- Email: [email protected]
Single event multilevel surgery in children with spastic cerebral palsy: 5 year follow-up of a RCT cohort
S48
Abstracts / Gait & Posture 36 (2012) S1–S101
Reference [1] Westhoff, et al. Gait Posture 2006.
doi:10.1016/j.gaitpost.2011.10.260
muscle function during gait and principal components analysis to determine key factors contributing to gait impairment. The findings have implications for the understanding of gait in this condition, and for the evaluation of outcome following surgery. Disclosure: No significant relationships.
O80 Three-dimensional gait analysis in cervical spondylotic myelopathy: Comparison with age- and gender-matched healthy controls
Reference [1] Maezawa Y, Uchida K, Baba H. Journal of Orthopaedic Science 2001;6(5):378–84.
A. Malone 1,∗ , D. Meldrum 1 , C. Bolger 2 1
School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland 2 Department of Neurosurgery, Beaumot Hospital, Dublin, Ireland
Introduction: Gait impairment is a primary symptom of cervical spondylotic myelopathy (CSM). People with CSM walk more slowly than those without the disorder, and demonstrate changes in range of motion at the knee and ankle [1]. However, information on specific kinetic and kinematic parameters is lacking. Furthermore, gait in CSM has previously been compared with healthy controls walking at self-selected, faster speeds. Gait speed is a known confounding factor for kinematic and kinetic parameters, therefore comparison with healthy controls at matched speed is necessary to determine true, non-speed dependent differences in CSM. The objectives of this study were to compare gait patterns of people with untreated CSM to those of age and gender-matched healthy controls, and to examine the effect of speed on the observed kinematic and kinetic parameters. Patients/materials and methods: Ethical approval was obtained from a local ethics committee. Participants with a diagnosis of CSM were recruited consecutively from a neurosurgery clinic between December 2008 and October 2010. Healthy controls, matched to age (within 5 years) and gender, were recruited for comparison from a local population. Participants with CSM and controls underwent three-dimensional gait analysis using a Vicon motion analysis system, at self-selected speed over a 10 m track. Controls were also assessed at the speed of the person with CSM to whom they were matched. The average temporal–spatial, kinematic and kinetic parameters from 10 trials of each participant were used for analysis. Results: Sixteen people with CSM and 16 healthy controls were recruited. Compared to healthy controls at self-selected speed, the CSM group walked significantly more slowly (p < 0.001), with shorter stride lengths (p < 0.001) and longer double support duration (p < 0.001). They were also found to have significant decreases in several kinematic and kinetic parameters, including total sagittal range of motion at the hip (p = 0.004) and knee (p = 0.004), peak ankle plantarflexion (p = 0.013), anteroposterior ground reaction force (GRF) at toe-off (p < 0.001), power absorption at the knee in loading response (K1, p = 0.002) and terminal stance (K4, p < 0.001), and power generation at the ankle (A2, p < 0.001). At matched speed, the CSM group showed significant decreases in knee flexion during swing (p = 0.006), total sagittal knee range of motion (p = 0.028), peak ankle plantarflexion (p = 0.018), and anteroposterior GRF (p = 0.02). Ankle A2 power was also reduced, but this was not statistically significant (p = 0.075). Discussion and conclusion: People with CSM were found to have significant gait abnormalities that have not been previously reported. At matched speed, differences persisted in kinematic and kinetic parameters of the knee and ankle at terminal stance and initial swing, suggesting that there are key differences in the motor strategies of people with CSM in these phases of gait that cannot be explained by speed alone. Further investigation of motor control strategies in CSM is warranted, using electromyography to evaluate
