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Ponseti method has superior functional outcome to surgery in clubfoot – Prospective randomized long-term trial
Gait & Posture 42S (2015) S1–S101
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
24th Annual Meeting of ESMAC 2015 Abstracts
Session OS01 Best-Paper-Session – Outcomes A kinematic analysis of one-leg vertical jump on average 23 years after injury of the anterior cruciate ligament J. Markström ∗ , E. Tengman, C. Häger Umeå University, Umeå, Sweden Research question: Are there differences in jump height and hip and knee kinematics between persons treated with surgery in combination with physiotherapy, or with physiotherapy only, and age- and gender-matched controls during one- leg vertical jump approximately 20 years after unilateral ACL injury? Introduction: Injury of the anterior cruciate ligament (ACL) may lead to reduced knee function in the long term, regardless of whether initial treatment includes surgery or is solely physiotherapy. The full impact of the injury is debatable and movement patterns long after injury are unknown. It would seem important to investigate knee and adjacent joint kinematics in the long term after different treatments to examine consequences of ACL injury. Materials and methods: Sixty-six persons with unilateral ACL injury on average 23 ± 2 years post injury performed the one-leg vertical jump. Thirty-two had been treated with physiotherapy and ACL reconstruction (ACLR: age 46 ± 5, BMI 27.1 ± 3.3, 20 men) and 34 with physiotherapy alone (ACLPT: age 48 ± 6, BMI 28.7 ± 4.3, 21 men). We also tested 33 age-and-gender matched controls (C: age 47 ± 5, BMI 24.6 ± 2.5, 21 men) [1]. The highest jump of three trials for each participant was analysed with jump height and maximal knee and hip joint angles (flexion/extension, adduction/abduction, and internal/external rotation) as outcome measures during Takeoff (TO) and Landing (La) phases. The TO was defined from maximal knee flexion in the initial squat movement to ground reaction force <10 N, and La was defined from ground reaction force >10 N to maximal knee flexion. An eight-camera movement analysis system (Oqus, Qualisys AB, 240 Hz) and one force plate (custom made) were used. MANOVAs with discriminant analyses as followup analysis were used for the injured leg of the ACL-subjects compared to the dominant leg of controls, and the non-injured leg of the ACL-subjects compared to the non-dominant leg of controls. Results: Significant main effects of group were found in both TO and La (p < 0.05 and p < 0.01, respectively) for the injured and the dominant legs. Discriminant analysis confirmed these results and separated ACLPT from ACLR and C in both phases. There was also
0966-6362/$ – see front matter
a significant difference for the non-injured legs between groups in TO (p < 0.05) where ACLPT was separated from ACLR and C. No significant difference was observed for the non-injured leg in La between groups. Discussion: This is to our knowledge the first study to examine hip and knee kinematics of the one-leg vertical jump in an ACL-injured population. Such long term investigations after ACL injury are rare, thus providing unique insights. Interestingly, ACLPT presented movement patterns that differed from both ACLR and C in both the injured and non-injured leg, whereas no differences between ACLR and C were found. These findings provide insights into the consequences of ACL injury in the long term with regard to treatment. Reference [1] Tengman E, et al. ACL injury after more than 20 years: I. Scand J Med Sci Sports 2014;24(6):491–500.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.010
Session OS01 Best-Paper-Session – Outcomes Ponseti method has superior functional outcome to surgery in clubfoot – Prospective randomized long-term trial M. Svehlik ∗ , G. Steinwender, U. Floh, T. Kraus Medizinische Universität Graz, University Klinik für Kinderchirurgie, Graz, Austria Research question: Is Ponseti method of casting more beneficial and functional treatment in children with idiopathic clubfoot deformity compared to surgical release? Introduction: In the last 20 years, the treatment of idiopathic clubfoot has shifted from extensive surgical release to conservative Ponseti method. However, long-term outcomes and randomized prospective trials comparing functional outcomes of both methods are lacking. Materials and methods: In 2001 we began a single center, prospective, randomized, controlled trial with a parallel design. Twenty-four feet in 15 patients were randomly divided into two groups: 12 ft received Ponseti casting and 12 ft were treated by McKey–Simons surgical procedure. The average follow-up for the present study was 10 years. To compare the morphology, functional, radiologic and subjective outcomes between the groups, several outcome measures were used (ICFSG = International Club-
