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Cirrincione PM, Nichols ET, Zucker CP, Chandran V, Zanini S, Jezequel J, Assip B, Backus SI, Doyle SM, Scher D, Selber P. Pelvic Tilt in Adults With Cerebral Palsy and Its Relationship With Prior Hamstrings Lengthening. Orthopedics 2024:1-6. [PMID: 38935848 DOI: 10.3928/01477447-20240619-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
BACKGROUND Current studies assessing the change in pelvic tilt for ambulatory patients with cerebral palsy (CP) after surgical hamstring lengthening (SHL) lack a comparison cohort without prior SHL and are limited to younger patients. This study presents gait data of middle-aged adults with CP, primarily focusing on the pelvis, and compares pelvic tilt, trunk tilt, and knee flexion between those with and without prior SHL. MATERIALS AND METHODS A consecutive series of 54 adults with CP, a mean age of 36±13 years, and Gross Motor Function Classification System (GMFCS) levels I-III were included. Thirty-two (59%) had SHL performed at a mean age of 8±5 years. Three-dimensional gait analysis data prospectively collected at a mean of 28±14 years postoperatively were retrospectively analyzed. Chi-square tests were used to compare demographic and surgical history data and statistical parameter mapping was used to compare knee flexion during stance and pelvic and trunk tilts during the gait cycle between SHL and SHL-naive groups. RESULTS Age, GMFCS level, sex, race, topography, and ethnicity were not different between the groups (P=.217-.612). Anterior pelvic tilt throughout gait was significantly greater in the SHL group compared with the SHL-naive group (63%-87%; P=.033). This difference was augmented after accounting for other surgical history and revision SHL (0%-32%, P=.019; and 46%-93%, P=.007). CONCLUSION Within a cohort of adults with CP, GMFCS levels I-III, and a mean age of 36 years, those with a history of SHL, performed a mean of 28 years prior to 3-dimensional gait analysis, walked with increased anterior pelvic tilt compared with those without a history of SHL. [Orthopedics. 202x;4x(x):xx-xx.].
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Nabian MH, Zadegan SA, Mallet C, Neder Y, Ilharreborde B, Simon AL, Presedo A. Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy. Gait Posture 2024; 110:53-58. [PMID: 38492261 DOI: 10.1016/j.gaitpost.2024.02.019] [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: 02/27/2023] [Revised: 02/23/2024] [Accepted: 02/28/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures. PATIENTS AND METHODS We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively. RESULTS Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery. CONCLUSION Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Mohammad Hossein Nabian
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran; Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France
| | - Shayan Abdollah Zadegan
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Cindy Mallet
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France
| | - Yamile Neder
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France
| | - Brice Ilharreborde
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France
| | - Anne Laure Simon
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France
| | - Ana Presedo
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
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Seth A, Watkins CJ, Miller PE, Shore BJ. Anterior Distal Femoral Hemiepiphysiodesis in Children With Fixed Knee Flexion Deformities: Does Screw Position Matter? J Pediatr Orthop 2024; 44:e255-e259. [PMID: 38108334 DOI: 10.1097/bpo.0000000000002599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
BACKGROUND Anterior distal femoral hemiepiphysiodesis (ADFH) using 2 percutaneous screws is an effective technique for the treatment of fixed knee flexion deformities in children with neuromuscular disorders. The role of sagittal screw position on the outcome of the procedure is unknown. METHODS This is a retrospective case series of patients who underwent ADFH at a single pediatric hospital from 2013 to 2020. Radiographs were evaluated for sagittal screw position and the associated change in lateral distal femoral physeal angle over time. The position of the 2 screws was classified as either being both in the anterior third of the physis (AA), one screw in the anterior third and the other screw in the middle third (AM), or both screws in the middle third of the physis (MM). RESULTS The study population included 68 knees in 36 patients. The mean physeal angle at the time of surgery was 93 degrees (SD 4.0 degrees), which increased to 102.4 degrees (SD 5.7 degrees) at 12 months, for a change of 9.4 degrees ( P <0.001). At 24 months, the mean physeal angle was 104.6 degrees (SD 6.3 degrees) for a further change of 2.9 degrees ( P <0.001). When stratified by screw position all screw configurations resulted in an increase in the physeal angle at 12 months. At the 24-month follow-up, the physeal angle in knees with AA screws continued to increase another 3.5 degrees ( P <0.05), there was a minimal change in knees with AM screws (1.47°, P >0.05) and knees with MM screws saw a reversal of physeal angle change (-7.1 degrees, P <0.05). CONCLUSIONS ADFH using percutaneous screws results in an increase in the lateral distal femoral physeal angle. The rate of correction is largest in the first 12 months after the procedure. As such, this procedure should be considered in patients with less than 2 years of growth remaining. However, initial screw positioning influences the amount of change over time, and close postoperative surveillance until physeal closure is essential for all patients. LEVEL OF EVIDENCE Level IV-retrospective case series.
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Affiliation(s)
- Akshay Seth
- Orthopedic, Sports Injury Clinic, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Colyn J Watkins
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
| | | | - Benjamin J Shore
- Department of Orthopaedic Surgery, Boston Children's Hospital
- Harvard Medical School, Boston, MA
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Galán-Olleros M, Lerma-Lara S, Torres-Izquierdo B, Ramírez-Barragán A, Egea-Gámez RM, Hosseinzadeh P, Martínez-Caballero I. Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies. J Child Orthop 2024; 18:13-25. [PMID: 38348440 PMCID: PMC10859119 DOI: 10.1177/18632521231217542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 02/15/2024] Open
Abstract
Purpose To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Methods Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Results Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Conclusions Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level of evidence Level III, Systematic review of level III studies.
