Foot & Ankle International - July 2018 - 813

Putz et al

813

Figure 1. Outline of in- and exclusion criteria of cerebral palsy patients, BSCP, bilateral spastic cerebral palsy; GMFCS, Gross Motor
Function Classification System; SEMLS, single-event multilevel surgery. *Gastrocnemius-soleus intramuscular aponeurotic recession,
Achilles tendon lengthening.

have been described primarily for fixed equinus.12,13,21,34,36
Operative treatment for equinus gait in children is successful, if multilevel surgery is done in combination with orthoses and rehabilitation.13 Further mid-term and long-term
results after gastrocnemius-soleus intramuscular aponeurotic lengthening as part of SEMLS provide satisfactory
outcome.12,13,29,33 The main goal in children with CP is to
avoid a decrease of muscle strength of the triceps surae
resulting in calcaneal gait and to strengthen the antagonists
(eg, tibialis anterior muscle).37 It is not clear, so far, if adults
with CP show similar results after correction of equinus.
Furthermore, compared with children, further growth cannot
influence the postoperative course of rehabilitation. Outcome
studies of orthopedic operative procedures in adults using
objective 3-dimensional gait analysis are common.6,40 Our
research group has investigated a large series of adult
patients with CP who underwent SEMLS.25
The purpose of the present clinical cohort study, extracted
from a large cohort study published previously, was to analyze the functional outcome after correction of equinus
deformity in the context of SEMLS in ambulatory adults
with CP. The hypothesis of this investigation was that gastrocnemius-soleus intramuscular aponeurotic recession as
part of multilevel surgery would improve foot function and
equinus deformity in adults.

Methods
This retrospective clinical cohort study contains prospectively collected data (1996-2014) of ambulatory adults (1755 years) with BSCP or unilateral CP (level I, II, or III,
according to the Gross Motor Function Classification

System23 [GMFCS]) of a single center specialized in the
treatment of CP. In the present analysis (Figure 1), we
included adolescent and adult ambulatory patients (n = 103)
with (1) BSCP, (2) GMFCS I and II who were treated with
(3) SEMLS and as principal procedure correction of equinus
deformity for fixed or partially fixed equinus uni- or bilaterally. Overall, 3 patients with GMFCS 3 were excluded. This
study constitutes a subgroup analysis of our previously published study and analyzes the influence of gastrocnemiussoleus intramuscular aponeurotic recession and Achilles
tendon lengthening as part of SEMLS in adults with bilateral
CP and a equinus deformity.25 All operative procedures were
performed by 3 senior orthopedic surgeons (T.D., L.D., F.B.).
Multilevel surgery in adults included femoral and tibial osteotomies, muscle tendon lengthening, tendon transfers, and
stabilization of the foot. Overall, 10 patients had previous
orthopedic operative procedures in childhood or adolescence, including 6 patients who had either gastrocnemiussoleus lengthening (n = 2) or Achilles tendon lengthening (n
= 4). These patients were not excluded from the analysis. All
patients with (4) a minimum follow-up of 1 to 5 years (mean,
1.6 years) were selected. The prerequisite was further (5)
pre- and postoperative 3-dimensional gait analysis and (6)
clinical examination by a physiotherapist and a study nurse
with special training in CP therapy and gait analysis.
Exclusion criteria were previous selective dorsal rhizotomy,
use of an intrathecal Baclofen pump, or Botulinum toxin A
injections within the preceding 6 months.
Overall, 31 patients (62 legs), 12 (38.7%) women and 19
(61.3%) men, with a mean age of 25.0 ± 7.7 (range, 16.843.2) years were selected for the present clinical retrospective study.



Table of Contents for the Digital Edition of Foot & Ankle International - July 2018

Contents
Foot & Ankle International - July 2018 - Intro
Foot & Ankle International - July 2018 - Cover1
Foot & Ankle International - July 2018 - Cover2
Foot & Ankle International - July 2018 - i
Foot & Ankle International - July 2018 - ii
Foot & Ankle International - July 2018 - Contents
Foot & Ankle International - July 2018 - iv
Foot & Ankle International - July 2018 - v
Foot & Ankle International - July 2018 - vi
Foot & Ankle International - July 2018 - vii
Foot & Ankle International - July 2018 - viii
Foot & Ankle International - July 2018 - 1A
Foot & Ankle International - July 2018 - 1B
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Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
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Foot & Ankle International - July 2018 - 3B
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Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
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