Clinical Orthopaedics and Related Research®

, Volume 471, Issue 3, pp 1028–1038 | Cite as

Are Results After Single-event Multilevel Surgery in Cerebral Palsy Durable?

  • Erich Rutz
  • Richard Baker
  • Oren Tirosh
  • Reinald Brunner
Clinical Research

Abstract

Background

Gait and function may deteriorate with time in patients with spastic diplegia. Single-event multilevel surgery often is performed to either improve gait or prevent deterioration. However it is unclear whether the presumed gait improvements are durable.

Questions/purposes

We therefore determined whether (1) single-event multilevel surgery improves gait in patients with spastic diplegia and (2) whether the improved function is durable.

Methods

We retrospectively reviewed the data of 14 patients with spastic diplegia. At the time of surgery, one patient had gross motor Level I function, 10 patients had Level II function, and three patients had Level III function. There were four females and 10 males with a mean age of 13 years (range, 7–18 years). The mean number of orthopaedic procedures per single-event multilevel surgery session was 7.4 ± 2.8 (median, 6.5; range, 4–15). We used instrumented gait analysis to determine joint ROM, movement analysis profiles, and the gait profile score. The minimum followup was 1 year (mean, 2 years; range, 1–3 years).

Results

At last followup, movement analysis profiles for knee flexion, for ankle dorsiflexion, and for foot progression improved as did the gait profile score. Additional surgery after the index procedure was performed in nine of the 14 patients because of relapse of the original or new gait problems. Major surgical adverse events occurred in one of the 14 patients.

Conclusions

Severe gait dysfunction in patients with spastic diplegia can be improved short-term in one operative session by single-event multilevel surgery, but to preserve the early improvements many patients require additional surgery. It is unknown whether the improvements will last for decades.

Level of evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Notes

Acknowledgments

We thank Mary Sheedy and H. Kerr Graham, MD, FRCS (Ed), FRACS for help with preparation of this manuscript. In addition we thank Alejandra Speiser for help in copyediting the final version of this manuscript.

