Three-dimensional evaluation of skeletal deformities of the pelvis and lower limbs in ambulant children with cerebral palsy

Abstract

Skeletal abnormalities, affecting posture and walking pattern, increase with motor impairment in children with cerebral palsy (CP). However, it is not known whether these skeletal malalignments occur in children with slight motor impairment. Our aim was to evaluate skeletal malalignment at the level of the pelvis and lower limbs in ambulant children with CP, with slight motor impairment, using a low dose biplanar X-ray technique. Twenty-seven children with spastic CP (mean age: 10.9±4years, 7 Hemiplegia, 20 Diplegia, GMFCS levels I:17, II:10), with no previous treatments at the hips and knees, underwent EOS(®) biplanar X-rays. A control group consisting of 22 typically developing children was also included. Three-dimensional reconstructions of the pelvis and lower limbs were performed in order to calculate 11 radiological parameters related to the pelvis, acetabulum and lower limbs. Pelvic incidence and sacral slope were significantly increased in children with CP compared to TD children (48°±7° vs. 43°±8°, 42°±7° vs. 38°±5°, respectively, p=0.003). Acetabular parameters did not significantly differ between the two groups. Femoral anteversion and neck shaft angle were significantly increased in children with CP (25°±12° vs. 14°±7°, p<0.001; 134°±5° vs. 131°±5°, p=0.005 respectively). No difference was found for tibial torsion. This study showed that even slightly impaired children with CP have an anteverted and abducted femur and present positional and morphological changes of the pelvis in the sagittal plane. The orientation of the acetabulum in 3D seems to not be affected when children with CP present slight motor impairment.

Determinants of Hip and Femoral Deformities in Children With Spastic Cerebral Palsy

“…Delayed weight bearing was also suggested as the reason for excessive FA [ 17 21 24 25 ]. Previous studies suggested that non-community ambulatory children with CP had a larger FA angle compared to community ambulatory children [ 7 17 22 26 ]. These results were also different from our conclusion (p=0.960) ( Table 2 ).…”

“…Previous studies of clinical assessment using goniometry and plain radiography to measure FA might have had validity issues and confirmation bias [ 20 21 ]. Some studies only recruited children with minor motor impairment such as GMFCS level I and II [ 26 ], and analyzed all types of CP including dystonic, hypotonic, ataxic, and mixed types [ 17 ]. And one hypothesis is many factors can affect in the FA, during aging process, but we examined clinically in young age and follow-up after at least 5 years.…”

A New Approach in the Clinical Decision - Making for Cerebral Palsy Using Three - Dimensional Subject - Specific Musculoskeletal Reconstructions

“…Such proximal femoral deformities are known to affect gait patterns in this population and are commonly treated with osteotomies. However, slightly affected children with spastic CP were not found to have anomalies in acetabular orientation when compared to typically developing children [38].…”

“…These parameters are important for the quantification of postural anomalies, which are frequently encountered in children with CP. For example, a recent study comparing children with spastic cerebral palsy to a control group of typically developing children found that children with CP had anatomical and positional pelvic anomalies, with most notably a sig-nificant increase in pelvic incidence and sacral slope in children with CP [38]. Furthermore, femoral anteversion and neck-shaft angle were found to be increased in children with CP [39].…”

Pelvic incidence variation among individuals: functional influence versus genetic determinism

“…Surprisingly, in ambulatory children with cerebral palsy (CP) whose gait and posture are obviously disturbed owing to muscle impairment around the lumbopelvic region, there is no significant difference in the value of PI between patients with CP and normal children, although significant differences for LL and pelvic rotation have been reported [ 21 , 22 ]. Massaad et al [ 23 ] indicated that PI was significantly increased in children with CP (7 hemiplegia, 20 diplegia, GMFCS levels I:17, II:10) compared to typically developing children (48° ± 7° vs. 43° ± 8°), although this difference was small.…”