# Gastrocsoleus lengthening in combination with tibialis anterior tendon shortening for equinus deformity in children with cerebral palsy: a systematic review

## TL;DR

This study reviews evidence on combining two surgical procedures to treat foot deformity in children with cerebral palsy, finding it may improve gait and reduce orthosis use.

## Contribution

The study systematically evaluates the safety and effectiveness of adding tibialis anterior tendon shortening to gastrocsoleus lengthening for equinus deformity in cerebral palsy.

## Key findings

- Combined gastrocsoleus lengthening and tibialis anterior tendon shortening improved gait profile and variable scores.
- The procedure reduced the need for ankle-foot orthoses without causing long-term complications.
- Variations in surgical techniques suggest the need for further comparative studies to optimize outcomes.

## Abstract

Equinus is the most common deformity in cerebral palsy, and gastrocsoleus lengthening (GSL) is the most common surgical intervention in children with cerebral palsy (CwCP). GSL is a dose-dependent surgical concept carried out with consideration of the severity of equinus contracture, aimed at addressing this problem during the stance phase of gait. The addition of the novel procedure, tibialis anterior tendon shortening (TATS), may offer benefit in correcting the swing phase problem by addressing foot drop due to the agonist/antagonist relationship with gastrocsoleus. Given the small sample sizes and mixed results presented by current literature, our study aimed to collate the available evidence in order to review the effectiveness and safety of the addition of TATS to the GSL procedure for CwCP with equinus deformity.

In this PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses)-compliant systematic review, a systematic search of Medline, Embase, Web of Science, and Google Scholar retrieved 674 articles for title and abstract screening. Five original publications were included in the final review. The methodological index for non-randomised studies (MINORS) was used to critically appraise included studies.

Sample sizes ranged from 20 to 29, with a mean age at surgery ranging from 10.0 to 16.8 years. All participants underwent pre- and post-operative 3D gait analysis. Variations regarding the technique of the procedure included the suture material used to complete TATS and the anatomical level/zone of GSL. Studies found that combined GSL in combination with TATS demonstrated an improvement in gait profile score (GPS), Gait Variable Score (GVS) at the ankle, and reduced ankle–foot orthosis (AFO) use. No long-term complications were detected because of adding TATS to GSL.

The GSL in combined with the TATS procedure appears to be a safe procedure with a low complication rate, which may offer improvements in GPS, GVS, and reduced AFO use; however, comparative studies will assist in identifying the effect this has beyond GSL only and the patients for whom this procedure will provide the best outcomes.

Open Science Framework (https://osf.io/dp7ha/)

The online version contains supplementary material available at 10.1186/s13643-025-02985-y.