[Long-term results of reconstructive surgery in infantile cerebral palsy patients with high hip dislocation: is hip screening necessary?]. / Langzeitergebnisse nach operativer Rekonstruktion hoher Hüftluxationen bei infantiler Zerebralparese: Ist ein Hüftscreening notwendig?

BACKGROUND: Hip dislocation as a result of neurogenic hip displacement is a common focal motor symptom in children with infantile cerebral palsy (ICP). In addition to contracture of the hip joint, in up to 65 % of cases patients suffer from pain which leads to further loss of function and often to limitations in important basic functions, such as lying, care, sitting, standing and transfer. METHODS: In order to avoid hip dislocation and to be able to implement therapy at an early stage, screening programs have been developed in recent years which clearly demonstrate the risks of hip displacement in ICP depending on the ability to walk. An investigation of the natural course is practically impossible because as a rule patients with painful neurogenic hip displacement receive surgical therapy. PATIENTS: In this study 96 patients with high hip dislocation grade IV on the Tönnis classification were included and 68 could be followed up. The average age at the time of surgery was 10.9 years and the mean follow-up period was 7.7 years. In the postoperative course 6 out of 91 reconstructed hips became redislocated and a proximal femoral resection was carried out in one female patient. The migration index according to Reimers was 14.0 % at the time of the follow-up examination. CONCLUSION: Revision procedures can be avoided by screening programs. These should be strived for so that the neuro-orthopedic treatment on operation planning is not first initiated when pain occurs and revision procedures, such as angulation osteotomy or proximal femoral resection can be avoided. The reconstruction should also involve minimal deformation of the femoral head. In order to implement this, the interdisciplinary cooperation between neuropediatricians, social pediatriatricians and neuro-orthopedists should be intensified in the future.

Experts' Perceived Patient Burden and Outcomes of Knee-ankle-foot-orthoses (Kafos) Vs. Microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot Orthoses (Mp-sscos).

BACKGROUND: Patients with neuromuscular knee-instability assisted with orthotic devices experience problems including pain, falls, mobility issues and limited engagement in daily activities. OBJECTIVES: The aim of this study was to analyse current real-life burden, needs and orthotic device outcomes in patients in need for advanced orthotic knee-ankle-foot-orthoses (KAFOs). METHODOLOGY: An observer-based semi-structured telephone interview with orthotic care experts in Germany was applied. Interviews were transcribed and content-analysed. Quantitative questions were analysed descriptively. FINDINGS: Clinical experts from eight centres which delivered an average of 49.9 KAFOs per year and 13.3 microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot orthoses (MP-SSCOs) since product availability participated. Reported underlying conditions comprised incomplete paraplegia (18%), peripheral nerve lesions (20%), poliomyelitis (41%), post-traumatic lesions (8%) and other disorders (13%). The leading observed patient burdens were "restriction of mobility" (n=6), followed by "emotional strain" (n=5) and "impaired gait pattern" (n=4). Corresponding results for potential patient benefits were seen in "improved quality-of-life" (n=8) as well as "improved gait pattern" (n=8) followed by "high reliability of the orthosis" (n=7). In total, experts reported falls occurring in 71.5% of patients at a combined annual frequency of 7.0 fall events per year when using KAFOs or stance control orthoses (SCOs). In contrast, falls were observed in only 7.2 % of MPSSCO users. CONCLUSION: Advanced orthotic technology might contribute to better quality of life of patients, improved gait pattern and perceived reliability of orthosis. In terms of safety a substantial decrease in frequency of falls was observed when comparing KAFO and MP-SSCO users.

Effects of a Prosthetic Foot With Increased Coronal Adaptability on Cross-Slope Walking.

