Does the level of proximal femur rotation osteotomy influence the correction results in patients with cerebral palsy?

The long-term outcome of pelvic asymmetry during gait in children with cerebral palsy following unilateral femoral derotation osteotomy

In this retrospective study, children with cerebral palsy underwent a unilateral femoral derotation osteotomy and had a preoperative (PO), short-term postoperative (1-3 years), and a long-term postoperative (≥5 years) gait analysis. Patients were subdivided into groups by the PO pelvic presentation and Gross Motor Function Classification System level. In children with PO pelvic external rotation, femoral derotation osteotomy decreased the hip internal rotation and decreased the pelvic external rotation. These results could influence surgical planning to achieve long-term pelvic asymmetry.

The effect of the Majestro-Frost procedure on internal hip rotation during gait in patients with cerebral palsy

BACKGROUND

Muscle imbalance is related to persistent internal hip rotation (IHR) after femoral derotation osteotomy (FDO) in cerebral palsy (CP). The aim of this study was to evaluate the effect of the Majestro-Frost soft tissue procedure (MFP), which potentially addresses muscle imbalance, on IHR in CP patients during walking.

METHODS

A retrospective study of an existing database (medical records and gait laboratory data) was conducted and a search was performed using the following inclusion criteria: (1) diagnosis of spastic CP, (2) GMFCS levels I-III; (3) mean IHR during stance phase higher than 11° at baseline; (4) individuals who received single event multilevel orthopedic surgery in the lower limbs and had three-dimensional gait analyses (3DGA) before and after the intervention. Patients who underwent a FDO were excluded. Eighty-three individuals were considered for the study and they were divided into two groups: No MFP (45 patients who did not receive a MFP) and MFP (36 patients who underwent a MFP). A full clinical examination and 3DGA, with kinematics calculated according to a standard software procedure (Plugin Gait), were performed before and after the intervention, and the results were compared.

RESULTS

The studied groups matched regarding demographic data and GMFCS distribution. The mean follow-up time was more than 20 months on both groups. The increase of clinical external hip rotation (EHR) on physical examination was observed only in the MFP group (from 26.4° to 33°, p = 0.002). During gait analysis, IHR decreased from 21.2° to 4.5° in the MFP group (p < 0.001) and from 16.9° to 7.9° in the No MFP group (p < 0.001). The reduction of IHR during gait was more significant in the MFP group (p = 0.001).

SIGNIFICANCE

In the present study, patients who underwent a MFP showed more reduction of IHR during gait than those which did not undergo a MFP.

Correlation between physical examination and three-dimensional gait analysis in the assessment of rotational abnormalities in children with cerebral palsy

Objective

To evaluate the correlation between physical examination data concerning hip rotation and tibial torsion with transverse plane kinematics in children with cerebral palsy; and to determine which time points and events of the gait cycle present higher correlation with physical examination findings.

Methods

A total of 195 children with cerebral palsy seen at two gait laboratories from 2008 and 2016 were included in this study. Physical examination measurements included internal hip rotation, external hip rotation, mid-point hip rotation and the transmalleolar axis angle. Six kinematic parameters were selected for each segment to assess hip rotation and shank-based foot rotation. Correlations between physical examination and kinematic measures were analyzed by Spearman correlation coefficients, and a significance level of 5% was considered.

Results

Comparing physical examination measurements of hip rotation and hip kinematics, we found moderate to strong correlations for all variables (p<0.001). The highest coefficients were seen between the mid-point hip rotation on physical examination and hip rotation kinematics (rho range: 0.48-0.61). Moderate correlations were also found between the transmalleolar axis angle measurement on physical examination and foot rotation kinematics (rho range 0.44-0.56; p<0.001).

Conclusion

These findings may have clinical implications in the assessment and management of transverse plane gait deviations in children with cerebral palsy.

Femoral derotation osteotomy in adults with cerebral palsy

BACKGROUND

Internal rotation gait constitutes a complex gait disorder in bilateral spastic cerebral palsy (BSCP) including static torsional and dynamic components resulting in lever arm dysfunction. Although femoral derotation osteotomy (FDO) is a standard procedure to correct increased femoral anteversion in children, unpredictable outcome has been reported. The effect of FDO when it is done as part of single-event multilevel surgery (SEMLS) in adulthood has not been investigated.

