Rutz Erich, McCarthy James, Shore Benjamin J, Shrader M Wade, Veerkamp Matthew, Chambers Henry, Davids Jon R, Kay Robert M, Narayanan Unni, Novacheck Tom F, Pierz Kristan, Rhodes Jason, Shilt Jeffrey, Theologis Tim, Van Campenhout Anja, Dreher Thomas, Graham Kerr
The Royal Children's Hospital, Melbourne, Australia.
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
J Child Orthop. 2020 Oct 1;14(5):405-414. doi: 10.1302/1863-2548.14.200145.
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.
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.
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).
The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research.
V.
马蹄足是脑瘫（CP）中最常见的畸形，而跟腱延长术（GSL）是改善能行走的CP儿童步态和功能最常施行的手术。GSL的手术指征和手术技术存在很大差异。本研究的目的是回顾跟腱的手术解剖学和生物力学，并通过德尔菲技术利用骨科专家意见，为能行走的CP儿童GSL的手术指征达成共识。
成立了一个由17名成员组成的小组，成员均为接受过 fellowship 培训的小儿骨科医生，每人在CP患儿手术治疗方面至少有9年的临床培训后经验。通过标准化的迭代德尔菲过程达成了GSL手术指征的共识。
达成共识支持在双侧瘫中采用保守的1区手术，禁忌3区手术（跟腱延长）。2区或3区手术作为偏瘫的一种选择达成了普遍共识，任何程度的矫正不足都比过度矫正更可取。达成的共识是，GSL手术的最佳年龄为6岁至10岁，4岁以下儿童应避免进行该手术。患儿清醒和麻醉状态下的体格检查措施在决策中很重要。支持结合患者报告结局（PROMS）进行步态分析以辅助决策和评估结果。
本研究结果可能会促进明智的实践评估，减少实践差异，改善临床结局，并指出进一步研究的问题。
V级。