References

  1. 1.
    Aiona MD, Sussman MD. Treatment of spastic diplegia in patients with cerebral palsy: Part II. J Pediatr Orthop B. 2004;13:S13–38.PubMedGoogle Scholar
  2. 2.
    Baker R, McGinley JL, Schwartz M, Thomason P, Rodda J, Graham HK. The minimal clinically important difference for the Gait Profile Score. Gait Posture. 2012;35:612–615.PubMedCrossRefGoogle Scholar
  3. 3.
    Baker R, McGinley JL, Schwartz MH, Beynon S, Rozumalski A, Graham HK, Tirosh O. The gait profile score and movement analysis profile. Gait Posture. 2009;30:265–269.PubMedCrossRefGoogle Scholar
  4. 4.
    Bell KJ, Ounpuu S, DeLuca PA, Romness MJ. Natural progression of gait in children with cerebral palsy. J Pediatr Orthop. 2002;22:677–682.PubMedGoogle Scholar
  5. 5.
    Bennett BC, Russell SD, Abel MF. The effects of ankle foot orthoses on energy recovery and work during gait in children with cerebral palsy. Clin Biomech (Bristol, Avon). 2012;27:287–291.CrossRefGoogle Scholar
  6. 6.
    Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987;67:206–207.PubMedGoogle Scholar
  7. 7.
    Browne AO, McManus F. One-session surgery for bilateral correction of lower limb deformities in spastic diplegia. J Pediatr Orthop. 1987;7:259–261.PubMedCrossRefGoogle Scholar
  8. 8.
    Cuthbert SC, Goodheart GJ Jr. On the reliability and validity of manual muscle testing: a literature review. Chiropr Osteopat. 2007;15:4.PubMedCrossRefGoogle Scholar
  9. 9.
    Gage JR. Gait analysis: an essential tool in the treatment of cerebral palsy. Clin Orthop Relat Res. 1993;288:126–134.PubMedGoogle Scholar
  10. 10.
    Gorton GE 3rd, Abel MF, Oeffinger DJ, Bagley A, Rogers SP, Damiano D, Romness M, Tylkowski C. A prospective cohort study of the effects of lower extremity or orthopaedic surgery on outcome measures in ambulatory children with cerebral palsy. J Pediatr Orthop. 2009;29:903–909.PubMedCrossRefGoogle Scholar
  11. 11.
    Gough M, Eve LC, Robinson RO, Shortland AP. Short-term outcome of multilevel surgical intervention in spastic diplegic cerebral palsy compared with the natural history. Dev Med Child Neurol. 2004;46:91–97.PubMedCrossRefGoogle Scholar
  12. 12.
    Gough M, Schneider P, Shortland AP. The outcome of surgical intervention for early deformity in young ambulant children with bilateral spastic cerebral palsy. J Bone Joint Surg Br. 2008;90:946–951.PubMedCrossRefGoogle Scholar
  13. 13.
    Hermens HJ, Freriks B, Merletti R, Stegeman D, Blok J, Rau G, et al. European Recommendations for Surface Electromyography (SENIAM). Enschede Roessingh Research and Development. Available at: http://seniam.org/. Accessed October 17, 2012.
  14. 14.
    Johnson DC, Damiano DL, Abel MF. The evolution of gait in childhood and adolescent cerebral palsy. J Pediatr Orthop. 1997;17:392–396.PubMedGoogle Scholar
  15. 15.
    Kadaba MP, Ramakrishnan HK, Wootten ME. Measurement of lower extremity kinematics during level walking. J Orthop Res. 1990;8:383–392.PubMedCrossRefGoogle Scholar
  16. 16.
    Khan MA. Outcome of single-event multilevel surgery in untreated cerebral palsy in a developing country. J Bone Joint Surg Br. 2007;89:1088–1091.PubMedCrossRefGoogle Scholar
  17. 17.
    Love SC, Novak I, Kentish M, Desloovere K, Heinen F, Molenaers G, O’Flaherty S, Graham HK; Cerebral Palsy Institute. Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement. Eur J Neurol. 2010;17(suppl 2):9–37.PubMedCrossRefGoogle Scholar
  18. 18.
    Ma FY, Selber P, Nattrass GR, Harvey AR, Wolfe R, Graham HK. Lengthening and transfer of hamstrings for a flexion deformity of the knee in children with bilateral cerebral palsy: technique and preliminary results. J Bone Joint Surg Br. 2006;88:248–254.PubMedCrossRefGoogle Scholar
  19. 19.
    McNee AE, Will E, Lin JP, Eve LC, Gough M, Morrissey MC, Shortland AP. The effect of serial casting on gait in children with cerebral palsy: preliminary results from a crossover trial. Gait Posture. 2007;25:463–468.PubMedCrossRefGoogle Scholar
  20. 20.
    Mendell JR, Florence J. Manual muscle testing. Muscle Nerve. 1990;13(suppl):S16–20.PubMedCrossRefGoogle Scholar
  21. 21.
    Nene AV, Evans GA, Patrick JH. Simultaneous multiple operations for spastic diplegia: outcome and functional assessment of walking in 18 patients. J Bone Joint Surg Br. 1993;75:488–494.PubMedGoogle Scholar
  22. 22.
    Norlin R, Odenrick P. Development of gait in spastic children with cerebral palsy. J Pediatr Orthop. 1986;6:674–680.PubMedCrossRefGoogle Scholar
  23. 23.
    Norlin R, Tkaczuk H. One-session surgery for correction of lower extremity deformities in children with cerebral palsy. J Pediatr Orthop. 1985;5:208–211.PubMedGoogle Scholar
  24. 24.
    Norlin R, Tkaczuk H. One session surgery on the lower limb in children with cerebral palsy: a five year follow-up. Int Orthop. 1992;16:291–293.PubMedCrossRefGoogle Scholar
  25. 25.
