1. Therapy of intoeing gait in cerebral palsy AOPA-Orlando-German Day, October 2010 F. Braatz MD, S. Wolf PhD

2. Introduction Internal Rotated Gait Functional & cosmetic problems  “squinting patella sign” (“knocking knees”)  internal foot progression  inefficient foot clearance  compensatory external tibial rotation  compensatory pelvic retraction

3. Operation D.E.12 Y.: CP, Diparesis, Derotation Femur35°., Evans, Hemstring Lengthening 07/08 Prae OP

4. Operation

5. Patient 1

7. V.T.12 y: Operation 27.11.02: 1) FDO right 30° left 20 ° 2) Chopartfusion 3) Rektus-transfer 27.10.2003 25.11.2002 Proximal vs. distal Type

8. 3D Gait Analysis 25.11.2002 27.10.2003

9. Proximal vs. distal Type

10. Team

11. Night Splint  Therapy overnight  Low-cost  Muscle-tone?  Stable hindfoot

12. KAFOs With hinges Night Splint

13. Foam Connected with a rod Night Splint

14. Night Splint-Foam

15. S.W.A.S.H. –MAO-Orthosis MAO Orthosis S.W.A.S.H. Orthosis

16. Soft Orthosis

18. Conservative Treatment  Botox ® (Typ A) : 1 Viole are 100 MU  Dysport ® (Typ A) : 1 Viole are 500 MU

20. 3D gait analysis-MRI or CT 20° 6° 11° 22° 2° 17° static dynamic

21. Materials and Methods Function vs. Static deformity Patients –30 ambulatory patients with CP (18 male, 12 female) –age 11.6 ± 2.9 years Methods –Gait analysis: mean hip rotation –MRI: femoral anteversion Dreher et al. Gait Posture 2007;26:25–31 Braatz et al. JBJS (submitted)

22. FDO– technique intertrochanteric supracondylar

23. a) K-wires (*) placed proximally and b) Osteotomy parallel to the K-wires distally to the derotation line * * * * Femur Osteotomy FDO– technique

24. c) K-wires (*) are parallel aligned d) After derotation the angle between before the osteotomy and the the two K-wires (*) determines the derotation amount of derotation * * * * FDO– technique

25. Results Unpaired, two-tailed t-test for pre-post comparison. P-values <0.05 were regarded as significant. Exam/ParameterPre-OPPost-OPp-value Mean Pelvic Rotation-0.1 ± 6.50.0 ± 6.60,892 Mean Hip Rotation in Stance13.8 ± 14.80.4 ± 10.2< 0.001 Foot progression angle11.1 ± 16.0-1.3 ± 8.4< 0.001 Table 2 – Pre- and postoperative results of dynamic examination in gait

26. Results Pearson’s correlation

27. Discussion Satisfactory results after FDO were reported [1] However, recent studies found over- and under-corrections [2] and recurrence [3] and discrepancy between intraoperative amount of derotation and functional outcome [2,4] Femoral anteversion is not useful as predictor for mean hip rotation in gait analysis Both, static and dynamic component should be taken into account when planning correction of internal rotation gait. [1] Ounpuu et al., (2002), J Pediatr Orthop., 22, 139–45. [2] Dreher et al., (2007), Gait Posture, 26, 25-31. [3] Kim et al., (2005), J. Pediatr Orthop., 25, 739-743. [4] Kay et al., (2003), J Pediatr Orthop., 23, 150–154.

28. Materials and Methods 48 children with spastic diplegic cerebral palsy and internal rotation gait underwent multilevel surgery including 85 FDOs 3D Gait Analysis pre- and postoperatively FDO intertrochanteric 42 supracondylar 43 Derotation (supramalleolar) 12 Multilevel soft tissue correction

29. Results Time (years)1,22,26,1 Mean (IRO)18,0-0,2-1,83,9 SD13,111,113,112,3 T-Test0,0000,7300,049 pre - post2 post1- post30,0000,022 pre - post30,000

30. Results

32. Literature  Patients having surgery prior to age 10 were more likely to show deterioration. Kim H, Aiona M, Sussman M ;J Pediatr Orthop. 2005 Nov-Dec;25(6):739-43.  This trend toward internal rotation with hip flexion was apparent in 15 of the 18 muscle compartments we examined, suggesting that excessive hip flexion may exacerbate internal rotation of the hip. Delp, S.L. ; J Biomech. 1999 May;32(5):493-501.

33. Conclusions  Conservative treatment, Physiotherapy, Orthosis  static and dynamic components  Proximal / distal type  asymmetry  Physical examination, X-ray, 3D Gait Analysis, CT/MRI

34. Thank You!