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Affiliation(s)
- María Galán-Olleros
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sergio Lerma-Lara
- Departament of Physiotherapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
| | - Beltran Torres-Izquierdo
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ana Ramírez-Barragán
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Rosa M Egea-Gámez
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Pooya Hosseinzadeh
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ignacio Martínez-Caballero
- Neuro-Orthopaedic Unit, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Al Badi H, Lorange JP, Alzeedi M, Marwan Y, Bernstein M, Hamdy RC. Distal Femur Anterior Hemiepiphysiodesis for Fixed Knee Flexion Deformity in Neuromuscular Patients: A Systematic Review. JBJS Rev 2023; 11:01874474-202306000-00003. [PMID: 37276266 DOI: 10.2106/jbjs.rvw.23.00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND In the past decade, distal femur anterior hemiepiphysiodesis for fixed knee flexion deformity has gained popularity. In this study, we aim to systematically review the literature on this technique as a treatment for fixed knee flexion deformity in patients with neuromuscular disorders. METHODS A systematic review was performed in the following databases: PubMed, Embase, and Medline. The inclusion criteria included anterior hemiepiphysiodesis of the distal femur for patients with neuromuscular disorders and fixed knee flexion deformities. RESULTS Our search yielded 419 titles. A total of 12 articles were qualified for final review based on the inclusion and exclusion criteria. The total number of patients was 279, with 483 knees corrected. The male to female ratio was 2.1:1, and the mean age of the patients was 11.3 ± 1.4 years (range 4-17 years). The mean preoperative flexion deformity was 23.1° ± 10.0° (range 10°-90°). The mean residual flexion deformity at the final follow-up was 8.6° ± 9.0° (range 0°-32.5°), which corresponds to a statistically significant decrease compared with the preoperative deformity (p < 0.05). CONCLUSION Anterior hemiepiphysiodesis for fixed knee flexion deformity provides favourable outcomes with low complication rates in patients with neuromuscular disorders. Future studies should focus on comparing the long-term outcomes of the different metal implants used for these operations. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hamid Al Badi
- Limb Deformity Unit, Department of Pediatric Orthopaedic Surgery, Shriners Hospital for Children, Montreal, Quebec, Canada
- Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Justin-Pierre Lorange
- Limb Deformity Unit, Department of Pediatric Orthopaedic Surgery, Shriners Hospital for Children, Montreal, Quebec, Canada
- Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Muadh Alzeedi
- Limb Deformity Unit, Department of Pediatric Orthopaedic Surgery, Shriners Hospital for Children, Montreal, Quebec, Canada
- Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Yousef Marwan
- Department of Surgery, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Mitchell Bernstein
- Limb Deformity Unit, Department of Pediatric Orthopaedic Surgery, Shriners Hospital for Children, Montreal, Quebec, Canada
- Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Reggie C Hamdy
- Limb Deformity Unit, Department of Pediatric Orthopaedic Surgery, Shriners Hospital for Children, Montreal, Quebec, Canada
- Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Bezuidenhout L, Church C, Henley J, Salazar-Torres JJ, Lennon N, Shields T, Miller F, Shrader MW. The effect of medial only versus medial and lateral hamstring lengthening on transverse gait parameters in cerebral palsy. J Pediatr Orthop B 2023; 32:80-86. [PMID: 36445368 DOI: 10.1097/bpb.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Louis Bezuidenhout
- Department of Orthopedics, University of Alberta, Edmonton, Alberta, Canada
| | - Chris Church
- Department of Orthopedics, Nemours Children's Health, Wilmington, Delaware, USA
| | - John Henley
- Department of Orthopedics, Nemours Children's Health, Wilmington, Delaware, USA
| | | | - Nancy Lennon
- Department of Orthopedics, Nemours Children's Health, Wilmington, Delaware, USA
| | - Thomas Shields
- Department of Orthopedics, Nemours Children's Health, Wilmington, Delaware, USA
| | - Freeman Miller
- Department of Orthopedics, Nemours Children's Health, Wilmington, Delaware, USA
| | - M Wade Shrader
- Department of Orthopedics, Nemours Children's Health, Wilmington, Delaware, USA
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7
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Rutz E, Novacheck TF, Dreher T, Davids JR, McCarthy J, Kay RM, Shore BJ, Shrader MW, Veerkamp M, Chambers H, Narayanan U, Pierz K, Rhodes J, Shilt J, Theologis T, Van Campenhout A, Graham K. Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review. J Child Orthop 2022; 16:442-453. [PMID: 36483640 PMCID: PMC9723875 DOI: 10.1177/18632521221137391] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/19/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement. METHOD A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022. RESULTS There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates. CONCLUSION The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research. LEVEL OF EVIDENCE level V.
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Affiliation(s)
- Erich Rutz
- Department of Orthopaedic Surgery, The Royal Children’s Hospital Melbourne, Parkville, VIC, Australia,Erich Rutz, Department of Orthopaedic Surgery, The Royal Children’s Hospital Melbourne, 50 Flemington Road, Parkville, VIC 3052, Australia; Bob Dickens Chair Paediatric Orthopaedic Surgery, Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.
| | - Tom F Novacheck
- Gillette Children’s Specialty Healthcare, Saint Paul, MN, USA
| | | | - Jon R Davids
- Shriners Hospitals for Children-Northern California, Sacramento, CA, USA
| | - James McCarthy
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Robert M Kay
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | | | - M Wade Shrader
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Matthew Veerkamp
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | | | | | | | | - Kerr Graham
- Department of Orthopaedic Surgery, The Royal Children’s Hospital Melbourne, Parkville, VIC, Australia
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Contribution of Different Impairments to Restricted Knee Flexion during Gait in Individuals with Cerebral Palsy. J Pers Med 2022; 12:jpm12101568. [PMID: 36294708 PMCID: PMC9604873 DOI: 10.3390/jpm12101568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/29/2022] Open
Abstract
The coexistence of overlapping impairments modulates the knee pattern in the swing phase of walking in children with cerebral palsy (CP). The impact and contribution of each impairment to the reduction of knee range-of-motion is unknown. The aim of the study was to establish the gradation of the impact of individual coexisting impairments on the knee flexion range-of-motion. Passive range-of-motion, selective motor control, strength, and spasticity from 132 patients (Male = 76, Female = 56, age:11 ± 4 years) with spastic CP were tested with clinical tools. Knee flexion range-of-motion at terminal stance, pre-swing, and initial swing phases were assessed by gait analysis. Hypertonia (β = −5.75) and weakness (β = 2.76) of knee extensors were associated with lower range of knee flexion (R2 = 0.0801, F = 11.0963, p < 0.0001). The predictive factors (R2 = 0.0744, F = 7.2135, p < 0.0001) were strength (β = 4.04) and spasticity (β = −2.74) of knee extensors and strength of hip flexors (β = −2.01); in swing those were knee extensors hypertonia (β = −2.55) and passive range of flexion (β = 0.16) (R2 = 0.0398, F = 3.4010, p = 0.01). Hypertonia of knee extensors has the strongest impact on knee flexion range-of-motion; secondary is the strength of knee extensors. The knee extensors strength with knee extensors hypertonia and strength of hip flexors contributes in stance. Knee extensors hypertonia with passive knee flexion range-of-motion contributes in swing.
