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Femoral anteversion in children with cerebral palsy is a leading cause of internal rotation gait amongst this important population. This comprehensive satellite symposium, held during the 35th European Paediatric Orthopaedic Society (EPOS) Congress in Rome, Italy, outlined not only the natural histories of femoral anteversion and other potential causes of internal rotation gait, but also the importance of careful and precise diagnosis when planning any intervention. Importantly, the logic and reasoning behind the choice of any particular intervention, be it a proximal, diapheseal or distal derotation osteotomy were carefully and thoroughly examined and discussed.
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EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
Friday, April 8, 201635th EPOS Congress, Waldorf Astoria, Rome, Italy
Torsional disorder of the femur in cerebral palsy patients
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
2
About the Satellite Symposium:Femoral anteversion in children with cerebral
palsy is a leading cause of internal rotation
gait amongst this important population. This
comprehensive satellite symposium, held during
the 35th European Paediatric Orthopaedic
Society (EPOS) Congress in Rome, Italy,
outlined not only the natural histories of femoral
anteversion and other potential causes of
internal rotation gait, but also the importance of
careful and precise diagnosis when planning any
intervention. Importantly, the logic and reasoning
behind the choice of any particular intervention,
be it a proximal, diapheseal or distal derotation
osteotomy were carefully and thoroughly
examined and discussed.
OrthoPediatrics, Leading Innovation in Pediatric Orthopedics
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
1
OPENING STATEMENTS 2Dr Peter F. Armstrong
CHAIRMAN’S WELCOME 3Prof. Pierre Lascombes
HIP INTERNAL ROTATION IN PATIENTS 4 WITH CEREBRAL PALSY Prof. Reinald Brunner
PROXIMAL OSTEOTOMY OF THE FEMUR AND 6 BLADE-PLATE FIXATION Prof. Guy Molenaers
DIAPHYSEAL FEMORAL DEROTATION OSTEOTOMY USING IM NAIL FIXATION 8Prof. Tim Theologis
DISTAL OSTEOTOMY OF THE FEMUR 10 AND IMLN FIXATION Prof. Franck Accadbled
BIOGRAPHIES 12
TABLE OF CONTENTS
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
2
Dr Peter Armstrong, the Chief Medical Officer
for OrthoPediatrics, welcomed all participants
and faculty to the OrthoPediatrics Satellite
Symposium at the 35th EPOS Annual Meeting in
Rome.
Dr Armstrong highlighted OrthoPediatrics
passion for helping children with orthopaedic
conditions through the provision of the
broadest spectrum of paediatric implants and
instruments: “In addition,OrthoPediatrics has a
very strong commitment, and we’re proud of that
commitment, to be supporters and providers of
excellent paediatric orthopaedic education”
The OrthoPediatrics satellite symposium is a
good example of that commitment. A panel of
world class key opinion leaders in management
of femoral anteversion were assembled to
freely share their experience and opinions with
the sizeable audience. Following this opening
statement, Dr Armstrong then introduced
the Chairman of the symposium, Prof. Pierre
Lascombes, and the expert faculty.
OPENING STATEMENTS
Dr Peter F. Armstrong Chief Medical Officer,
OrthoPediatrics
“OrthoPediatrics has a very strong commitment, and we’re
proud of that commitment, to be supporters and providers of
excellent paediatric orthopaedic education.”
Rome, Italy
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
3
Professor Pierre Lascombes welcomed attendees
to the 2016 OrthoPediatrics Satellite Symposium
on Femoral Derotation in Children with Cerebral
Palsy on Friday, April 8, at the 35th EPOS Annual
Conference, in Rome, Italy.
In his opening address, Prof. Lascombes
highlighted that there was a range of techniques
and opinions with respect to derotation
osteotomy: from the choice of device used in
effecting the surgery, such as nails, flexible
nails, plates and screws, to the position of the
osteotomy: proximal, middle or distal, and even
the absolute necessity to perform a derotation
osteotomy in some cases. Following his
introduction of the four experienced speakers,
Prof. Lascombes presented the assembled
attendees with two multiple choice questions, to
gauge the general temper of the audience with
respect to femoral derotation.
Posing the situation that, should one be
presented with a patient who unequivocally
displayed a large anteversion and internal
rotation gait, would one perform a proximal,
middle, or distal derotation osteotomy? An
overwhelming majority of the audience indicated
that a proximal osteotomy would be their
preference, with very few choosing distal, and no
one opting for the mid-diaphyseal solution.
Additionally, when asked their preference on
device style to perform a proximal osteotomy, a
large majority indicated a preference for plates
and screws compared with the few attendees
who would use an intramedullary nail - either
locking or flexible.
In rounding up his opening comments, Prof.
Lascombes highlighted the fact that before
beginning or planning any surgery, it is
crucially important to understand the causes
of any rotational deformity that exists. A full
understanding of the causes of any rotational
disorder and effective prediction of the effects
of any intervention are the cornerstone to
successful and long-lasting deformity correction.
With the scene set, Prof. Lascombes offered
up the lectern to Prof. Reinald Brunner from
Kinderspital Basel, Switzerland.
CHAIRMAN’S WELCOME
Prof. Pierre Lascombes Chef de Service, Orthopédie
Pédiatrique
Hôpitaux Universitaires de
Genève
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
4
Professor Reinald Brunner, a leading neuro-
orthopaedics consultant in the Orthopaedics
Department, Kinderspital Basel, Switzerland,
began the scientific satellite symposium.
As a world leading expert in paediatric
neuromuscular conditions, especially cerebral
palsy and gait correction, Prof. Brunner was
well positioned to give expert insight into not
only deformity correction in children, but also
into understanding the underlying causes of hip
internal rotation in children with cerebral palsy.
