1st Joint ESMAC-GCMAS Meeting - Análise de Marcha
1st Joint ESMAC-GCMAS Meeting - Análise de Marcha
1st Joint ESMAC-GCMAS Meeting - Análise de Marcha
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O-54<br />
THE IMPACT OF SINGLE EVENT MULTILEVEL SURGERY(SEMLS) FOR<br />
SEVERE CROUCH GAIT IN SPASTIC DIPLEGIC CEREBRAL PALSY: OUTCOME<br />
AT FIVE YEARS.<br />
Rodda, Jill, Dr 1 , Baker, Richard, Assoc Prof 1,2,3 , Galea, Mary, Prof 2, Nattrass, Gary, Dr 1 , and<br />
Graham, H Kerr, Prof 1,2 .<br />
1 Gait CCRE, Murdoch Childrens Research Institute, Royal Children’s Hospital, Melbourne,<br />
Australia. 2 The University of Melbourne, Melbourne, Australia. 3 Latrobe University,<br />
Melbourne, Australia.<br />
Summary/conclusions<br />
The natural history of gait in spastic diplegia is for <strong>de</strong>terioration with time[1-4]. The SEMLS<br />
programme aimed to correct severe crouch gait and inclu<strong>de</strong>d the wearing of ground reaction<br />
ankle foot orthoses (GRAFOs) and physiotherapy. After the intervention, subjects walked with<br />
improved extension at the hip and knee, patellar fractures healed, knee pain was relieved and<br />
the acute <strong>de</strong>terioration in functional mobility was reversed. The improvement in severe crouch<br />
gait at one year post intervention was maintained at five years, a significant improvement over<br />
the natural history. The surgical prescription did not a<strong>de</strong>quately address the involvement of the<br />
hip and pelvis and further study into the effect of psoas lengthening at the hip and pelvis and<br />
alternatives to excessive hamstring lengthening for the correction of severe crouch gait should<br />
be un<strong>de</strong>rtaken.<br />
Introduction<br />
Severe crouch gait may be associated with severe anterior knee pain, patellar fractures, fatigue<br />
and <strong>de</strong>terioration in gait pattern[5, 6]. These symptoms may lead the child and family to seek<br />
treatment. In crouch gait the antigravity muscles are long/weak (soleus, quadriceps and hip<br />
extensors), the hip flexors and hamstrings are usually contracted and the bony levers are often<br />
malaligned. We <strong>de</strong>vised a program of reconstructive surgery, which consisted of lengthening<br />
the contracted muscle tendon units, realigning the bony levers and supporting the new<br />
biomechanical alignment with Ground Reaction AFO’s until stable.<br />
Statement of clinical significance<br />
The long-term outcome of SEMLS on severe crouch gait has not been documented. This study<br />
is the first to confirm that improvement post-SEMLS at one year can be maintained at five<br />
years post-intervention.<br />
Methods<br />
This was a retrospective cohort study, conducted in a tertiary paediatric hospital/ gait analysis<br />
laboratory. A consecutive sample of 10 children with spastic diplegic cerebral palsy (GMFCS<br />
level II-III) in severe crouch gait, were recruited. Severe crouch gait was <strong>de</strong>fined as knee<br />
flexion >30 <strong>de</strong>grees[6, 7] and ankle dorsiflexion >15 <strong>de</strong>grees throughout stance.<br />
SEMLS was based on pre-operative gait analysis. Mean of 7 procedures (range 5-10) were<br />
un<strong>de</strong>rtaken consisting of lengthening of contracted muscle-tendon units and rotational<br />
osteotomies and bony stabilization procedures to correct lever arm dysfunction. During the <strong>1st</strong><br />
year post SEMLS, GRAFOs were worn routinely and an individually tailored physiotherapy<br />
programme in the community provi<strong>de</strong>d.<br />
All gait analyses were un<strong>de</strong>rtaken barefoot and with usual mobility aids. Post-operative<br />
changes were evaluated at one and five years: functional outcome by mobility scales and<br />
technical outcomes by 3D kinematics and kinetics, knee radiology and pain scores. Outcomes<br />
were analysed with linear regression with robust standard errors.<br />
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