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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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