Prof. Brunner began by questioning
preconceptions and assumptions regarding hip
internal rotation and underlying anteversion as
the cause, and asked us to consider that there
maybe other causes, which are not accounted for
in a perhaps and often overly simplified view of
the problem - “Is the femoral anteversion really
the most important factor for internal rotation
during gait? Are there other factors which
produce hip internal rotation and anteversion,
and maybe there’s another cause?”
Noting that it was important to ask these
questions given that correction of anteversion
can be unreliable in correcting internal rotation
gait, and that it is known that femoral inversion
can recur if it is corrected too early in childhood.
Prof. Brunner illustrated his point with video of
a patient from the gait laboratory, who showed
relatively good gait correction post-intervention.
Pointing out that with anteversion there is
an offset of the normal range of hip motion
towards internal rotation but there was often
poor correlation between the position of the hip
during gait and angle of anteversion. Citing data
from his own studies1, Prof. Brunner illustrated
the good correlation of all clinical and radiological
assessments, but the still very poor correlation
to the internal rotation gait. Expanding the
discussion to consider other factors that may
cause internal rotation, he introduced the roles of
the capsule and ligaments.
“If the anterior capsule is short ... then you get
a similar shift of the range of motion towards
internal rotation without changing anteversion.”
Muscles that are active might also play a role in
the production of internal rotation, and although
there was the hypothesis that adductors and
hamstrings may be involved, this was proven
not to be so, but there is the possibility that
long muscles, e.g. long hip external rotators, are
involved. This phenomenon has not yet been
studied but again would shift the range of motion
toward hip internal rotation without changing
anteversion.
After covering a range of internal factors, which
may play a role, Prof. Brunner then highlighted
three important external factors which may
also play a role: Midfoot break, toe walking and
rocking on the rotated foot.
Illustrating midfoot break with a video and
animation, Prof. Brunner explained that if one
tests dorsiflexion in a foot that shows midfoot
HIP INTERNAL ROTATION IN PATIENTS WITH CEREBRAL PALSY
Prof. Reinald BrunnerConsultant of
Neuro-Orthopaedics
Kindersspital Basel,
Switzerland
“Is the femoral anteversion really the most important factor for internal rotation
during gait? Are there other factors which produce hip internal rotation and
anteversion, and maybe there’s another cause?”
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
5
break, the foot goes into external rotation with
the shank being stable. However, as a patient
walks the foot is stable to the floor, and cannot
rotate, so the motion in the mid and rear of the
foot is translated into an internal rotation of the
leg without altering anteversion. Furthermore,
gait analysis data shows that foot rotation
correlates well with hip internal rotation so the
foot goes out and the hip goes in at the same
moment in time.
The second external factor to consider is
toe walking. Prof. Brunner highlighted the
importance of this factor by showing again the
patient shown in his initial video and pointing
our that if one walks on their toes, they push
their foot down and the hip is being flexed,
adducted, and internally rotated because the
pelvis is pushed back. He continued by pointing
out that the internal rotation and gait correction
of the patient we see in the video was mostly
due to correction of equinus and limited bilateral
adductor and hamstring lengthening, and that
she received no femoral derotation.
Thirdly, if a patient with already severe internal
rotation rocks on their foot when walking, it
increases the range of motion towards internal
rotation and decreases the range of motion
towards external rotation. This point was
illustrated with a video showing a patient who
with every step increases the amount of internal
rotation.
Based on Wolff’s Law2, Prof. Brunner then
explained that we know that form follows
function and that the growth plate tried to
be perpendicular with the forces acting up in.
Further, a multi-element modelling study by
Shefelbine3 explored the effect of various forces
on a growth plate in the proximal femur in a
paediatric setting. Applying the forces derived
from gait analyses of cerebral palsy patients
to the model resulted in anteversion. These
factors, Prof. Brunner suggested, indicate that
anteversion is probably a secondary rather than
primary phenomenon causing internal rotation
gait.
Placing this in the context of paediatric
development, in a normal heel-toe gait in the first
half of stance phase we have the hip externally
rotated and flexed and the pelvis pushes from
the back side against the femoral head, which
causes the inverse force on the femur and then
the growth plate would rotate and derotate
which is the spontaneous derotation that we all
know. However, with toe walking, the hip remains
in inflexion, the pelvis now does not press from
the back side but rather from the front side
against the femoral head and femoral anteversion
increases.
In conclusion, there are several factors that
produce an internal rotation gait: Femoral
anteversion, ligaments and capsule, muscles – all
internal factors, and external factors acting on
the leg. If we undertake an intervention on only
one of this whole list of active factors, one should
not assume a good and lasting correction will
result.
All the factors that can cause anteversion and
internal rotation must be considered to have
a long lasting and good correction, regardless
of whether a femoral derotation is undertaken
proximally, diaphyseally or distally.
Ultimately, anteversion may not be the only
factor causing internal rotation gait, and
correcting anteversion in isolation may not be
sufficient.
1. Brunner et al., 2016, in
preparation.
2. Wolff, J. (1892) Das Gesetz
der Transformation der
Knochen. Hirschwald, Berlin
3. Shefelbine, S.J. and Carter,
D.R. Ann Biomed Eng. 2004
Feb;32(2):297-305.
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
6
Following Prof. Brunner’s introduction into
causes of internal hip rotation, Prof. Guy
Molenaers, the Medical Head of the Department
of Orthopaedic Surgery at University Hospital
Leuven, Belgium, took up the baton and explained
at a biomechanical level what happens when
one has a real femoral inversion, and how one
can best correct the imbalance of forces with a
proximal derotation osteotomy.
Explaining initially that the prerequisite for
improvement in femoral anteversion is hip
extension, regardless of the multiple internal
and external factors that caused the malrotation,
Prof. Molenaers highlighted that a high femoral
anteversion, results in a malrotated lever arm,
and out-of-plane moment (torque). Out of plane
moments lead to a functional weakening of
important muscles.
