Is a Three-component Video-based Version of the Foot Posture Index Valid for Assessing Pediatric Patients With Orthopaedic and Neurologic Foot Conditions?

BACKGROUND: The Foot Posture Index-6 (FPI6) is an assessment of foot position that can be useful for patients with orthopaedic complaints. The FPI6 rates six components of foot position from -2 to +2, resulting in a total score on a continuum between -12 (severe cavus or supination) to +12 (severe planus or pronation). The subscores are ratings made by the examiner and are subjective assessments of deformity severity. The FPI6 requires palpation of bony structures around the foot and therefore must be administered live during physical examination. Because it is sometimes impractical to perform these assessments live, such as for retrospective research, a valid and reliable video-based tool would be very useful. QUESTIONS/PURPOSES: This study examines a version of the FPI using three of the original six components to determine: (1) Are scores from the three-component version of the FPI (FPI3) associated with those from the original six-component version (FPI6)? (2) Is the three-component FPI3 as reliable as the original six-component FPI6? (3) Are FPI3 assessments done retrospectively from video as reliable as those done live? METHODS: A retrospective group of 155 participants (106 males; mean age 13 ± 4 years) was studied. All had undergone gait analysis including videotaping and in-person assessment using the FPI6. Ratings for three components (calcaneus inversion/eversion, medial arch congruence, and forefoot abduction/adduction) were extracted yielding an FPI3 score ranging from -6 to +6. The other three components of the FPI6 (talar head palpation, curves above and below the lateral malleolus, talonavicular joint bulge) were excluded from the FPI3. FPI6 and FPI3 scores and side-to-side asymmetry were compared for all participants and for diagnosis subgroups (cerebral palsy and Charcot-Marie-Tooth disease) using a Pearson correlation. Agreement for foot posture categorization between the FPI6 and FPI3 was assessed using weighted kappa. Intra- and interrater reliability of live and video-based assessments for the FPI3 and its components were examined using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. RESULTS: Scores from the FPI3 and FPI6 are highly associated with each other, suggesting the FPI3 is an adequate substitute for the FPI6. FPI6 and FPI3 scores (r = 0.98) and asymmetry (r = 0.96) were highly correlated overall and within the cerebral palsy (r = 0.98 for scores; r = 0.98 for asymmetry) and Charcot-Marie-Tooth (r = 0.96 for scores; r = 0.90 for asymmetry) subgroups (all p < 0.001). Agreement between the FPI6 and FPI3 was high for foot posture categorization (weighted agreement = 95%, weighted κ = 0.88; p < 0.001). Interrater reliability for live ratings was similar for FPI3 and FPI6 and high for both measures (ICC = 0.95 for FPI6 and 0.94 for FPI3; both p < 0.001). High reliability was seen in video versus live ratings for the FPI3 total score and each of its components regardless of whether they were performed by the same (ICC = 0.98) or different (ICC = 0.97) raters (both p < 0.001), and interrater reliability remained high when the FPI3 was scored from video recordings (ICC = 0.96; p < 0.001). CONCLUSION: The FPI3 is valid and reliable when done live or from video or by the same or different examiners. It is suitable for retrospective and multicenter research studies, provided videos are done using standardized protocols. Further research is recommended investigating possible ceiling and floor effects in patients with pathologic conditions.Level of Evidence Level III, diagnostic study.

Natural history of ankle function during gait in youth with Charcot-Marie-Tooth disease types 1 and 2.

