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Musagara AR, Salami F, Götze M, Wolf SI. Functional knee joint axis calibration and outcome after femoral derotation in patients with cerebral palsy. Gait Posture 2024; 108:222-227. [PMID: 38128220 DOI: 10.1016/j.gaitpost.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/22/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients with cerebral palsy and increased femoral anteversion frequently show disturbing internal rotation gait which may be treated via femoral derotation osteotomy (FDO). A recent study monitored that hip rotation in gait may heavily depend on the procedure by which it is being determined. Traditional measures using the femoral epicondyles as reference for the knee axis (CONV) resulted in more severe transverse plane deviations compared to those using a functional method (FUNC) with relevant implications for treatment indication of FDO. RESEARCH QUESTION Is mean hip rotation in stance (mHipRotSt) as obtained via FUNC the more sensitive measure for explaining functional changes after FDO compared to CONV method taking the femoral epicondyles as reference for the knee axis? METHODS 3D-gait analysis before and one year after FDO was performed in fourteen patients including functional joint axis determination of the knee of which MR imaging was available in eight patients both pre- and postoperatively. Transverse plane gait parameters were calculated using both approaches (CONV, FUNC). Differences between examinations as well as between methods were determined. RESULTS Changes in femoral anteversion as measured by MR reasonably well confirm the structural changes as measured clinically and intraoperatively. The average change in mHipRotSt across the group was substantially smaller than the structural change implies. Further, using the FUNC approach led to much smaller values compared to when using the CONV approach. We address this to a mismatch between the axes determined in each method. SIGNIFICANCE In the presence of femoral deformity, the knee joint axis as determined via a functional method together with the conventional method (femoral epicondyles for the knee axis) allows to quantify knee rotation independent of torsional parameters of the tibia. It may therefore help to better quantify rotational malalignments in gait and improve decision making of FDO.
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Affiliation(s)
| | - Firooz Salami
- Clinic for Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Marco Götze
- Clinic for Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian I Wolf
- Clinic for Orthopedics, Heidelberg University Hospital, Heidelberg, Germany.
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Alexander N, Brunner R, Cip J, Viehweger E, De Pieri E. Increased Femoral Anteversion Does Not Lead to Increased Joint Forces During Gait in a Cohort of Adolescent Patients. Front Bioeng Biotechnol 2022; 10:914990. [PMID: 35733525 PMCID: PMC9207384 DOI: 10.3389/fbioe.2022.914990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
Orthopedic complications were previously reported for patients with increased femoral anteversion. A more comprehensive analysis of the influence of increased femoral anteversion on joint loading in these patients is required to better understand the pathology and its clinical management. Therefore, the aim was to investigate lower-limb kinematics, joint moments and forces during gait in adolescent patients with increased, isolated femoral anteversion compared to typically developing controls. Secondly, relationships between the joint loads experienced by the patients and different morphological and kinematic features were investigated. Patients with increased femoral anteversion (n = 42, 12.8 ± 1.9 years, femoral anteversion: 39.6 ± 6.9°) were compared to typically developing controls (n = 9, 12.0 ± 3.0 years, femoral anteversion: 18.7 ± 4.1°). Hip and knee joint kinematics and kinetics were calculated using subject-specific musculoskeletal models. Differences between patients and controls in the investigated outcome variables (joint kinematics, moments, and forces) were evaluated through statistical parametric mapping with Hotelling T2 and t-tests (α = 0.05). Canonical correlation analyses (CCAs) and regression analyses were used to evaluate within the patients’ cohort the effect of different morphological and kinematic predictors on the outcome variables. Predicted compressive proximo-distal loads in both hip and knee joints were significantly reduced in patients compared to controls. A gait pattern characterized by increased knee flexion during terminal stance (KneeFlextSt) was significantly correlated with hip and knee forces, as well as with the resultant force exerted by the quadriceps on the patella. On the other hand, hip internal rotation and in-toeing, did not affect the loads in the joints. Based on the finding of the CCAs and linear regression analyses, patients were further divided into two subgroups based KneeFlextSt. Patients with excessive KneeFlextSt presented a significantly higher femoral anteversion than those with normal KneeFlextSt. Patients with excessive KneeFlextSt presented significantly larger quadriceps forces on the patella and a larger posteriorly-oriented shear force at the knee, compared to patients with normal KneeFlextSt, but both patients’ subgroups presented only limited differences in terms of joint loading compared to controls. This study showed that an altered femoral morphology does not necessarily lead to an increased risk of joint overloading, but instead patient-specific kinematics should be considered.