Referencing the work of Delp1, from the late
1990s, Prof. Molenaers explained that the
gluteus medius acts as a strong internal rotator
and flexor of the femur when the child walks with
excessive hip flexion. Furthermore, he called
for surgeons not to lengthen hamstrings again
calling on the work of Delp et al. to illustrate this
point that if one has all medial hamstrings and the
adductors included the moment arm is not even
half of the moment arm created by the flexed hip
and activity of the gluteus medius.
The ultimate goal of the intervention should be to
improve the moment arm of the gluteus medius
and maximus thereby creating greater pelvic
stability and helping to prevent recurrence.
Prof. Molenaers then showed how one can
examine the effect of a proximal derotation
osteotomy on a patient’s moment generating
capacity, using the work of Arnold and Skodel,
and Prof. Molenaers, own research group to
illustrate. A patient was evaluated in the clinic
and a 3D MRI scan of the whole lower body
was made so that not only the skeleton - clearly
showing the anteversion and the combined
valgus of the neck shaft angle, but also the origin,
the insertion, the size and volume of all the
muscles were documented. In this way the real
strengths, forces, and moments acting at any time
could be calculated.
This patient specific modelling allows potential
interventions to be evaluated. In his example,
Prof. Molenaers showed that a proximal
intertrochanteric derotation osteotomy would
increase the extension moment of the gluteus
maximus, and that if the osteotomy were to
be performed lower than the insertion of the
gluteus maximus then there would be very little
improvement. (Figure 1)
Furthermore, when modelling the effect of
the hamstrings and psoas major on extension
moment generation, it could be seen that in this
case, there was no difference in effect between
a proximal or diaphyseal derotation. Increase in
extension moment due to the hamstrings was
the same for proximal or diaphyseal derotation,
and importantly neither intervention would
PROXIMAL OSTEOTOMY OF THE FEMUR AND BLADE-PLATE FIXATION
Prof. Guy MolenaersMedical Head of the Department
of Orthopaedic Surgery,
University Hospital Leuven,
Belgium
Figure 1. Patient specific modelling evaluation showing hypothetical effects of distal (green) or
proximal (red) derotation osteotomy compared with the original deformity (blue) on moment
generating capacity of the gluteus maximus relative to hip flexion angle. The modelled curve for
the original deformity sits perfectly underneath the curve for the distal osteotomy.
Gluteus MAX
9 29 49 69 89-11
0
2
8
10
12
Hip flexion angle (°)
proxDVO
distDVO
FemDef
Mo
men
t ge
ner
atin
g ca
pac
ity
(Nm
)
6
4
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
7
have a marked effect on effect on the hip flexion
moment generation of the psoas major.
Finally, potential improvements in pelvic stability
were modelled in the context of abduction
moment. In the example situation the moment arm
of the gluteus medius could be seen not to improve
with only a proximal osteotomy. However, addition
of a varus osteotomy – ultimately resulting in a 45°
proximal derotation and a neck shaft angle of 130°
was noted to improve the moment generating
capacity of the gluteus medius in hip abduction.
After his elegant explanation of the biomechanics
of proximal derotation osteotomy and the value
of careful and thorough patient specific modelling,
Prof. Molenaers then described his preferred
techniques for performing the osteotomy.
After careful calculation of the varus angle, a pin
is inserted, and the value of newer devices comes
to the fore as the chisel can be easily slid over the
pin, simplifying even osteomotic work. A cut is
made proximally then, perpendicular to the shaft,
[1] Delp, J Biomech. 1999
May;32(5):493-501.
[2] Ruwe PA, J Bone Joint Surg
Am. 1992 Jul;74(6):820-30.
Figure 2. X-ray of completed proximal derotation osteotomy
showing good alignment and combination of compression
principles with locked screws.
“The advantages of
newer devices such as the
OrthoPediatrics plates are
evident here because they afford
a good grip on the plate thereby
allowing the extension of the
hip that is essential to improve
the moment arm of the gluteus
maximus, which is the goal.”
a second cut allows the possibility to derotate
and achieve a good fit. (see picture sequence 1).
The advantages of newer devices, such as the
OrthoPediatrics plates, are evident here because
they afford a good grip on the plate thereby
allowing the extension of the hip that is essential
to improve the moment arm of the gluteus
maximus, which is the goal.
With the patient draped in the prone position,
one can perform a Ruwe test2 intra-operatively
for optimal derotation.
Prof. Molenaers illustrated his description with
some intra-operative photographs. These also
showed the use of a lift under the knee to put
the femur in extension to ensure that not only
the varus and derotation are achieved but also
extension of the proximal femor. Finally, Prof.
Molenaers showed X-ray images (Figure 2) of the
procedure in both planes to ensure correct
alignment and again highlighted the benefits
of the newer plates as one can combine
compression principles with locked screws and
get a very solid outcome.
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
8
Professor Tim Theologis, Consultant
Orthopaedic Surgeon at Oxford University
Hospitals in the United Kingdom, took the lectern
and prefaced his presentation by announcing
that although he would speak primarily about
diaphyseal derotation osteotomy, it is imperative
to remain flexible as a surgeon and that deformity
corrections should be undertaken only after
considering all factors. A major consideration
in practice with children with cerebral palsy is
that such deformity correction is always part of
multilevel surgery, and as such are associated
with the negative impacts that long procedures,
high blood loss, and large dissections have on
children and the necessarily long rehabilitations
afterwards. In particular, any of the femoral
osteotomies that require extensive muscle
dissection and periosteal stripping carry
heightened risks.
An additional and major impact of extensive
multilevel surgery is the loss of muscle strength.