BACKGROUND: Charcot-Marie-Tooth disease (CMT) can cause progressive muscle weakness and contracture, leading to gait abnormalities such as increased and delayed peak ankle dorsiflexion and reduced ankle power generation in terminal stance. Understanding strength loss on ankle function during gait is important for interpreting treatment outcomes and evaluating new therapies designed to improve gait. RESEARCH QUESTION: Do ankle kinematics and kinetics vary as a function of age, disease progression with associated loss of muscle strength and CMT type in youth with CMT types 1 and 2? METHODS: A prospective convenience sample of 45 participants with CMT1 and 2, ages 7-22 years, underwent comprehensive gait analysis. Seventeen patients underwent repeat analyses totaling 67 tests. Generalized mixed effects linear modeling was used to compare CMT1 versus CMT2 and to examine the effects of age on ankle strength, range of motion, kinematics, and kinetics within each CMT type. RESULTS: Plantarflexor and dorsiflexor strength were less in CMT2 compared with CMT1 (p ≤ 0.05), while peak dorsiflexion in terminal stance (TST) was greater (p = 0.02). Peak plantarflexion moment and power generation were also less in CMT2 (p ≤ 0.02). In CMT1, peak dorsiflexion in TST increased with age through 13 years (p = 0.004); then plateaued in the normal range (p = 0.73). Peak ankle angle in mid-swing was closely related to the angle in TST (p < 0.001) following a similar pattern with age. In CMT2, no significant associations were observed between age, peak dorsiflexion in TST, and peak ankle angle in mid-swing (p ≥ 0.19). There were no consistent trends with age for individual patients with repeat tests. SIGNIFICANCE: The heterogeneity of joint level impairments and gait kinematics and kinetics point to the importance of having an in-depth understanding of gait at the individual patient level using comprehensive gait analysis including valid and reliable strength measures.

Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review.

Purpose: In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement. Method: A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022. Results: There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates. Conclusion: The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research. Level of evidence: level V.

Stance and swing phase ankle phenotypes in youth with Charcot-Marie-Tooth type 1: An evaluation using comprehensive gait analysis techniques.

BACKGROUND: Charcot-Marie-Tooth disease (CMT) results in muscle weakness and contracture leading to a wide variety of gait issues including atypical ankle kinematics in both stance and swing. Knowledge of the stance and swing phase kinematic patterns for CMT type 1 (CMT1), the most common CMT type, will improve our understanding of expected gait outcomes and treatment needs to improve gait function. RESEARCH QUESTION: What are the stance/swing phase ankle phenotypes in CMT1? METHODS: A prospective convenience sample of 25 participants with CMT1, ages 7-19 years, underwent comprehensive gait analysis following standard procedures. Ankle phenotypes based on peak ankle dorsiflexion in terminal stance and mid-swing were defined and compared using linear mixed models. RESULTS: Patients with CMT1 presented with three stance phase ankle phenotypes: 21 limbs (42 %) with reduced (mean 5°, SD 2°), 19 limbs (38 %) with typical (mean 11°, SD 1°) and 10 limbs (20 %) with excessive (mean 15°, SD 2°) peak dorsiflexion in terminal stance (p < 0.05). There were two swing phase phenotypes: 19 limbs (38 %) with typical (mean -1.7°, SD 1.5°) and 31 limbs (62 %) with excessive (mean -5.6°, SD 1.4°) plantarflexion in mid-swing (p < 0.002). Eleven patients (44 %) had ankles that were classified into different stance groups, and 9 patients (36 %) had ankles that were classified into different swing groups. The most common combination of stance/swing ankle phenotypes was decreased dorsiflexion in terminal stance with increased plantarflexion in mid-swing (16 sides, 32 %). SIGNIFICANCE: This study shows that youth with CMT1 have multiple combinations of combined ankle kinematics for stance and swing. The ankle phenotypes identified in this study reflect contributions of both dorsi/plantarflexor weakness and plantarflexor contracture, which require different treatment approaches. Comprehensive gait analysis can distinguish between multiple ankle phenotypes to assist in determining the most appropriate treatment to improve gait for individual patients.

Assessment of foot alignment and function for ambulatory children with cerebral palsy: Results of a modified Delphi technique consensus study.

Purpose: The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results: Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment. Conclusion: The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy. Level of Evidence: V.

Finding consensus for hamstring surgery in ambulatory children with cerebral palsy using the Delphi method.

