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O53: Mid-term results after distal femoral extension osteotomy in children with cerebral palsy (CP) – a musculoskeletal analysis
Gait & Posture xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
O53
Mid-term results after distal femoral extension osteotomy in children with cerebral palsy (CP) – A musculoskeletal analysis ⁎
Mirjam Niklascha, , Stefan van Drongelenb, Julia Wagnera, Julia Brosaa, Matthias Klotza, Sebastian Wolfa, Firooz Salamia, Thomas Drehera a b
University Hospital Heidelberg, Heidelberg, Germany Orthopedic University Hospital Friedrichsheim gGmbH, Frankfurt, Germany
1. Introduction Flexed knee gait is a common gait deformity in children with CP and is surgically treated by hamstring lengthening or distal femoral extension (shortening) osteotomy (DFEO) with or without additional patellar tendon advancement (PTA). While previous studies showed that hamstring lengthening might lead to an increased anterior pelvic tilt and genu recurvatum in the long-term follow-up (more than 4 years postop) after satisfying short-term results, long-term data after DFEO (+ PTA) are still missing. DFEO (+PTA) is preferred in many centres for ambulatory children.
devices. Exclusion criteria were an additional hamstring lengthening and any botulinum toxin injections in the lower limbs. Kinematic data of 3D gait analysis were determined with the Plugin-gait model. Subject specific musculoskeletal models were created with OpenSim 3.3 using the generic musculoskeletal model 2392. The ‛Thelen 2003 muscle model’ [1] was used to determine peak muscle tendon length (MTL) and peak velocity of the hamstrings (M. semitendinosus, M. semimembranosus). Normal distribution of all parameters was confirmed by Shapiro-Wilk test. Significance level was set at p < 0.05. 4. Results
2. Research question How do both kinematics and muscle tendon length (MTL) and ve-
preop → postop postop → mid-term preop → mid-term
Peak MTL (hamstrings)
Peak Velocity (hamstrings)
Max knee flexion in stance phase
Max knee flexion in swing phase
Mean hip flexion in stance phase
Mean pelvic tilt in stance phase
↑ (p < 0.001) ↔ (p > 0.097) ↑ (p < 0.017)
↔ (p > 0.394) ↔ (p > 0.060) ↑ (p < 0.032)
↓ (p < 0.001) ↔ (p=0.176) ↓ (p < 0.001)
↓ (p=0.010) ↔ (p=0.211) ↓ (p=0.002)
↓ (p=0.004) ↑ (p=0.042) ↔ (p=0.071)
↔ (p=0.129) ↔ (p=0.980) ↔ (p=0.111)
locity of hamstrings change in the mid-term follow-up (2–5 years postop) after DFEO? 3. Methods 10 limbs of 8 children [12 ± 4 years] with bilateral spastic CP that received a DFEO with (4 limbs) or without (6 limbs) additional PTA in the context of SEMLS were retrospectively included in the study. Inclusion criterion was a pre-, one year postoperative and mid-term (3 ± 1 year postop, [24–55months]) gait analysis without assistive walking
⁎
(↑ = significant increase, ↓ significant decrease, ↔ no significant change)
Corresponding author.
http://dx.doi.org/10.1016/j.gaitpost.2017.06.307
0966-6362/ © 2017 Elsevier B.V. All rights reserved.
In the mid-term follow-up a decreased knee flexion in stance and swing phase and faster and longer hamstrings were seen compared to the preoperative assessment. There was no change in pelvic tilt and hip flexion. 5. Discussion To our knowledge, this is the first study assessing mid-term outcomes after DFEO. In contrast to former studies [2,3] who described increased anterior pelvic tilt after DFEO with additional PTA, we saw
Gait & Posture xxx (xxxx) xxx–xxx
M. Niklasch et al.
results are even more surprising, as the last follow-up in this study is performed during or past the pubertal growth spurt and the children gained 15 ± 14 cm in body height and 8 ± 9cm in leg length between the first and last exam.
no change in pelvic tilt over the whole period. This might have two reasons: In the present study, patients with and without PTA were included and besides all gait analyses were performed without walking devices, which themselves can lead to increased anterior pelvic tilt [4]. This study suggests that DFEO leads to longer hamstrings immediately and also faster hamstrings over the time. Similar results were described by Healy [5] after a follow-up of 7–36 months. Although the results of this study have limitations due to the small number of patients and the relatively “short” period of follow-up (only 24–55 months), it can be concluded, that recurrence of flexed knee gait and increased pelvic tilt are less probable after DFEO than after hamstring lengthening. The
References [1] [2] [3] [4] [5]
2
D.G. Thelen, ASME J. Biomech. Eng. 125 (1) (2003) 70–77. Klotz, et al. World J. Pediatr. December (2016) [epub ahead of print]. Stout, et al. J. Bone Joint Surg. Am. 90 (11) (2008) 2470–2484. Krautwurst, et al. Gait Posture 46 (2016) 184–187. Healy, et al. Gait Posture 33 (1) (2011) 1–5.