doi:10.1016/j.gaitpost.2011.10.261 O81 Single event multilevel surgery in children with spastic cerebral palsy: 5 year follow-up of a RCT cohort P.J. Thomason 1,∗ , P. Selber 2 , H.K. Graham 3 1 Hugh Williamson Gait Analysis Laboratory, Royal Children’s Hospital, Parkville, VIC, Australia 2 Department of Orthopaedics, Royal Children’s Hospital, Parkville, VIC, Australia 3 Paediatric Orthopaedics, The University of Melbourne, Parkville, VIC, Australia
Introduction: By mid childhood most children with CP will develop fixed deformities which may require surgical correction. The use of instrumented gait analysis has allowed surgeons to determine what specific procedures are required for each child. Surgeons combine these procedures into a single definitive procedure known as single event multilevel surgery (SEMLS). SEMLS improves the gait of children with CP 12 months after surgery with improvement in function observed at 24 months [1], but is this improvement maintained over time? The objective of this study is to evaluate the outcome of SEMLS at 5 years post surgery. Patients/materials and methods: Nineteen children with spastic diplegic CP, GMFCS Levels II (14) and III (5), mean age of 9.7 (range 7.7–12.2) years who participated in a RCT to have either SEMLS immediately or after a 12 month delay have been followed prospectively. All children regardless of group were assessed pre SEMLS, 1, 2 and 5 years post SEMLS. Outcome measures were the Gillette Gait Index (GGI), Gait Deviation Index (GDI), Gait Profile Score (GPS), Gross Motor Function Measure 66 (GMFM66). Results: All 19 children have completed 2 year follow-up, 15 have completed 5 year follow-up. One child has been excluded from analysis because his diagnosis has been changed from CP. Gait measures were calculated for 4 gait traces for each leg for each child then averaged, prior to comparison. Data were analyzed using linear regression. Results are presented in Table 1. There were no significant difference between gait measures between 1–5 and 2–5years. There was a small trend for deterioration in the gait parameters. GMFM showed a non significant deterioration and at 5 years was not significantly different from pre SEMLS. Discussion and conclusion: This study shows gait improvements are maintained 5 years post SEMLS. here is a trend for deterioration in gross motor function between 2 and 5 years. This may be due to children having their adolescent growth spurt or may be an expression of the natural history of functional deterioration in CP. However, function remains 1.7% better than pre SEMLS. SEMLS is the standard of care to improve gait and functioning in children with spastic diplegic CP. Improvements in gait are maintained at 5 years post SEMLS. Non significant trend for deterioration in function may be related to the natural progression of musculoskeletal pathology in CP. Disclosure: No significant relationships.
Abstracts / Gait & Posture 36 (2012) S1–S101
S49
Table 1 Mean (95% CI) gait measures and GMFM66 pre, 1, 2 and 5 years post SEMLS; linear regression of 5 years compared to pre, 1, 2 years post SEMLS. Measure mean (95% CI)
Post SEMLS 5 years, n = 15
GPS Diff 5 years (95% CI) GGI Diff 5 years (95% CI) GDI Diff 5 years (95% CI) GMFM66 Diff 5 years (95% CI)
9.67 (8.2, 11.1) 148 (99, 196) 79.0 (73.7, 84.3) 68.7 (61.1, 76.2)
2 years, n = 18
1 year, n = 18
9.23 (8.1, 10.3) −0.44 (−1.6, 0.67) 135 (100, 170) −12.7 (−40.8, 15.5) 80.8 (76.4, 85.3) 1.8 (−2.6,6.3) 71.0 (66.1, 75.8) −2.3 (−6.7, 2.1)
Pre, n = 18
9.9 (8.6, 11.2) 0.26 (−1.2, 1.7) 152 (111, 192) 4.1 (−36.5, 44.6) 78.0 (73.7, 82.3) −1 (−6.2,4.2) 67.1 (62.3, 71.8) 1.6 (−3.4, 6.6)
14.9 (12.9, 16.8) 5.2 (3.3, 7.1)# 360 (259, 460) 212 (127.5, 297)# 65.2 (60.4, 69.9) −13.8 (−19.1,−8.5)# 66.9 (61.2, 72.6) 1.7 (−2.4, 5.9)
Reference [1] Thomason P, et al. Single-event multilevel surgery in children with spastic diplegia: a pilot RCT. J Bone Joint Surg Am 2011;93:451–60.
