Mirjam Niklasch

Factors associated with recurrence after femoral derotation osteotomy in cerebral palsy

Femoral derotation osteotomy (FDO) as gold standard treatment for internal rotation gait in cerebral palsy (CP) leads to satisfying short-term results, whereas rates of recurrence up to 33% are reported in long-term outcome studies. The purpose of this study was therefore to identify factors contributing to recurrence of internal rotation gait in patients with CP who were treated with FDO in childhood. 70 patients (age: 10 (± 3.3) years at surgery) with bilateral CP and internal rotation gait were examined pre-, one year and at least five years (mean 8 ± 2 years) postoperatively after distal or proximal FDO, using standardized clinical examination and 3D gait-analysis. 27 patients had a good hip rotation one year postoperatively (between 5° external and 15° internal for both limbs) and were considered for the analysis of factors contributing to recurrence of internal rotation gait. Regarding all included patients both mean hip rotation and foot progression angle improved significantly (p < 0.001) from pre- to postoperative. A significant deterioration in hip rotation (more involved side) (p < 0.001) from one year postoperatively to the long-term follow-up can be observed. Younger age, reduced hip joint impulse, increased plantar flexion and internal foot progression angle postoperatively could be identified as factors for recurrence. FDO on average leads to a satisfactory correction of internal rotation gait. In order to improve the long-term outcome after FDO the time of multilevel surgery should be indicated as late as possible and the different factors leading to potential recurrence should be considered.

Motion patterns in activities of daily living: 3- year longitudinal follow-up after total shoulder arthroplasty using an optical 3D motion analysis system

BackgroundTotal shoulder arthroplasty (TSA) can improve function in osteoarthritic shoulders, but the ability to perform activities of daily living (ADLs) can still remain impaired. Routinely, shoulder surgeons measure range of motion (ROM) using a goniometer. Objective data are limited, however, concerning functional three-dimensional changes in ROM in ADLs after TSA in patients with degenerative glenohumeral osteoarthritis.MethodsThis study included ten consecutive patients, who received TSA for primary glenohumeral osteoarthritis. The patients were examined the day before, 6 months, and 3 years after shoulder replacement as well. We compared them with a control group (n = 10) without any shoulder pathology and measured shoulder movement by 3D motion analysis using a novel 3 D model. The measurement included static maximum values, the ability to perform and the ROM of the ADLs “combing the hair”, “washing the opposite armpit”, “tying an apron”, and “taking a book from a shelf”.ResultsSix months after surgery, almost all TSA patients were able to perform the four ADLs (3 out of 40 tasks could not be performed by the 10 patients); 3 years postoperatively all patients were able to carry out all ADLs (40 out of 40 tasks possible). In performing the ADLs, comparison of the pre- with the 6-month and 3-year postoperative status of the TSA group showed that the subjects did not fully use the available maximum flexion/extension ROM in performing the four ADLs. The ROM used for flexion/extension did not change significantly (preoperatively 135°-0° -34° vs. 3 years postoperatively 131° -0° -53°). For abduction/adduction, ROM improved significantly from 33°-0° -27° preoperatively to 76° -0° -35° postoperatively. Compared to the controls (118°) the TSA group used less ROM for abduction to perform the four ADLs 3 years postoperatively.ConclusionTSA improves the ability to perform ADL and the individual ROM in ADLs in patients with degenerative glenohumeral osteoarthritis over the course of 3xa0years. However, TSA patients do not use their maximum available abduction ROM in performing ADLs. This is not related to limitations in active ROM, but rather may be caused by pathologic motion patterns, impaired proprioception or both.

3D motion capture using the HUX model for monitoring functional changes with arthroplasty in patients with degenerative osteoarthritis.

