Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?

Background and Objectives: Medical registries evolved from a basic epidemiological data set to further applications allowing deriving decision making. Revision rates after non-traumatic amputation are high and dramatically impact the following rehabilitation of the amputee. Risk scores for revision surgery after non-traumatic lower limb amputation are still missing. The main objective was to create an amputation registry allowing us to determine risk factors for revision surgery after non-traumatic lower-limb amputation and to develop a score for an early detection and decision-making tool for the therapeutic course of patients at risk for non-traumatic lower limb amputation and/or revision surgery. Materials and Methods: Retrospective data analysis was of patients with major amputations lower limbs in a four-year interval at a University Hospital of maximum care. Medical records of 164 patients analysed demographics, comorbidities, and amputation-related factors. Descriptive statistics analysed demographics, prevalence of amputation level and comorbidities of non-traumatic lower limb amputees with and without revision surgery. Correlation analysis identified parameters determining revision surgery. Results: In 4 years, 199 major amputations were performed; 88% were amputated for non-traumatic reasons. A total of 27% of the non-traumatic cohort needed revision surgery. Peripheral vascular disease (PVD) (72%), atherosclerosis (69%), diabetes (42%), arterial hypertension (38%), overweight (BMI > 25), initial gangrene (47%), sepsis (19%), age > 68.2 years and nicotine abuse (17%) were set as relevant within this study and given a non-traumatic amputation score. Correlation analysis revealed delayed wound healing (confidence interval: 64.1% (47.18%; 78.8%)), a hospital length of stay before amputation of longer than 32 days (confidence interval: 32.3 (23.2; 41.3)), and a BKA amputation level (confidence interval: 74.4% (58%; 87%)) as risk factors for revision surgery after non-traumatic amputation. A combined score including all parameters was drafted to identify non-traumatic amputees at risk for revision surgery. Conclusions: Our results describe novel scoring systems for risk assessment for non-traumatic amputations and for revision surgery at non-traumatic amputations. It may be used after further prospective evaluation as an early-warning system for amputated limbs at risk of revision.

Effects of a full-body electrostimulation garment application in a cohort of subjects with cerebral palsy, multiple sclerosis, and stroke on upper motor neuron syndrome symptoms.

OBJECTIVES: Dysfunction of the central nervous system may inflict spastic movement disorder (SMD). Electrical stimuli were identified as promising therapeutic option. Electrical stimulation provided by a 58-electrode full body garment was investigated based on data from regular trial fittings. METHODS: Data from 72 testees were investigated. Age averages 36.6 (19.8) ys with 44 females. The cohort spans infantile cerebral paresis (CP) (n=29), multiple sclerosis (MS) (n=23) and stroke (n=20). Data were stratified by etiology and an entry BBS Score<45. RESULTS: Effect sizes (Cohen`s d) related BBS, TUG, FGA, 10mWT, WMFT, EQ5D5L and Pain. Significance levels are indicated by *: p<0.05, **: p<0.01, ***: p<0.001, (t): p<0.1: CP: 1.64***, 0.29*, 1.59***, 0.76(t), 1.00***, 0.5*, 1.28***; MS: 1.83***, 0.83***, 1.28**, 1.07***, 0.93*, 1,11**, 0.78*; Stroke: 1.28**, 0.78**, 0.89, 0.92**, 0.71, 1.26*, 0.78*. CONCLUSIONS: Multi-site transcutaneous electrical stimulation may increase ambulation related skills in subjects with SMD stemming from CP, MS and stroke. The results indicate effects on static and dynamic balance, fall risk, mobility, upper extremity improvement and an overall increase in health utility and a reduction in spasticity related pain. Effects are immediate as well as sustained. These results may inspire individual trial fittings and inform further controlled trials.

A microprocessor stance and swing control orthosis improves balance, risk of falling, mobility, function, and quality of life of individuals dependent on a knee-ankle-foot orthosis for ambulation.

