Prone vs Supine Positioning for Femoral Derotation Osteotomy: Kinematic and Physical Examination Outcomes Suggest Both Can Achieve Desired Results.

Background: Femoral derotation osteotomy (FDO) for correction of internal rotation gait resulting from cerebral palsy (CP) can be performed with the patient in the prone or supine position. It is not known whether patient positioning during FDO affects the change in hip rotation. Purpose/Questions: We sought to compare the change in hip rotation following FDO performed on patients with CP in the prone or supine position through kinematic analysis. Methods: We conducted a consecutive retrospective cohort study of children with CP, ages 3 to 18 years and with Gross Motor Function Classification System (GMFCS) levels I to III, who underwent prone or supine FDO and pre- and postoperative motion analysis. The prone group included 37 patients (68 limbs) between 1990 and 1995. The supine group included 26 patients (47 limbs) between 2005 and 2015. The groups were matched for gender, age, and GMFCS level. The primary outcome was hip rotation in degrees during stance phase. Secondary outcomes included temporal-spatial parameters, hip abduction, hip and knee extension, and hip and knee passive range of motion (ROM). Results: The prone group had more bilateral patients (100%) than the supine group (81%). The supine group underwent more concomitant procedures. There was no difference between the prone and supine groups in postoperative stance hip rotation; both groups had significantly improved stance hip rotation, step width, and hip rotation passive ROM, pre- to postoperatively. Prone patients had improved postoperative hip extension, pelvic tilt, velocity, and cadence. Conclusions: There was no significant different in stance hip rotation between supine and prone FDO groups. Advocates of prone positioning for FDO suggest it allows more accurate assessment of rotation. Supine positioning may be more convenient when additional procedures are required. Based on our findings, either approach can achieve the desired result.

The Root-Ely Modified Test of Rectus Femoris Spasticity Has Reliability in Individuals with Cerebral Palsy.

BACKGROUND: Stiff-knee gait is a common gait deviation in individuals with cerebral palsy (CP) due to rectus femoris (RF) muscle spasticity. The Duncan-Ely test is a velocity-dependent measurement of spasticity that is recorded as positive or negative. At our institution, we use a modification of the Duncan-Ely test, a 5-point ordinal rating scale, which delineates where the catch occurs within the rapid arc of knee flexion. It has been named the Root-Ely test. QUESTIONS/PURPOSES: We sought to determine the intra- and inter-rater reliability of the Duncan-Ely and Root-Ely tests in pediatric patients with CP. METHODS: A convenience sample of 20 ambulatory subjects was recruited; mean age was 10.5 ± 4.5 years, and the Gross Motor Function Classification System (GMFCS) levels were I-III. Five clinicians measured each individual's RF spasticity using the Root-Ely protocol during a single visit. Simple κ statistics with 95% confidence intervals (CI) were utilized for intra-rater reliability and weighted κ statistics with 95% CI for inter-rater reliability. RESULTS: The Root-Ely scale intra-rater reliability was 0.77 to 0.90 and inter-rater reliability was 0.32 to 0.87. Inter-rater reliability was good to excellent among experienced clinicians and fair to moderate in new clinicians. CONCLUSION: The Root-Ely 5-point scale has acceptable intra- and inter-rater reliability in pediatric individuals with CP among experienced clinicians. The Root-Ely test allows experienced clinicians to reliably quantify severity of RF spasticity and may give orthopaedic surgeons a clinical tool to better predict ideal candidates for RF transfers in individuals with CP in order to improve stiff-knee gait.

Reliability of the Arch Height Index as a Measure of Foot Structure in Children.

PURPOSE: To determine the intrarater and interrater reliability of the arch height index (AHI) in children developing typically. The AHI is tested with a device that measures foot structure. METHODS: Thirty children, ages 6 to 12 years, participated for a total of n = 60 feet. The AHI measurements were taken by 2 investigators in sitting and standing and repeated twice by each investigator in a single visit. Intrarater and interrater reliabilities were determined using intraclass correlation coefficient (ICC) (2,1) statistical analysis. RESULTS: The mean age was 9.61 ± 1.96 years. The intrarater and interrater reliability had an ICC 0.76 or more in both sitting and standing. The average AHI value was 0.36 ± 0.02 in sitting and 0.32 ± 0.02 in standing. CONCLUSIONS: Pediatric therapists, physicians, and orthotists should consider using the AHI as an objective measure to be used for research, to assess foot structure, monitor change over time, and assist with treatment planning in children.

Simulated Ankle Equinus Affects Knee Kinematics During Gait.

BACKGROUND: It is critical to distinguish gait compensations from true abnormalities when planning interventions to improve gait in individuals with neuromuscular disorders. QUESTIONS/PURPOSES: The aim of this study was to determine the effect of isolated ankle equinus on knee kinematics during the initial contact phase of gait. METHODS: Ten healthy subjects (29 + 4.3 years) participated, and testing occurred in a motion analysis laboratory. This cross-sectional study investigated five gait conditions in each subject: shoe alone, shoe with unilateral ankle foot orthosis locked at neutral, 10°, 20°, and 30° of fixed ankle plantar flexion. Gait kinematics were recorded and calculated with 3D motion analysis. The difference between the shoe and each brace condition was analyzed by repeated-measures ANOVA. The primary outcome was knee flexion at initial contact. RESULTS: With greater than 10° simulated ankle equinus, the primary gait compensation pattern was increased knee flexion at initial contact. A significant degree of knee flexion occurred ranging from 7° to 22°. CONCLUSION: Our data suggests that observed knee flexion at initial contact may be a compensation pattern in individuals with >10° ankle equinus. However, in individuals with ≤10° ankle equinus, observed knee flexion may represent a true gait deviation. This has clinical significance in the realm of cerebral palsy for treatment planning to improve gait.

The functional effect of a distal rectus femoris tenotomy in adults with cerebral palsy.

The purpose of this study was to determine the effect of a distal rectus femoris tenotomy on function and gait in adults with cerebral palsy who had diminished knee flexion during swing. A stiff knee gait pattern is commonly seen in individuals with cerebral palsy and frequently leads to tripping and falling. Five subjects, 25-51 years, (34.6±10.3 years) participated in the study; each individual had the surgery after the age of 18. Four of the five subjects underwent bilateral distal rectus femoris tenotomies for a total of nine limbs being studied. Four of the five subjects had a single procedure of a distal rectus femoris tenotomy and one subject also had bilateral adductor tenotomies. All individuals underwent a pre-operative and post-operative, (3.28±1.6 years) three-dimensional gait analysis. Pre-operative gait revealed diminished peak knee flexion and out of phase rectus femoris activity with a quiet vastus lateralis during swing in all subjects. Significant findings after a distal rectus femoris tenotomy included: improved peak swing knee flexion, improved peak stance hip extension, and increased total knee excursion without loss in knee extension strength. During swing, knee flexion angle improved on average 11° which correlated with subjective report of less shoe wear, tripping, and falling due to improved clearance. In conclusion, a distal rectus femoris tenotomy should be considered a surgical option for adults with cerebral palsy and a stiff knee gait pattern to improve mobility, function, and quality of life.