BACKGROUND: Walking on cross-slopes is a common but challenging task for persons with lower limb amputation. The uneven ground and the resulting functional leg length discrepancy in this situation requires adaptability of both user and prosthesis. OBJECTIVES: This study investigated the effects of a novel prosthetic foot that offers adaptability on cross-slope surfaces, using instrumented gait analysis and patient-reported outcomes. Moreover, the results were compared with two common prosthetic feet. METHODOLOGY: Twelve individuals with unilateral transtibial amputation and ten able-bodied control subjects participated in this randomized cross-over study. Participants walked on level ground and ±10° inclined cross-slopes at a self-selected walking speed. There were three prosthetic foot interventions: Triton Side Flex (TSF), Triton LP and Pro-Flex LP. The accommodation time for each foot was at least 4 weeks. The main outcome measures were as follows: frontal plane adaptation of shoe and prosthetic foot keel, mediolateral course of the center of pressure, ground reaction force in vertical and mediolateral direction, external knee adduction moment, gait speed, stance phase duration, step length and step width. Patient-reported outcomes assessed were the Activities specific Balanced Confidence (ABC) Scale, Prosthetic Limb Users Survey of Mobility (PLUS M) and Activities of Daily Living Questionnaire (ADL-Q). FINDINGS: The TSF prosthetic foot adapted both faster and to a greater extent to the cross-slope conditions compared to the Triton LP and Pro-Flex LP. The graphs for the mediolateral center of pressure course and mediolateral ground reaction force showed a distinct grouping for level ground and ±10° cross-slopes, similar to control subjects. In the ADL-Q, participants reported a higher level of perceived safety and comfort when using the TSF on cross-slopes. Eight out of twelve participants preferred the TSF over the reference. CONCLUSIONS: The frontal plane adaptation characteristics of the TSF prosthetic foot appear to be beneficial to the user and thus may enhance locomotion on uneven ground - specifically on cross-slopes.

Internal rotation gait in spastic diplegia--critical considerations for the femoral derotation osteotomy.

The purpose of this study was to assess under- and overcorrection following femoral derotation osteotomy (FDO) in spastic diplegic children with functionally compromising internally rotated gait, especially with respect to asymmetry. A total of 30 children with spastic diplegia and internally rotated gait underwent multilevel surgery including FDO and were assessed pre- and 1 year postoperatively by clinical examination and instrumented gait analysis. The amount of derotation was determined intra-operatively based on the neutral midpoint between passive internal and external hip rotation and was controlled with K-wires. Sixteen patients showed an asymmetry in mean hip rotation in stance of more than 10 degrees preoperatively. Accordingly, all legs were classified as the more or the less involved side. Improvement parameters were established for the evaluation of over- and undercorrection. For the clinical midpoint, no significant difference in change and improvement was found between the sides. The mean hip rotation in stance improved significantly in the more involved side with few incidences of mal-correction (13%). The less involved side, however, got worse due to a high occurrence of over- and undercorrections (59%). Hence the clinical midpoint as indication criterion does not give sufficient information about the functional alignment of the distal femur during gait, especially in legs with mild involvement. The study underlines the importance of gait analysis for indication in addition to the clinical midpoint. Taking into account the precision of gait analysis data and derotation amount, we suggest FDO to be carried out if the mean internal hip rotation in stance exceeds 15 degrees .

Effects of multilevel surgery on a flexed knee gait in adults with cerebral palsy.

AIMS: A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood. PATIENTS AND METHODS: At a mean of 22.9 months (standard deviation 12.9), after single event multi level surgery, 3D gait analysis was undertaken pre- and post-operatively for 37 adult patients with bilateral cerebral palsy and a fixed knee gait. RESULTS: There was a significant improvement of indices and clinical and kinematic parameters including extension of the hip and knee, reduction of knee flexion at initial contact, reduction of minimum and mean knee flexion in the stance phase of gait, improved range of movement of the knee and a reduction of mean flexion of the hip in the stance phase. Genu recurvatum occurred in two patients (n = 3 legs, 4%) and an increase of pelvic tilt (> 5°) was found in 12 patients (n = 23 legs, 31%). CONCLUSION: Adult patients with bilateral cerebral palsy and a flexed knee gait benefit from multilevel surgery including hamstring lengthening. The risk of the occurence of genu recurvatum and increased pelvic tilt is lower than has been previously reported in children. Cite this article: Bone Joint J 2017;99-B:1256-64.

