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Published on: February 17, 2023
Femoral derotation osteotomy with multi-level soft tissue procedures in children with cerebral palsy: Does it improve
Yavuz Saglam1, N Ekin Akalan2,3, Yener Temelli4,5
1Orthopedics and Traumatology Department, Bahcelievler State Hospital, Istanbul, Turkey. yavuz_saglam@hotmail.com.
Insights
Femoral derotational osteotomy (FDO) effectively corrects increased femoral anteversion (FA) in children with cerebral palsy (CP). This surgery improves hip rotation, gait parameters, and overall clinical function, offering a valuable treatment for associated in-toeing gait.
Area of Science:
- Orthopedic surgery
- Pediatric orthopedics
- Cerebral palsy management
Background:
- Children with cerebral palsy (CP) often exhibit increased femoral anteversion (FA) due to factors like poor motor control, delayed walking, muscular imbalance, and hip contractures.
- Increased FA contributes to gait abnormalities, including in-toeing, which can be a significant functional limitation in individuals with CP.
- Addressing FA is crucial for improving gait kinematics and overall motor function in children with CP.
Purpose of the Study:
- To retrospectively analyze the mid-term clinical and kinematic outcomes of femoral derotational osteotomy (FDO) in children diagnosed with CP and increased FA.
- To evaluate the effectiveness of FDO in correcting abnormal hip rotation and improving gait parameters in this patient population.
Main Methods:
- Retrospective review of 93 patients (175 extremities) with CP and increased FA treated with FDO and multi-level soft tissue surgeries between 1992 and 2011.
- FA assessment involved measuring hip internal and external rotation in the prone position without pelvic rotation.
- Clinical findings, Edinburgh Visual Gait Scores (EVGS), and 3D gait analysis parameters were assessed preoperatively and at the last follow-up (average 6.3 years).
Main Results:
- Significant improvements were observed in postoperative hip internal rotation (73.9° to 46.2°) and external rotation (23.8° to 37°).
- The Edinburgh Visual Gait Score (EVGS) significantly improved (35.2 to 22.5), indicating better clinical outcomes.
- Computed gait analysis revealed significant improvements in foot progression angle (-16.9° vs. 8.1°), hip rotation (5.7° vs. -13.9°), stance time, swing time, double support time, and cadence.
Conclusions:
- Femoral derotational osteotomy (FDO) is an effective surgical strategy for correcting increased femoral anteversion (FA) and associated in-toeing gait in children with cerebral palsy (CP).
- FDO leads to significant improvements in both clinical assessments (EVGS) and objective kinematic gait parameters, particularly in transverse plane hip rotation and foot progression angle.
- The combined approach of FDO with multi-level soft tissue release demonstrates favorable mid-term results for improving gait function in children with CP.
Purpose:
Poor motor control and delayed thumb function and a delay in walking are the main factors which retard the natural decrease of the femoral anteversion (FA) with age. In addition, cerebral palsy (CP) patients usually have muscular imbalance around the hip as well as muscle contractures, both of which are main factors accounting for the increased FA which is commonly present in CP patients. The purpose of this retrospective study was to analyze the mid-term results of femoral derotational osteotomy (FDO) on the clinical findings, temporospatial and kinematic parameters of gait in children with CP.
Methods:
We performed a retrospective review of all patients diagnosed with CP and increased FA who were treated with FDO with multi-level soft tissue surgeries at a single institution between 1992 and 2011. FA assessment was done in the prone position, and internal (IR) and external rotation (ER) of the hip was measured in the absence of pelvis rotation. Surgical procedures were performed on the basis of both clinical findings and video analysis. Clinical findings, Edinburgh Visual Gait Scores (EVGS) and results from three-dimensional gait analysis were analyzed preoperatively and last follow-up.
Results:
A total of 93 patients with 175 affected extremities were included in this review. Mean age was 6.2 ± 3.1 (standard deviation) at initial surgery. The average length of the follow-up period was 6.3 ± 3.7 years. At the last follow-up, the postoperative hip IR had significantly decreased (73.9° vs. 46.2°; p < 0.0001), the hip ER had significantly improved (23.8° vs. 37°; p < 0.0001) and the popliteal angle had significantly decreased (64.2° vs. 55.8°; p < 0.0001). The total EVGS showed significant improvement after FDO (35.2 ± 6.4 vs. 22.5 ± 6.1; p < 0.001). Computed gait analysis showed significant improvement in the foot progression angle (FPA; 8.1° vs. -16.9°; p = 0.005) and hip rotation (-13.9° vs. 5.7°; p = 0.01) at the last follow-up. Stance time was improved (60.2 vs. 65.1 %; p = 0.02) and swing time was decreased (39.9 vs. 35.2 %; p = 0.03). Double support time and cadence were both decreased (p = 0.032 and p = 0.01).
Conclusions:
Our data suggest that the FDO is an appropriate treatment strategy for the correction of FA and associated in-toeing gait in children with CP. Improvements in clinical and kinematic parameters were observed in both groups after FDO with multi-level soft tissue release. The most prominent effects of FDO were on transverse plane hip rotation and FPA.
