We studied the prevalence of severe crouch gait over a 15-year period in a defined population of children with spastic diplegia and Gross Motor Function Classification System levels II and III, to determine if there had been a decrease following changes to the management of equinus gait. These changes were replacing observational with three-dimensional gait analysis, replacing single level with multilevel surgery, and replacing gastrocsoleus lengthening with gastrocnemius recession. Of 464 children and adolescents with spastic diplegia who underwent three-dimensional gait analysis, 27 had severe crouch gait. Seventeen of these had been managed by isolated lengthening of the gastrocsoleus. Following changes in the management of equinus gait, the prevalence of severe crouch gait decreased from 25% and stabilised at a significantly lower rate, fluctuating between 0% and 4% annually (p < 0.001). . We conclude that severe crouch gait in this population was precipitated by isolated lengthening of the gastrocsoleus. These findings may be relevant to other surgical populations, as severe crouch gait may be a useful way to monitor the quality of the surgical management of abnormal gait in children with cerebral palsy and spastic diplegia

Patients with spastic diplegia who walk with a crouched posture often suffer from anterior knee pain, thought to be due to cephalad displacement of the patella. Ambulation with flexed knees elongates the patellar tendon, which leads to development of patella alta. Our study of 57 patients with spastic diplegia aimed to determine the severity of patella alta and to investigate its correlation with spasticity and muscle imbalance at the level of the knee. The ages of the 31 male and 26 female patients ranged from 3 months to 16 years. They were divided into two groups, one with spasticity of the hamstrings and the other with combined spasticity of the quadriceps and hamstrings. Clinical evaluation documented anterior knee pain, walking capacity, fixed deformities, hamstrings and rectus femoris shortening, and patellar mobility. Lateral radiographs were taken to measure the length of the patella and the patellar tendon. We used the method described by Insall and Salvati to calculate the patellar ratio. The clinical findings were examined for correlations with the severity of patella alta. We found that the group of patients with quadriceps and hamstring spasticity had a higher rate of patellar displacement but less frequent anterior knee pain than the group of patients with hamstring spasticity alone

Classifications of gait patterns in spastic diplegia have been either qualitative, based on clinical recognition, or quantitative, based on cluster analysis of kinematic data. Qualitative classifications have been much more widely used but concerns have been raised about the validity of classifications, which are not based on quantitative data. We have carried out a cross-sectional study of 187 children with spastic diplegia who attended our gait laboratory and devised a simple classification of sagittal gait patterns based on a combination of pattern recognition and kinematic data. We then studied the evolution of gait patterns in a longitudinal study of 34 children who were followed for more than one year and demonstrated the reliability of our classification

Purpose of Study. In children with spastic diplegia, surgery for equinus has a high incidence of both over and under correction. We wished to determine if conservative (mainly Zone 1) surgery for equinus gait, in the context of multilevel surgery, could result in the avoidance of calcaneus and crouch gait as well as an acceptable rate of recurrent equinus, at medium term follow-up. Description of Methods. This was a retrospective, consecutive cohort study of children with spastic diplegia, between 1996 and 2006. All children had distal gastrocnemius recession or differential gastrocsoleus lengthening, on one or both sides, as part of Single Event Multilevel Surgery. The primary outcome measures were the Gait Variable Scores (GVS) and Gait Profile Score (GPS) at two time points after surgery. Summary of Results. Forty children with spastic diplegia, GMFCS Level II and III were eligible for inclusion in this study. There were 25 boys and 15 girls, mean age 10 years at surgery. The mean age at final follow-up was 17 years and the mean postoperative follow-up period was seven years. The mean ankle GVS improved from 18.5° before surgery to 8.7° at short term follow-up (P<0.005) and 7.8° at medium term follow-up. Equinus gait was successfully corrected in the majority of children with a low rate of over-correction (2.5%) but a high rate of recurrent equinus (35.0%), as determined by sagittal ankle kinematics. Conclusion. Surgery for equinus gait, in children with spastic diplegia, was successful in the majority of children, at a mean follow-up of seven years, when combined with multilevel surgery, orthoses and rehabilitation. No patients developed crouch gait and the rate of revision surgery for recurrent equinus was 12.5%. NO DISCLOSURES