INTRODUCTION: The C-Brace microprocessor stance and swing control orthosis was designed to overcome safety and functional limitations of traditional knee-ankle-foot orthoses (KAFOs) for individuals with lower limb paresis. However, a systematic comparison to established KAFO types has not been performed in a bigger sample. METHODS: International multicenter, randomized, controlled, cross-over clinical trial. Legacy KAFO users at risk of falling were randomized to KAFO/C-Brace or C-Brace/KAFO use for three months with each orthosis. Primary outcome was balance assessed with the Berg Balance Scale (BBS). Secondary outcomes were falls, mobility, function, and quality of life. RESULTS: Intention-to-treat analysis with 102 participants. With the C-Brace, the BBS improved by 3.3 ± 6.3 points (p < 0.0001). Significantly fewer participants presented BBS scores <40 indicative of increased fall risk (16 vs. 36, p = 0.018). Mean falls reduced from 4.0 ± 16.8 to 1.1 ± 3.3 (p = 0.002). Outcomes for function, mobility, and quality of life showed significant improvements with the C-Brace. DISCUSSION: The improvements in fall risk and mobility can be attributed to the stumble recovery and controlled knee flexion during weight bearing of the C-Brace and have a positive impact on the quality of life of users. CONCLUSION: The C-Brace represents an option for KAFO users with increased fall risk and reduced mobility.

When prescribing traditional knee-ankle-foot orthoses (KAFOs), their known limitations, such as limited function and mobility, and the requirement to walk with compensatory mechanisms, especially on non-level terrains, should be considered.For patients with compromised balance and increased risk of falling when using a traditional KAFO, a microprocessor stance and swing control orthosis (MP-SSCO) may be considered as an orthotic option to reduce their fall risk.For patients with mobility restrictions using a traditional KAFO, a MP-SSCO may be considered to improve function, mobility, reintegration into normal living, and quality of life.

The impact of transfemoral socket adduction on pelvic and trunk stabilization during level walking - A biomechanical study.

BACKGROUND: It is common practice to align transfemoral prosthetic sockets in adduction, due to the physiologic, adducted femoral alignment in unimpaired legs. An adducted femoral and socket alignment helps tightening hip abductors to stabilize the pelvis and reduce pelvic and trunk related compensatory movements. RESEARCH QUESTION: How do different socket adduction conditions (SAC) of transfemoral sockets affect pelvic and trunk stabilization during level ground walking in the frontal plane? METHODS: Seven persons with transfemoral amputation with medium residual limb length participated in this study. The prosthetic alignment in the sagittal plane was performed according to established recommendations. SAC varied (0°, 3°, 6°, 9°). Kinematic and kinetic parameters were recorded in a gait laboratory with a 12-camera optoelectronic system and two piezoelectric force plates embedded in a 12-m walkway. The measurements were performed during level ground walking with self-selected comfortable gait speed. RESULTS: In the frontal plane, nearly all investigated kinematic and kinetic parameters showed a strong correlation with the SAC. The pelvis was raised on the contralateral side throughout the gait cycle with increasing SAC. During the prosthetic side stance phase, the mean shoulder obliquity and mean lateral trunk lean to the prosthetic side tended to be reduced with increased SAC. Prosthetic side hip abduction moment decreased with increasing SAC. SIGNIFICANCE: The results confirm that transfemoral SAC contributes to pelvic stabilization and reduced compensatory movements of the pelvis and trunk. Transfemoral SAC of 6 ± 1° for bench alignment seems adequate for amputees with medium residual limb length. However, the optimum value for the individual patient may differ slightly.

Mobility and satisfaction with a microprocessor-controlled knee in moderately active amputees: A multi-centric randomized crossover trial.

