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The article offers step-by-step instructions for surgical treatment of severe cavovarus foot deformity in charcot-marie-tooth disease.

Background: Equinus of the foot at the ankle is one of the most common deformities in patients with spastic diplegic cerebral palsy, leading to gait disturbances and secondary deformities. During single-event multilevel surgery, equinus is commonly corrected by calf muscle lengthening, such as gastrocnemius-soleus intramuscular aponeurotic recession. Various studies have described satisfactory short-term results after gastrocnemius-soleus intramuscular aponeurotic recession. However, there is no evidence for maintenance of equinus correction because of the small and heterogeneous case series and short follow-up time previously reported. Methods: The present study provides long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery for the treatment of equinus in forty-four patients with spastic diplegia who were able to walk (forty-eight legs had lengthening of the gastrocnemius and thirty-four legs had lengthening of the gastrocnemius and soleus). Standardized three-dimensional gait analysis and clinical examination were done preoperatively and at one year, a mean (and standard deviation) of 3 ± 1 years, and a mean of 9 ± 2 years after surgery. Results: Significant improvements in kinematic and kinetic ankle parameters on gait analysis as well as passive dorsiflexion in clinical examination were found one year after surgery. While there was a significant loss of passive dorsiflexion at the time of long-term follow-up, the improvements in gait analysis parameters were maintained. The endurance of gait improvements was accompanied by a persistent increase of dorsiflexor muscle strength without relevant loss of plantar flexor strength. Although it was not significant, there was a tendency for deterioration of gait analysis parameters over the nine years. The analysis of individual patterns showed recurrence of equinus at the ankle in 24% of the legs. Early-onset calcaneal gait was found one year after surgery in seven legs (9%), but without secondary crouch gait, and there was recovery at the time of the long-term follow-up. Late-onset calcaneal gait was seen at the time of long-term follow-up in eight legs (10%), of which four had an accompanying crouch gait. Conclusions: Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to sat-isfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession. [ABSTRACT FROM AUTHOR]

Background: Hamstring lengthening commonly is performed for the treatment of flexed knee gait in patients with spastic diplegic cerebral palsy. Satisfactory short-term results after hamstring lengthening have been demonstrated in various studies. However, evidence for the effectiveness of hamstring lengthening to correct flexed knee gait is scant because of small and inhomogeneous case series, different surgical techniques, and short follow-up. Methods: The long-term results for thirty-nine patients with spastic diplegia and flexed knee gait who were managed with intramuscular hamstring lengthening as a part of multilevel surgery are presented. Standardized three-dimensional gait analyses and clinical examinations were performed for all patients preoperatively and at one, three, and six to twelve years postoperatively. Results: Significant improvements in kinematic parameters and the popliteal angle were noted at short-term follow-up (p < 0.01), supporting the results of previous studies. Long-term results showed significant deterioration of minimum knee flexion in stance and the popliteal angle (p < 0.01), whereas the improvements in the Gross Motor Function Classification System and Gillette Gait Index were maintained. This recurrence of flexed knee gait is partial and measurable. Increased pelvic tilt was found in 49% of the limbs postoperatively, which may represent one factor leading to recurrence of flexed knee gait. Genu recurvatum was seen in eighteen patients (twenty-seven limbs; 35%) one year postoperatively, especially in the patients with a jump knee gait pattern preoperatively. At long-term follow-up, genu recurvatum resolved in many limbs, but 12% of the limbs showed residual genu recurvatum, indicating that overcorrection represents a problem following hamstring lengthening. Conclusions: The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning. [ABSTRACT FROM AUTHOR]

