Highlights • Significant pathology is reported with the Gait Deviation Index in children with IFA. • Knee abduction moments are altered in IFA and may have long term impacts on joint cartilage. • ...Compensatory ability of subjects results in many subtle changes in gait. • Gait pathology from a group of patients is best captured with a multidimensional index. • Femoral derotational osteotomy effectively eliminates gait pathology in IFA.
The primary aim of this study was to define and quantify three new measurements to indicate the position of the greater trochanter. Secondary aims were to define 'functional antetorsion' as it ...relates to abductor function in populations both with and without torsional abnormality.
Three new measurements, functional antetorsion, posterior tilt, and posterior translation of the greater trochanter, were assessed from 61 CT scans of cadaveric femurs, and their reliability determined. These measurements and their relationships were also evaluated in three groups of patients: a control group (n = 22), a 'high-antetorsion' group (n = 22) and a 'low-antetorsion' group (n = 10).
In the cadaver group, the mean anatomical antetorsion was 14.7° (sd 8.5; 0 to 36.5) and the functional antetorsion 21.5° (sd 8.1; 3.6 to 44.3): the posterior tilt was 73.3° (sd 10.8; 46.9 to 88.7) and the posterior translation 0.59 (sd 0.2; 0.2 to 0.9). These measurements had excellent intra and interobserver agreement with a range from 0.93 to 0.99. When the anatomical antetorsion decreased, the greater trochanter was more tilted and translated posteriorly in relation to the axis of the femoral neck, and the difference between functional and anatomical antetorsion increased. The results the three patient groups were similar to those of the cadaver group.
The position of the greater trochanter and functional antetorsion varied with anatomical antetorsion. In the surgical management of femoral retrotorsion, subtrochanteric osteotomy can result in an excessively posterior position of the greater trochanter and an increase in functional antetorsion. Cite this article: Bone Joint J 2018;100-B:712-19.
Objective:
This study aimed to evaluate the effectiveness of a static ground reaction ankle foot orthosis and strapping system on improving gait parameters in children with spastic diplegic cerebral ...palsy.
Setting:
The current study was conducted at the physical therapy faculty of Cairo University, Egypt.
Subjects:
This study included 57 children of both sexes, aged 6 to 8 years.
Study design:
Three-armed randomized control trial.
Intervention:
Participants in all groups received a traditional neuro-developmental physical therapy program that included standing and gait training exercises. Children in group A performed the training program without any orthotic management, in group B with the TheraTogs™ strapping system, and in group C with the TheraTogs™ strapping system and static ground reaction ankle foot orthoses. Children underwent treatment for two hours daily, except on weekends, for twelve successive weeks.
Main measure:
Gait speed, cadence, stride length, and hip and knee flexion angles in the mid-stance phase were evaluated pre-and post-treatment using a three-dimensional motion analysis system (pre-reflex system).
Results:
Statistically significant differences were recorded among the three groups post-treatment in gait speed, cadences, and stride length. The P-values for these variable differences were 0.03, 0.011, and 0.001 respectively. Significant post-treatment differences were also recorded for bilateral hip-and knee-flexion angles. For all measured parameters, better significant results were registered for group C than for the other groups.
Conclusion:
Orthotic intervention composed of a static ground reaction ankle foot orthosis combined with the TheraTogs™ strapping system improves gait more than conventional treatment with or without TheraTogs™ in children with spastic diplegic cerebral palsy.
