Simone Gantz

Long-Term Results After Gastrocnemius-Soleus Intramuscular Aponeurotic Recession as a Part of Multilevel Surgery in Spastic Diplegic Cerebral Palsy

BACKGROUND Equinus of the foot at the ankle is one of the most common deformities in patients with spastic diplegic cerebral palsy, leading to gait disturbances and secondary deformities. During single-event multilevel surgery, equinus is commonly corrected by calf muscle lengthening, such as gastrocnemius-soleus intramuscular aponeurotic recession. Various studies have described satisfactory short-term results after gastrocnemius-soleus intramuscular aponeurotic recession. However, there is no evidence for maintenance of equinus correction because of the small and heterogeneous case series and short follow-up time previously reported. METHODS The present study provides long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery for the treatment of equinus in forty-four patients with spastic diplegia who were able to walk (forty-eight legs had lengthening of the gastrocnemius and thirty-four legs had lengthening of the gastrocnemius and soleus). Standardized three-dimensional gait analysis and clinical examination were done preoperatively and at one year, a mean (and standard deviation) of 3 ± 1 years, and a mean of 9 ± 2 years after surgery. RESULTS Significant improvements in kinematic and kinetic ankle parameters on gait analysis as well as passive dorsiflexion in clinical examination were found one year after surgery. While there was a significant loss of passive dorsiflexion at the time of long-term follow-up, the improvements in gait analysis parameters were maintained. The endurance of gait improvements was accompanied by a persistent increase of dorsiflexor muscle strength without relevant loss of plantar flexor strength. Although it was not significant, there was a tendency for deterioration of gait analysis parameters over the nine years. The analysis of individual patterns showed recurrence of equinus at the ankle in 24% of the legs. Early-onset calcaneal gait was found one year after surgery in seven legs (9%), but without secondary crouch gait, and there was recovery at the time of the long-term follow-up. Late-onset calcaneal gait was seen at the time of long-term follow-up in eight legs (10%), of which four had an accompanying crouch gait. CONCLUSIONS Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to satisfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession.

Development of Knee Function After Hamstring Lengthening as a Part of Multilevel Surgery in Children with Spastic Diplegia: A Long-term Outcome Study

BACKGROUND Hamstring lengthening commonly is performed for the treatment of flexed knee gait in patients with spastic diplegic cerebral palsy. Satisfactory short-term results after hamstring lengthening have been demonstrated in various studies. However, evidence for the effectiveness of hamstring lengthening to correct flexed knee gait is scant because of small and inhomogeneous case series, different surgical techniques, and short follow-up. METHODS The long-term results for thirty-nine patients with spastic diplegia and flexed knee gait who were managed with intramuscular hamstring lengthening as a part of multilevel surgery are presented. Standardized three-dimensional gait analyses and clinical examinations were performed for all patients preoperatively and at one, three, and six to twelve years postoperatively. RESULTS Significant improvements in kinematic parameters and the popliteal angle were noted at short-term follow-up (p < 0.01), supporting the results of previous studies. Long-term results showed significant deterioration of minimum knee flexion in stance and the popliteal angle (p < 0.01), whereas the improvements in the Gross Motor Function Classification System and Gillette Gait Index were maintained. This recurrence of flexed knee gait is partial and measurable. Increased pelvic tilt was found in 49% of the limbs postoperatively, which may represent one factor leading to recurrence of flexed knee gait. Genu recurvatum was seen in eighteen patients (twenty-seven limbs; 35%) one year postoperatively, especially in the patients with a jump knee gait pattern preoperatively. At long-term follow-up, genu recurvatum resolved in many limbs, but 12% of the limbs showed residual genu recurvatum, indicating that overcorrection represents a problem following hamstring lengthening. CONCLUSIONS The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning.