METHODS

In this study mid-term data of 63 adults with BSCP and internal rotation gait, undergoing SEMLS including FDO were analyzed pre- and 1.7 years postoperatively by clinical examination and 3D-instrumented gait analysis. All legs were categorized as the more or less involved side to consider asymmetry. The mean hip rotation in stance preoperatively and the intraoperative derotation was correlated with the difference pre- and postoperatively.

RESULTS

The group as a whole experienced the following results postoperatively: improved mean hip rotation in stance (p=0.0001), mean foot progression angle (p=0.0001) and a significant improvement of the clinical parameter: passive internal and external hip rotation, midpoint and anteversion (p=0.0001) for both legs separately. With regard to the less and more involved side, clinical and kinematic parameters showed comparable significant changes (p=0.0001). The anteversion improved significantly in proximal compared to distal FDO (p=0.03).

CONCLUSION

This study emphasizes an overall good correction of internal rotation gait in adults with bilateral involvement after FDO. However, the results are more predictable in adults compared to studies reporting outcome after FDO in children.

The role of altered proximal femoral geometry in impaired pelvis stability and hip control during CP gait: A simulation study

Children with cerebral palsy (CP) often present aberrant hip geometry, more specifically increased femoral anteversion and neck-shaft angle. Furthermore, altered gait patterns are present within this population. This study analyzed the effect of aberrant femoral geometry, as present in subjects with CP, on the ability of muscles to control hip and knee joint kinematics. Given the specific gait deficits observed during crouch gait, increased ability to abduct, externally rotate the hip and extend the knee and hip were denoted as beneficial effects. We ran dynamic simulations of CP and normal gait using two musculoskeletal models, one reflecting normal femoral geometry and one reflecting proximal femoral deformities. The results show that the combination of aberrant bone geometry and CP-specific gait characteristics beneficially increased the ability of gluteus medius and maximus to extend the hip and knee. In contrast, the potentials of the hamstrings to extend the hip decreased whereas the potentials to flex the knee increased. These changes closely followed the observed changes in the muscle moment arm lengths. In conclusion, this study emphasizes the concomitant effect of the presence of proximal femoral deformity and CP gait characteristics on the muscle control of hip and knee joint kinematics during single stance. Not accounting for subject-specific geometry will affect the calculated muscles' potential during gait. Therefore, the use of generic models to assess muscle function in the presence of femoral deformity and CP gait should be treated with caution.

The effect of femoral derotation osteotomy on transverse plane hip and pelvic kinematics in children with cerebral palsy: a systematic review and meta-analysis

The purpose of this study was to systematically review the current literature to determine the effect of a femoral derotation osteotomy (FDRO) on hip and pelvic rotation kinematics during gait compared to no intervention in children with spastic cerebral palsy (CP). We performed a systematic search for prospective and retrospective cohort studies of children with CP, who were treated with a FDRO, and were assessed with pre and post surgery three-dimensional gait analysis. Medline, CINAHL, EMBASE, the Cochrane Library and Web of Science were searched up to December 2013. Data sources were prospective and retrospective studies. Mean differences were calculated on pooled data for both pelvic and hip rotation kinematics. Thirteen of 196 articles met the inclusion criteria (5 prospective, 8 retrospective). All included studies were of sufficient quality for meta-analysis as assessed using a customised version of the STROBE checklist. Meta-analysis showed that FDRO significantly reduced pelvic retraction by 9.0 degrees and hip internal rotation by 17.6 degrees in participants with unilateral CP involvement and hip internal rotation by 14.3 degrees in participants with bilateral CP involvement. Pelvic symmetry in children with unilateral spastic CP is significantly improved by FDRO. Patients with bilateral involvement do not improve their transverse plane pelvic rotation profiles during gait as a result to FDRO, although this result should be interpreted with caution due to the heterogeneous nature of these participants and of the methods used in the studies assessed.