Multilevel surgery in adults with cerebral palsy.

AIMS: Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate. METHODS: This study analysed the short-term outcome (mean 1.7 years, standard deviation 0.9) of 97 ambulatory adults with BSCP who performed three-dimensional gait analysis before and after SEMLS at one institution. RESULTS: Two objective gait variables were calculated pre- and post-operatively; the Gillette Gait Index (GGI) and the Gait Profile Score (GPS). The results were analysed in three groups according to their childhood surgical history (group 1 = no surgery, group 2 = surgery other than SEMLS, group 3 = SEMLS). Improvements in gait were shown by a significant decrease of GPS (p = 0.001). Similar results were obtained for both legs (GGI right side and left side p = 0.01). Furthermore, significant improvements were found in all subgroups although this was less marked in group 3, where patients had undergone previous SEMLS. DISCUSSION: SEMLS is an effective and safe procedure to improve gait in adults with cerebral palsy. However, a longer rehabilitation period is to be expected than found in children. SEMLS is still effective in adult patients who have undergone previous SEMLS in childhood. TAKE HOME MESSAGE: Single-event multilevel surgery is a safe and effective procedure to improve gait disorders in adults with bilateral spastic cerebral palsy.

Asymmetric pelvic and hip rotation in children with bilateral cerebral palsy: uni- or bilateral femoral derotation osteotomy?

Internal rotation gait is common among children with bilateral cerebral palsy. However, despite bilaterally increased femoral anteversion asymmetric internal rotation gait is often found. Femoral derotation osteotomy (FDO) is commonly performed bilaterally. Variable functional outcomes are reported especially in cases with mild internal hip rotation during gait and abnormal preoperative pelvic rotation. A major question is if a unilateral treatment of the more involved side in asymmetric cases leads to a comparable or even superior outcome. One hundred and nine children with spastic bilateral CP treated with FDO with pre- and 1-year postoperative 3D gait analysis were retrospectively collected. The asymmetry was calculated from the preoperative difference between both limbs in hip rotation obtained by 3D gait analysis. Twenty-eight children with asymmetry larger than 20° were selected and classified into two groups, according to whether they obtained a unilateral or bilateral FDO. Preoperative clinical examination and pre- and postoperative hip and pelvic rotation in gait analysis on the more and the less involved side did not differ significantly between both groups. Interestingly, in both groups, hip rotation did not change significantly in less-involved limbs, although intraoperative derotation averaged 25°. After unilateral FDO a significant change in pelvic rotation resulted, whereas this was not found after bilateral FDO. The results of this study suggest that unilateral FDO in children with asymmetric internal rotation gait leads to a comparable functional outcome compared to bilateral treatment. Furthermore, it was shown for the first time that considering the asymmetry has a positive effect on pelvic rotation.

[Femoral Derotation in Children with Cerebral Palsy - Does the Result Depend on the Age at Operation and the Kind of Surgery?]. / Derotation des Femurs bei Patienten mit infantiler Zerebralparese - ist das Ergebnis abhängig vom Alter zum Zeitpunkt der Operation und der OP-Technik?

INTRODUCTION: Patients with spastic cerebral palsy GMFCS I-III often develop gait dysfunctions. One of the most prevalent gait dysfunctions is the intoeing gait. Femoral derotation osteotomy is the common treatment for internal rotation gait in cerebral palsy. We now present 3D-gait analysis data of the hip rotation in gait before and after femoral derotation osteotomy. We analysed the influence of the age at the index operation on the risk of recurrence and the surgical technique. METHODS: We included 48 patients treated with femoral derotation osteotomy during a single event of multi-level surgery. Mean hip rotation in standing was measured before and after femoral derotation osteotomy (FDO). The patients were divided into two groups of different age and in a second analysis into two groups with the osteotomy in different locations, either inter-trochanteric (DO proximal) or supracondylar (DO distal). RESULTS: Age at FDO and surgical technique had no influence on the results. However, the variance of the results was very high. Differences were found in the walking speed between the DO proximal and DO distal groups. The walking speed in the group of distal femoral osteotomy was higher. This difference was not significant, but there was a trend to proximal osteotomy in slower walkers. Significant improvements in IRG after FDO were found in our investigation. Our results indicate that FDO as a part of single-event multilevel surgery SEMLS provides a satisfactory mean overall correction of IRG. The results were independent of the age at the index operation and the location of the osteotomy.