S2
ESMAC Abstracts 2015 / Gait & Posture 42S (2015) S1–S101
foot Study Group score, PODCI = Pediatric outcomes Data Collection Instrument and FRS = Functional Rating Score). Moreover, instrumented 3D gait analysis using the Oxford Foot Model was performed. The results were compared statistically by a nonparametric Mann–Whitney U test. Results: Both groups were comparable at the beginning of treatment with no significant difference in the Pirani score (p = 0.623). After 9.8 years of follow-up the Ponseti group presented superior in morphology (p = 0.024), functional (p = 0.006) as well as radiologic (p = 0.023) evaluation according to ICFSG. Also PODCI (p = 0.016) and FRS (p = 0.005) showed better functional status of children treated with the Ponseti method. Children treated with surgery had more troubles performing sports (p = 0.003) and experienced more pain (p = 0.006), which might also led to inferior results in happiness domain of PODCI (p = 0.03). Moreover, the gait analysis showed deficient hindfoot dorsiflexion (p = 0.039) in the surgical group. The forefoot kinematics did not show any differences between groups. Discussion: The most important finding comparing the longterm outcomes of Ponseti and surgical treatment is the increased stiffness and decreased range of motion at the ankle joint. The most probable reason for that is the scarring. Over time and with longer follow-up studies surgeons began to realize that scarring can lead to stiffness, residual and/or recurrent deformity and pain. This negatively influenced the activities of daily living and resulted in a significantly poorer outcome within the PODCI. The most important limitation of the study is a smaller number of included subjects and therefore limited power of the study. This long-term, prospective, randomized and controlled trial showed the Ponseti method to be superior to surgical treatment in idiopathic clubfeet. Thanks to better morphology, function, radiological outcomes as well as the patient’s overall health and a better ability to participate in activities of daily living seems Ponseti method be a low cost low-tec technique available for the widest spectrum of patients. http://dx.doi.org/10.1016/j.gaitpost.2015.06.011
Session OS01 Best-Paper-Session – Outcomes Long-term effects of patellar tendon advancement on patella height and proximal tibial growth J. Stout 1,∗ , C. Beimesch 2 , R. Varghese 3 , M. Schwartz 1 , T. Novacheck 1 1
Gillette Children’s Specialty Healthcare, Center for Gait & Motion Analysis, St. Paul, United States 2 Shriners Hospitals for Children-Shreveport, Pediatric Orthopaedic Surgeon, Shreveport, United States 3 Johns Hopkins Children’s Center, Baltimore, United States Research question: What are the long-term effects of PTA prior to skeletal maturity on patella height and proximal tibia growth? Introduction: Correcting extensor lag using patellar tendon advancement (PTA) is an essential aspect of the treatment of crouch gait in children with cerebral palsy (CP). When performed prior to skeletal maturity, the patellar tendon is shaved from the tibial tubercle preserving the proximal tibial growth plate [1,2]. Concerns exist for potential altered growth, early physeal closure, patella baja, and clinical recurvatum [3]. The altered loads
on the skeletally immature anterior tibia have not been fully evaluated. Materials and methods: A retrospective radiographic review was conducted of patients who underwent PTA prior to skeletal maturity. Patients had a minimum of 3 years of expected growth remaining at the time of surgery. All had a diagnosis of CP. Koshino Index (KI) and tibial-physeal angle (TPA) were measured to assess patellar height and growth of the proximal tibia on pre-operative, 3 month post-operative, and yearly follow-up X-rays (minimum 3 years or until skeletal maturity). The change of KI and TPA over time was evaluated. A step-wise linear regression was used for analysis. Predictor variables included: age at surgery, time from surgery, surgery type, amount of deformity, and amount of correction. Results: Thirty-eight patients (average age: 11.6 ± 1.5 years; 23 male, 15 female) met inclusion criteria. Average length of follow-up was 4.3 ± 1.5 years. 