Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Updated: Jun 15 2021

Cerebral Palsy - Gait Disorders

3.5

  • star icon star icon star icon
  • star icon star icon star icon
  • star icon star icon star icon
  • star icon star icon star icon
  • star icon star icon star icon

(57)

Images
https://upload.orthobullets.com/topic/4128/images/cp gait.jpg
  • 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
        • independent gait expected between 12 to 18 months old in non-CP children
  • Etiology
    • Cerebral Palsy General
    • 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
    • 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
        • new treatment strategies focus on understanding the
          • underlying pathophysiology (deviations)
          • planes of deformity (sagittal, coronal, transverse)
          • anatomic level (hip, knee, ankle)
  • 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
      • 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
        • 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)
    • 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
      • contraindications
        • spastic diplegia
          • leads to excessive weakening and development of calcaneus/crouch gait
      • 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
Card
1 of 2
Question
1 of 10
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options