It has been demonstrated in previous studies that
even a year after multilevel surgery a majority
of children have not regained their preoperative
muscle strength.
For these reasons, Oxford surgeons have
developed a minimally invasive, strength
preserving, programme of surgery that includes
doing some of the soft tissue procedures using
less invasive techniques, including some of the
hamstring lengthening. Prof. Theologis illustrated
this point with photographs of the patient’s leg
being held in the popliteal angle measurement
position with multiple small incisions being made
in the muscular tendonous junction for the
medial hamstrings and gradually correcting the
popliteal angle. This results in minimal scarring
and minimal postoperative pain.
A similarly less-invasive technique has been
developed for derotational osteotomy of the
femur and the tibia, however, Prof. Theologis was
careful to point out that if there is a need for a
sagittal or coronal plane deformity correction
at the same time one should not be doing the
rotational correction on the diaphysis. So if one
needs to varise the femur because the femoral
head is uncovered, or if there is a need to do
an extension supracondylar osteotomy at the
knee due to severe flexion contraction, then the
minimally invasive technique does not apply.
The minimally invasive technique, is usually only
used in younger children who simply require
derotation and no sagittal or coronal plane form
correction.
Prof. Theologis explained that in their minimally
invasive technique the flexible nails are inserted
distally to proximally. The osteotomy is effected
and a closed corticotomy at the isthmus is made.
The insertion is done distally because that’s
where the flexible nails would sit and provide
the major stability (Figure 3). The osteotomy
is completed and the nails advanced and fixed
proximally. Additionally, an anteversion wire is
inserted into the femoral neck to control rotation
during the process by measuring its angle to the
transcondylar axis at the knee with a goniometer.
DIAPHYSEAL FEMORAL DEROTATION OSTEOTOMY USING IM NAIL FIXATION
Prof. Tim TheologisConsultant Orthopaedic Surgeon
Oxford University Hospitals,
Oxford, UK
“A major consideration in practice with children with cerebral palsy is that
such deformity correction is always part of multilevel surgery, and as such are
associated with the negative impacts that long procedures.”
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
9
The flexible intramedullary nails have proven
to be surprisingly stable, perhaps because of
the corticotomy. They interdigitate when the
patient stands and walks a little. Also, they heal
very quickly - usually within the first four weeks.
It is recommend to remove the nails for the
same reasons they are removed when used for
fractures. Furthermore, for children who are
above 40 kg, locking nails are recommended.
In terms of rehabilitation, the children go through
a very rigorous programme focussing on post-
operative muscle strengthening. Prof. Theologis
showed some preliminary results of a 2-year
follow-up study and indicated that a 5-year
follow-up study is currently being undertaken.
A cohort of 18 children were compared to a
matched cohort of 20 children undergoing
conventional multilevel surgery. The types of
surgery were similar in the two groups – both
groups were undergoing multiple procedures
– with an average of six per leg. Clinical
measurements were made including X-ray, gait
analysis (Vicon MX40), Isometric Dynamometry
(MIE Medical Research Ltd.), and multifunctional
measurements (GMFM 88).
In terms of correction of gait index as measured
by gait analysis, the amount of correction
achieved post operatively, and foot progression
angle at 24 months, the cohorts were relatively
similar. However, when comparing operative
time, blood loss, and time to mobilise then
the minimally invasive approach was better.
Additionally, significant achievements in strength
preservation, particularly, in the knee and hip
extensors and in the hamstrings have been
demonstrated in the minimally invasive group.
Overall, the take home message from Prof.
Theologis was that his team achieved the same
result by doing less surgery - an achievement
with clear benefits for appropriate patients.
Figure 3. X-ray images showing
the advancement of the flexible
nails, first one and then the other,
across the femoral osteotomy.
An X-ray image of the completed
intervention shows where the
nails are fixed proximally.
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
10
Following Prof. Theologis, Franck Accadbled gave
the final scientific presentation on the benefits
of distal derotation osteotomy. Prof. Franck
Accadbled is an orthopaedic surgeon at Hôpital
des Enfants, Toulouse University Hospital,
France.
He began his presentation by citing a recently
published paper from the Journal of Pediatric
Orthopedics1 wherein the results of a preliminary
study and the technique of using a locking nail
in adolescent femoral antetorsion have been
published.
The rationale for the distal osteotomy, explained
Dr Accadbled, is to do with biomechanics.
The maximum varus forces are located in the
proximal third of the femur, as evidenced by a
number of examples of implant failure in this
region. Additionally, deformity correction in the
horizontal plane, such as derotation, may result
in induced deformities in the coronal and sagittal
planes because of the curve of the femur, and the
narrowness of the shaft, as depicted in Paley’s
book “Principles of deformity correction”2, and
demonstrated mathematically by Pailhé et al.3
Finally, bone healing is best at the distal
metaphysis of the femur, as demonstrated in leg
lengthening by Fischgrund et al.,4 and Aaronson
and Shen,5 and there is a strong correlation
between derotation osteotomy of over 30° and
poor post-operative consolidation.6
Prof. Accadbled pointed out that technique
planning is very important before commencing
any deformity correction, it is critical to
undertake gait analysis, and identify exactly
the indication for any particular procedure. “In
our experience, bone torsion is best evaluated
with EOS system,” and our radiologist has
validated this method over the gold standard CT
scan. However, the use of CT scans is still very
important for those patients who are unable to
stand still in the EOS machine.
Not dwelling longer on the theoretical details of
procedure choice, Prof. Accadbled moved quickly
into a detailed practical explanation illustrated
with numerous intraoperative photographs and
images.
He explained that he prefers to drape the patient
in a supine manner so the whole limb is accessible
to allow for concomitant associated procedures
such as tendon transfer or lengthening, or other
surgery. Additionally, a bag around the other
limb is beneficial as it allows free passage for the
imaging arm.
