Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: A delphi consensus study

Erich Rutz, James McCarthy, Benjamin J. Shore, M. Wade Shrader, Matthew Veerkamp, Henry Chambers, Jon R. Davids, Robert M. Kay, Unni Narayanan, Tom F. Novacheck, Kristan Pierz, Jason Rhodes, Jeffrey Shilt, Tim Theologis, Anja Van Campenhout, Thomas Dreher, H. Kerr Graham

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Purpose 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. Methods A 17-member panel, of Fellowship-trained paediat-ric 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, it-erative Delphi process. Results 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 overcor-rection. 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). Conclusions The results from this study may encourage in-formed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research.

Original languageEnglish (US)
Pages (from-to)405-414
Number of pages10
JournalJournal of Children's Orthopaedics
Issue number5
StatePublished - 2020
Externally publishedYes


  • Cerebral palsy
  • Consensus
  • Equinus
  • Gastrocsoleus lengthening
  • Surgical indications

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Orthopedics and Sports Medicine


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