To evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus.

Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10–35 years; mean 16.8 years). None had received botulinum toxin A injections or surgery in the preceding six and 12 months respectively. All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (± 5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 nineteen patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.25, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p = 0.024).

The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. However, distinguishing between the natural history of CP and interventions and isolating the effects of one intervention from others in multilevel surgery are well recognised difficulties in cohort studies in CP. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP.

Introduction

Given the increasing prevalence of hip and knee arthroplasties performed, measures have been implemented to standardize care and effectively improve patient outcomes and decrease costs. Length of stay (LOS) directly affects costs. The purpose of this study was to identify peri-operative and patient related factors that correlated with decreased or increased LOS.

A prospective, comparative study of two Total Knee Replacement systems was undertaken to compare the traditional end point of revision of the prosthesis with three other end points based on the British Orthopaedic Association Knee Assessment Protocol. These were an unacceptable pain score plus revision, Knee Score of 60% or less plus revision, and a fall to below the preoperative Knee Score plus revision. 182 Knees entered the trial (74 St Leger and 108 Miller-Galante 11 prostheses), and all were assessed for Knee Score pre-operatively. Patients were subsequently assessed for Knee Score at 6 months, 1 year and annually thereafter. 63 implants had reached the five year stage at the time of this study.

The results indicate that different patients are designated as ‘failures’ depending on the end point selected, and that different survivorship figures can therefore be calculated with up to 6% variation depending on the end point used. In addition, the most successful prosthesis varies with the end point selected. Although the 95% confidence intervals in this study did not permit us to draw any firm conclusions, we suggest that further investigation into the definition of failure in survivorship analysis is necessary in order to reflect the performance as well as the longevity of Total Knee Replacements.