Long-term outcome of femoral derotation osteotomy in children with spastic diplegia

Satisfactory short-term results after femoral derotation osteotomy (FDO) for the treatment of internal rotation gait in cerebral palsy have been reported by various authors. However, there are only a few longer-term studies reporting results 5 years after FDO and these are not in agreement. There are no reports on the clinical course beyond the pubertal growth spurt. 33 children with diplegia (n=59 legs, age: 10.5±3.6 years) and internally rotated gait were examined pre- (E0), 1 year (E1), 3±1 (E2) and 9±2 (E3) years after distal (27 legs) or proximal (32 legs) FDO as part of multilevel surgery, using standardized clinical exam and 3D gait-analysis at all examinations. The amount of intra-operative derotation averaged 25°. ANOVA was used for statistics (p<0.05). Mean hip internal rotation in stance at E0 of 17.3° was significantly changed to 1.0° of external rotation at E1 and was maintained at 4.2° at E3. The same clinical course was found for foot progression angle. The mid-point of passive hip rotation at E0 was 21°. This was significantly decreased to 6° at E1 and showed a small but significant increase reaching 12° at E3. The results of this study showed a good overall correction of internally rotated gait following FDO. These improvements were maintained at long-term follow-up after the pubertal growth spurt. Recurrence was observed in some cases with overall severe deterioration. In those patients persistent dynamic factors leading to recurrence should be further investigated.

Long-Term Results After Distal Rectus Femoris Transfer as a Part of Multilevel Surgery for the Correction of Stiff-Knee Gait in Spastic Diplegic Cerebral Palsy

BACKGROUND The evidence for distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in children with spastic diplegic cerebral palsy is limited because of inconsistent outcomes reported in various studies and the lack of long-term evaluations. METHODS This study investigated the long-term results (mean, nine years) for fifty-three ambulatory patients with spastic diplegic cerebral palsy and stiff-knee gait treated with standardized distal rectus femoris transfer as a part of multilevel surgery. Standardized three-dimensional gait analysis and clinical examination were carried out before surgery and at one year and nine years after surgery. Patients with decreased peak knee flexion in swing phase who had distal rectus femoris transfer to correct the decreased peak knee flexion in swing phase (C-DRFT) were evaluated separately from those with normal or increased peak knee flexion in swing phase who had distal rectus femoris transfer done as a prophylactic procedure (P-DRFT). RESULTS A significantly increased peak knee flexion in swing phase was found in the C-DRFT group one year after surgery, while a significant loss (15°) in peak knee flexion in swing phase was noted in the P-DRFT group. A slight but not significant increase in peak knee flexion in swing phase in both groups was noted at the time of the long-term follow-up. A significant improvement in timing of peak knee flexion in swing phase was only found for the C-DRFT group, and was maintained after nine years. Knee motion and knee flexion velocity were significantly increased in both groups and were maintained at long-term follow-up in the C-DRFT group, while the P-DRFT showed a deterioration of knee motion. CONCLUSIONS Distal rectus femoris transfer is an effective procedure to treat stiff-knee gait featuring decreased peak knee flexion in swing phase and leads to a long-lasting increase of peak knee flexion in swing phase nine years after surgery. Patients with more involvement showed a greater potential to benefit from distal rectus femoris transfer. However, 18% of the patients showed a permanently poor response and 15% developed recurrence. In patients with severe knee flexion who underwent a prophylactic distal rectus femoris transfer, a significant loss in peak knee flexion in swing phase was noted and thus a prophylactic distal rectus femoris transfer may not be indicated in these patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Longitudinal Observation of Changes in Pain Sensitivity during Opioid Tapering in Patients with Chronic Low‐Back Pain

