Introduction and Aims: We present the preliminary results of patellar tendon shortening (PTS), for severe crouch gait in children with spastic cerebral palsy who were household ambulators.

Method: We performed bilateral patellar tendon shortening in 15 patients with severe spastic diplegia between May 1996 and January 2002. The majority had acquired crouch gait because of isolated lengthening of the Achilles tendons in childhood and presented with anterior knee pain and rapidly deteriorating gait and function. The PTS procedure included dividing the patellar tendon in its mid portion, and performing an overlapping repair by suturing the distal tendon to the distal pole of the patella and the proximal segment to the tibial tubercle. The corrected position of the patella was maintained by a K-wire passed transversely through the patella and incorporated into a cylinder plaster, with the knee in extension, for a period of six weeks. Correction of knee flexion deformity was achieved by transfer of semitendonosis to the distal femur or extension osteotomy of the distal femur.

Results: Rehabilitation was predictably slow but all patients regained their pre-operative mobility status within one year and the majority surpassed their pre-operative functional level by two years after surgery. There were no tendon ruptures or growth disturbance in the proximal tibia. Average age at the time of surgery was 14.2 years (10–19 years). Mean follow-up was 27 months (12–48 months). Pre- and post-operative Insall index in 17 knees was 0.68cm (0.46 to 1.07cm, SD=0.16cm) and 0.85cm (0.56 to 1.08cm, SD=0.20) respectively (p< 0.001 Students-t test). Pre-operatively, only three sides had a normal index, but post-operatively 14 sides had a normal index. Crouch gait improved in all patients who were reclassified as community ambulators. Thirteen patients still needed crutches. One patient continued to complain of bilateral knee pain 12 months after surgery, had insufficient correction according to the Insall index (0.58cm on the left 0.56cm on the right).

Conclusion: Severe crouch gait after appropriate surgical and orthotic management, maybe due to patella alta, quadriceps and ankle plantarflexors insufficiency. We present preliminary results of a salvage procedure, patellar tendon shortening, which seems a reasonable option to treat complex crouch gait in selected patients with cerebral palsy.

Torsional deformities of the tibia are common in children, but in the majority both the torsion and the associated disturbance of gait resolve without intervention. There are, however, a significant number of children and adults with neuromuscular disease who present with pathological tibial torsion, which may require surgical correction.

We conducted a prospective study in two centres, to investigate the outcome of supramalleolar derotation osteotomy of the tibia, using internal fixation with the AO-ASIF T plate. A range of outcome variables was collected, prospectively, for 57 patients (91 osteotomies), including thigh foot angle, foot progression angle, post-operative complications and serial radiographs. Correction of thigh foot angle and foot progression angle was satisfactory in all patients. Three major complications were recorded; one aseptic nonunion, one fracture through the osteotomy site after removal of the plate and one distal tibial growth arrest.

We found that supramalleolar derotation osteotomy of the tibia, with AO-ASIF T plate fixation is an effective method for the correction of torsional deformities of the tibia and the associated disturbances of gait in children and adults with neuromuscular disease, with a 5.3% risk of major complications.