83% had reached skeletal maturity at final measurement. All TPA measurements were within typical limits pre-operatively. Average pre-op KI Z-score was 1.3. KI demonstrated an over-correction immediately post-surgery (average −3.3) and remained stable at final follow-up (average −2.9). TPA measurements remained within typical limits for most subjects. Regression analysis revealed main effects for age at surgery, time from surgery, and amount of correction, but not whether DFEO was performed (p < .001). Significant interactions were noted between: (1) age at surgery and time from surgery; (2) age at surgery and amount of correction; and (3) time from surgery and amount of correction (p < .001). Growth arrest was identified in 2 patients (4 knees). The percentage change in TPA between radiographs was greater in those subjects. Seven subjects were noted to exhibit recurvatum in at least one knee after surgery. Recurvatum was not exclusive to change in TPA beyond typical values. Discussion: PTA in patients prior to skeletal maturity is not associated with progressive patella baja, changes in physeal slope or recurvatum with subsequent growth. Change in TPA over time is a useful monitor of proximal tibial growth status after PTA. Age at PTA and amount of correction appear to be predictors for alterations of proximal tibial growth. Conservative management to delay PTA until closer to the end of growth is recommended. References [1] Stout JL, et al. J Bone Joint Surg 2008;90:2470–84. [2] Novacheck TF, et al. J Bone Joint Surg 2009;91(Suppl. 2):71–86. [3] Patthanacharoenphon C, et al. J Child Orthop 2013;7:139–46.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.012
Session OS01 Best-Paper-Session – Outcomes Predicting surgery effect on knee kinematics in cerebral palsy C.O.A. Galarraga 1,∗ , V. Vigneron 2 , B. Dorizzi 3 , N. Khouri 4 , E. Desailly 5 1 Fondation Ellen Poidatz, IBISC, Université d’Evry Val d’Essonne, St Fargeau-Ponthierry, France 2 IBISC, Université d’Evry Val d’Essonne, Courcouronnes, France 3 SAMOVAR, TELECOM SudParis, Evry, France 4 Fondation Ellen Poidatz, Hôpital Necker-Enfants Malades, Paris, France 5 Fondation Ellen Poidatz, St Fargeau-Ponthierry, France
Research question: Can we predict orthopedic surgery effect on knee flexion during gait of cerebral palsy (CP) children?
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
24th Annual Meeting of ESMAC 2015 Abstracts
Session OS01 Best-Paper-Session – Outcomes A kinematic analysis of one-leg vertical jump on average 23 years after injury of the anterior cruciate ligament J. Markström ∗ , E. Tengman, C. Häger Umeå University, Umeå, Sweden Research question: Are there differences in jump height and hip and knee kinematics between persons treated with surgery in combination with physiotherapy, or with physiotherapy only, and age- and gender-matched controls during one- leg vertical jump approximately 20 years after unilateral ACL injury? Introduction: Injury of the anterior cruciate ligament (ACL) may lead to reduced knee function in the long term, regardless of whether initial treatment includes surgery or is solely physiotherapy. The full impact of the injury is debatable and movement patterns long after injury are unknown. It would seem important to investigate knee and adjacent joint kinematics in the long term after different treatments to examine consequences of ACL injury. Materials and methods: Sixty-six persons with unilateral ACL injury on average 23 ± 2 years post injury performed the one-leg vertical jump. Thirty-two had been treated with physiotherapy and ACL reconstruction (ACLR: age 46 ± 5, BMI 27.1 ± 3.3, 20 men) and 34 with physiotherapy alone (ACLPT: age 48 ± 6, BMI 28.7 ± 4.3, 21 men). We also tested 33 age-and-gender matched controls (C: age 47 ± 5, BMI 24.6 ± 2.5, 21 men) [1]. The highest jump of three trials for each participant was analysed with jump height and maximal knee and hip joint angles (flexion/extension, adduction/abduction, and internal/external rotation) as outcome measures during Takeoff (TO) and Landing (La) phases. The TO was defined from maximal knee flexion in the initial squat movement to ground reaction force <10 N, and La was defined from ground reaction force >10 N to maximal knee flexion. An eight-camera movement analysis system (Oqus, Qualisys AB, 240 Hz) and one force plate (custom made) were used. MANOVAs with discriminant analyses as followup analysis were used for the injured leg of the ACL-subjects compared to the dominant leg of controls, and the non-injured leg of the ACL-subjects compared to the non-dominant leg of controls. Results: Significant main effects of group were found in both TO and La (p < 0.05 and p < 0.01, respectively) for the injured and the dominant legs. Discriminant analysis confirmed these results and separated ACLPT from ACLR and C in both phases. There was also