Purpose: There is marked variation in indications and techniques for hamstring surgery in children with cerebral palsy. There is particular uncertainty regarding the indications for hamstring transfer compared to traditional hamstring lengthening. The purpose of this study was for an international panel of experts to use the Delphi method to establish consensus indications for hamstring surgery in ambulatory children with cerebral palsy. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with statements regarding hamstring surgery, including surgical indications and techniques, post-operative care, and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither of these thresholds was reached. Results: The panel reached consensus or general agreement for 38 (84%) of 45 statements regarding hamstring surgery. The panel noted the importance of assessing pelvic tilt during gait when considering hamstring surgery, and also that lateral hamstring lengthening is rarely needed, particularly at the index surgery. They noted that repeat hamstring lengthening often has poor outcomes. The panel was divided regarding hamstring transfer surgery, with only half performing such surgery. Conclusion: The results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy. Level of evidence: level V.

Anterior distal femoral hemiepiphysiodesis in children with cerebral palsy: Establishing surgical indications and techniques using the modified Delphi method and literature review.

Purpose: The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. Methods: The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest 2 ratings. Results: For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and smaller (<30 degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture. Conclusion: Anterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery. Level of evidence: V.

Cost savings for single event multilevel surgery in comparison to sequential surgery in ambulatory children with cerebral palsy.

BACKGROUND: The purpose of this study was to determine the differences in billable provider charges between single event multilevel surgery (SEMLS) based on comprehensive gait analysis and a staged surgical approach (SSA) without comprehensive gait analysis for the orthopedic treatment of ambulatory children with cerebral palsy (CP). METHODS: The charges associated with nine common orthopedic surgical combinations (both unilateral and bilateral, soft tissue or soft tissue plus bony) for children with CP were determined and compared between SEMLS and SSA. The charges included surgical, anesthesia, operating room, recovery room, hospital stay, physical therapy, and, for SEMLS only, comprehensive computerized gait analysis. RESULTS: Total charges to complete each combination was higher for SSA than for SEMLS. The differential ranged from $10,247 to $75,069 with the percentage difference ranging from 20% to 47%. The mean difference was $43,606 (p = 0.0002). The dollar difference (r = 0.98, p < 0.0001) and percentage difference (r = 0.79, p = 0.01) were both related to the total charge of the SEMLS surgery. SIGNIFICANCE: Financial costs are lower for SEMLS vs. SSA for the treatment of multilevel gait issues in children with CP. The cost of gait analysis is much smaller than the cost differential between SEMLS and SSA. Although some patients who have SEMLS may need additional orthopedic surgery with associated costs, this is also possible for SSA. Therefore, due to the many benefits of SEMLS, which also include more informed treatment decision-making as well as reduced time away from school and work (for caregivers), SEMLS guided by gait analysis is recommended over SSA for the treatment of gait disorders in children with CP.

Percutaneous hamstring lengthening in cerebral palsy: Technique and gait outcomes based on GMFCS level.

BACKGROUND: Increased knee flexion at initial contact and in stance is a common problem for children with cerebral palsy. Surgical correction with percutaneous hamstring lengthening is an alternative to open hamstring lengthening; however, outcomes are less well documented, and there is concern about increasing anterior pelvic tilt. The purpose of this study was to evaluate the short-term outcomes of percutaneous hamstring lengthenings in children with cerebral palsy using comprehensive gait analysis techniques. RESEARCH QUESTION: Does percutaneous hamstring lengthening improve knee function, and do knee and anterior pelvic tilt outcomes vary by GMFCS level? METHODS: A convenience sample of 52 patients with both pre and post-surgical gait analyses was evaluated retrospectively for changes in gait function in terms of temporal-spatial parameters, kinematics and kinetics. Patients were divided into two GMFCS subgroups: GMFCS level I/II and III. RESULTS: The percutaneous hamstring lengthening results in statistically significant improvements in knee function during gait with increased knee extension at initial contact (mean 32° SD 13° to mean 21° SD 11°, p = 0.000) and improved mean knee flexion in stance (mean 23° SD 12° to mean 16° SD 11°, p = 0.000) for the total study cohort. Beneficial changes were found for knee function in both GMFCS level subgroups; however, there was an increase in pelvic tilt pre to post-surgery in the GMFCS level III subgroup (mean 21° SD 8° to mean 26° SD 6°, p = 0.012) but not the GMFCS level I/II subgroup (mean 18° SD 7° to mean 20° SD 8°, p = 0.427). SIGNIFICANCE: Percutaneous hamstring lengthening can improve knee function for all patients; however, the impact on anterior pelvic tilt varies by GMFCS level, with increasing anterior tilt for GMFCS level III only. This study highlights the importance of understanding differences in surgical outcomes by GMFCS level to better predict post-surgical function.

