Biomechanical gait parameters change with increasing virtual height in a child with spastic cerebral palsy: A case report

Virtual height exposure coupled with motion capture is feasible to elicit changes in spatiotemporal, kinematic, and kinetic gait parameters in a child with cerebral palsy and should be considered when investigating gait in real-world-scenarios.

Translating scientific recommendations into reality: a feasibility study using group-based high-intensity functional exercise training in adolescents with cerebral palsy

PURPOSE

To examine the feasibility and effects of a functional high-intensity exercise intervention performed in a group-setting on functionality, cardiovascular health and physical performance in adolescents with cerebral palsy (CP).

METHODS

Ten adolescents with a diagnosis of CP (2 females; 16.6 ± 3.4 years; GMFCS: I-II) participated in a 12-week training intervention, containing progressive resistance training using free weights and high-intensity workouts twice a week. The six-minute walking test, arterial stiffness and physical performance (strength and power tests) were measured before and after the intervention.

RESULTS

No adverse events were reported. We measured small increases in the six-minute walking test (Δ = 28.8 m, 95% CI [-1.78;52.7]; g = 0.34 [-0.04;0.72]) and a small reduction in arterial stiffness (Δ = -4.65% [-10.90;1.25]; g = -0.46 [-1.36;0.21]). All measures of physical performance increased (0.24 ≤ g ≤ 0.88).

CONCLUSION

Functional training with free weights in high-functioning adolescents with CP is safe and effective in increasing parameters of physical performance and cardiovascular health. Positively influenced indicators of everyday independence (i.e. strength parameters) showed a transfer into movements of daily life. Concerns about adverse events through high-intensity training in adolescents with CP appear unjustified when training is performed progressively, following basic training principles.

Identifying treatment non-responders based on pre-treatment gait characteristics - A machine learning approach

Background

Paediatric movement disorders such as cerebral palsy often negatively impact walking behaviour. Although clinical gait analysis is usually performed to guide therapy decisions, not all respond positively to their assigned treatment. Identifying these individuals based on their pre-treatment characteristics could guide clinicians towards more appropriate and personalized interventions. Using routinely collected pre-treatment gait and anthropometric features, we aimed to assess whether standard machine learning approaches can be effective in identifying patients at risk of negative treatment outcomes.

Methods

Observational data of 119 patients with movement disorders were retrospectively extracted from a local clinical database, comprising sagittal joint angles and spatiotemporal parameters, derived from motion capture data pre- and post-treatment (physiotherapy, orthosis, botulin toxin injections, or surgery). Participants were labelled based on their change in gait profile score (GPS, non-responders with a decline in GPS of <1.6° vs. responders). Their pre-treatment features (sagittal joint angles, spatiotemporal parameters, anthropometrics) were used to train a support vector machine classifier with 5-fold cross-validation and Bayesian optimization within a MATLAB-based Classification Learner App.

Results

An average accuracy of 88.2 ± 0.5 % was achieved for identifying participants whose gait will not respond to treatment, with 64 % true negative rate and an area under the curve of 88 %.

Conclusion

Overall, a classical machine learning model was able to identify patients at risk of not responding to treatment, based on gait features and anthropometrics collected prior to treatment. The output of such a model could function as a warning signal, notifying clinicians that a certain individual might not respond well to the standard of care and that a more personalized intervention might be needed.

Can developmental trajectories in gait variability provide prognostic clues in motor adaptation among children with mild cerebral palsy? A retrospective observational cohort study

Aim

To investigate whether multiple domains of gait variability change during motor maturation and if this change over time could differentiate children with a typical development (TDC) from those with cerebral palsy (CwCP).

Methods

This cross-sectional retrospective study included 42 TDC and 129 CwCP, of which 99 and 30 exhibited GMFCS level I and II, respectively. Participants underwent barefoot 3D gait analysis. Age and parameters of gait variability (coefficient of variation of stride-time, stride length, single limb support time, walking speed, and cadence; as well as meanSD for hip flexion, knee flexion, and ankle dorsiflexion) were used to fit linear models, where the slope of the models could differ between groups to test the hypotheses.

Results

Motor-developmental trajectories of gait variability were able to distinguish between TDC and CwCP for all parameters, except the variability of joint angles. CwCP with GMFCS II also showed significantly higher levels of gait variability compared to those with GMFCS I, these levels were maintained across different ages.

Interpretation

This study showed the potential of gait variability to identify and detect the motor characteristics of high functioning CwCP. In future, such trajectories could provide functional biomarkers for identifying children with mild movement related disorders and support the management of expectations.

Consequences of Virtual Reality Experience on Biomechanical Gait Parameters in Children with Cerebral Palsy: A Scoping Review

Virtual reality (VR), coupled with motion tracking, can investigate walking in a controlled setting while applying various walking challenges. The purpose of this review was to summarize the evidence on consequences of VR on biomechanical gait parameters in children with cerebral palsy. MEDLINE, Embase and Web of Science were searched. Among 7.574 studies, screened by two independent reviewers, seven studies were included, analyzing treadmill (n = 6) or overground walking (n = 1) under VR. Most frequently reported were the spatiotemporal parameters walking speed, stride length, step width, stance phase, and the kinematic parameters range of knee flexion and peak ankle dorsiflexion. However, methodological approaches and reporting of the results were inconsistent among studies. This review reveals that VR can complement information gained from clinical gait analysis. However, this is still an emerging field of research and there is limited knowledge on the effect of VR on gait parameters, notably during overground walking.

Fetal arthrogryposis-what do we tell the prospective parents?

Arthrogryposis, also termed arthrogryposis multiplex congenita, is a descriptive term for conditions with multiple congenital contractures (MCC). The etiology is extremely heterogeneous. More than 400 specific disorders have been identified so far, which may lead to or are associated with MCC and/or fetal hypo- and akinesia as a clinical sign. With improved sensitivity of prenatal ultrasound and expanding prenatal diagnostic options, clinicians are tasked with providing early detection in order to counsel the prospective parents regarding further prenatal diagnostic as well as management options. We summarize the most important knowledge to raise awareness for early detection in pregnancy. We review essential points for counseling when MCC is detected in order to provide answers to common questions, which, however, cannot replace interdisciplinary expert opinion in the individual case.

Prediction of ground reaction forces and moments during walking in children with cerebral palsy

Introduction

Gait analysis is increasingly used to support clinical decision-making regarding diagnosis and treatment planning for movement disorders. As a key part of gait analysis, inverse dynamics can be applied to estimate internal loading conditions during movement, which is essential for understanding pathological gait patterns. The inverse dynamics calculation uses external kinetic information, normally collected using force plates. However, collection of external ground reaction forces (GRFs) and moments (GRMs) can be challenging, especially in subjects with movement disorders. In recent years, a musculoskeletal modeling-based approach has been developed to predict external kinetics from kinematic data, but its performance has not yet been evaluated for altered locomotor patterns such as toe-walking. Therefore, the goal of this study was to investigate how well this prediction method performs for gait in children with cerebral palsy.

