S2 ESMAC 2012 abstract / Gait & Posture 38 (2013) S1–S116

Score (mHHS) [4]. 3D-gait-analysis was performed with a VICON512 system. Patients walked at a self-selected speed – barefoot.Spatiotemporal, kinematic and kinetic parameters were evaluatedand compared to the preoperative data and to a group of normalchildren (n = 30, 14 ♂, 16 ♀, average age 8.1 years.). In addition acomparison involved vs. uninvolved side was performed. The gaitpatterns in frontal plane were categorized according to Westhoffet al. [1]. The age at time of surgery was 8 + 1.7 years (5–11), thefollow-up time was 4.2 + 2,0 years (2–7.5)

Results: In comparison to the preoperative status the mHHSimproved significantly and ranged within normal values. Analysisof the spatio-temporal parameters showed significantly increasedgait velocity (p = 0.017), increased step-length on the involvedside (p < 0.001) and a normalized limp-index (p = 0.020). ROMof the pelvis (p < 0,001) and the maximum anterior tilt of thepelvis (p = 0,001) decreased to normal values. At the hip ROM(p < 0.001) in the sagittal plane increased due to increased hipextension (p < 0.001) to normal values. Comparison of the kine-matics uninvolved vs. involved side showed a completely normalsymmetric movement pattern in the sagittal and frontal planeon average. Analysis of the frontal plane gait pattern revealed anoverall improvement – while preoperative 10 patients showeda Duchenne-like pattern. This was the case postoperatively onlyin 3 patients. Power analysis of the hip joint revealed an increasein power generation to normal values (p = 0.01). Analysis of thehip flexor index according to Schwarz normalized in all but onepatients.

Discussion & conclusions: After containment improvingsurgery gait analysis demonstrated significant improvement ofthe gait pattern with regain of gait symmetry. 3D-gait analy-sis enables the analysis of the functional outcome of differenttreatment options after LCPD. Further studies are necessary todetermine the functional predictors for the development of sec-ondary osteoarthritis which may be influenced by conservative orsurgical treatment options.

References

[1] Westhoff, et al. Computerized gait analysis in LCPD – analysis of the frontal plane.Gait Posture 2006;24:196–202.

[2] Westhoff, et al. Correlation of functional outcome and X-ray-findings afterPerthes disease. International Orthopaedics 2011;35:1833–7.

[3] Westhoff, et al. Computerized gait analysis in LCPD – analysis of the sagittalplane. Gait Posture 2012;35:541–6.

[4] Byrd Jones. Hip arthroscopy in the presence of dysplasia. Arthroscopy2003;19:1055–60.

http://dx.doi.org/10.1016/j.gaitpost.2013.07.015

O03

Predictors of compensatory and adaptive trunkmovements during gait in children witharthogryposis multiplex congenita

Harald Böhm, Christel Multerer, LeonhardDöderlein

Behandlungszentrum Aschau GmbH, OrthopaedicHospital for Children, Aschau im Chiemgau, Germany

Introduction: Arthrogryposis multiplex congenita (AMC) is aheterogeneous condition which is characterized by multiple con-genital contractures and muscular deficits in multiple body areas.During walking increased compensatory movements of the pelvisand thorax have been reported [1]. Excessive movements betweenthorax and pelvis might cause degenerative changes in the inter-vertebral discs and in consequence low back pain [2]. Therefore theaims of this study were first, to quantify pathological trunk move-

ments during gait in children with AMC and second, to calculatepredictors for increased trunk movements.

Patients/materials and methods: 29 patients 10 ± 5 years wereincluded in the study. 19 were diagnosed as amyoplasia (AA), 10with distal arthrogryposis (DA), 15 typically developed children(TD) were used as controls. Pelvic, thorax and spine mean sagi-ttal flexion; range of frontal lean and range of transverse rotationduring gait were analyzed (ANOVA between AA, DA and TD). Rangeof motion and strength of the hip knee and ankle joints from clin-ical tests their corresponding gait parameters were included in astepwise multiple linear regression analysis.

Results: Patients with AA showed significantly increased pelvicand thorax movements in all three planes of motion (all p < 0.001).Patients with DA showed only significantly increased anteriorpelvic tilt in the sagittal plane (p < 0.001). For both patients groupsonly in the sagittal plane the spine was significantly more extended(AA: p = 0.002, DA: p < 0.001). For patients with AA, passive hipextension, hip flexion strength and knee extension together withhip flexion explained 33%, 39% and 60% of the variance in pelvicsagittal tilt, frontal lean and transverse rotation respectively. Forpatients with DA increased knee flexion during stance phase of gaitexplained 42% of pelvic anterior tilt.