Purpose To verify the influence that increased femoral anteversion (FA) has on patients with recurrent patellar instability (RPI) treated by anteromedialization tibial tubercle osteotomy (TTO) ...combined with medial patellofemoral ligament reconstruction (MPFLR) and to present the midterm outcomes of these patients. Methods From January 2008 to August 2013, skeletally mature patients with RPI and tibial tubercle (TT)–trochlear groove (TG) ≥ 17 mm who underwent anteromedialization TTO combined with MPFLR were evaluated for J sign, patellar glide, apprehension test, increased FA, Caton index, trochlea dysplasia, TT-TG, Kujala, International Knee Documentation Committee subjective knee evaluation form, and Tegner. Increased FA was determined clinically by a difference of more than 30° between hip internal and external rotation, 70° or more of hip internal rotation, and 30° or more of femoral neck anteversion. A subgroup analysis involving increased FA was made. Results Forty-eight patients composed the study group. Mean follow-up was 41.5 ± 11.05 months. The J-sign was present in 86% before surgery and none postoperatively ( P < .001). All patients had a positive apprehension test or a patellar luxation at the patellar glide test rated as grade 4 before surgery. After surgery, the mean glide was 1.29 ± 0.45 with no apprehension ( P < .001). Increased FA was present in 18.7%. Caton index before surgery was 1.11 ± 0.21 and 0.99 ± 0.11 postoperatively ( P = .004). Trochlea dysplasia was present in all patients. TT-TG preoperatively was 20.77 ± 2.12 mm and 11.33 ± 1.24 mm postoperatively ( P < .001). Functional scores improved preoperatively to postoperatively ( P < .001) with Kujala and International Knee Documentation Committee means: 59.08 to 84.37; 52.6 to 85.5, respectively. Tegner preinjury score was 5.4 and postoperatively was 5.2 ( P = .01). Increased FA group had worse Kujala compared with the normal FA group and worse Kujala improvement: 77.7 and 85.89 ( P = .012), and 21.7 and 26.1, respectively ( P < .001). Conclusions Increased FA in patients with RPI had a negative effect on the outcome of anteromedialization TTO combined with MPFLR. Combined anteromedialization TTO and MPFLR had good functional midterm outcomes in treating patients with RPI and TT-TG ≥ 17 mm. Level of Evidence Level III, comparative study.
Background. Increased metal ion levels following total hip arthroplasty (THA) with metal-on-metal bearings are a highly debated topic. Local soft tissue reactions with chronic pain and systemic side ...effects such as neuropathy are described. The aim of the current study was to determine the serum metal ion concentrations of Cobalt (Co) and Chrome (Cr) after THA with a ceramic-on-metal (CoM) bearing. Patients and Methods. Between 2008 and 2010, 20 patients underwent THA using a CoM bearing. Clinical function was evaluated by standardized scores systems (Harris Hip Score and WOMAC Score) and radiological examination included X-rays. Patient’s blood samples were obtained for metal ion analysis and correlation analysis was done between these results and implant position. Results. Overall, 13 patients with 14 CoM devices were available for the current series. The mean age at time of surgery was 61 years (range, 41 to 85). The postoperative follow-up ranged from 49 to 68 months (mean, 58). Metal ion determination showed mean concentrations of 3,1 µg/L (range, 0,3–15,2 µg/L) for Co and 1,6 µg/L (range, 0,1–5,5 µg/L) for Cr, respectively. A correlation between cup anteversion and Co and Cr concentrations was shown. Conclusion. The current series showed increments for Co and Cr following CoM THA. However, these levels are lower compared to metal ion concentrations in patients with metal-on-metal bearings and the international accepted threshold for revision of MoM devices. We recommend routine follow-up including at least one obligatory evaluation of serum metal ion concentrations and an MRI once to exclude local soft tissue reactions.
Total hip arthroplasty (THA) is often required to decrease the excessive anatomical femoral anteversion (AA) in developmental dysplasia of the hip. Studies have recommended decreasing the AA via the ...use of a retroverted modular neck. However, hip rotation after THA may strengthen or weaken the effect of changing the AA. Thus, the present study analyzed the effect of a retroverted neck on AA and hip rotation. Patients who underwent THA using a straight neck (ST group) or a 15° retroverted neck (RV group) in a version changeable dual modular system (Mainstay stem, Kyocera, Kyoto, Japan) were retrospectively reviewed. After matching for age, body mass index, and surgical approach, 44 patients were included in each group. The AA and hip rotation (femoral rotational angle: FRA) were measured on CT images acquired preoperatively and 1 month after THA, and were compared between the groups. The mean ± standard deviation preoperative AA of the ST group (26.1 ± 10.7°) was significantly smaller than that of the RV group (44.2 ± 7.8°) (
p
< 0.001). In contrast, the postoperative AA did not significantly differ between the groups (ST group 27.5 ± 9.8°, RV group 25.1 ± 8.3°,
p
= 0.406). The change in FRA after THA did not significantly differ between the groups (ST group − 3.8 ± 9.9°, RV group − 3.5 ± 9.1°,
p
= 0.841). In conclusion, a 15° retroverted neck was useful in controlling AA in hips with excessive AA, and the change in FRA after THA did not differ between the ST group and the RV group.
Abstract Pelvic tilt (PT) affects the functional anteversion and inclination of acetabular components in total hip arthroplasty (THA). One-hundred and thirty-eight consecutive patients who underwent ...unilateral primary THA were reviewed. Most cases had some degree of pre-operative PT, with 17% having greater than 10° of PT on standing pre-operative radiographs. There was no significant change in PT following THA. A computer model of a hemispheric acetabular component implanted in a range of anatomic positions in a pelvis with varying PT was created to determine the effects of PT on functional anteversion and inclination. Based on the study results, tilt-adjustment of the acetabular component position based on standing pre-operative imaging will likely improve functional component position in most patients undergoing THA.