OBJECTIVE   Several studies have shown that exposure to opioids for short or long periods alters pain sensitivity. Little is known about changes in pain sensitivity during and after tapering of long-term prescribed opioid treatment in chronic low-back pain (cLBP) patients. DESIGN   The goal of this prospective longitudinal study was to investigate pain sensitivity in a homogeneous patient population (cLBP patients only) after tapering of long-term (17 months) opioid use and to monitor the changes in pain sensitivity for 6 months. METHODS   Pain sensitivity (thermal sensation and thermal pain thresholds in low back and nondominant hand) was measured by quantitative sensory testing (QST) at 1 day before (T1), 3 weeks after (T2), and 6 months after the start of opioid tapering (T3) in 35 patients with both cLBP and opioid medication (OP), 35 opioid-naïve cLBP patients (ON), and 28 individuals with neither pain nor opioid intake (HC). RESULTS   Significant differences in heat pain thresholds were found among the three groups at all three time points (T1: P=0.001, T2: P=0.015, T3: P=0.008), but not between the two patient groups. OP patients showed lower cold pain thresholds at T2 than ON patients and HC. At T3, the heat pain thresholds of OP patients still remained lower than HC (P=0.017), while those of ON patients were normalized. CONCLUSIONS   Our findings suggest that long-term use of opioids does not reduce pain sensitivity in cLBP patients; opioid tapering may induce brief hyperalgesia that can be normalized over a longer period.

Motion capture of the upper extremity during activities of daily living in patients with spastic hemiplegic cerebral palsy

Investigations using motion capture to analyze limitations in range of motion (ROM) of the upper extremity in adults with cerebral palsy (CP) are scarce. To evaluate the influence of those limitations on activities of daily living (ADL) and to determine potential mechanisms of compensation, we investigated 15 adults with hemiplegic CP using motion capture while they performed 10 defined ADLs. Data from the nonaffected body side and those from an age-matched able-bodied group were also collected and compared with our subjects. We measured motion of the elbow, shoulder, and trunk and found significant differences in ROM at these sites. The most pronounced reduction in ROM was observed distally in supination and pronation of the elbow. Here, the affected body side of the adults showed a reduction in supination of 45° compared to the able-bodied group. Furthermore we found a correlation between the Manual Ability Classification System (MACS) and the limitations in ROM. In summary, adults with spastic, hemiplegic CP show limitations in ROM accentuated distally during ADLs. The MACS gives conclusive information about those limitations.

Influence of depression symptoms on serum tumor necrosis factor-α of patients with chronic low back pain.

IntroductionPatients with chronic low back pain (cLBP) have high rates of comorbid psychiatric disorders, mainly depression. Recent evidence suggests that depressive symptoms and pain, as interacting factors, have an effect on the circulating levels of inflammatory markers relevant to coronary artery disease. Our previous work showed a higher serum level of an inflammatory marker tumour necrosis factor-alpha (TNFα) in patients with cLBP, which did not correlate with intensity of low back pain alone. In the present study we investigated the cross-sectional associations of depressive symptoms, low back pain and their interaction with circulating levels of TNFα.MethodsEach group of 29 patients with cLBP alone or with both cLBP and depression was age-matched and sex-matched with 29 healthy controls. All subjects underwent a blood draw for the assessment of serum TNFα and completed a standardised questionnaire regarding medication, depression scores according to the German version of Centre for Epidemiological Studies Depression Scale (CES-D), pain intensity from a visual analogue scale, and back function using the Roland and Morris questionnaire. The correlations between TNFα level and these clinical parameters were analysed.ResultsThere were no differences in TNFα level between cLBP patients with and without depression. Both cLBP patients with (median = 2.51 pg/ml, P = 0.002) and without (median = 2.58 pg/ml, P = 0.004) depression showed significantly higher TNFα serum levels than healthy controls (median = 0 pg/ml). The pain intensity reported by both patient groups was similar, while the patients with depression had higher CES-D scores (P < 0.001) and worse back function (P < 0.001). The variance analysis showed that the interaction between TNFα level and pain intensity, CES-D scores, sex, body mass index and medication was statistically significant.ConclusionsDepression as a comorbidity to cLBP did not influence the serum TNFα level. It seems that TNFα somehow acts as a mediator in both cLBP and depression, involving similar mechanisms that will be interesting to follow in further studies.