Distal rectus femoris surgery in children with cerebral palsy: results of a Delphi consensus project.

PURPOSE: The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method. METHODS: The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. RESULTS: Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade. CONCLUSION: This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP. LEVEL OF EVIDENCE: V.

The impact of orthoses on gait in children with Charcot-Marie-Tooth disease.

BACKGROUND: Charcot-Marie-Tooth disease (CMT) results in distal muscle weakness that leads to gait difficulties in both the stance and swing phases, thus limiting function in the community. A primary purpose of ankle foot orthoses (AFOs) is to improve gait function; however, little is known about what AFOs are prescribed and how they benefit children with CMT. RESEARCH QUESTION: To determine the impact of previously prescribed AFOs on gait in children with CMT using comprehensive gait analysis techniques. METHODS: We examined strength, passive range of motion and gait (kinematics, kinetics and temporal-spatial) for barefoot and AFO walking on 15 children with a diagnosis of CMT. Participants used their prescribed AFOs, the design of which varied depending on the patient. Comparisons between barefoot and AFO walking were completed for selected ankle, knee and hip kinematics and kinetics and temporal-spatial parameters. Subgroups were also evaluated based upon specific ankle kinematics relevant to AFO prescription. RESULTS: AFOs resulted in increased walking velocity (0.91, SD 0.31 to 1.13, SD 0.23 m/sec, p = 0.001) and improved ankle kinematics (dorsiflexion in mid-swing: -11, SD 10 to 0, SD 5 degrees, p = 0.0001) and kinetics (peak plantar flexor moment in stance: 0.71, SD 0.30 to 0.85, SD 0.29 Nm/kg, p = 0.001). In patients with increased equinus in swing, AFOs resulted in improved ankle kinematics. In patients with increased dorsiflexion in terminal stance, AFOs did not provide the support that was needed to improve gait function. SIGNIFICANCE: AFOs enhance gait function in children with CMT by improving walking velocity and selected ankle kinematics and kinetics. It is important that the AFO design be aligned with the patient's specific joint level impairment and associated gait dysfunction. Comprehensive gait analysis techniques can measure differences between barefoot and AFO function and help to clarify the most appropriate AFO prescription for an individual child.

Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study.

PURPOSE: Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. METHODS: A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. RESULTS: Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). CONCLUSIONS: The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. LEVEL OF EVIDENCE: V.

Changes in walking velocity and stride parameters with age in children with Charcot-Marie-Tooth disease.

The purpose of this study is to assess how Charcot-Marie-Tooth disease, a group of inherited peripheral neuropathies that result in distal weakness, affects walking velocity over time in comparison to age-matched controls. Comprehensive gait analysis of 57 children (mean age 12.0, SD 3.7 years) compared to 76 age-matched controls (mean age 10.1, SD 3.4 years) demonstrated slower walking velocity (p<0.001) due to both shorter stride length (p<0.001) and diminished cadence (p=0.01). There was higher walking velocity (p<0.001), stride length (p=0.002) and cadence (p<0.001) in patients with dorsiflexor strength ≥3 and higher walking velocity (p=0.001) and cadence (p=0.03) in patients plantar flexor strength ≥4. Analysis of Charcot-Marie-Tooth type 1 and type 2 subgroups showed that walking velocity increased significantly with age in controls (p=0.001) but did not increase in children with either subtype (p>0.54). Stride length increased significantly with age in all groups (p<0.001) but at a slower rate in type 1 and 2 compared to controls. These differences contributed to increasing deficits in walking velocity and stride length with age in type 1 and 2 in comparison to controls, with deficits appearing earlier in type 2. Since the slower walking velocity in children with Charcot-Marie-Tooth disease is primarily due to short stride length, treatments that enable improved stride length, such as plantar flexor strengthening and bracing, may improve walking velocity and associated gait function.