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Affiliation(s)
- Nathalie Alexander
- Laboratory for Motion Analysis, Department of Paediatric Orthopaedics, Children’s Hospital of Eastern Switzerland, St. Gallen, Switzerland
- Department of Orthopaedics and Traumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Reinald Brunner
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Paediatric Orthopaedics, University of Basel Children’s Hospital, Basel, Switzerland
- Dpartment of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Johannes Cip
- Department of Paediatric Orthopaedics, Children’s Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Elke Viehweger
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Paediatric Orthopaedics, University of Basel Children’s Hospital, Basel, Switzerland
- Dpartment of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Enrico De Pieri
- Laboratory for Movement Analysis, University of Basel Children’s Hospital, Basel, Switzerland
- Dpartment of Biomedical Engineering, University of Basel, Basel, Switzerland
- *Correspondence: Enrico De Pieri,
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Geisbüsch A, Götze M, Putz C, Dickhaus H, Dreher T. Femoral derotation osteotomy-Does intraoperative electromagnetic tracking reflect the dynamic outcome? J Orthop Res 2022; 40:1312-1320. [PMID: 34432332 DOI: 10.1002/jor.25168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/27/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
Femoral derotation osteotomy (FDO) is a well-established procedure for the correction of internal rotation gait in children with cerebral palsy. Various studies have demonstrated good results for FDO both in short-term and long-term evaluation with some describing recurrence and over- or under-corrections. The present study evaluates the use of an objective intraoperative derotation measurement through electromagnetic tracking. We report the static and dynamic results of 11 cases with internal rotation gait (8 male, 3 female, mean age 22.2 years), that underwent FDO with intraoperative electromagnetic tracking and conventional goniometric measurement of the correction. The dynamic and static changes were assessed through three-dimensional gait analysis after a mean of 12 months after surgery and rotational imaging preoperative and after a mean of eleven days postoperatively. Mean hip rotation in stance significantly decreased from 20.9° (SD 5.9) to 5.8° (SD 4.7°) after FDO. The mean amount of derotation quantified by electromagnetic tracking was 23.2° (16.5°-28.8°) and 25.1° (20.0°-33.0°) for goniometric measurement. Both measurement modalities showed small differences to rotational imaging (electromagnetic bone tracking [EMT]: 0.72°; goniometer: 1.19°) but a large deviation when compared to three-dimensional gait analysis (EMT: 8.5°, goniometer: 9.1°). In comparison to the static changes and EMT measurement, the dynamic changes measured during 3-D-gait analysis reflected only 66% of the actual derotation performed during surgery. Although electromagnetic tracking allows a precise intraoperative assessment of the derotation during FDO, the amount of intraoperative correction is not reflected in the improvements in three-dimensional gait analysis.
