Twenty years of multisite surgery

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<ul><li><p> pidResultats. La diffrence moyenne entre les mesures en CT-Scan et EOS taitentre 1,978 et 2,468 (non significatif). Les deux sries de mesures prsentaientune excellente corrlation (r = 0,92). Les reproductibilits intra et inter-observateur pour la mesure EOS taient excellentes (ICC = 0,98, SEM = 6,728et ICC = 0,98, SEM = 6,888, respectivement). En situation dantversionmodifie les deux mthodes diffraient de 1,188 2,348 (non significatif).Discussion. Ces premires donnes mtrologiques in vitro, ncessaires du faitde la double irradiation, montre la validit et la fiabilit du systme EOS pour lamesure de lantversion fmorale physiologique et pathologique. Une tude in-vivo devra confirmer les limites dagrments de cette mesure sur la populationdes personnes atteint de paralysie crbrale.</p><p>Rfrence[1] Sugano N. A comparison of alternative methods of measuring femoral</p><p>anteversion. J Comput Assist Tomogr 1998;22:6104.</p><p>http://dx.doi.org/10.1016/j.rehab.2012.07.557</p><p>CO04-006-f</p><p>Effet de la vitesse de marche sur la co-activationmusculaire pendant la marche chez lenfant paralysecerebral hemiplegiqueR. Gross a,*, F. Leboeuf a, J.-B. Hardouin b, S. Brochard c, B. Perrouin-Verbe d,</p><p>O. Remy-Neris c</p><p>a Laboratoire danalyse du mouvement, CHU de Nantes,</p><p>85, rue Saint-Jacques, 44093 Nantes, FrancebDepartement de biophysique informatique, faculte de medecine</p><p>de Nantes, Nantes, Francec LATIM, CHU de Brest, Brest, Franced Service de MPR neurologique, CHU de Nantes, Nantes, France</p><p>*Auteur correspondant.Adresse e-mail : raphael.gross@chu-nantes.fr.</p><p>Mots cles : Paralysie cerebrale ; Electromyographie dynamique ;</p><p>Co-activation ; Spasticite</p><p>Introduction. La co-activation musculaire (CA) est dfinie comme lactivationlectrique simultane de deux muscles antagonistes. Pendant la marche, la CAest augmente par la vitesse de marche et en cas de syndrome pyramidal. Il estimportant, dans un but thrapeutique, de distinguer les composantespathologique et compensatoire de lactivit musculaire. Le but de cette tudeest de mettre en vidence la composante pathologique de la CA chez les enfantsprsentant une paralysie crbrale (PC) unilatrale.Methodes. La marche de dix enfants PC et dix enfants sains apparis a ttudie vitesse spontane, trs lente, et trs rapide. Les paramtres spatio-temporels et lactivit lectromyographique des muscles rectus femoris (RF),vastus medialis (VM), semi-tendinosus (ST), tibialis anterior (TA) et soleus(SO) des deux membres infrieurs ont t enregistrs. Un index de CA a tcalcul selon Unnithan et al. [1]. Un modle linaire mixte a t tabli pourvaluer leffet de la vitesse de marche sur lindice de CA pour les diffrentscouples de muscles (RF/ST, VM/ST et TA/SO).Resultats. Limpact de la vitesse de marche sur lindice de CA tait suprieurdans les membres infrieurs atteints des enfants PC que dans leurs membressains ou ceux des enfants sains, quel que soit le couple de muscle. Leffet de lavitesse tait moindre dans le couple RF/ST que dans les autres chez les enfantssains, mais pas chez les enfants PC.Discussion. Une composante spastique, due au syndrome pyramidal, estpotentiellement responsable de leffet suprieur de la vitesse sur la CA dans lemembre spastique des enfants PC. Lutilisation dun modle musculo-squelettique pourrait tablir un lien entre tirement et activation musculaire.La spcificit du couple RF/ST, dont la CA est moins sensible la vitesse chezlenfant sain est perdue chez lenfant PC indiquant un trouble du contrlemoteur. Lamlioration de la modlisation linaire ainsi que ltude de la CAsur les diffrentes phases du cycle de marche pourraient identifier lescompensations du ct sain.</p><p>Rfrence[1] Unnithan VB, et al. Cocontraction and phasic activity during gait in</p><p>children with cerebral palsy. Electromyogr Clin Neurophysiol 1996;36:48794.</p><p>Pathologies de lenfant et de ladolescent (I) / Revue dEe220http://dx.doi.org/10.1016/j.rehab.2012.07.558CO04-007-f</p><p>Evolution des parame`tres biomecaniques etbioenergetiques de la marche lors dune epreuvede marche prolongee chez le jeune paralyse cerebralC. Mietton a,*, N. Peyrot b, P. Jimenez b, F. Degache b, V. Gautheron c</p><p>aMPR pediatrique, CHU de Saint-Etienne, MPR pediatrique</p><p>3e etage, boulevard pasteur, 42100 Saint-Etienne, Franceb Laboratoire de physiologie de lexercice, EA 4338, universite Jean-Monnet,</p><p>St-Etienne, Francec EA 4338, laboratoire de physiologie de lexercice, universite Jean-Monnet,</p><p>service de medecine physique et de readaptation, CHU de St-Etienne,</p><p>St-Etienne, France</p><p>*Auteur correspondant.Adresse e-mail : claire.mietton@yahoo.fr.