[Aneurysmal bone cyst of the fourth metacarpal bone--a case report]. / Aneurysmatische Knochenzyste des Os metacarpale IV - Ein Fallbericht.

Aneurysmal bone cysts of the hand skeleton are rare (only 3 to 4 % of all ABC; Tillmann and v. Torklus 1966 ) and require a differentiated treatment. In the presented case, the fourth metacarpal bone of the right hand was affected (Enneking stage 3). On account of its rapid growth, radical excision was performed and the resected metacarpal bone was replaced by a bicortical iliac crest graft. The bone graft healed in without complications, the functional result is satisfactory. On twelve-month follow-up there were no signs of relapse.

Distal Rectus Femoris Tendon Transfer for the Correction of Stiff-Knee Gait in Cerebral Palsy.

INTRODUCTION: Distal rectus femoris tendon transfer is the standard surgical procedure for the treatment of stiff-knee gait in patients with cerebral palsy and is commonly performed during single-event multilevel surgery. STEP 1 POSITIONING AND APPROACH: With the patient supine, make a 3 to 4-cm longitudinal incision 2 to 3 cm above the patellar proximal pole. STEP 2 PREPARATION OF THE RECTUS FEMORIS TENDON: Separate the rectus femoris tendon from the vasti; avoid releasing the entire quadriceps at all cost. STEP 3 PREPARATION OF THE GRACILIS OR SEMITENDINOSUS TENDON FOR TRANSFER: Isolate the gracilis tendon proximally, release it from its muscle belly, and pull it out distally through a small incision at the pes anserinus insertion. STEP 4 TRANSFERRING THE GRACILIS TENDON TO THE RECTUS FEMORIS TENDON: Insert a long tendon passer above the fascia and beneath the sartorius muscle belly from anterior to posterior to the mini-incision in the pes anserinus region to grasp and transfer the gracilis tendon to the anterior approach. STEP 5 TENDON TENSIONING AND SUTURING: Weave the gracilis tendon into the released rectus femoris tendon with the interlacing technique described by Pulvertaft. RESULTS: Various studies have demonstrated good initial results, with an improvement in peak knee flexion in swing phase and knee motion in swing phase, following distal rectus femoris tendon transfer. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Reduction in primary genu recurvatum gait after aponeurotic calf muscle lengthening during multilevel surgery.

Knee hyperextension (genu recurvatum, GR) is often seen in children with bilateral spastic cerebral palsy (CP). Primary GR appears essential without previous treatment. As equinus deformity is suspected to be one of the main factors evoking primary GR, the purpose of this study was to determine whether lengthening the calf muscles to decrease equinus would decrease coexisting GR in children with bilateral spastic CP. In a retrospective study, 19 CP patients with primary GR (mean age: 9.4 years, 13 male, 6 female, 26 involved limbs) in whom an aponeurotic calf muscle lengthening procedure was performed during single-event multilevel surgery were included and investigated using three-dimensional gait analysis before and at a mean follow-up of 14 months after the procedure according to a standardized protocol. After calf muscle lengthening, a significant improvement in ankle dorsiflexion (9.5°) and a significant reduction (10.5°) in knee hyperextension (p<0.001) were found during mid-stance of the gait cycle. Six limbs (23%) showed no improvement concerning knee hyperextension and were designated as nonresponders. In these patients no significant improvement in ankle dorsiflexion was found after surgery either. Improvement in ankle dorsiflexion and reduction in knee hyperextension in stance phase correlated significantly (r=0.46; p=0.019). These findings indicate that equinus deformity is a Major underlying factor in Primary GR and that calf muscle lengthening can effectively reduce GR in patients with CP.

The effects of muscle-tendon surgery on dynamic electromyographic patterns and muscle tone in children with cerebral palsy.