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Affiliation(s)
- Andreas Geisbüsch
- Department of Orthopedics, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Marco Götze
- Department of Orthopedics, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Cornelia Putz
- Department of Orthopedics, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Hartmut Dickhaus
- Department of Medical Biometrics and Computer Sciences, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Thomas Dreher
- Pediatric Orthopaedics and Traumatology, University Children's Hospital Zürich, Zürich, Switzerland
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Roth T, Rahm S, Jungwirth-Weinberger A, Süess J, Sutter R, Schellenberg F, Taylor WR, Snedeker JG, Widmer J, Zingg P. Restoring range of motion in reduced acetabular version by increasing femoral antetorsion - What about joint load? Clin Biomech (Bristol, Avon) 2021; 87:105409. [PMID: 34144389 DOI: 10.1016/j.clinbiomech.2021.105409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acetabular retroversion results in reduced range of motion, and is thought to contribute to femoroacetabular impingement. Severe retroversion can be corrected with a periacetabular osteotomy, which is a technically demanding intervention. In this study, we investigated whether increasing femoral antetorsion is a potential alternative to restore the range of motion and how this approach would affect hip joint loading. METHODS Six different finite element models of the same subject were built from MRI and used to simulate different load scenarios during stance phase, including healthy and pathological configurations with different acetabular version and femoral torsion angles. The subject's gait was analysed in our gait lab and motion data as well as joint reaction forces were integrated into the model. Hip range of motion, hip abductor muscle forces as well as localization and magnitude of hip joint loads were determined. FINDINGS The negative effects of acetabular retroversion on hip range of motion including flexion and internal rotation can be reversed by increasing femoral anteversion. The rotation of the femur furthermore affected muscular functionality by shortening the moment arms of the hip abductor muscles, resulting in increased abductor muscle forces, joint reaction forces and hip joint loading. INTERPRETATION Even though increased femoral antetorsion can compensate for the loss of hip range of motion due to reduced acetabular version, rotational ostotomy of the proximal femur is likely to alter muscular moment arms and therefore increase hip joint load, conflicting the goal of a long-term healthy joint.
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Affiliation(s)
- Tabitha Roth
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Stefan Rahm
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Anna Jungwirth-Weinberger
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Janine Süess
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Reto Sutter
- Radiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Florian Schellenberg
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland.
| | - William R Taylor
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland.
| | - Jess G Snedeker
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Jonas Widmer
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Patrick Zingg
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
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Schranz C, Belohlavek T, Sperl M, Kraus T, Svehlik M. Does femoral anteversion and internally rotated gait correlate in subjects with patellofemoral instability? Clin Biomech (Bristol, Avon) 2021; 84:105333. [PMID: 33845347 DOI: 10.1016/j.clinbiomech.2021.105333] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patellar instability is a considerable problem that leads to pain and anxiety during simple functional tasks. Femoral derotational osteotomy has become a common surgical procedure to improve patella mechanics, stability and loading. However, it remains unclear if static (MRI measured) femoral anteversion is sufficient to capture the dynamic femoral rotation during walking and represents a good indication for the surgical procedure. This research investigates the relationship between static femoral anteversion and internally rotated gait in adolescents with patellofemoral instability. METHODS This retrospective study included 30 adolescents with recurrent patella instability (minimum three patella dislocations) aged 12 to 18 years (28 female/2 male; 22 unilateral/8 bilateral). All participants were assessed with 3D gait analysis and the femoral anteversion was examined using a rotational MRI. Multiple kinematic parameter were correlated with the ipsilateral femoral anteversion and tibia torsion using the Pearson coefficient. FINDINGS The correlation between parameters of dynamic hip rotation (e.g. maximum and mean internal hip rotation in stance and swing) and MRI measured femoral anteversion (mean 26.5° ± 9°) was weak and did not reach statistical significance. We found 47% (14 out of 30) subjects with increased femoral anteversion but normal hip rotation in stance. INTERPRETATION There was no relationship between increased femoral anteversion and dynamic hip rotation. Consequently, femoral anteversion should not be used as the only indication for femoral derotational osteotomy. Three-dimensional gait analysis might be necessary to assess the appropriate surgical intervention in adolescents with patello femoral instability.
