Kinematics after unilateral femoral derotation osteotomy in children with diplegic cerebral palsy

Predictors of Changes in Pelvic Rotation after Surgery with or without Femoral Derotational Osteotomy in Ambulatory Children with Cerebral Palsy

Asymmetry of pelvic rotation affects function. However, predicting the post-operative changes in pelvic rotation is difficult as the root causes are complex and likely multifactorial. This retrospective study explored potential predictors of the changes in pelvic rotation after surgery with or without femoral derotational osteotomy (FDRO) in ambulatory children with cerebral palsy (CP). The change in the mean pelvic rotation angle during the gait cycle, pre- to post-operatively, was examined based on the type of surgery (with or without FDRO) and CP distribution (unilateral or bilateral involvement). In unilaterally involved patients, pelvic rotation changed towards normal with FDRO (p = 0.04), whereas patients who did not undergo FDRO showed a significant worsening of pelvic asymmetry (p = 0.02). In bilaterally involved patients, the changes in pelvic rotation did not differ based on FDRO (p = 0.84). Pelvic rotation corrected more with a greater pre-operative asymmetry (β = -0.21, SE = 0.10, p = 0.03). Sex, age at surgery, GMFCS level, and follow-up time did not impact the change in pelvic rotation. For children with hemiplegia, internal hip rotation might cause compensatory deviation in pelvic rotation, which could be improved with surgical correction of the hip. The predicted changes in pelvic rotation should be considered when planning surgery for children with CP.

Assessment of gait quality and efficiency after undergoing a single-event multilevel surgery in children with cerebral palsy presenting an intoeing gait pattern

PURPOSE

The biomechanical impact of undergoing a single-event multilevel surgery (SEMLS) for children with cerebral palsy (CP) presenting an intoeing gait pattern has been widely documented. However, past studies mostly focused on gait quality rather than efficiency. Thus, there is a need to determine the impact of undergoing a SEMLS on gait quality and efficiency in children with CP presenting an intoeing gait pattern.

METHODS

Data from 16 children with CP presenting an intoeing gait pattern who underwent a SEMLS were retrospectively selected. Gait kinematics was quantified before (baseline) and at least 1 year after the surgery (follow-up). Gait quality was investigated with the Gait Profile Score (GPS), hip internal rotation angle and foot progression angle (FPA). Gait efficiency was analysed using clinically accessible variables, namely the normalised gait speed and medio-lateral and vertical centre of mass excursions (COMp). Dependent variables were compared between sessions with paired t-tests.

RESULTS

At the follow-up, children with CP exhibited a more outward FPA and GPS as well as a decreased hip internal rotation angle. No changes in normalised gait speed and vertical COMp excursion were observed, and medio-lateral COMp excursion was slightly decreased.

CONCLUSION

Children with CP presenting an intoeing gait pattern who underwent a SEMLS exhibited an increased gait quality, but gait efficiency was only minimally improved at the follow-up compared to baseline. Further studies are needed to identify contributors of gait efficiency in children with CP, and the best treatment modalities to optimise both their gait quality and efficiency.

Long-term outcomes of hip reconstruction surgery in children with GMFCS III diplegic cerebral palsy

INTRODUCTION

The results of hip reconstruction surgery are known for non-walking (GMFCS IV and V) and walking (GMFCS I and II) patients. Few studies deal with GMFCS III patients in isolation. Their intermediate functional status can be deteriorated by asymmetrical contractures, hip dislocation, multi-level deformities of the lower limbs, leading to motor function degradation, and possibly losing their ability to walk. The aim of our study was to establish whether surgical results were maintained over time and whether the functional status changed.

MATERIAL AND METHODS

Fifteen patients with GMFCS III spastic diplegia, treated for hip subluxation, were reviewed. The mean age at the time of surgery was 10 years old. The mean follow-up after surgery was 11 years. Reconstructive surgery was performed on 21 hips including pelvic osteotomy in all cases, with associated femoral osteotomy in 19 cases. Clinical (pain, joint mobility, walking aids, walking distance, GMFCS level) and radiological data (Melbourne Cerebral Palsy Hip Classification, standard coxometry) were recorded preoperatively and at the last follow-up.

