[Insoles, knee braces and ankle-foot orthoses in the treatment of medial gonarthrosis : A literature review]. / Einlagen, Knie- und Unterschenkelorthesen in der Behandlung der medialen Gonarthrose : Eine aktuelle Literaturübersicht.

BACKGROUND: Osteoarthritis is the most common joint disease worldwide and mostly affects the knee joint (gonarthrosis). In treatment algorithms, technical aids in the form of laterally wedged insoles, valgizing knee braces and ankle-foot orthoses have an importance in the treatment of medial unicompartmental knee joint disease. However, national and international guidelines differ in their recommendations. INSOLES: Taking into account a great amount of scientific work, the measurable effect of laterally wedged insoles appears to be low, so that a justifying indication only exists at low gonarthrosis levels. KNEE BRACES: Valgizing knee braces have shown stronger biomechanical and clinical effects, but with a slightly increased complication potential and low compliance. Low to medium-grade arthrosis can be treated. ANKLE-FOOT ORTHOSES: Ankle-foot arthroses have not yet been conclusively examined. Initial work indicates biomechanical and clinical efficacy. The overall effects and indications appear comparable to knee braces, probably with less complication potential.

[Expert assessment of lower extremity prosthetics]. / Begutachtung von Prothesenversorgungen der unteren Extremität.

Although the number of major amputations is declining throughout Germany, more than 57,000 surgical procedures for amputation still take place. As a consequence of high prosthetic care costs, these often lead to disputes before the social court in which expert medical opinions are required. With knowledge of the legal norms, the remit of the expert opinion can be fulfilled. The expert begins with evaluation of the patient's file and a search of the contested parts. The investigation includes a medical history, in addition to a physical examination, in order to be able to comment on the disputed beneficial use of the therapeutic appliance and respond to questions of proof. Questionnaires may be helpful.

Structural changes in the thigh muscles following trans-femoral amputation.

INTRODUCTION: Early ambulation is the principal objective in trans-femoral amputees. Postamputation modifications complicate the rehabilitation process due to a reduced control at the interface between stump and prosthesis. The aim of this study is to determine whether magnetic resonance imaging depicts the amount of fatty degeneration of the thigh muscles after trans-femoral amputation (TFA). METHODS: A total of 12 patients following a TFA on the basis of a bone neoplasm or metastasis with an evaluable postoperative MRI were identified. Using the Goutallier classification, the fatty degeneration of the thigh muscles was analyzed in the middle (M) and at the distal end (E) of the residual limb at T1 (10.6 months) and T2 (25.6 months). RESULTS: Analysis at two different levels showed different grades of fatty degeneration of thigh muscles after TFA at T1 and T2. Comparing fatty degeneration at both levels of the stump, the quadriceps femoris revealed a significant change (p = 0.01) at T1 and M. sartorius and adductor (p = 0.02) at T2. CONCLUSIONS: MRI is an excellent diagnostic tool to evaluate fatty degeneration after TFA. The highest amount of fatty degeneration of the quadriceps muscle was monitored within the first 10 months. Early physiotherapy is important to strengthen the remaining stump muscles during rehabilitation.

[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.

[Instrumented gait and movement analysis of musculoskeletal diseases]. / Instrumentelle Gang- und Bewegungsanalyse bei muskuloskelettalen Erkrankungen.

Instrumented 3-dimensional gait analysis is increasingly being used for the evaluation of movement disorders in orthopedic and neurological musculoskeletal diseases. Due to the high reliability of the measurements the procedures are appropriate for diagnostic purposes as well as for outcome assessment after conservative or surgical interventions. Contrary to conventional clinical assessments gait analysis parameters are able to demonstrate a normal physiological gait pattern that can be achieved with improved kinematic and kinetic parameters. For a suitable application in clinically relevant problems the limitations of the procedures should be taken into account. Due to the high instrumental involvement combined with time and cost expenditure instrumented gait analysis will probably not develop to a clinical routine procedure. Nevertheless, an excellent set of information for answering clinical questions is provided. The present contribution presents selected measurement procedures and technologies and illustrates the wide variety of possibilities with the use of selected clinical examples.

Focusing on functional knee parameter determination to develop a better clinical gait analysis protocol.

