Patients with spastic diplegic cerebral palsy are prone to develop equinus deformities of the foot. Surgical treatment of equinus deformities involves lengthening of the Achilles tendon or the musculotendinous unit. Commonly utilized procedures are the open Z-lengthening of the Achilles tendon (TAL), the open vulpius gastrocnemius recession (GR), and the percutaneous (Hoke type) lengthening (PAL). This study attempts to provide insight into the procedure with the highest level of efficacy.
19 patients (38 limbs) with diplegic cerebral palsy who had failed PT and bracing. Patients were randomly assigned to one of three groups. Group 1 consisted of patients who received TAL and PAL, Group 2 patients received GR and PAL and Group 3 patients received GR and TAL. A single senior surgeon performed all surgeries. Pre and post-operative passive dorsiflexion, Gross Motor Function Classification Scores (GMFCS), Functional Goal Attainment Scores (FGAS), Observational Gait Scores, and POSNA scores were obtained.
Passive maximal dorsiflexion at the ankle joint improved immediately following surgery for all groups (p < 0.001). Upon final follow-up (average 18.8 months), there was 1 recurrence and no re-operations within the TAL group; 4 recurrences with 2 fixed equinus contractures and 2 re-operations in the GR group; 5 recurrences with 1 fixed equinus contracture and 1 re-operation in the PAL group. GMFCS and FGAS scores showed improvement in all groups. On observation of gait, foot position during gait at both initial contact and midstance was consistently improved across all treatment groups. There were no significant differences in POSNA scores at 6 month follow-up.
The results of this study showed that all three techniques were able to achieve improvement in patient observational gait scores without adversely affecting the position of the knee. Of the procedures TAL was able to effectively preserve the most dorsiflexion, achieve the greatest improvement in GMFCS, and had the lowest rate of recurrence. Long term studies are needed to further differentiate these procedures, however the results in this short term study had significant trends supporting the use of TAL.