Internal rotation gait in spastic diplegia--critical considerations for the femoral derotation osteotomy

The purpose of this study was to assess under- and overcorrection following femoral derotation osteotomy (FDO) in spastic diplegic children with functionally compromising internally rotated gait, especially with respect to asymmetry. A total of 30 children with spastic diplegia and internally rotated gait underwent multilevel surgery including FDO and were assessed pre- and 1 year postoperatively by clinical examination and instrumented gait analysis. The amount of derotation was determined intra-operatively based on the neutral midpoint between passive internal and external hip rotation and was controlled with K-wires. Sixteen patients showed an asymmetry in mean hip rotation in stance of more than 10 degrees preoperatively. Accordingly, all legs were classified as the more or the less involved side. Improvement parameters were established for the evaluation of over- and undercorrection. For the clinical midpoint, no significant difference in change and improvement was found between the sides. The mean hip rotation in stance improved significantly in the more involved side with few incidences of mal-correction (13%). The less involved side, however, got worse due to a high occurrence of over- and undercorrections (59%). Hence the clinical midpoint as indication criterion does not give sufficient information about the functional alignment of the distal femur during gait, especially in legs with mild involvement. The study underlines the importance of gait analysis for indication in addition to the clinical midpoint. Taking into account the precision of gait analysis data and derotation amount, we suggest FDO to be carried out if the mean internal hip rotation in stance exceeds 15 degrees .     

Long-term functional outcomes after an external femoral derotation osteotomy in individuals with cerebral palsy

BackgroundIt is unknown how a femoral derotation osteotomy (FDO) during childhood affects functional outcomes in adulthood among individuals with bilateral cerebral palsy (CP).Research questionsHow do long-term functional outcomes after an FDO compare to matched individuals who did not have an FDO? How do outcomes change over time?MethodsWe queried the gait laboratory database for individuals who underwent an external FDO in childhood and were currently ≥25 years old. Participants returned for a long-term analysis (gait, physical examination, functional tests, imaging, questionnaires). The matched non-FDO group included only individuals in Gross Motor Function Classification System levels I-II, yielding three groups (non-FDO I-II, FDO I-II, FDO III-IV).ResultsSixty-one adults (11 non-FDO, 34 FDO I-II, 16 FDO III-IV) returned 13–25 years after baseline (non-FDO) or surgery (FDO). The non-FDO and FDO I-II groups were matched at baseline on most variables, except the FDO group had weaker hip abductors. At long-term, groups were similar on gait variables (median long-term hip rotation [primary outcome], non-FDO: −4°, FDO I-II: −4°, FDO III-IV: −5°), hip abduction test, fear of falling, and most pain measures despite anteversion being 29° greater in the non-FDO group. The FDO I-II group reported more falls than the non-FDO group. All groups improved on hip rotation, foot progression, and hip abductor strength. Speed and step length decreased/tended to decrease for all three groups. Hip abduction moment and gait deviation index did not change. Improvements in the FDO groups were maintained from short- to long-term.SignificanceThese results challenge the notion that an FDO is necessary to correct mean stance hip rotation for higher functioning individuals since nearly identical results were achieved by adulthood in the non-FDO I-II group. However, an FDO provides improvement earlier and maintenance from short- to long-term. This should factor into the shared decision-making process.     

Long-term outcomes of external femoral derotation osteotomies in children with cerebral palsy

External femoral derotation osteotomy (FDO) is an orthopaedic intervention to correct increased femoral anteversion and associated excessive internal hip rotation and internal foot progression during gait in children with cerebral palsy. The resulting functional issues may include clearance problems and hip abductor lever-arm dysfunction. The purpose of this study was to evaluate long-term gait outcomes of FDO. Twenty ambulatory patients (27 sides) with cerebral palsy who underwent pre-operative (P0) and a one year post-operative (P1) gait analysis as part of the standard of care had a second post-operative analysis (P2) approximately 11 years post-surgical intervention. Mean hip rotation in stance showed statistically significant decreases in internal rotation at P1 post-surgical intervention that were maintained long-term (mean hip rotation P0: 21 ± 9, P1: 0 ± 9 and P2: 6 ± 12  degrees internal). Similar results were seen with mean foot progression (P0: 9 ± 16 degrees internal, P1: 14 ± 13 degrees external, P2: 13 ± 16 degrees external). However, 2/27 sides (9%) showed a recurrence of internal hip rotation of >15° at the 11 year follow-up. The reasons for this recurrence could include age, surgical location and ongoing disease process all of which need to be further examined. We conclude that FDO can show long-term kinematic and functional benefits when performed in the prepubescent child with cerebral palsy in comparison to the natural progression of of hip rotation in cerebral palsy.     