We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 ± 1.3 v 10.7 ± 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 ± 11° internal to 3 ± 9.5° external in the proximal group and from 9 ± 14° internal to 4 ± 12.4° external in the distal group. Correction of the foot progression angle was from a mean of 10.0 ± 17.3° internal to 13.0 ± 11.8° external in the proximal group (p < 0.001) compared with a mean of 7.0 ± 19.4° internal to 10.0 ± 12.2° external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia

Some radiological features of the lumbar spine of 84 patients with spastic diplegia were compared with 50 control subjects. The average age of the patients was 20.1 years (3 to 39). Spondylolysis of the fifth lumbar vertebra was found in 21%, four times more frequently than in normal subjects. No patient under nine years of age had spondylolysis and the frequency increased with age. The average angle of lumbar lordosis in spastic patients in the standing position was greater than in normal subjects, and increased with age. The patients had a decreased sacrofemoral angle which caused an increase in Ferguson's angle and explained the increased angle of lumbar lordosis

Introduction and Aims: We studied the outcome of single event multilevel surgery (SEMLS) for the correction of severe crouch gait in spastic diplegia, over a five-year period. It was unknown if gait correction post-SEMLS could be sustained at skeletal maturity. Method: This was a prospective cohort study, utilising validated outcome measures. Presenting symptoms were increasingly abnormal gait, anterior knee pain, patellar fractures and fatigue. SEMLS was based on pre-operative gait analysis: mean of seven procedures (range 5–10), including lengthening of contracted muscle-tendon units (particularly hamstrings and psoas), as well as rotational osteotomies and bony stabilisation procedures to correct lever arm dysfunction. Post-operatively subjects wore Ground Reaction Ankle Foot Orthoses (GRAFOs) and received a community-based rehabilitation program. Post-operative changes were evaluated at five years: technical outcome by 3D kinematics and functional outcome by mobility status. Outcomes were analysed with linear regression with robust standard errors. Results: Eleven children with spastic diplegic cerebral palsy fulfilled the criteria for ‘severe crouch gait’, defined as knee flexion > 30 degrees and ankle dorsiflexion > 15 degrees throughout stance. Ten of 11 subjects had previous Tendo Achilles lengthening. Mean age pre-operatively was 12 years one month (range 8–16) and at follow-up 17 years 10 months (range 16–21). All subjects regained pre-operative mobility levels with improved gait pattern, relief of knee pain and healing of patellar fractures. There was a significant decrease in dependence on assistive devices. Pre- versus five years post-operative kinematics showed clinically and statistically significant increases in knee extension and decreases in ankle dorsiflexion. Improvements were seen in knee extension initial contact (p< 0.001, 95% CI 15°, 31°); maximum knee extension (p< 0.001, 95% CI 16°, 37°), ankle dorsiflexion (p< 0.001, 95% CI 8°, 18°) and plantarflexion 3rd rocker in stance (p=0.03, 95% CI 1°, 17°); knee excursion (p=0.003, 95% CI –24°, −6°), and peak knee flexion timing (p=0.02, 95% CI 2%, 20%). Conclusion: Multilevel surgery for severe crouch gait in spastic diplegia results in consistently marked improvements in dynamic knee and ankle function, but not at the hip and pelvic levels. The results are durable in most patients, after five years and after reaching skeletal maturity