0966-6362/$ – see front matter
a significant difference for the non-injured legs between groups in TO (p < 0.05) where ACLPT was separated from ACLR and C. No significant difference was observed for the non-injured leg in La between groups. Discussion: This is to our knowledge the first study to examine hip and knee kinematics of the one-leg vertical jump in an ACL-injured population. Such long term investigations after ACL injury are rare, thus providing unique insights. Interestingly, ACLPT presented movement patterns that differed from both ACLR and C in both the injured and non-injured leg, whereas no differences between ACLR and C were found. These findings provide insights into the consequences of ACL injury in the long term with regard to treatment. Reference [1] Tengman E, et al. ACL injury after more than 20 years: I. Scand J Med Sci Sports 2014;24(6):491–500.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.010
Session OS01 Best-Paper-Session – Outcomes Ponseti method has superior functional outcome to surgery in clubfoot – Prospective randomized long-term trial M. Svehlik ∗ , G. Steinwender, U. Floh, T. Kraus Medizinische Universität Graz, University Klinik für Kinderchirurgie, Graz, Austria Research question: Is Ponseti method of casting more beneficial and functional treatment in children with idiopathic clubfoot deformity compared to surgical release? Introduction: In the last 20 years, the treatment of idiopathic clubfoot has shifted from extensive surgical release to conservative Ponseti method. However, long-term outcomes and randomized prospective trials comparing functional outcomes of both methods are lacking. Materials and methods: In 2001 we began a single center, prospective, randomized, controlled trial with a parallel design. Twenty-four feet in 15 patients were randomly divided into two groups: 12 ft received Ponseti casting and 12 ft were treated by McKey–Simons surgical procedure. The average follow-up for the present study was 10 years. To compare the morphology, functional, radiologic and subjective outcomes between the groups, several outcome measures were used (ICFSG = International Club-
S2
ESMAC Abstracts 2015 / Gait & Posture 42S (2015) S1–S101
foot Study Group score, PODCI = Pediatric outcomes Data Collection Instrument and FRS = Functional Rating Score). Moreover, instrumented 3D gait analysis using the Oxford Foot Model was performed. The results were compared statistically by a nonparametric Mann–Whitney U test. Results: Both groups were comparable at the beginning of treatment with no significant difference in the Pirani score (p = 0.623). After 9.8 years of follow-up the Ponseti group presented superior in morphology (p = 0.024), functional (p = 0.006) as well as radiologic (p = 0.023) evaluation according to ICFSG. Also PODCI (p = 0.016) and FRS (p = 0.005) showed better functional status of children treated with the Ponseti method. Children treated with surgery had more troubles performing sports (p = 0.003) and experienced more pain (p = 0.006), which might also led to inferior results in happiness domain of PODCI (p = 0.03). Moreover, the gait analysis showed deficient hindfoot dorsiflexion (p = 0.039) in the surgical group. The forefoot kinematics did not show any differences between groups. Discussion: The most important finding comparing the longterm outcomes of Ponseti and surgical treatment is the increased stiffness and decreased range of motion at the ankle joint. The most probable reason for that is the scarring. Over time and with longer follow-up studies surgeons began to realize that scarring can lead to stiffness, residual and/or recurrent deformity and pain. This negatively influenced the activities of daily living and resulted in a significantly poorer outcome within the PODCI. The most important limitation of the study is a smaller number of included subjects and therefore limited power of the study. This long-term, prospective, randomized and controlled trial showed the Ponseti method to be superior to surgical treatment in idiopathic clubfeet. Thanks to better morphology, function, radiological outcomes as well as the patient’s overall health and a better ability to participate in activities of daily living seems Ponseti method be a low cost low-tec technique available for the widest spectrum of patients. http://dx.doi.org/10.1016/j.gaitpost.2015.06.011