OBJECTIVE: Microprocessor-controlled knees are generally prescribed and reimbursed for active amputees. Recent studies suggested that this technology could be useful for amputees with moderate activity level. We compared the efficiency of a microprocessor-controlled knee (MPK, Kenevo, Otto Bock) and non-MPKs (NMPKs) in these indications. METHODS: A multi-centric randomized crossover trial was conducted in 16 hospitals from 3 European countries. Participants were randomized to an MPK-NMPK sequence, testing the MPK for 3 months and the NMPK for 1 month, or to an NMPK-MPK sequence, testing the NMPK for 1 month and the MPK for 3 months. Dynamic balance, the main criteria, was assessed with the Timed-Up and Go test (TUG), functional mobility with the Locomotor Capability Index (LCI-5), quality of life with the Medical Outcomes Study Short Form 36 v2 (SF-36v2) and satisfaction with the Quebec User Evaluation of Satisfaction with Assistive Technology 2.0. The occurrence of falls was monitored during the last month of trial. Analysis was by intent-to-treat and per-protocol (PP). RESULTS: We recruited 35 individuals with transfemoral amputation or knee disarticulation (27 males; mean age 65.6years [SD 10.1]). On PP analysis, dynamic balance and functional mobility were improved with the MPK, as shown by a reduced median TUG time (from 21.4s [Q1-Q3 19.3-26.6] to 17.9s [15.4-22.7], P=0.001) and higher mean global LCI-5 (from 40.4 [SD 7.6] to 42.8 [6.2], P=0.02). Median global satisfaction score increased (from 3.9 [Q1-Q3 3.8-4.4] to 4.7 [4.1-4.9], P=0.001) and quality of life was improved for the mental component summary of the SF-36v2 (median score from 53.3 [Q1-Q3 47.8-60.7] to 60.2 [51.6-62.6], P=0.03) and physical component summary but not significantly (mean score from 44.1 [SD 6.3] to 46.3 [7.0], P=0.08). Monitoring of adverse events including falls revealed no differences between both assessed devices. CONCLUSION: This study enhances the level of evidence to argue equal opportunity for all individuals with transfemoral amputation or knee disarticulation, regardless of their mobility grade, to be provided with appropriate prostheses.

Preoperative hip rotation moments do not predict long-term development after femoral derotation osteotomy in children with cerebral palsy.

BACKGROUND: Femoral derotation osteotomy (FDO) is the standard treatment for internal rotation gait (IRG) in children with cerebral palsy (CP) although high rates of recurrence have been reported recently. Various factors associated with recurrence could be identified, but no predictor named. RESEARCH QUESTIONS: Does FDO lead to a change of internal transversal hip moments? Are preoperative internal transversal hip moments a predictor for recurrence of IRG? METHODS: 41 children with spastic bilateral CP and 72 limbs that received a FDO (10.4 ±â€¯2.7 years at surgery) were included retrospectively. Kinematic data were analyzed pre- (2 ±â€¯3 months), postoperatively (12 ±â€¯3 months) and at long-term follow-up (at least five years postoperatively; 84 ±â€¯13 months), internal transversal hip moments were analyzed pre- and postoperatively. RESULTS: The maximum peaks of the internal hip rotation moment during loading response decreased significantly (p = 0.003). The minimum during the second half of the stance phase increased significantly (p = 0.004) and the initially internal externally rotating moment changed to an internal internally rotating moment. No correlation between changes in hip rotation from postoperatively to the long-term follow-up and the preoperative internal hip rotation moment could be identified. SIGNIFICANCE: FDO leads to changes in internal hip rotation moments. Preoperative internal hip rotation moments can't be used as predicting factor for recurrence of IRG. The data suggest, that recurrence of IRG depends less on patient specific motion patterns, but more on the time point of surgery and the therapy of all concomitant deformities during SEMLS.

Effect of floor reaction ankle-foot orthosis on crouch gait in patients with cerebral palsy: What can be expected?

BACKGROUND: Floor reaction ankle-foot orthoses are commonly prescribed to improve knee extension of children with cerebral palsy having crouch gait. Their effectiveness is debated. Therefore, the objective of this study is to optimize current prescription criteria for the improvement of crouch gait. STUDY DESIGN: Cross-sectional interventional study. METHODS: A total of 22 patients with bilateral spastic cerebral palsy, between 6 and 17 years, Gross Motor Function Classification System II-IV participated in this study. Instrumented gait analysis was done under three conditions: barefoot, shoed, and with orthotics. Patients were divided into two groups: good and non-responders with more and less than 8.8° improvement of knee extension during walking, respectively. A multiple predictor analysis was done on parameters that were different between groups. RESULTS: In total, 12 of 22 patients showed good response in knee extension with a mean change of 17° (standard deviation = 5°). Good responders showed a significantly smaller walking velocity, knee extension strength, ankle plantarflexion strength, and greater external foot progression angle compared to non-responders. Foot progression angle together with ankle plantarflexion strength explained 37% of the variance in improvement of knee extension. CONCLUSION: With appropriate patient selection, an improvement of crouch gait by ankle-foot orthoses of 17° (standard deviation = 5°) can be expected. Patients with slow velocity, weak plantarflexors, and external foot progression benefit most. Joint contractures were no contraindications. Clinical relevance This study showed that gait in patients with low functional level benefit most from ankle-foot orthoses. Unlike in patients with higher functional status, contractures of hip, knee, and ankle did not reduce the positive effects on gait. The suggested prescription criteria may help to better select appropriate patients for orthotics.