Discussion & conclusions: Our results suggest that increasedtrunk movements in patients with AA were compensatory forreduced step length and foot clearance. Whereas increased ante-rior pelvic tilt in patients with DA was suggested to be adaptive tothe increased knee flexion during gait.

Increased hyperlordosis caused by pelvic anterior tilt mightincrease the risk of developing back pain. Therefore treatmentshould focus on pelvic anterior tilt, helping AMC children to developinto an adult without developing back pain.

References

[1] Eriksson M, et al. Journal of Children’s Orthopaedics 2010;4:21–31.[2] Beckers L, et al. Acta Orthopaedica Belgica 1991;57:198–202.

http://dx.doi.org/10.1016/j.gaitpost.2013.07.016

O04

Botulinum toxin a does not improve casttreatment for idiopathic toe-walking – Aprospective randomized trial

Pähr Engström 1, Åsa Bartonek 1, KristinaTedroff 1, Yvonne Haglund-Åkerlind 1, ChristinaOrefelt 1, Elena M. Gutierrez-Farewik 2

1 Karolinska Institutet, Department of Women’s andChildren’s Health, Stockholm, Sweden2 Royal Institute of Technology, KTH Mechanics,Stockholm, Sweden

Introduction: Many treatments have been suggested for idio-pathic toe-walking (ITW), such as casting, alone or in combinationwith botulinum toxin-A (BTX). Combined treatment with castingand BTX has become more common despite few studies of its effi-cacy and safety. It is also unknown whether treatment outcomediffers in children with ITW and co-existing neuropsychiatric prob-lems.

Our aims were to conduct a randomized controlled trial to testthe hypotheses that a combination of BTX and casting is more effec-tive than casting treatment alone in reducing toe-walking in 5–15year old children, and that overall treatment effect correlates toextent of co-existing neuropsychiatric problems.

Patients/materials and methods: All consecutively admittedITW patients to the pediatric orthopedics department between

ESMAC 2012 abstract / Gait & Posture 38 (2013) S1–S116 S3

November 2005 and April 2010 were considered for inclusion.Forty-seven children constituted the study population.

Children were randomized to either 4-week treatment withbelow knee circular casts either as the sole treatment or 1–2 weeksafter undergoing injections with 12 units/kg bodyweight BTX in thecalves.

Before treatment, and 3 and 12 months after cast removal, allchildren underwent 3-D gait analysis. Classification of ITW sever-ity based on the gait analysis was performed and parents wereasked to rate the time their child spent on toes during barefootwalking. Passive range of motion in hip, knee and ankle joints wasmeasured with a goniometer and ankle dorsiflexor strength wasmeasured with a hand-held dynamometer. Before treatment allchildren were evaluated with a screening questionnaire for neu-ropsychiatric problems.

Results: No significant differences were found in any outcomeparameter between the groups before treatment or at 3 or 12-month follow-ups. In both groups, several gait analysis parameters,passive range of motion and ankle dorsiflexor strength improvedsignificantly both after 3 and 12 months. Treatment outcome wasnot correlated to co-existing neuropsychiatric problems.

Discussion & conclusions: Adding BTX injections prior to cast-ing treatment for ITW does not improve the treatment outcome ofcast-only treatment.

http://dx.doi.org/10.1016/j.gaitpost.2013.07.017

O05

Outcome of 23 h bracing for tip-toe-walkingchildren with cerebral palsy

Andreas Kranzl 1, Robert Csepan 2, ChristianGrasl 3, Franz Grill 2

1 Orthopaedic Hospital Speising, Vienna, Laboratoryfor Gait and Movement Analysis, Vienna, Austria2 Orthopaedic Hospital Speising, Vienna, Departmentof Pediatric Orthopaedics, Vienna, Austria3 Fa. Pohlig/Tappe, Vienna, Austria

Introduction: One of the most common problems in patientswith cerebral palsy is the deterioration of the musculoskele-tal system, especially the legs and feet, manifested in tip toewalking. As conservative treatment there are orthopaedic shoes,splints, physiotherapy used and in more severe cases injectionsof Botulinum toxin in combination with serial casting to avoidoperation. Fulltime-bracing with orthopaedic devices is one option.Aim of the study was to prove the functional outcome orthopaedicdynamic orthotics.

