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Proximal rectus femoris release does not influence the effects of distal rectus femoris transfer on the knee in cerebral palsy
ESMAC 2012 abstract / Gait & Posture 38 (2013) S1–S116
Reference [1] Ma FY, Selber P, Nattrass GR, Harvey AR, Wolfe R, Graham HK. Lengthening and transfer of hamstrings for a flexion deformity of the knee in children with bilateral cerebral palsy. Journal of Bone and Joint Surgery – British Volume 2006;88B:248–54.
http://dx.doi.org/10.1016/j.gaitpost.2013.07.078 O65 Supervised classification of the effect of hamstrings lengthening in cerebral palsy children after single event multilevel surgery
S39
validation and 6.5% in generalization. In view of the classification system 1/3 of G1 LL were not improved by HL. Discussion and conclusions: This supervised classification and data conditioning techniques are able to categorize the specific effect of HL among all the associated performed procedures in two classes “positive effect” and “not-positive effect”. While 83% of patients were improved by SEMLS, HL had positively contributed to this improvement in only 70% of these cases. This methodology can be generalized to study the effect of other surgical procedures.
Reference [1] Schwartz M., Rozumalski A., Gait and Posture, 28(3), 351–357.
Eric Desailly 1 , Abdennour Sebsadji 1 , Daniel Yepremian 1 , Khalifa Djemal 2 , Philippe Hoppenot 2 , Néjib Khouri 3,1
http://dx.doi.org/10.1016/j.gaitpost.2013.07.079 O66
1 Fondation Ellen Poidatz, Motion Analysis Unit, St Fargeau Ponthierry, France 2 Université d’Evry, IBISC, Evry, France 3 Armand Trousseau Hospital, Department of Pediatric Orthopaedic Surgery, Paris, France
Proximal rectus femoris release does not influence the effects of distal rectus femoris transfer on the knee in cerebral palsy
Introduction: Single event multilevel surgery (SEMLS) purpose is to improve the cerebral palsy (CP) children’s gait by associating multiple surgeries on the same therapeutic time. It is therefore complex to isolate the effect of these actions in this multifocal context. To address this problem we chose to specifically identify the effect of hamstrings lengthening (HL) in CP children with crouch gait. The aims of this study were to describe the specific parameters influenced by HL and to classify the positive or not-positive effect of HL in SEMLS. Patients/materials and methods: 42 CP children (12 ± 3 years) were divided into two groups: 31 (G1 = 60 lower limbs (LL)) and 11 (G2 = 20 LL), respectively having followed and not-followed HL among all the associated surgeries. All patients had clinical gait analysis before and 1.9 ± 0.8 years after surgery. The GDI is calculated [1]. All kinematic data (angles, velocities) were doublenormalized and conditioned in two vectors. A homogeneity test (G1 vs G2) selected the kinematic parameters influenced by HL (t-test, p < 0.005). Principal component analysis identified the minimum descriptors characterizing the effect of HL. Several classifiers (Regularized Discriminant Analysis (RDA) and linear or nonlinear Support Vector Machines (SVM)) were supervised by 6 experts’ opinions. Experts’ opinions were based on video and kinematic curves comparison between pre and post-surgery conditions. The classifiers performances in learning, validation (leave one out) and generalization were compared. Results: GDI results showed that 83% of the subjects of G1 were globally improved by SEMLS. Among all the kinematic data, 16 sub-vectors, significantly influenced by HL were selected. Their dimensionality was reduced by principal component analysis. The 6 experts have classified the effect of HL for 37 LL: 24 were positive and 13 not-positive. The classification method with the best performance was the linear SVM with error rate 0% in learning, 5.4% in
