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Õunpuu S, Pierz KA, Rethlefsen SA, Rodriguez-MacClintic J, Acsadi G, Kay RM, Wren TAL. Outcomes of Triceps Surae Lengthening Surgery in Children With Charcot-Marie-Tooth Disease: A Multisite Investigation. J Pediatr Orthop 2025; 45:226-233. [PMID: 40042801 DOI: 10.1097/bpo.0000000000002899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2025]
Abstract
BACKGROUND Orthopaedic surgical intervention in children with Charcot-Marie-Tooth (CMT) often includes triceps surae lengthening (TSL) and foot procedures to address instability and pain due to equinus and cavovarus deformities. These surgeries may unmask underlying weakness in this progressive disease causing increased calcaneal pitch and excessive dorsiflexion in terminal stance leading to crouch. The purpose of this study was to evaluate changes in ankle function during gait following TSL surgery in children with CMT. METHODS Nineteen participants (11 male; age 12.8, SD 3.6 y) with CMT underwent gait analysis and clinical examination preoperatively and postoperatively to determine the outcomes of (1) triceps surae lengthening (TSL) and (2) plantar fascia release with bony foot surgery with or without TSL. TSL was performed in limbs with limited passive dorsiflexion range of motion (ROM) and decreased peak dorsiflexion in terminal stance, with gastrocnemius recession (GR) being preferred over tendo-Achilles lengthening (TAL) in cases with smaller dorsiflexion deficits. Passive dorsiflexion ROM, gait kinematics and kinetics, and foot posture index (FPI) were examined within and across surgical groups using linear mixed models. RESULTS Dorsiflexion ROM, peak dorsiflexion in terminal stance and mid-swing, and peak nondimensional plantar flexor moment improved significantly after both GR (n=8 limbs) and TAL (n=11 limbs) ( P ≤0.02). After plantar fascia release with bony foot surgery (n=20 limbs), FPI changed significantly, indicating reduced cavovarus regardless of whether TSL was done ( P <0.05). Passive and dynamic dorsiflexion and ankle kinetics (moment and power) increased only when concomitant TSL was done ( P ≤0.04). CONCLUSIONS In patients with increased equinus due to reduced passive dorsiflexion range of motion, TSL is an effective surgery for reducing excessive equinus in terminal stance and mid-swing, decreasing toe-walking, and improving swing phase clearance. It can be combined with extensive foot surgery to correct cavovarus deformity without leading to excessive dorsiflexion in terminal stance and crouch gait. Clinical gait analysis is an important tool to help identify appropriate candidates for TSL based on the key indicator of peak dorsiflexion in terminal stance. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sylvia Õunpuu
- Center for Motion Analysis, Division of Orthopedics, Connecticut Children's Medical Center, Farmington, CT
- Orthopedic Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Kristan A Pierz
- Center for Motion Analysis, Division of Orthopedics, Connecticut Children's Medical Center, Farmington, CT
- Orthopedic Surgery, University of Connecticut School of Medicine, Farmington, CT
| | - Susan A Rethlefsen
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | | | - Gyula Acsadi
- Neurology, Connecticut Children's Medical Center, St. Hartford, CT
- University of Connecticut School of Medicine, Farmington, CT
| | - Robert M Kay
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA
- Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Tishya A L Wren
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA
- Denney Research Center (DRB), Biomedical Engineering, University of Southern California, Los Angeles, CA
- Radiology, University of Southern California, Los Angeles, CA
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Park J, Joo SY, Choi BO, Kim DH, Park JB, Lee JW, Kim DY. Gait Pattern in Charcot-Marie-Tooth Disease Type 1A According to Disease Severity. J Pers Med 2023; 13:1473. [PMID: 37888085 PMCID: PMC10608009 DOI: 10.3390/jpm13101473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
The aim of this study was to evaluate the characteristics of gait patterns in Charcot-Marie-Tooth disease type 1A (CMT1A) patients according to disease severity. Twenty-two CMT1A patients were enrolled and classified into two groups, according to the disease severity. The healthy control group consisted of 22 subjects with no gait impairment. Full barefoot three-dimensional gait analysis with temporospatial, kinematic, and kinetic data was performed among the mild and moderate CMT1A group and the control group. Minimal hip abduction, maximal hip extension generation, peak knee flexion moment at stance, ankle dorsiflexion at initial contact, maximal ankle plantarflexion at push-off and maximal ankle rotation moment at stance in the CMT1A group showed a significant difference compared to the control group (p < 0.05). In the moderate group, there were greater maximal hip flexion angles in swing, and smaller dorsiflexion angles at initial contact compared to the control group and mild group. CMT patients had typical gait characteristics and their gait patterns were different according to severity. The analysis of gait patterns in patients with CMT1A will help to understand gait function and provide important information for the treatment of patients with CMT in the future.
