Changes in lower limb rotation after soft tissue surgery in spastic diplegia

Abstract

Background and purpose Rotational osteotomies are usually necessary to correct pronounced rotational deformities in ambulant children with cerebral palsy. The effects of soft tissue surgery on such deformities are unclear. In this retrospective study, we determined whether multilevel soft tissue surgery, performed to correct deformities in the sagittal plane, would also have an effect on rotational parameters.Patients and methods We examined 28 ambulant children with spastic diplegia with an average age of 12 (7–19) years. They underwent multilevel soft tissue surgery (with 6 surgical procedures per child on average). 3-dimensional gait analysis was performed preoperatively and at an average follow-up of 1–2 years. The indications for surgery were abnormalities in the sagittal plane. Gait analysis data from healthy children were used in defining normal ranges of kinematic variables. For assessment of changes in the transverse plane, the angles of foot progression, hip rotation, and pelvic rotation were studied.Results The transverse plane kinematic results showed no statistically significant postoperative changes when the preoperative parameters were within the normal range (within 2 SD of the mean of the normal material). In limbs where the preoperative values were abnormal (more than 2 SD above the normal mean), there was a mean reduction in internal foot progression of 12° (p = 0.01) and a mean reduction in external pelvic rotation of 6° (p = 0.02). The effect was more pronounced in children under 12 years of age. Internal hip rotation was not significantly reduced.Interpretation When the preoperative rotational parameters were abnormal, multilevel soft tissue surgery resulted in improved transverse plane kinematics. This could be of importance in preoperative decision making, especially when there is doubt as to whether to include rotational osteotomies in multilevel operations in younger children.

A Descriptive Study of Lower Limb Torsional Kinematic Profiles in Children With Spastic Diplegia

“…The prevalence of hip/pelvis compensatory directions was similar to the results reported by De Luca et al [21][22][23] In their study, they assumed that external pelvic rotation could be a compensatory mechanism for excessive internal hip rotation, but no proof was reported. 25 Pelvic rotation could as well be a primary deformity from the ipsilateral side or the contralateral side, compensated by excessive hip rotation.…”

“…Therefore, identification of each individual rotational anomaly is essential to rectify foot progression angle and to avoid unsatisfactory results if surgical procedures are considered. [20][21][22] If one rotational anomaly is undetected or not taken into account, a lever arm dysfunction will persist.…”

Transverse Plane Gait Problems in Children With Cerebral Palsy

“…Internal hip rotation is more commonly seen in bilaterally involved patients than in those with hemiplegia presenting to the gait laboratory (57% and 41%, respectively). 5,6 Internal rotation of the hip during gait is almost always attributable to osseus deformity (femoral anteversion). However, these muscles are now known to have insufficient lever arms to produce internal rotation about the hip, and in some limb positions may even produce external hip rotation.…”

Correction of gait after derotation osteotomies in cerebral palsy: Are the effects predictable?

“…Therefore, one is tempted to estimate the outcome on transverse plane foot progression angle from the arithmetic sum of the expected changes in pelvic, hip and knee rotation angles. However, the situation is complex since additional soft tissue surgeries [21] and foot surgeries that change foot addand abduction may likely affect foot progression. In addition, rotation osteotomies are performed along local segment transverse plane axes that may not directly rotate the foot alignment with respect to the walking direction.…”

“…Mean follow up time was 21.4 months (SD = 1.8) range: (17)(18)(19)(20)(21)(22)(23). Kinematic and kinetic data were collected using the Vicon Plug-in-Gait marker set on an 8-cameraVicon system (Vicon, Oxford, UK) and two force plates (AMTI, Watertown, MA, USA) In addition medial ankle and knee markers were used during the standing trial to improve the accuracy of the joint rotations in the transverse plane [12,13].…”