BACKGROUNDnAlthough shoulder hemiarthroplasty (SHA) can improve function in osteoarthritic shoulders, the ability to perform activities of daily living (ADL) may remain impaired. Shoulder surgeons routinely measure parameters such as range of motion, pain, satisfaction and strength. A common subjective assessment of ADL is part of the Constant Score (CS). However, there is limited objective evidence on whether or not shoulder hemiarthroplasty can restore normal range of motion (ROM) in ADL.nnnMETHODSnThe study included eight consecutive patients (n=8; seven women, one man), who underwent SHA for glenohumeral osteoarthritis. The patients were examined the day before, as well as 6 months and 3 years after shoulder replacement. They were compared with a control group with no shoulder pathology, and shoulder movement was measured with 3D motion analysis using the Heidelberg Upper Extremity (HUX) model. Measurements included static maximum values and four ADL.nnnRESULTSnComparing the preoperative to the 3-year postoperative static maximum values, there were significant improvements for abduction from 50.5° (SD ± 3 2.4°) to 72.4° (SD ± 38.2°; p=0.031), for adduction from 6.2° (SD ± 7.7°) to 66.7° (SD ± 18.0°; p=0.008), for external rotation from 15.1° (SD ± 27.9°) to 50.9° (SD ± 27.3°; p=0.031), and for internal rotation from -0.6° (SD ± 3.9°) to 35.8° (SD ± 28.2°; p=0.031). There was a trend of improvement for flexion from 105.8° (SD ± 45.7°) to 161.9° (SD ± 78.2°; p=0.094) and for extension from 20.6° (SD ± 17.0°) to 28.0° (SD ± 12.5°; p=0.313). The comparison of the 3-year postoperative ROM between the SHA group and controls showed significant differences in abduction; 3-year postoperative SHA ROM 72.4° (SD ± 38.2°) vs. 113.5° (SD ± 29.7°) among controls (p=0.029). There were no significant differences compared to the control group in adduction, flexion/extension and rotation 3 years after SHA surgery. In performing the ADL, the pre- to the 6-month and 3-year postoperative status of the SHA group resulted in a significant increase in ROM in all planes (p<0.05). Comparing the preoperative to the 3-year postoperative ROM used in ADL, there was an improvement in the flexion/extension plane, showing an improvement trend from preoperative 85°-0°-25° to postoperative 127°-0°-38° (p=0.063). In comparison, controls used a significantly greater ROM during ADL with mean flexion/extension of 139°-0°-63° (p=0.028). For the abduction/adduction plane, ROM improved significantly from preoperative 25°-0°-19° to postoperative 78°-0°-60° (p=0.031). In comparison to controls with abduction/adduction of 118°-0°-37° 3 years postoperative, the SHA group also used significantly less ROM in the abduction/adduction plane (p=0.028).nnnCONCLUSIONnWhile SHA improves ROM in ADL in patients with degenerative glenohumeral osteoarthritis, it does not restore the full ROM available for performing ADL compared to controls. 3D motion analysis with the HUX model is an appropriate measurement system to detect surgery-related changes in shoulder arthroplasty.

Electromagnetic bone segment tracking to control femoral derotation osteotomy—A saw bone study

Correction of rotational gait abnormalities is common practice in pediatric orthopaedics such as in children with cerebral palsy. Femoral derotation osteotomy is established as a standard treatment, however, different authors reported substantial variability in outcomes following surgery with patients showing over‐ or under‐correction. Only 60% of the applied correction is observed postoperatively, which strongly suggests intraoperative measurement error or loss of correction during surgery. This study was conducted to verify the impact of error sources in the derotation procedure and assess the utility of a newly developed, instrumented measurement system based on electromagnetic tracking aiming to improve the accuracy of rotational correction. A supracondylar derotation osteotomy was performed in 21 artificial femur sawbones and the amount of derotation was quantified during the procedure by the tracking system and by nine raters using a conventional goniometer. Accuracy of both measurement devices was determined by repeated computer tomography scans. Average derotation measured by the tracking system differed by 0.1°u2009±u20091.6° from the defined reference measurement . In contrast, a high inter‐rater variability was found in goniometric measurements (range: 10.8°u2009±u20096.9°, mean interquartile distance: 6.6°). During fixation of the osteosynthesis, the tracking system reliably detected unintentional manipulation of the correction angle with a mean absolute change of 4.0°u2009±u20093.2°. Our findings show that conventional control of femoral derotation is subject to relevant observer bias whereas instrumental tracking yields accuracy better than ±2°. The tracking system is a step towards more reliable and safe implementation of femoral correction, promising substantial improvements of patient safety in the future.