Hip-joint congruity after Dega osteotomy in patients with cerebral palsy: long-term results.

INTRODUCTION: Neurogenic hip dislocation is quite common in children with cerebral palsy (CP). The purpose of this study was to evaluate the long-term outcome of single-event multilevel surgery (SEMLS) in combination with hip reconstruction by using a periacetabular osteotomy as described by Dega concerning post-operative remodeling and plasticity of the femoral head post-operatively. METHODS: A total of 72 patients with CP as the primary disease and in whom a complex surgical hip reconstruction was performed during SEMLS between 1998 and 2004 were included in the study. There were 45 men and 27 women, with a median age of 7.6 (4.7-16.3) years at the time SEMLS was performed. The mean follow-up time was 7.7 years (4.9-11.8). X-rays were taken before and after surgery, and Rippstein 1 and 2 were used for follow-up. As the most reliable value for decentration, migration percentage (MP) as described by Reimers was used. To measure hip-joint cover at follow-up, the centre-edge angle was used. The hip was divided into four different categories according to sphericity and congruity. Using this approach, we could evaluate joint remodeling. RESULTS: Pre-operatively, the mean MP measured by X-ray was 68 %. Directly after surgery, this value decreased on average by 12 % and at the long-term follow-up was 16.0 % on average. A high rate of incongruence was observed on X-rays taken directly after surgery: 66 hip joints were classified as incongruent. The number of aspherical and incongruent joints decreased to 54 at the follow-up examination. CONCLUSION: Data of our study with high plasticity of the hip joint suggest that even if the femoral head is deformed and a persistent incongruency after surgery is expected, hip reconstruction can be recommended.

Hip reconstruction surgery is successful in restoring joint congruity in patients with cerebral palsy: long-term outcome.

PURPOSE: Neurogenic hip dislocation is frequently observed in patients with cerebral palsy (CP). If the hip is not centred but not dislocated, the hip joint can be recentered with minor operative effort. Reconstructive procedures are indicated if the femoral head is subluxated or dislocated. There are no data as to when destruction of the femoral head requires a salvage procedure or whether hip reconstruction surgery is successful in restoring joint congruity in patients with CP. Our aim was to investigate femoral head plasticity after hip reconstruction surgery in a long-term outcome study. METHODS: We studied a large cohort of patients with CP and high hip dislocation (Tönnis grade IV) before surgery. Sixty-eight patients were assessed, of whom 23 presented with bilateral high hip dislocation, and 91 complex hip reconstructions were conducted. Standardised radiographic examination was performed before and directly after surgery and at the long-term follow-up examination. RESULTS: Pain was the most frequent reason for complex hip-joint reconstruction (49 patients, 72%). An impressive improvement in pain was demonstrated postoperatively. Forty-five hip joints presented aspheric incongruity postoperatively, which improved on average 7.7 years after surgery and 59 hip joints showed congruency. Only 15% of patients experienced pain at the time of final follow-up, and that was of low intensity. CONCLUSIONS: Early conservative treatment for hip dislocation is helpful, and operative reconstruction should also be scheduled early. Continued surveillance is necessary, and Reimers index is useful for monitoring the development of hip centering. In case of hip pain and femoral head deformity, our long-term study indicates that hip reconstruction surgery as a part of multilevel surgery improves pain and function in patients with CP and Tönnis IV hip dislocation, even if the hip joint is incongruent after operation. This incongruity improves over the long-term. If possible, a reconstruction procedure should be performed before the femoral head becomes deformed. High plasticity of the hip joint suggest that even if the femoral head is deformed, hip reconstruction can be recommended.

The association of equinus and primary genu recurvatum gait in cerebral palsy.

