The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 7

Scientific Articles | April 04, 2012

Long-Term Results After Gastrocnemius-Soleus Intramuscular Aponeurotic Recession as a Part of Multilevel Surgery in Spastic Diplegic Cerebral Palsy

Thomas Dreher, MD¹; Tanja Buccoliero¹; Sebastian I. Wolf, PhD¹; Daniel Heitzmann, PhD¹; Simone Gantz, MSc¹; Frank Braatz, MD¹; Wolfram Wenz, MD¹

¹ Department of Orthopaedic and Trauma Surgery, Paediatric Orthopaedics and Foot Surgery, Heidelberg University Clinics, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany. E-mail address for T. Dreher: thomas.dreher@med.uni-heidelberg.de

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Investigation performed at the Department of Orthopaedic and Trauma Surgery, Heidelberg University Clinics, Heidelberg, Germany

J Bone Joint Surg Am, 2012 Apr 04;94(7):627-637. doi: 10.2106/JBJS.K.00096

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Abstract

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 satisfactory 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.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Equinus of the foot at the ankle is one of the most common deformities in children with cerebral palsy^1-3. Spasticity and abnormal shortness of the triceps surae are responsible for the toe-walking gait pattern^4-7, which leads to a variety of problems such as a decrease of stance phase stability, swing phase clearance, or increased forefoot load⁸. While dynamic equinus is common in early childhood⁹, fixed equinus and secondary osseous deformities may develop during growth^9,10.

Different surgical procedures for treating equinus are described in the literature^11-15. Most of those studies have recommended surgery, either after unsuccessful conservative management or in patients with fixed equinus^14,16-18.

Numerous studies^{11,14,16,17,19} have used the Silfverskiöld test, which is reported to be valid only with the patient under anesthesia²⁰, to differentiate between dynamic and fixed equinus. Other definitions of fixed equinus are provided in some studies^21,22. Basically, fixed equinus may be corrected by intramuscular aponeurotic recession or tendon-lengthening surgery^3,23-27. Equinus in patients with cerebral palsy is commonly treated during single-event multilevel surgery^14,16. Achilles tendon lengthening has led to a high rate of overcorrection in various studies^28,29. In general, this technique is therefore seen to be obsolete³⁰ for patients with diplegia, with very few exceptions. For this reason, gastrocnemius-soleus intramuscular aponeurotic recession is preferably used for patients with cerebral palsy who have spastic diplegia²⁹. Some studies have addressed the outcome after calf muscle lengthening in cerebral palsy^{13-17,22,29,31}. Initial satisfactory results could be shown after surgery, with improvements in clinical examination and in three-dimensional gait analysis^14,16,22. Moreover, weakening of the muscle did not occur^14,16. The evidence of these results is limited because of the small numbers of patients and heterogeneous groups as well as short follow-up periods^13-16. A major problem is that, because of the lack of studies with long-term results, there are no reports about the clinical course, recurrence, late weakness of the calf muscles, and overcorrection as a result of this surgery. The purpose of the present investigation was to provide long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery. The hypothesis of this study was that the improvements after surgery are maintained in the long-term follow-up examination.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Subjects

At our institution, ambulatory patients with cerebral palsy who are selected for multilevel surgery regularly receive a standardized three-dimensional gait analysis and clinical examination before surgery and at multiple regular follow-up examinations. For the present study, all eighty-six ambulatory patients with spastic diplegic cerebral palsy (Gross Motor Function Classification System³² [GMFCS] level I, II, or III) and fixed equinus as a part of multilevel gait abnormality who were treated with gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery in childhood (with a minimum age of six years at the time of surgery), between 1998 and 2004, were considered for inclusion (Fig. 1). Six patients who had previous orthopaedic surgery or dorsal rhizotomy, three with dyskinetic cerebral palsy, four who received botulinum toxin injections six months prior to surgery, and one patient with severe mental retardation who was not able to follow instructions were excluded (Fig. 1).

Fig. 1

The inclusion and exclusion criteria as well as the number of patients are displayed. “Isolated equinus” refers to patients with the diagnosis of cerebral palsy but without any concomitant multilevel problems. “Rejection” refers to patients who declined to return for a long-term follow-up examination or who declined to participate in this study. “Moved” refers to patients whom we were not able to reach by telephone or letter. GSIAR = gastrocnemius-soleus intramuscular aponeurotic recession, CP = cerebral palsy, BTX = botulinum toxin, and SEMLS = single-event multilevel surgery;

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The remaining seventy-two patients were reinvited for a long-term follow-up examination at least six years after gastrocnemius-soleus intramuscular aponeurotic recession. Eleven of those patients had moved, and nine others refused to return for follow-up or for participation in this study because of personal reasons. For two patients, long-term follow-up examination was not possible because of the loss of the ability to walk as a result of untreated hip displacement over the years. Six patients were also excluded over the years because they underwent relevant secondary surgery other than revision gastrocnemius-soleus intramuscular aponeurotic recession (four had revision femoral derotation osteotomy because of a recurrence of internal rotation gait and two had hip reconstruction because of progressive hip dislocation) (Fig. 1).

