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Gait & Posture

Volume 58, October 2017, Pages 457-462
Gait & Posture

Full length article
Long-term follow-up after tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy

https://doi.org/10.1016/j.gaitpost.2017.08.028Get rights and content

Highlights

  • Satisfactory long-term (5.8 years) results.

  • Active ankle dorsiflexion was possible in all patients.

  • All 20 included patients were able to walk without Ankle Foot Orthosis.

  • Significant improvement of Movement Analysis Profile dorsiflexion/Gait Profile Score.

  • Recurrence rate of 13% and no overcorrection could be shown.

Abstract

Using Tibialis Anterior Shortening (TATS) in combination with Achilles Tendon Lengthening (TAL) to treat spastic equinus in children with cerebral palsy (CP) was described in 2011. Short-term results have indicated a good outcome, especially an improvement of the drop foot in swing phase and the correction of equinus in stance phase. The aim of this study was to analyse the results of the long-term follow-up and to determine the relapse rate of TATS and TAL.

The kinematics of the sagittal, frontal and transversal planes were measured by using instrumented 3D gait analysis at three defined time points and then described using the Gait Profile Score (GPS) and Movement Analysis Profile (MAP). The data was exported into Gaitabase and then the preoperative (T0), short- term (T1) and long-term (T2) follow-up data was statistically compared.

23 patients (mean age at index-surgery = 14.9 years) were included, there was a mean follow-up time of 5.8 years. 3 children (13%) have shown a relapse. The data of 12 children with spastic hemiplegia (12 legs), as well as 8 children with spastic diplegia (10 legs) has been analysed. There has been a significant (p < 0.05) improvement in GPS and MAP for ankle dorsiflexion (describes equinus and drop foot) of the operated legs versus not operated legs.

TATS in combination with TAL shows a satisfactory long-term result after 5.8 years in the correction of fixed equinus and drop foot in children with CP. Postoperatively all subjects were able to walk without an AFO.

Introduction

Among all deformities in children with cerebral palsy (CP) equinus is the most common one [1]. There are conservative and surgical treatment options available. The conservative therapy includes physiotherapy [2], ankle foot orthoses (AFO), castings [3] and injections of botulinum toxin type A [4], [5]. Recent studies showed, that the age at time of surgery plays an important role in the development of recurrences [6]. As a consequence, surgery should be evaluated well and, if possible, conservative treatment options should be considered in a young child.

There are several different surgical procedures for the treatment of spastic equinus. The main concept of these methods is to lengthen the gastrocnemicus-soleus muscle-tendon complex. After surgery it is important to continue with the conservative treatment in order to avoid recurrence.

Many surgical procedures have been described over the last few decades. A systematic review by Shore et al. in 2010 [6] has summarized and grouped the outcomes of ten different procedures by anatomic zones. It describes Zone 1 as starting at the gastrocnemius origin and ending at the most distal fibres of the medial belly of the gastrocnemius. Zone 1 procedures include the Baumann [7] and the Strayer [8] distal gastrocnemius recession. Zone 2 is between the distal gastrocnemicus belly and the end of the soleus muscle fibres, procedures belonging to this group are Baker [9] and Vulpius [10] gastrosoleus aponeurotic lengthening. The Achilles tendon is described as Zone 3 including all forms of lengthening of the Achilles tendon, one of them is the Z-tendo-Achilles lengthening (TAL).

In 2011 Rutz et al. published a new concept about the tibialis anterior tendon shortening (TATS) in combination with Achilles tendon lengthening (TAL) in spastic equinus [11]. In manual muscle tests during clinical assessment there was no change in muscle strength of the gastro-soleus and tibialis anterior muscle at short-term. Nevertheless 27 out of 29 patients showed active dorsiflexion of the ankle postoperatively, which was absent in the preoperative test. In 2016 Tsang et al. [12] confirmed favorable outcomes in a similar patient population with a mean follow-up time of 17.9 months.

The aim of our study is to perform a retrospective analysis of all ambulatory children with CP with Gross motor function classification system (GMFCS) level I–II [13] and spastic equinus, equivalent to fixed equinus, to evaluate the long-term clinical and kinematic outcomes using the Movement Analysis Profile (MAP) and the Gait Profile Score (GPS) [14]. In addition we would like to report the relapse rate of TATS and TAL and the clinical results after TATS in combination with a TAL.

Section snippets

Materials and methods

All ambulatory children (GMFCS level I and II) with unilateral or bilateral spastic CP and two postoperative follow-ups (T1 (1–2 years) and T2 (at least 3 years)) were included.

In clinical examination there was no active ankle dorsiflexion (over 0°) was not possible in any of the patients preoperatively. The exclusion criteria for the study were a diagnosis other than CP, dystonic or mixed movement disorder, Botulinum toxin A injections in the previous 6 months, GMFCS level III or higher.

All

Results

23 patients with 25 legs, who underwent TATS in combination with TAL between April 2004 and April 2011 and had 2 follow-ups (T1 = 1–2 years, T2 at least 3 years) were included. 3 children with hemiplegia (13%) have shown a relapse (one at T1, two at T2) and therefore they have been excluded from the analysis. The relapses were 2 female (age 19.3 years, 16.2 years) patients and 1 male (age 13.6 years). All of the children with relapses were hemiplegic. Group I consists of 12 children with spastic

Discussion

We found a significant improvement of MAP for ankle dorsiflexion and GPS after an average of 5.8 years follow-up time in both groups. Active dorsiflexion was possible in all patients. 30% of the patients showed an improvement of the GCMFS level at T2. Our results show a recurrence rate of 13% (3 out of 25, all hemiplegic patients), but no overcorrection. All 20 included patients were able to walk without AFO (Ankle foot orthosis) at T2. This therefore supports the positive results of the

Conflicts of interest

There are no conflicts of interest and no benefits in support of this study.

Acknowledgements

We would like to thank Mary Sheedy and Grenville Deasy for the help with the preparation of this manuscript.

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