To ensure accurate rotational correction Prof.
Accadbled uses 2 rotation landmarks consisting
of 4mm Steinmann pins, one positionned rather
posterior at the level of the lesser trochanter,
the other at the posterior aspect of the distal
metaphysis. Pin position should be posterior
enough to avoid interference with the nail and
leave the approach clear for reaming and nail
positioning.
DISTAL OSTEOTOMY OF THE FEMUR AND IMLN FIXATION
Prof. Franck AccadbledOrthopaedic surgeon
Hôpital des Enfants, Toulouse
University Hospital,
France
“It is a percutaneous surgery, which provides an accurate correction, and stable
fixation using a locked nail - we don’t have an immobilization and we get early
weight bearing as well.”
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
11
The two pins are very useful to assess the angle
between the two segments, both before the
osteotomy, and again during to check that the
planned degree of correction is achieved. To help
in assessing this, Prof. Accadbled’s team have
developed a special goniometer that is fitted
sequentially on the proximal pin and then the
distal pin, thereby allowing the angular difference
between the pins to be determined.
Prof Accadbled begins by performing a
percutaneous post stamp osteotomy, with just
the holes to start with acting as venting holes
to reduce the risk of fatty embolism. Moving to
the entry point, which is lateral regardless of the
implant and brand that is used.
Prof. Accadbled stressed the importance of
using narrow shaft deep fluted reamers, as
these next-generation reamers are very sharp.
Reaming is conducted in 0.5 mm increments and
should be carried out until 1.5 mm overeaming is
achieved. The guidewire is then pulled back and
the osteotomy is completed using an osteotome,
and the nail is inserted with gentle taps - sledging
should be strictly avoided. Additionally, it is
important to check the progression of the nail
using the image intensifier until the narrowest
(diaphyseal) part of the femur has been passed.
To fix the nail in position, two locking screws
should be used proximally and two screws distally
(Figure 4). This provides greater stability, and
gives a lower chance of error should a screw
be out of the nail simply by giving the surgeon
two chances rather than just one. Additionally,
blocking screws can prove to be very useful in
providing more stability or to perform further
deformity correction. Prof. Accadbled prefers to
bone graft percutaneously, using the products of
reaming in a tube.
[1] Pailhé R., J Pediatr Orthop B.
2014 Nov;23(6):523-8.
[2] Paley, D. Principles of
deformity correction, 200
Springer-Verlag, Berlin.
[3] Pailhé R., J Pediatr Orthop B.
2015 Mar;24(2):171.
[4] Fischgrund J, Paley D, Suter
C.. Clin Orthop Relat Res.
1994;301:31–37.
[5] Aronson, J. and Shen, X.,
Clin Orthop Relat Res. 1994
Apr;(301):25-30.
[6] Donnan LT, Saleh M, Rigby
AS. J Bone Joint Surg Br.
2003;85:254–260
In the case that Prof. Accadbled showed, which
was a bilateral procedure, he used a staged
procedure with at least 2 days between separate
interventions, again to reduce the risk of fat
embolization. Ultimately, no post-operative
immobilisation is required and weight bearing is
encouraged after the third week.
In conclusion Prof. Accadbled emphasised the
importance of preoperative planning and nail
diameter selection, finishing by stating “It is
a percutaneous surgery, which provides an
accurate correction, and stable fixation using a
locked nail - we don’t have an immobilization and
we get early weight bearing as well.”
Figure 4. X-ray image showing the
positioning of the intramedulary
nail (left) and distal and proximal
fixation each with two screws
(right)
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
12
Following the faculty presentations, Prof.
Lascombes invited questions from the audience.
Dr Paulo Selber, consultant orthopedic surgeon
at the Royal Children’s Hospital, Victoria,
Australia, commented on the range of techniques
to achieve a femoral derotation osteotomy and
the contrasting levels of invasiveness shown,
from minimally invasive to reaming out the entire
femur. More importantly, Dr Selber enquired as
to the experts’ opinions on the importance of the
level at which the osteotomy is done, if above or
below the lesser trochanter.
However, Prof. Brunner considered the insertion
of the gluteus maximus, not the lesser trochanter,
to be the relevant point in the position of the
osteotomy. Dr Selber enquired if the were aware
of what he calls “the fate of the hamstrings and
the Achilles tendons”, which, he pointed out,
are are known to be very superficial hence the
most frequently operated muscles in cerebral
palsy. Prof. Molenaers agreed that this was an
important consideration stating, “If you have
knee flexion pressure, then of course you change
the moment arm of the hamstrings too, and that
if you want to get to the real problem you have to
address it proximally.”
Dr Selber suggested that the fate of the
hamstrings and the Achillies could be that they
are too superficial, and the fate of the psoas is
that it is too deep and hence very rarely treated.
He further suggested that, “We derotate in the
inter trochanteric region, not only to improve the
abductor moment through gluteus medius, but
also to relax the iliopsoas.”
A further question was raised regarding a video
of Prof. Brunner’s patient, shown during the
presentations, and that the patient appeared
to walk with excessive anterior pelvic tilt. Prof.
Brunner responded that the patient’s anterior
pelvic tilt was due to long hamstrings and
because she was walking in equinus. If you walk
on your toes you get more hip flexion so you have
a tendency to lean forward and this is not due to
psoas activity in my opinion but rather related to
less activity of the hip extensors.
Prof. Brunner further explained that if the psoas
were to contract during stance one would bend
forward and fall. However, the iliopsoas is needed
as an accelerator for swing, so after stance
phase we need swing phase. The psoas is needed
because in most CP patients the plantar flexors
are weak or kept in ankle foot orthoses, so their
effect is known considering acceleration, and so
the only muscle remaining to get that forward in-
swing is the iliopsoas muscle, therefore it may be
lengthened slightly but should not be released.