doi:10.1016/j.gaitpost.2011.10.262 O82 Long-term outcome of femoral derotation osteotomy in spastic diplegia T. Dreher ∗ , B. Swartman, S.I. Wolf, J. Korber, W. Schuster, P. Armbrust, F. Braatz Department of Orthopaedic Surgery and Traumatology, University of Heidelberg, Heidelberg, Germany Introduction: Internal rotation gait is a common gait disorder in spastic diplegia [1] and accompanied by several functional problems. Femoral derotation osteotomy (FDO) is accepted as the standard corrective procedure [2]. Initial satisfactory results were reported by various studies [3]. However, there are only a handful studies addressing the “longer-term” outcome. While Kim found recurrence of internal rotation after 5 years [4], Ounpuu postulated its maintenance after the same time [5]. There are no reports about the clinical course beyond this period, which is of particular interest, especially since many patients are still in growth after surgery. The purpose of this study was the evaluation of clinical course in grown-up patients at least 6 years after FDO carried out in childhood. Patients/materials and methods: 33 children with diplegic CP (n = 59 legs, age: 10.5 ± 3.6 years) with functional disturbing internal rotation gait were examined pre-, 1 ± 0 year and 9 ± 2 years (mean age: 18.9 ± 3.2) after distal (27 legs) or proximal (32 legs) FDO as a part of multilevel surgery. Standardized clinical exam and 3D gait-analysis were carried out in all subjects at all examinations. The intra-operative derotation amount averaged 25◦ . Results: Significant improvements were found for all parameters 1 year after FDO, which showed a slight but significant deterioration after 9 years (Fig. 1 and Table 1) Discussion and conclusion: Increased femoral anteversion and dynamic components (spasticity of internal rotators, compensatory mechanisms) are discussed as possible factors leading to internal rotation gait. Since FDO is frequently carried out in growing children and only addresses femoral anteversion, the long-term development after FDO is of major importance. Only few studies exist reporting inconsistent results 5 years after FDO [4,5]. The results of the present study indicate that FDO leads to satisfactory initial correction. However, a mild but significant deterioration 9 years after FDO could be found. This development may be explained by the clinical course of specifically 7 cases showing prominent recurrence of internal rotation gait. Those cases need to be fur-
Fig. 1. Transversal plane kinematics. The mean values of mean hip rotation (, solid line) and mean foot progression angle (䊉, dashed line) in stance of all 59 legs at all three examination dates are displayed.
Table 1 Mean values of all legs pre- and post-surgical ± (1 SD); clinical mid-point according to Kerr (Gait Posture 2003;17:88–91). Parameters
Pre-op
1 year post
9 years post
Mean hip rotation ST Mean foot progression ST Mean pelvic rotation ST Mid-point in 90◦ hip flex. Mid-point in hip ext.
17.7 (12.0) 15.6 (16.1) 0.3 (8.2) 10 (11) 20 (13)
−1.0 (11.3)# −3.1 (9.8)# 0.7 (6.0) −5 (10)# 6 (9)#
4.3 (13.6)# , + 1.9 (11.2)# , + 0.8 (7.5) −3 (7)# , + 11 (9)# , +
# +
Significant difference to pre-op (t-test, p < 0.01). Significant difference to 1-year postop (t-test, p < 0.01).
ther addressed for a better outcome prediction. It is not sufficient to take only the increased femoral anteversion into account when planning correction of internal rotation gait. Dynamic components as well as growth should be considered as possible factors leading to recurrence. Disclosure: No significant relationships. References [1] [2] [3] [4] [5]
Wren TAL, et al. J Pediatr Orthop 2005;25:79–83. Pirpiris M, et al. J Bone Joint Surg Br 2003;85:265–72. Kay RM, et al. J Pediatr Orthop 2003;23:150–4. Kim H, et al. J Pediatr Orthop 2005;25:739–43. Ounpuu S, et al. J Pediatr Orthop 2002;22:139–45.
doi:10.1016/j.gaitpost.2011.10.263
Abstracts / Gait & Posture 36 (2012) S1–S101
Reference [1] Westhoff, et al. Gait Posture 2006.
doi:10.1016/j.gaitpost.2011.10.260
muscle function during gait and principal components analysis to determine key factors contributing to gait impairment. The findings have implications for the understanding of gait in this condition, and for the evaluation of outcome following surgery. Disclosure: No significant relationships.