Methods

The method was applied to 25 subjects with various forms of hemiplegic spastic locomotor patterns. Predicted GRFs and GRMs, in addition to associated joint kinetics derived using inverse dynamics, were statistically compared against those based on force plate measurements.

Results

The results showed that the performance of the predictive method was similar for the affected and unaffected limbs, with Pearson correlation coefficients between predicted and measured GRFs of 0.71–0.96, similar to those previously reported for healthy adults, despite the motor pathology and the inclusion of toes-walkers within our cohort. However, errors were amplified when calculating the resulting joint moments to an extent that could influence clinical interpretation.

Conclusion

To conclude, the musculoskeletal modeling-based approach for estimating external kinetics is promising for pathological gait, offering the possibility of estimating GRFs and GRMs without the need for force plate data. However, further development is needed before implementation within clinical settings becomes possible.

High tibial osteotomy effectively redistributes compressive knee loads during walking

The objectives of this study were to estimate pre- and postoperative lower limb kinematics and kinetics and knee intra-articular forces during gait using musculoskeletal modeling in a cohort of patients with knee osteoarthritis (OA) undergoing high tibial osteotomy (HTO), compare these to controls, and determine correlations between changes in these parameters and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores after HTO. Sixteen patients with isolated, symptomatic medial compartment knee OA completed pre- and postoperative gait analysis (mean follow-up time: 8.6 months). Sixteen age- and sex-matched asymptomatic volunteers participated as controls. Musculoskeletal modeling was used to evaluate lower limb joint moments and knee contact forces during gait. While HTO had limited influence on sagittal plane kinematics and moments, significant changes in the load distribution at the knee after HTO were observed with a lower postoperative compressive load on the medial compartment during midstance and a higher compressive load on the lateral compartment during early and late stance. Moreover, the lateral shear force in midstance was significantly lower after HTO. Changes in the external knee adduction moment (KAM) did not always coincide with reductions in the knee compressive force in the medial compartment. Biomechanical changes did not correlate with improvements in KOOS subscores. Hence, HTO effectively unloaded the medial compartment by redistributing part of the overall compressive force to the lateral compartment during gait with limited influence on gait function. The KAM may not adequately describe compartmental load magnitude or changes induced by interventions at the compartment level. Clinical trial registration: ClinicalTrials. gov Identifier-NCT02622204. Clinical significance: This study provides important evidence for changes in joint level loads after corrective osteotomy as joint preserving surgery and emphasizes the need for additional biomechanical outcomes of such interventions.

Evolution of muscle coordination and mechanical output following four weeks of arm cranking submaximal training

Muscle synergies is extensively studied to understand how the neuromusculoskeletal system deals with abundancy. The synergies represent covariant muscles that acts as building blocks for movement production. Nevertheless, little is known on how those synergies evolve following training, learning and expertise. This study reports the influence a 4-weeks submaximal training of arm-cranking on novice participants' muscle synergies.

METHODS

12 participants performed 8 sessions of submaximal training for 4 weeks. One session consisted in two 30-second-maximal power tests followed by six 2-minutes-bouts at 30% of maximal recorded power. Cranking torque and EMG of 11 muscles were recorded during the entire protocol. After EMG normalization, muscle synergies were extracted using NNMF. Similarity was computed using cross-correlation and cosine similarities and statistical evolution across training was tested using repeated measured ANOVA.

RESULTS

While maximal power increased across training days nor torque management, EMG or muscle synergies were significantly affected by submaximal training. Nevertheless, results suggest slights modifications of muscle synergies across day despite to non-significant differences.

DISCUSSION

Despite the strong complexity of the upper limbs anatomy, our results showed that training didn't induce significant changes in movement realization (mechanical and coordination level). A low-dimensional organization of muscle synergies is selected from the first day and kept through the following training days, despite slight but non-significant modifications.This study supports the hypothesis that motor control for movement production could be simplify using low-dimensional building blocks (muscle synergies). Such building blocks allow stability in movement execution and are slightly adjusted to fit movement requirements with training.

A deep-learning approach for automatically detecting gait-events based on foot-marker kinematics in children with cerebral palsy-Which markers work best for which gait patterns?

Neuromotor pathologies often cause motor deficits and deviations from typical locomotion, reducing the quality of life. Clinical gait analysis is used to effectively classify these motor deficits to gain deeper insights into resulting walking behaviours. To allow the ensemble averaging of spatio-temporal metrics across individuals during walking, gait events, such as initial contact (IC) or toe-off (TO), are extracted through either manual annotation based on video data, or through force thresholds using force plates. This study developed a deep-learning long short-term memory (LSTM) approach to detect IC and TO automatically based on foot-marker kinematics of 363 cerebral palsy subjects (age: 11.8 ± 3.2). These foot-marker kinematics, including 3D positions and velocities of the markers located on the hallux (HLX), calcaneus (HEE), distal second metatarsal (TOE), and proximal fifth metatarsal (PMT5), were extracted retrospectively from standard barefoot gait analysis sessions. Different input combinations of these four foot-markers were evaluated across three gait subgroups (IC with the heel, midfoot, or forefoot). For the overall group, our approach detected 89.7% of ICs within 16ms of the true event with a 18.5% false alarm rate. For TOs, only 71.6% of events were detected with a 33.8% false alarm rate. While the TOE|HEE marker combination performed well across all subgroups for IC detection, optimal performance for TO detection required different input markers per subgroup with performance differences of 5-10%. Thus, deep-learning LSTM based detection of IC events using the TOE|HEE markers offers an automated alternative to avoid operator-dependent and laborious manual annotation, as well as the limited step coverage and inability to measure assisted walking for force plate-based detection of IC events.

Evidence-based, Implementable Motor Rehabilitation Guidelines for Individuals With Cerebral Palsy

BACKGROUND

Cerebral palsy is a life-long condition that causes heterogeneous motor disorders. Motor rehabilitation interventions must be adapted to the topography of the symptoms, ambulatory capacity and age of the individual. Current guidelines do not differentiate between the different profiles of individuals with cerebral palsy, which limits their implementation.

OBJECTIVES

To develop evidence-based, implementable guidelines for motor rehabilitation interventions for individuals with cerebral palsy according to the age, topography of the cerebral palsy and ambulatory capacity of the individual, and to determine a level of priority for each intervention.

METHODS

We used a mixed methods design that combined a systematic review of the literature on available motor rehabilitation interventions with expert opinions. Based on the French National Authority for Health methodology, recommendations were graded as strong, conditional or weak. Interventions were then prioritized by the experts according to both the evidence and their own opinions on relevance and implementability to provide a guide for clinicians. All recommendations were approved by experts who were independent from the working group.