Purpose: In neuromuscular conditions, ankle foot orthoses (AFO) prevent deformity and improve functional balance by increasing the base of support, stabilizing the ankle joint and influencing the kinematics of more proximal joints; this study was designed to evaluate the role of fixed AFOs on balance in spastic diplegic children. Methods: 12 children (age 7–15yrs) with spastic diplegia were recruited. All were community ambulators (GMFCS II/III). All had used AFOs for 12 months. Each child walked along the GAITRite electronic walkway at their preferred speed: barefoot, in shoes, and in AFOs with shoes. The order of the walks was randomized limiting the effects of fatigue and confidence. Normalized velocity, cadence, stride length and percentage of gait cycle in single leg support were selected as surrogate measures of stability. The child’s balance during other functional activities was assessed with the paediatric balance scale (PBS). A two-way analysis of variance (ANOVA) explored differences in gait between the various walks. Fried-man’s test tested for differences in PBS scores between subjects and conditions. Results: Significant improvements were seen in mean values for normalized velocity (p=0.02), stride length (p< 0.01) and percentage of gait cycle in single leg support (p< 0.01) in footwear-AFO compared to barefoot. Whilst there were also improvements in mean values for these parameters in shoes alone compared to barefoot, only the difference in stride length reached statistical significance (p< 0.01). There were no significant differences in PBS scores in shoes alone or with AFOs compared with walking barefoot. Conclusions: AFOs improved balance during gait but had no effect on balance during other activities. Whilst shoes alone had a positive impact on gait, the most significant effects were seen in the AFO-footwear combination. Significance: Advice regarding AFO use and footwear choice should consider the effects on gait as well as prevention of deformity

We assessed the outcome after simultaneous multiple operations performed on 18 children with spastic diplegia, with emphasis on the changes in the physiological cost index (PCI) of walking. Fourteen patients had a measurable reduction at one year, but the more severely affected patients took up to two years to reach a new functional plateau. The level of the preoperative PCI allows prediction of the outcome of surgery in terms of reducing the effort of walking, or improving its appearance only. Intrapelvic intramuscular psoas tenotomy produced an improvement of hip flexion deformity in 15 of 17 patients without the loss of muscle power to initiate the swing phase. Fractional lengthening corrected hamstring tightness in 17 cases, and the mean popliteal angle was reduced from 63 degrees preoperatively to 30.2 degrees, with almost complete resolution of the fixed knee flexion deformity present in ten patients. Distal transfer of the rectus femoris, when it was shown to be contracting inappropriately, improved the knee flexion arc during walking from a mean of 28.3 degrees to 45.2 degrees

Introduction: The purpose of this study was to quantify changes in lower limb muscle strength in children with spastic diplegic cerebral palsy 6 months after multi-level orthopaedic surgery. Method: A consecutive sample of 20 children ( 10 girls and 10 boys, mean age 10.6) with spastic diplegia was studied prospectively. All participants had soft-tissue and bony surgical procedures performed as part of their clinical management. Physiotherapy treatment commenced following surgery. Lower limb muscle strength, pre and 6 months post-surgery, was measured, in addition to routine gait and function assessment. Maximum voluntary isometric strength of 5 muscle groups was measured bilaterally using a digital dynamometer. Paired-samples t-tests were performed. Results: There was a marked deterioration of muscle strength (p < 0.05) in all muscle groups. Medial hamstrings and hip flexors showed the greatest decline with an average decrease of 54% and 41% respectively. Analysis of gait parameters showed a significant improvement in kinematics (p< 0.05) but a decrease in walking velocity and cadence. Motor function decreased significantly (p< 0.05). There was reduced motor power in 18 of the 20 at 6 months. Discussion: Our results quantified objectively the magnitude of strength changes after multi-level surgery and show that weakness may be greater and persist longer than expected. This information will be useful for planning treatment after multi-level surgery and is part of a randomised trial investigating strength training. In general there is a decrease in power but an improvement in gait

We treated 20 children (40 limbs) with diplegic cerebral palsy who could walk by multilevel soft tissue operative procedures including conversion of the biarticular semitendinosus and gastrocnemius to monoarticular muscles. The mean age at surgery was 11.5 years (5.6 to 17.0). All patients underwent clinical and radiological examination and three-dimensional instrumented gait analysis before and at a mean of 3.1 years (2.0 to 4.5) after surgery.

The passive range of movement at the ankle, knee and hip showed improvement at follow-up. Kinematic parameters indicated a reduced pelvic range of movement and improvement of extension of the knee in single stance after operation (p < 0.0001). However, postoperative back-kneeing was detected in five of the 40 limbs. The kinetic studies showed that the power of the hamstrings and plantar flexors of the ankle was maintained while the maximum knee extensor moment during stance was reduced. The elimination of knee flexor activity of semitendinosus and gastrocnemius combined with transfer of distal rectus femoris led to an improvement in gait as confirmed by gait analysis.

