Gastrocsoleus lengthening in combination with tibialis anterior tendon shortening for equinus deformity in children with cerebral palsy: a systematic review

Background Equinus is the most common deformity in cerebral palsy, and gastrocsoleus lengthening (GSL) is the most common surgical intervention in children with cerebral palsy (CwCP). GSL is a dose-dependent surgical concept carried out with consideration of the severity of equinus contracture, aimed at addressing this problem during the stance phase of gait. The addition of the novel procedure, tibialis anterior tendon shortening (TATS), may offer benefit in correcting the swing phase problem by addressing foot drop due to the agonist/antagonist relationship with gastrocsoleus. Given the small sample sizes and mixed results presented by current literature, our study aimed to collate the available evidence in order to review the effectiveness and safety of the addition of TATS to the GSL procedure for CwCP with equinus deformity. Methods In this PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses)-compliant systematic review, a systematic search of Medline, Embase, Web of Science, and Google Scholar retrieved 674 articles for title and abstract screening. Five original publications were included in the final review. The methodological index for non-randomised studies (MINORS) was used to critically appraise included studies. Results Sample sizes ranged from 20 to 29, with a mean age at surgery ranging from 10.0 to 16.8 years. All participants underwent pre- and post-operative 3D gait analysis. Variations regarding the technique of the procedure included the suture material used to complete TATS and the anatomical level/zone of GSL. Studies found that combined GSL in combination with TATS demonstrated an improvement in gait profile score (GPS), Gait Variable Score (GVS) at the ankle, and reduced ankle–foot orthosis (AFO) use. No long-term complications were detected because of adding TATS to GSL. Conclusion The GSL in combined with the TATS procedure appears to be a safe procedure with a low complication rate, which may offer improvements in GPS, GVS, and reduced AFO use; however, comparative studies will assist in identifying the effect this has beyond GSL only and the patients for whom this procedure will provide the best outcomes. Systematic review registration Open Science Framework ( https://osf.io/dp7ha/ )