In total, forty-four diplegic patients (twenty-six boys and eighteen girls with a mean age of 9.8 years at the time of surgery) were recruited (Table I). The majority of the patients had passed their adolescent growth spurt at the time of the long-term follow-up. The distribution of sagittal gait patterns associated with equinus (true equinus, jump gait, and mixed type) according to Rodda et al.³³ is shown in Table I. The subjects or their parents provided informed consent to participate in this study, which had been approved by an institutional ethics committee.

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TABLE I Demographic Data on Forty-four Patients with Complete Follow-up*

Parameters	Baseline	1 Yr Postop.	3 Yr Postop.	9 Yr Postop.
Duration of follow-up†(yr)		1.0 ± 0.1	3.3 ± 1.3	8.6 ± 2
Age of patients†(yr)	9.8 ± 3.4	10.9 ± 3.4	13.2 ± 3.2	18.3 ± 4.3
Body mass index†(kg/m2)	16.9 ± 3.4	17.8 ± 3.8	19.0 ± 4.0	21.0 ± 4.3
Weight†(kg)	31.1 ± 13.8	35.2 ± 13.9	43.5 ± 14.2	58.1 ± 14.6
Height†(m)	1.3 ± 0.2	1.4 ± 0.2	1.5 ± 0.1	1.7 ± 0.1
GMFCS level‡(no. of patients)
I	7	12	16	17
II	28	20	18	18
III	9	12	10	9
Carbon-fiber ankle-foot orthosis (no. of patients)
Needed	26	44	14	11
Not needed	18	0	30	33
Preoperative sagittal gait pattern§
Group I (true equinus)	15
Group II (jump knee)	24
Group V (mixed type)	5

*There were sixteen female and twenty-eight male patients.
†The values are given as the mean and the standard deviation.
‡GMFCS = Gross Motor Function Classification Scale.
§Sagittal gait pattern was classified according to the system of Rodda et al.³³ and was obtained from preoperative three-dimensional gait analysis.

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TABLE I Demographic Data on Forty-four Patients with Complete Follow-up*

Parameters	Baseline	1 Yr Postop.	3 Yr Postop.	9 Yr Postop.
Duration of follow-up†(yr)		1.0 ± 0.1	3.3 ± 1.3	8.6 ± 2
Age of patients†(yr)	9.8 ± 3.4	10.9 ± 3.4	13.2 ± 3.2	18.3 ± 4.3
Body mass index†(kg/m2)	16.9 ± 3.4	17.8 ± 3.8	19.0 ± 4.0	21.0 ± 4.3
Weight†(kg)	31.1 ± 13.8	35.2 ± 13.9	43.5 ± 14.2	58.1 ± 14.6
Height†(m)	1.3 ± 0.2	1.4 ± 0.2	1.5 ± 0.1	1.7 ± 0.1
GMFCS level‡(no. of patients)
I	7	12	16	17
II	28	20	18	18
III	9	12	10	9
Carbon-fiber ankle-foot orthosis (no. of patients)
Needed	26	44	14	11
Not needed	18	0	30	33
Preoperative sagittal gait pattern§
Group I (true equinus)	15
Group II (jump knee)	24
Group V (mixed type)	5

Methods

The patients were examined at four points in time: before surgery and at one year, two to four years, and six to thirteen years after surgery (Table I). The mean long-term follow-up time was 8.6 years postoperatively in this cohort. Standardized clinical examination (range of ankle motion and assessment with the Medical Research Council [MRC] scale³⁴ and the modified Ashworth scale³⁵) as well as conventional instrumented three-dimensional gait analysis (Vicon, Oxford Metrics, United Kingdom), according to the protocol of Kabada et al.³⁶, were carried out by an experienced physiotherapist and a study nurse who had special training in pediatric neurodevelopmental therapy. At all examinations, gait analysis was done while the patient walked barefoot without an orthosis along a 7-m walkway at a self-selected speed.

Surgical Indications and Technique

The indication for surgery was unsuccessful conservative management (botulinum toxin injections, serial casting, night splinting, and the use of an ankle-foot orthosis) in patients with fixed equinus (the ankle was not correctable to more than neutral position measured in knee extension) in combination with kinematic findings of increased plantar flexion in stance that was one standard deviation above the norm. A Silfverskiöld test had been performed intraoperatively, with the patient under anesthesia, to eliminate dynamic components of equinus.