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles. Cite this article: Bone Joint J 2015;97-B:564–71

We studied the results of multi-level surgical intervention for children with cerebral palsy. Thirty patients, aged 7–16 years, with spastic diplegia (n=20), or spastic hemiplegia (n=10) were studied prospectively by gait analysis. Multilevel surgery included a combination of psoas lengthening, medial hamstring lengthening, rectus femoris transfer and gastrocnemius lengthening +/− foot surgery or femoral derotation osteotomies. Gait analyses were carried out pre-op and at 6 and 24 months post-op. Children with spastic diplegia increased their walking velocity by an average of 20% at two years (p< 0.05). Mean stride length increased from 89cm pre-op to 102cm at two years (p< 0.05) with similar improvements in both groups of children. Maximum knee extension in stance improved from an average 17.5 degrees flexion pre-operatively to an average 5 degrees flexion postoperatively (p< 0.05). Peak knee flexion in swing was maintained and the timing improved. Peak ankle dorsiflexion in stance was unchanged following surgery but the timing of peak ankle dorsiflexion was normalised to late stance (from 24% of cycle pre-operatively to 48% of cycle post-operatively (norm = 48%). Average maximum hip extension in stance did not change. The mean anterior pelvic tilt did not change post-operatively. However, a number of children with spastic diplegia had increased anterior pelvic tilt post-operatively. These results are similar to those reported internationally, with most improvement seen distally at the knee and ankle and less improvement at the hip. Increased anterior pelvic tilt was seen as a consequence of hamstring lengthening in some more involved patients

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

We describe unexpected adverse psychological and social results in three adult men with severe Little's disease who were made more mobile by successful surgery

We report the case of a child with cerebral palsy and spastic diplegia treated for bilateral fixed flexion of the knee by bilateral hamstring lengthening. An attempt to straighten the legs from 90 degrees to 20 degrees flexion damaged the sciatic nerve. There are no objective means of estimating how much deformity can be reduced safely. We present a method of calculating the extra strain in the sciatic nerve produced by reducing a flexion deformity. The result, combined with clinical judgement, provides guidelines for safe corrective surgery

The aim of this study was to validate the SENIAM recommendations for surface electromyography placement(sEMG) over rectus femoris(RF) muscle in healthy children and in children with cerebral palsy(CP) during gait analysis and compare placement using these guidelines to using ultrasonography. Methods & Results:. The study included 10 healthy children volunteers and 10 CP children volunteers, aged 8–12. All the CP children had spastic diplegia, were GMFCS levels I–II and had not previously undergone surgery. RF electrodes were placed following SENIAM recommendations. RF was then identified by ultrasound. The distance between the lateral edge of RF and the position of the sEMG electrode as per SENIAM guidelines and the width of RF was measured, to the nearest millimetre. We considered ‘ideal electrode’ position to be at halfway between the edges of RF (i.e. 50%). The mean percentage difference in distance from the ‘ideal electrode’ position as measured by ultrasound to electrode placement following SEMIAN guidelines was 2.7% in the healthy children group compared with 19.5% in the CP group. By performing unpaired t tests we showed that there was no significant difference between the mean electrode position using SEMIAN guidelines and ‘ideal electrode’ position in the healthy children (p=0.0531), however the mean electrode position using SEMIAN guidelines in the CP patients was significantly different from the ‘ideal electrode’ position (p=0.0001). Conclusion:. SENIAM recommendations for sEMG electrode placement over RF muscle were validated in 10 healthy children. We showed that ultrasonography improved the accuracy of sEMG electrode placement in children with CP, who can exhibit anatomical variation due to their condition. Accurate electrode placement will ensure that a more accurate signal is recorded which may have a direct clinical bearing on the decision to proceed with surgical intervention. Level of evidence: II

