Multilevel Surgery Improves Gait in Spastic Hemiplegia But Does Not Resolve Hip Dysplasia

Background: Multilevel orthopaedic surgery may improve gait in Type IV hemiplegia, but it is not known if proximal femoral osteotomy combined with adductor release as part of multilevel surgery in patients with hip dysplasia improves hip development. Questions/purposes: We asked whether varus derotational osteotomy of the proximal femur, combined with adductor release, influenced hip development in patients with Type IV hemiplegia having multilevel surgery. Patients and Methods: We retrospectively reviewed 11 children and adolescents with Type IV hemiplegia who had a proximal femoral osteotomy due to unilateral hip displacement to correct gait dysfunction between 1999 and 2006. The mean age at the time of surgery was 11.1years (range, 7 to 16 years). We obtained the Movement Analysis Profile and Gait Profile Score before and after surgery. We also measured the Migration Percentage of Reimers and applied the Melbourne Cerebral Palsy Hip Classification System (MCPHCS). The minimum followup was 2years 3months (mean, 6years 6months; range, 2years 3months to 10years 8months). Results: The majority of gait parameters improved but hip development was not normalized. According to the MCPHCS at last followup, no hips were classified as Grade I, two hips were classified as Grade II, and the remainder were Grade III and IV. Conclusions: Unilateral surgery including a proximal femoral osteotomy improved gait and walking ability in individuals with spastic hemiplegic cerebral palsy. However, hip dysplasia persists. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidenc

Effect of lower-limb torsional deformities on muscle and joint function during gait

© 2017 Dr. Elyse Halley Purves PassmoreTorsional deformities of the femur and tibia have been associated with walking difficulties, lower-limb pain and joint dysfunction. Patients presenting with torsional deformities typically undergo medical imaging and 3D gait analysis, prior to consideration of surgical correction. To date, much of the research has focused on kinematic and kinetic deviations during gait. However, little is known in regards to the effect of torsional deformities on muscle and joint contact forces. The overall goal of this dissertation was to understand the effect of lower-limb torsional deformities on muscle and joint function during gait, to improve surgical decision-making and hence clinical outcomes. Prior to addressing the overall goal of this dissertation we investigated three key areas; 1) the evaluation of suitable clinical methods for the measurement of lower-limb torsion, 2) determining accurate anatomical based joint parameters (joint centres and axes) for the lower-limbs and 3) separating the effects of bone geometry (lower-limb torsion) and joint parameters on musculoskeletal modelling results (kinematics, kinetics, muscle-tendon unit lengths, muscle moment arms, muscle forces and joint contact forces). Various clinical methods of measuring lower-limb torsion were compared to the gold standard, computed tomography (CT) measurements. Physical examination measurements were unreliable, showing poor agreement with measurements from CT. Freehand 3D ultrasound and low dose biplanar radiography (EOS imaging) showed good agreement with measurements from CT. Validation of methods to determine joint centres and axes has been limited, often assessed with indirect outcome measures. For this study, patient-specific joint parameters were identified from low dose biplanar radiography and registered with respect to the skin markers used during 3D gait analysis. This was done for the hip joint centre, condylar axis (knee axis) and bimalleolar axis (ankle axis). This method was used as a reference to evaluate previously described methods. For the hip joint centre recent regression equations obtained from CT or magnetic resonance imaging showed good agreement with the reference, with the majority being less than 30mm from the reference. For the condylar axis both the conventional gait model and functional calibration methods were unreliable. Freehand 3D ultrasound imaging showed the closest results to the reference. The separate effects of bone geometry and joint parameters on the results from musculoskeletal modelling were investigated. Joint parameters had a significant effect on the kinematics, kinetics and hip and knee joint contact forces. Bone geometry had a significant effect on the muscle forces and hip and knee joint contact forces. Both bone geometry and joint parameters where deemed necessary inclusions in patient-specific musculoskeletal models. To address the overall goal of the dissertation we investigated the relationship between lower-limb torsional deformities, physical examination measures, gait parameters (kinematics, kinetics, muscle forces and joint contact forces) and pain in two clinical populations; children with idiopathic torsion and children with spastic diplegic cerebral palsy. This was done by creating musculoskeletal models with patient-specific anatomy, accurately registered to the skin markers used during 3D gait analysis. These models were created using low dose biplanar radiographs combined with 3D gait analysis. This investigation showed that both patients with idiopathic torsion and those with spastic cerebral palsy have similar gait deviations. However, the cerebral palsy patients showed additional gait deviations likely the result of muscle spasticity, muscle weakness and impaired selective motor control. Additionally, lower-limb torsion and joint contact forces were predictors of pain in both populations. This dissertation presents clinically feasible methods for the creation of musculoskeletal models on a patient-specific basis. This is the first study to combine low dose biplanar radiography with 3D gait analysis to obtain patient-specific musculoskeletal models. These models have the advantage of registering patient-specific anatomy with respect to the skin markers in a standing position, with short scan times (10 seconds) and low radiation exposure

Ankle Dorsiflexor Function after Gastrocsoleus Lengthening in Children with Cerebral Palsy: A Literature Review

Background and Objectives: Ambulant children with cerebral palsy can demonstrate persistent “foot drop” after successful gastrocsoleus lengthening (GSL) surgery for equinus deformity. This may be due to inadequate strength and/or selective motor control of the ankle dorsiflexor muscles. A procedure has been developed to reduce foot drop—Tibialis Anterior Tendon Shortening (TATS), to be performed in conjunction with GSL. However, it is currently unclear how ankle dorsiflexor function changes after surgery and which children could benefit from TATS. This review summarises changes in ankle dorsiflexor function after GSL for equinus, as reported in the literature. Methods: A search was performed of the Medline, Embase and PubMed databases from 1980 to 5 March 2021. Keywords included “cerebral palsy”, “equinus deformity”, “orthopedic procedures” and “gait analysis”. The search identified 1974 studies. Thirty-three cohort studies met the inclusion criteria for this review. Results: Twenty-two studies reported improvement in swing phase ankle dorsiflexion kinematics, after GSL. There was also evidence that clinical measures of ankle dorsiflexor strength improved after surgery. Four studies reported changes in selective motor control, with mixed results across the studies. Conclusions: There is good evidence that swing phase ankle dorsiflexion improves after GSL surgery. Although, there is limited evidence that this correlates with reduced foot drop or diminished need for an ankle-foot orthosis. Future research should be prospective, randomised, include a large sample size, and should focus on identifying the optimal candidates for TATS