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Affiliation(s)
- Jihyun Park
- Department of Rehabilitation Medicine, Hallym University Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong 18450, Republic of Korea;
| | - So Young Joo
- Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul 07247, Republic of Korea;
| | - Byung-Ok Choi
- Department of Neurology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Republic of Korea;
| | - Dae-Hyun Kim
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Republic of Korea;
| | - Jong Bum Park
- Department of Rehabilitation Medicine, College of Medicine, Konyang University, Daejeon 35365, Republic of Korea;
| | - Jong Weon Lee
- Department of Rehabilitation Medicine, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea;
- Research Institute of Rehabilitation Medicine, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea;
- Research Institute of Rehabilitation Medicine, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
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Õunpuu S, Pierz K, Mack WJ, Rodriguez-MacClintic J, Acsadi G, Wren TAL. Natural history of ankle function during gait in youth with Charcot-Marie-Tooth disease types 1 and 2. Gait Posture 2023; 103:146-152. [PMID: 37167760 DOI: 10.1016/j.gaitpost.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Charcot-Marie-Tooth disease (CMT) can cause progressive muscle weakness and contracture, leading to gait abnormalities such as increased and delayed peak ankle dorsiflexion and reduced ankle power generation in terminal stance. Understanding strength loss on ankle function during gait is important for interpreting treatment outcomes and evaluating new therapies designed to improve gait. RESEARCH QUESTION Do ankle kinematics and kinetics vary as a function of age, disease progression with associated loss of muscle strength and CMT type in youth with CMT types 1 and 2? METHODS A prospective convenience sample of 45 participants with CMT1 and 2, ages 7-22 years, underwent comprehensive gait analysis. Seventeen patients underwent repeat analyses totaling 67 tests. Generalized mixed effects linear modeling was used to compare CMT1 versus CMT2 and to examine the effects of age on ankle strength, range of motion, kinematics, and kinetics within each CMT type. RESULTS Plantarflexor and dorsiflexor strength were less in CMT2 compared with CMT1 (p ≤ 0.05), while peak dorsiflexion in terminal stance (TST) was greater (p = 0.02). Peak plantarflexion moment and power generation were also less in CMT2 (p ≤ 0.02). In CMT1, peak dorsiflexion in TST increased with age through 13 years (p = 0.004); then plateaued in the normal range (p = 0.73). Peak ankle angle in mid-swing was closely related to the angle in TST (p < 0.001) following a similar pattern with age. In CMT2, no significant associations were observed between age, peak dorsiflexion in TST, and peak ankle angle in mid-swing (p ≥ 0.19). There were no consistent trends with age for individual patients with repeat tests. SIGNIFICANCE The heterogeneity of joint level impairments and gait kinematics and kinetics point to the importance of having an in-depth understanding of gait at the individual patient level using comprehensive gait analysis including valid and reliable strength measures.
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Affiliation(s)
- Sylvia Õunpuu
- Center for Motion Analysis, Connecticut Children's Medical Center, Farmington, CT, USA.