Primary genu recurvatum (GR) is less investigated and data presenting the prevalence among patients with bilateral spastic cerebral palsy (BSCP) is lacking in the literature. Equinus is mentioned as one of the main underlying factors in GR, but its influence on the severity and onset type of GR is mainly unanswered, yet. Hence, the purpose of this retrospective study was to assess the prevalence of GR in a large sample size in children with BSCP and to investigate sagittal plane kinematics to evaluate the influence of equinus on different GR types using data of three-dimensional gait analysis. GR was defined as a knee hyperextension of more than one standard deviation of an age matched control group during stance phase in either one or both of the limbs. Primary GR was defined as a GR without having previous surgery regarding the lower extremity, no selective dorsal rhizotomy and/or interventions like botulinum toxin injection, shock wave therapy or serial casting during the last 6 months in the patient history. In a retrospective study 463 patients with BSCP (GMFCS Level I-III) received three-dimensional gait analysis and were scanned for the presence of primary GR. Finally, 37 patients (23 males, 14 females) matched the determined inclusion criteria and were therefore included for further analysis in this study. Out of those patients seven walked with orthoses or a walker and were excluded from further statistical comparison: Kinematics of the lower limbs were compared between patients having severe (knee hyperextension>15°) and moderate (knee hyperextension 5-15°) GR and between patients showing an early (first half of stance phase) and a late (second half of stance phase) GR. Primary GR was present in 37 patients/52 limbs (prevalence 8.0/5.6%). Severe GR was associated with a decreased ankle dorsiflexion compared with moderate GR. Early GR showed an increased knee hyperextension compared to late GR. In conclusion GR is less frequent compared with crouch or stiff gait. Our findings support the importance of equinus as a major underlying factor in primary GR. In this context the influence of equinus seems to be more important in early GR.

Do changes in torsional magnetic resonance imaging reflect improvement in gait after femoral derotation osteotomy in patients with cerebral palsy?

PURPOSE: Femoral derotation osteotomy (FDO) is commonly used to correct internal rotation gait (IRG) in spastic diplegia. The purpose of this study was to investigate whether the extent of intraoperative derotation is reflected in changes in static (clinical ROM and anteversion angle measured on torsional MRI) and dynamic parameters (transverse plane kinematics in three-dimensional gait analysis) after FDO in children with spastic diplegia. METHODS: In a prospective study, 30 children with spastic diplegia and IRG were treated with FDO as part of a multilevel surgery and were examined pre- and postoperatively clinically, by three-dimensional gait analysis and by torsional MRI according to a standardised protocol. RESULTS: A correlation (r = 0.317, p = 0.015) between the extent of intraoperative derotation and mean hip rotation in stance as well as the anteversion angle measured on torsional MRI (r = 0.454, p < 0.001) was found. However, no significant correlation was observed between anteversion angle (tMRI) and mean hip rotation in stance, either before or after FDO. CONCLUSIONS: Significant improvements were found in IRG after FDO, confirming the results of previous studies. There was no correlation between the anteversion measured on MRI and the mean hip rotation in stance in 3D gait analysis before or after FDO. Thus, the data suggest that if the intraoperative extent of derotation is determined only by the anteversion angle, the result will not be better after FDO. It might only help to avoid retroversion and indicate the maximum amount of femoral derotation. In this study the extent of the intraoperative derotation was orientated at the preoperative midpoint of rotation. Based on the small, but significant correlation between the clinical midpoint and the mean hip rotation in stance in the gait analysis, determination of the intraoperative extent of derotation according to the mean hip rotation in stance seems to give the best results.

Integrating strength tests of amputees within the protocol of conventional clinical gait analysis: a novel approach.