Patients/materials and methods: A total of 10 children withCP, hemi- or diplegic, mean age 9.3 (±2.4) years were included.Exclusion criteria were fixed ankle contractures. All patients werefree ambulating, tip-toe-walking before the first examinationand treatment. GMFCS classification ranged from I to II. Patientswere adjusted with dynamic ankle foot orthosis including thering shaped foot support developed by Baise/Pohlig [1]. 3D-gait-analysis has been done to discriminate differences before treatmentand after 3 months. No orthosis was worn during the analy-sis. Kinematic and kinetic parameters were calculated, as well astime–distance-parameters. Normal distribution was assessed andpaired t-test (two-tailed) was used to determine statistical signifi-cance.

Results: No statistical differences were found for gait velocity,cadence. Walking speed tends to be reduced at the second gaitanalysis. Step length reduced significantly (p = 0.027). All patientschanged their initial contact from toe to heel. Ankle joint ROM

improved significantly (p = 0.001). Improvements in the knee-jointin sagittal plane like the reduction of hyperextension in midstance (p = 0.000), better max. knee flexion timing (p = 0.009) andincreased maximal knee-flexion in swing (p = 0.024). The maximumof ankle moment was increased (p = 0.003). Maximal ankle-powerincreased significantly (p = 0.001). Foot progression angle showeda tendency to normalize but not statistical difference.

Discussion & conclusions: This study shows the positive effectof bracing with night-and-day splints for 23 h. A long wearing timeof the splints, nearly 24 h per day for 3 months in combination withthe design of the orthosis are the key features. No deteriorationswere seen. The ankle joint pattern improves towards normal. Theslightly reduced walking speed, slightly increased ankle power atpush off and a better foot progression angle indicate a better func-tional outcome. The question is how long can this improvementbe maintained? Especially high standard deviation is present atpelvis rotation and foot progression angle. For further studies, thesample size should be increased. 23 h bracing with splints showedsignificant improvements concerning gait parameters and can berecommended as a treatment option.

Reference

[1] Baise, M. Behandlung des reversible dynamischen Spitzfußes mittels Unter-schenkelorthesen mit ringförmiger Fußfassung, Ergebnisse bei Kindern mitinfantiler. Zerebralparese. Med. Orth. Tech. 3.

http://dx.doi.org/10.1016/j.gaitpost.2013.07.018

O06

Do physical examination and CT-scan measuresof femoral neck anteversion and tibial torsionrelate to each other?

Morgan Sangeux, H. Kerr Graham

Royal Children’s Hospital, Hugh Williamson GaitAnalysis Laboratory, Melbourne, Australia

Introduction: Gait analysis is crucial in the functional assess-ment of gait impairments. It complements physical examination(PE) which looks at the impairments from an anatomical point ofview. The PE measures the joints’ range of movement, to estimatemuscle contracture or spasticity, and bony alignment to estimatetorsional deformities. The surgical decision for derotation of thefemur or the tibia requires two conditions to be fulfilled: an abnor-mal bony torsion and a functional impairment due to this torsion.However, since contradictory results have been reported about thevalidity of the PE estimate of the femoral neck anteversion (FNA)and the tibial torsion (TT), [1–3], surgical decision about derotationof the femur and/or tibia may require CT-scans. The purpose of thisstudy was to assess the agreement between the PE and CT-scanmeasures of FNA and TT.

Patients/materials and methods: A retrospective cohort ofpatients presenting abnormal PE estimates of their FNA wasextracted from our database. The selection criteria for the patientswere a maximum internal hip rotation greater than 65◦, a max-imum external hip rotation less than 35◦ and a trochantericprominence angle test (TPAT, [1]) greater than 25◦. The patientsshould have had a CT- scan measurement of the FNA and TT lessthan 6 months before or after the gait analysis.

Results: Results on 60 subjects for FNA and 43 for TT wereobtained (table below). The PE measures were significantly (*:˛ < 0.1) smaller than the CT-scan measures. Linear correlationsbetween PE and CT-scan measures were significant. Correlation forFNA was weak (R2 = 12%) but good (R2 = 61%) for TT. Although weak(R2 = 35%), the best PE measure to predict the CT-scan FNA was not