Pelvic Retraction Research Articles

The Variable Influence of Orthotic Management on Hip and Pelvic Rotation in Children with Unilateral Neurogenic Equinus Deformity.

Equinus deformity with or without concomitant drop foot is a common finding in children with unilateral spastic cerebral palsy and spastic hemiplegia of other causes. Hypothetically, these deformities may lead to pelvic retraction and hip internal rotation during gait. Orthoses are used to reduce pes equinus during gait and to restore hindfoot first contact. We aimed to investigate whether the use of orthotic equinus correction reduces rotational hip and pelvic asymmetries. In a retrospective study, 34 children with unilateral spastic cerebral palsy or spastic hemiplegia of other causes underwent standardized instrumented 3D gait analysis with and without orthotic equinus management. We analyzed the differences in the torsional profile during barefoot walking and while wearing orthoses, as well as investigated the influence of ankle dorsiflexion and femoral anteversion on pelvic and hip kinematics and hip kinetics. Wearing orthoses corrected pes equinus and pelvic internal rotation at the end of the stance phase and in the swing phase compared to barefoot walking. Hip rotation and the rotational moment did not significantly change with orthoses. Orthotic management or femoral anteversion did not correlate to pelvic and hip asymmetry. The findings indicate that the correction of the equinus by using orthoses had a variable effect on the asymmetry of the hip and pelvis and internal rotation; both appear to have a multifactorial cause that is not primarily driven by the equinus component.

Transversal Malalignment and Proximal Involvement Play a Relevant Role in Unilateral Cerebral Palsy Regardless the Subtype.

Classification of gait disorders in cerebral palsy (CP) remains challenging. The Winters, Gage, and Hicks (WGH) is a commonly used classification system for unilateral CP regarding the gait patterns (lower limb kinematics) solely in the sagittal plane. Due to the high number of unclassified patients, this classification system might fail to depict all gait disorders accurately. As the information on trunk/pelvic movements, frontal and transverse planes, and kinetics are disregarded in WGH, 3D instrumented gait analysis (IGA) for further characterization is necessary. The objective of this study was a detailed analysis of patients with unilateral CP using IGA taking all planes/degrees of freedom into account including pelvic and trunk movements. A total of 89 individuals with unilateral CP matched the inclusion criteria and were classified by WGH. Subtype-specific differences were analyzed. The most remarkable findings, in addition to the established WGH subtype-specific deviations, were pelvic obliquity and pelvic retraction in all WGH types. Furthermore, the unclassified individuals showed altered hip rotation moments and pelvic retraction almost throughout the whole gait cycle. Transversal malalignment and proximal involvement are relevant in all individuals with unilateral CP. Further studies should focus on WGH type-specific rotational malalignment assessment (static vs. dynamic, femoral vs. tibial) including therapeutic effects and potential subtype-specific compensation mechanisms and/or tertiary deviations of the sound limb.

Clinical and Gait Parameters Related to Pelvic Retraction in Patients with Spastic Hemiplegia.

Pelvic retraction during walking is a common finding seen in patients with spastic hemiplegia. However, potential factors related to this condition have not been comprehensively examined in a systemic manner in previous studies. The purpose of this study was to elucidate any clinical and gait parameters related to pelvic retraction in patients with hemiplegic cerebral palsy. A total of 212 independent ambulatory patients were enrolled in the study. Group I consisted of 113 patients who had persistent pelvic retraction, and Group II of 99 with a normal range of pelvic rotation throughout the gait cycle as evidenced by kinematic analysis. A multivariate logistic regression analysis using a clustering technique was performed, with use of eight gait factors and five clinical factors. Decreased ankle dorsiflexion, increased hip internal rotation, increased anterior pelvic tilt, the Winters classification type II, and asymmetrical posturing of the upper extremity during gait were found to be related to pelvic retraction. This is the only study including a broader array of assessment domains of both clinical and gait parameters with a considerably large and homogenous population with hemiplegia. Further studies will be needed to see whether the rectification of those parameters may improve abnormal gait and pelvic retraction in hemiplegia.