O80 Three-dimensional gait analysis in cervical spondylotic myelopathy: Comparison with age- and gender-matched healthy controls
Reference [1] Maezawa Y, Uchida K, Baba H. Journal of Orthopaedic Science 2001;6(5):378–84.
A. Malone 1,∗ , D. Meldrum 1 , C. Bolger 2 1
School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland 2 Department of Neurosurgery, Beaumot Hospital, Dublin, Ireland
Introduction: Gait impairment is a primary symptom of cervical spondylotic myelopathy (CSM). People with CSM walk more slowly than those without the disorder, and demonstrate changes in range of motion at the knee and ankle [1]. However, information on specific kinetic and kinematic parameters is lacking. Furthermore, gait in CSM has previously been compared with healthy controls walking at self-selected, faster speeds. Gait speed is a known confounding factor for kinematic and kinetic parameters, therefore comparison with healthy controls at matched speed is necessary to determine true, non-speed dependent differences in CSM. The objectives of this study were to compare gait patterns of people with untreated CSM to those of age and gender-matched healthy controls, and to examine the effect of speed on the observed kinematic and kinetic parameters. Patients/materials and methods: Ethical approval was obtained from a local ethics committee. Participants with a diagnosis of CSM were recruited consecutively from a neurosurgery clinic between December 2008 and October 2010. Healthy controls, matched to age (within 5 years) and gender, were recruited for comparison from a local population. Participants with CSM and controls underwent three-dimensional gait analysis using a Vicon motion analysis system, at self-selected speed over a 10 m track. Controls were also assessed at the speed of the person with CSM to whom they were matched. The average temporal–spatial, kinematic and kinetic parameters from 10 trials of each participant were used for analysis. Results: Sixteen people with CSM and 16 healthy controls were recruited. Compared to healthy controls at self-selected speed, the CSM group walked significantly more slowly (p < 0.001), with shorter stride lengths (p < 0.001) and longer double support duration (p < 0.001). They were also found to have significant decreases in several kinematic and kinetic parameters, including total sagittal range of motion at the hip (p = 0.004) and knee (p = 0.004), peak ankle plantarflexion (p = 0.013), anteroposterior ground reaction force (GRF) at toe-off (p < 0.001), power absorption at the knee in loading response (K1, p = 0.002) and terminal stance (K4, p < 0.001), and power generation at the ankle (A2, p < 0.001). At matched speed, the CSM group showed significant decreases in knee flexion during swing (p = 0.006), total sagittal knee range of motion (p = 0.028), peak ankle plantarflexion (p = 0.018), and anteroposterior GRF (p = 0.02). Ankle A2 power was also reduced, but this was not statistically significant (p = 0.075). Discussion and conclusion: People with CSM were found to have significant gait abnormalities that have not been previously reported. At matched speed, differences persisted in kinematic and kinetic parameters of the knee and ankle at terminal stance and initial swing, suggesting that there are key differences in the motor strategies of people with CSM in these phases of gait that cannot be explained by speed alone. Further investigation of motor control strategies in CSM is warranted, using electromyography to evaluate
