Long-term follow-up after multilevel surgery in cerebral palsy



Single-event multilevel surgery (SEMLS) is frequently used to correct pathological gait patterns in children with bilateral spastic cerebral palsy (BSCP) in a single session surgery. However, in-depth long-term evaluation reports of gait outcomes are limited. Therefore, we investigated if SEMLS is able to correct lower extremity joint and pelvic angles during gait towards typically developing gait patterns (TDC) in children with BSCP, and if so, if this effect is durable over a 10-year period.

Materials and methods

In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7–18.2 years at the time of SEMLS were retrospectively recruited. Three-dimensional gait data were captured preoperatively, as well as at short-, mid-, and long-term post-operatively, and used to analyze: movement analysis profile (MAP), gait profile score (GPS), and lower extremity joint and pelvic angles over the course of a gait cycle using statistical parametric mapping.


In agreement with previous studies, MAP and GPS improved towards TDCs after surgery, as did knee extension during the stance phase (ɳ2 = 0.67; p < 0.001), while knee flexion in the swing phase (ɳ2 = 0.67; p < 0.001) and pelvic tilt over the complete gait cycle (ɳ2 = 0.36; p < 0.001) deteriorated; no differences were observed between follow-ups. However, further surgical interventions were required in 8 out of 13 of the participants to maintain improvements 10 years post-surgery.


While the overall gait pattern improved, our results showed specific aspects of the gait cycle actually deteriorated post-SEMLS and that a majority of the participants needed additional surgery, supporting previous statements for the use of multilevel surgery rather than SEMLS. The results highlight that the field should not only focus on the overall gait scores when evaluating treatment outcomes but should offer additional long-term follow-up of lower extremity function.

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The authors thank the Ralf-Loddenkemper Stiftung for their financial support to this project and they thank the members of the gait analysis lab at the University Children’s Hospital Basel for their assistance in data collection and their continuous support.

Author information




ER, RB, MF, NH and RV contributed to the study conception and design. Material preparation, data collection and analysis were performed by MF, NH and RV. The first draft of the manuscript was written by NH and RV, all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Rosa Visscher.

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This study, approved by the local ethical committee (EKNZ 304/08, PB_2018-00168), was conducted according to the current version of the World Medical Association Declaration of Helsinki.

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All participants and/or their parents gave written informed consent for the study.

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Visscher, R., Hasler, N., Freslier, M. et al. Long-term follow-up after multilevel surgery in cerebral palsy. Arch Orthop Trauma Surg (2021). https://doi.org/10.1007/s00402-021-03797-0

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  • Cerebral palsy
  • Multilevel surgery
  • Statistical parametric mapping
  • Long-term outcomes
  • Clinical gait analysis
  • Longitudinal care