RESULTS

Strong recommendations as first-line treatments were made for gait training, physical activities and hand-arm bimanual intensive therapy for all children and adolescents with cerebral palsy. Moderate recommendations were made against passive joint mobilizations, muscle stretching, prolonged stretching with the limb fixed, and neurodevelopmental therapies for all children and adolescents with cerebral palsy. Strong recommendations as first-line treatments were made for gait training for all adults with cerebral palsy and moderate recommendations as moderate importance interventions for strengthening exercises and ankle-foot orthoses for motor impairment of the feet and the ankles.

DISCUSSION

These guidelines, which combine research evidence and expert opinion, could help individuals with cerebral palsy and their families to co-determine rehabilitation goals with health professionals, according to their preferences.

Increased Femoral Anteversion Does Not Lead to Increased Joint Forces During Gait in a Cohort of Adolescent Patients

Orthopedic complications were previously reported for patients with increased femoral anteversion. A more comprehensive analysis of the influence of increased femoral anteversion on joint loading in these patients is required to better understand the pathology and its clinical management. Therefore, the aim was to investigate lower-limb kinematics, joint moments and forces during gait in adolescent patients with increased, isolated femoral anteversion compared to typically developing controls. Secondly, relationships between the joint loads experienced by the patients and different morphological and kinematic features were investigated. Patients with increased femoral anteversion (n = 42, 12.8 ± 1.9 years, femoral anteversion: 39.6 ± 6.9°) were compared to typically developing controls (n = 9, 12.0 ± 3.0 years, femoral anteversion: 18.7 ± 4.1°). Hip and knee joint kinematics and kinetics were calculated using subject-specific musculoskeletal models. Differences between patients and controls in the investigated outcome variables (joint kinematics, moments, and forces) were evaluated through statistical parametric mapping with Hotelling T2 and t-tests (α = 0.05). Canonical correlation analyses (CCAs) and regression analyses were used to evaluate within the patients’ cohort the effect of different morphological and kinematic predictors on the outcome variables. Predicted compressive proximo-distal loads in both hip and knee joints were significantly reduced in patients compared to controls. A gait pattern characterized by increased knee flexion during terminal stance (KneeFlex_tSt) was significantly correlated with hip and knee forces, as well as with the resultant force exerted by the quadriceps on the patella. On the other hand, hip internal rotation and in-toeing, did not affect the loads in the joints. Based on the finding of the CCAs and linear regression analyses, patients were further divided into two subgroups based KneeFlex_tSt. Patients with excessive KneeFlex_tSt presented a significantly higher femoral anteversion than those with normal KneeFlex_tSt. Patients with excessive KneeFlex_tSt presented significantly larger quadriceps forces on the patella and a larger posteriorly-oriented shear force at the knee, compared to patients with normal KneeFlex_tSt, but both patients’ subgroups presented only limited differences in terms of joint loading compared to controls. This study showed that an altered femoral morphology does not necessarily lead to an increased risk of joint overloading, but instead patient-specific kinematics should be considered.

Altered Muscle Contributions are Required to Support the Stance Limb During Voluntary Toe-Walking

Toe-walking characterizes several neuromuscular conditions and is associated with a reduction in gait stability and efficiency, as well as in life quality. The optimal choice of treatment depends on a correct understanding of the underlying pathology and on the individual biomechanics of walking. The objective of this study was to describe gait deviations occurring in a cohort of healthy adult subjects when mimicking a unilateral toe-walking pattern compared to their normal heel-to-toe gait pattern. The focus was to characterize the functional adaptations of the major lower-limb muscles which are required in order to toe walk. Musculoskeletal modeling was used to estimate the required muscle contributions to the joint sagittal moments. The support moment, defined as the sum of the sagittal extensive moments at the ankle, knee, and hip joints, was used to evaluate the overall muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Compared to a normal heel-to-toe gait pattern, toe-walking was characterized by significantly different lower-limb kinematics and kinetics. The altered kinetic demands at each joint translated into different necessary moment contributions from most muscles. In particular, an earlier and prolonged ankle plantarflexion contribution was required from the soleus and gastrocnemius during most of the stance phase. The hip extensors had to provide a higher extensive moment during loading response, while a significantly higher knee extension contribution from the vasti was necessary during mid-stance. Compensatory muscular activations are therefore functionally required at every joint level in order to toe walk. A higher support moment during toe-walking indicates an overall higher muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Higher muscular demands during gait may lead to fatigue, pain, and reduced quality of life. Toe-walking is indeed associated with significantly larger muscle forces exerted by the quadriceps to the patella and prolonged force transmission through the Achilles tendon during stance phase. Optimal treatment options should therefore account for muscular demands and potential overloads associated with specific compensatory mechanisms.

Subject specific muscle synergies and mechanical output during cycling with arms or legs

Background

Upper (UL) and lower limb (LL) cycling is extensively used for several applications, especially for rehabilitation for which neuromuscular interactions between UL and LL have been shown. Nevertheless, the knowledge on the muscular coordination modality for UL is poorly investigated and it is still not known whether those mechanisms are similar or different to those of LL. The aim of this study was thus to put in evidence common coordination mechanism between UL and LL during cycling by investigating the mechanical output and the underlying muscle coordination using synergy analysis.

Methods

Twenty-five revolutions were analyzed for six non-experts' participants during sub-maximal cycling with UL or LL. Crank torque and muscle activity of eleven muscles UL or LL were recorded. Muscle synergies were extracted using nonnegative matrix factorization (NNMF) and group- and subject-specific analysis were conducted.

Results

Four synergies were extracted for both UL and LL. UL muscle coordination was organized around several mechanical functions (pushing, downing, and pulling) with a proportion of propulsive torque almost 80% of the total revolution while LL muscle coordination was organized around a main function (pushing) during the first half of the cycling revolution. LL muscle coordination was robust between participants while UL presented higher interindividual variability.

Discussion

We showed that a same principle of muscle coordination exists for UL during cycling but with more complex mechanical implications. This study also brings further results suggesting each individual has unique muscle signature.

Paralytic dislocation of the hip in children

Despite the progress made in the past decades, hip disorders are one of the most common orthopedic problems in the context of paralysis. The etiology can be congenital (malformation such as myelomeningoceles, genetic neuromuscular disorders) or acquired (cerebral palsy, post-traumatic). In these conditions, the orthopedic deformities are minimal at birth. They can develop as the child grows, at different ages, depending on the etiology, severity of the neuromuscular disorder and functional potential. Hip subluxation and dislocation can compromise standing and walking capacities, but also the quality of the seated position and the personal care. Daily life activities and participation are restricted and influence the disabled person's quality of life. Paralytic dislocation of the hip is the orthopedic deformity that has be biggest impact on day-to-day life, general health and the overall orthopedic result in adulthood. Neuro-orthopedic care is challenging. However, there are basic principles that one must know to ensure good long-term quality of life in patients suffering from paralytic dislocations of the hip. When planning the treatment strategy, it is essential to take into consideration the day-to-day life and to integrate the patient's experiences and needs, along with those of their caretakers. The objective of this review is to outline the differences in paralytic dislocations of the hip of diverse etiology, to present evaluation principles useful in daily clinical practice and to help practitioners in choosing a treatment strategy.