Session OS01 Best-Paper-Session – Outcomes Long-term effects of patellar tendon advancement on patella height and proximal tibial growth J. Stout 1,∗ , C. Beimesch 2 , R. Varghese 3 , M. Schwartz 1 , T. Novacheck 1 1
Gillette Children’s Specialty Healthcare, Center for Gait & Motion Analysis, St. Paul, United States 2 Shriners Hospitals for Children-Shreveport, Pediatric Orthopaedic Surgeon, Shreveport, United States 3 Johns Hopkins Children’s Center, Baltimore, United States Research question: What are the long-term effects of PTA prior to skeletal maturity on patella height and proximal tibia growth? Introduction: Correcting extensor lag using patellar tendon advancement (PTA) is an essential aspect of the treatment of crouch gait in children with cerebral palsy (CP). When performed prior to skeletal maturity, the patellar tendon is shaved from the tibial tubercle preserving the proximal tibial growth plate [1,2]. Concerns exist for potential altered growth, early physeal closure, patella baja, and clinical recurvatum [3]. The altered loads
on the skeletally immature anterior tibia have not been fully evaluated. Materials and methods: A retrospective radiographic review was conducted of patients who underwent PTA prior to skeletal maturity. Patients had a minimum of 3 years of expected growth remaining at the time of surgery. All had a diagnosis of CP. Koshino Index (KI) and tibial-physeal angle (TPA) were measured to assess patellar height and growth of the proximal tibia on pre-operative, 3 month post-operative, and yearly follow-up X-rays (minimum 3 years or until skeletal maturity). The change of KI and TPA over time was evaluated. A step-wise linear regression was used for analysis. Predictor variables included: age at surgery, time from surgery, surgery type, amount of deformity, and amount of correction. Results: Thirty-eight patients (average age: 11.6 ± 1.5 years; 23 male, 15 female) met inclusion criteria. Average length of follow-up was 4.3 ± 1.5 years. 83% had reached skeletal maturity at final measurement. All TPA measurements were within typical limits pre-operatively. Average pre-op KI Z-score was 1.3. KI demonstrated an over-correction immediately post-surgery (average −3.3) and remained stable at final follow-up (average −2.9). TPA measurements remained within typical limits for most subjects. Regression analysis revealed main effects for age at surgery, time from surgery, and amount of correction, but not whether DFEO was performed (p < .001). Significant interactions were noted between: (1) age at surgery and time from surgery; (2) age at surgery and amount of correction; and (3) time from surgery and amount of correction (p < .001). Growth arrest was identified in 2 patients (4 knees). The percentage change in TPA between radiographs was greater in those subjects. Seven subjects were noted to exhibit recurvatum in at least one knee after surgery. Recurvatum was not exclusive to change in TPA beyond typical values. Discussion: PTA in patients prior to skeletal maturity is not associated with progressive patella baja, changes in physeal slope or recurvatum with subsequent growth. Change in TPA over time is a useful monitor of proximal tibial growth status after PTA. Age at PTA and amount of correction appear to be predictors for alterations of proximal tibial growth. Conservative management to delay PTA until closer to the end of growth is recommended. References [1] Stout JL, et al. J Bone Joint Surg 2008;90:2470–84. [2] Novacheck TF, et al. J Bone Joint Surg 2009;91(Suppl. 2):71–86. [3] Patthanacharoenphon C, et al. J Child Orthop 2013;7:139–46.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.012
Session OS01 Best-Paper-Session – Outcomes Predicting surgery effect on knee kinematics in cerebral palsy C.O.A. Galarraga 1,∗ , V. Vigneron 2 , B. Dorizzi 3 , N. Khouri 4 , E. Desailly 5 1 Fondation Ellen Poidatz, IBISC, Université d’Evry Val d’Essonne, St Fargeau-Ponthierry, France 2 IBISC, Université d’Evry Val d’Essonne, Courcouronnes, France 3 SAMOVAR, TELECOM SudParis, Evry, France 4 Fondation Ellen Poidatz, Hôpital Necker-Enfants Malades, Paris, France 5 Fondation Ellen Poidatz, St Fargeau-Ponthierry, France
Research question: Can we predict orthopedic surgery effect on knee flexion during gait of cerebral palsy (CP) children?