Does additional patella tendon shortening influence the effects of multilevel surgery to correct flexed knee gait in cerebral palsy: A randomized controlled trial

BACKGROUNDnThe aims of this study were to investigate if patellar tendon shortening (PTS) as a part of SEMLS (single event multilevel surgery) is effective for reduction of flexed knee gait in children with cerebral palsy (CP) and, if PTS leads to stiff knee gait.nnnMETHODSnIn a randomized controlled study 22 children with flexed knee gait (age: 10.4u202f±u202f2.6u202fyears, GMFCS Level I-III) were randomized and allocated to two groups (1: SEMLSu202f+u202fPTS; 2: SEMLS no PTS): SEMLS was performed for correction of flexed knee gait either with or without additional PTS. Before and after surgery (follow up: 12.7u202f±u202f1.6u202fmonths) kinematics (3-D motion analysis) and clinical parameters were compared.nnnRESULTSnTwo children were lost to follow up. Maximum knee extension improved significantly in both groups after SEMLS while the patients with additional PTS showed much more correction (SEMLSu202f+u202fPTS: 37.6° to 11.4°, pu202f=u202f0.007; SEMLS no PTS: 35.1° to 21.8°, pu202f=u202f0.016). After surgery peak knee flexion decreased significantly (14.6°, pu202f=u202f0.004) in the SEMLSu202f+u202fPTS group while there was no relevant change in the other group. There was a trend of increase in anterior pelvic tilt after surgery in both groups, but no statistical significant difference. After surgery knee flexion contracture (15.9°, pu202f<u202f0.001) and popliteal angle (27.2, pu202f=u202f0.009) measured on clinical examination only decreased significantly in the SEMLSu202f+u202fPTS group.nnnCONCLUSIONnPTS is effective for correction of flexed knee gait and knee flexion contracture leading to superior stance phase knee extension. However, additional PTS may lead to stiff knee gait and a higher increase of anterior pelvic tilt.

Equinus Correction During Multilevel Surgery in Adults With Cerebral Palsy

Background: Equinus foot deformity constitutes a common gait disorder in ambulatory adults with bilateral spastic cerebral palsy (BSCP). The outcome after intramuscular aponeurotic lengthening in the context of single-event multilevel surgery (SEMLS) in adulthood has not been investigated. Methods: We followed a group of 31 ambulatory adults with BSCP and equinus who underwent SEMLS including gastrocnemius-soleus intramuscular aponeurotic recession or Achilles tendon lengthening. All patients were analyzed preoperatively and at least 1 year (mean follow-up period: 1.6 years) postoperatively by clinical examination and 3-dimensional instrumented gait analysis including the Gait Profile Score (GPS). Results: Clinical examination showed no significant improvement of ankle dorsiflexion (P = .5) and an unchanged plantarflexion (P = .7) with knee extended but a significant postoperative reduction of spasticity in the calf muscle (P = .0001) as measured by clinical examination following the modified Ashworth scale. Significant improvement of mean ankle dorsiflexion in stance and swing (P = .0001) was found. The GPS decreased and improved significantly (15.9 ± 4.6 to 11.4 ± 3.1; P = .0001). Persistence of equinus and calcaneal gait indicating under- and overcorrection at follow-up was found in 1 patient (3%), respectively. Conclusion: Intramuscular gastrocnemius-soleus aponeurotic recession is part of multilevel surgery corrected equinus deformity in adults. The increase in muscle length led to significant improvement of kinetic and kinematic parameters during walking without a loss of muscle strength and push-off capacity. The risk of overcorrection after equinus correction in adults with BSCP was found to be relatively low. Level of Evidence: Level IV, retrospective case series.