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9
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Cloodt E, Lindgren A, Lauge-Pedersen H, Rodby-Bousquet E. Sequence of flexion contracture development in the lower limb: a longitudinal analysis of 1,071 children with cerebral palsy. BMC Musculoskelet Disord 2022; 23:629. [PMID: 35780097 PMCID: PMC9250270 DOI: 10.1186/s12891-022-05548-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background To prevent severe contractures and their impact on adjacent joints in children with cerebral palsy (CP), it is crucial to treat the reduced range of motion early and to understand the order by which contractures appear. The aim of this study was to determine how a hip–knee or ankle contracture are associated with the time to and sequence of contracture development in adjacent joints. Methods This was a longitudinal cohort study of 1,071 children (636 boys, 435 girls) with CP born 1990 to 2018 who were registered before 5 years of age in the Swedish surveillance program for CP and had a hip, knee or ankle flexion contracture of ≥ 10°. The results were based on 1,636 legs followed for an average of 4.6 years (range 0–17 years). The Cox proportional-hazards model adjusted for Gross Motor Function Classification System (GMFCS) levels I–V was used to compare the percentage of legs with and without more than one contracture. Results A second contracture developed in 44% of the legs. The frequency of multiple contractures increased with higher GMFCS level. Children with a primary hip or foot contracture were more likely to develop a second knee contracture. Children with a primary knee contracture developed either a hip or ankle contracture as a second contracture. Conclusions Multiple contractures were associated with higher GMFCS level. Lower limb contractures appeared in specific patterns where the location of the primary contracture and GMFCS level were associated with contracture development in adjacent joints.
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Affiliation(s)
- Erika Cloodt
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden.
| | - Anna Lindgren
- Centre for Mathematical Sciences, Lund University, Lund, Sweden
| | | | - Elisabet Rodby-Bousquet
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden.,Centre for Clinical Research Västerås, Uppsala University-Region Västmanland, Västerås, Sweden
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10
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Shore BJ, McCarthy J, Shrader MW, Graham HK, Veerkamp M, Rutz E, Chambers H, Davids JR, Narayanan U, Novacheck TF, Pierz K, Dreher T, Rhodes J, Shilt J, Theologis T, Van Campenhout A, Kay RM. Anterior distal femoral hemiepiphysiodesis in children with cerebral palsy: Establishing surgical indications and techniques using the modified Delphi method and literature review. J Child Orthop 2022; 16:65-74. [PMID: 35615394 PMCID: PMC9124914 DOI: 10.1177/18632521221087529] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. METHODS The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest 2 ratings. RESULTS For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and smaller (<30 degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture. CONCLUSION Anterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Benjamin J Shore
- Boston Children’s Hospital, Boston, MA, USA,Benjamin J. Shore, Boston Children’s Hospital, Boston, MA 02115, USA.
| | - James McCarthy
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - M Wade Shrader
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - H Kerr Graham
- The Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Matthew Veerkamp
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Erich Rutz
- The Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
| | | | - Jon R Davids
- Shriners Hospitals for Children—Northern California, Sacramento, CA, USA
| | | | - Tom F Novacheck
- Gillette Children’s Specialty Healthcare, Saint Paul, MN, USA
| | | | | | | | | | | | | | - Robert M Kay
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
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Pantzar-Castilla EHS, Wretenberg P, Riad J. Knee flexion contracture impacts functional mobility in children with cerebral palsy with various degree of involvement: a cross-sectional register study of 2,838 individuals. Acta Orthop 2021; 92:472-478. [PMID: 33870826 PMCID: PMC8381963 DOI: 10.1080/17453674.2021.1912941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The impact of knee flexion contracture (KFC) on function in cerebral palsy (CP) is not clear. We studied KFC, functional mobility, and their association in children with CP.Subjects and methods - From the Swedish national CP register, 2,838 children were defined into 3 groups: no (≤ 4°), mild (5-14°), and severe (≥ 15°) KFC on physical examination. The Functional Mobility Scale (FMS) levels were categorized: using wheelchair (level 1), using assistive devices (level 2-4), walking independently (level 5-6). Standing and transfer ability and Gross Motor Function Classification (GMFCS) were assessed.Results - Of the 2,838 children, 73% had no, 14% mild, and 13% severe KFC. KFC increased from 7% at GMFCS level I to 71% at level V. FMS assessment (n = 2,838) revealed around 2/3 were walking independently and 1/3 used a wheelchair. With mild KFC (no KFC as reference), the odds ratio for FMS level 1 versus FMS level 5-6 at distances of 5, 50, and 500 meters, was 9, 9, and 8 respectively. Correspondingly, with severe KFC, the odds ratio was 170, 260, and 217. In no, mild, and severe KFC 14%, 47%, and 77% could stand with support and 11%, 25%, and 33% could transfer with support.Interpretation - Knee flexion contracture is common in children with CP and the severity of KFC impacts function. The proportion of children with KFC rose with increased GMFCS level, reduced functional mobility, and decreased standing and transfer ability. Therefore, early identification and adequate treatment of progressive KFC is important.
