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Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_21 | Pages 33 - 33
1 Dec 2016
Leveille L Erdman A Jeans K Tulchin-Francis K Karol L
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The natural history of gait pattern change in children with spastic diplegia is a transition from toe walking to progressive hip and knee flexion with eventual crouch gait. This has been attributed to the adolescent growth spurt, progressive lever arm dysfunction, and iatrogenic weakening of the soleus with isolated tendo achilles lengthening (TAL). The relative contribution of TAL to the development of crouch gait is uncertain. The purpose of this study was to identify the frequency of crouch gait in spastic diplegic patients with and without history of prior TAL.

Patients with spastic diplegia greater than 10 years of age with instrumented gait analysis were reviewed. Exclusion criteria included diagnosis other than cerebral palsy, prior dorsal root rhizotomy, or incomplete past surgical history. Patients were divided into three groups: Group 1, no prior orthopaedic surgical intervention; Group 2, prior orthopaedic surgery without TAL; Group 3, prior orthopaedic surgery with TAL. Instrumented gait analysis data was analysed. Gait data were analysed using a single randomised limb from each patient.

One hundred and seventy-eight patients were identified: 39 in Group 1, 49 in Group 2, and 90 in Group 3. Mean time from TAL to gait analysis was 7.5 years (range 1.0–14.6 years). Mean age at TAL was 6.3 years (range 1.2–17.5 years). There was no significant difference in age, BMI, walking speed, or cadence between groups. Kinematic analysis showed no significant difference in mean stance phase maximum knee or ankle flexion between groups. There was no significant difference in frequency of increased mid stance knee flexion between groups (Group 1, 53.8%; Group 2 46.9%; Group 3, 43.3%, p=0.546). There was a trend towards increased frequency in excessive stance phase ankle dorsiflexion in Group 3 (60% Group 3 vs 46.2% Group 1, and 40% Group 2, p=0.071). Crouch gait (stance minimum hip flexion > 30, mid stance minimum knee flexion > 200, and stance maximum ankle dorsiflexion > 150) was seen with similar frequency in all groups (Group 1, 23.1%; Group 2, 18.4%; Group 3, 26.7%; p=0.544).

There is a trend towards increased frequency of excessive stance phase ankle dorsiflexion in spastic diplegic patients with prior TAL. However, no significant difference in frequency of crouch gait between patients with and without history of TAL was identified. Crouch gait is part of the natural history of gait pattern change in spastic diplegic patients independent of prior surgical intervention.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 235 - 235
1 May 2009
El-Hawary R Jeans K Karol LA Richards BS
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To evaluate the gait of five-year old children with club-feet initially treated non-operatively with the French functional technique and to compare these results to the data from this same cohort at the age of two years. Thirty-three patients (fifty-two idiopathic clubfeet) were initially treated with the French functional (physiotherapy) program. At the age of two years, no child underwent surgery for its clubfoot. Gait Analysis was performed with the VICON system (kinematics). At the age of five years, these patients were all re-evaluated in the gait laboratory.

Of the thirty-three patients (fifty-two clubfeet) initially treated non-operatively and tested in the gait lab at two years of age, thirty-seven feet required subsequent surgery by the age of five years. This included posterior release (41%), posteromedial release (35%), tibial osteotomy (19%), and tendo Achilles lengthening (5%). The proportion of feet with the following gait parameters changed significantly (p< 0.05) between the ages of two and five years: Equinus (15% at 2 yrs vs. 2% at 5 yrs), Calcaneus (7% vs. 23%), Foot Drop (18% vs. 4%). The proportion of patients with internal foot progression angle did not change over this time (46% vs. 50%), nor did the proportion with normal sagittal plane ankle motion (61% vs. 54%). At age two years, the majority of patients treated with the French Functional non-operative treatment had normal sagittal plane ankle motion. Gait disturbances, when present at this age, were generally ankle equinus, foot drop and in-toeing. By the age of five years, 71% of these patients underwent surgery for their clubfeet. When re-tested in the gait laboratory at age five years, the proportion of feet with normal sagittal plane ankle motion did not change significantly, however, their resultant gait disturbances, when present, were predominantly calcaneus rather than equinus and foot drop. By treating patients with clubfeet with the French Functional technique exclusively, equinus gait may result in a small proportion.

By subsequently treating these patients surgically after the age of two years, over-lengthening or over-release may occur and result in calcaneus gait. The French originators of this technique now incorporate an early gastrocsnemius fascial lengthening as part of their technique. This modification of their technique should improve the gait characteristics observed at two years of age and should decrease the necessity for late surgery that may have contributed to the gait characteristics observed at five years of age.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 141 - 141
1 Mar 2008
El-hawary R Karol L Jeans K Richards BS
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Purpose: Currently, clubfoot is initially treated with non-operative methods including Ponseti casting and the French physical therapy program (PT). Our purpose was to evaluate the function of children treated with these techniques.

Methods: Seventy-six idiopathic clubfoot patients were enrolled. Successful non-operative outcomes were achieved in 32 patients (44 feet) treated with casting and 44 patients (66 feet) treated by PT. Initial Dimeglio scores were 10–17. At average age 2.3 years (1.9–3.3yr), subjects’ gait was evaluated with a VICON 512 motion analysis system. Cadence and kinematic data was classified as abnormal if it fell outside of one standard deviation from normal.

Results: No statistical differences for cadence parameters were found between the two groups. Two kinematic patterns were identified: Children treated with PT walked with knee hyperextension (41% of feet)*, equinus (17%)*, and foot-drop (28%)*; whereas zero casted patients walked in equinus and only one demonstrated foot-drop. In contrast, the casted group demonstrated increased stance dorsiflexion (47%)* and calcaneus (18%). More PT feet had increased internal foot progression angle (34% vs. 13%)* and increased shank-based foot rotation (56% vs. 33%)*. Both groups had equal rates of normal sagittal-plane ankle motion (59% PT vs. 55%). [*p< 0.05].

Conclusions: Half of the two year-old patients treated non-operatively for clubfoot had normal sagittal-plane ankle motion. Less than 20% in each group experienced calcaneus and equinus gaits, respectively. These differences may be the result of performing percutaneous tendo Achilles lengthening as part of the Ponseti casting technique, but not as part of the PT program.