Attachment, Symptom Severity, and Depression in Medically Unexplained Musculoskeletal Pain and Osteoarthritis: A Cross-Sectional Study

Background Attachment insecurity relates to the onset and course of chronic pain via dysfunctional reactions to pain. However, few studies have investigated the proportion of insecure attachment styles in different pain conditions, and results regarding associations between attachment, pain severity, and disability in chronic pain are inconsistent. This study aims to clarify the relationships between insecure attachment and occurrence or severity of chronic pain with and without clearly defined organic cause. To detect potential differences in the importance of global and romantic attachment representations, we included both concepts in our study. Methods 85 patients with medically unexplained musculoskeletal pain (UMP) and 89 patients with joint pain from osteoarthritis (OA) completed self-report measures of global and romantic attachment, pain intensity, physical functioning, and depression. Results Patients reporting global insecure attachment representations were more likely to suffer from medically unexplained musculoskeletal pain (OR 3.4), compared to securely attached patients. Romantic attachment did not differ between pain conditions. Pain intensity was associated with romantic attachment anxiety, and this relationship was more pronounced in the OA group compared to the UMP group. Both global and romantic attachment anxiety predicted depression, accounting for 15% and 17% of the variance, respectively. Disability was independent from attachment patterns. Conclusions Our results indicate that global insecure attachment is associated with the experience of medically unexplained musculoskeletal pain, but not with osteoarthritis. In contrast, insecure attachment patterns seem to be linked to pain intensity and pain-related depression in unexplained musculoskeletal pain and in osteoarthritis. These findings suggest that relationship-informed focused treatment strategies may alleviate pain severity and psychological distress in chronic pain independent of underlying pathology.

Does the reverse shoulder prosthesis medialize the center of rotation in the glenohumeral joint

Reverse shoulder arthroplasty is commonly used to improve the function of osteoarthritic shoulders in cases with irreparable refractory rotator cuff-tear arthropathy when conventional prosthesis designs cannot be applied. There is indication that moving the glenohumeral joint center more medially may lead to improved shoulder function by extending the lever arm for the deltoid muscle and facilitating muscle recruitment. However, there is little experimental evidence for this medialization effect. Marker based motion data of pre- and one year postoperative examinations on nine subjects who underwent reverse shoulder arthroplasty were analyzed applying functional methods for joint center estimation. The aim was to determine the location of the functional center of rotation in the operated and the non-operated contralateral side before and after surgery to verify if the joint center of this reverse prosthesis design is located more medially compared to the anatomic situation before surgery. It was shown that the operated shoulders demonstrated a medialization effect of 8.3±4.3mm. For the non-operated side the difference was 0.1±2.3mm, proving the accuracy of measurements.

Multilevel surgery in adults with cerebral palsy

AIMS Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate. METHODS This study analysed the short-term outcome (mean 1.7 years, standard deviation 0.9) of 97 ambulatory adults with BSCP who performed three-dimensional gait analysis before and after SEMLS at one institution. RESULTS Two objective gait variables were calculated pre- and post-operatively; the Gillette Gait Index (GGI) and the Gait Profile Score (GPS). The results were analysed in three groups according to their childhood surgical history (group 1 = no surgery, group 2 = surgery other than SEMLS, group 3 = SEMLS). Improvements in gait were shown by a significant decrease of GPS (p = 0.001). Similar results were obtained for both legs (GGI right side and left side p = 0.01). Furthermore, significant improvements were found in all subgroups although this was less marked in group 3, where patients had undergone previous SEMLS. DISCUSSION SEMLS is an effective and safe procedure to improve gait in adults with cerebral palsy. However, a longer rehabilitation period is to be expected than found in children. SEMLS is still effective in adult patients who have undergone previous SEMLS in childhood. TAKE HOME MESSAGE Single-event multilevel surgery is a safe and effective procedure to improve gait disorders in adults with bilateral spastic cerebral palsy.