During multilevel surgery, muscle-tendon lengthening (MTL) is commonly carried out in children with cerebral palsy. However, it is unclear if MTL also modifies increased muscle tone and if pathologic activation patterns are changed as an indirect effect of the biomechanical changes. Since investigations addressing this issue are limited, this study aimed at evaluating the effects of MTL on muscle tone and activation pattern. Forty-two children with spastic diplegia who were treated by MTL underwent standardized muscle tone testing (modified Ashworth and Tardieu test), dynamic EMG and three-dimensional gait analysis before, one and three years after MTL. For the evaluation of muscle activation patterns the norm-distance of dynamic EMG data was analyzed. Range of motion and joint alignment in clinical examination were found to be significantly improved one year after MTL. However, deterioration of these parameters was noted after three years. Muscle tone was significantly reduced one year postoperatively but showed an increase after three years. Joint kinematics were found significantly closer to reference data of age matched controls initially after surgery, but deteriorated until three years postoperatively. However, the EMG patterns of the muscles which were surgically addressed were found to be unchanged in either follow-up. These findings suggest that despite the influence of MTS on biomechanics and physiology (muscle tone reduction and improvements of joint mobility and gait pattern) MTS does not change abnormal patterns of muscle activation. Recurrence of increased muscle tone and deterioration of kinematic parameters three years after surgery may be attributed to these persistent pathologic activation patterns.

Motion capture of the upper extremity during activities of daily living in patients with spastic hemiplegic cerebral palsy.

Investigations using motion capture to analyze limitations in range of motion (ROM) of the upper extremity in adults with cerebral palsy (CP) are scarce. To evaluate the influence of those limitations on activities of daily living (ADL) and to determine potential mechanisms of compensation, we investigated 15 adults with hemiplegic CP using motion capture while they performed 10 defined ADLs. Data from the nonaffected body side and those from an age-matched able-bodied group were also collected and compared with our subjects. We measured motion of the elbow, shoulder, and trunk and found significant differences in ROM at these sites. The most pronounced reduction in ROM was observed distally in supination and pronation of the elbow. Here, the affected body side of the adults showed a reduction in supination of 45° compared to the able-bodied group. Furthermore we found a correlation between the Manual Ability Classification System (MACS) and the limitations in ROM. In summary, adults with spastic, hemiplegic CP show limitations in ROM accentuated distally during ADLs. The MACS gives conclusive information about those limitations.

Autologous capping during resection arthroplasty of the hip in patients with cerebral palsy.

In patients with severe quadriplegic cerebral palsy and painful hip dislocation proximal femoral resection arthroplasty can reduce pain, but the risk of heterotopic ossification is significant. We present a surgical technique of autologous capping of the femoral stump in order to reduce this risk, using the resected femoral head as the graft. A retrospective study of 31 patients (43 hips) who had undergone proximal femoral resection arthroplasty with (29 hips) and without autologous capping (14 hips) was undertaken. Heterotopic ossification was less frequent in patients with autologous capping, and a more predictable pattern of bony overgrowth was found. For a selected group of non-ambulatory patients with long-standing painful dislocation of the hip, we recommend femoral resection arthroplasty over more complicated reconstructive operations. The risk of heterotopic ossification, which is a major disadvantage of this operation, is reduced by autologous capping.

[Functional impact of carbon fiber springs in ankle-foot orthoses]. / Funktionelle Auswirkungen des Einsatzes von Karbonfedern bei Unterschenkelorthesen.

BACKGROUND: Patients with calf muscle insufficiency are often dependent on ankle-foot orthoses (AFO). The orthosis should improve walking and posture and should prevent structural deformities. AFOs are usually manufactured with a dorsiflexion stop. In the current study, orthoses with a dorsal carbon fiber spring were compared with the classic design. PATIENTS AND METHODS: Five patients with spina bifida, one with poliomyelitis, and one with a tibial nerve block took part in the study. All participants underwent a 3-D gait analysis including data collection of kinematics (VICON) and kinetics (Kistler). RESULTS: It was found that the use of a carbon fiber spring significantly increases the energy return during the third rocker for a push-off effect (p<0.05). The measurements showed further that the carbon spring was able to support the patient during the complete stance phase. The analysis of the ankle and knee kinematics reveals that the spring contributes to a more physiological gait (p<0.05). CONCLUSION: This investigation showed that the use of a carbon spring and the alignment positively influenced the gait pattern during the stance phase.

