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Background: Femoral derotation osteotomy (FDO) is the standard treatment for internal rotation gait (IRG) in children with cerebral palsy (CP) although high rates of recurrence have been reported recently. Various factors associated with recurrence could be identified, but no predictor named.Research Questions: Does FDO lead to a change of internal transversal hip moments? Are preoperative internal transversal hip moments a predictor for recurrence of IRG?Methods: 41 children with spastic bilateral CP and 72 limbs that received a FDO (10.4 ± 2.7 years at surgery) were included retrospectively. Kinematic data were analyzed pre- (2 ± 3 months), postoperatively (12 ± 3 months) and at long-term follow-up (at least five years postoperatively; 84 ± 13 months), internal transversal hip moments were analyzed pre- and postoperatively.Results: The maximum peaks of the internal hip rotation moment during loading response decreased significantly (p = 0.003). The minimum during the second half of the stance phase increased significantly (p = 0.004) and the initially internal externally rotating moment changed to an internal internally rotating moment. No correlation between changes in hip rotation from postoperatively to the long-term follow-up and the preoperative internal hip rotation moment could be identified.Significance: FDO leads to changes in internal hip rotation moments. Preoperative internal hip rotation moments can't be used as predicting factor for recurrence of IRG. The data suggest, that recurrence of IRG depends less on patient specific motion patterns, but more on the time point of surgery and the therapy of all concomitant deformities during SEMLS. [ABSTRACT FROM AUTHOR]

Increased anterior pelvic and trunk tilt is a common finding in patients with bilateral cerebral palsy especially during walking with assistive devices. As previous studies demonstrate various gait alterations when using assistive devices, the assessment of surgical interventions may be biased when the patients become independent of (or dependent on) assistive devices after therapy. Furthermore, some of these patients in fact are able to walk without devices even though in daily life they prefer to use them. Consequently, for such patients the classification into GMFCS level II or III may be ambiguous. The specific aim of this study was therefore to assess the influence of the use of forearm crutches and posterior walker during walking and to set this influence in relation to outcome effects of surgical intervention studies. 26 ambulatory patients with spastic bilateral CP (GMFCS II-III) were included who underwent 3D gait analysis. All patients used forearm crutches or posterior walkers in everyday life even though they were able to walk without assistive devices for short distances. Independent of the type of assistive devices, the patients walk on average with more anterior trunk tilt and pelvic tilt (7°±6° and 3°±2°) and with a maximum ankle dorsiflexion decreased by 2° (±3°) when walking with assistive devices, enhancing the mal-positioning present without device. Oppositely, the knees on average are more extended by 6° (±4°) when using the assistive devices. These effects have to be taken into account when assessing gait patterns or when monitoring the outcome after intervention as assistive devices may partially hide or exaggerate therapeutic effects. [ABSTRACT FROM AUTHOR]

Abstract: Adverse effects such as increased anterior pelvic tilt (APT) are reported after muscle-tendon lengthening (MTL) for the correction of flexed knee gait in cerebral palsy. The conversion of biarticular muscles (CBM) to monoarticular muscles represents an alternative treatment, but only few short-term results have been published, without comparison with MTL. The long-term outcome of 21 diplegic patients treated with CBM in a prospective study was compared with the results in MTL patients in a matched-pair analysis. Standardized clinical examination and three-dimensional gait analysis were done before surgery, 1 year thereafter, and at long-term follow-up a mean of 9.2 years postoperatively. Mean APT increased one year after surgery in both groups. This increase was higher in MTL patients and statistically significant only for this group. Knee flexion at initial contact and minimum knee flexion in stance were significantly decreased in both groups, while in swing the CBM group tended to show more of a decrease in knee flexion but at the cost of reduced peak flexion. Both groups showed deterioration of kinematic knee parameters through to long-term follow-up; the favourable effects of CBM disappeared, and the two groups displayed comparable average pelvic and knee kinematics. Considering individual patterns the prevalence of increased APT was lower in the CBM group 1 year after surgery, indicating that sparing the semitendinosus may have a positive effect on pelvic stability. However, after 9 years 30% of the patients in both groups showed increased APT indicative of persistent hamstring insufficiency. These results demonstrate that CBM, a significantly more extensive procedure, has no long-term advantage over MTL. [Copyright &y& Elsevier]