BACKGROUND: Attempts to improve protocol standards of marker-based clinical gait analysis (CGA) have been one of the main focuses of research to enhance robustness and reliability outcomes since the 1990s. Determining joint centres and axes constitutes an important aspect of those protocols. Although the hip joint is more prominent in such studies, knee joint center (KJC) and axis (KJA) directly affect all outcomes. RESEARCH QUESTION: What recommendations arise from the study of the scientific literature for determining knee joint parameters (KJP) for protocols of CGA? METHODS: A systematic, electronic search was conducted on November 2018 using three databases with the keyword combination ("functional approach" OR "functional method" OR "functional calibration") AND ("hip joint" OR "knee joint" OR "ankle joint") and analyzed by four reviewers. Given the existence of a recent review about the hip joint and the lack of material about the ankle joint, only papers about the knee joint were kept. The references cited in the selected papers were also screened in the final round of the search for these publications. The quality of the selected papers was assessed and aspects regarding accuracy, repeatability, and feasibility were thoroughly considered to allow for a comparison between studies. Technical aspects, such as marker set choice, KJP determination techniques, demographics, and functional movements, were also included. RESULTS: Thirty-one papers were included and on average received a rating of about 75 % according to the quality scale used. The results showed that functional methods are superior or equivalent to predictive methods to estimate the KJA, while a regression method was slightly better for KJC prediction. SIGNIFICANCE: Calibration methods should be applied to CGA whenever feasibility is reached. No study to date has focused on evaluating the in vivo RoM required to obtain reliable and repeatable results and future work should aim in this direction.

Biomechanical analysis of stair ascent in persons with Chopart amputation.

BACKGROUND: Compared to walking on level ground, ascending stairs requires a large range of motion not only of the hip and knee joint, but also of the ankle joint. The prosthesis often worn by persons with partial foot amputation largely prevents the ankle motion needed during stair ascent. OBJECTIVES: Aim of this study was to assess subjects with a Chopart amputation utilizing a clamshell device during stair ascent to identify potential biomechanical deficits. STUDY DESIGN: Cross-sectional study with reference group. METHODS: Six subjects with unilateral Chopart amputation and 17 unimpaired subjects underwent three-dimensional motion analysis while ascending stairs in a step-over-step manner. RESULTS: During weight acceptance, the involved side showed increased external hip-flexing and reduced knee-flexing moments and the sound side a higher ankle power than in the control group. The sound side showed higher external knee-flexing, dorsi-flexing, and hip-adducting moments than the controls during weight acceptance. CONCLUSION: The mechanism observed on the involved side differs from that in controls, but is comparable to the mechanisms used by subjects with transtibial amputation reported in the literature. However, compensatory movements on the sound side take place at the ankle and knee joint, differing from subjects with more proximal amputations. CLINICAL RELEVANCE: This study underpins the importance of adequate foot leverage and ankle function in cases of partial foot amputation, particularly in transfer situations such as stair ascent. If ankle range of motion is adequate, prosthetic/orthotic devices combining shank leverage with a hinged spring mechanism at the ankle may be promising.

The added value of orthotic management in the context of multi-level surgery in children with cerebral palsy.

BACKGROUND: Treatment of cerebral palsy includes an interdisciplinary concept and in more severe cases the well-established multi-level surgery (MLS). Different kinds of orthoses are typically part of postoperative treatment but there is a lack of knowledge about their additional benefit. RESEARCH QUESTION: Do ankle foot orthoses lead to an additional, measurable improvement of gait after MLS? METHODS: 20 children with bilateral spastic cerebral palsy (9 retrospective, 11 in a postoperative clinical routine) were included. All had a preoperative gait analysis before MLS. Postoperatively, they were fitted with different ankle foot orthoses (AFO), depending on their individual needs. Dynamic ankle foot orthoses (DAFO), combined DAFO with additional dynamic, elastic shank adaptation (DESA) and ground reaction force AFOs (GRAFO) were used. Patients underwent a second gait analysis 1.5 (± 0.6) years postoperatively barefoot and with orthoses. Data analysis included testing for normal distribution (Shapiro-Wilk-Test) and further nonparametric statistical testing on basis of a Wilcoxon Single-Rank Test. RESULTS: The operation produced changes in the hip, knee and ankle joint, and the pelvis. Spatiotemporal parameters showed significant changes due to additional use of the orthoses. Further, additional kinematic changes occurred at the hip, knee and ankle joint as well as the foot. The Gillette Gait Index (GGI) improved significantly by supplementary orthoses, but not by surgery alone. The Gait Profile Score (GPS) and Gait Deviation Index (GDI) rather showed changes due to the surgery. SIGNIFICANCE: MLS significantly improves GPS and GDI more than a year after surgery, which can be interpreted as an improvement in gait pattern. In contrast, the GGI is improved by additional postoperative orthotic treatment, which implies that walking ability itself has improved, rather than the gait pattern. Orthoses show a positive additional effect on surgical results at different anatomical levels. Spatiotemporal parameters are positively influenced solely by additional orthotic support.