    Novacheck TF, Stout JL, Tervo R. Reliability and validity of the Gillette Functional Assessment Questionnaire as an outcome measure in children with walking disabilities. J Pediatr Orthop. 2000;20:75–81.PubMedGoogle Scholar
  26. 26.
    Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214–223.PubMedCrossRefGoogle Scholar
  27. 27.
    Robb JE, Brunner R. A Dega-type osteotomy after closure of the triradiate cartilage in non-walking patients with severe cerebral palsy. J Bone Joint Surg Br. 2006;88:933–937.PubMedCrossRefGoogle Scholar
  28. 28.
    Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery. J Bone Joint Surg Am. 2006;88:2653–2664.PubMedCrossRefGoogle Scholar
  29. 29.
    Rutz E, Baker R, Tirosh O, Romkes J, Haase C, Brunner R. Tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy. Gait Posture. 2011;33:152–157.PubMedCrossRefGoogle Scholar
  30. 30.
    Rutz E, Brunner R. The pediatric LCP hip plate for fixation of proximal femoral osteotomy in cerebral palsy and severe osteoporosis. J Pediatr Orthop. 2010;30:726–731.PubMedCrossRefGoogle Scholar
  31. 31.
    Rutz E, Gaston MS, Camathias C, Brunner R. Distal femoral osteotomy using the LCP pediatric condylar 90-degree plate in patients with neuromuscular disorders. J Pediatr Orthop. 2012;32:295–300.PubMedCrossRefGoogle Scholar
  32. 32.
    Rutz E, Gaston MS, Tirosh O, Brunner R. Hip flexion deformity improves without psoas-lengthening after surgical correction of fixed knee flexion deformity in spastic diplegia. Hip Int. 2012;22:379–386.PubMedCrossRefGoogle Scholar
  33. 33.
    Rutz E, Hofmann E, Brunner R. Preoperative botulinum toxin test injections before muscle lengthening in cerebral palsy. J Orthop Sci. 2010;15:647–653.PubMedCrossRefGoogle Scholar
  34. 34.
    Rutz E, Passmore E, Baker R, Graham HK. Multilevel surgery improves gait in spastic hemiplegia but does not resolve hip dysplasia. Clin Orthop Relat Res. 2012;470:1294–1302.PubMedCrossRefGoogle Scholar
  35. 35.
    Rutz E, Tirosh O, Thomason P, Barg A, Graham HK. Stability of the Gross Motor Function Classification System after single event multi level surgery in cerebral palsy. Dev Med Child Neurol. 2012;Oct 16. [Epub ahead of print].Google Scholar
  36. 36.
    Saraph V, Zwick EB, Auner C, Schneider F, Steinwender G, Linhart W. Gait improvement surgery in diplegic children: how long do the improvements last? J Pediatr Orthop. 2005;25:263–267.PubMedCrossRefGoogle Scholar
  37. 37.
    Saraph V, Zwick EB, Zwick G, Steinwender C, Steinwender G, Linhart W. Multilevel surgery in spastic diplegia: evaluation by physical examination and gait analysis in 25 children. J Pediatr Orthop. 2002;22:150–157.PubMedGoogle Scholar
  38. 38.
    Schutte LM, Narayanan U, Stout JL, Selber P, Gage JR, Schwartz MH. An index for quantifying deviations from normal gait. Gait Posture. 2000;11:25–31.PubMedCrossRefGoogle Scholar
  39. 39.
    Schwartz MH, Rozumalski A. The Gait Deviation Index: a new comprehensive index of gait pathology. Gait Posture. 2008;28:351–357.PubMedCrossRefGoogle Scholar
  40. 40.
    Schwartz MH, Viehweger E, Stout J, Novacheck TF, Gage JR. Comprehensive treatment of ambulatory children with cerebral palsy: an outcome assessment. J Pediatr Orthop. 2004;24:45–53.PubMedCrossRefGoogle Scholar
  41. 41.
    Sussman MD, Aiona MD. Treatment of spastic diplegia in patients with cerebral palsy. J Pediatr Orthop B. 2004;13:S1–12.PubMedGoogle Scholar
  42. 42.
    Thomason P, Baker R, Dodd K, Taylor N, Selber P, Wolfe R, Graham HK. Single-event multilevel surgery in children with spastic diplegia: a pilot randomized controlled trial. J Bone Joint Surg Am. 2011;93:451–460.PubMedCrossRefGoogle Scholar
  43. 43.
    Thomason P, Selber P, Graham HK. Single Event Multilevel Surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study. Gait Posture. 2012 Jul 18. [Epub ahead of print].Google Scholar
  44. 44.
    Tirosh O, Baker R, McGinley J. GaitaBase: Web-based repository system for gait analysis. Comput Biol Med. 2010;40:201–207.PubMedCrossRefGoogle Scholar
  45. 45.
    van Wely L, Becher JG, Balemans AC, Dallmeijer AJ. Ambulatory activity of children with cerebral palsy: which characteristics are important? Dev Med Child Neurol. 2012;54:436–442.PubMedCrossRefGoogle Scholar
  46. 46.
    Yngve DA, Scarborough N, Goode B, Haynes R. Rectus and hamstring surgery in cerebral palsy: a gait analysis study of results by functional ambulation level. J Pediatr Orthop. 2002;22:672–676.PubMedGoogle Scholar
  47. 47.
    Zwick EB, Saraph V, Strobl W, Steinwender G. [Single event multilevel surgery to improve gait in diplegic cerebral palsy: a prospective controlled trial][in German]. Z Orthop Ihre Grenzgeb. 2001;139:485–489.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Erich Rutz
    • 1
    • 2
  • Richard Baker
    • 1
  • Oren Tirosh
    • 1
  • Reinald Brunner
    • 2
  1. 1.Murdoch Childrens Research InstituteThe Royal Children’s HospitalVictoriaAustralia
  2. 2.Pediatric Orthopaedic DepartmentUniversity Children’s Hospital Basle, UKBBBasleSwitzerland

Personalised recommendations