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Affiliation(s)
| | | | - Jacques Riad
- Department of Orthopaedics, Skaraborg Hospital, Skövde, Sweden
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Intramuscular psoas lengthening at the pelvic brim plus proximal lengthening of the rectus femoris as a treatment for fixed knee flexion deformity in cerebral palsy. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recote.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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13
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Intramuscular psoas lengthening at the pelvic brim plus proximal lengthening of the rectus femoris as a treatment for fixed knee flexion deformity in cerebral palsy. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021; 65:216-222. [PMID: 33461940 DOI: 10.1016/j.recot.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/07/2020] [Accepted: 09/28/2020] [Indexed: 11/23/2022] Open
Abstract
Although the correction of knee flexion by lengthening the hamstring musculature is traditionally contemplated in cerebral palsy, literature suggests that treatment of hip flexion also improves knee extension. The aim of the study was to first show the efficacy of the sequence of intrapelvic tenotomy of the psoas followed by intramuscular lengthening of the proximal rectus anterior and, later, that of both surgical soft tissue surgeries separately. For this, a prospective study was carried out in 10 patients with a mean age of 14 years, which presented 16 fixed knee flexes with a mean of deformity of 22°. The data was analyzed through means of an ANOVA of repeated measures and to determine the effect separately of each one of the techniques, the improvements obtained with respect to the previous level were contrasted. The mean extension achieved was 12°, 7° corresponding to the intrapelvic tenotomy of the psoas and, on the remaining knee flexion, a correction of 5° after intramuscular lengthening of the anterior rectus at the proximal level. Both the sequence of proposed gestures and those that form separately, showed statistically significant differences (P <0.001) in the correction of the deformity. In conclusion, the proposed techniques applied sequentially or separately are effective in reducing knee flexion in predominantly spastic cerebral palsy, facilitating or even being able to avoid the treatment that is directly needed.
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Patel RM, Gombosh M, Polster J, Andrish J. Patellar Tendon Imbrication Is a Safe and Efficacious Technique to Shorten the Patellar Tendon in Patients With Patella Alta. Orthop J Sports Med 2020; 8:2325967120959318. [PMID: 33195712 PMCID: PMC7605011 DOI: 10.1177/2325967120959318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/11/2020] [Indexed: 01/17/2023] Open
Abstract
Background Patella alta has been noted to be a risk factor for recurrent patellar instability. Purpose We conducted a radiographic study to determine whether a patellar tendon imbrication technique normalizes patellar height as well as whether the shortened length is maintained at a minimum 2-year follow-up. Study Design Case series; Level of evidence, 4. Methods A total of 54 consecutive patients were identified after a retrospective chart review was performed on patients who underwent patellar tendon imbrication between 2008 and 2013. Preoperative, 3 weeks postoperative, and minimum 2 years postoperative lateral radiographs were analyzed using Insall-Salvati (IS), Blackburne-Peel (BP), and Caton-Deschamps (CD) indices to determine the amount of shortening that was achieved after the procedure and to what degree that shortening was maintained at a minimum 2-year follow-up. Results A total of 27 patients (32 knees) completed a minimum 2-year follow-up. The mean patellar tendon length preoperatively was 6.1 cm (range, 5-8 cm). At 3 weeks and 2 years, the mean tendon lengths were 5.1 and 5.2 cm, respectively. Thus, the mean ± SD change in patellar tendon length from preoperative to 3 weeks postoperative was 0.97 ± 0.67 cm. IS, BP, and CD ratios had minimal change (loss of correction) from 3-week to 2-year follow-up; the delta values were 0.04, -0.03, and 0.09, respectively. There were no complications directly related to the technique. Conclusion Patellar tendon imbrication is a safe and effective procedure to correct patella alta in the setting of lateral patellar instability. On average, the technique allowed 1 cm of patellar tendon shortening and maintained the correction at a minimum 2-year follow-up. In the skeletally immature patient, this technique allows correction of patella alta by avoidance of a tibial tuberosity osteotomy.
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Affiliation(s)
- Ronak M Patel
- Illinois Center for Orthopaedic Research and Education, Hinsdale Orthopaedic Associates, Westmont, Illinois, USA
| | - Michael Gombosh
- South Florida International Orthopaedics, Miami, Florida, USA
| | - Joshua Polster
- Sports Health, The Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
| | - Jack Andrish
- Sports Health, The Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
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15
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Screw Anterior Distal Femoral Hemiepiphysiodesis in Children With Cerebral Palsy and Knee Flexion Contractures: A Retrospective Case-control Study. J Pediatr Orthop 2020; 40:e873-e879. [PMID: 32658158 DOI: 10.1097/bpo.0000000000001634] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In children with cerebral palsy who demonstrate hamstring tightness, increasing attention is being paid to less invasive methods of correcting knee flexion contractures. Guided growth principles represent one such approach, and in tandem with a serial extension casting protocol, may provide a less invasive method of addressing these contractures. To date, no evidence is available on this combination of procedures. The purpose of this study was to investigate the effectiveness of a combined lengthening/guided growth procedure (hamstring lengthening, percutaneous anterior screw hemiepiphysiodesis, and serial extension casting) in addressing knee flexion contracture, and to compare this approach to hamstring lengthening and serial extension casting alone. METHODS Measures from preoperative and postoperative gait analyses were reviewed retrospectively for 10 patients with cerebral palsy who underwent anterior screw hemiepiphysiodesis and hamstring lengthening followed by serial extension casting [anterior epiphysiodesis (AE) group]. These findings were compared with measures from 19 patients with cerebral palsy who underwent hamstring lengthening followed by serial extension casting [no anterior epiphysiodesis (NAE) group]. Postoperative changes in clinical, functional, and kinematic parameters were assessed. Radiographic parameters were also assessed for the AE group. RESULTS In the AE group, improvements were measured in knee contracture, popliteal angle, peak stance phase knee extension, knee range of motion, and Gait Deviation Index. Similar results were observed in the NAE group. In the AE group, the lateral distal femoral angle increased into extension by 20.9 degrees at an average of 26-month follow-up. Both groups showed an increase in pelvic tilt postoperatively. There were no surgical complications associated with the screw anterior hemiepiphysiodesis. Four patients did have complaints of knee pain, but the pain was attributable to the implants in only one patient. DISCUSSION The AE group demonstrated statistically greater postoperative improvement in popliteal angle, knee flexion contracture, and peak knee extension during stance than the NAE group. Both procedures led to improvements in clinical and functional measures, indicating the validity of this approach as a means of correcting flexion contracture that is less invasive and allows immediate weight bearing. LEVEL OF EVIDENCE Level III-therapeutic study.
