Therapy of intoeing gait in cerebral palsy AOPA-Orlando-German Day, October 2010 F. Braatz MD, S. Wolf PhD
Therapy of intoeing gait in cerebral palsy
AOPA-Orlando-German Day, October 2010
F. Braatz MD, S. Wolf PhD
IntroductionInternal Rotated Gait
• Functional & cosmetic problems
“squinting patella sign” (“knocking knees”)
internal foot progression inefficient foot clearancecompensatory external tibial rotationcompensatory pelvic retraction
Operation
D.E.12 Y.: CP, Diparesis, Derotation Femur35°., Evans, Hemstring Lengthening 07/08D.E.12 Y.: CP, Diparesis, Derotation Femur35°., Evans, Hemstring Lengthening 07/08
Prae OP
Operation
Patient 1
Patient 1
V.T.12 y:Operation 27.11.02:1) FDO right 30° left 20 ° 2) Chopartfusion 3) Rektus-transfer
27.10.2003
25.11.2002
Proximal vs. distal Type
3D Gait Analysis3D Gait Analysis25.11.2002 27.10.2003
Proximal vs. distal Type
Team
Night Splint
Therapy overnight Low-cost Muscle-tone?
Stable hindfoot
KAFOs
With hinges
Night Splint
Foam Connected with a rod
Night Splint
Night Splint-Foam
S.W.A.S.H. –MAO-Orthosis
MAO Orthosis
S.W.A.S.H. Orthosis
Soft Orthosis
Conservative Treatment
Botox® (Typ A) : 1 Viole are
100 MU
Dysport® (Typ A) : 1 Viole are500 MU
3D gait analysis-MRI or CT
20°6°
11° 22°
2°17°
staticdynamic
Materials and Methods
Function vs. Static deformity• Patients
– 30 ambulatory patients with CP (18 male, 12 female)
– age 11.6 ± 2.9 years• Methods
– Gait analysis: mean hip rotation– MRI: femoral anteversion
Dreher et al. Gait Posture 2007;26:25–31Braatz et al. JBJS (submitted)
FDO– techniqueintertrochanteric
supracondylar
a) K-wires (*) placed proximally and b) Osteotomy parallel to the K-wires distally to the derotation line
* * * *
FemurOsteotomy
FDO– technique
c) K-wires (*) are parallel aligned d) After derotation the angle between before the osteotomy and the the two K-wires (*) determines the derotation amount of derotation
** **
FDO– technique
Results
Unpaired, two-tailed t-test for pre-post comparison. P-values <0.05 were regarded as significant .
Exam/Parameter Pre-OP Post-OP p-value
Mean Pelvic Rotation -0.1 ± 6.5 0.0 ± 6.6 0,892
Mean Hip Rotation in Stance 13.8 ± 14.8 0.4 ± 10.2 < 0.001
Foot progression angle 11.1 ± 16.0 -1.3 ± 8.4 < 0.001
Table 2 – Pre- and postoperative results of dynamic examination in gait
Results
Pearson’s correlation
DiscussionSatisfactory results after FDO were reported [1]
However, recent studies found over- and under-corrections [2] and recurrence [3] and discrepancy between intraoperative amount of derotation and functional outcome [2,4]
Femoral anteversion is not useful as predictor for mean hip rotation in gait analysis
Both, static and dynamic component should be taken into account when planning correction of internal rotation gait.
[1] Ounpuu et al., (2002), J Pediatr Orthop., 22, 139–45. [2] Dreher et al., (2007), Gait Posture, 26, 25-31.[3] Kim et al., (2005), J. Pediatr Orthop., 25, 739-743.[4] Kay et al., (2003), J Pediatr Orthop., 23, 150–154.
Materials and Methods48 children with spastic diplegic cerebral palsy and
internal rotation gait underwent multilevel surgery including
85 FDOs
3D Gait Analysis pre- and postoperatively
FDOintertrochanteric 42supracondylar 43Derotation (supramalleolar) 12
Multilevel soft tissue correction
ResultsTime (years) 1,2 2,2 6,1Mean (IRO) 18,0 -0,2 -1,8 3,9SD 13,1 11,1 13,1 12,3
T-Test 0,000 0,730 0,049
pre - post2post1-
post3 0,000 0,022
pre - post3 0,000
Results
-40
-20
0
20
40
60
1 2 3 4
-20.0
-10.0
0.0
10.0
20.0
30.0
40.0
1 2 3 4
Results
-30-20-10
0102030405060
0 5 10 15
age pre-op
IRO
long
term
Mean Hip rotation in stance
-30-20-10
0102030405060
0 5 10 15
age pre-op
IRO
pre
-op
Literature Patients having surgery prior to age 10 were more likely to
show deterioration. Kim H, Aiona M, Sussman M ;J Pediatr Orthop. 2005 Nov-Dec;25(6):739-43.
This trend toward internal rotation with hip flexion was apparent in 15 of the 18 muscle compartments we examined, suggesting that excessive hip flexion may exacerbate internal rotation of the hip.
Delp, S.L. ; J Biomech. 1999 May;32(5):493-501.
Conclusions
Conservative treatment, Physiotherapy, Orthosis
static and dynamic components
Proximal / distal type
asymmetry
Physical examination, X-ray, 3D Gait Analysis, CT/MRI
Thank You!