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Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study
Erich Rutz1, James McCarthy2, Benjamin J Shore3
1The Royal Children's Hospital, Melbourne, Australia.
Insights
Gastrocsoleus lengthening surgery for equinus in cerebral palsy (CP) has varied indications. This study established expert consensus on optimal surgical zones, age, and techniques for ambulatory children with CP.
Area of Science:
- Orthopaedic surgery
- Pediatric orthopaedics
- Cerebral palsy management
Background:
- Equinus deformity is the most common in cerebral palsy (CP).
- Gastrocsoleus lengthening (GSL) is a common surgical intervention for ambulatory children with CP.
- Significant variability exists in GSL indications and surgical techniques.
Purpose of the Study:
- To review gastrocsoleus anatomy and biomechanics.
- To establish expert consensus on surgical indications for GSL in ambulatory children with CP using the Delphi technique.
Main Methods:
- A 17-member panel of experienced pediatric orthopaedic surgeons participated.
- A standardized, iterative Delphi process was employed to achieve consensus.
Main Results:
- Consensus supported conservative Zone 1 surgery for diplegia; Zone 3 surgery was contraindicated.
- Zone 2 or Zone 3 surgery was generally agreed upon for hemiplegia, with under-correction preferred.
- Optimal age for GSL is 6-10 years; avoid in children under 4.
- Physical examination and gait analysis are crucial for decision-making and outcome assessment.
Conclusions:
- This study provides consensus guidelines for GSL in ambulatory children with CP.
- Findings may reduce practice variability and improve clinical outcomes.
- Highlights areas for future research in CP management.
Purpose:
Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP.
Methods:
A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process.
Results:
Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS).
Conclusions:
The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research.
Level Of Evidence:
V.