Prosthetic restoration of the forefoot lever after Chopart amputation and its consequences onto the limb during gait.

BACKGROUND: In subjects with Chopart amputation the foot lever is clearly diminished. Usually high or low profile prostheses are routinely utilized to re-establish the lost forefoot lever. RESEARCH QUESTION: The aim of this study was to investigate to what extent the proposed prostheses were able to replace the forefoot lever in chopart-amputees. METHODS: An instrumented 3D gait analysis, including plantar and socket pressure measurements, was performed in thirteen subjects with Chopart amputation using a clamshell and/or a Bellmann prosthesis including an ankle foot orthosis during level ground walking. RESULTS: The largest range of motion (p < 0.05) in the ankle joint was seen for the Bellmann prosthesis (32 ±â€¯3°) followed by the Bellmann prosthesis with ankle-foot orthosis (22 ±â€¯6°) whereas in the clamshell prosthesis (10 ±â€¯4°) almost no ankle motion was seen. Conversely, the highest ankle joint moment (p < 0.05) was seen for the clamshell prosthesis (1.04 ±â€¯0.24Nm/kg) followed by the Bellmann prosthesis with ankle-foot orthosis (0.66 ±â€¯0.14Nm/kg) and, finally, the Bellmann (0.37 ±â€¯0.11Nm/kg) alone offering the lowest joint moment. CONCLUSION: High-profile prostheses with ventral shell are more suitable to reacquire the lost forefoot lever after Chopart amputation. However, the issue of restricted range of motion in the ankle joint with the clamshell prosthesis needs to be addressed.

Wearing Time of Ankle-Foot Orthoses with Modular Shank Supply in Cerebral Palsy: A Descriptive Analysis in a Clinically Prospective Approach.

OBJECTIVE: To date there is only limited knowledge about the wearing time of orthoses. Ankle-foot orthoses (AFOs) have not been studied with this research question. Additional influences of the orthotic design as well as weekdays and the weekend are also unknown. DESIGN: Monocentric, clinically prospective intervention study. PATIENTS: Inclusion of 10 patients with bilateral spastic cerebral palsy. METHODS: Equipment of all subjects with a dynamic ankle-foot orthosis (DAFO) and modular shank supply (MSS, dynamic elastic shank adaptation or ground reaction AFO). Integration of temperature sensors for recording the wearing time for a period of 3 months. RESULTS: The actual wearing time was below the recommendations on actually worn days as well as the average of the entire study period. In addition, the actual usage in terms of days and hours was well below the recommendations. The wearing time showed differences between weekdays and weekend. Differences between DAFO and MSS were not detectable. CONCLUSION: The actual usage behavior of ankle-foot orthoses differs from the recommendations of the prescriber. This applies to both DAFOs and modular use with shank supplies. Environmental factors may have a significant impact on wearing times on weekdays and the weekend.

Does additional patella tendon shortening influence the effects of multilevel surgery to correct flexed knee gait in cerebral palsy: A randomized controlled trial.

