Coronal plane knee moments improve after correcting external tibial torsion in patients with cerebral palsy

Bony Procedures for surgical patellar stabilization

Surgery for patellofemoral instability is usually considered in patients with recurrent patellar dislocation and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence due to the presence of several risk factors. Risk factors include demographics such as age, contralateral dislocation, as well as anatomic risk factors (ARF) such as abnormal coronal and rotational alignment, trochlear dysplasia, lateral quadriceps vector, and patella alta. Surgery with soft tissue procedures includes restoring the medial patellar restraints and balancing the lateral side of the joint and can be successful in most patients. However, patients that have excessive and/or several ARF have a high risk of failure with isolated soft tissue stabilization procedures; associated surgical correction of select ARFs is recommended. This article will discuss an approach to evaluate the risk-benefit of adding bony procedures which may decrease the changes of recurrence of patellar instability but can increase surgery-related complications. Approaching patellofemoral instability in a patient-specific approach and combining corrective osteotomies and trochleoplasties with a shared decision with the patient/family, guiding surgeons to deliver optimal care for the patellar instability patient.

Comparative Analysis of Physical Examination, CT Scan, and Three-Dimensional Gait Analysis in Evaluating Lower Extremity Torsion Deformities in Children with Cerebral Palsy

BACKGROUND The aim of this study was to analyze the correlation and the accuracy of lower-extremity torsion deformities measured by physical examination, CT scan, and three-dimensional gait analysis in children with CP. MATERIAL AND METHODS The study group included 72 children with CP with lower-extremity torsion deformities. All subjects were assessed by: 1. physical examination: maximum internal rotation (MIR), maximum external rotation (MER) for hip joint torsion, and transmalleolar axis (TMA) for tibial torsion; 2. CT scanning: femoral anteversion (FAV) and tibial torsion (TT); 3. three-dimensional gait analysis kinematic parameters: single-support phase of femoral rotation, double-support phase of femoral rotation, swing phase of femoral rotation and single-support phase of tibial rotation, double-support phase of tibial rotation, and swing phase of tibial rotation. Statistical analysis was performed using the Pearson correlation test. A significance level of P<0.05 was set. RESULTS In femurs, MIR and MER were correlated with FAV, and the correlation of MER was higher, while physical examination and FAV were not correlated with any kinematic data in gait analysis. In tibias, there was no correlation between TMA and TT, but both TMA and TT were correlated with the gait analysis kinematic data, and the correlation of TT was higher. TMA was more correlated with tibial rotation during swing phase, while TT was more correlated with tibial rotation in single-support phase. CONCLUSIONS Three-dimensional gait analysis can analyze the tibial rotation of children with cerebral palsy, which is highly correlated with CT and physical examination. However, femoral rotation was not associated with CT and physical examination.

The effect of medial only versus medial and lateral hamstring lengthening on transverse gait parameters in cerebral palsy

Benefits of hamstring lengthening surgery on the sagittal plane in children with cerebral palsy have been previously demonstrated, but there is limited information on its effects on the transverse plane. This study compared the effects of medial hamstring lengthening (MHL) with those of medial and lateral hamstring lengthening (MLHL) procedures in the transverse plane. Children with gross motor function classification system (GMFCS) levels I-III who had MHL or MLHL were included. Baseline, short- (1-2 years), and long-term (3+ years) postoperative three-dimensional gait analysis outcomes were compared using analysis of variance. Children were excluded if they had concurrent osteotomies or tendon transfers. One hundred fifty children (235 limbs) were included, with 110 limbs in the MHL group (age 8.5 ± 4.1 years, GMFCS I-27%, II-52%, and III-21%) and 125 limbs in the MLHL group (age 10.0 ± 4.0 years, GMFCS I-23%, II-41%, and III-37%). Time between surgery and short- and long-term follow-up gait analysis was 1.5 ± 0.6 years and 6.6 ± 2.9 years, respectively. Transmalleolar axis became more external after MHL at both short and long terms ( P < 0.05), whereas there were only significant differences at long term in MLHL ( P < 0.05). Although hamstring lengthening has a positive impact on stance phase knee extension in children with cerebral palsy, intact lateral hamstrings after MHL likely contribute to increased tibial external rotation after surgery. Significant increases in external rotation at the knee in the long term are likely related to a trend present with growth in children with cerebral palsy rather than a direct result of surgical intervention.

Rotational Osteotomy for Femoral Version/Tibial Torsion

PURPOSE OF REVIEW

The purpose of this review is to discuss the current state of knowledge regarding axial plane deformities in patellofemoral instability, indications and techniques for treatment of those deformities, and outcomes following treatment.

RECENT FINDINGS

There is opportunity for more information in the literature on all aspects of axial plane deformities in patellofemoral instability. This includes how to assess axial plane deformities on imaging, what is normal and what is an appropriate goal for correction, what techniques are best used depending on the deformity or concomitant pathology, and larger and more discriminating studies on outcomes. Rotational deformity of both the tibia and femur is an important risk factor to consider as a cause of patellar instability. Recent research has shown that surgical correction of these deformities on either the femoral or tibial side can have a positive effect on outcome in terms of patellar instability and knee pain. Further research, however, is warranted to determine what are normal values for femoral version and tibial torsion, and at what values surgical intervention is warranted.

