Relationship between kinematic gait quality and caregiver-reported everyday mobility in children and youth with spastic Cerebral Palsy.

BACKGROUND: 3D gait analysis (3DGA) is a common assessment in Cerebral Palsy (CP) to quantify the extent of movement abnormalities. Yet, 3DGA is performed in laboratories and may thus be of debatable significance to everyday life. AIM: The aim was to assess the relationship between kinematic gait abnormality and everyday mobility in ambulatory children and youth with spastic CP. METHODS: 73 paediatric and juvenile patients with uni- or bilateral spastic CP (N = 21 USCP, N = 52, BSCP, age: 4-20 y, GMFCS I-III) underwent a 3DGA, while the MobQues47 Questionnaire quantified caregiver-reported mobility. We calculated the Gait Profile Score (GPS), a metric that summarizes how far the lower limb joint angles during walking deviate from those of matched controls. RESULTS: The GPS correlated well with indoor and outdoor mobility (rho = -0.69 and -0.70, both p < 0.001) and the relationships were not significantly different for USCP and BSCP. Still, mobility was lower in BSCP (p < 0.001) and more compromised outdoors (p = 0.002). Indoor mobility could be predicted by walking speed, GPS and age (adj. R2 = 0.62). Outdoor mobility was best predicted by walking speed and GPS (adj. R2 = 0.60). The additive explained variance by the GPS was even higher outdoors than indoors (17.1% vs. 11.4%). CONCLUSIONS: Measuring movement deviations with 3DGA seems equally meaningful in uni- and bilaterally affected children and has considerable relevance for real-life ambulation, particurlarly outdoors, where children with spastic CP typically face greater difficulties. Therapeutic strategies that achieve faster walking and reduction of kinematic deviations may increase outdoor mobility.

Assessment of in vivo loading history of the patellofemoral joint: a study combining patellar position, tilt, alignment and bone SPECT/CT.

PURPOSE: The current study investigates whether patella height and tilt or leg alignment influence the intensity values as well as the distribution pattern of single photon emission computerized tomography/computerized tomography (SPECT/CT) tracer uptake in the patellofemoral joint. METHODS: 99mTc-HDP-SPECT/CT and radiographs of consecutive 84 knees were prospectively obtained. Lateral radiographs were analyzed in terms of patellar height, Insall-Salvati index and modified Insall-Salvati index. Skyline views were analyzed for Laurin's lateral patellofemoral angle. On long-leg radiographs, the mechanical leg alignment was classified as varus, valgus or neutral. SPECT/CT was analyzed for each anatomical region using a previously validated SPECT/CT localization and grading algorithm. Mean, standard deviation, minimum and maximum of grading for each area of the localization scheme were recorded. Nonparametric Spearman's correlations were used to correlate patellar height, lateral patellar angle and leg alignment with the tracer uptake intensity. Chi-square statistics were used for categorical data (p < 0.05). RESULTS: A patella baja correlated significantly with higher SPECT/CT tracer uptake in all patellar and lateral femoral regions (p < 0.001). A higher lateral patellar tilt correlated significantly with higher tracer uptake in the superior lateral femoral parts and the tibial tubercle. In mechanically varus aligned knees, there was significantly higher SPECT/CT tracer uptake on the medial and in valgus knees on the lateral part of the patellofemoral joint (p < 0.05). CONCLUSIONS: As the intensity and distribution of the SPECT/CT significantly correlated with patella baja and patellar tilt, SPECT/CT might be considered as imaging modality for evaluating patients with patellofemoral disorders and for follow-up of patients after patellofemoral realignment procedures. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Single photon emission computerized tomography and conventional computerized tomography (SPECT/CT) for evaluation of patients after anterior cruciate ligament reconstruction: a novel standardized algorithm combining mechanical and metabolic information.

