SLR - January 2022 - Ryan J. Stone

Outcome of Gastrocnemius Soleus Facial Lengthening in Ambulatory Patients with Cerebral Palsy
Reference: Stotts AK, Carroll KL, Naatz E, et al. Outcome of Gastrocnemius Soleus Facial Lengthening in Ambulatory Patients with Cerebral Palsy, J Pediatr Orthop. 2021;23(0)

Level of Evidence: IV
Scientific Literature Review
Reviewed By: Ryan J. Stone, DPM
Residency Program: Grant Medical Center – Columbus, OH
Podiatric Relevance: Equinus is a common and often disabling deformity in children with cerebral palsy (CP). Historically, various surgical techniques have been employed to treat equinus in CP patients, with inconsistent and unpredictable outcomes. The overall heterogeneity of the type of CP, surgical technique, outcome measurements and inconsistent follow-up have created difficulty in assessing functional outcomes in this patient population. The purpose of this study is to assess the recurrence of equinus in an ambulatory CP population following gastroc soleus fascial lengthening (GSFL).
Methods: A retrospective chart review was performed to evaluate pediatric CP patients with prior operative equinus deformity. All patients previously underwent the same GSFL technique, referred to as a transverse Vulpius. CP patients with a gross motor function classification system (GMFCS) score 1-III, and minimum of five-year follow-up were included. Functional outcomes were evaluated using physical exam measures and computational gait analysis at short-term, mid-term, and long-term follow-up. Revision rates and potential factors related to requiring revisions were analyzed to evaluate the efficacy of GSFL at various follow-up times.             
Results: Sixty-four (64) patients (87 limbs) met inclusion criteria. Sixteen subjects (25 percent) required revision surgery. Concomitant proximal lower extremity procedures occurred in 12 patients. GMFCS levels and age at index surgery were found to be significant factors in predicting recurrence. When interaction between variables were considered, degree of contracture was not affected by age. Forty-four percent of index surgeries performed at age younger than seven required revisions, and children under 12 were 9.6 times more likely to require revisions. Revisional surgeries occurred at mean age of 13.1 years and mean of 5.4 years after the index procedure. Severity of preoperative contraction, type of CP (unilateral or bilateral), and sex did not influence revision rates. Excessive dorsiflexion was evident in 13 percent of limbs at long-term follow-up.
Conclusions: When considering surgical intervention in children with ambulatory CP equinus, the authors recommend isolated release of the gastrocnemius, or GSFL based on the results of the Silfverskio¨ld test. This study confirms that GSFL is effective in restoring ankle joint motion in children with CP, and results are maintained at long-term follow-up with improvement in ankle dorsiflexion, functionality, and gait characteristics. It is important to note that younger age at index surgery and GMFCS III children were both identified as risks of needing future revision. This finding should not be intended to delay necessary surgery, but rather to inform expectations. GSFL consisting of a transverse Vulpius-type lengthening in ambulatory CP patients with equinus deformity has shown encouraging results and improved long-term functionality. Ultimately, CP equinus remains a challenging deformity to manage. These long-term findings may help in the counselling and care of children with CP, with hopes of adding predictability to the operative treatment of CP equinus.  

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