Femoral neck fracture in acetabular protrusions secondary to rheumatoid arthritis: a case report and literature review

The present study shows the case of a patient with acetabular protrusions secondary to rheumatoid arthritis pro-gressing to femoral neck fracture. The patient, a 64 years female, had a history of rheumatoid arthritis for 38 years. The left hip pain and abnormal sound occurred when hip flexion for picking up. She was diagnosed with rheumatoid arthritis secondary to acetabular pelvic retraction and left femoral neck fracture by medical history, physical examination and imaging. Total hip arthroplasty was performed after preoperative examination. Hip dislocation, femoral head removal, acetabular reconstruction, cup fixation, and bone mass assessment are technical challenges during surgery. Based on literature review, this case is belonging to secondary acetabular pelvic retraction, which may be related to acetabular softening caused by rheumatoid arthritis. When the stress from the femoral head exceeds the endurance of the softened acetabulum, the acetabulum protrudes into the pelvis and gradually wraps around the femoral head. Based on the pathological characteristics, it is speculated that the cause of femoral neck fracture is the direct hit of the femoral neck-acetabular rim during hip flexion. In this case, spiral cup prosthesis was used to achieve both the initial stability of the prosthesis and saving bone mass around the acetabulum. The patient was followed up for 3 months with satisfactory position of prosthesis and joint function.

Are flexible flat feet associated with proximal joint problems in children?

The role of flexible flat feet (FF) in the development of musculoskeletal symptoms at joints proximal to the ankle is unclear. We undertook an observational study to investigate the relationship between foot posture and the proximal joints in children. It was hypothesised that reduced arch height would be associated with proximal joint symptoms and altered gait kinematics and kinetics particularly in the transverse plane at the hip and knee. Ninety-five children between the ages of 8–15 were recruited into this ethically approved study. Foot posture was classified using the arch height index (AHI). The frequency of knee and hip/back pain was documented, and each child underwent three dimensional gait analysis. Reduced arch height was associated with increased odds of knee symptoms (p<0.01) and hip/back symptoms (p=0.01). A flat foot posture was also significantly associated with a reduction in the second peak of the vertical ground reaction force (p=0.03), which concomitantly affected late stance hip and knee moments. A reduced AHI was also associated with increased pelvic retraction and increased knee valgus in midstance. No kinematic and kinetic parameter associated with a flat foot posture related to increased proximal joint symptoms in the FF group. Children with a flatter foot posture are more likely to have pain or discomfort at the knee, hip and back; however, the mechanisms by which this occurs remain unclear. Treating FF without explicit understanding of how it relates to symptoms is difficult, and further work in this area is required.

Effects of Soft Tissue Surgery on Pelvic and Hip Rotation in Patients with Spastic Diplegia: A Meta-Analysis.

BackgroundThere are several different opinions regarding the improvements seen on the transverse plane after soft tissue surgery alone in independently ambulant patients with cerebral palsy. We performed a meta-analysis using data from previous studies to identify the effects of soft tissue surgery alone on pelvic and hip rotation in children with spastic diplegia.MethodsWe conducted a pilot study to evaluate the improvement in pelvic and hip rotation after muscle-tendon lengthening surgery in children with spastic diplegia. We also searched EMBASE and PubMed and selected 2 previous studies using the same test conditions with kinematic data on the pelvis and hip joints. A meta-analysis of the results of these 3 studies, including this pilot study, was then performed.ResultsThe meta-analysis results showed an external rotation decrease (p = 0.005) in the mean difference of pelvic rotation of -3.61 (95% confidence interval [CI], -6.13 to –1.09) and a mean difference in hip rotation of 6.60 (95% CI, 3.34 to 9.86), indicating a significant increase in the hip external rotation after surgery (p < 0.001).ConclusionsIn independently community-ambulant pediatric patients with spastic diplegia, pelvic retraction and hip internal rotation could be improved after soft tissue surgery.

Can a turning inwards patella predict an excess of femoral anteversion?

Introduction: In children with spastic diplegia, a turning inwards patella during gait is often considered to be related to an excess of femoral anteversion. The aim of our studywas to investigate the relationship of these two parameters during gait. Patients/materials andmethods:We retrospectively reviewed the charts of 188 children with spastic diplegia. One hundred three of them showed a turning inwards patella during gait (206 lower limbs). Data collected were: hip range of motion, femoral anteversion, spasticity and tightness of internal rotators, patella orientation, hip and pelvis kinematics at mid stance. Results: One hundred forty nine lower limbs showed excess of femoral anteversion (72%). Among patients with excessive femoral anteversion, only 66 had kinematic internal hip rotation. Other causes were: internal pelvic rotation, isolated spasticity and/or retraction of medial rotator muscles. Discussion and conclusions: Observational gait analysis was not sufficient to identify pelvic rotational troubles. The lack of kinematic data could conduct to amisinterpretation of turning inwards patella gait. Turning inwards patella during gait does not necessarily mean excessive femoral anteversion and excessive femoral anteversion does not necessarily result in turning inwards patella gait. 3D gait analysis is an essential tool to complete physical examination. It should help therapeutic decisions and limit the errors in diagnosis.