PURPOSE: The purpose of this study was to introduce a novel standardized algorithm using SPECT/CT, which promises the potential combined assessment of the biology of the joint in particular the bone-graft-fixation complex and the 3D tunnel placement in patients after ACL reconstruction. Its clinical application and inter- and intra-observer reliability should be critically evaluated. METHODS: A novel SPECT/CT localization scheme consisting of 13 tibial, 9 femoral and 4 patellar regions on standardized axial, coronal and sagittal slices is proposed. The tracer activity on SPECT/CT was localized and recorded in 25 consecutive patients using a 3D volumetric and quantitative analysis software. The inter- and intra-observer reliability was assessed for localization and tracer activity. The tunnel position was assessed in 3D-CT using standardized frames of reference. The inter- and intra-observer reliability (OR) of the measured distances were calculated (ICC). RESULTS: The localization scheme for tracer uptake analysis was useful and easily applicable in all 25 knees. It showed very high inter-OR and intra-ORs for all regions (ICC > 0.80). Tibial and femoral tunnel position measurements showed strong agreement between the readings of the two observers; the ICCs for the position, angulation, length and entry point of the femoral tunnel were >0.88 (intra-OR) and >0.86 (inter-OR). The ICC for the position of the tibial tunnel (angulation, length and entry point) was >0.79 (intra-OR) and >0.74 (inter-OR). CONCLUSIONS: The SPECT/CT algorithm presented is highly reliable and clinically feasible. Combining the 3D-mechanical information on tunnel placement and attachment areas and the 3D metabolic data will be helpful in evaluating patients with pain after ACL reconstruction.

Assessment of loading history of compartments in the knee using bone SPECT/CT: a study combining alignment and 99mTc-HDP tracer uptake/distribution patterns.

This study investigates if the mechanical/anatomical alignment influences the intensity values as well as the distribution pattern of SPECT/CT tracer uptake. Eighty-five knees (mean age 48 ± 16) undergoing 99mTc-HDP-SPECT/CT due to pain were prospectively included. SPECT/CTs were analyzed using a previously validated localization method. The maximum intensities in each femoral, tibial, and patellar joint compartment (medial, lateral, central, superior, and inferior) were noted using a color-coded grading scale (0-10). The Kellgren-Lawrence osteoarthritis score (KL) was assessed on standardized radiographs. Long leg radiographs were used to assess the mechanical/anatomical leg alignment, which was classified as varus, valgus, or neutral. The alignment and KL was correlated with the intensity of tracer uptake in each area of interest (p < 0.05). The intensity of SPECT/CT tracer uptake in the medial and lateral knee compartment significantly correlated with varus or valgus alignment of the knee. A higher degree of osteoarthritis was significantly related to higher tracer uptake in the corresponding joint compartments. SPECT/CT reflects the specific loading pattern of the knee with regard to its alignment. It is also related to the degree of osteoarthritis. Hence, SPECT/CT should be considered for follow-up of patients after realignment treatments, osteotomies, deloader devices, or insoles.

Combined gracilis tendon autograft reconstruction and discus repair of a chronic anterior-superior sternoclavicular joint dislocation.

A case of an 18-year-old gardener who sustained an anterior-superior dislocation of the sternoclavicular joint while playing handball and falling on his right shoulder is presented. Non-surgical treatment failed, and the patient could willingly dislocate the right clavicle while abduction and external rotation of the arm. This painful condition was finally treated with surgical reconstruction of the sternoclavicular joint using gracilis tendon autograft and repair of the discus. Level of evidence Therapeutic study, case report and technical note, Level IV.

Navigated total hip arthroplasty using a 3-D freehand ultrasound system: technical note and preliminary results.

Ultrasound-navigated cementless total hip arthroplasty (THA) was performed in 10 consecutive patients with primary osteoarthritis of the hip between August 2008 and October 2009 (M:F, 6:4; median age, 61 years; age range, 30-86 years). The pelvic orientation was defined by preoperative digitization and registration of bony landmarks. Cup inclination and anteversion were documented for each patient intraoperatively (epidigitized vs ultrasound-assessed landmarks). The median difference between the palpated and ultrasound anterior pelvic plane was 8° (range, 4°-18°) for pelvic tilt (rotation around the transversal axis), 1° (range, -3° to 2°) for rotation around the longitudinal axis, and 0.25° (range, -2.0° to 5.0°) for rotation around the sagittal axis. The median difference in cup orientation resulting from pelvic tilt error was 6° (range, 3°-13°) for anteversion and 3° (range, -1° to 5°) for inclination. There were no intra- or postoperative complications. The measured width of soft tissue layer anterior to the pelvic symphysis correlated significantly with the measured difference in cup inclination and anteversion. One centimeter of soft tissue anterior to the symphysis resulted in a median 2° (range, 1.75°-2.3°) difference in pelvic tilt. Ultrasound-assisted navigation in THA is a promising technology able to eliminate systematic errors in anterior pelvic plane orientation, in contrast to conventionally navigated THA using percutaneous palpation of landmarks or THA without navigational support.