Dóra Vegvari 1 , Sebastian I. Wolf 2 , Daniel Heitzmann 2 , Frank Braatz 2 , Matthias Klotz 2 , Thomas Dreher 2 1 Semmelweis University, Department of Orthopaedics, Budapest, Hungary 2 Heidelberg University Clinics, Department for Orthopedics and Trauma Surgery, Heidelberg, Germany
Introduction: Dysfunction of the biarticular rectus femoris (RF) muscle is common among CP children [1,2]. While the proximal part works as a hip flexor, the distal part extends the knee [3]. In CP children with increased anterior pelvic tilt and hip flexion contracture proximal RF release was considered [4]. At the knee, pathological RF activation leads to stiff knee gait, which is commonly treated by distal rectus femoris transfer (DRFT) [1,2]. The benefits after DRFT for knee joint motion are well described. However, no reports evaluated if a concomitant proximal RF release affects the knee kinematics. Patients/materials and methods: In a matched pair analysis, the short- and long-term outcome of 20 patients with spastic diplegic cerebral palsy, who were treated with DRFT and concomitant proximal RF release (RTRR group) was compared with the outcome of 20 patients, in which DRFT but no proximal RF release (RT group) was done. The matching criteria included: maximum knee flexion in swing and ROM in swing as well as age at surgery, BMI and GGI. Standardized three-dimensional gait analysis was done before (E0), 1 year (E1) and 8–9 years (E2; RT: 8.1 ± 2.1; RTRR: 9.2 ± 2.2) after surgery. Results: Knee kinematics no group differences were found at any examination (Table 1). Peak knee flexion in swing (pKFSw) showed a slight but not significant increase in both groups at E1. While this was maintained in RTRR group at E2, there was a minimal
Table 1 Gait analysis outcome. RT
Mean anterior pelvic tilt pKFSw Timing of pKFSw Knee ROM in swing Knee flexion velocity
[deg.] [deg.] [%GC] [deg] [deq./%GCl
RTRR
Group diff
E0
E1
E2
E0
E1
E2
167) 52(12) 81()4 22(8) 0.8(0.4)
19(7) 55(8) 79 (5)* 37(10)* 1.2(0.4)*
17(9) 53(10) 78 (3)* 34(11)* 1.0 (0.5)*
20(7) 51 (10) 80 (5) 22 (8) 0.8 (0.3)
22(7) 54(9) 78(5) 37(10)* 1.2 (0.4)*
20(7) 55(8) 78(5) 33(10)* 1.0(0–6)*
Two-way ANOVA: * significant difference from E0, pKFSw [peak knee flexion in swing). ROM (range of motion).
E0,E1 – – – –
S40
ESMAC 2012 abstract / Gait & Posture 38 (2013) S1–S116
but not significant decrease in RT group. Timing of pKFSw, range of knee flexion and knee flexion velocity improved after surgery but tended to deteriorate over the years in either group. Discussion and conclusions: The results of the present study for the first time suggest that the influences of proximal RF release on DRFT effects on the knee joint are negligible. Two possible explanations should be considered. First, the findings may be explained by a permanent elimination of RF function on the knee after DRFT, which would be unaffected by proximal release and would underline the efficiency of DRFT. Secondly, surgery in the proximal part does not influence the distal part. This would represent a new impact on function of biarticular muscles with a clinical importance for treatment planning in CP. References
enjoyed moving more. The operation enabled a change in functioning and possibility to maintain mobility in the future. Second category included unrealistic expectations before the operation and perception of deterioration in mobility over time after the operation. Participants related this to the fast growth period, other surgical procedures and giving up intensive physiotherapy. Perception of deterioration was combined with contentment and acceptance of current abilities and disability as a permanent part of life. Discussion and conclusions: The study revealed valuable insights from young people‘s perspectives. They viewed that multilevel surgery improved their physical functioning and were satisfied with their ability to participate in age related activities five years after surgery even though deterioration of abilities was both experienced and seen in quantitative data.