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Affiliation(s)
- Christian Schranz
- Paediatric Orthopaedic Unit, Department of Orthopeadics and Trauma, Medical University of Graz, Auenbruggerplatz 34, A-8036 Graz, Austria.
| | - Teresa Belohlavek
- Physiotherapy Unit, KAGES - University hospital Graz, Auenbruggerplatz 1, A-8036 Graz, Austria
| | - Matthias Sperl
- Paediatric Orthopaedic Unit, Department of Orthopeadics and Trauma, Medical University of Graz, Auenbruggerplatz 34, A-8036 Graz, Austria
| | - Tanja Kraus
- Paediatric Orthopaedic Unit, Department of Orthopeadics and Trauma, Medical University of Graz, Auenbruggerplatz 34, A-8036 Graz, Austria
| | - Martin Svehlik
- Paediatric Orthopaedic Unit, Department of Orthopeadics and Trauma, Medical University of Graz, Auenbruggerplatz 34, A-8036 Graz, Austria
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Amirmudin NA, Lavelle G, Theologis T, Thompson N, Ryan JM. Multilevel Surgery for Children With Cerebral Palsy: A Meta-analysis. Pediatrics 2019; 143:peds.2018-3390. [PMID: 30918016 DOI: 10.1542/peds.2018-3390] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP). OBJECTIVE To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP. DATA SOURCES Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched. STUDY SELECTION Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected. DATA EXTRACTION Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events. RESULTS Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: -0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: -0.01 to 0.25) but did improve gait (SMD: -0.80; 95% CI: -0.95 to -0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies. LIMITATIONS Data were largely from cohort studies. CONCLUSIONS Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.
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Affiliation(s)
- Noor Amirah Amirmudin
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Grace Lavelle
- Department of Clinical Sciences, Brunel University London, London, United Kingdom; and
| | - Tim Theologis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Nicky Thompson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jennifer M Ryan
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; .,Department of Clinical Sciences, Brunel University London, London, United Kingdom; and
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O'Sullivan R, Kiernan D. Recurrent internal hip rotation gait in cerebral palsy: Case reports of two patients. HRB Open Res 2019; 1:28. [PMID: 32596628 PMCID: PMC7308961 DOI: 10.12688/hrbopenres.12893.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 11/20/2022] Open
Abstract
Internal hip rotation in cerebral palsy (CP) is typically treated with a femoral derotation osteotomy. This has been shown to be largely a successful procedure but recurrence rates up to 41% have been reported. Reported risk factors include younger age, reduced hip joint impulse and ankle plantar-flexion. We report on two patients with bilateral CP demonstrating recurrent unilateral internal hip rotation despite surgical intervention(s). Both demonstrate a number of the reported risk factors for recurrence. In addition, this case report specifically compared gait kinematic patterns pre and post recurrence. On comparing both patient’s hip rotation and ankle dorsi/plantarflexion kinematics they are seen to be almost identical both pre-operatively and post-operatively. Both patients appear to revert to approximately 30
o of internal hip rotation which has been shown to maximise hip abductor function. Therefore, this case report suggests that surgical derotation in isolation is unlikely to be successful in this group and we suggest that this hip and ankle pattern may help predict recurrence in unilateral internal hip rotation.
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Affiliation(s)
- Rory O'Sullivan
- Gait Analysis Laboratory, Central Remedial Clinic, Dublin, Dublin, Dublin 3, Ireland
| | - Damien Kiernan
- Gait Analysis Laboratory, Central Remedial Clinic, Dublin, Dublin, Dublin 3, Ireland
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8
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O'Sullivan R, Kiernan D. Recurrent internal hip rotation gait in cerebral palsy: Report of two patients. HRB Open Res 2018; 1:28. [DOI: 10.12688/hrbopenres.12893.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2018] [Indexed: 11/20/2022] Open
Abstract
Internal hip rotation in cerebral palsy (CP) is typically treated with a femoral derotation osteotomy. This has been shown to be largely a successful procedure but recurrence rates up to 41% have been reported. Reported risk factors include younger age, reduced hip joint impulse and ankle plantar-flexion. We report on two patients with bilateral CP demonstrating recurrent unilateral internal hip rotation despite surgical intervention(s). Both demonstrate a number of the reported risk factors for recurrence. In addition, this case report specifically compared gait kinematic patterns pre and post recurrence. On comparing both patient’s hip rotation and ankle dorsi/plantarflexion kinematics they are seen to be almost identical both pre-operatively and post-operatively. Both patients appear to revert to approximately 30o of internal hip rotation which has been shown to maximise hip abductor function. Therefore, surgical derotation in isolation is unlikely to be successful in this group and we suggest that this hip and ankle pattern may help predict recurrence in unilateral internal hip rotation.
