Abstract
Equinus is the most common deformity in cerebral palsy. However, despite the large volume of published studies, there are poor levels of evidence to support surgical intervention. This study was undertaken to examine the current evidence base for the surgical management of equinus deformity in cerebral palsy. A systematic review of the literature using "equinus deformity", "cerebral palsy" and "orthopaedic surgery" generated 49 articles. After applying inclusion and exclusion criteria, 35 articles remained. The Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence and the Methodological Index for Non-Randomized Studies (MINORS) were used to grade the articles. Studies ranged in sample size from 9 to 156 subjects, with an average of 38 subjects. The mean age of subjects at index surgery ranged from 5 to 19years. Nineteen studies used instrumented gait analysis, with an average follow-up of 2.8years. Seven studies reported that a younger age at index surgery was associated with an increased risk of recurrent equinus. The average rate of calcaneus in hemiplegic children was 1% and it was 15% in those with spastic diplegia. Most studies were level 4 quality of evidence, leading to, at best, only grade C recommendation. Cerebral palsy subtype (hemiplegia versus diplegia) and age at index surgery were the two most important variables for determining the outcome of surgery for equinus deformity in cerebral palsy. Despite the great emphasis on differences in surgical procedures, there was less evidence to support the type of operation in relation to outcome.
Highlights
Equinus is a very common deformity in children with cerebral palsy [1]
Seven studies reported that a younger age at index surgery was associated with an increased risk of recurrent equinus
Descriptive aspects of the reviewed studies earlier procedures [30], while other studies reported on combinations of surgical procedures, such as the Strayer combined with slide lengthening of the Achilles tendon [18]
Summary
Equinus is a very common deformity in children with cerebral palsy [1]. Equinus is defined as the inability to dorsiflex the foot above plantigrade, with the hindfoot in neutral and the knee extended [2]. In the literature, there exist many definitions for both equinus deformity and equinus gait, which contribute to the difficulty in interpreting the results on this deformity. There is extensive literature on the management of equinus deformity in cerebral palsy by both operative and non-operative measures. Goldstein and Harper [3] published the results of a multi-disciplinary workshop convened to explore the current state of knowledge, best clinical practice and research needs for the management of equinus gait associated with cerebral palsy. This report compared the evidence base for physical therapy, orthoses, casting, botulinum toxin A and surgery across the domains of treatment, which had been suggested by Condie and
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