The purpose of this study was to investigate the relationship between femoral neck version and pre- and intraoperative findings in hips with femoroacetabular impingement (FAI). The authors ...retrospectively reviewed prospectively collected data on 188 patients (204 hips) who underwent hip arthroscopy for FAI and labral pathology. Femoral version was measured on magnetic resonance imaging by a fellowship-trained musculoskeletal radiologist. The study group comprised 100 men and 88 women with a mean age of 35 years (range, 18 to 62 years). Mean femoral version was 9° (range, -10° to 27°). No relationship was found between femoral version and patient demographics (ie, age, sex, weight, height, and body mass index). A significant correlation was found between version and degrees of external rotation (r=-0.208; P=.027) and internal rotation (r=0.231; P=.002) on physical examination. Patients with femoral version less than 5° had significantly increased external rotation (P=.027). Intraoperative findings demonstrated that femoral version greater than 15° was related to larger labral tears that averaged approximately 38 mm in size, whereas patients with anteversion less than 5° had tear sizes measuring 30 mm and patients with angles between 5° and 15° had tear sizes averaging 34 mm (P=.008). Hips with femoral version greater than 15° were 2.2 times more likely (95% confidence interval, 1.2 to 4.1) to have labral tears that extended beyond the 3 o'clock position, denoting more anterior tears. Hips in which a psoas release was performed had higher version angles (8° vs 11°; P=.023).
Purpose To investigate the possible relation between femoral anteversion (AV) and trochlear morphology. Methods Among 560 available lower-limb computed tomography (CT) scans, those with previous ...fracture, arthroplasty, or osteotomy were excluded and 40 cases were randomly selected. The following 4 lines were determined from the CT scans: 1 through the center of the femoral head and neck; 1 through the lesser trochanter and the center of the femoral shaft; 1 as a tangent to the dorsal part of the distal femur, just above the gastrocnemius insertion; and 1 as a tangent to the posterior condyles. Between the respective lines, the following parameters of femoral AV were determined: (1) total AV, (2) proximal AV, (3) diaphyseal AV, and (4) distal AV. Trochlea parameters were determined from 2 separate axial CT slices (proximal trochlea and 5 mm farther distally): trochlea height (medial, central, lateral), transverse trochlea shift, trochlea depth, sulcus angle, lateral trochlea slope, and Dejour trochlea type. To prove or disprove our study hypothesis, a correlation analysis was performed between the variables of AV and trochlear morphology. Results The total AV was significantly correlated with the trochlea parameters trochlea depth ( P = .032), sulcus angle ( P = .05), and lateral trochlea slope ( P = .001). The diaphyseal AV was significantly correlated with the sulcus angle ( P = .009). The distal AV showed significant correlations with medial, central, and lateral trochlea height (.005 < P < .032) and with Dejour trochlea type ( P = .043). Conclusions The morphology of the trochlea is significantly related to femoral AV. Increased AV is associated with a flatter, more dysplastic trochlea. This was particularly true for AV located at the distal femur. Level of Evidence Level III, diagnostic study of nonconsecutive patients.
To investigate long-term changes in femoral anteversion angle (FAA) in children with intoeing gait and to identify factors that affect FAA changes.
We retrospectively analyzed three-dimensional ...computed tomography data from 2006 to 2022 of children with intoeing gait with ≥3 years of follow-up without active treatment. The study examined the mean changes in FAA, the effects of sex, age, and initial FAA on FAA change, and mean FAAs by age. Changes in FAA severity up to eight years of age were also observed and analyzed by sex.
A total of 126 lower limbs of 63 children (30 males, 33 females) with intoeing gait were included, with a mean age of 5.11±1.05 years and a mean follow-up period of 43.59±7.74 months. The initial FAA was 41.42°±8.29° and the follow-up FAA was 33.25°±9.19°, indicating a significant decrease (p<0.001). Significant correlations were observed between age and changes in FAA, as well as between initial FAA and changes in FAA (r=0.248, p=0.005; r=-0.333, p<0.001). At age 8 years, only 22 limbs were classified as having mild FAA severity.
During the follow-up period, children with intoeing gait had a significant decreased in FAA. No significant difference in FAA change was found between sex, but younger children and those with greater initial FAA were more likely to have decreased FAA. However, most children retained moderate to severe severity of increased FAA. Further studies are required to validate these findings.
PDF
