Surgical correction of equinus deformity in children with cerebral palsy: A systematic review

PURPOSE: 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. METHODS: 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. RESULTS: 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 19 years. Nineteen studies used instrumented gait analysis, with an average follow-up of 2.8 years. 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. CONCLUSIONS: 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.