Mid‐term development of hamstring tendon length and velocity after distal femoral extension osteotomy in children with bilateral cerebral palsy: a retrospective cohort study

Flexed knee gait can be treated with distal femoral extension osteotomy (DFEO) and additional patellar tendon advancement (PTA) in children with cerebral palsy (CP). This study assesses changes in hamstring muscle tendon length (MTL) and velocity after DFEO (+PTA).

Proximal versus distal femoral derotation osteotomy in bilateral cerebral palsy

Femoral derotation osteotomy (FDO) can be conducted either proximally or distally to correct internal rotation gait (IRG) and increased anteversion in children with cerebral palsy (CP). Previous studies with limited numbers of participants have presented comparable short‐term static and kinematic outcomes for both techniques. The objective of this retrospective multicentre study was to verify this thesis with a larger number of patients.

The influence of timing of knee recurvatum on surgical outcome in cerebral palsy

Recent reports have shown that timing of genu recurvatum (GR) might be caused by different underlying factors and that equinus leads to GR especially during early stance. The purpose of this study was to investigate the reduction of GR after surgical correction of equinus in children with bilateral spastic cerebral palsy and whether the children with early and late type GR show differences in reduction of knee hyperextension after a surgery. In 24 limbs (mean age 10.3 years, GMFCS I-III) showing equinus and GR the kinematics of the knee and ankle as well as the kinetics of the knee were evaluated before and one year (mean follow up period: 12.8 months) after surgical correction of equinus. The study was approved by the local ethical committee. Limbs with early type GR showed a reduction by 11.1° (p<0.001) and those with late type GR by 6.0° (p<0.049) in GR after surgery. Before surgery limbs with early type GR showed increased external extending moments, which decreased significantly after surgery. In contrast limbs with late GR did not show a significant reduction of those moments. The findings of this study underline the influence of equinus on early GR as an underlying factor. As equinus is attributed to early knee hyperextension and proximal factors are more important as underlying factors in late type GR, a classification into early and late onset GR is useful to identify underlying factors and to choose adequate treatment.

Long-term results of multilevel surgery in adults with cerebral palsy

BackgroundDeterioration of gait in adolescent and adult patients with cerebral palsy can be associated with multiple factors. Multilevel surgery (MLS) is one option in adults with cerebral palsy to improve gait function with encouraging short-term results. It is a question whether these improvements are maintained over time.MethodsIn a retrospective consecutive cohort study, adults with bilateral spastic cerebral palsy (BSCP) treated with MLS between 1995 and 2011 were scanned for potential inclusion. Patients needed to fulfill the following inclusion criteria: age at MLS >u200917, standardized three-dimensional gait analysis (3D-GA) including clinical examination at pre-operative (E0), a short-term follow-up (E1) and at least sevenxa0years (E2) after the index MLS. Twenty adults (10 women, 10 men) with a Gross Motor Function Classification Level (GMFCS) I–III and a mean age at MLS of 24.8xa0years were included in this study. The average long-term follow-up was 10.9xa0years. The Gait Profile Score (GPS) was used as primary outcome measure.ResultsThe GPS improved significantly from 13.8° before surgery to 11.2° at short-term (pu2009=u20090.007) and to 11.3° at long-term follow-up (pu2009=u20090.002). Mean GPS showed a slight deterioration between E1 and E2 due to a minority of six patients (30%) who showed a significant loss of correction.ConclusionSurgical treatment in adults with BSCP was feasible and effective in the long-term. Significant improvement of gait and function was maintained in the majority of patients, while some patients were prone to develop crouch gait, hip flexion contractures, or pain.