All patients underwent standardized gastrocnemius-soleus intramuscular aponeurotic recession according to the technique described by Baumann and Koch²³ (Fig. 2). Gastrocnemius lengthening was performed first. The intraoperative goal for the correction was to achieve ankle dorsiflexion of 15° to 20° in knee extension and flexion. For patients with insufficient correction, lengthening of the soleus muscle was added through the same incision. Of the forty-four patients (eighty-eight legs), thirty-eight patients (seventy-six legs) had gastrocnemius-soleus intramuscular aponeurotic recession bilaterally, while six patients (four left legs and two right legs) were treated unilaterally as the contralateral side showed only dynamic equinus. In total, eighty-two gastrocnemius-soleus intramuscular aponeurotic recession procedures were performed; forty-eight legs received isolated gastrocnemius lengthening, and thirty-four legs needed additional soleus lengthening. If additional soleus lengthening did not lead to adequate correction, limited Achilles tendon lengthening was done through an additional distal approach (two legs). Additional procedures within the multilevel surgery are given in Table II. Postoperative management included early mobilization with immediate weight-bearing transfers, and subsequently walking was allowed from the first postoperative week onward, depending on concomitant procedures. Walking plaster casts were used during the first four to five weeks. Subsequently, a carbon-fiber ankle-foot orthosis was used during walking, and a splint, with the ankle at neutral dorsiflexion, was worn during the night for one year to maintain correction in all patients.

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TABLE II Number of Surgical Procedures Carried Out in Single-Event Multilevel Surgery

Procedures	No. of Legs*
Gastrocnemius-soleus intramuscular aponeurotic recession	82
Isolated gastrocnemius	48
Gastrocnemius and soleus	34
Psoas over the brim	11
Proximal rectus femoris recession	32
Hamstring lengthening	68
Distal rectus femoris transfer	79
Achilles tendon lengthening	2
Femoral derotation osteotomy	58
Tibial derotation osteotomy	6
Foot stabilization for treatment of valgus foot†	23

*The study included forty-four patients (eighty-two legs).
†The procedures included calcaneal lengthening osteotomy (Evans), extra-articular subtalar fusion (Grice), calcaneocuboid-joint distraction fusions, and Chopart or triple fusion.

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TABLE II Number of Surgical Procedures Carried Out in Single-Event Multilevel Surgery

Procedures	No. of Legs*
Gastrocnemius-soleus intramuscular aponeurotic recession	82
Isolated gastrocnemius	48
Gastrocnemius and soleus	34
Psoas over the brim	11
Proximal rectus femoris recession	32
Hamstring lengthening	68
Distal rectus femoris transfer	79
Achilles tendon lengthening	2
Femoral derotation osteotomy	58
Tibial derotation osteotomy	6
Foot stabilization for treatment of valgus foot†	23

Fig. 2

Figs. 2-A through 2-D The surgical technique of gastrocnemius-soleus intramuscular aponeurotic recession according to Baumann and Koch²³ is presented. Fig. 2-A With the patient placed in the supine position, a medial approach is carried out at the proximal third of the leg. After incision of the fascia, the interval between the gastrocnemius and the soleus muscle is opened, and the aponeuroses of the gastrocnemius and soleus are exposed. Fig. 2-B With use of scissors or a scalpel, the aponeurosis of the gastrocnemius muscle is transected on one level, sparing the underlying muscle tissue. Figs. 2-C and 2-D Passive dorsiflexion with the hindfoot held in varus position is carried out in knee flexion and extension to test the amount of correction. In case of insufficient correction, additional incisions of the aponeuroses on one to two other levels may be done. When the soleus muscle is also involved, concomitant soleus aponeurotic lengthening should be carried out through the same incision.

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Data Evaluation and Statistics

Since data on the right and left legs showed significant correlation (p < 0.05), further analysis used only data on the left legs. The Gillette Gait Index was calculated for all subjects at all examinations³⁷. Overcorrection was defined as postoperative dorsiflexion (at the one-year evaluation) that was at least two standard deviations above the reference (an age-matched group of twenty-four normal subjects) for at least 50% of the stance phase. Recurrence of equinus gait was defined as a loss of mean dorsiflexion in stance between the one-year and the nine-year evaluation of >50% of the improvement reached initially after surgery in combination with mean dorsiflexion of two standard deviations below the age-matched reference value.

Descriptive statistics were used for basic statistical analysis. To show the effects of change over time, one-way repeated measures analysis of variance was applied. For the categorical variables of the MRC and Ashworth scales, nonparametric Wilcoxon signed-rank tests are used likewise. To show the effects of change over time, box plots were calculated. A p value of <0.05 was considered to be significant, and the Bonferroni correction was used to adjust for multiple comparisons. Statistical analysis was done with use of PASW (Predictive Analytics SoftWare) Statistics (version 18; SPSS, Chicago, Illinois).

Source of Funding

No external source of funding was used for this investigation.

