The increase of anterior pelvic tilt after semitendinosus transfer to distal femur in patients with spastic diplegic cerebral palsy

Pelvic Tilt in Adults With Cerebral Palsy and Its Relationship With Prior Hamstrings Lengthening

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.].

Anterior Distal Femoral Hemiepiphysiodesis Does Not Change Pelvic Tilt in Children With Cerebral Palsy

BACKGROUND

Anterior distal femoral hemiepiphysiodesis (ADFH) is a surgical treatment choice to correct flexed knee gait and fixed knee flexion deformities in children with cerebral palsy who are skeletally immature. Increased anterior pelvic tilt has been reported after surgeries that correct knee flexion deformities, including hamstring lengthening (HSL) and distal femoral extension osteotomies, but anterior pelvic tilt has not been studied after ADFH. We hypothesized that anterior pelvic tilt would increase after ADFH, especially when combined with HSL, and it would correlate with the change in minimum knee flexion in stance and dynamic hamstring lengths.

METHODS

Thirty-four eligible participants (age: 13.0, SD: 2.0) were included. Change in mean pelvic tilt across the gait cycle was compared as a function of clinical and gait parameters using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation.

RESULTS

Overall, anterior pelvic tilt increased significantly after ADFH by 4.4 degrees ( P = 0.02). Further, the analysis revealed anterior pelvic tilt only increased significantly in the group that had concurrent HSL (11.1 degrees, P < 0.001). Overall, minimum knee flexion significantly decreased (increase in knee extension) in stance (-19.1 degrees, P < 0.001) and there was an increase in maximum normalized dynamic hamstring lengths (0.03, P < 0.001). The anterior pelvic tilt increased significantly in Gross Motor Function Classification System levels III to IV (5.9 degrees, P = 0.02) but did not change significantly in Gross Motor Function Classification System I to II (2.5 degrees, P = 0.37). Change in pelvic tilt was correlated with change in maximum dynamic hamstring lengths ( r = 0.87, P < 0.0001) and change in minimum knee flexion in stance ( r = -0.71, P < 0.0001).

CONCLUSIONS

Anterior distal hemiepiphysiodesis without concurrent HSL for flexion knee deformities does not result in increased anterior pelvic tilt. Surgeons should consider anterior distal hemiepiphysiodesis in patients with cerebral palsy and flexed knee gait, who preoperatively have long dynamically modeled hamstrings, are skeletally immature, and when maintenance of pelvic tilt is desired.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Mid-Term Results of Distal Femoral Extension and Shortening Osteotomy in Treating Flexed Knee Gait in Children with Cerebral Palsy

Background: Distal femoral extension and shortening osteotomy (DFESO) seems to be an effective method for the treatment of flexed knee gait in children with cerebral palsy. Nevertheless, studies investigating the mid- and long-term outcomes after such procedures are lacking in the literature. Therefore, the purpose of this study was to assess the mid-term outcomes regarding sagittal plane kinematics of the knee after DFESO with or without concomitant patella advancement. Furthermore, an evaluation of the postoperative course and possible recurrence of flexed knee gait was planned. Methods: In a prospective observational study, 19 patients (28 limbs; mean age 11.8 years (6.7–16.0 years)) were examined using 3-D gait analysis and clinical exam before (E₀) and at a mean of 38 months (E₂: 24–55 months) after surgery. Fifteen patients (22 limbs) had an additional first postoperative gait analysis (E₁) after a mean of 14 (10–20) months after surgery. In these patients, the postoperative changes between the short-term and mid-term gait analyses were evaluated. Results: DFESO led to a significant decrease in flexed knee gait with an improvement in sagittal plane kinematics during the stance phase. In addition, a slightly increased anterior pelvic tilt was observed at E₁, and we found a tendency towards stiff knee gait with a decrease in mean knee flexion in swing at E₂. Conclusions: DFESO led to a significant improvement in flexed knee gait in children with cerebral palsy. The therapeutic effect seems to be lasting on mid-term follow-up with a slight overall tendency to recurrence.

Finding consensus for hamstring surgery in ambulatory children with cerebral palsy using the Delphi method

PURPOSE

There is marked variation in indications and techniques for hamstring surgery in children with cerebral palsy. There is particular uncertainty regarding the indications for hamstring transfer compared to traditional hamstring lengthening. The purpose of this study was for an international panel of experts to use the Delphi method to establish consensus indications for hamstring surgery in ambulatory children with cerebral palsy.

METHODS

The panel used a five-level Likert-type scale to record agreement or disagreement with statements regarding hamstring surgery, including surgical indications and techniques, post-operative care, and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither of these thresholds was reached.

RESULTS

The panel reached consensus or general agreement for 38 (84%) of 45 statements regarding hamstring surgery. The panel noted the importance of assessing pelvic tilt during gait when considering hamstring surgery, and also that lateral hamstring lengthening is rarely needed, particularly at the index surgery. They noted that repeat hamstring lengthening often has poor outcomes. The panel was divided regarding hamstring transfer surgery, with only half performing such surgery.

CONCLUSION

The results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy.

LEVEL OF EVIDENCE

level V.

Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review

AIM

To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework.

METHOD

This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework.

RESULTS

Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%).

INTERPRETATION

The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.

Crouch gait or flexed-knee gait in cerebral palsy: Is there a difference? A systematic review

BACKGROUND

Crouch or flexed-knee gait is one of the most common pathological gait patterns in cerebral palsy (CP). Differences exist in definitions used; the degree of knee flexion, inclusion of hip or ankle position, and timing in the gait cycle. This ambiguity may be responsible for variations in prevalence rates and difficulty comparing data across studies.

RESEARCH QUESTION

What are the kinematic parameters used to define crouch or flexed-knee gait in CP gait? A secondary aim was to examine the quality of data reporting, focusing on the sample characteristics, inclusion/exclusion criteria and the choice of limb included for analysis.

METHODS

Articles included in this review reported on a specified cohort of adults or children with crouch or flexed-knee gait assessed with 3-dimensional gait analysis. A customised data extraction and quality assessment table was designed specific to the research question.

RESULTS

The majority (75 %) of included studies used the term crouch gait. Where the pattern was defined, 80 % of crouch papers and 94 % of flexed-knee gait papers based this solely on knee position. Kinematic parameters were clearly defined when they provided objective values of knee flexion, supported this with rationale and provided a reference point in the gait cycle. Only 22 % of crouch papers and 19 % of flexed-knee gait papers provided this information. The majority of studies (67 % crouch; 90 % flexed-knee) specified which limb(s) were included for analysis with the majority including both limbs. Objective values of knee flexion ranged from 8 o to 30 o.

SIGNIFICANCE

This review highlights that crouch and flexed knee are synonymous and ambiguity exists in the kinematic definition making it difficult to make compare data amongst study cohorts. Future research should provide detailed definitions including the threshold value of knee flexion, how it was derived, the timing in the gait cycle and the limb(s) included in analysis.