Abstract: The evidence in support of distal rectus femoris transfer (DRFT) as part of single-event multilevel surgery (SEMLS) is limited due to inconsistent outcome reports and a lack of randomized studies. The purpose of this prospective randomized trial was to establish whether the results of SEMLS without DRFT are similar to those of a conventional approach that includes DRFT in the SEMLS. In all, 32 children with spastic diplegia (GMFCS I–III) and an indication for DRFT were recruited and randomized into a DRFT (15 children) and a NON-DRFT group (17 children) using a minimization method. During SEMLS, bilateral DRFT was performed only in the DRFT group. Three-dimensional gait analysis and clinical examination were performed before and 1year after surgery. In both groups a significant increase in range of motion during swing and knee flexion velocity were found, which was significantly higher in the DRFT group. While peak knee flexion in swing (pKFSw) was preserved in the DRFT group and significantly decreased in the NON-DRFT group, pKFSw timing was significantly earlier in both groups. The clinical relevance of the higher overall benefits in the DRFT group is limited, considering that 33% of patients in this group did not benefit from the procedure. Furthermore, 53% of the NON-DRFT patients did not undergo what proved to be an unnecessary DRFT. Subgroup analysis showed benefits for patients with decreased pKFSw, while those with severe flexed-knee gait (normal or increased pKFSw) did not profit from DRFT. This may explain the inconsistent overall results, and DRFT is therefore not recommended as a “prophylactic” procedure in patients with severe flexed-knee gait. [Copyright &y& Elsevier]

Planovalgus foot is a common pediatric deformity which may be associated with pain. To evaluate flexibility of the foot, the heel raise test is used. During this test the arch and hindfoot are assessed. Several studies have described planovalgus foot based on 3D gait and standing analysis. However, no studies have evaluated foot flexibility during heel raise using an objective 3D analysis. Therefore, the purpose of this study is to evaluate the flexibility of planovalgus feet during the heel raise test using an objective 3D assessment and to determine whether any hypotheses can be generated about potential differences between painful and painless flexible planovalgus feet and reference feet. Here, 3D foot analysis was conducted in 33 children (7 reference feet, 16 painless, and 10 painful flexible planovalgus feet) during the heel raise test. To identify the characteristics of planovalgus foot, the concept of 3D projection angles was used as introduced in the Heidelberg Foot Measurement Method (HFMM), with a modified marker set. All feet showed dynamic movements of the medial arch and hindfoot from valgus to varus position during heel raise. Reference feet had the smallest range of motion, perhaps due to joint stability and absence of foot deformity. Painful and painless flexible planovalgus feet demonstrated similar movements. No significant differences were found between the painful and painless groups. However, the kinematics of the pain group seemed to differ more from those of the reference group than did kinematics of the painless group. This assessment is a new, practical, and objective method to measure the flexibility of small children's feet. [ABSTRACT FROM AUTHOR]

Background: Bilateral internal rotation gait is a common gait abnormality in children with bilateral cerebral palsy, but still not fully understood.Research Question: The aim of this clinical study was to analyze the effects of artificially induced bilateral internal rotation gait on kinematics and kinetics. Our hypothesis was, that the internal rotation gait defined as increased dynamic internal hip rotation itself causes significant alterations in gait kinematics and kinetics.Methods: 30 typically developing children with a mean age of 12 (SD 3) years (range 8 - 16) performed three-dimensional gait analysis in two different conditions: with unaffected gait and with artificially induced bilateral internal rotation gait with two rotation bandages worn in order to internally rotate the hips. Kinematic and kinetic changes between these two conditions were calculated and compared using a mixed linear model with "gait condition" as fixed effect and both "limb" and "patient" as random effects.Results: The rotation bandages induced a significant increase in internal hip rotation and foot progression angle towards internal without affecting pelvic rotation. The peak hip internal rotator moment during loading response and the peak hip external rotator moment during the first half of stance phase increased significantly and the peak hip internal rotator moment during the second half of stance phase decreased significantly. Anterior pelvic tilt, hip flexion, knee flexion and ankle dorsiflexion increased significantly. The first peak of the frontal hip moment decreased, and the second increased significantly. The second peak of the frontal knee moment decreased significantly, while the first didn't change significantly.Significance: The data suggest, that the bilaterally increased dynamic internal hip rotation itself has a relevant impact on frontal hip moments. The increased anterior pelvic tilt, hip and knee flexion may be either induced by the pull of the rotation bandage or a secondary gait deviation. [ABSTRACT FROM AUTHOR]