Predictors of pelvic retraction in children with cerebral palsy derived from gait parameters and clinical testing

Excessive pelvic rotation in the transverse plane is common in patients with cerebral palsy. Knowing the underlying reasons is important for clinical decision making, since changes in pelvic retraction might have an effect on internally rotated gait. We hypothesized that the contralateral leg contributes considerably to pelvic rotation on the retracted side. Therefore the aim of this study is to calculate predictors for pelvic retraction using both, parameters from the retracted and from the contralateral protracted side.Thirty-two children with diplegia and 18 children with hemiplegia were examined by three-dimensional gait analysis followed by a clinical examination protocol. Stepwise multilinear regression of the response value mean pelvic retraction during stance phase was performed on 10 potential predictors of dynamic gait data and 10 corresponding predictors of clinical data of the retracted and the contralateral protracted side.Gait analysis revealed ankle push-off energy on the protracted side as the best predictors in hemiplegic patients explaining 59% of the variance in pelvic retraction. In diplegic patients external hip rotation of the protracted side was most accurate in predicting pelvic retraction (27%). Best clinical predictors for hemiplegic patients were ankle dorsiflexion on the retracted side (46%) and for diplegic patients it was the knee extension strength on the protracted side together with hip rotation on the retracted side (36%). In hemiplegic patients ankle push-off energy of the contralateral side is a significant compensation mechanism that might cause increased pelvic retraction to compensate for the weakness of the involved side. In diplegic patients prediction of pelvic retraction was only moderate and requires further investigation.

Influence of the structural deformity of the spine on the gait pathology in scoliotic patients

Scoliosis is not only a spinal deformity, but also leads to the development of a pathological gait pattern. Nearly all studies examining walking in scoliotic patients report some degree of gait abnormality, however the results are somewhat contradictory. Therefore the aim of this study is to explore the relationship between gait pathology and degree of scoliotic deformity in a group of patients with idiopathic scoliosis.Sixty three females with idiopathic scoliosis, aged between 12 and 17 participated in the study. They were not treated previously, neither surgically, nor conservatively. They underwent objective gait analysis with a VICON 460 system. Data for the following parameters were analysed: gait velocity, cadence, step length, pelvic tilt, pelvic retraction, pelvic range of motion in the transverse plane, pelvic obliquity, hip and knee range of motion in the sagittal plane, knee flexion at initial contact, ankle dorsiflexion in swing, foot progression angle.Additionally a Gillette Gait Index (GGI) was calculated.Prior to the gait analysis all patients underwent a clinical examination, an X-ray, clinical tests and anthropometric measurements.In conclusion our results indicate that the gait pathology of the patients with idiopathic thoraco-lumbar (i.e. double curve) scoliosis depends on the severity of the spinal deformity and the type of pelvic deformity.

Pelvic kinematics and their relationship to gait type in hemiplegic cerebral palsy

While there is general clinical consensus that children with Unilateral Spastic Cerebral Palsy (USCP) walk with an increased anterior pelvic tilt and the affected hemipelvis retracted, there is less agreement to observations in the coronal plane. Furthermore, the relationship of 3D pelvic kinematic parameters to the Winters, Gage and Hicks (WGH) hemiplegic gait classification has not been reported in the literature. Valid 3-D kinematic gait data were obtained in a representative population of 91 children with hemiplegia (56M, mean age 10.8yrs, age range 5–18yrs; WGH classification Type I n=32, II n=5, III n=7, IV n=9, unclassified n=38). Deviations of symmetry and range of movement from our normative data set (n=48; 26F; mean age 9.9yrs; age range 5–18yrs) for mean tilt, tilt range, and difference between affected and unaffected sides for obliquity and rotation were defined as normal, mild, moderate or severe (<1 standard deviation (SD); >1<2SD; >2<3SD; >3SD, respectively). Increased pelvic tilt range (>1SD) was observed in 60.4% and pelvic retraction (>1SD) was observed in 61.5% of USCP children in this study. Weak but significant correlations were found between WGH gait type and pelvic obliquity (ρ=0.29; p<0.01). No other correlations were found. Factors such as leg length discrepancy modify the functional leg length throughout the gait cycle contributing to the deviations observed. The evaluation of gait abnormalities in USCP should not be limited to the use of classifications based on sagittal plane kinematics but should seek to include 3D kinematics of the pelvis.