Torsional deformities and overuse injuries: what does the literature tell us

Overuse injuries imply the occurrence of a repetitive or an increased load on a specific anatomical segment which is unable to recover from this redundant microtrauma, thus leading to an inflammatory process of tendons, physis, bursa, or bone.

Even if the aetiology is controversial, the most accepted is the traumatic one.

Limb malalignment has been cited as one of the major risk factors implicated in the development of overuse injuries.

Many authors investigated correlations between anatomical deviations and overuse injuries, but results appear mainly inconclusive.

Establishing a causal relationship between mechanical stimuli and symptoms will remain a challenge, but 3D motion analysis, musculoskeletal, and finite element modelling may help in clarifying which are the major risk factors for overuse injuries.

Impact of the Marker Set Configuration on the Accuracy of Gait Event Detection in Healthy and Pathological Subjects

For interpreting outcomes of clinical gait analysis, an accurate estimation of gait events, such as initial contact (IC) and toe-off (TO), is essential. Numerous algorithms to automatically identify timing of gait events have been developed based on various marker set configurations as input. However, a systematic overview of the effect of the marker selection on the accuracy of estimating gait event timing is lacking. Therefore, we aim to evaluate (1) if the marker selection influences the accuracy of kinematic algorithms for estimating gait event timings and (2) what the best marker location is to ensure the highest event timing accuracy across various gait patterns. 104 individuals with cerebral palsy (16.0 ± 8.6 years) and 31 typically developing controls (age 20.6 ± 7.8) performed clinical gait analysis, and were divided into two out of eight groups based on the orientation of their foot, in sagittal and frontal plane at mid-stance. 3D marker trajectories of 11 foot/ankle markers were used to estimate the gait event timings (IC, TO) using five commonly used kinematic algorithms. Heatmaps, for IC and TO timing per group were created showing the median detection error, compared to detection using vertical ground reaction forces, for each marker. Our findings indicate that median detection errors can be kept within 7 ms for IC and 13 ms for TO when optimizing the choice of marker and detection algorithm toward foot orientation in midstance. Our results highlight that the use of markers located on the midfoot is robust for detecting gait events across different gait patterns.

Does static trunk motion analysis reflect its true position during daily activities in adolescent with idiopathic scoliosis?

INTRODUCTION

Adolescent idiopathic scoliosis is common condition in pediatric orthopedics that is generally analyzed with standard radiographs. However, the conditions under which the radiographs are made are completely different than the position that patients use during day-to-day activities. We hypothesized that the trunk's static position differs from its dynamic one. The aim of this study was to determine differences between the trunk's static and dynamic positions using motion analysis in adolescents with idiopathic scoliosis.

PATIENTS AND METHODS

This prospective, single-center study enrolled adolescents with idiopathic scoliosis who were scheduled to undergo surgical correction. The day before the surgery, radiographs were made and motion analysis was performed (static and dynamic acquisitions). Various parameters were measured on the radiographs and motion analysis, including the coronal vertical axis (CVA), sagittal vertical axis (SVA) and coronal shoulder tilt.

RESULTS

The study enrolled 62 patients with a mean age of 15.5 years. There was a significant correlation between the radiographic measurements and the static motion analysis results for most parameters. Conversely, dynamic measurements of CVA, SVA and coronal shoulder tilt were not correlated to their static measurements (R=0.229; 0.198 and -0.109 respectively, all p>0.05). The static coronal shoulder tilt was opposite to the one found during walking (-0.9° vs. 0.5°, p=0.031).

DISCUSSION

Our study is the first to compare the trunk's static position with its dynamic position during walking in a cohort of adolescents with idiopathic scoliosis. Motion analysis provides new information about the trunk's dynamic positions. Based on our findings, radiographic analysis only partially captures the spinal alignment and cannot be used to draw reliable conclusions about the trunk's dynamic balance.

Curve location influences spinal balance in coronal and sagittal planes but not transversal trunk motion in adolescents with idiopathic scoliosis: a prospective observational study

PURPOSE

In adolescent idiopathic scoliosis (AIS), spinal deformity can be seen in the thoracic or in the lumbar area. Although differences according to curve location are well described on standard radiographs, dynamic consequences of such difference remain unclear. Our objective was to explore the differences in dynamic spinal balance according to curve location in AIS patients using gait analysis METHODS: We prospectively included 22 females with AIS planned for surgical correction (16.3 years old, 81% Risser ≥ 4). Patients were divided into two matched cohorts, according to major curve location [right thoracic (Lenke 1) or left lumbar (Lenke 5)]. Gait analysis was performed the day before surgery. Global balance was analyzed as the primary outcome. Local curves parameters (dynamic Cobb angles) were defined as the secondary outcome.

RESULTS

In coronal plane, Lenke 5 patients had a left trunk shift, whereas trunk was shifted to the right in Lenke 1 patients (- 20.7 vs 6.3, p = 0.001). In the sagittal plane, the main difference between the two groups was T12 position that remained over the pelvis during gait in Lenke 5 patients, whereas it was anterior to the pelvis in Lenke 1 patients. In the transversal plane, Lenke 5 and Lenke 1 patients presented the same gait abnormalities, with a global trunk rotation to the left (- 4.8 vs - 7.6, p = 0,165).

CONCLUSION

This is the first study to provide the results of a direct comparison between Lenke 1 and Lenke 5 patients during gait. Curve location influenced coronal and sagittal balance, but abnormalities of transversal trunk motion were the same, wherever the curve was located. These slides can be retrieved under Electronic Supplementary Material.

Cerebral palsy with dislocated hip and scoliosis: what to deal with first?

PURPOSE

Hip dislocation and scoliosis are common in children with cerebral palsy (CP). Hip dislocation develops in 15% and 20% of children with CP, mainly between three and six years of age and especially in the spastic and dyskinetic subtypes. The risk of scoliosis increases with age and increasing disability as expressed by the Gross Motor Function Score.

METHODS

A hip surveillance programme and early surgical treatment have been shown to reduce the hip dislocation, but it remains unclear if a similar programme could reduce the need for neuromuscular scoliosis. When hip dislocation and neuromuscular scoliosis are co-existent, there appears to be no clear guidelines as to which of these deformities should be addressed first: hip or spine.

RESULTS

Hip dislocation or windswept deformity may cause pelvic obliquity and initiate scoliosis, while neuromuscular scoliosis itself leads to pelvic obliquity and may increase the risk of hip dislocation especially on the high side. It remains unclear if treating imminent hip dislocation can prevent development of scoliosis and vice versa, but they may present at the same time for surgery. Current expert opinion suggests that when hip dislocation and scoliosis present at the same time, scoliosis associated pelvic obliquity should be corrected before hip reconstruction. If the patient is not presenting with pelvic obliquity the more symptomatic condition should be addressed first.

CONCLUSION

Early identification of hip displacement and neuromuscular scoliosis appears to be important for better surgical outcomes.