BACKGROUND: The aims of this study were to investigate if patellar tendon shortening (PTS) as a part of SEMLS (single event multilevel surgery) is effective for reduction of flexed knee gait in children with cerebral palsy (CP) and, if PTS leads to stiff knee gait. METHODS: In a randomized controlled study 22 children with flexed knee gait (age: 10.4 ±â€¯2.6 years, GMFCS Level I-III) were randomized and allocated to two groups (1: SEMLS + PTS; 2: SEMLS no PTS): SEMLS was performed for correction of flexed knee gait either with or without additional PTS. Before and after surgery (follow up: 12.7 ±â€¯1.6 months) kinematics (3-D motion analysis) and clinical parameters were compared. RESULTS: Two children were lost to follow up. Maximum knee extension improved significantly in both groups after SEMLS while the patients with additional PTS showed much more correction (SEMLS + PTS: 37.6° to 11.4°, p = 0.007; SEMLS no PTS: 35.1° to 21.8°, p = 0.016). After surgery peak knee flexion decreased significantly (14.6°, p = 0.004) in the "SEMLS + PTS" group while there was no relevant change in the other group. There was a trend of increase in anterior pelvic tilt after surgery in both groups, but no statistical significant difference. After surgery knee flexion contracture (15.9°, p < 0.001) and popliteal angle (27.2, p = 0.009) measured on clinical examination only decreased significantly in the "SEMLS + PTS" group. CONCLUSION: PTS is effective for correction of flexed knee gait and knee flexion contracture leading to superior stance phase knee extension. However, additional PTS may lead to stiff knee gait and a higher increase of anterior pelvic tilt.

Electromyographic patterns in children with cerebral palsy: do they change after surgery?

The purpose of this study was to investigate the changes in electromyographic (EMG) patterns after multilevel surgical treatment in children with spastic cerebral palsy. Children with diplegia (n=18) and hemiplegia (n=16) aging from 6 to 16 years participated in the study. Twenty healthy children within the same age span are presented as reference. Gait analysis and surface electromyograms of seven major lower limb muscles were assessed before and 1-5 years after the multilevel surgery. The most frequent procedures were equinus correction, distal rectus femoris transfer, femoral derotation osteotomy and hamstrings lengthening. The results showed that the EMG pattern of the soleus, lateral gastrocnemius and tibialis anterior muscles became closer to normal after the surgery, while no differences were detected between diplegic and hemiplegic patients. Furthermore, a subgroup of 10 patients showed an increase in medial hamstrings activation during preswing that decreased postoperatively. These findings indicate that changes in EMG patterns should not be ruled out after surgical treatment, although the extent of these changes is limited compared to changes in the kinematics. Abnormal muscle activation before the operation can be related to a compensatory response in some patients and this can be manipulated after surgery.

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.

The Heidelberg foot measurement method: development, description and assessment.

The aim of this study was to develop and evaluate a kinematic measurement method for the foot that could be applied clinically to measure foot function including all typical foot deformities. The ankle was modelled as two anatomically based hinge joints rotating around anatomical axes estimated by the use of projection angles. For the mid- and forefoot a descriptive approach was chosen by defining angles between anatomical landmarks or reference points derived from these landmarks. The motion of 17 markers on the lower leg and foot was measured during walking gait on 10 adult participants with no known abnormalities to determine the pattern of normal foot motion, assess reliability and provide a reference against which pathological foot behaviour could be compared. Functional angles for mid- and forefoot motions were developed to improve clinical applications of the data. The combination of anatomically and technically oriented marker placement on the foot is a reliable basis for reproducible kinematic measurements and the method was shown to be viable for clinical practice.

Effect of kinesiotaping, non-elastic taping and bracing on segmental foot kinematics during drop landing in healthy subjects and subjects with chronic ankle instability.

OBJECTIVE: To evaluate the effects of kinesiotape, non-elastic tape, and soft brace on segmental foot kinematics during drop landing in subjects with chronic ankle instability and healthy subjects. DESIGN: Controlled study with repeated measurements. SETTING: Three-dimensional motion analysis laboratory. PARTICIPANTS: Twenty participants with chronic ankle instability and 20 healthy subjects. INTERVENTIONS: The subjects performed drop landings with 17 retroreflective markers on the foot and lower leg in four conditions: barefoot, with kinesiotape, with non-elastic tape and with a soft brace. MAIN OUTCOME MEASURES: Ranges of motion of foot segments using a foot measurement method. RESULTS: In participants with chronic ankle instability, midfoot movement in the frontal plane (inclination of the medial arch) was reduced significantly by non-elastic taping, but kinesiotaping and bracing had no effect. In healthy subjects, both non-elastic taping and bracing reduced that movement. In both groups, non-elastic taping and bracing reduced rearfoot excursion in inversion/eversion significantly, which indicates a stabilisation effect. No such effect was found with kinesiotaping. All three methods reduced maximum plantar flexion significantly. CONCLUSIONS: Non-elastic taping stabilised the midfoot best in patients with chronic ankle instability, while kinesiotaping did not influence foot kinematics other than to stabilise the rearfoot in the sagittal plane. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT01810471.