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Abstract
BACKGROUND Excessive femoral anteversion is a developmental condition that can become symptomatic into adolescence and manifest as anterior knee pain, tripping, and or problems with sports. Femoral derotational osteotomy about an antegrade intramedullary nail (IMN) is an accepted option to treat this condition. This is the first report of the clinical and functional outcomes of treatment of excessive anteversion with femoral derotational osteotomy stabilized with an IMN. METHODS We prospectively enrolled 28 consecutive patients between 2013 and 2014 who underwent derotational osteotomy. Physical examination measures were used to calculate the amount of angular correction with focus on internal and external rotation of the hip, as well as the trochanteric prominence angle test of femoral anteversion. The International Knee Documentation Committee-9, Marx, and Tegner activity scales were 3 patient-reported outcomes recorded. RESULTS After femoral derotation osteotomy over an IMN, femoral anteversion, as measured by the trochanteric prominence angle, improved an average of 29 degrees (P<0.0001). At 1-year minimum follow-up, 22 of 28 subjects (78.5%) demonstrated a mean significant improvement of 13 points for International Knee Documentation Committee-9 (SD=15.4, P=0.0007), which surpassed the level of minimal clinically important change. Furthermore, the Tegner inventory scores for the cohort improved by an average of 1.9 activity levels (SD=2.4, P=0.0012). CONCLUSIONS For adolescents with symptomatic excessive femoral anteversion, derotational osteotomy over an IMN offers a reliable surgical option that provides predictable deformity correction and significant improvements in both function and pain scales. LEVELS OF EVIDENCE Level II-prospective, consecutive, nonrandomized, internally controlled cohort study.
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Sung KH, Kwon SS, Chung CY, Lee KM, Cho GH, Park MS. Long-term outcomes over 10 years after femoral derotation osteotomy in ambulatory children with cerebral palsy. Gait Posture 2018; 64:119-125. [PMID: 29902714 DOI: 10.1016/j.gaitpost.2018.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 05/23/2018] [Accepted: 06/03/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Femoral derotation osteotomy (FDO) is generally reported to be excellent for correcting the hip rotation and foot progression angles in children with cerebral palsy (CP). However, it is unclear how long the favorable outcomes are maintained. RESEARCH QUESTION This study was performed to evaluate the long-term outcomes at more than 10 years after FDO in children with CP. METHODS FDO, as part of single event multilevel surgery to improve gait function, was performed at the intertrochanteric level with the patient in the prone position. The goal of the index surgery was femoral anteversion of 15°, measured using a modified trochanteric prominence angle test intraoperatively. All patients underwent three-dimensional gait analysis preoperatively and at 1 year and over 10 years postoperatively. RESULTS Thirty-four ambulatory patients (53 hips) with CP undergoing FDO were included. The mean age at surgery was 7.8 years (SD = 3.0 years) and mean follow-up duration was 12.9 years (SD = 2.7 years). The mean hip rotation decreased significantly from 9.6° preoperatively to 3.1° at 1 year postoperatively (p = 0.004), and decreased significantly to -5.9° at the final follow-up (p < 0.001). The mean foot progression in stance decreased from 7.9° preoperatively to -7.4° at 1 year postoperatively (p < 0.001), and was maintained at -10.9° at the final follow-up. The GDI significantly improved from 68.2 preoperatively to 83.4 1 year postoperatively (p < 0.001), and was maintained at 82.3 at the final follow-up. No patients underwent revision surgery due to recurrence of rotation deformity. SIGNIFICANCE Proximal FDO performed in the prone position provides favorable long-term outcomes at more than 10 years postoperatively, without recurrence of rotation deformity. To avoid under-correction or recurrence due to insufficient derotation, surgeons should consider not only dynamic gait analysis findings but also the measurement of anatomic femoral anteversion during intraoperative derotation.