Results

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

In two patients (two legs), gastrocnemius-soleus intramuscular aponeurotic recession did not lead to adequate correction. These patients had an Achilles tendon lengthening on one side and gastrocnemius-soleus intramuscular aponeurotic recession on the contralateral side. Their data were not used for further analysis because of the relationship of gait pattern between the two legs. In three patients (five legs [6%]; bilateral involvement in two patients and unilateral involvement in one), revision gastrocnemius-soleus intramuscular aponeurotic recession was done after the second follow-up evaluation. These five legs were categorized as recurrent equinus and were used for the calculation of recurrence rate but were not further used for the calculation of mean values. Detailed results from the clinical examination and three-dimensional gait analysis for the remaining thirty-nine patients are given in Table III.

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TABLE III Statistical Results for Selected Parameters of the Left Legs

		Postop. Evaluations*
Parameters	Baseline*	1 Yr	3 Yr	9 Yr
Clinical examination
Passive ankle dorsiflexion with knee extended (deg)	–3 (12)†‡§	8 (9)#§	6 (8)#	4 (6)†#
Passive ankle dorsiflexion with knee flexed (deg)	6 (12)†‡	15 (10)§#	13 (10)#	9 (8)†
Ankle plantar flexion with knee extended (deg)	44 (9)§	40 (9)§	39 (10)§	34 (10)†‡#
Ankle dorsiflexion power (MRC scale)**	3 (4)†‡§	3 (3)§#	4 (4)#	4 (4)†#
Ankle plantar flexion power (MRC scale)**	4 (3)†§	3 (4)#	4 (3)§	3 (4)‡#
Tonus triceps surae with knee extended (modified Ashworth scale)**	2 (4)†‡§	1 (2)#	0 (2)#	1 (2)#
Tonus triceps surae, knee flexed (modified Ashworth scale)**	2 (3)†‡§	1 (2)#	1 (2)#	1 (2)#
Gillette Gait Index	347 (267)†‡§	197 (181)#	163 (132)#	181 (117)#
Ankle kinematic data (deg)
Dorsiflexion at initial contact	–7 (10)†‡§	–1 (5)#	–2 (7)#	–2 (6)#
Dorsiflexion at the end of the first double limb support	1 (13)	3 (6)	5 (7)	6 (6)
Maximum dorsiflexion in stance	4 (12)†‡§	11 (6)#	12 (7)#	12 (6)#
Minimum dorsiflexion in stance	–23 (18)†‡§	–7 (6)#	–8 (7)#	–9 (8)#
Mean dorsiflexion in stance	–5 (15)†‡§	4 (5)#	5 (6)#	5 (6)#
Range of motion in stance	27 (11)†‡§	18 (5)§#	20 (4)#	21 (5)†#
Maximum dorsiflexion in swing	–5 (11)†‡§	3 (4)#	3 (7)#	3 (6)#
Mean dorsiflexion in swing	–11 (11)†‡§	–1 (5)#	–2 (7)#	–1 (7)#
Range of motion in swing	16 (8)†‡#	10 (4)#	12 (5)#	12 (5)#
Ankle kinetic data
Ankle moment (Nm/kg)
Mean flexion moment by 30% to 40% of gait cycle	0.7 (0.3)‡§	0.7 (0.2)‡§	0.9 (0.2)†#	0.9 (0.2)†#
Maximum flexion moment in stance	1.1 (0.3)	0.9 (0.2)‡§	1.1 (0.2)†§	1.1 (0.2)†‡
Time of maximum moment in stance	23 (16)†‡§	45 (8)#	45 (9)#	42 (12)#
Maximum moment in loading response	1.0 (0.4)†‡§	0.3 (0.4)#	0.5 (0.3)#	0.6 (0.4)#
Ankle power (W/kg)
Maximum in stance	1.4 (0.9)	1.2 (0.7)‡§	1.7 (0.8)†	1.9 (0.8)†
Time of peak power in stance (% gait cycle)	45 (16)†	56 (4)#	55 (7)#	54 (7)#
Minimum in stance	–1.6 (0.9)†‡§	–0.7 (0.3)#	–0.8 (0.4)#	–1.0 (0.5)#
Time of peak absorption in stance (%)	12 (13)†	28 (17)#	23 (16)	24 (16)
Minimum in loading response	–1.6 (0.9)†‡§	–0.4 (0.4)#	–0.6 (0.4)#	–0.7 (0.4)#
Time distance parameters
Stride length (m)	0.9 (0.2)§	0.8 (0.2)‡§	0.9 (0.2)†§	1.0 (0.2)†‡#
Walking speed (m/s)	0.9 (0.2)†§	0.8 (0.3)‡§#	0.9 (0.2)†	1.0 (0.2)†#
Cadence (steps/min)	124 (23)†§	109 (31)‡#	117 (18)	113 (17)#
Time of toe-off (percent of gait cycle)	65 (5)†	68 (7)‡§#	65 (4)†	65 (4)†

*The evaluations were performed preoperatively (baseline) and at one year, a mean of three years (range, two to four years), and a mean of nine years (range, six to thirteen years) postoperatively. The values are given as the mean (and the standard deviation) for thirty-nine left legs for all outcome parameters except the parameters assessed with use of the Medical Research Council (MRC) and Ashworth scales (see below). Kinetic data were recorded and analyzed only in independent walkers (twenty-five left legs). Significance was determined by repeated-measures analysis of variance (Bonferroni corrected, p < 0.05).
†Significantly different compared with one-year evaluation.
‡Significantly different compared with three-year evaluation.
§Significantly different compared with nine-year evaluation.
#Significantly different compared with baseline.
**For MRC and Ashworth scales, the values are given as the median and range; the nonparametric Wilcoxon signed-rank test was used for statistical analysis.