[1] Gage JR, Perry J, et al. Developmental Medicine and Child Neurology 1987;29, 159- 66. [2] Saw A, et al. Journal of Pediatric Orthopaedics 2003;23, 672- 8. [3] Markee JE, et al. Journal of Bone and Joint Surgery American Volume 1955;37, 125-42 7. [4] Sutherland DH, et al. Journal of Pediatric Orthopaedics 1990;10, 433- 41.
[1] McGinley, et al. Developmental Medicine and Child 2012;54(2):117–28. ˚ [2] Akerlind G. Teaching in Higher Education 2008;13(6):633–44.
http://dx.doi.org/10.1016/j.gaitpost.2013.07.080
http://dx.doi.org/10.1016/j.gaitpost.2013.07.081
O67
O68
The impact of multilevel surgery on functional abilities and participation in adolescents with cerebral palsy (CP)
Gait status of adults with bilateral spastic cerebral palsy more than 15 years after orthopaedic interventions
Krista Lehtonen 1,2 , Nea Vänskä 2 , Tuula Niemelä 3 , Arja Piirainen 2 , Helena Mäenpää 3
Nelleke G. Langerak 1 , Robert P. Lamberts 2 , John Cockcroft 3 , Jacques Du Toit 4 , Graham Fieggen 5
1 Metropolia University of Applied Sciences, Helsinki, Finland 2 University of Jyväskylä, Finland 3 Helsinki University Hospital for Children and Adolescents, HUCH, Helsinki, Finland
1
Introduction: The outcome of Single Event Multilevel Surgery (SEMLS) has mainly been studied by using quantitative data eg. gait analysis. The focus has been on body functions and structure and on activities (gait) classified according to WHO International Classification of Functioning, Disability and Health (ICF) domains. There is growing evidence that SEMLS can improve gait. Functional abilities and changes in ICF participation domain have been studied less [1]. The purpose of this mixed method study was to evaluate the long-term effectiveness of SEMLS in children with CP on physical functioning and coping in real life environment. This paper shares the pilot results from an ongoing project in Helsinki University Central Hospital (HUCH). Patients/materials and methods: The participants were 8 adolescents with CP (GMFCS II-IV, age at operation 10,1–14,8 years) who had SEMLS in HUCH. In this study quantitative data was collected from both gait analysis (3D Vicon System, UK) and clinical examination done preoperatively and two and five years after. Quantitative data was analysed using SPSS 19. Qualitative data was gathered by interviewing the patients five years or more postoperatively. Sessions were taped, written down and analysed by phenomenographic methology [2]. Results: Quantitative data showed that changes seen 2 years postoperatively in gait kinematics, time-distance parameters and clinical examination results were reduced 5 years postoperatively, when only significant changes were improvements in knee extension and foot progression in stance and popliteal angle ROM. Qualitative data showed that conceptions of the impact of SEMLS formed two main categories. In the first category patients expressed that their mobility, function, gait pattern improved and they
References Neurology
Stellenbosch University, Physiotherapy, Parow, Cape Town, South Africa 2 University of Cape Town, Human Biology, Cape Town, South Africa 3 Stellenbosch University, Mechanical and Mechatronic Engineering, Stellenbosch, South Africa 4 Tygerberg Hospital, Paediatric Orthopaedic Surgery, Parow, Cape Town, South Africa 5 University of Cape Town, Neurosurgery, Cape Town, South Africa
Introduction: In the last decades an increased number of publications focused on the effects of orthopaedic interventions in children with cerebral palsy (CP) [1]. However, there is a lack of information on the long-term effects of these interventions into adulthood. Therefore the aim of this study is to describe the gait
Table 1 Number of subjects who underwent at least one orthopaedic intervention. n(%) Soft- tissue surgery Achilles temdon Gastrocnemiusu Hamstrngs Rectus Femoris Adductors lliopsoas Abd Halluces Longus Tibialis Posterior At least one soft-tissue Surgery Bony Surgery Femoral derotaion Tibial drotation Ankle/foot Toe At least one bony surgery
19 (9 5) 4(20) 11(55) 7(35) 6(30) 5(25) 2(10) 3(15) 20(100) 2(10) 2(10) 5(25) 0(0) 6(30)
Reference [1] Ma FY, Selber P, Nattrass GR, Harvey AR, Wolfe R, Graham HK. Lengthening and transfer of hamstrings for a flexion deformity of the knee in children with bilateral cerebral palsy. Journal of Bone and Joint Surgery – British Volume 2006;88B:248–54.