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Affiliation(s)
- Ki Hyuk Sung
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea
| | - Soon-Sun Kwon
- Department of Mathematics, College of Natural Sciences, Ajou University, Gyeonggi, South Korea
| | - Chin Youb Chung
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea
| | - Kyoung Min Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea
| | - Gyeong Hee Cho
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea
| | - Moon Seok Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea.
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Kim HY, Cha YH, Byun JY, Chun YS, Choy WS. Changes in gait parameters after femoral derotational osteotomy in cerebral palsy patients with medial femoral torsion. J Pediatr Orthop B 2018; 27:194-199. [PMID: 28537994 PMCID: PMC5895112 DOI: 10.1097/bpb.0000000000000467] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Medial femoral torsion (MFT) is a common pathologic gait in cerebral palsy (CP) children that can be corrected by femoral derotational osteotomy (FDO). It is not clearly known as to how much various gait parameters change after FDO. The aim of this study was to quantify changes in gait parameters after FDO. The study group included 19 young CP patients (28 limbs, age<20 years, average age: 13.2 years) with symptomatic MFT, treated with distal FDO. The study group was divided into two groups: the unilateral FDO group (UG) and the bilateral FDO group (BG). The mean degree of derotation was 24.6° (25.0° for UG, 24.4° for BG). Pre-FDO and post-FDO values of Staheli's rotational profiles and kinematic data were compared. A paired t-test and Pearson's correlation were used for statistical analysis. The mean internal hip rotation was 71.4±6.9° before surgery and 48.6±10.7° after surgery in the UG (P<0.05) and it was 63.8±15.8° before surgery and 40.9±9.2° after FDO in the BG (P<0.05). The change in the foot progression angle (FPA) was 12.9° in the UG group (P<0.05) and 12.6° in the BG group (P<0.05). The degree of FPA had changed by about a half of the surgical derotation angle. Changes in the mean hip rotation during gait were 14.8° in the UG (P<0.05) and 6.7° in the BG (P<0.05) groups. The overall pelvic rotation was not changed after surgery. However, in patients with preoperative compensatory pelvic rotation of more than 5°, there was a change of 5.3±4.8° in the UG and 6.6±1.54° in the BG after surgery (P<0.05). There was also a trend showing that the younger the patient, the more the pelvic rotation changed (P=0.069). In-toeing gait because of MFT improved with FDO in CP patients. The expected degree of postoperative correction of FPA and hip rotation is about a half of the FDO degree. The degree of compensatory pelvic rotation should be considered to determine the correction angle of FDO, especially in young patients with preoperative pelvic rotation of more than 5°.
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Affiliation(s)
- Ha Yong Kim
- Department of Orthopedic Surgery, Eulji University College of Medicine, Daejeon, Korea
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Braatz F, Dreher T, Wolf SI, Niklasch M. Preoperative hip rotation moments do not predict long-term development after femoral derotation osteotomy in children with cerebral palsy. Gait Posture 2018; 61:215-219. [PMID: 29413787 DOI: 10.1016/j.gaitpost.2018.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/30/2017] [Accepted: 01/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Femoral derotation osteotomy (FDO) is the standard treatment for internal rotation gait (IRG) in children with cerebral palsy (CP) although high rates of recurrence have been reported recently. Various factors associated with recurrence could be identified, but no predictor named. RESEARCH QUESTIONS Does FDO lead to a change of internal transversal hip moments? Are preoperative internal transversal hip moments a predictor for recurrence of IRG? METHODS 41 children with spastic bilateral CP and 72 limbs that received a FDO (10.4 ± 2.7 years at surgery) were included retrospectively. Kinematic data were analyzed pre- (2 ± 3 months), postoperatively (12 ± 3 months) and at long-term follow-up (at least five years postoperatively; 84 ± 13 months), internal transversal hip moments were analyzed pre- and postoperatively. RESULTS The maximum peaks of the internal hip rotation moment during loading response decreased significantly (p = 0.003). The minimum during the second half of the stance phase increased significantly (p = 0.004) and the initially internal externally rotating moment changed to an internal internally rotating moment. No correlation between changes in hip rotation from postoperatively to the long-term follow-up and the preoperative internal hip rotation moment could be identified. SIGNIFICANCE FDO leads to changes in internal hip rotation moments. Preoperative internal hip rotation moments can't be used as predicting factor for recurrence of IRG. The data suggest, that recurrence of IRG depends less on patient specific motion patterns, but more on the time point of surgery and the therapy of all concomitant deformities during SEMLS.