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.

Femoral derotation osteotomy in adults with cerebral palsy.

BACKGROUND: Internal rotation gait constitutes a complex gait disorder in bilateral spastic cerebral palsy (BSCP) including static torsional and dynamic components resulting in lever arm dysfunction. Although femoral derotation osteotomy (FDO) is a standard procedure to correct increased femoral anteversion in children, unpredictable outcome has been reported. The effect of FDO when it is done as part of single-event multilevel surgery (SEMLS) in adulthood has not been investigated. METHODS: In this study mid-term data of 63 adults with BSCP and internal rotation gait, undergoing SEMLS including FDO were analyzed pre- and 1.7 years postoperatively by clinical examination and 3D-instrumented gait analysis. All legs were categorized as the more or less involved side to consider asymmetry. The mean hip rotation in stance preoperatively and the intraoperative derotation was correlated with the difference pre- and postoperatively. RESULTS: The group as a whole experienced the following results postoperatively: improved mean hip rotation in stance (p=0.0001), mean foot progression angle (p=0.0001) and a significant improvement of the clinical parameter: passive internal and external hip rotation, midpoint and anteversion (p=0.0001) for both legs separately. With regard to the less and more involved side, clinical and kinematic parameters showed comparable significant changes (p=0.0001). The anteversion improved significantly in proximal compared to distal FDO (p=0.03). CONCLUSION: This study emphasizes an overall good correction of internal rotation gait in adults with bilateral involvement after FDO. However, the results are more predictable in adults compared to studies reporting outcome after FDO in children.

Superior functional outcome after femoral derotation osteotomy according to gait analysis in cerebral palsy.

The femoral derotation osteotomy (FDO) is seen as the golden standard treatment in children with cerebral palsy and internal rotation gait. Variable outcomes with cases of over- and undercorrection mainly in the less involved patients have been reported. The determination of the amount of derotation is still inconsistent. 138 patients (age: 11 (± 3.3) years) with cerebral palsy and internal rotation gait were examined pre- and 1 year postoperatively after distal or proximal FDO, using standardized clinical examination and 3D gait analysis. Three groups were defined retrospectively depending on the amount of derotation in relation to the mean hip rotation in stance (MHR) during gait analysis: Group A (derotation angle > MHR + 10°), Group B (derotation angle = MHR ± 10°), Group C (derotation angle

[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.

Factors associated with recurrence after femoral derotation osteotomy in cerebral palsy.

Femoral derotation osteotomy (FDO) as gold standard treatment for internal rotation gait in cerebral palsy (CP) leads to satisfying short-term results, whereas rates of recurrence up to 33% are reported in long-term outcome studies. The purpose of this study was therefore to identify factors contributing to recurrence of internal rotation gait in patients with CP who were treated with FDO in childhood. 70 patients (age: 10 (± 3.3) years at surgery) with bilateral CP and internal rotation gait were examined pre-, one year and at least five years (mean 8 ± 2 years) postoperatively after distal or proximal FDO, using standardized clinical examination and 3D gait-analysis. 27 patients had a good hip rotation one year postoperatively (between 5° external and 15° internal for both limbs) and were considered for the analysis of factors contributing to recurrence of internal rotation gait. Regarding all included patients both mean hip rotation and foot progression angle improved significantly (p < 0.001) from pre- to postoperative. A significant deterioration in hip rotation (more involved side) (p < 0.001) from one year postoperatively to the long-term follow-up can be observed. Younger age, reduced hip joint impulse, increased plantar flexion and internal foot progression angle postoperatively could be identified as factors for recurrence. FDO on average leads to a satisfactory correction of internal rotation gait. In order to improve the long-term outcome after FDO the time of multilevel surgery should be indicated as late as possible and the different factors leading to potential recurrence should be considered.