Background: The evidence for distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in children with spastic diplegic cerebral palsy is limited because of inconsistent outcomes reported in various studies and the lack of long-term evaluations. Methods: This study investigated the long-term results (mean, nine years) for fifty-three ambulatory patients with spastic diplegic cerebral palsy and stiff-knee gait treated with standardized distal rectus femoris transfer as a part of multilevel surgery. Standardized three-dimensional gait analysis and clinical examination were carried out before surgery and at one year and nine years after surgery. Patients with decreased peak knee flexion in swing phase who had distal rectus femoris transfer to correct the decreased peak knee flexion in swing phase (C-DRFT) were evaluated separately from those with normal or increased peak knee flexion In swing phase who had distal rectus femoris transfer done as a prophylactic procedure (P-DRFT). Results: A significantly Increased peak knee flexion in swing phase was found in the C-DRFT group one year after surgery, while a significant loss (15°) in peak knee flexion in swing phase was noted in the P-DRFT group. A slight but not significant increase in peak knee flexion in swing phase in both groups was noted at the time of the long-term follow-up. A significant improvement in timing of peak knee flexion in swing phase was only found for the C-DRFT group, and was maintained after nine years. Knee motion and knee flexion velocity were significantly increased in both groups and were maintained at long-term follow-up In the C-DRFT group, while the P-DRFT showed a deterioration of knee motion. Conclusions: Distal rectus femoris transfer is an effective procedure to treat stiff-knee gait featuring decreased peak knee flexion in swing phase and leads to a long-lasting increase of peak knee flexion in swing phase nine years after surgery. Patients with more involvement showed a greater potential to benefit from distal rectus femoris transfer. How-ever, 18% of the patients showed a permanently poor response and 15% developed recurrence. In patients with severe knee flexion who underwent a prophylactic distal rectus femoris transfer, a significant loss in peak knee flexion in swing phase was noted and thus a prophylactic distal rectus femoris transfer may not be Indicated in these patients. [ABSTRACT FROM AUTHOR]

Objective: The aim of the investigation was to assess the contribution of pain to functional, social, and health-related quality-of-life outcomes in adults with cerebral palsy. Design: This monocentric, prospective study included long-term data for ambulant adults with cerebral palsy and at levels I-III in the Gross Motor Function Classification System who had received orthopedic multilevel surgery in adulthood and in whom preoperative and postoperative three-dimensional gait analysis was conducted, including the Gait Profile Score. A questionnaire including the Visual Analog Scale, Oswestry Disability Index, and European Quality of Life 5 Dimensions 3 Level was analyzed. Results : Twenty-four adults at a mean age of 38.0 yrs were included. Sixteen patients (66.7%) indicated that they experienced pain and 10 patients (41.7%) had pain for more than 6 mos. Overall, 13 patients (54%) experienced both pain and anxiety. There was no correlation of the Gait Profile Score with pain, Gross Motor Function Classification System, and Oswestry Disability Index. The Oswestry Disability Index showed a positive correlation with the Gross Motor Function Classification System (r = 0.39, P = 0.05) and pain (r = 0.57, P = 0.004). Conclusions: Pain and anxiety represent relevant comorbidities in adults with cerebral palsy. The occurrence of pain correlates with the Oswestry Disability Index and is higher than in children with cerebral palsy. [ABSTRACT FROM AUTHOR]

Introduction: Conservative therapy for bilateral spastic cerebral palsy (BSCP) regularly includes a modular orthosis setup with dynamic ankle-foot orthosis (DAFO) and modular shank supply (MSS). Additional effects by this modular supply have not been studied so far. The goal was thus an exploratory investigation of what effects can be expected by supplementing a DAFO with an additional MSS. Materials and Methods: Ten children with BSCP were fitted with DAFO and MSS. Dynamic elastic shank adaptations (DESAs) and ground reaction force AFOs (GRAFOs) were used, depending on the participants' individual needs. Participants underwent a gait analysis after supply and 3 months later. Data analysis included a descriptive analysis and further statistical testing using a Friedman test and post hoc Wilcoxon rank test. Results: The Gillette Gait Index (GGI) improved significantly with MSS compared with barefoot and DAFO, the Gait Deviation Index (GDI) only comparing DAFO to MSS. However, no further changes had occurred at follow-up, and for the Gait Profile Score (GPS), not at all. Step length, velocity, cadence, stance duration, and step width changed significantly after supply. Kinematic changes developed at ankle, knee, hip, and trunk. However, only minor changes had occurred at follow-up. Conclusions: DAFOs and MSS show positive effects, as observed in spatiotemporal parameters, gait indices, and kinematic data. Most kinematic effects occur at the ankle and knee joint. MSS produces additional effects, with a particular emphasis on the extending effect on the knee in terminal stance. Only minor beneficial effects on kinematic parameters of knee and trunk during swing phase occur after a familiarization phase. The changes in the spatiotemporal parameters imply a slight deterioration. [ABSTRACT FROM AUTHOR]