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Affiliation(s)
- Frank Braatz
- University Medical Center Göttingen, Department of Trauma Surgery and Orthopaedics and Plastic Surgery, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Thomas Dreher
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Sebastian I Wolf
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Mirjam Niklasch
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
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Boyer ER, Novacheck TF, Schwartz MH. Changes in hip abductor moment 3 or more years after femoral derotation osteotomy among individuals with cerebral palsy. Dev Med Child Neurol 2017; 59:912-918. [PMID: 28660621 DOI: 10.1111/dmcn.13494] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 11/28/2022]
Abstract
AIM To examine the effect of femoral derotation osteotomy (FDO) on dimensionless hip abductor moment during gait in children with cerebral palsy. METHODS We retrospectively analyzed data from independent ambulators within our database. Postoperative visits 1 year (short-term) and at least 3 years (mid-term) were analyzed. We estimated the coronal plane hip abductor moment arm based on musculoskeletal modeling that accounted for anteversion and hip rotation. RESULTS There were 140 individuals with a short-term analysis (77 males, 63 females; age at surgery 9y 11mo [range 4y 5mo-17y 5mo]) and 29 with mid-term analysis (15 males, 14 females; age at surgery 8y 7mo [range 4y 5mo-13y 1mo]). At short-term, anteversion and internal hip rotation decreased 35° and 13° respectively, which increased median (IQR) moment arms from 20 (23) per cent below normal to 2 (12) per cent above normal. Dimensionless mean hip abductor moment remained unchanged at short-term. Mid-term anteversion did not change but hip rotation increased 8° and hip abductor moment increased to 0.040 (0.029). There was no change in pelvic and trunk obliquity, although hip abductor strength increased and walking velocity decreased at mid-term. INTERPRETATION The unexpected lack of improvement in hip abductor moment from pre- to short-term may be caused by gait compensations that unload the hip. The increase in hip abductor moment beyond 3 years postoperatively underscores the benefits of an FDO into adolescence for independent ambulating individuals with cerebral palsy.
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Affiliation(s)
- Elizabeth R Boyer
- Gillette Children's Specialty Healthcare, University of Minnesota, St. Paul, MN, USA
| | - Tom F Novacheck
- Gillette Children's Specialty Healthcare, University of Minnesota, St. Paul, MN, USA
| | - Michael H Schwartz
- Gillette Children's Specialty Healthcare, University of Minnesota, St. Paul, MN, USA
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Putz C, Wolf SI, Geisbüsch A, Niklasch M, Döderlein L, Dreher T. Femoral derotation osteotomy in adults with cerebral palsy. Gait Posture 2016; 49:290-296. [PMID: 27475618 DOI: 10.1016/j.gaitpost.2016.06.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 04/12/2016] [Accepted: 06/25/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Internal rotation gait constitutes a complex gait disorder in bilateral spastic cerebral palsy (BSCP) including static torsional and dynamic components resulting in lever arm dysfunction. Although femoral derotation osteotomy (FDO) is a standard procedure to correct increased femoral anteversion in children, unpredictable outcome has been reported. The effect of FDO when it is done as part of single-event multilevel surgery (SEMLS) in adulthood has not been investigated. METHODS In this study mid-term data of 63 adults with BSCP and internal rotation gait, undergoing SEMLS including FDO were analyzed pre- and 1.7 years postoperatively by clinical examination and 3D-instrumented gait analysis. All legs were categorized as the more or less involved side to consider asymmetry. The mean hip rotation in stance preoperatively and the intraoperative derotation was correlated with the difference pre- and postoperatively. RESULTS The group as a whole experienced the following results postoperatively: improved mean hip rotation in stance (p=0.0001), mean foot progression angle (p=0.0001) and a significant improvement of the clinical parameter: passive internal and external hip rotation, midpoint and anteversion (p=0.0001) for both legs separately. With regard to the less and more involved side, clinical and kinematic parameters showed comparable significant changes (p=0.0001). The anteversion improved significantly in proximal compared to distal FDO (p=0.03). CONCLUSION This study emphasizes an overall good correction of internal rotation gait in adults with bilateral involvement after FDO. However, the results are more predictable in adults compared to studies reporting outcome after FDO in children.