Background: Despite of many attempts to determine or correct hip and knee joint parameters via non-invasive techniques such as regression or functional methods, in conventional gait models the position of the ankle joint center still is assumed at the center point between malleoli.Research Question: The aim of this study was to estimate the ankle joint parameters using a functional approach.Methods: To this aim, we used data of 23 typically developed adults performing two different calibration motions. Subsequently, we applied functional approaches to determine the functional joint center and axis.Results: The results show significant differences for ankle joint parameters in all directions for both calibration motions applied with respect to the malleoli line. Most prominently, we find a shift of the ankle joint center of 7 % of the foot length anteriorly to the malleoli mid-point when applying functional calibration.Conclusion: These significant alterations of the ankle joint center and axis indicate the importance of accurate determination of ankle joint parameters and consequently their influence on the clinical outcome. [ABSTRACT FROM AUTHOR]

Background: Recent studies showed rates of recurrence of internal rotation gait (IRG) after femoral derotation osteotomy (FDO) up to 40%. Some surgeons even advice overcorrection during FDO to avoid a later recurrence.Research Question: Evaluation of the long-term development of limbs with initial overcorrection after FDO.Methods: 29 limbs of 20 children (9.9 ± 3.2 years at surgery) with IRG, cerebral palsy (CP) and more than 5° external hip rotation postoperatively were included retrospectively. A gait analysis and clinical examination were performed preoperatively (less than one year, E0), postoperatively (9-23 months, E1) and at the long-term follow-up (at least five years postoperatively, E2). Differences between those children that remained overcorrected at E2 and those with a hip rotation within normal range at E2 were evaluated.Results: At E2 41% of these limbs remained overcorrected, 52% showed a hip rotation within normal range and 7% showed recurrence of IRG. A comparison of those limbs that remained overcorrected and those ending within normal range revealed neither a difference in age at surgery nor in static and dynamic torsional parameters at E0 and E1 except for pelvic rotation. A significantly larger pelvic internal rotation at E1 for those with remaining overcorrection could be identified.Significance: A general overcorrection during FDO in children with CP to avoid recurrence of IRG cannot be recommended, as 41% remain overcorrected. Preoperative predictors for long-term development couldn't be identified. If pelvic mal-rotation is corrected, hip rotation may change into normal range over the time in combination with the development of a flexed knee gait. [ABSTRACT FROM AUTHOR]

Duchenne gait is characterized by trunk lean towards the affected stance limb with the pelvis stable or elevated on the swinging limb side during single limb stance phase. We assessed the relationship between hip abduction moments and trunk kinetics in patients with cerebral palsy showing excessive lateral trunk motion. Data of 18 subjects with bilateral spastic cerebral palsy (CP) and 20 aged matched typically developing subjects (TD) were collected retrospectively. Criteria for patient selection were barefoot walking without aid presenting with excessive lateral trunk motion. Subjects had been monitored by conventional 3D gait analysis of the lower extremity including four markers for monitoring trunk motion. Post-hoc, a generic musculoskeletal full body model (OpenSim 3.3) assuming a rigid trunk articulated to the pelvis by a single ball joint was applied for analyzing joint kinematics and kinetics of the lower limb joints including this spine joint. Joint angle ranges of motion, maximum joint moments and powers in the frontal plane as well as mechanical work were calculated and averaged within groups showing prominent differences between groups in all parameters. To the best of our knowledge, this is the first work explicitly looking into the kinetics of Duchenne gait in patients with CP, clinically known as compensation for unloading hip abductor muscles. The results show that excessive lateral trunk motion may indeed be an extremely effective compensation mechanism to unload the hip abductors in single limb stance but for the price of a drastic increase in demand on trunk muscle effort and work. [ABSTRACT FROM AUTHOR]