Background: Stiff gait resulting from rectus femoris dysfunction in cerebral palsy commonly is treated by distal rectus femoris transfer (DRFT), but varying outcomes have been reported. Proximal rectus femoris release was found to be less effective compared with DRFT. No study to our knowledge has investigated the effects of the combination of both procedures on gait.Questions/purposes: We sought to determine whether an additional proximal rectus release affects knee and pelvic kinematics when done in combination with DRFT; specifically, we sought to compare outcomes using the (1) range of knee flexion in swing phase, (2) knee flexion velocity and (3) peak knee flexion in swing phase, and (4) spatiotemporal parameters between patients treated with DRFT, with or without proximal rectus release. Furthermore the effects on (5) anterior pelvic tilt in both groups were compared.Methods: Twenty patients with spastic bilateral cerebral palsy treated with DRFT and proximal rectus femoris release were matched with 20 patients in whom only DRFT was performed. Standardized three-dimensional gait analysis was done before surgery, at 1 year after surgery, and at a mean of 9 years after surgery. Basic statistics were done to compare the outcome of both groups.Results: The peak knee flexion in swing was slightly increased in both groups 1 year after surgery, but was not different between groups. Although there was a slight but not significant decrease found the group with DRFT only, there was no significant difference at long-term followup between the groups. Timing of peak knee flexion, range of knee flexion, and knee flexion velocity improved significantly in both groups, and in both groups a slight deterioration was seen with time; there were no differences in these parameters between the groups at any point, however. There were no group differences in spatiotemporal parameters at any time. There were no significant differences in the long-term development of anterior pelvic tilt between the groups.Conclusions: The results of our study indicate that the short- and long-term influences of adding proximal rectus femoris release on the kinematic effects of DRFT and on pelvic tilt in children with cerebral palsy are negligible.Level Of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: With cerebral palsy (CP), an equinus deformity may lead to genu recurvatum. Botulinum toxin A (BtA) injection into the calf muscles is a well-accepted treatment for dynamic equinus deformity. Questions/purposes: The purpose of this study was to determine whether BtA injections into the calf muscles to decrease equinus would decrease coexisting genu recurvatum in children with diplegic CP. Methods: In a retrospective study, 13 children (mean age, 5 years) with spastic diplegic CP showing equinus and coexisting primary genu recurvatum, who were treated with BtA injections into the calf muscles, were included. Evaluations were done before and 6 and 18 weeks after intervention using three-dimensional gait analysis and clinical examinations according to a standardized protocol. Basic statistical analyses (power analysis, ANOVA) were performed to compare genu recurvatum before treatment and at 6 and 18 weeks after injection with BtA. Results: During stance phase, maximum ankle dorsiflexion was increased substantially from −3.0° ± 14.3° before to 6.2° ± 14.2° 6 weeks after the injections. Despite this, with the numbers available, the amount of recurvatum in stance did not improve with treatment at either 6 or 18 weeks. There was significant improvement of knee hyperextension during stance phase of 6.2° between baseline and 18 weeks after BtA injection, but a genu recurvatum was still present in most patients. Conclusions: Despite improvement of ankle dorsiflexion after injection with BtA, genu recurvatum did not show relevant improvement at 6 or 18 weeks after injection with the numbers available. Because knee hyperextension remained in most patients, other factors leading to genu recurvatum should be taken into consideration. In addition, a botulinum toxin-induced weakness of the gastrocnemius may explain why recurvatum gait was not significantly reduced. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Hamstring lengthening commonly is performed for the treatment of flexed knee gait in patients with spastic diplegic cerebral palsy. Satisfactory short-term results after hamstring lengthening have been demonstrated in various studies. However, evidence for the effectiveness of hamstring lengthening to correct flexed knee gait is scant because of small and inhomogeneous case series, different surgical techniques, and short follow-up.Methods: The long-term results for thirty-nine patients with spastic diplegia and flexed knee gait who were managed with intramuscular hamstring lengthening as a part of multilevel surgery are presented. Standardized three-dimensional gait analyses and clinical examinations were performed for all patients preoperatively and at one, three, and six to twelve years postoperatively.Results: Significant improvements in kinematic parameters and the popliteal angle were noted at short-term follow-up (p < 0.01), supporting the results of previous studies. Long-term results showed significant deterioration of minimum knee flexion in stance and the popliteal angle (p < 0.01), whereas the improvements in the Gross Motor Function Classification System and Gillette Gait Index were maintained. This recurrence of flexed knee gait is partial and measurable. Increased pelvic tilt was found in 49% of the limbs postoperatively, which may represent one factor leading to recurrence of flexed knee gait. Genu recurvatum was seen in eighteen patients (twenty-seven limbs; 35%) one year postoperatively, especially in the patients with a jump knee gait pattern preoperatively. At long-term follow-up, genu recurvatum resolved in many limbs, but 12% of the limbs showed residual genu recurvatum, indicating that overcorrection represents a problem following hamstring lengthening.Conclusions: The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning. [ABSTRACT FROM AUTHOR]