Rotational Deformity-When and How to Address Femoral Anteversion and Tibial Torsion

Rotational deformity is a less common cause of patellar instability than trochlear dysplasia and patella alta. In some cases, rotational deformity is the primary bony factor producing the instability and should be corrected surgically. More research is needed on what are normal values for femoral version and tibial torsion, as well as when the axial plane alignment needs to be corrected. Many tools can be used to evaluate the axial plane and surgeons should be familiar with each of them. Understanding the advantages and disadvantages of each site for osteotomy will help the surgeon choose the most appropriate osteotomy.

Differences between Two Methods to Stabilize Supramalleolar Osteotomies in Children-A Retrospective Case Series

Supramalleolar osteotomy (SMO) in pediatric patients can be fixed in various ways. We analyzed the records of 77 pediatric patients (124 SMOs) aged ≤16 years. In 56 patients (96 SMOs), K-wires were used to stabilize SMOs (WF group), while 21 patients (28 SMOs) were treated with locking compression plates (LCPs; PF group). We recorded time to radiographic consolidation, rate of complications, length of hospital stay (LOS), and time to implant removal. Mean time to radiographic consolidation of SMOs was 7.2 weeks in the WF group and 11.1 weeks in the PF group. Complication rate in the WF group was 10.7%. LOS was similar in the two groups (7.0 days in the WF group vs. 7.3 days in the PF group). K-wire stabilization resulted in a shortened interval until consolidation of osteotomies, but children were required to use a cast. Stabilization of SMOs with LCPs facilitated early mobilization and functional rehabilitation with no need to apply a cast. In conclusion, both methods provided safe fixation of SMOs with a low rate of complications. K-wire stabilization combined with a cast achieves fast consolidation of SMOs. We recommend SMO stabilization with angular stable LCPs in patients with muscular weakness or spasticity in whom early mobilization and physiotherapy are necessary to prevent loss of muscle power, muscle function, and bone mass.

Muscle capacity to accelerate the body during gait varies with foot position in cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) often have altered gait patterns compared to their typically developing peers. These gait patterns are characterized based on sagittal plane kinematic deviations; however, many children with CP also walk with altered transverse plane kinematics.

RESEARCH QUESTION

How do both altered skeletal alignment and kinematic deviations affect muscles' capacity to accelerate the body during gait?

METHODS

A three-dimensional gait analysis was completed for 18 children with spastic CP (12.5 ± 2.9 years; GMFCS level II). Musculoskeletal models were developed for each participant, and tibial torsion, measured during a static standing trial and assessed using motion capture, was incorporated. An induced acceleration analysis was performed to evaluate the capacity of muscles to accelerate the body center of mass throughout stance. Differences between the root-mean-square muscle capacity for children with CP walking with internally rotated, standard, and externally rotated postures were evaluated.

RESULTS

Externally rotated postures resulted in a lower capacity to accelerate the body center of mass compared with internally rotated postures. Both changes in skeletal alignment and kinematics contributed to changes in muscle capacity to accelerate the body.

SIGNIFICANCE

Altered transverse plane skeletal alignment and compensatory kinematics should both be considered in surgical treatment of children with CP.

Effect of twister wrap orthosis on foot pressure distribution and balance in diplegic cerebral palsy

OBJECTIVES

To evaluate the effectiveness of twister wrap orthosis (TWO) on foot pressure distribution and postural balance in children with spastic diplegic cerebral palsy (CP).

METHODS

Thirty children with spastic diplegic CP, with ages ranging from 6 to 8 years, were assigned randomly into two groups. The control group received the conventional physical therapy and ankle foot orthosis (AFO), whereas the study group received the same program as the control group in addition to TWO. Measurement of foot pressure distribution using a pressure platform as well as stability indices using the Biodex Stability System was performed before and after 12 weeks of the treatment program.

RESULTS

Both groups showed a significant increase in mean and peak planter pressure on forefoot and rear foot with a significant decrease on mid foot after treatment (P⟨0.05). The study group showed a significant improvement in balance after treatment (P⟨0.05) while there was no significant difference in the control group. After treatment, the study group showed significant improvement in planter pressure and balance compared with the control group (P⟨0.05).

CONCLUSIONS

TWO could provide correction of foot pressure distribution and improve postural balance in children with spastic diplegic CP.

Long-term Outcome of Internal Tibial Derotation Osteotomies in Children With Cerebral Palsy

BACKGROUND

External tibial torsion (ETT) is a common bony deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome following TDO to correct ETT in ambulatory children with CP.

METHODS

Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ETT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, E0 MTR, E0 gait velocity, gross motor function classification system (GMFCS) score, and foot deformity were evaluated to determine their influence on long-term results.