Establishing surgical indications for hamstring lengthening and femoral derotational osteotomy in ambulatory children with cerebral palsy.

PURPOSE: Surgical procedures, such as medial hamstring lengthening (MHL) and femoral derotational osteotomy (FDO), can improve the gait of children with cerebral palsy (CP); however, substantial variation exists in the factors that influence the decision to perform surgery. The purpose of this study was to use expert surgeon opinion through a Delphi technique to establish consensus for indications in ambulatory children with CP. METHODS: A 15-member panel, all established experts with at least nine years' experience in the surgical management of children with CP, was created (mean of 20.81 years' experience). All panel members also had expertise of the use of movement analysis for the assessment of gait disorders in children with CP. The group initially focused on two of the most commonly performed procedures, MHL and FDO, in an attempt to gain consensus (> 80%). This was obtained through a standardized, iterative Delphi process. RESULTS: For MHL, a total of 59 questions were surveyed: 41 indication questions and 18 outcome questions, for which there was consensus on ten indication questions and seven outcomes. For FDO, a total of 55 questions were surveyed: 43 indication questions and 12 outcome questions, for which there was consensus on 29 indication questions and eight outcomes. CONCLUSION: This study is the first to use an expert panel to identify best-practice indications for common surgical procedures of children with CP. The results from this study will allow for more informed evaluation of practice and form the basis for future improvement efforts to standardize surgical recommendations internationally. LEVEL OF EVIDENCE: Level IV.

Comparison of gait patterns and functional measures between Charcot-Marie-Tooth disease type I and II in children to young adults.

INTRODUCTION: Charcot-Marie-Tooth (CMT) disease is an inherited peripheral neuropathy that causes progressive distal extremity nerve degeneration and muscle atrophy which can negatively impact function, gait and quality of life. The purpose of this study was to determine if differences exist in gait patterns, clinical examination and functional measures between CMT type I (CMT1) and type II (CMT2) in childhood to young adults. It was hypothesized that individuals with CMT2 would present with greater ankle weakness, increased and/or prolonged ankle dorsiflexion in stance during gait and demonstrate greater disease severity on the CMT Pediatric Scale (CMTPedS) compared to CMT1. METHODS: Twenty-seven individuals diagnosed with CMT1 or CMT2 underwent three-dimensional gait analysis, clinical examination and evaluation of disease severity using the CMTPedS. Subjects groups were divided based on CMT type: CMT1 (n = 20) and CMT2 (n = 7). RESULTS: CMT2 group presented with a trend towards increased plantar flexion weakness compared to CMT1 of 61.1 ±â€¯58.1 N to 137.9 ±â€¯51.4 N (p < 0.012), respectively. CMT2 presented with significantly decreased dorsiflexion strength, 31.9 ±â€¯30.9 N, compared to CMT1, 80.4 ±â€¯37.4 N, (p < 0.0052) which negatively influenced gait patterns in CMT2. Associated gait findings demonstrated CMT2 group with significantly decreased peak ankle power generation in stance compared to CMT1 (1.46 ±â€¯0.39 W/kg to 3.13 ±â€¯0.98 W/kg respectively) (p < 0.0001). CMT1 was more likely to demonstrate a dorsiflexion moment in loading response than CMT2. There was a consistent trend of a higher score and therefore greater disease severity for CMT2 based on CMTPedS. CONCLUSION: Study results suggest that at a given age, individuals with CMT2 have greater limitations in terms of gait function and disease severity than individuals with CMT1. Overall the CMT2 was shown to have greater gait limitations at the ankle during stance and swing with associated compensatory mechanisms at the knee and hip in swing.

