumented gait analysis shows quadriceps activity from terminal stance throughout swing phase
        • Complications
          • Stiff knee gait can be a compenstation due to deviations at the hip; surgical management will not help this subset of stiff-knee gait
  • Transverse Plane Deviations
    • Introduction
      • while the sagittal plane gait deviations are both named and referred to more commonly, the transverse plane should not be forgotten in a comprehensive gait analysis or surgical intervention
      • internal, external, and neutral progression angles may occur at the hip, knee, and foot
        • kinematic analysis will assist in detection of segmental progression angle deviations
    • Evaluation
      • physical exam for torsional deformities
      • these are commonly due to secondary deviations as torsional forces are placed on the long bones due to underlying spastic tone
    • Management
      • Secondary deviations may be corrected at time of SEMLS surgery
Evaluation
  • 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
    • gait analysis includes comprehensive examination with
      • physical exam findings
        • contractures and torsional abnormalities
        • Silfverskiöld test distinguishes between contracture of gastrocnemius only versus combined gastrocnemius and soleus
      • kinetic analysis
        • linear and angular motion analysis
      • kinematic analysis
        • description of movement including time-dependent variable (velocity, etc.)
      • 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
Treatment
  • Non-operative Management
    • Bracing
      • ankle foot orthosis 
        • flexible deformities - ankle is passively correctable to neutral while maintaining a subtalar neutral position
        • posterior leaf-spring orthoses used in presence of excessive ankle plantar flexion in the swing phase
    • chemodenervation (botulinum neurotoxin A)
      • common indications for ambulatory patients
        • hamstring spasticity without fixed deformity (jump gait)
      • may be useful to combine with AFOs, either in isolation or before/after surgical intervention
  • Surgical Treatments
    • Single-event, multi-level surgery (SEMLS)
      • indications
        • SEMLS approach has become the gold-standard of CP gait surgery
      • goals
        • addressing all primary (spasticity) and secondary (i.e. contractures) at a single surgery is essential to avoiding iatrogenic worsening of gait
      • requires a comprehensive gait analysis (see above)
      • often, these patients have foot breakdown (planovalgus and hallux valgus) that may need to be corrected concurrently if the goal is to achieve a heel-toe gait pattern
      • AFOs and aggressive physical therapy for re-training and strengthening following releases is an essential component of SEMLS intervention
    • Sagittal Plane Deviations
      • Ankle Equinus
        • tendo-achilles lengthening
          • indications
            • rigid deformities - ankle is not passively correctable to neutral
            • true equinus
          • CAUTION - isolated heel cord lengthening in the presence of tight hamstrings and hip flexors will lead to progressive flexion at the hips and knees, possibly worsening a crouched gait
          • techniques
            • gastrocnemius recessionSilfverskiöld test positive
              • intra-operative goal is to obtain 10 degrees of dorsiflexion with the knee extended
            • achilles lengthening
              • multiple hemi-lengthenings or a Z-lengthing can be performed - Silfverskiöld negative; 
            • when possible, a gastrocnemius recession limits the risk of iatrogenic over-lengthening
      • Knee Flexion Contractures (static and dynamic)
        • medial hamstring lengthening 
          • for mild knee dysfunction, usually younger patients with less than 5 degrees knee flexion deformity
          • Fractional lengthening at the myotendinous junction is ideal
          • Hamstring contractures often recur, especially in jump gait
        • 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 +/- patellar tendon advancement or shortening 
          • for knee flexion deformities of 10-30 degrees, with severe quadriceps lag close to or already at skeletal maturity
      • Stiff-knee Gait
        • Rectus Transfer to create knee flexion vector with rectus activation
      • Transverse Plane Deviations
        • Treatment
          • operative interventions should be part of SEMLS surgeries whenever possible
        • femoral anteversion / Hip internal rotation deviation
          • external rotation proximal femur osteotomy
        • external tibial torsion
          • Supramalleolar osteotomy
        • Complications
        • correcting a planovalgus foot (e.g. lateral column lengthening, talonavicular fusion) may obviate the need for tibial rotational correction
        • Examination underanesthesia after each segmental correction is important
Techniques
  • Gastrocnemius recession
    • Horizontal or Verticle incision at the level of the myotendinous junction of the gastroc
    • Identify and protect the sural nerve (superficial to fascia)
    • Sharply devide 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
Complications
 
  • multiple simultaneous soft tissue releases without careful gait analysis
    • elongated patellar tendon (patellar alta) is another complication of this condition that is difficult to treat
    • 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%

(1084/1807)

2

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

23%

(424/1807)

3

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

10%

(181/1807)

4

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

5%

(98/1807)

5

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

0%

(6/1807)

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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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