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Abstract
BACKGROUND Outcomes after orthopaedic interventions in patients with dystonic cerebral palsy (DCP) are historically regarded as unpredictable. This study aims to evaluate the overall outcome of orthopaedic surgery in children with DCP. METHOD Children with DCP who underwent lower limb orthopaedic surgery with a minimum follow-up of 12 months were included. Data collected included age at time of surgery, surgical procedures performed, Gross Motor Function Classification System (GMFCS) level, and Barry Albright Dystonia Scale (BADS) score. The cohort was divided into 2 groups. Group 1 (GMFCS levels I to III), mean age 12 years 7 months and group 2 (GMFCS levels IV to V), mean age 10 years 7 months. Group 1 had surgery aimed at deformity correction to improve gait and mobility, and group 2 for the management or prevention of hip displacement. Outcome measures analyzed were: the incidence of unpredictable results related to surgery and early recurrence of deformity in both groups. Functional mobility scale scores were evaluated for group 1 and hip migration percentage for group 2. Linear mixed models were used to take into account repeated measures over time and correlations between measurements from the same patient. RESULTS Group 1 (n=18); had low BADS scores and were considered to have mild dystonia. Three children experienced unpredictable results, 2 had early recurrence of deformity, 3 had a decline, and 1 child improved in the functional mobility scale.Group 2 (n=19); had high BADS scores and were considered to have moderate to severe dystonia. Nine surgical events involved bony procedures and 15 were soft tissue surgery only. One surgical event lead to unpredictable results and 2 children had early recurrence of deformity. Postoperatively, a linear trend of increasing migration percentage [0.49% (95% confidence interval, 0.23-0.74; P=0.0002)] was seen up to 21 months. There was no significant change after 21 months [-0.08% (95% confidence interval, -0.24 to +0.041; P=0.18)]. CONCLUSIONS This study suggests that unpredictable results and early recurrence of deformity following orthopaedic surgery in children with DCP are not as common as previously regarded. Furthermore, functional mobility and hip morphology can be improved. LEVEL OF EVIDENCE Level IV-this is a case-series.
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18
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Abstract
Two common knee problems in cerebral palsy are increased knee flexion during stance phase and reduced knee flexion during the swing phase of gait. We reviewed the recent literature and based on that, we formed this review. Hamstring spasticity, quadriceps weakness, soleus weakness, and lever-arm dysfunction are few factors which lead to increased knee flexion during stance phase. Rectus spasticity diminishes knee flexion in the swing. Resulting gait-stiff knee gait interferes with ground clearance. Both gait patterns result into esthetically poor gait and increased energy consumption. Knee flexion gait may lead to pain in the knee. Natural history of knee flexion gait suggests deterioration over time. In the early stage, these gait abnormalities are managed by nonoperative treatment. Cases in which nonoperative measures fail or advance cases need surgical treatment. Various variables which are taken into consideration before selecting a particular treatment option are described. We also present an algorithm for decision-making. Nonsurgical options and surgical procedures are discussed.
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Affiliation(s)
- Dhiren Ganjwala
- Department of Pediatric Orthopedics, Ganjwala Orthopaedic Hospital, Ahmedabad, Gujarat, India,Address for correspondence: Dr. Dhiren Ganjwala, Ganjwala Orthopaedic Hospital, Ahmedabad, Gujarat, India. E-mail:
| | - Hitesh Shah
- Department of Pediatric Orthopedics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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19
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Stiel N, Babin K, Vettorazzi E, Breyer S, Ebert N, Rupprecht M, Stuecker R, Spiro AS. Anterior distal femoral hemiepiphysiodesis can reduce fixed flexion deformity of the knee: a retrospective study of 83 knees. Acta Orthop 2018; 89:555-559. [PMID: 29902104 PMCID: PMC6202731 DOI: 10.1080/17453674.2018.1485418] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Fixed knee flexion deformity in children is a common problem in various diseases including myelomeningocele and cerebral palsy. Until now, only a few studies focusing on the surgical procedure of anterior distal femoral hemiepiphysiodesis have been published. We analyzed outcome and correction rate in the largest case series to date of patients treated by staples or 8-plates. Patients and methods - We reviewed the medical records of all patients with fixed knee flexion deformity who were treated with anterior distal femoral hemiepiphysiodesis using either staples or 8-plates between the years 2002 and 2017 (73 patients; 130 knees). 49 patients (83 knees) had completed treatment with implant removal at the time of full correction of the deformity or at skeletal maturity and were included. The average age at operation was 12 years (6-20). Patients were assigned to 3 different groups based on their diagnosis: cerebral palsy, myelomeningocele, and the "other" group.d Results - Mean fixed knee flexion deformity improved from 21° (10-60°) to 8° (0-50°) (p < 0.001) with an average correction rate of 0.44° per month (range -2.14° to 1.74°). The correction rate per month was lowest for patients with cerebral palsy (0.20°), followed by the myelomeningocele group (0.50°), and the "other" group (0.58°). Implant loosening occurred in 10% of the treated knees with consecutive re-implantation in 5% of the cases. Interpretation - Anterior distal femoral hemiepiphysiodesis is an effective and safe method for the treatment of fixed knee flexion deformity in children. The optimal timing depends on the remaining individual growth potential, the underlying disease, and the extent of the deformity.
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Affiliation(s)
- Norbert Stiel
- Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Hamburg, Germany; ,Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
| | - Kornelia Babin
- Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Hamburg, Germany; ,Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Breyer
- Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Hamburg, Germany; ,Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
| | - Nicola Ebert
- Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Hamburg, Germany; ,Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
| | - Martin Rupprecht
- Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Hamburg, Germany; ,Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
| | - Ralf Stuecker
- Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Hamburg, Germany; ,Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
| | - Alexander S Spiro
- Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Hamburg, Germany; ,Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; ,Correspondence:
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20
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Dynamic spasticity determines hamstring length and knee flexion angle during gait in children with spastic cerebral palsy. Gait Posture 2018; 64:255-259. [PMID: 29960141 DOI: 10.1016/j.gaitpost.2018.06.163] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/01/2018] [Accepted: 06/24/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Previous researchers reported that popliteal angle did not correlate well with knee angle during gait in individuals with spastic cerebral palsy (CP). RESEARCH QUESTION To determine if hamstring spasticity, as measured by Modified Tardieu Scale (MTS) at rest, is associated with knee flexion angle at initial contact and midstance during gait. METHODS Thirty ambulatory children (mean age 8.7 ± 2.4 years) diagnosed with spastic CP participated. The hamstrings' spasticity was assessed in the supine position with the MTS, measuring R1 (muscle reaction to passive fast stretch), R2 (passive range of motion), and R2-R1 (dynamic component of spasticity). We conducted 3-dimensional computerized gait analysis and calculated semimembranosus muscle-tendon length and lengthening velocity during gait using musculoskeletal modeling and inverse kinematic analysis by OpenSim. Pearson correlation coefficients were calculated to estimate the association of MTS with biomechanical parameters during gait. RESULTS Knee flexion angle at initial contact and maximal knee extension angle during stance phase significantly positively correlated with both R1 and ㅣR2 - R1ㅣ of MTS, but not with R2 angle. The length of semimembranosus at initial contact, end of swing, and minimal length during stance phase were strongly negatively associated with R1, rather than R2 or ㅣR2 - R1ㅣ angles. SIGNIFICANCE The R1 angle of MTS (muscle reaction to passive fast stretch) is more relevant correlate of knee flexion angle during gait than the R2 (passive range of motion).
