Outcome of Patients After Achilles Tendon Lengthening for Treatment of Idiopathic Toe Walking Yoram Hemo, MD,* Samuel J. Macdessi, MBBS,† Rosemary A. Pierce, PT,‡ Michael D. Aiona, MD,‡ and Michael D. Sussman, MD‡ Abstract: Fifteen children who were diagnosed with idiopathic toe walking that cannot be corrected by nonoperative treatment were assessed by clinical examination and computer-based gait analysis preoperatively and approximately 1 year after Achilles tendon lengthening. Passive dorsiflexion improved from a mean plantar- flexion contracture of 8 degrees to dorsiflexion of 12 degrees after surgery. Ankle kinematics normalized, with mean ankle dorsiflexion in stance improving from j8 to 12 degrees and maximum swing phase dorsiflexion improving from j20 to 2 degrees. Peak ankle power generation increased from 2.05 to 2.37 W/kg but did not reach values of population norms. No patient demonstrated clinically relevant triceps surae weakness or a calcaneal gait pattern. Seven patients had a stance phase knee hyperextension preoperatively, and 6 of these corrected after surgery. Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery. Key Words: Achilles tendon, idiopathic toe walking, gait analysis (J Pediatr Orthop 2006;26:336Y340) P ersistent tiptoe gait after the age of 2 years in children without discernible neurological or orthopedic abnor- mality is termed Bidiopathic toe walking^ (ITW). 1 This diagnosis is made after other disease processes have been excluded. The most common cause of toe walking in childhood is cerebral palsy; however, the differential diagnosis of toe walking includes conditions such as muscular dystrophies, tethered cord syndrome, diastematomyelia, and other neuromuscular diseases. 2 Typically, patients with ITW commence this toe-to-toe gait at the initiation of walking, which occurs at a normal age. There is a positive family history in about 30% of cases. 3,4 If left untreated, this pattern of gait has a tendency to persist, and although initially, there is full passive dorsi- flexion, an equinus contracture develops with time. 3,5Y7 Nonoperative treatment of ITW includes physical therapy, bracing, and serial casting. When toe walking fails to respond to these treatment modalities and contracture develops, then Achilles tendon lengthening is necessary to correct the problem. Surgical treatment is reported to provide good clinical outcomes, but objective assessment of out- comes is limited. 4,5,7Y15 Our goal in this study was to determine whether children maintain adequate power generation at the ankle joint and how the kinematic parameters change after Achilles tendon lengthening for treatment of ITW. MATERIALS AND METHODS Between 1996 and 2001 a retrospective analysis of all patients undergoing lengthening of the Achilles tendon for treatment of ITW was performed at our institution. Approval through the institutional review board was obtained. Only patients who had completed full motion laboratory assess- ments preoperatively and postoperatively were entered into the study. All had a clinical diagnosis of ITW, and 12 of the 15 failed nonsurgical treatments, including serial castings, prolonged ankle-foot orthosis (AFO), and physical therapy. Three patients had surgery without a period of nonoperative treatment because they presented with fixed contracture felt to be too severe for nonoperative treatment. All measurements were performed by the motion analysis laboratory staff before kinematic gait studies. Preoperative and postoperative assessment of passive range of motion at the ankle with the knee in both extension and flexion was recorded with a goniometer. To clinically assess plantarflexion strength, the patient was asked to perform single leg heel raises. The number of elevations was recorded up to a maximum of 10, which was considered normal. All patients underwent a full gait analysis in our Motion Analysis Laboratory before surgery. The same study was repeated, as is our routine, at about 1 year postoperatively. A Vicon 370 Motion Analysis System with 6 cameras was used. Two AMTI (AMTI, Watertown, MA) force plates were used to record ground reaction forces. The Vicon Clinical Manager Software (Vicon Motion Systems, Inc, Lake Forest, CA) was used for data processing and a Microsoft Excel (Microsoft Corp, Santa Rosa, CA) data extraction program was used for data analysis. All subjects performed at least 3 trials with clean force plate information on each side. The mean of each variable was calculated preoperatively and postoperatively. The decision regarding the optimal surgical procedure to perform and the postoperative management was based upon surgeons_ preference. The surgical technique consisted ORIGINAL ARTICLE 336 J Pediatr Orthop & Volume 26, Number 3, May/June 2006 From the *Dana Children_s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel; †Orthopaedic Registrar, Sydney, New South Wales, Australia; and ‡The Shriners Hospital for ChildrenYPortland Unit, Portland, OR. None of the authors received financial assistance support for this study. The study was conducted at the Shriners Hospital for Children, Portland, OR. Reprints: Michael D Sussman, MD, Shriners Hospital for ChildrenYPortland Unit, 3101 SW Sam Jackson Park Rd, Portland, OR 97239 (e-mail: msussman@shrinet.org). Copyright * 2006 by Lippincott Williams & Wilkins Copyr ight © Lippincott Williams & Wilkins. Unauthor iz ed reproduction of this article is prohibited.