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Characteristics of adults with equinus foot deformity and
BSCP were collected (Table 1), and the need for assistive
devices was analyzed. Ultimately, 52 legs were analyzed,
because 10 patients had an unilateral equinus. These 10
patients had only 1 involved side that required equinus correction. The contralateral side showed no equinus deformity
and was not included in the analysis. The patients gave
informed consent, and the protocol was approved by the
local ethics committee .
For the quantitative 3-dimensional gait analysis a 120Hz 9-camera system (Vicon, Oxford Metrics, Oxford, UK)
and 2 piezoelectric force plates (Kistler, Winterthur,
Switzerland) were used. Skin-mounted markers were
applied to bony landmarks of the patients according to the
protocol of Kadaba et al.20 Further, patients were asked to
perform a walk along a 7-m walkway at a self-selected
speed pre- and postoperatively. The Gait Profile Score
(GPS)1 and the Gillette Gait Index (GGI)15 as objective gait
indices to measure pre- and postoperative changes were
collected. Further, we ascertained if patients walked with or
without orthotic devices (eg, crutches) pre- and postoperatively. However, at all examinations, gait analysis was done
while the patient walked barefoot without an orthosis along
a 7-m walkway with self-selected speed.
The time of rehabilitation and the number of peri- and
postoperative complications were extracted from postoperative medical reports. We used the classification system for
orthopedic procedures adapted by Sink et al.32

Operative Indication
The indication to correct partially fixed or fixed equinus
uni- or bilaterally was based on previous insufficient conservative treatment including botulinum toxin injections
with or without casting, ankle-foot orthosis, and night
splinting. The Silfverskiöld test31 was performed during
anesthesia to obviate spasticity as a principal dynamic component (lack of dorsiflexion of the ankle to neutral position
with the knee in extension and flexion). Further patients
showed increased plantarflexion in stance that was 1 standard deviation above the norm.12 All patients underwent
standardized gastrocnemius-soleus intramuscular aponeurotic lengthening according to the technique described by
Baumann and Koch.3 Proximal gastrocnemius lengthening
within the proximal third of the gastrocnemius was performed, if plantarflexion in knee extension was ≤20° but
correctable to neutral position in knee flexion. Further gastrocnemius and soleus lengthening at the proximal third
was performed if plantarflexion was ≤20° measure in knee
extension and flexion. If fixed equinus of >20° remained
only in knee extension, a Strayer procedure was performed.
In 3 legs of 2 patients, an Achilles tendon lengthening was
performed after a lengthening of the gastrocnemius and
soleus, because the patients still had a plantarflexion of less

Foot & Ankle International 39(7)
Table 1. Characteristics of Adults With Equinus Foot
Deformity and BSCP (N = 31).
Parameter
Females/males
Age (y), mean (min-max)
GMFCS
GMFCS 1 pre (post)
GMFCS 2 pre (post)
GMFCS 3 post
Assistive devices
Preoperative
Postoperative
Interval pre- and postoperative
GA, mo/y
Interval SEMLS - postoperative
GA, mo/y
interval preoperative GA -
SEMLS, mo

Cases (N = 31)
12/19
25.0 ± 7.7 (range, 16.8-43.2)
Distribution of GMFCS
11 (10)
20 (20)
1
0
1 (one crutch)
24.3 ± 9.2/1.9 ± 0.9
19.2 ± 9.1/1.6
4.7 ± 5.6

Abbreviations: BSCP, bilateral spastic cerebral palsy; GA, gait analysis;
GMFCS, Gross Motor Function Classification System; SEMLS, singleevent multilevel surgery.

than 20° in knee extension and knee flexion (Figure 2).
Additional procedures within multilevel surgery are
depicted in Table 2. Further multilevel interventions were
performed in case of additional torsional problems and
instability of the foot.25 Postoperative management included
early mobilization in a walking cast for 6 weeks, if no further bony procedures were performed. In case of supplemental osteotomies at different levels of the affected side,
the treatment included 6 weeks' immobilization in a cast
and additionally weight bearing for 6 weeks with a walking
cast. After this time interval, carbon-fiber ankle-foot orthosis and a night-splint in neutral ankle position was added for
4 to 6 and 12 months.

Data Evaluation and Statistical Analysis
Basic descriptive statistics, including means and standard
deviations (SD), were calculated, and 2-tailed dependent t
tests for paired samples were conducted to compare preand postoperative GGI und GPS values as well as clinical
and kinematic data. For the categorical variables Medical
Research Council18 (MRC) scale and modified Ashworth
scale,4 the nonparametric Wilcoxon signed-rank test was
calculated. Further, the clinical and kinematic pre- and postoperative difference of ankle range of motion (ROM) was
calculated (nonparametric test, Wilcoxon test) between
groups (Baumann [n = 17], Strayer [n = 32], and Achilles
tendon [n = 3] lengthening). Kolmogorov-Smirnov (KS)
and Shapiro-Wilk (SW) test were computed to show if preoperative data were normally distributed. Calcaneal gait
indicating overcorrection was defined if postoperative

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