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21
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Pulido-Valdeolivas I, Gómez-Andrés D, Martín-Gonzalo JA, Rodríguez-Andonaegui I, López-López J, Pascual-Pascual SI, Rausell E. Gait phenotypes in paediatric hereditary spastic paraplegia revealed by dynamic time warping analysis and random forests. PLoS One 2018. [PMID: 29518090 PMCID: PMC5843164 DOI: 10.1371/journal.pone.0192345] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The Hereditary Spastic Paraplegias (HSP) are a group of heterogeneous disorders with a wide spectrum of underlying neural pathology, and hence HSP patients express a variety of gait abnormalities. Classification of these phenotypes may help in monitoring disease progression and personalizing therapies. This is currently managed by measuring values of some kinematic and spatio-temporal parameters at certain moments during the gait cycle, either in the doctor´s surgery room or after very precise measurements produced by instrumental gait analysis (IGA). These methods, however, do not provide information about the whole structure of the gait cycle. Classification of the similarities among time series of IGA measured values of sagittal joint positions throughout the whole gait cycle can be achieved by hierarchical clustering analysis based on multivariate dynamic time warping (DTW). Random forests can estimate which are the most important isolated parameters to predict the classification revealed by DTW, since clinicians need to refer to them in their daily practice. We acquired time series of pelvic, hip, knee, ankle and forefoot sagittal angular positions from 26 HSP and 33 healthy children with an optokinetic IGA system. DTW revealed six gait patterns with different degrees of impairment of walking speed, cadence and gait cycle distribution and related with patient's age, sex, GMFCS stage, concurrence of polyneuropathy and abnormal visual evoked potentials or corpus callosum. The most important parameters to differentiate patterns were mean pelvic tilt and hip flexion at initial contact. Longer time of support, decreased values of hip extension and increased knee flexion at initial contact can differentiate the mildest, near to normal HSP gait phenotype and the normal healthy one. Increased values of knee flexion at initial contact and delayed peak of knee flexion are important factors to distinguish GMFCS stages I from II-III and concurrence of polyneuropathy.
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Affiliation(s)
- Irene Pulido-Valdeolivas
- Department of Anatomy, Histology and Neuroscience, TRADESMA-IdiPaz Universidad Autónoma de Madrid, Madrid, Spain
- Center of Neuroimmunology and Service of Neurology, Institute of Biomedical Research "August Pi Sunyer", Hospital Clinic of Barcelona, Universidad de Barcelona, Barcelona, Spain
- * E-mail: (ER); (IPV)
| | - David Gómez-Andrés
- Department of Anatomy, Histology and Neuroscience, TRADESMA-IdiPaz Universidad Autónoma de Madrid, Madrid, Spain
- Child Neurology Unit Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Reçerca, Barcelona, Spain
| | - Juan Andrés Martín-Gonzalo
- Department of Anatomy, Histology and Neuroscience, TRADESMA-IdiPaz Universidad Autónoma de Madrid, Madrid, Spain
- School of Physiotherapy ONCE, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Javier López-López
- Department of Anatomy, Histology and Neuroscience, TRADESMA-IdiPaz Universidad Autónoma de Madrid, Madrid, Spain
- Department of Physical Medicine and Rehabilitation, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Samuel Ignacio Pascual-Pascual
- Department of Child Neurology, Hospital Universitario La Paz, TRADESMA-IdiPaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Estrella Rausell
- Department of Anatomy, Histology and Neuroscience, TRADESMA-IdiPaz Universidad Autónoma de Madrid, Madrid, Spain
- * E-mail: (ER); (IPV)
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Matsuda M, Mataki Y, Mutsuzaki H, Yoshikawa K, Takahashi K, Enomoto K, Sano K, Mizukami M, Tomita K, Ohguro H, Iwasaki N. Immediate effects of a single session of robot-assisted gait training using Hybrid Assistive Limb (HAL) for cerebral palsy. J Phys Ther Sci 2018; 30:207-212. [PMID: 29545679 PMCID: PMC5851348 DOI: 10.1589/jpts.30.207] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/02/2017] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Robot-assisted gait training (RAGT) using Hybrid Assistive Limb (HAL,
CYBERDYNE) was previously reported beneficial for stroke and spinal cord injury patients.
Here, we investigate the immediate effect of a single session of RAGT using HAL on gait
function for cerebral palsy (CP) patients. [Subjects and Methods] Twelve patients (average
age: 16.2 ± 7.3 years) with CP received a single session of RAGT using HAL. Gait speed,
step length, cadence, single-leg support per gait cycle, hip and knee joint angle in
stance, and swing phase per gait cycle were assessed before, during, and immediately after
HAL intervention. [Results] Compared to baseline values, single-leg support per gait cycle
(64.5 ± 15.8% to 69.3 ± 12.1%), hip extension angle in mid-stance (149.2 ± 19.0° to 155.5
± 20.1°), and knee extension angle in mid-stance (137.6 ± 20.2° to 143.1 ± 19.5°) were
significantly increased immediately after intervention. Further, the knee flexion angle in
mid-swing was significantly decreased immediately after treatment (112.0 ± 15.5° to 105.2
± 17.1°). Hip flexion angle in mid-swing also decreased following intervention (137.2 ±
14.6° to 129.7 ± 16.6°), but not significantly. Conversely, gait speed, step length, and
cadence were unchanged after intervention. [Conclusion] A single-time RAGT with HAL
improved single-leg support per gait cycle and hip and knee joint angle during gait,
therapeutically improving gait function in CP patients.