| | - Kristan Pierz
- Center for Motion Analysis, Connecticut Children's Medical Center, Farmington, CT, USA; Division of Orthopedics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Wendy J Mack
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Gyula Acsadi
- Division of Neurology, Connecticut Children's Medical Center, Farmington, CT, USA; Department of Pediatrics, Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Tishya A L Wren
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA; Departments of Orthopedic Surgery and Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Õunpuu S, Pierz K, Garibay E, Acsadi G, Wren TAL. Stance and swing phase ankle phenotypes in youth with Charcot-Marie-Tooth type 1: An evaluation using comprehensive gait analysis techniques. Gait Posture 2022; 98:216-225. [PMID: 36179412 DOI: 10.1016/j.gaitpost.2022.09.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Charcot-Marie-Tooth disease (CMT) results in muscle weakness and contracture leading to a wide variety of gait issues including atypical ankle kinematics in both stance and swing. Knowledge of the stance and swing phase kinematic patterns for CMT type 1 (CMT1), the most common CMT type, will improve our understanding of expected gait outcomes and treatment needs to improve gait function. RESEARCH QUESTION What are the stance/swing phase ankle phenotypes in CMT1? METHODS A prospective convenience sample of 25 participants with CMT1, ages 7-19 years, underwent comprehensive gait analysis following standard procedures. Ankle phenotypes based on peak ankle dorsiflexion in terminal stance and mid-swing were defined and compared using linear mixed models. RESULTS Patients with CMT1 presented with three stance phase ankle phenotypes: 21 limbs (42 %) with reduced (mean 5°, SD 2°), 19 limbs (38 %) with typical (mean 11°, SD 1°) and 10 limbs (20 %) with excessive (mean 15°, SD 2°) peak dorsiflexion in terminal stance (p < 0.05). There were two swing phase phenotypes: 19 limbs (38 %) with typical (mean -1.7°, SD 1.5°) and 31 limbs (62 %) with excessive (mean -5.6°, SD 1.4°) plantarflexion in mid-swing (p < 0.002). Eleven patients (44 %) had ankles that were classified into different stance groups, and 9 patients (36 %) had ankles that were classified into different swing groups. The most common combination of stance/swing ankle phenotypes was decreased dorsiflexion in terminal stance with increased plantarflexion in mid-swing (16 sides, 32 %). SIGNIFICANCE This study shows that youth with CMT1 have multiple combinations of combined ankle kinematics for stance and swing. The ankle phenotypes identified in this study reflect contributions of both dorsi/plantarflexor weakness and plantarflexor contracture, which require different treatment approaches. Comprehensive gait analysis can distinguish between multiple ankle phenotypes to assist in determining the most appropriate treatment to improve gait for individual patients.
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Affiliation(s)
- Sylvia Õunpuu
- Center for Motion Analysis, Connecticut Children's Medical Center, Farmington, CT, USA.
| | - Kristan Pierz
- Center for Motion Analysis, Connecticut Children's Medical Center, Farmington, CT, USA; Division of Orthopedics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Erin Garibay
- Center for Motion Analysis, Connecticut Children's Medical Center, Farmington, CT, USA
| | - Gyula Acsadi
- Division of Neurology, Connecticut Children's Medical Center, Farmington, CT, USA
| | - Tishya A L Wren
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Counter-movement jump characteristics in children with Charcot-Marie-Tooth type 1a disease. Gait Posture 2022; 93:218-224. [PMID: 35183839 DOI: 10.1016/j.gaitpost.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/26/2021] [Accepted: 02/12/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Poor performance in sports, especially activities that require explosive movements, is a common reason for initial presentation of children with Charcot-Marie-Tooth type 1a (CMT1a) to the paediatric neuromuscular specialist. RESEARCH QUESTION The aim of this descriptive, retrospective study was to analyse counter-movement jump characteristics in children with CMT1a in comparison to those in typically developing children (TDC). METHODS This retrospective study included seven patients with CMT1a and 44 TDC from our data pool. All the participants performed counter-movement jumps, and jump height, peak force, time to peak force, average and peak rate of force development and net vertical impulse were then calculated. For statistical comparison by means of an independent Student's t-test, children with CMT1a were compared to seven sex- and age-matched TDC. Correlation coefficients were calculated to determine the relationship between the force-time variables and jump height. RESULTS Peak force, net vertical impulse and jump height values in the CMT1a group were significantly lower than those in the TDC group. There were no between-group differences in the time to peak force or average and peak rate of force development. In terms of task symmetry, the correlation between the time-force curve of the left and right leg in the CMT1a group was reduced as compared with that in the TDC group. In both groups, among the parameters measured, there was a significant correlation between jump height and net vertical impulse. SIGNIFICANCE This study showed that reduced jump performance in children with CMT1a, as demonstrated by decreased counter-movement jump height, was due to a reduced net impulse during this explosive movement task. This finding is critical for children with CMT1a and has to be considered in clinical management and activities of daily living (e.g. sports lessons in school).
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