RESULTS

Preoperatively, 6 patients were losing their ability to walk due to pain and flexion-adduction contracture. At the last follow-up, no patients had pain and joint mobility was improved in all cases. For one patient, recovery to their previous functional state required a period of two years. In the long term, 14 patients were GMFCS III and only one patient was GMFCS IV due to reasons unrelated to hip surgery. The radiological parameters improved significantly. The Melbourne score was IV preoperatively for all patients. At the last follow-up, 10 hips were grade I, 6 hips were grade II and 5 hips were grade III.

DISCUSSION

Correction of architectural disorders of the subluxed hip by pelvic osteotomy, in most cases associated with femoral osteotomy, improves functional and radiological status for GMFCS III patients. This improvement is maintained in the long-term. Complementary surgeries correcting the other deformities of the lower limbs were necessary in more than half of the patients.

LEVEL OF EVIDENCE

IV.

Relationship between 3D lower limb bone morphology and 3D gait variables in children with uni and bilateral Cerebral Palsy

BACKGROUND

Medical and surgical interventions to prevent or reduce bone deformities and improve gait in children with cerebral palsy (CP) are based on empirical evidence that there is a relationship between bone deformities and gait deviations.

RESEARCH QUESTION

What is the relationship between tibial-femoral bone morphology and kinematic gait variables in ambulant children with CP?

METHODS

A retrospective analysis was conducted on data from 121 children with uni- (n = 64, mean age 9.9 (SD 3.4) years) and bi- lateral (n = 57, mean age 10.4 (SD 3.6) years) CP who had undergone 3D gait analysis and biplanar X-rays (EOS® system). The limbs were split as DIP (the more impaired limb of children with bilateral CP), HEMI (the impaired limb of unilateral CP) and REF (the unimpaired limb of unilateral CP). Multi-variable Linear Regressions were performed between 23 kinematic variables, the Gait Deviation Index (GDI) and a model composed of nine 3D bone variables for each limb type.

RESULTS

When the whole sample was pooled, 72% of R² values were poor, 16% were fair, and 12% were moderate. Lower limb bone morphology models explained less than 1% of GDI variability. Correlations between tibial-femoral rotational parameters and hip rotation were mostly poor. Mean foot progression angle was the only kinematic parameter that was fairly to moderately correlated with bone variables in the 3 limb types. A tibial-femoral bone model explained 48% of the variability of mean foot progression angle in the REF limbs, 31% in the HEMI limbs and 25% in the DIP limbs.

SIGNIFICANCE

Tibial-femoral bone morphology was only weakly related to kinematic gait variables, in contrast with common clinical assumptions. These results suggest that factors other than bone morphology influence gait quality and thus a thorough clinical examination and gait analysis is required prior to making treatment decisions.

The Effects of Preterm Birth on Musculoskeletal Health-Related Disorders

Preterm birth is associated with various diseases and conditions which demand multidisciplinary medical care. Approximately 10% of all neonates are born prematurely with an increasing survival rate in almost all Western countries. This ongoing, yet desirable trend is creating new challenges for sufficient medical treatment regimens, which should be upheld throughout the patients' lives. Orthopedic surgeons are focused on musculoskeletal disorders and the improvement of patients' ability to cope with the challenges of everyday life. The most common conditions associated with preterm birth are cerebral palsy and a dysregulation of the calcium/phosphorus metabolism, which may lead to fractures. These diseases may vary greatly in their organic manifestation and clinical presentation. This demands multidisciplinary cooperation and parental support. Clinical management is aimed on the early enhancement of a patient's physical, as well as neurological condition, and to prevent the development of secondary musculoskeletal disorders. In this article, we give an overview of the current literature on the most common musculoskeletal disorders associated with preterm birth and critically discuss state of the art diagnostic standards and treatment algorithms.