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Affiliation(s)
- Mayumi Matsuda
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital:4733 Ami, Ibaraki 300-0331, Japan.,Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences, Japan
| | - Yuki Mataki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences Hospital, Japan
| | - Hirotaka Mutsuzaki
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences, Japan.,Center for Medical Science, Ibaraki Prefectural University of Health Sciences, Japan
| | - Kenichi Yoshikawa
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital:4733 Ami, Ibaraki 300-0331, Japan
| | - Kazushi Takahashi
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital:4733 Ami, Ibaraki 300-0331, Japan
| | - Keiko Enomoto
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital:4733 Ami, Ibaraki 300-0331, Japan
| | - Kumiko Sano
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital:4733 Ami, Ibaraki 300-0331, Japan
| | - Masafumi Mizukami
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences, Japan.,Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Japan
| | - Kazuhide Tomita
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences, Japan.,Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Japan
| | - Haruka Ohguro
- Department of Pediatrics, Ibaraki Prefectural University of Health Sciences Hospital, Japan
| | - Nobuaki Iwasaki
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences, Japan.,Center for Medical Science, Ibaraki Prefectural University of Health Sciences, Japan.,Department of Pediatrics, Ibaraki Prefectural University of Health Sciences Hospital, Japan
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Ling KK, Yiu CAK, Hay MAK, Miu LML, Chi CNN, Leung KT. Correction of Combined Flexed and Stiff Knee Gait in Spastic Diplegic Cerebral Palsy by Double Tendon Transfers around the Knee as Part of Multilevel Surgery. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2017. [DOI: 10.1016/j.jotr.2016.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background/Purpose Flexed knee gait and stiff knee gait are common coexisting gait disturbances in children with cerebral palsy. We analyzed the effect of medial hamstring transfer and distal rectus transfer around the knee as part of multi-level surgery for this group of patient. Methods Eleven lower limbs of six patients who received double transfer were retrospectively studied. Instrumented gait analysis were carried out before and a minimum of 2 years after operation. Results Comparing the kinematic study before and after the operation, maximum knee extension in stance phase (MKES), total knee swing (TKS) and the time to maximum knee flexion in swing phase (TMKFS) showed statistically significant improvement (p <0.05). Hip extension in swing phase and hip extension power were maintained. The oxygen consumption during walking also decreased after operation (p <0.05). Conclusion Double transfer around the knee can improve both flexed knee gait and stiff knee gait, without causing significant hip extension weakness.
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Affiliation(s)
- Kung Kam Ling
- Department of Orthopaedics & Traumatology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | | | - Ma Arthur King Hay
- Department of Orthopaedics & Traumatology, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Lao Miko Lai Miu
- Department of Physiotherapy, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | | | - Kwun Tung Leung
- Department of Orthopaedics & Traumatology, Tuen Mun Hospital, Tuen Mun, Hong Kong
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Abstract
Orthopedic surgery (OS) plays an important role in the management of cerebral palsy (CP). The objectives of OS are to optimize functions and prevent deformity. Newer developments in OS for CP include emphasis on hip surveillance, minimally invasive procedures, use of external fixators instead of plates and screws, better understanding of lever arm dysfunctions (that can only be corrected by bony OS), orthopedic selective spasticity-control surgery, and single-event multilevel lever arm restoration and anti spasticity surgery, which have led to significant improvements in gross motor function and ambulation, especially in spastic quadriplegia, athetosis, and dystonia. The results of OS can be dramatic and life altering for the person with CP and their caregivers if it is performed meticulously by a specialized surgical team, at the appropriate age, for the correct indications, employing sound biomechanical principles and is followed by physician-led, protocol based, intensive, multidisciplinary, institutional rehabilitation, and long term followup. However, OS can be a double-edged sword, and if performed less than optimally, and without the supporting multidisciplinary medical and rehabilitation team, expertise and infrastructure, it often leads to significant functional worsening of the person with CP, including irretrievable loss of previous ambulatory capacity. OS must be integrated into the long term management of the person with CP and should be anticipated and planned at the optimal time and not viewed as a "last resort" intervention or failure of rehabilitation. This instructional course lecture reviews the relevant contemporary principles and techniques of OS in CP.
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Affiliation(s)
- Deepak Sharan
- Department of Pediatric Orthopedics and Rehabilitation, RECOUP Neuromusculoskeletal Rehabilitation Centre, Bengaluru, Karnataka, India,Address for correspondence: Dr. Deepak Sharan, Department of Pediatric Orthopedics and Rehabilitation, RECOUP Neuromusculoskeletal Rehabilitation Centre, 312, Further Extension of Anjanapura Layout, 10th Block, Bengaluru - 560 108, Karnataka, India. E-mail:
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25
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The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy. J Pediatr Orthop B 2016; 25:543-50. [PMID: 27392300 DOI: 10.1097/bpb.0000000000000370] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Crouched gait is common in children with cerebral palsy (CP), and there are various treatment options. This study evaluated the effectiveness of single-event multilevel surgery including posterior knee capsulotomy or distal femoral extension osteotomy to correct knee flexion contracture in children with CP. Gait analyses were carried out to evaluate gait preoperatively and postoperatively. Significant improvements were found in physical examination and kinematic measures, which showed that children with CP and crouched gait who develop knee flexion contractures can be treated effectively using single-event multilevel surgery including a posterior knee capsulotomy or distal femoral extension osteotomy.
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26
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Muhly WT, Gurnaney HG, Ganesh A. Regional anesthesia for pediatric knee surgery: a review of the indications, procedures, outcomes, safety, and challenges. Local Reg Anesth 2015; 8:85-91. [PMID: 26609245 PMCID: PMC4644165 DOI: 10.2147/lra.s73458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The indications for surgery on the knee in children and adolescents share some similarity to adult practice in that there are an increasing number of sports-related injuries requiring surgical repair. In addition, there are some unique age-related conditions or congenital abnormalities that may present as indications for orthopedic intervention at the level of the knee. The efficacy and safety of peripheral nerve blocks (PNBs) for postoperative analgesia following orthopedic surgery has been well established in adults. Recent studies have also demonstrated earlier functional recovery after surgery in patients who received PNBs. In children, PNB is gaining popularity, and increasing data are emerging to demonstrate the feasibility, efficacy, and safety in this population. In this paper, we will review some of the most common indications for surgery involving the knee in children and the anatomy of knee, associated dermatomal and osteotomal innervation, and the PNBs most commonly used to produce analgesia at the level of the knee. We will review the evidence in support of regional anesthesia in children in terms of both the quality conferred to the immediate postoperative care and the role of continuous PNBs in maintaining effective analgesia following discharge. Also we will discuss some of the subtle challenges in utilizing regional anesthesia in the pediatric patient including the use of general anesthesia when performing regional anesthesia and the issue of monitoring for compartment syndrome. Finally, we will offer some thoughts about areas of practice that are in need of further investigation.
