The Impact of Orthopedic Surgery on Gait Kinematics, Postural Balance, and Walking Speed in Children with Spastic Cerebral Palsy: A Multidimensional Approach

Kazemi, Khadijeh; Shayesteh Azar, Masoud; Moradi, Marzieh; Nezamoddini, Meisam; Gharib, Masoud

doi:10.22034/ijos.2025.547939.1165

The Impact of Orthopedic Surgery on Gait Kinematics, Postural Balance, and Walking Speed in Children with Spastic Cerebral Palsy: A Multidimensional Approach

Document Type : Original Article

Authors

Khadijeh Kazemi ¹ ^¶

Masoud Shayesteh Azar ²

Marzieh Moradi ¹

Meisam Nezamoddini ¹

Masoud Gharib ²

¹ Department of Rehabilitation Sciences, School of Allied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Iran.

² Orthopedic Research Center, Mazandaran University of Medical Science, Sari, Iran.

https://doi.org/10.22034/ijos.2025.547939.1165

Abstract

Abstract
Introduction: Spastic cerebral palsy (CP) is the most prevalent motor disability in children, defined by chronic spasticity, muscle stiffness, and motor control impairment, resulting in gait disturbances, postural instability, and decreased walking speed. Orthopedic surgery, including tendon lengthening and muscle releases, is routinely employed to rectify musculoskeletal deformities and enhance motor function. The extent to which these surgeries affect gait kinematics, postural balance, and walking speed is uncertain. The purpose of the current study was to assess the influence of orthopedic surgery on gait kinematics, postural balance, and gait speed in children with spastic CP via a multi-dimensional approach.
Materials & Methods: A prospective observational cohort study was carried out in 30 children (5–12 years, GMFCS Levels I–III) who were scheduled for orthopedic surgery. Participants were evaluated preoperatively and 6 and 12 months after surgery. Outcomes were gait kinematics (stride length, cadence, joint angles), postural balance (Pediatric Balance Scale [PBS], Timed Up and Go [TUG] test), and gait speed (10-Meter Walk Test [10MWT]). Data were analyzed using repeated-measures ANOVA, and effect sizes (Cohen's d) were determined.
Results & Discussion: At 12 months after surgery, there were significant improvements in all outcome measures. Stride length improved by 12.5% (p < 0.01), and cadence by 8.3% (p < 0.05). Knee flexion angle and ankle dorsiflexion angle also improved significantly (p < 0.01). Postural balance was improved, with PBS scores rising from 42.3 to 48.7 (p < 0.01) and TUG test times falling from 12.5 to 9.8 seconds (p < 0.01). Walking speed was enhanced by 18.6% in comfortable speed and 15.2% in fast speed (p < 0.01). Subgroup analysis showed greater improvement in children with GMFCS Level I compared to Levels II and III (p < 0.05). No differences were noted between tendon lengthening and muscle releases (p > 0.05).
Conclusion: Orthopedic surgery significantly improves gait kinematics, postural balance, and gait velocity in children with spastic CP, with the effects being preserved 12 months post-surgery. The findings emphasize the contribution of surgical interventions and personalized rehabilitation protocols in improving functional mobility and quality of life in these patients.

Keywords

Cerebral palsy

Orthopedic surgery

Gait

Subjects

Orthopedi

1 Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M. A report: The definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109:8–14. doi.org/10.1111/j.1469-8749.2007.tb12610.x

2 Graham HK, Rosenbaum P, Paneth N, et al. Cerebral palsy. Nat Rev Dis Primers. 2016;2:15082. doi.org/10.1038/nrdp.2015.82

3 Gough M, Shortland AP. Can clinical gait analysis guide the management of ambulant children with cerebral palsy? J Pediatr Orthop. 2012;32(Suppl 2):S1–S4. 10.1097/BPO.0b013e31818e197c

4 Thompson N, Stebbins J, Seniorou M, Newham D. The use of gait analysis in the treatment of cerebral palsy. J Pediatr Orthop. 2018;38(5):e1–e6, doi.org/10.1302/2058-5241.1.000052

5 Wren TA, Rethlefsen S, Kay RM. Prevalence of specific gait abnormalities in children with cerebral palsy: Influence of cerebral palsy subtype, age, and previous surgery. J Pediatr Orthop. 2005;25(1):79–83. doi.org/10.1097/00004694-200501000-00018

6 Rutz E, Hofmann E, Brunner R. Preoperative botulinum toxin test injections in children with cerebral palsy considering single event multilevel surgery. Dev Med Child Neurol. 2013;55(9):774–779. doi.org/10.1007/s00776-010-1509-6

7 Novacheck TF, Stout JL, Tervo R. Reliability and validity of the Gillette Functional Assessment Questionnaire as an outcome measure in children with walking disabilities. J Pediatr Orthop. 2000;20(1):75–81. doi.org/10.1097/01241398-200001000-00017

8 Dreher T, Wolf SI, Maier M, et al. Long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery in spastic diplegic cerebral palsy. J Bone Joint Surg Am. 2012;94(7):627–637. doi.org/10.2106/jbjs.k.00096

9 McGinley JL, Dobson F, Ganeshalingam R, Shore BJ, Rutz E, Graham HK. Single-event multilevel surgery for children with cerebral palsy: A systematic review. Dev Med Child Neurol. 2012;54(2):117–128. doi.org/10.1111/j.1469-8749.2011.04143.x

10 Novak I, McIntyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy: State of the evidence. Dev Med Child Neurol. 2013;55(10):885–910. doi.org/10.1111/dmcn.12246

11 Thomason P, Selber P, Graham HK. Single event multilevel surgery in children with bilateral spastic cerebral palsy: A 5-year prospective cohort study. Gait Posture. 2013;37(1):23–28. doi.org/10.1016/j.gaitpost.2012.05.022

12 Papageorgiou E, Nieuwenhuys A, Vandekerckhove I, et al. Systematic review on gait classifications in children with cerebral palsy: An update. Gait Posture. 2019;69:209–223. doi.org/10.1016/j.gaitpost.2019.01.038

13 Gage JR, Novacheck TF. An update on the treatment of gait problems in cerebral palsy. J Pediatr Orthop B. 2001;10(4):265–274. doi.org/10.1097/01202412-200110040-00001

14 Desloovere K, Molenaers G, Feys H, Huenaerts C, Callewaert B, Van de Walle P. Do dynamic and static clinical measurements correlate with gait analysis parameters in children with cerebral palsy? Gait Posture. 2006;24(3):302–313. doi.org/10.1016/j.gaitpost.2005.10.008

15 Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R. Sagittal gait patterns in spastic diplegia. J Bone Joint Surg Br. 2004;86(2):251–258. doi.org/10.1302/0301-620x.86b2.13878

16 Bell KJ, Õunpuu S, DeLuca PA, Romness MJ. Natural progression of gait in children with cerebral palsy. J Pediatr Orthop. 2002;22(5):677–682. doi.org/10.1097/01241398-200209000-00020

17 Wren TA, Rethlefsen S, Kay RM. Prevalence of specific gait abnormalities in children with cerebral palsy: Influence of cerebral palsy subtype, age, and previous surgery. J Pediatr Orthop. 2005;25(1):79–83. doi.org/10.1097/00004694-200501000-00018