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
O53
Mid-term results after distal femoral extension osteotomy in children with cerebral palsy (CP) – A musculoskeletal analysis ⁎
Mirjam Niklascha, , Stefan van Drongelenb, Julia Wagnera, Julia Brosaa, Matthias Klotza, Sebastian Wolfa, Firooz Salamia, Thomas Drehera a b
University Hospital Heidelberg, Heidelberg, Germany Orthopedic University Hospital Friedrichsheim gGmbH, Frankfurt, Germany
1. Introduction Flexed knee gait is a common gait deformity in children with CP and is surgically treated by hamstring lengthening or distal femoral extension (shortening) osteotomy (DFEO) with or without additional patellar tendon advancement (PTA). While previous studies showed that hamstring lengthening might lead to an increased anterior pelvic tilt and genu recurvatum in the long-term follow-up (more than 4 years postop) after satisfying short-term results, long-term data after DFEO (+ PTA) are still missing. DFEO (+PTA) is preferred in many centres for ambulatory children.
devices. Exclusion criteria were an additional hamstring lengthening and any botulinum toxin injections in the lower limbs. Kinematic data of 3D gait analysis were determined with the Plugin-gait model. Subject specific musculoskeletal models were created with OpenSim 3.3 using the generic musculoskeletal model 2392. The ‛Thelen 2003 muscle model’ [1] was used to determine peak muscle tendon length (MTL) and peak velocity of the hamstrings (M. semitendinosus, M. semimembranosus). Normal distribution of all parameters was confirmed by Shapiro-Wilk test. Significance level was set at p < 0.05. 4. Results
2. Research question How do both kinematics and muscle tendon length (MTL) and ve-
preop → postop postop → mid-term preop → mid-term
Peak MTL (hamstrings)
Peak Velocity (hamstrings)
Max knee flexion in stance phase
Max knee flexion in swing phase
Mean hip flexion in stance phase
Mean pelvic tilt in stance phase
↑ (p < 0.001) ↔ (p > 0.097) ↑ (p < 0.017)
↔ (p > 0.394) ↔ (p > 0.060) ↑ (p < 0.032)
↓ (p < 0.001) ↔ (p=0.176) ↓ (p < 0.001)
↓ (p=0.010) ↔ (p=0.211) ↓ (p=0.002)
↓ (p=0.004) ↑ (p=0.042) ↔ (p=0.071)
↔ (p=0.129) ↔ (p=0.980) ↔ (p=0.111)
locity of hamstrings change in the mid-term follow-up (2–5 years postop) after DFEO? 3. Methods 10 limbs of 8 children [12 ± 4 years] with bilateral spastic CP that received a DFEO with (4 limbs) or without (6 limbs) additional PTA in the context of SEMLS were retrospectively included in the study. Inclusion criterion was a pre-, one year postoperative and mid-term (3 ± 1 year postop, [24–55months]) gait analysis without assistive walking
⁎
(↑ = significant increase, ↓ significant decrease, ↔ no significant change)
Corresponding author.
http://dx.doi.org/10.1016/j.gaitpost.2017.06.307
0966-6362/ © 2017 Elsevier B.V. All rights reserved.
In the mid-term follow-up a decreased knee flexion in stance and swing phase and faster and longer hamstrings were seen compared to the preoperative assessment. There was no change in pelvic tilt and hip flexion. 5. Discussion To our knowledge, this is the first study assessing mid-term outcomes after DFEO. In contrast to former studies [2,3] who described increased anterior pelvic tilt after DFEO with additional PTA, we saw
Gait & Posture xxx (xxxx) xxx–xxx
M. Niklasch et al.
results are even more surprising, as the last follow-up in this study is performed during or past the pubertal growth spurt and the children gained 15 ± 14 cm in body height and 8 ± 9cm in leg length between the first and last exam.
no change in pelvic tilt over the whole period. This might have two reasons: In the present study, patients with and without PTA were included and besides all gait analyses were performed without walking devices, which themselves can lead to increased anterior pelvic tilt [4]. This study suggests that DFEO leads to longer hamstrings immediately and also faster hamstrings over the time. Similar results were described by Healy [5] after a follow-up of 7–36 months. Although the results of this study have limitations due to the small number of patients and the relatively “short” period of follow-up (only 24–55 months), it can be concluded, that recurrence of flexed knee gait and increased pelvic tilt are less probable after DFEO than after hamstring lengthening. The
References [1] [2] [3] [4] [5]
2
D.G. Thelen, ASME J. Biomech. Eng. 125 (1) (2003) 70–77. Klotz, et al. World J. Pediatr. December (2016) [epub ahead of print]. Stout, et al. J. Bone Joint Surg. Am. 90 (11) (2008) 2470–2484. Krautwurst, et al. Gait Posture 46 (2016) 184–187. Healy, et al. Gait Posture 33 (1) (2011) 1–5.