[Modelling critical information measurement traumatic surgery decisions. "Sequential Information Appraisal Module (SIAM)"]. / Modellierung kritischer Informationsmengen für unfallchirurgische Entscheidungen. Das "Sequenzielle Informations-Angebots-Modul" (SIAM).

We studied the quality and quantity of information leading to the emergency physician's decision to intubate severely injured patients on scene. Our aim was to assess intuitive aspects of clinical decision making. The experiment involved three different phases, with a fourth phase examining retest reliability. We used trauma register data from 98 patients. Based on various parameters (physiological data, injury assessment on scene, definite injury pattern), three emergency surgeons were requested to decide on the need for endotracheal intubation.We applied multivariate logistic regression to estimate the likelihood of intubation given certain clinical characteristics or combinations of characteristics. We compared the participants' decisions to those made by "true" emergency physicians on scene. Kappa statistics marked inter-observer agreement beyond chance. The Glasgow Coma Scale (GCS) was the only single predictor of intubation in the ideal test setting (area under the receiver operating characteristics curve [AUC] >98%) as well as on scene (AUC 0.85, 95% confidence interval 0.78-0.92). There was no difference between the discriminatory features of the single item GCS and complex multivariate models that included anatomically defined injury scales (best model in phase 2: AUC 0.96, best model in phase 3: AUC 0.98). Overall inter-observer agreement was substantial in phase 1 (kappa=0.74), fair to moderate in phase 2 (kappa=0.49) and slight to fair in phase 3 (kappa=0.23). Retest reliability ranged from 51% to 91%. Doctors give priority to only a small part of the information available in deciding for or against a particular intervention.

[Treatment outcome after surgical management of osseous breast carcinoma metastases. Preventive stabilization vs. management after pathological fracture]. / Behandlungsergebnisse nach operativer Versorgung ossärer Mammakarzinommetastasen. Prophylaktische Stabilisierung vs. Versorgung nach pathologischer Fraktur.

UNLABELLED: AIM OF THE STUDY, METHOD: The advantages of a prophylactic care of fracture-endangered, osseous metastasis of the mammary cancer stand opposite to the perioperative risk and to conservative alternatives. As a pathologic fracture cannot surely be excluded while performing a conservative proceeding, a retrospective trial was set up to compare the results of treatment after a pathologic fracture (n = 35) with those undergoing a prophylactic attendance (n = 44). RESULTS: The intraoperative, cardio-pulmonary complications were distributed in balance totally amounting to 20.3% (n = 16). Intraoperative complications concerning surgical procedure (n = 3) exclusively occurred within the fracture group. Generally, postoperative complications arose in 20.3% (n = 16) of all cases, in which the patients belonging to the fracture group were increasingly afflicted [28.6% (n = 11/35) vs. 11.4% (n = 5/44); p < 0.02]. While there were no differences between both groups concerning the postoperative, surgery-technical complications, significantly more patients (91.8% [n = 40/44]) of the prophylactic-care group achieved a complete postoperative usability of the operated area than in the fracture-group [74.3% (n = 26/35)] (p < 0.05). The average survival time tended to be longer within the prophylactic-care group [19.3 +/- 15.6 month (prophylactic-care group) vs. 15.0 +/- 16.9 month (fracture group)]. CONCLUSIONS: The prophylactic treatment of fracture endangered, osseous metastasis of the mammary cancer leads to reduction of the general, postoperative complications compared to the patients with a pathologic fracture. Further, those patients have a better chance to recover full mobility after surgery. Considering the long survival time after the incidence of osseous metastasis at the mammary cancer a prophylactic treatment represents the method of first choice compared with the conservative treatment which persistently contains the risk of fracturing.