Therapy of intoeing gait in cerebral palsy

AOPA-Orlando-German Day, October 2010

F. Braatz MD, S. Wolf PhD

IntroductionInternal Rotated Gait

• Functional & cosmetic problems

“squinting patella sign” (“knocking knees”)

internal foot progression inefficient foot clearancecompensatory external tibial rotationcompensatory pelvic retraction

Operation

D.E.12 Y.: CP, Diparesis, Derotation Femur35°., Evans, Hemstring Lengthening 07/08D.E.12 Y.: CP, Diparesis, Derotation Femur35°., Evans, Hemstring Lengthening 07/08

Prae OP

Operation

Patient 1

Patient 1

V.T.12 y:Operation 27.11.02:1) FDO right 30° left 20 ° 2) Chopartfusion 3) Rektus-transfer

27.10.2003

25.11.2002

Proximal vs. distal Type

3D Gait Analysis3D Gait Analysis25.11.2002 27.10.2003

Proximal vs. distal Type

Team

Night Splint

Therapy overnight Low-cost Muscle-tone?

Stable hindfoot

KAFOs

With hinges

Night Splint

Foam Connected with a rod

Night Splint

Night Splint-Foam

S.W.A.S.H. –MAO-Orthosis

MAO Orthosis

S.W.A.S.H. Orthosis

Soft Orthosis

Conservative Treatment

Botox® (Typ A) : 1 Viole are

100 MU

Dysport® (Typ A) : 1 Viole are500 MU

3D gait analysis-MRI or CT

20°6°

11° 22°

2°17°

staticdynamic

Materials and Methods

Function vs. Static deformity• Patients

– 30 ambulatory patients with CP (18 male, 12 female)

– age 11.6 ± 2.9 years• Methods

– Gait analysis: mean hip rotation– MRI: femoral anteversion

Dreher et al. Gait Posture 2007;26:25–31Braatz et al. JBJS (submitted)

FDO– techniqueintertrochanteric

supracondylar

a) K-wires (*) placed proximally and b) Osteotomy parallel to the K-wires distally to the derotation line

* * * *

FemurOsteotomy

FDO– technique

c) K-wires (*) are parallel aligned d) After derotation the angle between before the osteotomy and the the two K-wires (*) determines the derotation amount of derotation

** **

FDO– technique

Results

Unpaired, two-tailed t-test for pre-post comparison. P-values <0.05 were regarded as significant .

Exam/Parameter Pre-OP Post-OP p-value

Mean Pelvic Rotation -0.1 ± 6.5 0.0 ± 6.6 0,892

Mean Hip Rotation in Stance 13.8 ± 14.8 0.4 ± 10.2 < 0.001

Foot progression angle 11.1 ± 16.0 -1.3 ± 8.4 < 0.001

Table 2 – Pre- and postoperative results of dynamic examination in gait

Results

Pearson’s correlation

DiscussionSatisfactory results after FDO were reported [1]

However, recent studies found over- and under-corrections [2] and recurrence [3] and discrepancy between intraoperative amount of derotation and functional outcome [2,4]

Femoral anteversion is not useful as predictor for mean hip rotation in gait analysis

Both, static and dynamic component should be taken into account when planning correction of internal rotation gait.

[1] Ounpuu et al., (2002), J Pediatr Orthop., 22, 139–45. [2] Dreher et al., (2007), Gait Posture, 26, 25-31.[3] Kim et al., (2005), J. Pediatr Orthop., 25, 739-743.[4] Kay et al., (2003), J Pediatr Orthop., 23, 150–154.

Materials and Methods48 children with spastic diplegic cerebral palsy and

internal rotation gait underwent multilevel surgery including

85 FDOs

3D Gait Analysis pre- and postoperatively

FDOintertrochanteric 42supracondylar 43Derotation (supramalleolar) 12

Multilevel soft tissue correction

ResultsTime (years) 1,2 2,2 6,1Mean (IRO) 18,0 -0,2 -1,8 3,9SD 13,1 11,1 13,1 12,3

T-Test 0,000 0,730 0,049

pre - post2post1-

post3 0,000 0,022

pre - post3 0,000

Results

-40

-20

0

20

40

60

1 2 3 4

-20.0

-10.0

0.0

10.0

20.0

30.0

40.0

1 2 3 4

Results

-30-20-10

0102030405060

0 5 10 15

age pre-op

IRO

long

term

Mean Hip rotation in stance

-30-20-10

0102030405060

0 5 10 15

age pre-op

IRO

pre

-op

Literature Patients having surgery prior to age 10 were more likely to

show deterioration. Kim H, Aiona M, Sussman M ;J Pediatr Orthop. 2005 Nov-Dec;25(6):739-43.

This trend toward internal rotation with hip flexion was apparent in 15 of the 18 muscle compartments we examined, suggesting that excessive hip flexion may exacerbate internal rotation of the hip.

Delp, S.L. ; J Biomech. 1999 May;32(5):493-501.

Conclusions

Conservative treatment, Physiotherapy, Orthosis

static and dynamic components

Proximal / distal type

asymmetry

Physical examination, X-ray, 3D Gait Analysis, CT/MRI

Thank You!