RESULTS

The study sample consisted of 43 legs (with E0 and E2) and 22 legs (with E0, E1, and E2). The mean age at surgery was 10.3±3.4 years (range, 6 to 19.2 y). In the group MTR trended toward improvement moving from -26±17 degrees (E0, external negative) to -16±16 degrees (E1) and relapsed to -23±17 degrees at the long term (P=0.071, E0/E1; P=0.589, E0/E2). Improvement was also seen in the transmalleolar axis (P=0.074), mean ankle rotation, and mean foot orientation (P<0.05, E0/E2). At the long-term evaluation, 16 legs (37%) were found to be in the kinematic corrected group, 25 legs (58%) in the kinematic undercorrected group, and 2 legs (5%) in the kinematic overcorrected group. There were no significant differences between the corrected and undercorrected groups of children with respect to age at surgery, GMFCS, E0 MTR, gait velocity, or foot deformity.

CONCLUSIONS

Although internal TDO improves ETT in the short term, recurrence is frequent with an apparent developmental trend toward external rotation of the tibia.

LEVELS OF EVIDENCE

Level IV-therapeutic study.

Correction of Tibial Torsion in Children With Cerebral Palsy by Isolated Distal Tibia Rotation Osteotomy: A Short-term, In Vivo Anatomic Study

BACKGROUND

Excessive internal or external tibial torsion is frequently present in children with cerebral palsy. Several surgical techniques have been described to correct excessive tibial torsion, including isolated distal tibial rotation osteotomy (TRO). The anatomic changes surrounding this technique are poorly understood. The goal of the study was to examine the anatomic relationship between the tibia and fibula following isolated distal TRO in children with cerebral palsy.

METHODS

Twenty patients with 29 limbs were prospectively entered for study. CT scans of the proximal and distal tibiofibular (TF) articulations were obtained preoperatively, at 6 weeks, and 1 year postoperatively. Measurements of tibia and fibula torsion were performed at each interval. Qualitative assessments of proximal and distal TF joint congruency were also performed.

RESULTS

The subjects with internal tibia torsion (ITT, 19 limbs) showed significant torsional changes for the tibia between preoperative, postoperative, and 1 year time points (mean torsion 13.21, 31.05, 34.84 degrees, respectively). Measurement of fibular torsion in the ITT treatment group also showed significant differences between time points (mean -36.77, -26.77, -18.54 degrees, respectively). Proximal and distal TF joints remained congruent at all time points in the study.Subjects with external tibia torsion (ETT, 10 limbs) showed significant differences between preoperative and postoperative tibial torsion, but not between postoperative and 1 year (mean torsion 54, 19.3, 23.3 degrees, respectively). Measurement of fibular torsion in the ETT treatment group did not change significantly between preoperative and postoperative, but did change significantly between postoperative and 1 year (mean torsion -9.8,-16.9, -30.7 degrees, respectively). Nine of 10 proximal TF joints were found to be subluxated at 6 weeks postoperatively. At 1 year, all 9 of these joints had reduced.

CONCLUSIONS

Correction of ITT by isolated distal tibial external rotation osteotomy resulted in acute external fibular torsion. The fibular torsion alignment remodeled over time to accommodate the corrected tibial torsional alignment and reduce the strain associated with the plastic deformity of the fibula. Correction of ETT by isolated distal internal TRO resulted in acute subluxation of the proximal TF articulation in almost all cases. Subsequent torsional remodeling of the fibula resulted in correction of the TF subluxation in all cases. Acute correction of TT by isolated distal TRO occurs by distinct mechanisms, based upon the direction of rotational correction.

LEVEL OF EVIDENCE

Level II-Diagnostic.

The clinical impact of orthotic correction of lower limb rotational deformities in children with cerebral palsy: a randomized controlled trial

Objective:

This study aimed to evaluate the effectiveness of a static ground reaction ankle foot orthosis and strapping system on improving gait parameters in children with spastic diplegic cerebral palsy.

Setting:

The current study was conducted at the physical therapy faculty of Cairo University, Egypt.

Subjects:

This study included 57 children of both sexes, aged 6 to 8 years.

Study design:

Three-armed randomized control trial.

Intervention:

Participants in all groups received a traditional neuro-developmental physical therapy program that included standing and gait training exercises. Children in group A performed the training program without any orthotic management, in group B with the TheraTogs™ strapping system, and in group C with the TheraTogs™ strapping system and static ground reaction ankle foot orthoses. Children underwent treatment for two hours daily, except on weekends, for twelve successive weeks.

Main measure:

Gait speed, cadence, stride length, and hip and knee flexion angles in the mid-stance phase were evaluated pre-and post-treatment using a three-dimensional motion analysis system (pre-reflex system).

Results:

Statistically significant differences were recorded among the three groups post-treatment in gait speed, cadences, and stride length. The P-values for these variable differences were 0.03, 0.011, and 0.001 respectively. Significant post-treatment differences were also recorded for bilateral hip-and knee-flexion angles. For all measured parameters, better significant results were registered for group C than for the other groups.

Conclusion:

Orthotic intervention composed of a static ground reaction ankle foot orthosis combined with the TheraTogs™ strapping system improves gait more than conventional treatment with or without TheraTogs™ in children with spastic diplegic cerebral palsy.