Characterization of trunk motion in adolescents with right thoracic idiopathic scoliosis

BACKGROUND

Although standard radiography is currently used for deformity assessment in AIS patients, it is performed in a constrained position and probably not reflective of spinal balance during daily-life activities. Our main objective was to compare trunk motion in Lenke 1 and 2 AIS patients to healthy volunteers, using gait analysis.

MATERIAL AND METHODS

Lenke 1 or 2 AIS patients planned for surgery were included. The day before surgery, they underwent radiographic evaluation and gait analysis. Among the gait parameters, sagittal vertical axis (Dyn-SVA), shoulder line rotation (Dyn-SL rotation), pelvis rotation (Dyn-P rotation) and acromion pelvis angle (Dyn-APA) were measured. AIS patients were compared to 25 asymptomatic controls.

RESULTS

A total of 57 patients were included in the study, with a mean Cobb angle of 55.4°. AIS patients had a lower Dyn-SVA when compared to controls (47.0 vs. 62.9 mm, p = 0.012). Dyn-APA and Dyn-SL rotation were negative in AIS patients, meaning that shoulder line was rotated towards the left (- 6.4 vs. 7.8° and - 7.5 vs. - 0.4°, p<0.001, respectively). On the other hand, Dyn-P rotation was positive, meaning that pelvis was rotated towards the right side during gait (1.1 vs. - 0.5, p = 0.026).

DISCUSSION

This is one of the largest series of gait analysis in AIS patients. We demonstrated that AIS patients have an abnormal gait pattern, with a decreased anterior tilt of the trunk and transverse plane abnormalities. We found that gait deviation was not related to radiographic measurements, pointing out that dynamic assessment provides new data about spinal posture. These slides can be retrieved under Electronic Supplementary Material.

Correlations linking static quantitative gait analysis parameters to radiographic parameters in adolescent idiopathic scoliosis

BACKGROUND

Radiography is the main tool used to assess spinal deformities in patients with adolescent idiopathic scoliosis (AIS) but requires repeated exposure to ionising radiation, potentially raising safety concerns. Consequently, new methods are needed. Among them, the acquisition of static parameters during quantitative gait analysis (QGA) has received attention in recent years. However, no data on correlations linking static QGA parameters to standard radiographic parameters are available. The objective of this study was to assess correlations between static QGA parameters and standard radiographic parameters in patients with AIS.

HYPOTHESIS

Spinal deformities in patients with AIS can be evaluated based on static QGA parameters.

PATIENTS AND METHODS

We studied patients scheduled for surgery to treat AIS. On the day before surgery, QGA was performed and antero-posterior and lateral radiographs obtained. QGA involved analysing the positions of 32 reflective markers, including 6 used to assess the spine. The coronal vertical axis (CVA), thoracic and lumbar Cobb angles, sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis, and pelvic tilt were recorded and compared to the corresponding radiographic parameters.

RESULTS

The study included 57 patients, including 48 (84%) females, with a mean age of 15.2 years. Among them, 45 had Lenke 1 and 12 Lenke 5 scoliosis. The mean main Cobb angle was 51.9°. In the coronal plane, significant correlations with the corresponding radiographic parameters were found for the CVA (R=0.524, p<0.01) and thoracic Cobb angle (R=0.599, p<0.01). All the sagittal parameters correlated significantly with the corresponding radiographic parameters: SVA, R=0.313; pelvic tilt, R=0.342; thoracic kyphosis, R=0.575; and lumbar lordosis, R=0.360 (p<0.05 for all four parameters).

CONCLUSIONS

In this study, static QGA parameters accurately reflected the spinal deformities visualised radiographically. The lumbar deformity was more difficult to characterise, probably because it was mild in our population. Research efforts should focus on improving the performance of QGA, notably for detecting curve progression. Thus, QGA may allow a decrease in radiation exposure of patients with AIS.

LEVEL OF EVIDENCE

III.

Operative management of supracondylar humeral fractures in children: Comparison of five fixation methods

BACKGROUND

The best method for stabilising supracondylar humeral fractures (SHFs) in children remains unclear. The objective of this study was to compare the outcomes of five different fixation methods for SHFs in children.

HYPOTHESIS

Differences in intra-operative and short-term post-operative parameters can be demonstrated across different fixation methods for SHFs in children.

PATIENTS AND METHODS

We reviewed the medical files of paediatric patients managed at our centre between 2006 and 2016 for SHF with major displacement (type 3 or 4 in the Lagrange-Rigault classification). Clinical and radiological parameters collected post-operatively and at last follow-up included Baumann's angle, anteversion of the distal humeral epiphysis, and operative time. Over the 11-year study period, 251 patients were included; mean age was 6.4 years and mean follow-up 4.7 months. The five fixation methods used were elastic stable intra-medullary nailing (ESIN, n=16), two pins in an X configuration (n=33), two lateral pins and one medial pin (n=144), two lateral pins (n=33), and three lateral pins (n=25). A minimally invasive 2-cm approach was used to insert the medial pins. Immediate instability of the fixation was considered in patients with an at least 15° deficit in Baumann's angle or anteversion, or with rotational malalignment, on the radiographs taken on day 1. Outcomes were analysed in each of the five internal fixation groups.

RESULTS

Immediate instability showed no significant differences across the five groups. Operative time was significantly shorter with two lateral pins (33min, P=0.046). Time to hardware removal was longer in the ESIN group (54 days, P=0.03). Use of a medial pin was associated with a lower risk of secondary displacement (2.0% vs. 8.6%, P=0.04) but did not affect the risk of nerve injury (4% vs. 3%, P=0.86).

DISCUSSION

This is one of the largest retrospective cohort studies of outcomes according to the fixation technique used to treat SHFs in children. Adding a medial pin through a minimally invasive approach is associated with a longer operative time but limits the risk of secondary displacement without increasing the frequency of iatrogenic nerve injury and improves fracture site stability. Use of a medial pin therefore deserves to be considered in paediatric SHFs.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Knee function after limb salvage surgery for malignant bone tumor: comparison of megaprosthesis and distal femur allograft with epiphysis sparing

PURPOSE

Limb salvage surgery is increasingly used for the treatment of distal femur bone sarcomas. Total knee replacement using megaprosthesis and epiphysis-sparing biologic reconstruction using an allograft are widely used in order to preserve joint motion. We aimed to compare the results of these procedures using gait analysis in patients undergoing limb salvage surgery.

METHODS

Fifteen patients were included, nine undergoing allograft with epiphysis sparing (Allograft group) and six undergoing megaprosthesis (Megaprosthesis group). Every patient underwent a gait analysis using the Plug-in-Gait protocol. Spatiotemporal parameters, knee kinematics, and kinetics were compared between the two groups and a cohort of ten asymptomatic subjects. Knee function was assessed by the Gait Deviation Index (GDI) and the Gilette Gait Index (GGI).