Clinical experience tells us that the lower-limb amputees are one of the patient groups who clearly suffer from a strength deficit in their involved side. However, there is no obvious evidence for the relation between the residual limb strength and walking ability in this population. Correlating the results of the conventional clinical gait analysis (CGA) with strength tests could help to find out how deficits in strength impact the amputees' gait. In this contribution, a new device for measuring the isometric muscle strength of the hip and the knee was tested for feasibility. Three groups were tested: one group of 11 healthy subjects (29±5 years) to test the repeatability of the device, two unilateral amputees (one transfemoral for 56 years, one transtibial for 65 years), and a reference group of 17 healthy subjects (55±10 years). The new method presents an adequate technique to integrate strength testing within a standard protocol of the CGA. Results showed to be repeatable within sessions [i.e., within-day, intraclass correlation coefficient (ICC)>0.972] and between repeated measurements (i.e., day-to-day, ICC>0.765). The tested amputees showed clear deficits in maximum isometric joint moments in their most distal joint. The first results suggest evidence for a relation between the maximum isometric joint moments and gait deviations in amputees.

The influence of botulinum toxin A injections into the calf muscles on genu recurvatum in children with cerebral palsy.

BACKGROUND: With cerebral palsy (CP), an equinus deformity may lead to genu recurvatum. Botulinum toxin A (BtA) injection into the calf muscles is a well-accepted treatment for dynamic equinus deformity. QUESTIONS/PURPOSES: The purpose of this study was to determine whether BtA injections into the calf muscles to decrease equinus would decrease coexisting genu recurvatum in children with diplegic CP. METHODS: In a retrospective study, 13 children (mean age, 5 years) with spastic diplegic CP showing equinus and coexisting primary genu recurvatum, who were treated with BtA injections into the calf muscles, were included. Evaluations were done before and 6 and 18 weeks after intervention using three-dimensional gait analysis and clinical examinations according to a standardized protocol. Basic statistical analyses (power analysis, ANOVA) were performed to compare genu recurvatum before treatment and at 6 and 18 weeks after injection with BtA. RESULTS: During stance phase, maximum ankle dorsiflexion was increased substantially from -3.0° ± 14.3° before to 6.2° ± 14.2° 6 weeks after the injections. Despite this, with the numbers available, the amount of recurvatum in stance did not improve with treatment at either 6 or 18 weeks. There was significant improvement of knee hyperextension during stance phase of 6.2° between baseline and 18 weeks after BtA injection, but a genu recurvatum was still present in most patients. CONCLUSIONS: Despite improvement of ankle dorsiflexion after injection with BtA, genu recurvatum did not show relevant improvement at 6 or 18 weeks after injection with the numbers available. Because knee hyperextension remained in most patients, other factors leading to genu recurvatum should be taken into consideration. In addition, a botulinum toxin-induced weakness of the gastrocnemius may explain why recurvatum gait was not significantly reduced. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The influence of hip abductor weakness on frontal plane motion of the trunk and pelvis in patients with cerebral palsy.

Trendelenburg walking pattern is a common finding in various disorders, including cerebral palsy (CP), where it is seen in children and adults. Clinically, this deviation is viewed as a consequence of hip abductor weakness resulting in pelvic obliquity. Trunk lean to the ipsilateral side is a common compensatory mechanism to counteract pelvic obliquity and to maintain gait stability. However, no published investigations objectively address pelvic and trunk motions in the frontal plane or examine the correlation with hip abductor weakness in patients with CP. We selected 375 ambulatory (GMFCS I-III) patients with spastic bilateral CP and 24 healthy controls from our gait laboratory database. They had all undergone a standardized three-dimensional analysis of gait, including trunk motion, and a clinical examination including hip abductor strength testing. Selected frontal plane kinematic and kinetic parameters were investigated and statistically tested for correlation (Spearman rank) with hip abductor strength. Only a weak (r=0.278) yet highly significant correlation between trunk lean and hip abductor strength was found. Hip abductor weakness was accompanied by decreased hip abduction moment. However, no significant differences in pelvic position were found between the different strength groups, indicating that the pelvis remained stable regardless of the patients' strength. Our findings indicate that weak hip abductors in patients with CP are accompanied by increased trunk lean to the ipsilateral side while pelvic position is preserved by this compensatory mechanism. However, since this correlation is weak, other factors influencing lateral trunk lean should be considered. In patients with severe weakness of the hip abductors compensatory trunk lean is no longer fully able to stabilize the pelvis, and frontal pelvic kinematics differs from normal during loading response. The results indicate that the stable pelvic position seems to be of greater importance than trunk position for patients with CP. Further studies are needed to investigate other factors influencing lateral trunk lean.