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TABLE III Statistical Results for Selected Parameters of the Left Legs

		Postop. Evaluations*
Parameters	Baseline*	1 Yr	3 Yr	9 Yr
Clinical examination
Passive ankle dorsiflexion with knee extended (deg)	–3 (12)†‡§	8 (9)#§	6 (8)#	4 (6)†#
Passive ankle dorsiflexion with knee flexed (deg)	6 (12)†‡	15 (10)§#	13 (10)#	9 (8)†
Ankle plantar flexion with knee extended (deg)	44 (9)§	40 (9)§	39 (10)§	34 (10)†‡#
Ankle dorsiflexion power (MRC scale)**	3 (4)†‡§	3 (3)§#	4 (4)#	4 (4)†#
Ankle plantar flexion power (MRC scale)**	4 (3)†§	3 (4)#	4 (3)§	3 (4)‡#
Tonus triceps surae with knee extended (modified Ashworth scale)**	2 (4)†‡§	1 (2)#	0 (2)#	1 (2)#
Tonus triceps surae, knee flexed (modified Ashworth scale)**	2 (3)†‡§	1 (2)#	1 (2)#	1 (2)#
Gillette Gait Index	347 (267)†‡§	197 (181)#	163 (132)#	181 (117)#
Ankle kinematic data (deg)
Dorsiflexion at initial contact	–7 (10)†‡§	–1 (5)#	–2 (7)#	–2 (6)#
Dorsiflexion at the end of the first double limb support	1 (13)	3 (6)	5 (7)	6 (6)
Maximum dorsiflexion in stance	4 (12)†‡§	11 (6)#	12 (7)#	12 (6)#
Minimum dorsiflexion in stance	–23 (18)†‡§	–7 (6)#	–8 (7)#	–9 (8)#
Mean dorsiflexion in stance	–5 (15)†‡§	4 (5)#	5 (6)#	5 (6)#
Range of motion in stance	27 (11)†‡§	18 (5)§#	20 (4)#	21 (5)†#
Maximum dorsiflexion in swing	–5 (11)†‡§	3 (4)#	3 (7)#	3 (6)#
Mean dorsiflexion in swing	–11 (11)†‡§	–1 (5)#	–2 (7)#	–1 (7)#
Range of motion in swing	16 (8)†‡#	10 (4)#	12 (5)#	12 (5)#
Ankle kinetic data
Ankle moment (Nm/kg)
Mean flexion moment by 30% to 40% of gait cycle	0.7 (0.3)‡§	0.7 (0.2)‡§	0.9 (0.2)†#	0.9 (0.2)†#
Maximum flexion moment in stance	1.1 (0.3)	0.9 (0.2)‡§	1.1 (0.2)†§	1.1 (0.2)†‡
Time of maximum moment in stance	23 (16)†‡§	45 (8)#	45 (9)#	42 (12)#
Maximum moment in loading response	1.0 (0.4)†‡§	0.3 (0.4)#	0.5 (0.3)#	0.6 (0.4)#
Ankle power (W/kg)
Maximum in stance	1.4 (0.9)	1.2 (0.7)‡§	1.7 (0.8)†	1.9 (0.8)†
Time of peak power in stance (% gait cycle)	45 (16)†	56 (4)#	55 (7)#	54 (7)#
Minimum in stance	–1.6 (0.9)†‡§	–0.7 (0.3)#	–0.8 (0.4)#	–1.0 (0.5)#
Time of peak absorption in stance (%)	12 (13)†	28 (17)#	23 (16)	24 (16)
Minimum in loading response	–1.6 (0.9)†‡§	–0.4 (0.4)#	–0.6 (0.4)#	–0.7 (0.4)#
Time distance parameters
Stride length (m)	0.9 (0.2)§	0.8 (0.2)‡§	0.9 (0.2)†§	1.0 (0.2)†‡#
Walking speed (m/s)	0.9 (0.2)†§	0.8 (0.3)‡§#	0.9 (0.2)†	1.0 (0.2)†#
Cadence (steps/min)	124 (23)†§	109 (31)‡#	117 (18)	113 (17)#
Time of toe-off (percent of gait cycle)	65 (5)†	68 (7)‡§#	65 (4)†	65 (4)†