http://dx.doi.org/10.1016/j.gaitpost.2013.07.078 O65 Supervised classification of the effect of hamstrings lengthening in cerebral palsy children after single event multilevel surgery
S39
validation and 6.5% in generalization. In view of the classification system 1/3 of G1 LL were not improved by HL. Discussion and conclusions: This supervised classification and data conditioning techniques are able to categorize the specific effect of HL among all the associated performed procedures in two classes “positive effect” and “not-positive effect”. While 83% of patients were improved by SEMLS, HL had positively contributed to this improvement in only 70% of these cases. This methodology can be generalized to study the effect of other surgical procedures.
Reference [1] Schwartz M., Rozumalski A., Gait and Posture, 28(3), 351–357.
Eric Desailly 1 , Abdennour Sebsadji 1 , Daniel Yepremian 1 , Khalifa Djemal 2 , Philippe Hoppenot 2 , Néjib Khouri 3,1
http://dx.doi.org/10.1016/j.gaitpost.2013.07.079 O66
1 Fondation Ellen Poidatz, Motion Analysis Unit, St Fargeau Ponthierry, France 2 Université d’Evry, IBISC, Evry, France 3 Armand Trousseau Hospital, Department of Pediatric Orthopaedic Surgery, Paris, France
Proximal rectus femoris release does not influence the effects of distal rectus femoris transfer on the knee in cerebral palsy
Introduction: Single event multilevel surgery (SEMLS) purpose is to improve the cerebral palsy (CP) children’s gait by associating multiple surgeries on the same therapeutic time. It is therefore complex to isolate the effect of these actions in this multifocal context. To address this problem we chose to specifically identify the effect of hamstrings lengthening (HL) in CP children with crouch gait. The aims of this study were to describe the specific parameters influenced by HL and to classify the positive or not-positive effect of HL in SEMLS. Patients/materials and methods: 42 CP children (12 ± 3 years) were divided into two groups: 31 (G1 = 60 lower limbs (LL)) and 11 (G2 = 20 LL), respectively having followed and not-followed HL among all the associated surgeries. All patients had clinical gait analysis before and 1.9 ± 0.8 years after surgery. The GDI is calculated [1]. All kinematic data (angles, velocities) were doublenormalized and conditioned in two vectors. A homogeneity test (G1 vs G2) selected the kinematic parameters influenced by HL (t-test, p < 0.005). Principal component analysis identified the minimum descriptors characterizing the effect of HL. Several classifiers (Regularized Discriminant Analysis (RDA) and linear or nonlinear Support Vector Machines (SVM)) were supervised by 6 experts’ opinions. Experts’ opinions were based on video and kinematic curves comparison between pre and post-surgery conditions. The classifiers performances in learning, validation (leave one out) and generalization were compared. Results: GDI results showed that 83% of the subjects of G1 were globally improved by SEMLS. Among all the kinematic data, 16 sub-vectors, significantly influenced by HL were selected. Their dimensionality was reduced by principal component analysis. The 6 experts have classified the effect of HL for 37 LL: 24 were positive and 13 not-positive. The classification method with the best performance was the linear SVM with error rate 0% in learning, 5.4% in
Dóra Vegvari 1 , Sebastian I. Wolf 2 , Daniel Heitzmann 2 , Frank Braatz 2 , Matthias Klotz 2 , Thomas Dreher 2 1 Semmelweis University, Department of Orthopaedics, Budapest, Hungary 2 Heidelberg University Clinics, Department for Orthopedics and Trauma Surgery, Heidelberg, Germany
