Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study

Published

Friday, July 24, 2020 - 12:00 PM

https://online.boneandjoint.org.uk/doi/epub/10.1302/1863-2548.14.200145

Equinus is the most common posture and deformity in cerebral palsy. The term “equinus” is used to describe the way that the foot points downwards usually due to the tight calf muscles at the back of the leg. This results in the child walking up on his / her toes.

The two muscles at the back of the leg are called gastrocnemius and soleus and
they join together to form the Achilles tendon which attaches at the back of the
heel. Lengthening of the gastrocnemius and soleus muscles, called gastrocsoleus
lengthening, is the most commonly performed surgery to improve walking and
function in children with cerebral palsy. Historically, substantial variation existed in
how these surgeries were performed leading to unpredictable outcomes, too much,
too little or just right. The purpose of this study was to use expert orthopaedic opinion
through a series of questions called a Delphi process, to establish agreement about
the best type of surgery and the best age to undertake the operation. Seventeen
paediatric orthopaedic surgeons, from 16 centres across the world took part in
the study. They have a cumulative experience of more than 300 years in surgery
for children with cerebral palsy! The group has been working together for several
years in a collaboration known as “Mission Impossible”. The “Mission” is to establish
agreement across the whole area of orthopaedic surgery, to improve walking in
children with cerebral palsy. The Royal Children’s Hospital and CP-Achieve were
represented by Dr Erich Rutz as first author and Professor Kerr Graham, as the
senior author.

The Mission Impossible group agreed that one type of surgery was best for children
with diplegia and another type for children with hemiplegia. This is a new consensus
and a departure from historical practice, in which outcomes were unpredictable.
Agreement was also reached that the best age for surgery was 6 to 10 years and
should be avoided in children aged under 4 years. Gait analysis was agreed as
essential both for making decisions and for assessing results, in combination with
patient reported outcomes. The staff of the Hugh Williamson Gait Laboratory at
the Royal Children’s Hospital are leaders in both areas: gait analysis and patient
reported outcomes. The results from this study are very important. It should result in
children receiving the correct surgery, thereby improving outcomes, and will make
possible further research.