Clinical Examination

The mean passive ankle dorsiflexion showed a significant increase after surgery from 6° preoperatively to 15° at the one-year examination, measured in 90° of knee flexion, and from −3° preoperatively to 8° at the one-year evaluation, measured in knee extension. Between the one-year and nine-year evaluations, a significant deterioration of ankle dorsiflexion (50%) was found. The ankle plantar flexion was almost identical one year after surgery and showed a subsequent significant decrease over the years. A significant increase of ankle dorsiflexor strength (MRC scale³⁴) was noticed one year after surgery compared with the preoperative values. Another significant increase of dorsiflexor strength was found between the one-year and the long-term follow-up examination. Functional plantar flexion strength was decreased initially after surgery but showed an increase over the years. The tone of the plantar flexor muscles measured by the modified Ashworth scale³⁵ was significantly reduced after surgery, and this decrease was maintained in the long-term follow-up.

Data on the development of global gait function (GMFCS) in this cohort are provided in Table I. Ten more patients showed GMFCS level I at the time of the long-term follow-up in comparison with baseline, while there were ten fewer patients with level II accordingly.

Orthotic Requirements

Eighteen patients walked without an orthosis, while twenty-six patients used a carbon-fiber ankle-foot orthosis bilaterally at the baseline evaluation (Table I). For the first year after surgery, all patients were fitted with carbon-fiber ankle-foot orthoses according to our standardized protocol. During the years, more patients were able to walk short distances and some were able to walk longer distances without an ankle-foot orthosis, and only eleven patients still required an ankle-foot orthosis at the time of the long-term follow-up (Table I) because of recurrent equinus or calcaneal gait.

Kinematic Measurements

Ankle flexion at initial contact increased significantly from −7 to −1° (negative values indicate plantar flexion) initially after surgery with a long-lasting effect seen at the time of long-term follow-up (Fig. 3-A). Between the one-year and nine-year postoperative examinations, there was a slight but not significant decrease of dorsiflexion at initial contact. The maximum dorsiflexion as well as the mean dorsiflexion in stance phase were significantly increased at the one-year postoperative examination. In mid-term (three-year) and long-term (nine-year) evaluations, both parameters showed a further, but not significant, increase (Fig. 3-B).

Fig. 3-A Fig. 3-B Fig. 3-C

Box-and-whisker plots of ankle flexion at initial contact (Fig. 3-A), maximum dorsiflexion in stance phase (Fig. 3-B), and maximum dorsiflexion in swing phase (Fig. 3-C) obtained from three-dimensional gait analysis parameters of the legs at baseline and at one year, three years, and nine years postoperatively. All parameters were significantly improved after surgery and were maintained over the study period. The circles represent outliers. The boxes represent the 25th to 75th percentile, the midline represents the median, and the I bars represent maximum and minimum value, excluding outliers. *Significantly different compared with baseline obtained from one-way analysis of variance (p < 0.01).

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The minimum dorsiflexion in the end of stance phase was significantly diminished from −23° at baseline to −7° at the one-year examination. The minimum dorsiflexion at the end of stance phase showed a permanent and significant loss of 14° at the examination at nine years postoperatively in comparison with the measurement at baseline.

In swing phase, the maximum ankle dorsiflexion increased significantly from baseline to the one-year examination, with a mean difference of 8° that remained constant compared with baseline in further follow-up (Fig. 3-C). The ankle range of motion in stance and swing phase initially decreased significantly but was increased again at the time of the long-term follow-up.

The quantitative determination of global gait pathology, measured by the Gillette Gait Index, was significantly reduced after multilevel surgery, and the improvements were maintained at the time of the long-term follow-up for the entire cohort.

The average changes (and standard deviations) in ankle and knee kinematics in the sagittal plane for all legs during the whole gait cycle at baseline and at a mean of one year, three years, and nine years postoperatively are shown as cumulative curves in Figure 4. The reference data for physiologic gait obtained by an age-matched group of twenty-four normal subjects are also presented.

Fig. 4

Sagittal plane kinematic graphs of the ankle and knee are shown. Average values (blue line) and standard deviation (lucent blue area) during the whole gait cycle are given for all parameters for all patients at the baseline examination and at one year, a mean of three years (range, two to four years), and a mean of nine years (range, six to thirteen years) postoperatively. The reference data for physiologic gait obtained by an age-matched group of twenty-four normal subjects are also presented (gray area). Positive values indicate knee flexion and ankle dorsiflexion.

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Kinetic Measurements

The maximum flexion moment in loading response was significantly reduced after intervention, and a long-lasting effect was found at the examination at a mean of nine years postoperatively. The maximum ankle power in stance phase was reduced one year after surgery. At the time of the three-year examination, there was a significant return of plantar flexion power, which remained at the time of the long-term follow-up. The minimum plantar flexion power in stance phase as well as during loading response showed a long-lasting significant decrease from baseline to the time of the final follow-up.