Introduction: Dysfunction of the biarticular rectus femoris (RF) muscle is common among CP children [1,2]. While the proximal part works as a hip flexor, the distal part extends the knee [3]. In CP children with increased anterior pelvic tilt and hip flexion contracture proximal RF release was considered [4]. At the knee, pathological RF activation leads to stiff knee gait, which is commonly treated by distal rectus femoris transfer (DRFT) [1,2]. The benefits after DRFT for knee joint motion are well described. However, no reports evaluated if a concomitant proximal RF release affects the knee kinematics. Patients/materials and methods: In a matched pair analysis, the short- and long-term outcome of 20 patients with spastic diplegic cerebral palsy, who were treated with DRFT and concomitant proximal RF release (RTRR group) was compared with the outcome of 20 patients, in which DRFT but no proximal RF release (RT group) was done. The matching criteria included: maximum knee flexion in swing and ROM in swing as well as age at surgery, BMI and GGI. Standardized three-dimensional gait analysis was done before (E0), 1 year (E1) and 8–9 years (E2; RT: 8.1 ± 2.1; RTRR: 9.2 ± 2.2) after surgery. Results: Knee kinematics no group differences were found at any examination (Table 1). Peak knee flexion in swing (pKFSw) showed a slight but not significant increase in both groups at E1. While this was maintained in RTRR group at E2, there was a minimal
Table 1 Gait analysis outcome. RT
Mean anterior pelvic tilt pKFSw Timing of pKFSw Knee ROM in swing Knee flexion velocity
[deg.] [deg.] [%GC] [deg] [deq./%GCl
RTRR
Group diff
E0
E1
E2
E0
E1
E2
167) 52(12) 81()4 22(8) 0.8(0.4)
19(7) 55(8) 79 (5)* 37(10)* 1.2(0.4)*
17(9) 53(10) 78 (3)* 34(11)* 1.0 (0.5)*
20(7) 51 (10) 80 (5) 22 (8) 0.8 (0.3)
22(7) 54(9) 78(5) 37(10)* 1.2 (0.4)*
20(7) 55(8) 78(5) 33(10)* 1.0(0–6)*
Two-way ANOVA: * significant difference from E0, pKFSw [peak knee flexion in swing). ROM (range of motion).
E0,E1 – – – –
S40
ESMAC 2012 abstract / Gait & Posture 38 (2013) S1–S116
but not significant decrease in RT group. Timing of pKFSw, range of knee flexion and knee flexion velocity improved after surgery but tended to deteriorate over the years in either group. Discussion and conclusions: The results of the present study for the first time suggest that the influences of proximal RF release on DRFT effects on the knee joint are negligible. Two possible explanations should be considered. First, the findings may be explained by a permanent elimination of RF function on the knee after DRFT, which would be unaffected by proximal release and would underline the efficiency of DRFT. Secondly, surgery in the proximal part does not influence the distal part. This would represent a new impact on function of biarticular muscles with a clinical importance for treatment planning in CP. References
enjoyed moving more. The operation enabled a change in functioning and possibility to maintain mobility in the future. Second category included unrealistic expectations before the operation and perception of deterioration in mobility over time after the operation. Participants related this to the fast growth period, other surgical procedures and giving up intensive physiotherapy. Perception of deterioration was combined with contentment and acceptance of current abilities and disability as a permanent part of life. Discussion and conclusions: The study revealed valuable insights from young people‘s perspectives. They viewed that multilevel surgery improved their physical functioning and were satisfied with their ability to participate in age related activities five years after surgery even though deterioration of abilities was both experienced and seen in quantitative data.
[1] Gage JR, Perry J, et al. Developmental Medicine and Child Neurology 1987;29, 159- 66. [2] Saw A, et al. Journal of Pediatric Orthopaedics 2003;23, 672- 8. [3] Markee JE, et al. Journal of Bone and Joint Surgery American Volume 1955;37, 125-42 7. [4] Sutherland DH, et al. Journal of Pediatric Orthopaedics 1990;10, 433- 41.