doi:10.1016/j.gaitpost.2011.10.261 O81 Single event multilevel surgery in children with spastic cerebral palsy: 5 year follow-up of a RCT cohort P.J. Thomason 1,∗ , P. Selber 2 , H.K. Graham 3 1 Hugh Williamson Gait Analysis Laboratory, Royal Children’s Hospital, Parkville, VIC, Australia 2 Department of Orthopaedics, Royal Children’s Hospital, Parkville, VIC, Australia 3 Paediatric Orthopaedics, The University of Melbourne, Parkville, VIC, Australia
Introduction: By mid childhood most children with CP will develop fixed deformities which may require surgical correction. The use of instrumented gait analysis has allowed surgeons to determine what specific procedures are required for each child. Surgeons combine these procedures into a single definitive procedure known as single event multilevel surgery (SEMLS). SEMLS improves the gait of children with CP 12 months after surgery with improvement in function observed at 24 months [1], but is this improvement maintained over time? The objective of this study is to evaluate the outcome of SEMLS at 5 years post surgery. Patients/materials and methods: Nineteen children with spastic diplegic CP, GMFCS Levels II (14) and III (5), mean age of 9.7 (range 7.7–12.2) years who participated in a RCT to have either SEMLS immediately or after a 12 month delay have been followed prospectively. All children regardless of group were assessed pre SEMLS, 1, 2 and 5 years post SEMLS. Outcome measures were the Gillette Gait Index (GGI), Gait Deviation Index (GDI), Gait Profile Score (GPS), Gross Motor Function Measure 66 (GMFM66). Results: All 19 children have completed 2 year follow-up, 15 have completed 5 year follow-up. One child has been excluded from analysis because his diagnosis has been changed from CP. Gait measures were calculated for 4 gait traces for each leg for each child then averaged, prior to comparison. Data were analyzed using linear regression. Results are presented in Table 1. There were no significant difference between gait measures between 1–5 and 2–5years. There was a small trend for deterioration in the gait parameters. GMFM showed a non significant deterioration and at 5 years was not significantly different from pre SEMLS. Discussion and conclusion: This study shows gait improvements are maintained 5 years post SEMLS. here is a trend for deterioration in gross motor function between 2 and 5 years. This may be due to children having their adolescent growth spurt or may be an expression of the natural history of functional deterioration in CP. However, function remains 1.7% better than pre SEMLS. SEMLS is the standard of care to improve gait and functioning in children with spastic diplegic CP. Improvements in gait are maintained at 5 years post SEMLS. Non significant trend for deterioration in function may be related to the natural progression of musculoskeletal pathology in CP. Disclosure: No significant relationships.
Abstracts / Gait & Posture 36 (2012) S1–S101
S49
Table 1 Mean (95% CI) gait measures and GMFM66 pre, 1, 2 and 5 years post SEMLS; linear regression of 5 years compared to pre, 1, 2 years post SEMLS. Measure mean (95% CI)
Post SEMLS 5 years, n = 15
GPS Diff 5 years (95% CI) GGI Diff 5 years (95% CI) GDI Diff 5 years (95% CI) GMFM66 Diff 5 years (95% CI)
9.67 (8.2, 11.1) 148 (99, 196) 79.0 (73.7, 84.3) 68.7 (61.1, 76.2)
2 years, n = 18
1 year, n = 18
9.23 (8.1, 10.3) −0.44 (−1.6, 0.67) 135 (100, 170) −12.7 (−40.8, 15.5) 80.8 (76.4, 85.3) 1.8 (−2.6,6.3) 71.0 (66.1, 75.8) −2.3 (−6.7, 2.1)
Pre, n = 18
9.9 (8.6, 11.2) 0.26 (−1.2, 1.7) 152 (111, 192) 4.1 (−36.5, 44.6) 78.0 (73.7, 82.3) −1 (−6.2,4.2) 67.1 (62.3, 71.8) 1.6 (−3.4, 6.6)
14.9 (12.9, 16.8) 5.2 (3.3, 7.1)# 360 (259, 460) 212 (127.5, 297)# 65.2 (60.4, 69.9) −13.8 (−19.1,−8.5)# 66.9 (61.2, 72.6) 1.7 (−2.4, 5.9)
Reference [1] Thomason P, et al. Single-event multilevel surgery in children with spastic diplegia: a pilot RCT. J Bone Joint Surg Am 2011;93:451–60.