Back to stance phase and it is a different
situation because it is necessary to preserve
hamstring strength, because they are active as
hip extensors, and they help to extend the hip. At
this point in time that has nothing to do with the
iliopsoas.
This explanation was not universally accepted
and a counter explanation for the patient case
seen in Prof. Brunner’s video was put forward.
Dr Selber considered that the patient was most
likely a GFMCS 2 patient and would then have
much better selective motor control than a
GFMCS 3 patient. So, when they have a lot of
femoral torsion, because they have very good
selective motor control, they can adopt one of
two patterns of strategies; one, they go into
equinus if they have a little bit of spasticity down
there, or two, they tilt their pelvis forward to
improve the lever arm. Dr Selber considered that
for the patient shown, the second situation was
likely - that the patient still had femoral torsion
- and that patient was just adopting a different
pattern, to cover for and to produce a better
fulcrum, in the hip.
Prof. Brunner pointed out that he had shown the
patient only to illustrate that deformity and gait
OPEN DISCUSSION
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
13
may be considerably modified by interventions
other than a derotation osteotomy. In this case
just correcting the toe walking may have an
influence on the rotational position of the leg
during gait, the patient does not otherwise
change muscle activity, and does not develop an
obligate pattern but does, however, adjust and
has the same gait as before if one were to view
the whole gait cycle.
Nowadays [video is 25y old] the patient would
also undergo femoral derotation because one
believes that this is a need. However, in modelling
studies you see that the typical gait approach
that the patient shows may derive only from toe
walking, and one needs no further muscle activity
in the leg.
Prof. Theologis added that the opposite can also
be true, “because there are children who walk on
their toes because they have a quite excessive
internal rotation of the hip. When you try and
walk with your hips fully internally rotated you
will be on your toes to achieve that, but arguably
sometimes the assessment of which comes first is
a challenge.”
Prof. Molenaers felt it should encourage people
and it is a clear indication to do what he does
- dynamic muscle length assessment, as that
reveals a lot of problems that can then be avoided
e.g. over lengthening the modular hamstrings,
because of the importance of the hamstrings
and most of the paediatric CP patients don’t
have enough motor control to control the
muscles. On the other hand, often we do have to
lengthen and and with full imaging assessment
this can be determined, e.g. the psoas muscle
intramuscularly, because everything has to do
with the balance across the joints as too much
inflexion is not good but we need enough.
A question directed towards Prof. Brunner
regarding what to do at the leg below the knee,
if faced with external rotation of the femur in
crouch patients. Prof. Brunner clarified that
if one operates on a patient with a multi level
problem he would first make a list of all the
deformities present and then would decide
whether correcting each one is of importance or
not. Following this prioritization, he would then
correct everything at once. “So if I have a foot
which is unstable or a tibia which is externally
or internally rotated, I would correct these
deformities at the same time [as a derotation].”
Professor Theologis was then asked about
how he could be sure of the accuracy of the
surgery when performing the percutaneous
lengthening of the hamstrings. He responded
that in the context of accurately cutting only
the hamstring and nothing else, or only the
fascia etc., the location of the surgery at the
margin of lower and middle thirds of the thigh
is important. In this area there should be
muscle overlapping the fascia, therefore this
is an intramuscular lengthening. In the context
of cutting the hamstrings and nothing else,
Prof. Theologis professed to not having had
any complications. Finally, in the context of the
“If you walk on your toes
you get more hip flexion
so you have a tendency to
lean forward and this is not
due to psoas activity in my
opinion but rather related
to less activity of the hip
extensors.”
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
14
accuracy of correction, the aim is to correct a
mild contracture, which he would do gradually,
until sufficient correction is achieved.
When asked if there was a risk of muscle injury,
Prof. Theologis continued that they have done
ultra sound checks of the hamstrings in a
subgroup of children in order to see exactly what
is cut, and that they hadn’t found any significant
muscle injury in this group.
A question was raised as to how one avoids
coronal knee malalignment at the distal
osteotomy because the distal part of the canal is
very large and when the distal part of the femur
is derotated and because the nail is very thin,
about 7-9 mm, one can induce varus or valgus
deformity.
Prof. Accadbled responded that he likes to do
the distal reaming first then the derotation over
the guide wire which maintains the general
alignment, and if he is not satisfied once the
nail is in, he checks the mechanical axis with
a radiolucent plate including a metal grid. If
unsatisfactory, Prof. Accadbled uses blocking
(Poller) screws to reroute the nail and thus
correct the alignment. The use of blocking screws
is a fast technique for intramedulary nail use and
is good for deformity correction or trauma.
Prof. Lascombes asked the panel to comment on
the role of the adductor muscles. Prof. Molenaers
highlighted the ongoing problem of severe
adductor involvement. However, by using the
evaluation tools, the clinical evaluation, and the
data from the gait lab, one can determine, in
much the same way as for the hamstrings, that
for example, in a diplegic child there is often over
lengthening from the adductors. Another thing is
the pelvic stability because pelvic stability is the
key to a good result in cerebral palsy patients.
So it is something one should be careful not to
destroy, and that if you have 15° of abduction in
the flexed knee stay away from the adductors.
Prof. Brunner added that in the case of a
complex problem, like in CP, then he likes to play
with “toys” – “toys” being modelling. Through
modelling, one can change the situation slightly
and see what happens. Prof. Brunner’s team
have done this and modelled the outcome if
one were to take away hip extensors. The result
is that that the hip adductors became more
active, especially the adductor minimus. This
means that if the hip extensors get weak, as a
compensatory mechanism, the hip adductors
become more active – that is to increase hip
stability. This in turn means, but not necessarily,
they produce internal rotation and Skodol has
shown that the hip adductors are not powerful
hip internal rotators. Prof. Brunner added that
in his experience at least, he gets good results
and increased hip abduction if he does adductor
lengthenings, but hardly ever gets a major
influence on hip internal rotation. Therefore,
he doesn’t think the focus should be on the hip
adductors, nor even on the hamstrings, as he
feels they influence rotation only to a minor
degree. The rotation derives from the psoas and
anatomy, you have origin and insertion and if that
has a little twist you get rotation – “I think that
this simple principle of deriving muscle activity
from this anatomical structures and position
“So if I have a foot which is unstable or a tibia which is externally or internally rotated, I would correct these deformities at the same time [as a derotation].”