RESULTS

Both treatment groups showed decreased knee flexion during the loading response phase. Megaprosthesis patients showed a decreased knee flexion all along stance phase. There was no difference in gait pattern between the treatment groups. GDI was significantly lower in Megaprosthesis and Allograft patients when compared to controls (86.4 and 84.3 vs 94, all p < 0.05). This difference was not clinically relevant.

CONCLUSION

Our study reveals that Megaprosthesis and Allograft patients did not show differences in gait patterns and global function. Even though Allograft and Megaprosthesis patients have significant changes in gait pattern, knee function is acceptable with effective gait mechanisms. Changes occur during stance phase and are due to the quadriceps weakness. The particular pattern of gait in Megaprosthesis patients could be a concern for prosthesis wear and should be investigated on this specific aspect.

LEVEL OF EVIDENCE

4.

Spinal alignment evolution with age: A prospective gait analysis study

AIM

To describe, using gait analysis, the development of spinal motion in the growing child.

METHODS

Thirty-six healthy children aged from 3 to 16 years old were included in this study for a gait analysis (9 m-walk). Various kinematic parameters were recorded and analyzed such as thoracic angle (TA), lumbar angle (LA) and sagittal vertical axis (SVA). The kinetic parameters were the net reaction moments (N.m/kg) at the thoracolumbar and lumbosacral junctions.

RESULTS

TA and LA curves were not statistically correlated to the age (respectively, P = 0.32 and P = 0.41). SVA increased significantly with age (P < 0.001). Moments in sagittal plane at the lumbosacral junction were statistically correlated to the age (P = 0.003), underlining the fact that sagittal mechanical constraints at the lumbosacral junction increase with age. Moments in transversal plane at the thoracolumbar and lumbosacral junctions were statistically correlated to the age (P = 0.0002 and P = 0.0006), revealing that transversal mechanical constraints decrease with age.

CONCLUSION

The kinetic analysis showed that during growth, a decrease of torsional constraint occurs while an increase of sagittal constraint is observed. These changes in spine biomechanics are related to the crucial role of the trunk for bipedalism acquisition, allowing stabilization despite lower limbs immaturity. With the acquisition of mature gait, the spine will mainly undergo constraints in the sagittal plane.

The John Insall Award: No Functional Benefit After Unicompartmental Knee Arthroplasty Performed With Patient-specific Instrumentation: A Randomized Trial

BACKGROUND

Component alignment can influence implant longevity as well as perhaps pain and function after unicompartmental knee arthroplasty (UKA), but correct alignment is not consistently achieved. To increase the likelihood that good alignment will be achieved during surgery, smart tools such as robotics or patient-specific instrumentation (PSI) have been introduced.

QUESTIONS/PURPOSES

We hypothesized that UKA performed with PSI would result in improved level gait as ascertained with three-dimensional analysis, implant positioning, and patient-reported outcomes measured by a validated scoring system when compared with conventional instrumentation 3 months and 1 year after surgery.

METHODS

We randomized 60 patients into two groups using either the PSI technique or a conventional technique. All patients were operated on using the same technique and the same cemented metal-backed implant. Mean age of the patients was 63 ± 4 years (range, 54-72 years) and mean body mass index was 28 ± 3 kg/m(2). Patients were evaluated preoperatively, at 3 months, and 1 year after surgery by an independent observer blind to the type of technique. Gait parameters were assessed with three-dimensional analysis during level walking preoperatively and at 1 year, frontal and sagittal position of the implant was evaluated on full-length radiographs at 3 months, and subjective functional outcome and quality of life using routine questionnaires (SF-12, new Knee Society Score [KSS], Knee Injury and Osteoarthritis Outcome Score) at 3 months and 1 year. This study had 80% power to detect a 15% difference in walking speed at the p < 0.05 level.

RESULTS

One year after surgery, there were no differences between the two groups in the analyzed gait spatiotemporal parameters, respectively, for PSI UKA and conventional UKA : double limb support 31% (25%-54%) versus 30% (23%-56%; p = 0.67) and walking speed (1.59 m/s [0.86-1.87 m/s] versus 1.57 m/s [0.71-1.96 m/s]; p = 0.41). No difference was observed between the two groups in terms of lower limb alignment (PSI group 178° ± 3°, conventional group 178° ± 4°; p = 0.24) or implant positioning on mediolateral and anteroposterior radiographs. There were no differences in the functional score between the PSI and conventional TKA groups at 3 months and 1 year after surgery: KSS objective knee scores (PSI: 85 ± 8 points at 3 months, 87 ± 5 points at 1 year and conventional instrumentation: 82 ± 8 points at 3 months 83 ± 6 points at 1 year; p = 0.10) and functional activity scores were similar in both group (PSI: 71 ± 12 points at 3 months and 74 ± 7 points at 1 year versus conventional group: 73 ± 11 points at 3 months and 75 ± 6 at 1 year; p = 0.9).

CONCLUSIONS

Our observations suggest that PSI may confer small, if any, advantage in alignment, pain, or function after UKA. This argument can therefore not be used to justify the extra cost and uncertainty related to this technique.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Postural spinal balance defined by net intersegmental moments: Results of a biomechanical approach and experimental errors measurement

AIM: To describe initial results and experimental error measurement of a protocol analyzing Human posture through sagittal intersegmental moments.

METHODS: Postural analysis has been recently improved by development of three-dimensional radiographic imaging systems. However, in various situations such as global sagittal anterior malalignment interpretation of radiographs may not represent the real alignment of the subject. The aim of this study was to present initial results of a 3D biomechanical protocol. This protocol is obtained in a free standing position and characterizes postural balance by measurement of sagittal intersegmental net moments. After elaboration of a specific marker-set, 4 successive recordings were done on two volunteers by three different operators during three sessions in order to evaluate the experimental error measurement. A supplementary acquisition in a “radiographic” posture was also obtained. Once the data acquired, joint center, length, anatomical frame and the center of mass of each body segment was calculated and a mass affected. Sagittal net intersegmental moments were computed in an ascending manner from ground reaction forces at the ankles, knees, hips and the lumbo-sacral and thoraco-lumbar spinal junctions. Cervico-thoracic net intersegmental moment was calculated in a descending manner.

RESULTS: Based on average recordings, clinical interpretation of net intersegmental moments (in N.m) showed a dorsal flexion on the ankles (8.6 N.m), a flexion on the knees (7.5 N.m) and an extension on the hips (8.5 N.m). On the spinal junctions, it was flexion moments: 0.34 N.m on the cervico-thoracic; 6.7 N.m on the thoraco-lumbar and 0.65 N.m on the lumbo-sacral. Evaluation of experimental error measurement showed a small inter-trial error (intrinsic variability), with higher inter-session and inter-therapist errors but without important variation between them. For one volunteer the “radiographic” posture was associated to significant changes compared to the free standing position.

