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Simultaneous multiple operations for spastic diplegia. Outcome and functional assessment of walking in 18 patients
A V Nene1, G A Evans, J H Patrick
1Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, England.
Insights
Simultaneous multiple operations can improve walking in children with spastic diplegia. Preoperative physiological cost index (PCI) predicts surgical outcomes for reduced walking effort and improved gait.
Area of Science:
- Orthopedic surgery
- Pediatric neurology
- Rehabilitation medicine
Background:
- Spastic diplegia often leads to gait abnormalities and increased energy expenditure during walking.
- Multiple surgical interventions are frequently required to address complex deformities in affected children.
Purpose of the Study:
- To evaluate the outcomes of simultaneous multiple orthopedic surgeries in children with spastic diplegia.
- To assess the impact of these procedures on the physiological cost index (PCI) of walking.
- To determine if preoperative PCI can predict surgical success.
Main Methods:
- A cohort of 18 children with spastic diplegia underwent simultaneous multiple operations.
- Surgical procedures included intrapellvic intramuscular psoas tenotomy, fractional lengthening of hamstrings, and distal rectus femoris transfer.
- The physiological cost index (PCI) of walking was measured preoperatively and at one and two years postoperatively.
Main Results:
- Fourteen patients showed a reduced PCI at one year; severely affected patients required two years to stabilize.
- Preoperative PCI levels correlated with the degree of improvement in walking effort and appearance.
- Procedures effectively addressed hip flexion deformity, hamstring tightness, and knee flexion deformities, improving gait parameters.
Conclusions:
- Simultaneous multiple surgeries are effective in improving gait and reducing the physiological cost of walking in children with spastic diplegia.
- Preoperative PCI is a valuable predictor of surgical outcomes.
- Specific surgical techniques demonstrated significant improvements in key gait metrics.
Abstract:
We assessed the outcome after simultaneous multiple operations performed on 18 children with spastic diplegia, with emphasis on the changes in the physiological cost index (PCI) of walking. Fourteen patients had a measurable reduction at one year, but the more severely affected patients took up to two years to reach a new functional plateau. The level of the preoperative PCI allows prediction of the outcome of surgery in terms of reducing the effort of walking, or improving its appearance only. Intrapelvic intramuscular psoas tenotomy produced an improvement of hip flexion deformity in 15 of 17 patients without the loss of muscle power to initiate the swing phase. Fractional lengthening corrected hamstring tightness in 17 cases, and the mean popliteal angle was reduced from 63 degrees preoperatively to 30.2 degrees, with almost complete resolution of the fixed knee flexion deformity present in ten patients. Distal transfer of the rectus femoris, when it was shown to be contracting inappropriately, improved the knee flexion arc during walking from a mean of 28.3 degrees to 45.2 degrees.