Long-term effects after conversion of biarticular to monoarticular muscles compared with musculotendinous lengthening in children with spastic diplegia.

Adverse effects such as increased anterior pelvic tilt (APT) are reported after muscle-tendon lengthening (MTL) for the correction of flexed knee gait in cerebral palsy. The conversion of biarticular muscles (CBM) to monoarticular muscles represents an alternative treatment, but only few short-term results have been published, without comparison with MTL. The long-term outcome of 21 diplegic patients treated with CBM in a prospective study was compared with the results in MTL patients in a matched-pair analysis. Standardized clinical examination and three-dimensional gait analysis were done before surgery, 1 year thereafter, and at long-term follow-up a mean of 9.2 years postoperatively. Mean APT increased one year after surgery in both groups. This increase was higher in MTL patients and statistically significant only for this group. Knee flexion at initial contact and minimum knee flexion in stance were significantly decreased in both groups, while in swing the CBM group tended to show more of a decrease in knee flexion but at the cost of reduced peak flexion. Both groups showed deterioration of kinematic knee parameters through to long-term follow-up; the favourable effects of CBM disappeared, and the two groups displayed comparable average pelvic and knee kinematics. Considering individual patterns the prevalence of increased APT was lower in the CBM group 1 year after surgery, indicating that sparing the semitendinosus may have a positive effect on pelvic stability. However, after 9 years 30% of the patients in both groups showed increased APT indicative of persistent hamstring insufficiency. These results demonstrate that CBM, a significantly more extensive procedure, has no long-term advantage over MTL.

Long-term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in spastic diplegic cerebral palsy.

BACKGROUND: The evidence for distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in children with spastic diplegic cerebral palsy is limited because of inconsistent outcomes reported in various studies and the lack of long-term evaluations. METHODS: This study investigated the long-term results (mean, nine years) for fifty-three ambulatory patients with spastic diplegic cerebral palsy and stiff-knee gait treated with standardized distal rectus femoris transfer as a part of multilevel surgery. Standardized three-dimensional gait analysis and clinical examination were carried out before surgery and at one year and nine years after surgery. Patients with decreased peak knee flexion in swing phase who had distal rectus femoris transfer to correct the decreased peak knee flexion in swing phase (C-DRFT) were evaluated separately from those with normal or increased peak knee flexion in swing phase who had distal rectus femoris transfer done as a prophylactic procedure (P-DRFT). RESULTS: A significantly increased peak knee flexion in swing phase was found in the C-DRFT group one year after surgery, while a significant loss (15°) in peak knee flexion in swing phase was noted in the P-DRFT group. A slight but not significant increase in peak knee flexion in swing phase in both groups was noted at the time of the long-term follow-up. A significant improvement in timing of peak knee flexion in swing phase was only found for the C-DRFT group, and was maintained after nine years. Knee motion and knee flexion velocity were significantly increased in both groups and were maintained at long-term follow-up in the C-DRFT group, while the P-DRFT showed a deterioration of knee motion. CONCLUSIONS: Distal rectus femoris transfer is an effective procedure to treat stiff-knee gait featuring decreased peak knee flexion in swing phase and leads to a long-lasting increase of peak knee flexion in swing phase nine years after surgery. Patients with more involvement showed a greater potential to benefit from distal rectus femoris transfer. However, 18% of the patients showed a permanently poor response and 15% developed recurrence. In patients with severe knee flexion who underwent a prophylactic distal rectus femoris transfer, a significant loss in peak knee flexion in swing phase was noted and thus a prophylactic distal rectus femoris transfer may not be indicated in these patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term outcome of femoral derotation osteotomy in children with spastic diplegia.