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
15
that we have on a dead body, does not mean
that these muscles really work that way during
function and gait.”
When one does gait analysis to understand what
happens when we export these gait data to more
complex models then we see that Skodol is right,
we don’t see a major influence of rotation from
the adductors.
A final question was raised wherein the
panel were asked to address the leg extensor
mechanism and power. When discussing tiptoe
gait, it is necessary to see whether it’s a true
equinus or masked one from the knee.
Discussion about the hip and the importance
of the hip extensor should also address the
importance of the knee extensor mechanism,
especially as lengthening the so called strong
hamstrings can result in weak extensor and weak
hamstrings and there is risk that the gait could be
ruined.
Prof. Molenaers commented that one at balance
across joints, and that we should all remember
that there is no “strong” in CP because they
are all weak – all muscles are weak. Too much
spasticity doesn’t mean that the muscles are
too strong, because if you look at the muscle
structure they are all weak. Ultimately, we have
to work strength in those patients rather than
weakening muscles even more. Prof. Molenaers’
sentiments were echoed by Prof. Brunner who
indicated that it is a complex problem, and
for that reason he aimed to show during his
presentation that we should not focus on just
one part, the femur, because you have to have
a summary of all possible structures in the leg
which may produce part of or the complete
internal rotation that we see during gait.
The second thing is that we usually consider only
the effects of the muscles being active in our
joints. However, this is not true, because on earth
we have gravity. If we talk about muscle balance
this is actually an erroneous concept because
we do not only have muscles acting on the joints,
there are external forces like gravity and inertia,
which all together have another influence.
The term “balance of forces” is a far more
comprehensive and therefore correct expression.
Having balance between all forces, internal and
external, acting on the joint. The problem is we
have only little idea which external forces are
contributing, and that’s why we concentrate on
the muscles.
“This simple principle of deriving muscle activity from the anatomical structures
and position on a cadaver, does not really reflect how muscles work during
function and gait.”
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
16
(French Society of Paediatric Orthopaedics)
including the redaction of medical books: Imaging
of the hip in children (1985), Benign bone tumors
(1996), Fractures in children (2005), Long bone
deformities and their correction (2009).
He contributed to the development of the
instrumentation and implants “Legacy®”
(Medtronic Spine) for the surgical treatment of
scoliosis, and implants and instruments for “T2
Kids®” as flexible intramedullary nails.
He is currently Past President of The European
Pediatric Orthopedic Society (EPOS), as well
as The French Paediatric Orthopedic Society
(SOFOP).
In January of 2013, Dr Armstrong joined
OrthoPediatrics as the first, full-time Chief
Medical Officer of the company.
Prof. Pierre Lascombes Chef de Service, Orthopédie Pédiatrique,
Hôpitaux Universitaires de Genève, Switzerland
Professor Pierre Lascombes is a paediatric
orthopaedic surgeon and Chairman of the
Division of Paediatric Orthopaedic Surgery
and Professor of Orthopaedics in Geneva,
Switzerland. Prior to this appointment, he
was Head of the Department of Paediatric
Orthopaedics and Professor of Anatomy at the
University of Nancy, France.
Professor Lascombes has a vast experience
in scoliosis in children and adolescents, bone
deformity correction and limb lengthening,
as well as neuromuscular orthopaedics. He
has published more than 130 peer reviewed
papers and book chapters, and extensively on
traumatology in children. He has organized
several educational courses with the SOFOP
Dr Peter F. Armstrong Chief Medical Officer
OrthoPediatrics
Dr Armstrong received his medical degree from
the University of Western Ontario, Canada in
1972. His orthopaedic residency was undertaken
at the University of Toronto followed by a
paediatric orthopaedic fellowship with Toronto’s
Hospital for Sick Children.
Subsequently, he became chief of staff of Shriners
Hospitals for Children, Intermountain (Salt Lake
City, USA). In 2000, he was selected as Chief
Medical Officer of the 22 Shriners Hospitals and
moved to the Headquarters in Tampa.
BIOGRAPHIES
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
17
and spine deformities. His research interests are
focused on spine biomechanics.
He is currently the treasurer and president of
the scientific committee of SOFOP, the French
Paediatric Orthopaedics Association.
Disclosures: Consultant, OrthoPediatrics
Prof. Dr. med. Reinald Brunner, FRCS Consultant of Neuro-Orthopaedics
Kindersspital Basel, Switzerland
Professor Reinald Brunner is Professor of
Orthopaedics and a Consultant of Neuro-
Orthopaedics at the Orthopaedic Department,
Children’s University Hospital Basel, Switzerland.
He joined the department in 1987 and has been
its leader/director since 1992.
Prof. Brunner has had a longstanding clinical
and research interest in the biomechanics of
gait. His findings have led to the development of
biomechanically-oriented treatment approaches
that focus on the efficient correction of functional
deformities of the musculoskeletal system.
His special fields of interest also include
orthopaedics of neuromuscular diseases, gait
disturbances, hip joint problems and conservative
paediatric orthopaedics. Prof. Brunner is the
chairman of the Swiss Society for Prosthetics
and Orthotics (APO), and he also headed the
European Society for Movement Analysis in
Adults and Children (ESMAC) between 2001 and
2005.
