Achilles tendon lengthening (ATL) surgery can help to treat ‘equinus foot,’ also known as tiptoe walking, which is a common symptom of cerebral palsy (CP). However, many children who have ATL surgery experience overcorrection, and end up walking with a crouch gait. Therefore, it would be valuable to identify individual characteristics that could predict the likelihood of ATL surgery being successful and not resulting in overcorrection. Giuseppina Pilloni and colleagues in Italy set out to do just that, and published the results of their research in the European Journal of Physical and Rehabilitation Medicine (click here to download a pdf of their paper).
Methods: assessing whether gait pattern could predict surgery outcome
Pilloni et al. conducted a cross-sectional retrospective study in order to assess whether a child’s gait pattern before surgery could predict the outcome of ATL. Their subjects were 18 children, with a mean age of 9.6, who had spastic diplegia CP. All of the children underwent a 3D gait analysis prior to and again about 12 months after surgery. The authors examined spatiotemporal, kinematic, and kinetic parameters, and defined gait patterns for each leg by using a classification system called the Plantar Flexor Knee Extension index. Then, their subjects were split into “jump gait” and “true equinus.” Pilloni et al. define these terms as follows:
“The jump gait pattern is characterized by equinus, knee flexion, hip extension and pelvic anterior tilt. In some cases, stiff knee is present due to abnormal activation of the rectus femoris during the swing phase. In true equinus, the stance phase is characterized by plantar flexion of the ankle and extension of both knee and hip due to spasticity of the sural triceps. However, children may still be able to maintain an upright posture with flexed knees, masking the true equinus gait pattern.”
Results: higher incidence of overcorrection in children with true equinus gait pattern
The authors found that both groups had improvement of GVS ankle dorsi-plantar flexion. However, children who walked in the true equinus gait were more likely to experience overcorrection.
“In view of the results obtained in our study, we can suggest that the distinction between true equinus and jump gait could be a useful means for limiting the development rate of crouch gait in the postoperative period,” Pilloni et. al write. “If ATL surgery is necessary in diplegia, we suggest preoperative gait analysis and correct identification of the motor phenotype in order to carry out appropriate rehabilitative treatment.”
Pilloni, G., Pau, M., Costici, F., Condoluci, C., & Galli, M. (2018). Use of 3D gait analysis as predictor of achilles tendon lengthening surgery outcomes in children with cerebral palsy. European journal of physical and rehabilitation medicine.
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