[1] McGinley, et al. Developmental Medicine and Child 2012;54(2):117–28. ˚ [2] Akerlind G. Teaching in Higher Education 2008;13(6):633–44.
http://dx.doi.org/10.1016/j.gaitpost.2013.07.080
http://dx.doi.org/10.1016/j.gaitpost.2013.07.081
O67
O68
The impact of multilevel surgery on functional abilities and participation in adolescents with cerebral palsy (CP)
Gait status of adults with bilateral spastic cerebral palsy more than 15 years after orthopaedic interventions
Krista Lehtonen 1,2 , Nea Vänskä 2 , Tuula Niemelä 3 , Arja Piirainen 2 , Helena Mäenpää 3
Nelleke G. Langerak 1 , Robert P. Lamberts 2 , John Cockcroft 3 , Jacques Du Toit 4 , Graham Fieggen 5
1 Metropolia University of Applied Sciences, Helsinki, Finland 2 University of Jyväskylä, Finland 3 Helsinki University Hospital for Children and Adolescents, HUCH, Helsinki, Finland
1
Introduction: The outcome of Single Event Multilevel Surgery (SEMLS) has mainly been studied by using quantitative data eg. gait analysis. The focus has been on body functions and structure and on activities (gait) classified according to WHO International Classification of Functioning, Disability and Health (ICF) domains. There is growing evidence that SEMLS can improve gait. Functional abilities and changes in ICF participation domain have been studied less [1]. The purpose of this mixed method study was to evaluate the long-term effectiveness of SEMLS in children with CP on physical functioning and coping in real life environment. This paper shares the pilot results from an ongoing project in Helsinki University Central Hospital (HUCH). Patients/materials and methods: The participants were 8 adolescents with CP (GMFCS II-IV, age at operation 10,1–14,8 years) who had SEMLS in HUCH. In this study quantitative data was collected from both gait analysis (3D Vicon System, UK) and clinical examination done preoperatively and two and five years after. Quantitative data was analysed using SPSS 19. Qualitative data was gathered by interviewing the patients five years or more postoperatively. Sessions were taped, written down and analysed by phenomenographic methology [2]. Results: Quantitative data showed that changes seen 2 years postoperatively in gait kinematics, time-distance parameters and clinical examination results were reduced 5 years postoperatively, when only significant changes were improvements in knee extension and foot progression in stance and popliteal angle ROM. Qualitative data showed that conceptions of the impact of SEMLS formed two main categories. In the first category patients expressed that their mobility, function, gait pattern improved and they
References Neurology
Stellenbosch University, Physiotherapy, Parow, Cape Town, South Africa 2 University of Cape Town, Human Biology, Cape Town, South Africa 3 Stellenbosch University, Mechanical and Mechatronic Engineering, Stellenbosch, South Africa 4 Tygerberg Hospital, Paediatric Orthopaedic Surgery, Parow, Cape Town, South Africa 5 University of Cape Town, Neurosurgery, Cape Town, South Africa
Introduction: In the last decades an increased number of publications focused on the effects of orthopaedic interventions in children with cerebral palsy (CP) [1]. However, there is a lack of information on the long-term effects of these interventions into adulthood. Therefore the aim of this study is to describe the gait
Table 1 Number of subjects who underwent at least one orthopaedic intervention. n(%) Soft- tissue surgery Achilles temdon Gastrocnemiusu Hamstrngs Rectus Femoris Adductors lliopsoas Abd Halluces Longus Tibialis Posterior At least one soft-tissue Surgery Bony Surgery Femoral derotaion Tibial drotation Ankle/foot Toe At least one bony surgery
19 (9 5) 4(20) 11(55) 7(35) 6(30) 5(25) 2(10) 3(15) 20(100) 2(10) 2(10) 5(25) 0(0) 6(30)