CONCLUSION: These initial results confirm the technical feasibility of the protocol. The low intrinsic error and the small differences between inter-session and inter-therapist errors seem to traduce postural variability over time, more than a failure of the protocol. Characterization of sagittal intersegmental net moments can have clinical applications such as evaluation of an unfused segment after a spinal arthrodesis.

Quantifying foot deformation using finite helical angle

Foot intrinsic motion originates from the combination of numerous joint motions giving this segment a high adaptive ability. Existing foot kinematic models are mostly focused on analyzing small scale foot bone to bone motions which require both complex experimental methodology and complex interpretative work to assess the global foot functionality. This study proposes a method to assess the total foot deformation by calculating a helical angle from the relative motions of the rearfoot and the forefoot. This method required a limited number of retro-reflective markers placed on the foot and was tested for five different movements (walking, forefoot impact running, heel impact running, 90° cutting, and 180° U-turn) and 12 participants. Overtime intraclass correlation coefficients were calculated to quantify the helical angle pattern repeatability for each movement. Our results indicated that the method was suitable to identify the different motions as different amplitudes of helical angle were observed according to the flexibility required in each movement. Moreover, the results showed that the repeatability could be used to identify the mastering of each motion as this repeatability was high for well mastered movements. Together with existing methods, this new protocol could be applied to fully assess foot function in sport or clinical contexts.

Best clinical practice in botulinum toxin treatment for children with cerebral palsy

Botulinum toxin A (BoNT-A) is considered a safe and effective therapy for children with cerebral palsy (CP), especially in the hands of experienced injectors and for the majority of children. Recently, some risks have been noted for children with Gross Motor Classification Scale (GMFCS) of IV and the risks are substantial for level V. Recommendations for treatment with BoNT-A have been published since 1993, with continuous optimisation and development of new treatment concepts. This leads to modifications in the clinical decision making process, indications, injection techniques, assessments, and evaluations. This article summarises the state of the art of BoNT-A treatment in children with CP, based mainly on the literature and expert opinions by an international paediatric orthopaedic user group. BoNT-A is an important part of multimodal management, to support motor development and improve function when the targeted management of spasticity in specific muscle groups is clinically indicated. Individualised assessment and treatment are essential, and should be part of an integrated approach chosen to support the achievement of motor milestones. To this end, goals should be set for both the long term and for each injection cycle. The correct choice of target muscles is also important; not all spastic muscles need to be injected. A more focused approach needs to be established to improve function and motor development, and to prevent adverse compensations and contractures. Furthermore, the timeline of BoNT-A treatment extends from infancy to adulthood, and treatment should take into account the change in indications with age.

Proximal migration of fibular malleolus during tibial lengthening despite syndesmotic screw fixation: a series of 22 cases

INTRODUCTION

During tibial lengthening procedures, it is recommended to prevent fibular malleolus proximal migration using a distal tibiofibular syndesmotic screw, which is removed at 6 months. We have observed proximal migrations of the fibular malleolus despite placement of this syndesmotic screw.

OBJECTIVE

The objective of this study was to demonstrate this migration and to study the influence of two factors that may favor its occurrence: positioning of the syndesmotic screw and union of the fibula at the time of removal.

HYPOTHESIS

An unhealed fibula at the time the distal tibiofibular syndesmotic screw is removed and its tricortical position promote the proximal migration of the fibular malleolus.

MATERIAL AND METHODS

This was a retrospective, single-center, analytical study that included 22 lengthening procedures in 18 patients from 5 to 17 years of age who had undergone tibial lengthening and presented a preoperative continuous fibula. The position of the fibular malleolus, union of the fibula, and the tri- or quadricortical position of the screw were assessed based on four successive x-rays.

RESULTS

Tricortical positioning of the syndesmotic screw was significantly associated with proximal migration of the fibular malleolus during lengthening (P=0.0248<0.05). However, there was no significant relation between an unhealed fibula and proximal migration of the fibular malleolus when the screw was removed (P=0.164>0.05).

DISCUSSION

Proximal migration of the fibular malleolus during lengthening is promoted by placing a non-quadricortical syndesmotic screw. Quadricortical positioning of the screw should be recommended. Migration of the fibular malleolus after ablation of the syndesmotic screw seems to be related to absence of fibular union but this series was too small to demonstrate this clearly.

LEVEL OF EVIDENCE

Level IV: Retrospective study.

No benefit of patient-specific instrumentation in TKA on functional and gait outcomes: a randomized clinical trial

BACKGROUND

Although some clinical reports suggest patient-specific instrumentation in TKA may improve alignment, reduce surgical time, and lower hospital costs, it is unknown whether it improves pain- and function-related outcomes and gait.

QUESTIONS/PURPOSES

We hypothesized that TKA performed with patient-specific instrumentation would improve patient-reported outcomes measured by validated scoring tools and level gait as ascertained with three-dimensional (3-D) analysis compared with conventional instrumentation 3 months after surgery.

METHODS

We randomized 40 patients into two groups using either patient-specific instrumentation or conventional instrumentation. Patients were evaluated preoperatively and 3 months after surgery. Assessment tools included subjective functional outcome and quality-of-life (QOL) scores using validated questionnaires (New Knee Society Score(©) [KSS], Knee Injury and Osteoarthritis Outcome Score [KOOS], and SF-12). In addition, gait analysis was evaluated with a 3-D system during level walking. The study was powered a priori at 90% to detect a difference in walking speed of 0.1 m/second, which was considered a clinically important difference, and in a post hoc analysis at 80% to detect a difference of 10 points in KSS.

RESULTS

There were improvements from preoperatively to 3 months postoperatively in functional scores, QOL, and knee kinematic and kinetic gait parameters during level walking. However, there was no difference between the patient-specific instrumentation and conventional instrumentation groups in KSS, KOOS, SF-12, or 3-D gait parameters.

CONCLUSIONS

Our observations suggest that patient-specific instrumentation does not confer a substantial advantage in early functional or gait outcomes after TKA. It is possible that differences may emerge, and this study does not allow one to predict any additional variances in the intermediate followup period from 6 months to 1 year postoperatively. However, the goals of the study were to investigate the recovery period as early pain and functional outcomes are becoming increasingly important to patients and surgeons.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the Instructions to Authors for a complete description of levels of evidence.

Dynamic equinus with hindfoot valgus in children with hemiplegia

In children with hemiplegia, it is important to distinguish between equinus with hindfoot varus (equinovarus) or valgus (equinovalgus). Premature onset of medial gastrocnemius (GM) EMG in individuals with equinus is well documented. Premature onset of Peroneus longus (PL) EMG has been described in neurologically impaired adults with equinovalgus, but not in children. Our aim was to record the onset of PL and GM activity on the hemiplegic side of children with equinovalgus deformity. Fifteen children GMFCS 1 (3.8 yrs ± 2) with hemiplegia had a goniometric assessment of passive ankle range of motion and assessment of ankle function from video and surface EMG recording during gait. The clinical and video observations were used to determine the equinovalgus, as defined by Wren, at initial contact (IC). The premature onset of muscle activity was normalised as a swing (SW) percentage prior to IC of the following stance (ST). A paired T-test compared the onset of muscle activity between PL and GM. The ankle passive dorsiflexion was 13° ± 12° (hemiplegic side) versus 18° ± 10° (non-involved side) (p<0.05). For the non-involved limb, the onset of GM activity was at 14% of the gait cycle (midstance), the onset of PL activity was at 19% (p<0.05). For the hemiplegic limb with equinovalgus, there was a premature onset activity of PL (-24%) and GM(-8%) (p<0.001). On the non involved side, the onset of PL activity occurred, as in adults, after the onset of GM activity, during ST. On the hemiplegic side, there was no triceps surae contracture and the onset of PL activity occurred prior to the onset of GM activity, during terminal SW. This study confirmed the overactivity of PL in hemiplegic children with equinovalgus.