Long-term changes in femoral anteversion and hip rotation following femoral derotational osteotomy in children with cerebral palsy

BackgroundExcessive femoral anteversion is common in cerebral palsy (CP), is often associated with internal hip rotation during gait, and is frequently treated with a femoral derotational osteotomy (FDO). Concerns exist regarding long-term maintenance of surgical outcomes. Past studies report varying rates of recurrence, but none have employed a control group.MethodsWe conducted a retrospective analysis examining long-term (∼5 years) changes in anteversion and hip rotation following FDO in children with CP. We included a control group that was matched for age and exhibited excessive anteversion (>30°) but did not undergo an FDO. Anteversion, mean stance hip rotation, and rates of problematic remodeling and recurrence were assessed (>15° change and final level outside of normal limits).ResultsThe control group was reasonably well matched, but exhibited 9° less anteversion and 3° less internal hip rotation at the pre time point. At a five year follow-up, the FDO group had less anteversion than the control group (20° vs. 35°, p < 0.05). The mean stance phase hip rotation did not differ between the groups (4° vs. 5°, p = 0.17). Over one third of limbs remained excessively internal in both groups (FDO: 34%, Control: 37%). Rates of problematic recurrence and remodeling were low (0%–11%).ConclusionsAn FDO is an effective way to correct anteversion in children with CP. Long-term hip rotation is not fully corrected by the procedure, and is not superior to a reasonably well matched control group. Rates of problematic recurrence and remodeling are low, and do not differ between the groups.     

Three-dimensional head and trunk movement characteristics during gait in children with spastic diplegia

This study uses a recently developed trunk model to determine which head and trunk kinematic parameters differentiate children with spastic diplegia from typically developing (TD) children while walking. Differences in head and trunk parameters in relation to the severity of the motor involvement (GMFCS levels) were additionally examined. The trunk model consisted of five segments (pelvis, thorax, head, shoulder line, spine). Discrete kinematic parameters (ROM, mean position) and angular waveforms were compared between 20 children with spastic diplegia (age 9.8 years ± 2.9 years; GMFCS I: n = 10, GMFCS II: n = 10) and 20 individually age-matched TD children (9.7 years ± 3 years). A new measure for overall trunk pathology, the trunk profile score (TPS), was proposed and included in the comparative analysis. Compared to TD children, children with GMFCS II showed a significantly higher TPS and increased ROM for pelvis tilt, for thorax and head in nearly all planes, and the angle of kyphosis. In children with GMFCS I, only ROM of thorax lateral bending was significantly increased. Sagittal ROM differentiated best between GMFCS levels, with higher ROM found in children with GMFCS II. Current results provide new insights into head and trunk kinematics during gait in children with spastic diplegia.     

Immediate effects of therapeutic music on loaded sit-to-stand movement in children with spastic diplegia

The effects of patterned sensory enhancement (PSE) music on muscle power and movement control in children with spastic diplegia (SD) during loaded sit-to-stand (LSTS) were investigated. Twenty-three children with SD aged 5 to 12 years were recruited. Individualized PSE was composed by a music therapist based on each subject's sit-to-stand (STS) movement with 50% 1-repetition maximum load. Each subject performed LSTS continuously for eight repetitions under randomly assigned music or no-music (Control) conditions while the kinematic and kinetic data were measured simultaneously. For the music condition, PSE music was played only during the first five repetitions (PSE condition), and the following three repetitions were referred to as the Continuation condition. Paired t- or Wilcoxon signed rank tests were used to compare the variables between the PSE and Control conditions, and between the Continuation and Control conditions. Compared to the Control condition, greater peak knee extensor power (P=0.009), greater total extensor power (P=0.015), and better center-of-mass smoothness (P=0.01), but less movement time (P=0.003) were found in the PSE condition. Significant effects of the PSE music on the above variables were also found for Continuation condition. The current results showed that individualized PSE music helped improve the performance of LSTS in children with SD. The associated biomechanical features also continued to exist in subsequent movement cycles after the music had ceased. These findings suggest that therapy using LSTS combined with PSE music may be beneficial for rehabilitating children with SD.     

MR imaging of spastic diplegia

Summary Eighteen children (eleven preterm birth and seven term birth) with clinical evidence of spastic diplegia (SD) were studied to clarify the differences of the lesions between preterm and term SD on MR imaging. All with preterm birth showed similar abnormalities of the periventricular white matter represented by high intensity in T2-weighted imaging and low intensity in T1 imaging. It seemed that the lesions were periventricular leukomalacia (PVL) and dysmyelination pathologically and correlated well clinically with spastic diplegia. SD with term birth group showed various lesions, two brain anomalies (schizencephaly and corpocephaly), one PVL, four showed no lesions. We suggested that SD with preterm birth is not only a clinical but also a pathological entity.     

Femoral derotation osteotomy in adults with cerebral palsy

BackgroundInternal 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.MethodsIn 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.ResultsThe 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).ConclusionThis 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.     