doi:10.1016/j.gaitpost.2011.10.262 O82 Long-term outcome of femoral derotation osteotomy in spastic diplegia T. Dreher ∗ , B. Swartman, S.I. Wolf, J. Korber, W. Schuster, P. Armbrust, F. Braatz Department of Orthopaedic Surgery and Traumatology, University of Heidelberg, Heidelberg, Germany Introduction: Internal rotation gait is a common gait disorder in spastic diplegia [1] and accompanied by several functional problems. Femoral derotation osteotomy (FDO) is accepted as the standard corrective procedure [2]. Initial satisfactory results were reported by various studies [3]. However, there are only a handful studies addressing the “longer-term” outcome. While Kim found recurrence of internal rotation after 5 years [4], Ounpuu postulated its maintenance after the same time [5]. There are no reports about the clinical course beyond this period, which is of particular interest, especially since many patients are still in growth after surgery. The purpose of this study was the evaluation of clinical course in grown-up patients at least 6 years after FDO carried out in childhood. Patients/materials and methods: 33 children with diplegic CP (n = 59 legs, age: 10.5 ± 3.6 years) with functional disturbing internal rotation gait were examined pre-, 1 ± 0 year and 9 ± 2 years (mean age: 18.9 ± 3.2) after distal (27 legs) or proximal (32 legs) FDO as a part of multilevel surgery. Standardized clinical exam and 3D gait-analysis were carried out in all subjects at all examinations. The intra-operative derotation amount averaged 25◦ . Results: Significant improvements were found for all parameters 1 year after FDO, which showed a slight but significant deterioration after 9 years (Fig. 1 and Table 1) Discussion and conclusion: Increased femoral anteversion and dynamic components (spasticity of internal rotators, compensatory mechanisms) are discussed as possible factors leading to internal rotation gait. Since FDO is frequently carried out in growing children and only addresses femoral anteversion, the long-term development after FDO is of major importance. Only few studies exist reporting inconsistent results 5 years after FDO [4,5]. The results of the present study indicate that FDO leads to satisfactory initial correction. However, a mild but significant deterioration 9 years after FDO could be found. This development may be explained by the clinical course of specifically 7 cases showing prominent recurrence of internal rotation gait. Those cases need to be fur-
Fig. 1. Transversal plane kinematics. The mean values of mean hip rotation (, solid line) and mean foot progression angle (䊉, dashed line) in stance of all 59 legs at all three examination dates are displayed.
Table 1 Mean values of all legs pre- and post-surgical ± (1 SD); clinical mid-point according to Kerr (Gait Posture 2003;17:88–91). Parameters
Pre-op
1 year post
9 years post
Mean hip rotation ST Mean foot progression ST Mean pelvic rotation ST Mid-point in 90◦ hip flex. Mid-point in hip ext.
17.7 (12.0) 15.6 (16.1) 0.3 (8.2) 10 (11) 20 (13)
−1.0 (11.3)# −3.1 (9.8)# 0.7 (6.0) −5 (10)# 6 (9)#
4.3 (13.6)# , + 1.9 (11.2)# , + 0.8 (7.5) −3 (7)# , + 11 (9)# , +
# +
Significant difference to pre-op (t-test, p < 0.01). Significant difference to 1-year postop (t-test, p < 0.01).
ther addressed for a better outcome prediction. It is not sufficient to take only the increased femoral anteversion into account when planning correction of internal rotation gait. Dynamic components as well as growth should be considered as possible factors leading to recurrence. Disclosure: No significant relationships. References [1] [2] [3] [4] [5]
Wren TAL, et al. J Pediatr Orthop 2005;25:79–83. Pirpiris M, et al. J Bone Joint Surg Br 2003;85:265–72. Kay RM, et al. J Pediatr Orthop 2003;23:150–4. Kim H, et al. J Pediatr Orthop 2005;25:739–43. Ounpuu S, et al. J Pediatr Orthop 2002;22:139–45.
doi:10.1016/j.gaitpost.2011.10.263