Satisfactory short-term results after femoral derotation osteotomy (FDO) for the treatment of internal rotation gait in cerebral palsy have been reported by various authors. However, there are only a few longer-term studies reporting results 5 years after FDO and these are not in agreement. There are no reports on the clinical course beyond the pubertal growth spurt. 33 children with diplegia (n=59 legs, age: 10.5±3.6 years) and internally rotated gait were examined pre- (E0), 1 year (E1), 3±1 (E2) and 9±2 (E3) years after distal (27 legs) or proximal (32 legs) FDO as part of multilevel surgery, using standardized clinical exam and 3D gait-analysis at all examinations. The amount of intra-operative derotation averaged 25°. ANOVA was used for statistics (p<0.05). Mean hip internal rotation in stance at E0 of 17.3° was significantly changed to 1.0° of external rotation at E1 and was maintained at 4.2° at E3. The same clinical course was found for foot progression angle. The mid-point of passive hip rotation at E0 was 21°. This was significantly decreased to 6° at E1 and showed a small but significant increase reaching 12° at E3. The results of this study showed a good overall correction of internally rotated gait following FDO. These improvements were maintained at long-term follow-up after the pubertal growth spurt. Recurrence was observed in some cases with overall severe deterioration. In those patients persistent dynamic factors leading to recurrence should be further investigated.

Long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery in spastic diplegic cerebral palsy.

BACKGROUND: Equinus of the foot at the ankle is one of the most common deformities in patients with spastic diplegic cerebral palsy, leading to gait disturbances and secondary deformities. During single-event multilevel surgery, equinus is commonly corrected by calf muscle lengthening, such as gastrocnemius-soleus intramuscular aponeurotic recession. Various studies have described satisfactory short-term results after gastrocnemius-soleus intramuscular aponeurotic recession. However, there is no evidence for maintenance of equinus correction because of the small and heterogeneous case series and short follow-up time previously reported. METHODS: The present study provides long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery for the treatment of equinus in forty-four patients with spastic diplegia who were able to walk (forty-eight legs had lengthening of the gastrocnemius and thirty-four legs had lengthening of the gastrocnemius and soleus). Standardized three-dimensional gait analysis and clinical examination were done preoperatively and at one year, a mean (and standard deviation) of 3 ± 1 years, and a mean of 9 ± 2 years after surgery. RESULTS: Significant improvements in kinematic and kinetic ankle parameters on gait analysis as well as passive dorsiflexion in clinical examination were found one year after surgery. While there was a significant loss of passive dorsiflexion at the time of long-term follow-up, the improvements in gait analysis parameters were maintained. The endurance of gait improvements was accompanied by a persistent increase of dorsiflexor muscle strength without relevant loss of plantar flexor strength. Although it was not significant, there was a tendency for deterioration of gait analysis parameters over the nine years. The analysis of individual patterns showed recurrence of equinus at the ankle in 24% of the legs. Early-onset calcaneal gait was found one year after surgery in seven legs (9%), but without secondary crouch gait, and there was recovery at the time of the long-term follow-up. Late-onset calcaneal gait was seen at the time of long-term follow-up in eight legs (10%), of which four had an accompanying crouch gait. CONCLUSIONS: Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to satisfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession.

Distal rectus femoris transfer as part of multilevel surgery in children with spastic diplegia--a randomized clinical trial.

The evidence in support of distal rectus femoris transfer (DRFT) as part of single-event multilevel surgery (SEMLS) is limited due to inconsistent outcome reports and a lack of randomized studies. The purpose of this prospective randomized trial was to establish whether the results of SEMLS without DRFT are similar to those of a conventional approach that includes DRFT in the SEMLS. In all, 32 children with spastic diplegia (GMFCS I-III) and an indication for DRFT were recruited and randomized into a DRFT (15 children) and a NON-DRFT group (17 children) using a minimization method. During SEMLS, bilateral DRFT was performed only in the DRFT group. Three-dimensional gait analysis and clinical examination were performed before and 1 year after surgery. In both groups a significant increase in range of motion during swing and knee flexion velocity were found, which was significantly higher in the DRFT group. While peak knee flexion in swing (pKFSw) was preserved in the DRFT group and significantly decreased in the NON-DRFT group, pKFSw timing was significantly earlier in both groups. The clinical relevance of the higher overall benefits in the DRFT group is limited, considering that 33% of patients in this group did not benefit from the procedure. Furthermore, 53% of the NON-DRFT patients did not undergo what proved to be an unnecessary DRFT. Subgroup analysis showed benefits for patients with decreased pKFSw, while those with severe flexed-knee gait (normal or increased pKFSw) did not profit from DRFT. This may explain the inconsistent overall results, and DRFT is therefore not recommended as a "prophylactic" procedure in patients with severe flexed-knee gait.