Overcorrection

In six legs (7%; three patients) among the seven legs (9%; four patients) that were overcorrected (early-onset calcaneal gait) at the time of the one-year examination, dorsiflexion in stance phase decreased to normative values over the years. In nine legs (11%) with overcorrection at the time of final follow-up, one had overcorrection that had persisted from one year and eight legs (10%; four patients) had late-onset calcaneal deformity. Four of these nine legs demonstrated weakness of the calf muscles and accompanying crouch gait, with a mean knee flexion in stance of >30°.

Recurrence

Of the eighty-two legs treated with gastrocnemius-soleus intramuscular aponeurotic recession, twenty (24%; fourteen patients) demonstrated recurrent equinus at the time of the final follow-up.

Discussion

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Several studies have analyzed calf muscle lengthening procedures^{13,16,22,38,39} and found satisfactory initial results after intervention. The present study is the first investigation, as far as we know, to provide long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery. Satisfactory results were found one year after surgery, underlining the findings of previous studies^13,22,39. The results in the studies by Steinwender et al. and Saraph et al. were comparable with our findings regarding the mid-term follow-up period of two to four years^14,16. Considering the long-term results in the present study, the overall outcome after gastrocnemius-soleus intramuscular aponeurotic recession is very satisfying. In fact, a correct interaction of the gastrocnemius-soleus complex and dorsiflexors is important for efficient walking⁸. In stance phase, calf muscles are necessary for weight-bearing, stability, and propulsion. In swing phase, a pathological gastrocnemius-soleus muscle tone, in combination with frequent accompanying weakness of foot dorsiflexors^40-43, leads to foot clearance problems. The evaluation of kinematic and kinetic data in this study showed continuing benefits for the entire cohort at the time of the long-term follow-up accompanied by a diminished need for the use of an ankle-foot orthosis. The improvements in dorsiflexion in stance and swing phase remained, indicating a long-lasting correction of ankle position and motion. The initial abnormal power absorption during loading response was significantly reduced, as well, after surgery, and the improvement was maintained at the long-term follow-up examination. These results are underlined by the long-lasting strengthening of the ankle dorsiflexors found in clinical examination. The improved ankle dorsiflexion improves the swing phase for a smoother and more effective gait pattern, with a decreased tendency for imbalance, tripping, and falling.

All of these improvements were accompanied by a decrease in maximum plantar flexion and a decrease in ankle motion. Thus, the maximum plantar flexion power generation was reduced one year after surgery at the transition at toe-off, indicating a weakening of the calf muscles. At the same follow-up period, Tylkowski et al. also reported a postoperative decrease of maximum ankle power generation²². The long-term results of the present study showed only a partial recovery of plantar flexion power. Wren et al. stated that children with cerebral palsy and equinus gait patterns have longer Achilles tendons and shorter calf muscle bellies⁴⁴. Therefore, it is not expected that calf muscles will develop entirely normal muscle force after gastrocnemius-soleus intramuscular aponeurotic recession. However, the number of patients needing ankle-foot orthoses was reduced over the years.

Concerning improvements of passive dorsiflexion and ankle kinematics, there were discrepancies between the intraoperative lengthening amount and the outcome. This can be explained by the dynamic component of equinus, which is nearly eliminated under anesthesia but evokes tonic calf muscle shortness under normal conditions. Another explanation may be a loss of dorsiflexion between the time of surgery and the one-year postoperative examination because of growth or spasticity.

Although it was not significant, most of the gait analysis parameters showed a tendency for deterioration between the one-year and nine-year examinations. This trend is underlined by a significant loss of passive ankle dorsiflexion in the clinical examination. We suggest that this loss is of minor clinical relevance for the entire cohort because of the fact that the dynamic parameters did not show a significant deterioration. However, this trend is of particular interest for the explanation of recurrent equinus found nine years after surgery in 24% of the legs. These changes may be the effects of the natural development of children with cerebral palsy⁴⁵ and a persistent dynamic component of equinus. However, recurrent equinus is a minor problem in comparison with overcorrection since calcaneal gait represents a marked functional deficit that is difficult to treat. Aggressive initial treatment with overcorrection should be avoided.

The definitions of recurrence in the literature are controversial³⁵, and the rate of recurrence has been reported to range from 0% to 48%^{1,11-15,31,38,46,47}. Some studies have attributed a higher recurrence rate to the use of intramuscular lengthening techniques than to Achilles tendon lengthening^11,17. However, Sharrard and Bernstein found a higher recurrence rate after Achilles tendon lengthening than after gastrocnemius recession¹. Moreover, some studies have evaluated a correlation between age at the time of surgery and the recurrence rate. In particular, children younger than eight years at the time of surgery are more likely than older children to develop recurrent equinus^1,11,12,47. The question about when the recurrence of equinus should be seen as clinically relevant remains because some patients may need some degree of equinus for knee extension and stabilization.