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Affiliation(s)
- Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, USA
| | - Harshad G Gurnaney
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, USA
| | - Arjunan Ganesh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, USA
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27
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Sossai R, Vavken P, Brunner R, Camathias C, Graham HK, Rutz E. Patellar tendon shortening for flexed knee gait in spastic diplegia. Gait Posture 2015; 41:658-65. [PMID: 25701014 DOI: 10.1016/j.gaitpost.2015.01.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 01/14/2015] [Accepted: 01/18/2015] [Indexed: 02/02/2023]
Abstract
UNLABELLED We evaluated the outcome of three different approaches to the management of flexed knee gait patients with spastic diplegia. The three surgical procedures were patellar tendon shortening (PTS), PTS combined with rotational osteotomies of the femur and/or tibia, and PTS combined with supracondylar extension osteotomy (SEO) of the distal femur. The primary outcome measure was gait kinematics. The knee gait variable score (GVS) and the gait profile score (GPS) were derived from gait kinematics. 24 patients (16 male and 8 female), mean age 16.1 years (SD 5.8 years), who had surgery between 2002 and 2008, were followed for a mean of 22 months. Knee extension during gait improved by a mean of 20° throughout the gait cycle, with an improvement in the knee GVS of 14° (p<0.001). The overall gait pattern improved with a mean decrease in GPS of 4.6°. Correction of patella alta was demonstrated by an improvement in the Koshino index from 1.34 pre-operatively to 1.10 post-operatively (p<0.001). Knee and gait kinematics, physical examination measures and Koshino Index improved in all three surgical groups, suggesting that a tailored approach to the correction of flexed knee gait in spastic diplegia is both feasible and appropriate. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Roberto Sossai
- Pediatric Orthopaedic Department, University Children's Hospital, UKBB, Basle, Switzerland.
| | - Patrick Vavken
- Pediatric Orthopaedic Department, University Children's Hospital, UKBB, Basle, Switzerland; Orthopaedic Department, University Hospital Basle, Switzerland; Department of Orthopaedic Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
| | - Reinald Brunner
- Pediatric Orthopaedic Department, University Children's Hospital, UKBB, Basle, Switzerland
| | - Carlo Camathias
- Pediatric Orthopaedic Department, University Children's Hospital, UKBB, Basle, Switzerland
| | - H Kerr Graham
- Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia; The University of Melbourne, Melbourne, Victoria, Australia
| | - Erich Rutz
- Pediatric Orthopaedic Department, University Children's Hospital, UKBB, Basle, Switzerland; Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
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28
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Quantification of patellar tendon shortening in a patient with cerebral palsy. J Appl Biomater Funct Mater 2014; 12:57-63. [PMID: 22798243 DOI: 10.5301/jabfm.2012.9251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In the last few years the use of patellar tendon shortening procedure appears to give good results for the treatment of crouch gait in Cerebral Palsy (CP) patients. It offers a secondary approach in cases where conventional hamstrings lengthening failed. The evidence for the effectiveness of knee extensor shortening is poor and only one study quantitatively assessed the effects of this technique performed in addition to other procedures in CP patients. In this case study we used Gait Analysis (GA) to quantify the effects of patellar tendon shortening for the management of crouch gait persisting after hamstring lengthening. METHODS Crouch persisted seven years after a first multilevel procedure including hamstring lengthening in a 15-year old male. Gait was assessed over time (before and from six to 18 months after knee extensor shortening) with Gait Analysis (GA). RESULTS Before treatment the patient walked slowly and with a high duration stance phase; sagittal kinematics revealed excessive hip and knee flexion and ankle dorsiflexion during the whole gait cycle. After surgery, data showed progressive significant improvements at all lower limb levels during the follow-ups considered; gait became more physiologic and lower limb joint kinematics improved overall. CONCLUSIONS The results demonstrated that addressing the other side and shortening the antagonists may be a valuable option to treat crouch gait in patients with CP especially if this persists after hamstring and knee extension surgery.
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Adair B, Said CM, Rodda J, Morris ME. Psychometric properties of functional mobility tools in hereditary spastic paraplegia and other childhood neurological conditions. Dev Med Child Neurol 2012; 54:596-605. [PMID: 22524640 DOI: 10.1111/j.1469-8749.2012.04284.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To evaluate studies on the psychometric properties of measurement tools used to quantify functional mobility in children with hereditary spastic paraplegia (HSP) and other childhood neurological conditions. METHOD Two independent reviewers identified measures previously used by clinicians to quantify functional mobility. Because our primary interest was HSP, the first search identified measurement tools in studies that included those with HSP. To enhance the generalizability, the second search examined the reliability, validity, and responsiveness of tools in children with a range of neurological conditions such as cerebral palsy, spinal muscular atrophy, Down syndrome, and traumatic brain injury. The Consensus-based Standards for the Selection of Health Measurement Instruments was used to rate the methodological quality of identified articles. RESULTS The Gillette Functional Assessment Questionnaire (FAQ), the Functional Mobility Scale (FMS), the Gross Motor Function Measure (GMFM), the Rivermead Motor Assessment, and the Walking Index for Spinal Cord Injury II were identified for quantifying functional mobility. The FMS and GMFM were reliable, valid, and responsive to changes across a range of childhood neurological conditions. The FAQ was reliable and valid for measuring functional mobility in similar populations. INTERPRETATION The FAQ, FMS, and GMFM are valid, reliable, and responsive measures in children with a range of neurological conditions.
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Affiliation(s)
- Brooke Adair
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
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Dagge B, Firth GB, Palamara JEA, Eizenberg N, Donath S, Graham HK. Biomechanics of medial hamstring lengthening. ANZ J Surg 2012; 82:355-61. [DOI: 10.1111/j.1445-2197.2012.06030.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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