SLR - June 2013 - Zachary G. Jagmin
Reference: Lin CL, Lin CJ, Huang MT, Su WR, Wu TT. Mesh Achilles Tendon Lengthening – A New Method to Treat Equinus Deformity in Patients With Spastic Cerebral Palsy: Surgical Technique and Early Results. J Pediatr Orthop B 2013 22: 14-19.Scientific Literature Review
Reviewed by: Zachary G. Jagmin, DPM
Residency Program: Massachusetts General Hospital, Boston, MA
Podiatric Relevance: Ankle equinus contracture is a deformity, with associated gait disorder, balance problems and foot pain, frequently seen in podopediatric practice. The most common surgical treatment of this deformity in children with cerebral palsy (CP) at the authors’ institution includes lengthening at the gastrocneumius aponeurosis and Z-lengthening of the Achilles tendon. The current consensus procedure of choice is the Vulpius ‘sliding’ lengthening procedure. Muscle weakness and calcaneal gait are iatrogenic concerns following surgical treatment. This study reviews results of a relatively new method of ‘sliding’ procedure - the mesh ATL procedure, which consists of multiple small transverse cuts in the tendinous portion of the gastrocnemius and soleus fascia, followed by passive ankle dorsiflexion - which might require a shorter immobilization period and lead to less cast morbidity and a more rapid recovery.
Methods: This study is a retrospective review of patients who, after failure of conservative therapy, underwent surgery for correction of equinus deformity at that authors’ institution, conducted from June 1997 to March 2004, including fifty-five (55) patients with cerebral palsy (93 limbs). Three methods of surgical lengthening were performed: mesh ATL, Vulpius, and traditional Z-lengthening. Forty-two (42) patients without fixed contracture were randomly assigned to undergo the mesh ATL procedure (22 patients - 36 tendons) or Vulpius procedure (20 patients - 33 tendons). Thirteen (13) patients (24 tendons) with fixed contracture underwent traditional Z-lengthening. Ancillary tendon lengthening procedures were performed when necessary. Short leg cast (SLC) immobilization was used for all patients, but for a longer period in the Z-lengthening group. All procedures were performed by the same pediatric orthopedic surgeon.
Results: The average age of the patients in the Z-lengthening ATL group (7.2 years) was greater than the average ages in the mesh ATL and Vulpius groups (6.2 and 6.5 years). Post-operatively, fewer children could walk independently (GMFCS I + II) in the traditional Z-lengthening group compared to the mesh ATL (82 percent) and Vulpius groups (85 percent). The Z-lengthening ATL group had less passive ankle dorsiflexion with the knee fully extended than the other groups, with no statistical significant difference between the three groups. At two years post-procedure, there was no statistically significant difference in dorsiflexion angles between the mesh ATL group and the Vulpius group, but each were less than those of the Z-lengthening group. The time interval required prior to rehabilitation, walking, and stability training for patients in the mesh ATL group was significantly less than that for both the Vulpius and traditional ATL Z-lengthening groups.
Conclusions: This relatively new mesh ATL procedure achieves successful correction of ankle equinus contracture in children with spastic cerebral palsy, with results comparable to that of the Vulpius procedure, but with less correction than the traditional Z-lengthening ATL procedure. This procedure also preserves the gastrocnemius muscle and results in a shorter recovery time for the patient.