Factors associated with pelvic asymmetry in transverse plane during gait in patients with cerebral palsy

The purpose of this study was to describe the patterns of pelvic rotational asymmetry in the transverse plane and identify the possible factors related to this problem. One thousand and forty-five patients with cerebral palsy (CP) and complete documentation in the gait laboratory were reviewed in a retrospective study. Pelvic asymmetry in the transverse plane was observed in 52.7% of the patients; and to identify the possible causes of pelvic retraction, clinical (Thomas test, popliteal angle, and gastrocnemius tightness) and dynamic parameters (mean rotation of the hip in stance, minimum hip flexion, minimum knee flexion, and peak ankle dorsiflexion) were evaluated. The association between these parameters and pelvic retraction was assessed statistically. The results showed that 75.7% of patients with asymmetric pattern of the pelvis had clinical diagnosis of diplegic spastic CP. Among the patients with asymmetrical CP, the most common pattern was pelvic retraction on the affected side. The relationship between pelvic retraction and internal hip rotation was stronger in patients with asymmetrical diplegic CP than in those with hemiplegic (P<0.001) or symmetrical diplegic CP (P = 0.014). All of the patients exhibited a significant association among clinical parameters (Thomas test, popliteal angle, and gastrocnemius tightness) and pelvic retraction. In conclusion, pelvic retraction seems to be a multifactorial problem, and the etiology can change according to topographic classification, which must be taken into account during the decision-making process in patients with CP.

P071 Does equinus cause pelvic retraction and increased internal femoral rotation in gait?

Oxaliplatin, a platinum-based chemotherapeutic agent, induces acute cold allodynia and dysesthesia. Cold-sensitive transient receptor potential channels (TRPM8 and TRPA1) have been implicated as candidates to mediate oxaliplatin-induced cold allodynia and hyperalgesia, but precise roles of these channels remain unclear. In this study, we investigated the role of TRPM8 in oxaliplatin-induced cold allodynia.Oxaliplatin was injected intraperitoneally in mice. Cold allodynia was evaluated by the acetone test. Expression levels of TRPM8 mRNA and protein were measured using reverse transcription-polymerase chain reaction and Western blotting, respectively.Oxaliplatin-induced cold allodynia was alleviated by the TRPM8 blockers N-(2-aminoethyl)-N-[4-(benzyloxy)-3-methoxybenzyl]-N′-(1S)-1-(phenyl) ethyl] urea and TC-I 2014. Oxaliplatin increased the expression levels of TRPM8 mRNA and protein in the dorsal root ganglia and plantar skin, respectively. Prophylactic administration of the c-Myc inhibitor 10058-F4 prevented cold allodynia and the increase of TRPM8 mRNA after oxaliplatin injection.These results suggest that oxaliplatin induces cold allodynia through the increase of c-Myc-mediated TRPM8 expression in primary sensory neurons.

Effects of plantarflexion on pelvis and lower limb kinematics

Modelling the effect of soleus and gastrocnemius contractions against the floor resistance in a forward dynamics simulation revealed that hip flexion, internal rotation and adduction together with external pelvic rotation could be attributed to a direct, but distant effect of triceps surae contraction. Knee flexion smoothed out the effect. To validate this clinically relevant biomechanical observation, ankle plantar flexion was correlated with hip and pelvic rotation retrospectively in children with spastic cerebral palsy. In 49 children with spastic hemiplegia, plantar flexion showed a significant correlation with increased pelvic retraction and hip internal rotation. In contrast, in 47 children with spastic diplegia no significant effect of the triceps surae on hip and pelvis kinematics was found. Bilateral hip and knee flexion in diplegia appeared to prevent the proximal effect of the triceps surae seen in the hemiplegics. In diplegia triceps surae overactivity did not appear to be a significant cause of internal rotation gait.