The objective and dynamic documentation of the knee kinematics in ambulatory children with spastic cerebral palsy and the examination of possible causes of differences when compared to normals. 17 ambulatory patients with an average age of 10,5 years (6–17 years) with cerebral palsy, spastic diplegia where examined clinically including Duncan-Ely test. They were also examined with 3-D instrumented gait analysis. The Elite system with six cameras was used and the knee kinematics in the sagittal plane was recorded. Almost all patients (16/17) had a positive Duncan-Ely test during clinical examination. The knee kinematics in the sagittal plane showed that in 20/34 knees the range of motion was decreased compared to normal values. In 30/34 knees there was a delayed maximum knee flexion in swing phase and in 16/34 knees the amplitude of the maximum knee flexion was decreased compared to normals. Patients with severe crouch or mild rectus spasticity had almost normal knee flexion. Foot clearance in swing phase is one of the basic prerequisites of normal gait. Patients with spastic cerebral palsy who are able to walk have an impaired foot clearance because of the pathological action of the rectus femoris. In our study the majority of the patients with clinically confirmed rectus spasticity had decreased timing and amplitude of max. knee flexion in swing. In patients with severe co-contraction of the knee flexors and extensors max. knee flexion within normal range. Therefore it should not be considered as the only evaluation parameter in rectus femoris spasticity

Severely involved patients with spastic diplegia or mild quadriplegia have increasing difficulty remaining ambulatory as they progress to adolescence and young adulthood, often becoming wheelchair bound. This presentation addresses effort to prevent or reverse this progressive state, allowing continued ambulation in a select group of patients. They must be highly motivated to keep walking, have a willingness to undergo extensive rehabilitation and have good psycholsocial support. The program consists of multiple surgeries to the spine, pelvis/hip, knee, foot and ankle followed by a spika or long casts, leg braces (HKAFO to final GRO), 12–18 months of intense physical therapy and permanent use of crutches. Seventeen patients, 16 adilescents and young adults, one adult over 50 adult, who were within 6 months of permanent wheelchair existence qualified and underwent this program. They were followed for a minimum of 10 years post surgery. All patients but one have remained supported community ambulators. The extent of the surgery, complications and problems are described. An additional group of wheelchair bound patients with quandriplegia and severe diplegia were treated with extensive global surgery (described). The purpose was stabile symmetric seating with no pain and allowing the use of the hands and upper extremities for other than support in seating. The ability to achieve these goals has required addressing the controversy associated with extensive surgey in the non-ambulatory patient

Aim: To report the clinical and radiological outcome of intramedullary fixation following corrective femoral diaphyseal derotational osteotomy, particularly in children with cerebral palsy. Methods: We conducted a retrospective study of all femoral diaphyseal derotational osteotomies with Trigen antegrade intramedullary fixation (TAN system, Smith & Nephew) from April 2005 to June 2006. There were 9 patients with 14 affected limbs. The diagnosis was spastic diplegia in 8 of the 9 children, of whom 5 underwent the osteotomy as part of multilevel surgery. Results: The mean age at surgery was 13.7 years (Range 11.2 – 17.3 years). The mean preoperative femoral anteversion was 43.6 degrees (Range 30 – 50 degrees) with the mean internal & external rotation being 61.6 (Range 50 – 70) & 8.3 (Range 0 – 20) degrees respectively. The average follow-up period was 9.5 months (Range 1.5 – 15 months). All patients mobilised with crutches in an average of 5 days (Range 3 – 12 days) and full weight bearing was achieved by 65 days (Range 45 – 150 days). Marked improvement in gait was noted in all children with postoperative mean internal & external rotation being 42.9 & 52.6 degrees respectively. There have been no instances of avascular necrosis or postoperative complications to date. Correction was maintained at the final follow up in all children with good bony union by 8 – 12 weeks. Conclusion: The key to the success of femoral derotational osteotomy for correction of excessive femoral anteversion in children lies in achieving correction and early mobilisation. Intramedullary fixation following diaphyseal derotational osteotomy in children is a safe, effective, cosmetic and reliable procedure with rapid bony union, attributable to biological fixation and early mobilisation. Good early results have been obtained in children with cerebral palsy undergoing this procedure as a part of multilevel corrective surgery