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Affiliation(s)
- C Putz
- Pediatric Orthopedics and Foot Surgery, Center for Orthopedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - S I Wolf
- Pediatric Orthopedics and Foot Surgery, Center for Orthopedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - A Geisbüsch
- Pediatric Orthopedics and Foot Surgery, Center for Orthopedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - M Niklasch
- Pediatric Orthopedics and Foot Surgery, Center for Orthopedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - L Döderlein
- Orthopedic Hospital for Children, Behandlungszentrum Aschau GmbH, Bernauerstrasse 18, 83229 Aschau i. Chiemgau, Germany
| | - T Dreher
- Pediatric Orthopedics and Foot Surgery, Center for Orthopedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
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Niklasch M, Dreher T, Döderlein L, Wolf SI, Ziegler K, Brunner R, Rutz E. Superior functional outcome after femoral derotation osteotomy according to gait analysis in cerebral palsy. Gait Posture 2015; 41:52-6. [PMID: 25217494 DOI: 10.1016/j.gaitpost.2014.08.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 08/04/2014] [Accepted: 08/18/2014] [Indexed: 02/02/2023]
Abstract
The femoral derotation osteotomy (FDO) is seen as the golden standard treatment in children with cerebral palsy and internal rotation gait. Variable outcomes with cases of over- and undercorrection mainly in the less involved patients have been reported. The determination of the amount of derotation is still inconsistent. 138 patients (age: 11 (± 3.3) years) with cerebral palsy and internal rotation gait were examined pre- and 1 year postoperatively after distal or proximal FDO, using standardized clinical examination and 3D gait analysis. Three groups were defined retrospectively depending on the amount of derotation in relation to the mean hip rotation in stance (MHR) during gait analysis: Group A (derotation angle > MHR + 10°), Group B (derotation angle = MHR ± 10°), Group C (derotation angle <MHR-10°), and compared according to their postoperative mean hip rotation. ANOVA with Bonferroni post hoc test was used for statistics (p < 0.05). Group B had the greatest benefit with the highest rate (86%) of good results (postoperative MHR = ± 15°). In contrast there were 14% cases of overcorrection and 5% cases of deterioration in Group A with only 81% good results and only 79% good results in Group C. It can be concluded, that it is less likely to have unsatisfactory outcomes if the amount of FDO is defined according to the findings of gait analysis compared with clinical examination.
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Affiliation(s)
- M Niklasch
- Pediatric Orthopaedics and Foot Surgery, Clinic for Orthopaedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - T Dreher
- Pediatric Orthopaedics and Foot Surgery, Clinic for Orthopaedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - L Döderlein
- Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH, Bernauerstrasse 18, 83229 Aschau i. Chiemgau, Germany
| | - S I Wolf
- Pediatric Orthopaedics and Foot Surgery, Clinic for Orthopaedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - K Ziegler
- Pediatric Orthopaedics and Foot Surgery, Clinic for Orthopaedic and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - R Brunner
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Spitalstrasse 33, 4056 Basel, Switzerland
| | - E Rutz
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Spitalstrasse 33, 4056 Basel, Switzerland
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