Fatal lung metastasis secondary to index finger giant cell tumor in an 8-year-old child

We report the case of a 7-year-old girl presenting with giant cell tumor (GCT) of the index finger, complicated by lung metastases. Index disarticulation, pulmonary metastasectomy and chemotherapy failed to produce a cure, and the child died at the age of 8 years after 1 year's evolution. The pulmonary metastases were discovered following hypoxia during initial biopsy. A review of the literature shows this observation to be original, in terms of the patient's age and of the location, onset and fatal outcome of metastasis. The hypoxic episode complicating biopsy raises the issue of early screening for lung metastases in GCT. Pulmonary dissemination of GCT is of severe prognosis.

Botulinum toxin-A (Botox) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review

OBJECTIVES

Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB).

METHODS

A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis.

RESULTS

A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events.

CONCLUSIONS

Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

Multidimensional outcome assessment in cerebral palsy: is it feasible and relevant?

BACKGROUND

To examine feasibility and relevance of a multidimensional outcome assessment approach using instrumented 3-dimensional gait analysis, via the Gillette Gait Index (GGI), and a set of validated functional and health-related quality of life tools in diplegic cerebral palsy children, before introduction as a nationwide evaluation set.

METHODS

A 3-year prospective government-funded multicenter study was conducted, recruiting patients during a 9-month period classified using the Gross Motor Function Classification System and the Rodda et al sagittal walking patterns. The Gross Motor Classification System Dimensions D and E, the 10-level Gillette Functional Assessment Questionnaire, the Energy Expenditure Index (EEI), the GGI out of 3D gait analysis, and health-related quality of life, assessed by self or proxy with the questionnaire "Vècu et Santè Perçu de l'Adolescent," were selected for the study.

RESULTS

Cross-sectional data subset at inclusion of 160 spastic diplegic cerebral palsy patients, the largest series in our country, 6 to 18 years old (mean age, 11.0 years), are reported. The GGI correlated significantly (P < 0.001) with the Gross Motor Classification System, the Functional Assessment Questionnaire, and the EEI for all the patients, and all but one (EEI) correlated if grouped according to Gross Motor Function Classification System or Rodda. No systematic correlation was found between the quality of life scores and the other outcome tools.

CONCLUSIONS

The outcome evaluation instrument set tested in our study helps to adopt common tools, to be integrated in an evidence-based practice and to compare health status and treatment outcome between countries, specifically in different linguistic environments like in European countries.

[Melorheostosis and anterior cruciate ligament tear in a 15-year-old female]

We report the case of a 15-year-old girl who suffered an indirect knee trauma. The standard X-rays revealed a tract of ivory-like bone partially obstructing the medullary canal of the femur and the tibia. Magnetic resonance imaging produced a hypointense signal on the T1 and T2 sequences. The radiographic diagnosis was melorheostosis which was confirmed on the biopsy specimen which ruled out other diagnoses. The MRI also revealed a tear of the anterior cruciate ligament, treated conservatively. Clinical and radiological surveillance were proposed for the melorheostosis.

[Informative value of the popliteal angle in walking cerebral palsy children]

PURPOSE OF THE STUDY

In clinical practice, it is generally accepted that hamstring tightness results in incomplete knee extension when the hip is in flexion and in smaller conventional and modified popliteal angles. Similarly, a difference between the conventional popliteal angle and the modified popliteal angle (popliteal differential) would be associated with a permanent deficit in knee extension. The purpose of this study was to determine whether these two hypothesis correlate with clinical findings.

MATERIAL AND METHODS

The series was composed of 35 walking cerebral palsy children, 16 girls and 19 boys, mean age 11+/-3.6 years with a pathological conventional popliteal angle. These children walked using the jump knee (n=24) or the crouch knee (n=11) pattern. Permanent hip flexion and the conventional and modified popliteal angles were noted. SPSS version 10.1.3 for Window was used to search for a correlation between the popliteal differential and the presence of permanent hip flexion using several values for the popliteal differential (5, 10, 15, 20, and 30 degrees ). Data were adjusted for age and gender.

RESULTS

The statistical analyses demonstrated a significant relationship between the presence of permanent hip flexion and a popliteal differential strictly less than 10 degrees and between the absence of permanent hip flexion and a popliteal angle greater or equal to 10 degrees . These statistically significant results, which demonstrated the opposite of what was expected, were independent of age and gender.

DISCUSSION

Our findings demonstrate that examination of the knee joint is indispensable but insufficient. The conventional popliteal angle is not a reliable indicator of hamstring tightness. The normal value of the modified popliteal angle has not been established so that it is impossible to determine what a pathological angle is. We do not know whether measurement of this angle is sufficient to establish indications for surgery. In the future, the development of muscle models coupled with gait analysis should enable more reliable prediction of outcome after surgery. At the present time, we recommend repeated physical examination using a standardized protocol, taking into consideration, several parameters including spasticity, selectivity and muscle force and to perform quantified gait analysis before scheduling hamstring lengthening surgery for walking cerebral palsy children.

Rotational profile of the lower limb in 1319 healthy children

Lower limb rotational profile in children may cause great concern to parents and relatives. In order to give parents clear information, there is a need for referential studies giving normative data of lower limb rotational profile and its normal changes expected over growth. Our aim was to collect a large clinical series of healthy children, out of a clinic, selected from a non-consulting population and to analyse Tibial Torsion and Femoral Anteversion according to age and gender. One thousand three hundred and nineteen healthy children underwent a clinical evaluation. Tibial Torsion was assessed using the method described by Staheli and Engel, whereas Femoral Anteversion was assessed using the method described by Netter. Our results showed that there was a significant difference between males and females in Femoral Anteversion, whereas there was no significant difference between the right side and the left side. Femoral Anteversion was higher in females, and was markedly correlated with age in both genders. There was no significant difference between males and females in Tibial Torsion, nor significant difference between the right side and the left side. Tibial Torsion was slightly correlated with age in both genders. Normative data were statistically defined in this work using the +/-2S.D. range. To our knowledge, there is no large and comprehensive series in the English speaking literature that gives normative data of Femoral Anteversion. Concerning Tibial Torsion, our results compared to those published in the literature.