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Correction of Severe Crouch Gait in Patients with Spastic Diplegia with Use of Multilevel Orthopaedic Surgery
J.M. Rodda, PhD1; H.K. Graham, MD, FRCS(Ed), FRACS1; G.R. Nattrass, MD, FRCS(C), FRACS1; M.P. Galea, PhD2; R. Baker, PhD, CEng1; R. Wolfe, PhD3
1 Hugh Williamson Gait Laboratory, University of Melbourne, Royal Children's Hospital, Flemington Road, Parkville 3052, Victoria, Australia. E-mail address for H.K. Graham: kerr.graham@rch.org.au
2 School of Physiotherapy, University of Melbourne, Parkville 3010, Victoria, Australia
3 Department of Epidemiology and Preventive Medicine, Monash University, Commercial Road, Melbourne 3004, Victoria, Australia
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from a National Health and Medical Research Council, Clinical Centre of Research Excellence grant. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at The Royal Children's Hospital, Melbourne, Australia

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Dec 01;88(12):2653-2664. doi: 10.2106/JBJS.E.00993
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Background: Severe crouch gait in patients with spastic diplegia causes excessive loading of the patellofemoral joint and may result in anterior knee pain, gait deterioration, and progressive loss of function. Multilevel orthopaedic surgery has been used to correct severe crouch gait, but no cohort studies or long-term results have been reported, to our knowledge.

Methods: In order to be eligible for the present retrospective cohort study, a patient had to have a severe crouch gait, as defined by sagittal plane kinematic data, that had been treated with multilevel orthopaedic surgery as well as a complete clinical, radiographic, and instrumented gait analysis assessment. The surgical intervention consisted of lengthening of contracted muscle-tendon units and correction of osseous deformities, followed by the use of ground-reaction ankle-foot orthoses until stable biomechanical realignment of the lower limbs during gait was achieved. Outcome at one and five years after surgery was determined with use of selected sagittal plane kinematic and kinetic parameters and valid and reliable scales of functional mobility. Knee pain was recorded with use of a Likert scale, and all patients had radiographic examination of the knees.

Results: Ten subjects with severe crouch gait and a mean age of 12.0 years at the time of surgery were studied. After surgery, the patients walked in a more extended posture, with increased extension at the hip and knee and reduced dorsiflexion at the ankle. Pelvic tilt increased, and normalized walking speed was unaltered. Knee pain was diminished, and patellar fractures and avulsion injuries healed. Improvements in functional mobility were found, and, at the time of the five-year follow-up, fewer patients required the use of wheelchairs or crutches in the community than had been the case prior to intervention.

Conclusions: Multilevel orthopaedic surgery for older children and adolescents with severe crouch gait is effective for relieving stress on the knee extensor mechanism, reducing knee pain, and improving function and independence.

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

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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