Prof. Brunner has been a honorary member of
the Royal College of Surgeons of Edinburgh since
2013.
Prof. Franck Accadbled Orthopaedic surgeon
Hôpital des Enfants, Toulouse University
Hospital, France
Professor Accadbled qualified from Toulouse
School of Medicine in France, before completing
a clinical fellowship in paediatric orthopaedic
trauma at the Women’s and Children’s Hospital in
Adelaide, Australia.
His clinical interests are in paediatric
orthopaedics and trauma - especially of the lower
limb, sports injuries, limb lengthening and growth,
TORSIONAL DISORDER OF THE FEMUR IN CEREBRAL PALSY PATIENTS
18
Prof. Guy MolenaersMedical Head of the Department of Orthopaedic
Surgery,
University Hospital Leuven, Belgium
Guy Molenaers is graduated as medical doctor
in 1982 and as an orthopaedic surgeon in 1988
at the Catholic University of Leuven, Belgium.
After his fellowship in paediatric orthopaedics,
he joined the medical staff of the Orthopaedic
Department of the University Hospitals Leuven
in 1989. He became the medical director of the
Clinical Motion Analysis Laboratory in Pellenberg
in 1996. From 2004 to 2014, he was head of the
CP Reference Centre. In 2014, he was elected
as chairman of the Department of Orthopaedic
Surgery at the University Hospitals Leuven.
In 2003, he received his PhD in Paediatric
Orthopaedics and in 2004, he was appointed as
an associate professor at the Faculty of Medicine,
Department of Orthopaedics and the Faculty of
Kinesiology and Rehabilitation Sciences at the
Tim Theologis, MSc, PhD, FRCSConsultant Orthopaedic Surgeon
Oxford University Hospitals, Oxford, UK
Tim Theologis studied medicine in Athens,
Greece, and completed his surgical and
orthopaedic training in Oxford, UK. He
completed a paediatric orthopaedic fellowship at
the Hospital for Sick Children in Toronto, Canada.
In 1996 he was appointed at the Nuffield
Orthopaedic Centre in Oxford, as a Consultant
Orthopaedic Surgeon with special interest in
children and neuromuscular disorders.
He is a Senior Clinical Lecturer at Oxford
University and a Research Professor at Oxford
Brookes University.
He has a strong clinical and research link
with the Oxford Gait Laboratory. He looks
after children with orthopaedic conditions,
primarily developmental dysplasia of the
hip and musculoskeletal tumours, as well as
neuromuscular disorders, including cerebral
palsy.
He was Editor in Chief for Gait and Posture from
2005 to 2015, and has been a board member of
the British Society for Children’s Orthopaedic
Surgery since 2009 and is now President-elect.
He has been a member of EPOS since 2001.
Catholic University of Leuven.
His main research interests include
neuropediatrics with focus on optimizing
treatment based on 3D movement analysis,
objective spasticity assessment, dynamic
muscle lengths and simulation techniques
(musculoskeletal models) with the ultimate goal
to improve quality of life in children with neuro-
orthopaedic problems.
He is a member and contributes to EPOS,
ESMAC, AACPDM, EMCPDM and an honorary
member of the ‘Gesellschaft für Neuropädiatrie’.
Besides reviewing for several journals, he
functions as editorial board member of the
Journal of Children’s Orthopaedics and Gait and
Posture.
EPOS INDUSTRIAL SATELLITE SYMPOSIUM PROCEEDINGS
19
NOTES/DISCUSSION
ColophonThis meeting report was written by
Medicalwriters.com LLC and commissioned by
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based on presentations given during the EPOS
luncheon satellite symposium in Rome, Italy, on
April 8, 2016.
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© OrthoPediatrics Corp. 2016
NoteThis document is intended exclusively for experts in
the field, i.e. physicians and surgeons in particular,
and is expressly not for laypersons.
The information on the procedures contained in
this document is of a general nature and does not
represent medical advice or recommendations. This
information does not constitute any diagnostic or
therapeutic statement with regard to any individual
medical case. Individual examination and advising
of the respective patient are absolutely necessary
and are not replaced by this document in whole or in
part.
This document was commissioned by
OrthoPediatrics. The contents of this document
are based upon presentations given during the
EPOS Industrial Satellite Symposium hosted by
OrthoPediatrics, in Rome, Italy, April 8, 2016. The
statements presented within this document are
the opinions of the presenters and may or may not
represent the opinions of OrthoPediatrics.
The information contained in this document was
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OrthoPediatrics employees to the best of their
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the accuracy and ease of understanding of the
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Creating QualityEnsuring Accuracy
Infusing KnowledgeInstilling Confidence
ACL Reconstruction SystemTreats the full spectrum of developing patients and utilizes ShieldLoc™ and ArmorLink™ technologies
RESPONSE™ Spine SystemFeatures Jiminy rod reducers for
versatile rod reduction and one of the lowest profile pedicle screws on
the market
PediFrag™ System 2.7/3.5 PediPlates®
®
Leading Innovation in Pediatric OrthopedicsTreatment Options for Trauma, Limb Deformity, Spine & Sports Medicine
Instructions For Use (IFU), cleaning instructions, and surgical techniques may be obtained by calling OrthoPediatrics®
Customer Service at 574-268-6379. Read and understand indications, warnings, and adverse effects explained in IFU’s prior to use.
OrthoPediatrics, Children Are Not Just Small Adults, ArmorLink, PediFlex, PediFrag, PediLoc, PediNail, PediPlates, PLEO, Response, Scwire, ShieldLoc, and
the OP and Pedi logos are trademarks of OrthoPediatrics Corp.
All-in-one fragment set, built with the entire operating staff in mind, that provides innovative instruments to facilitate all procedures
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Tibia & PediFlex
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