Results of cast treatment and percutaneous achilles tendon lengthening for children with an achilles tendon contracture.

Background:

We present the design of an open randomized study of conservative versus
surgical treatment for children with an equinus contracture. The study is designed to evaluate the difference in dorsiflexion after treatment with cast immobilization versus percutaneous gastrocnemius muscular lengthening for neurologically healthy children (6-18 years) with a symptomatic equinus contracture unresponsive to non-operative care.



Methods/Design:

80 patients with an equinus contracture will be randomized to percutaneous gastrocnemius muscular lengthening followed by a below knee cast for 6 weeks and intensive physical therapy for 12 weeks or no surgery but a below knee cast for 6 weeks also followed by physical therapy for 12 weeks. Both treatment arms use a 18 weeks protocol. Primary end-point will be ankle dorsiflexion. Secondary end-point will be functional outcome, satisfaction, walking pattern, pain, complications, activity level and foot pressure. Patients follow-up will be 1 year.



Discussion:

By making this design study we wish to contribute to more profound research on percutaneous gastrocnemius lengthening for children with an equinus contracture and prevent publication bias for this open-labelled randomized trial.

It is not unusual for children to have an intermittent tiptoe gait when they start to walk. Older children with persistent tiptoe gait in absence of developmental, neurological or neuromuscular conditions, are diagnosed idiopathic toe walkers (ITW's). Most of the time it resolves spontaneously. Sometimes the plantar flexion has a tendency to persist and it's possible a equinus contracture develops with time, eventually with permanent shortening of the gastrocnemius. Further a relationship has been reported between persistent toe walking and the development of ankle equinus and recognition is increasing that a wide variety of pathologies are associated with longstanding equinus contracture. The management of children with ITW is still controversial. To our knowledge, there aren't prospective studies to compare cast and surgical treatment.

We hypothesized a mean difference of> 5 degrees passive ankle dorsiflexion after treatment with percutaneous gastrocnemius lengthening, compared to ankle dorsiflexion of children after treatment with cast immobilization, after one year follow-up.

This study starts at screening on the outpatient clinic (T0) (table 1). Follow-up visits for assessment of primary and secondary endpoints will be scheduled for both treatment groups after two weeks for plaster change (T2). Thereafter follow-up visits will be planned at six weeks (T3), 12 weeks (T4), 6 months (T5), and one (T6) year, after cast immobilization (T1)

Patients will be treated by percutaneous gastrocnemius lengthening. After surgery patients will be placed in a below-knee cast with also minimal weightbearing for 2 weeks and 4 weeks full weightbearing plaster, followed by physical therapy for 12 weeks.



Control: Patients will be treated by a below knee cast, set in plantigrade, with six weeks full weightbearing plaster, also followed by physical therapy for 12 weeks.