Lower extremity characteristics in recurrent clubfoot: Clinical and gait analysis findings that may influence decisions for additional surgery.

BACKGROUND: Patients with recurrent clubfoot may seek intervention to address impairments that impact gait function. An understanding of these impairments and associated gait issues will provide valuable information about ongoing treatment requirements. RESEARCH QUESTION: The purpose of this study was to describe the prevalence of impairments and associated gait deviations in children with recurrent clubfoot and to evaluate whether these findings differ depending on unilateral or bilateral presentation. METHODS: Eighty-four affected feet (42 unilateral, 21 bilateral) were retrospectively reviewed. History, clinical exam, and gait data were collected. Statistical analysis included evaluations of associations between clinical exam and gait parameters and differences among patients with unilateral versus bilateral clubfoot and a database of healthy controls. RESULTS: The average age was 7.5 ±â€¯3.3 years for unilateral and 7.0 ±â€¯2.8 years for bilateral patients. Patients presented with limited passive ankle dorsiflexion (unilateral/bilateral:67%/57%), limited ankle plantar flexion strength (unilateral/bilateral:53%/55%), metatarsus adductus (unilateral/bilateral:86%/83%) and internal foot-thigh angles (unilateral/bilateral:83%/82%), while only a subset presented with internal bi-malleolar axis angles (unilateral/bilateral:36%/45%). The most common gait deviations were internal foot progression (unilateral/bilateral:76%/73%), external hip rotation (unilateral/bilateral:66%/69%), reduced peak ankle plantar flexion moments (unilateral/bilateral:84%/83%), and reduced peak ankle power generation (unilateral/bilateral:67%/74%). Passive dorsiflexion was significantly correlated with peak dorsiflexion during stance and swing in both groups. Patients with unilateral compared to bilateral clubfoot showed decreased peak dorsiflexion and an associated knee flexor moment. SIGNIFICANCE: Patients with recurrent clubfoot show gait deviations at the ankle that can be explained by joint level impairment and compensations at the knee, hip and pelvis. Patients with unilateral clubfoot typically show decreased dorsiflexion range of motion and associated greater gait impacts and compensations than bilateral clubfoot. Understanding the relationships between impairments and gait function and the implications of unilateral versus bilateral clubfoot will help improve prognostic ability and optimize future treatment outcomes.

Long-term outcomes of external femoral derotation osteotomies in children with cerebral palsy.

External femoral derotation osteotomy (FDO) is an orthopaedic intervention to correct increased femoral anteversion and associated excessive internal hip rotation and internal foot progression during gait in children with cerebral palsy. The resulting functional issues may include clearance problems and hip abductor lever-arm dysfunction. The purpose of this study was to evaluate long-term gait outcomes of FDO. Twenty ambulatory patients (27 sides) with cerebral palsy who underwent pre-operative (P0) and a one year post-operative (P1) gait analysis as part of the standard of care had a second post-operative analysis (P2) approximately 11 years post-surgical intervention. Mean hip rotation in stance showed statistically significant decreases in internal rotation at P1 post-surgical intervention that were maintained long-term (mean hip rotation P0: 21±9, P1: 0±9 and P2: 6±12 degrees internal). Similar results were seen with mean foot progression (P0: 9±16 degrees internal, P1: 14±13 degrees external, P2: 13±16 degrees external). However, 2/27 sides (9%) showed a recurrence of internal hip rotation of >15° at the 11year follow-up. The reasons for this recurrence could include age, surgical location and ongoing disease process all of which need to be further examined. We conclude that FDO can show long-term kinematic and functional benefits when performed in the prepubescent child with cerebral palsy in comparison to the natural progression of of hip rotation in cerebral palsy.