Factors associated with pelvic retraction during gait in cerebral palsy

Clinical and dynamic (gait-related) measures thought to be associated with pelvic retraction were investigated in patients with cerebral palsy. Gait laboratory data of 233 patients with cerebral palsy were studied retrospectively. Two groups were selected; those who demonstrated pelvic retraction during gait <−6.85° (mean – 2 standard deviations from normal ( n = 88) and those with >−4.83° (mean – 1 standard deviation from normal) ( n = 101). About 37.8% of the total population reviewed showed pelvic retraction of <−6.85°. There was a higher prevalence of retraction among hemiplegics (46.3%) compared to diplegics (30.4%). Differences were also found between hemiplegic and diplegic subjects in terms of factors associated with pelvic retraction. Clinical and dynamic tightness of the gastro-soleus were the most significant features associated with pelvic retraction among hemiplegic subjects. Clinical and dynamic flexion and internal rotation of the hip were the most significant features associated with retraction in the diplegic population. This study suggests that pelvic retraction is multifactorial in origin and secondary to both static clinical measures as well as dynamic features during gait.

Gait Evaluation of an Automatic Stance-Control Knee Orthosis in a Patient With Postpoliomyelitis

Hebert JS, Liggins AB. Gait evaluation of an automatic stance-control knee orthosis in a patient with postpoliomyelitis. Objective To determine gait differences in a subject ambulating with a knee-ankle-foot orthosis (KAFO) with a locked knee joint versus an automatic stance-control knee joint. Design Single-subject crossover design. Setting Tertiary rehabilitation facility with a motion analysis laboratory. Participant A 61-year-old ambulatory male volunteer with postpoliomyelitis walking with a stance-control KAFO. Interventions Instrumented gait analysis and Physiological Cost Index in the locked knee and stance-control modes. Main Outcome Measure Differences in gait parameters. Results On the braced limb, stance-control mode showed a near-normal knee flexion wave in swing, reduced pelvic retraction and rotational excursion, and improved hip power generation. On the nonbraced limb, the stance-control mode allowed elimination of vaulting, reduction in abnormal ankle and hip power generation, increased knee power absorption, and more typical quadriceps activation. There was a trend toward improved energy efficiency in the stance-control mode. Conclusions Use of a stance-control knee joint in a KAFO appears to improve gait biomechanics and improve energy efficiency compared with a locked knee.

Multilevel orthopaedic surgery in group IV spastic hemiplegia

Most children with spastic hemiplegia have high levels of function and independence but fixed deformities and gait abnormalities are common. The classification proposed by Winters et al is widely used to interpret hemiplegic gait patterns and plan intervention. However, this classification is based on sagittal kinematics and fails to consider important abnormalities in the transverse plane. Using three-dimensional gait analysis, we studied the incidence of transverse-plane deformity and gait abnormality in 17 children with group IV hemiplegia according to Winters et al before and after multilevel orthopaedic surgery. We found that internal rotation of the hip and pelvic retraction were consistent abnormalities of gait in group-IV hemiplegia. A programme of multilevel surgery resulted in predictable improvement in gait and posture, including pelvic retraction. In group IV hemiplegia pelvic retraction appeared in part to be a compensating mechanism to control foot progression in the presence of medial femoral torsion. Correction of this torsion can improve gait symmetry and function.

Spastic Hemiplegic Cerebral Palsy and the Femoral Derotation Osteotomy: Effect at the Pelvis and Hip in the Transverse Plane During Gait

Gait analysis techniques were used to evaluate the outcome of the femoral derotation osteotomy in children with hemiplegic cerebral palsy. Seventy-one patients were evaluated and classified according to the Winters and Gage scale. Nine of the 13 patients classified as type IV underwent a femoral derotation osteotomy. Postoperatively, all nine patients demonstrated less internal hip rotation, pelvic retraction, and internal foot progression angle. Before surgery patients improve the foot progression by an externally biased hip position within the hip rotation arc. After surgery the hip position is allowed to be more centered within the rotation arc without compromising foot progression. Interestingly, the changed hip position during gait was significantly less than the magnitude of the derotation osteotomy. When contemplating postoperative outcome, consideration of hip position within the arc of rotation and pelvic retraction should be given to avoid undercorrection and residual pelvic compensation with femoral osteotomy based solely on foot progression.