Biplanar supracondylar femoral derotation osteotomy for patellofemoral malalignment: the anterior closed-wedge technique

Patellofemoral malalignment can be caused by several factors including increased internal torsion of the femur. As a causative treatment method, supracondylar femoral derotation osteotomies have been proposed. For valgus- and varus-producing supracondylar femoral osteotomies, a biplanar osteotomy has been introduced in order to enhance primary fixation stability and osseous consolidation by increased bone-to-bone contact. In this article, a modification of this technique is described, which allows for a biplanar supracondylar femoral derotation osteotomy. Level of evidence V.     

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.     

Outcomes of correction of internal hip rotation in patients with spastic cerebral palsy using proximal femoral osteotomy

Internal hip rotation (IHR) is the major cause of intoeing gait in patients with cerebral palsy (CP). Femoral derotation osteotomy (FDO) is the preferred treatment to correct excessive anteversion, however the condition may persist or recur postoperatively. Retrospective clinical and kinematic evaluation of 75 spastic diplegic CP patients was conducted for a mean duration of 22 months following proximal FDO. The patients were divided into two groups depending on the correction or persistence of IHR evident at kinematics after surgery. If corrected, mean patient follow-up was extended to 53 months. Outcomes were analyzed using Two Proportions Equality, Mann-Whitney and Wilcoxon tests. IHR persisted in 33.3% of cases at mean follow-up of 22 months and subtrochanteric femur osteotomy was more frequent in this group (p=0.033). Thirty-five of the fifty-four patients with first-round gait correction were monitored during the extended follow-up. Those for whom IHR recurred (9.5%) had undergone FDO at a comparatively younger age. Patient gender, operations prior to or at the time of femoral osteotomy, topographic classification, GMFCS level, or the extent of preoperative clinical and kinematic abnormalities had no apparent influence on persistence or recurrence of abnormal gait.     

Medial hamstring lengthening in the presence of hip flexor tightness in spastic diplegia

This study evaluated the effects of medial hamstring lengthening on gait in patients with diplegic cerebral palsy. A group of patients who underwent medial hamstring lengthening and distal rectus transfer was compared to a group of patients who underwent intramuscular psoas lengthening as well. Patients who underwent a psoas lengthening showed an increased anterior pelvic tilt and a tendency towards genu recurvatum, features that could indicate postoperative hamstring weakness. These results underline the importance of medial hamstrings for pelvis and knee motion in the sagittal plane during walking. In additional the limitations of the popliteal angle as a clinical measure to evaluate hamstring length in the presence of hip flexor tightness are discussed.     

Compensatory gait deviations in patients with increased outward tibial torsion pre and post tibial derotation osteotomy

BackgroundTibial torsion describes the rotation between the proximal and distal joint axis along the shaft, which can be, as rotational deformity, pathologically increased or decreased. Some patients might increase hip internal rotation during walking to compensate increased outward tibial torsion.Research questionThe aim of this study was to assess the effect of tibial derotation osteotomy on gait deviations in patients with increased outward tibial torsion.MethodsThirteen patients (13.5 ± 1.4 yrs, 22 limbs) with increased tibial torsion (CT confirmed 49.2 ± 4.8°) were analyzed pre and post tibial derotation osteotomy and compared with 17 typically developing children (TDC, 13.5 ± 2.3 yrs, 32 limbs). Kinematic and kinetic data were recorded. Subgroup analyses were performed whether patients showed compensatory hip internal rotation (Comp) or not (NoComp). Principal component (PC) analysis was used to achieve data transformation. A linear mixed model was used to estimate the main effect of PC-scores of retained PCs explaining 90% of the cumulative variance.ResultsCompensatory hip internal rotation (Comp, present in 45.5% of limbs analyzed) led to a lower external foot progression angle compared to patients without compensatory hip internal rotation (NoComp). In both patient groups foot progression angle was normalized after tibial derotation osteotomy. Post-operative NoComp had normalized frontal plane joint loadings, while Comp showed an increased hip and knee adduction moment.SignificanceFuture studies should investigate if more time is needed for Comp to normalize gait patterns post-operative or if a pre and post-operative gait training might help. Otherwise the increased knee adduction moment might be clinically relevant due to previous studies reporting a possible association with knee osteoarthritis.     

Common abnormal kinetic patterns of the knee in gait in spastic diplegia of cerebral palsy

We studied the kinetic characteristics of the knee in patients with spastic diplegia. Twenty three children with spastic diplegia were recruited and had their 46 limbs categorised into the following four groups: jump (n=7), crouch (n=8), recurvatum (n=14) and mild (n=17). In the crouch pattern, the patients usually had a larger and longer lasting internal knee extensor moments in stance suggesting that rectus femoris had a relatively high activation. In the recurvatum pattern, the internal knee flexor moment was large and long lasting in stance. The biceps femoris showed less activity on EMG although the knee flexor moment was large and we concluded that the soft tissue behind the knee joint provided this flexor moment. In the jump knee pattern there was abnormal power generation at the knee and ankle joints in initial stance, which did not contribute to normal progression but aided upward body motion. In the mild group the kinetic data was similar to that seen in normal children. Knowledge of kinetic patterns in these patients may help in their subsequent management.