In the present study, there was a tendency for the development of genu recurvatum at the one-year examination (Fig. 4). This development could be attributed mainly to hamstring lengthening, which was carried out frequently in this cohort. Gastrocnemius-soleus intramuscular aponeurotic recession corrects ankle kinematics in stance phase, which counteracts the plantar flexion-knee extension couple, and therefore should reduce the risk for the development of genu recurvatum.

Only a few studies have compared the methods of Achilles tendon lengthening with those of calf muscle lengthening^1,13,48, as both procedures lead to identical satisfactory results with regard to clinical and three-dimensional gait parameters^1,13,31. The limitation of those studies is the lack of long-term results. It is well known that the risk of overcorrection is higher with an Achilles tendon lengthening^1,17,28,38, which may lead to calf muscle insufficiency with calcaneal gait and resulting crouch gait^28-30. Saraph et al., in a study of patients with diplegic cerebral palsy who were treated with the gastrocnemius-soleus intramuscular aponeurotic recession described by Baumann and Koch, reported that no patient had overcorrection^14,23. In the present study, early-onset calcaneal gait at one year postoperatively was distinguished from late-onset calcaneal gait at the time of long-term follow-up. Besides the recurrence of knee flexor tightness, these patients with late-onset calcaneal gait and an accompanying crouch gait demonstrated increased flexed knee gait at the time of the three-year and nine-year evaluations (Fig. 4). However, the data in our study suggest that the tendency for overcorrection was substantially less after gastrocnemius-soleus intramuscular aponeurotic recession than after Achilles tendon lengthening (30% to 35%) and the Baker procedure (32%)^28,29. Equinus in patients with spastic diplegia should be treated with gastrocnemius-soleus intramuscular aponeurotic recession rather than tendon lengthening to avoid any over-lengthening.

The present study had several limitations. Gastrocnemius-soleus intramuscular aponeurotic recession is not recommended in patients with a fixed equinus of >30° of plantar flexion since it does not provide sufficient correction. In two patients (two legs; 2%), open Achilles tendon lengthening was added to gastrocnemius-soleus intramuscular aponeurotic recession to achieve enough correction.

There are relevant influencing factors to consider when interpreting the results, because of the concomitant procedures that are carried out at the time of single-event multilevel surgery. Correction of a flexed knee, as was frequently done in this study by medial hamstring lengthening, may have an impact on ankle positioning during gait³³. Furthermore, lever-arm dysfunctions¹⁰, such as instability of the foot, planovalgus foot, or torsional deformities, should also be considered since they were corrected at the same multilevel surgery by foot stabilization and femoral or tibial derotation osteotomies. An evaluation of single procedures is difficult because the multilevel approach is established as the so-called gold standard as it has several advantages^49,50. However, there are definite preoperative criteria with regard to when to perform each single procedure as a part of the multilevel surgery. These criteria consist of specific parameters from clinical examination and three-dimensional gait analysis. Additional important factors influencing kinematics are growth and an increase in the body mass index, which may lead to unpredictable changes in muscle function and osseous architecture and may influence the development of gait as well as the results after multilevel surgery. According to some studies, age at the time of surgery is an important aspect^1,11,12,47.

Last but not least, a limitation of this study is the potential for selection bias in this cohort as only forty-four of the eighty-six patients with multilevel problems could be reevaluated and included in the study. However, in consideration of the follow-up time of nine years, this appears to be a valid cross section.

In conclusion, gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery is an effective procedure that sufficiently corrects the equinus deformity in diplegic patients with isolated gastrocnemius or combined gastrocnemius and soleus involvement. The improvements were maintained at the time of the long-term follow-up examination for the entire cohort. However, recurrence of equinus deformity was found in 24% of the legs. Parents of the patients should be informed about this possible development and the potential need for later revision surgery. Early-onset overcorrection improved during the follow-up period, but late-onset calcaneal gait is often associated with flexed knee gait at the time of long-term follow-up. Because of the minimal risk for late-onset overcorrection with resulting crouch gait, gastrocnemius-soleus intramuscular aponeurotic recession is recommended over tendon-lengthening surgery for the treatment of equinus deformity in patients with spastic diplegic cerebral palsy.

Acknowledgements

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Note: The first author kindly acknowledges his former mentor Leo Döderlein, former chief of the cerebral palsy unit in Heidelberg, for his memorable work in the field of cerebral palsy and his extraordinary support during all the years of work together.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

gait ; ankle ; equinus deformity ; spastic diplegia ; soleus muscle ; gastrocnemius muscle structure ; gastrocnemius recession

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Thomas Dreher, Tanja Buccoliero, Sebastian I. Wolf, Daniel Heitzmann, Simone Gantz, Frank Braatz, Wolfram Wenz; Long-Term Results After Gastrocnemius-Soleus Intramuscular Aponeurotic Recession as a Part of Multilevel Surgery in Spastic Diplegic Cerebral Palsy. The Journal of Bone & Joint Surgery. 2012 Apr;94(7):627-637.

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