</p><p>Mots cles : Paralysie cerebrale ; Biomecanique ; Bioenergetique ; Fatigue a` la</p><p>marche</p><p>Lvolution des paramtres biomcaniques et bionergtiques la marcheprolonge chez lenfant PC est peu dcrite dans la littrature.Objectif. Dterminer lvolution des paramtres bionergtiques et biomca-niques au cours dune preuve de fatigue.Methodologie. tude prospective non randomise, incluant quatre jeunes PC etquatre tmoins, avec tests sur deux demi-journes : une pour mesurer lesparamtres nergtiques et biomcaniques durant 20 min de marche sur tapis,lautre pour suivre leur volution avec la fatigue musculaire pure induite par descontractions maximales volontaires.Resultats. Les cots nergtiques (nergie dpense lors de la contractionmusculaire) taient plus levs chez les PC [Cw/kg net (dpense dnergie propre lactivit de la marche) suprieure de 28 % et Cw/kg brut (dpense nergietotale) suprieur de 36 %]. Le travail mcanique externe (Wext = travaileffectu par les muscles ncessaire acclrer et lever le centre de masse ducorps) augmente significativement avec le temps (F = 5,611 ; p &lt; 0,0001), avecune diffrence significative entre sujets hmiplgiques et sains (F = 3,292,p &lt; 0,01). Avec la fatigue musculaire, Cw/kg net tait en moyenne 22 % pluslev chez les sujets PC (Fgroupe = 14,65 ; p &lt; 0,01), avec une augmentationdu Cw/kg net aprs la fatigue chez les jeunes hmiplgiques (F = 20,44,p &lt; 0,01). Cw/kg brut tait en moyenne suprieur de 25 % chez les sujets PC.De mme, il existe une augmentation du Cw/kg brut aprs la fatigue, chez leshmiplgiques (F = 8,32 ; p &lt; 0,01). Il existe une diffrence significative entreles sujets pour le Wint,dc (travail mcanique interne de double contactcompensant le travail mcanique ngatif effectu par le membre infrieuravant).Discussion. La dpense nergtique est suprieure chez lhmiplgique lors dela fatigue musculaire, mais celle-ci ferait intervenir dautres mcanismes queWext. Il faudrait poursuivre ltude afin de vrifier ces rsultats, en incluant plusde patients.</p><p>Pour en savoir plusBell KL, SW Davies P. Energy expenditure and physical activity of ambulatorychildren with CP and of typically developing children. Am J Clin Nutr2010;92:3139.Kurtz J, et al. Mechanical work performed by the legs of children with spasticdiplegic cerebral palsy. Gait Posture 2010;34750.</p><p>http://dx.doi.org/10.1016/j.rehab.2012.07.559</p><p>Version anglaise</p><p>CO04-001-e</p><p>Twenty years of multisite surgeryG.-F. Pennecot</p><p>Pole chirurgie, chirurgie orthopedique et maxillo-faciale,</p><p>CHU Robert-Debre pour la me`re et lenfant, 48, boulevard Serurier,</p><p>75935 Paris cedex 19, FranceE-mail address: georges.pennecot@rdb.ap-hop-paris.fr.</p><p>emiologie et de Sante Publique 55S (2012) e218e223</p></li><li><p>Service de reeducation fonctionnelle, CHU Morvan, 2, avenue Foch,</p><p>Pathologies de lenfant et de ladolescent (I) / Revue dEpidemiologie et de Sante Publique 55S (2012) e218e223 e22129609 Brest cedex, France</p><p>*Corresponding author.E-mail address: christelle.pons@chu-brest.fr.</p><p>Keywords: Cerebral palsy; Children; Radiological measures; Validity;</p><p>Reproductibility; Hip migration; Acetabular dysplasia; Neck-shaft angle;</p><p>Femoral anteversion</p><p>Introduction. Numerous radiological methods with various levels of validityare available to assess the specific hip deformities of children with cerebralpalsy. The aim of this systematic review was to assess the current in vivovalidity, reliability and limits of use of the different radiological methodsmeasuring the proximal hip geometry in this population.Methods. A data base search was conducted using relevant key words andinclusion/exclusion criteria in seven databases. The quality assessment wasrated using a customized scale that evaluates both the quality of the article andthe metrological strength of the evaluated method (Q = score/100).Results. Eighteen articles with a mean Q-score of 65/100 (SD 15) met theinclusion criteria. The migration percentage using X-ray, evaluated in sevenstudies (mean Q = 68.42), showed an excellent reliability and concurrentvalidity with a 3D CT scan measure of hip migration. Thresholds for a truechange were between 8.3% and 22%.Regarding acetabular dysplasia, the acetabular index (X-ray), evaluated in threestudies (Mean Q =63.5). Despite only moderate validity with a measure carriedout in 3D CT scanner, the acetabular index had a good to excellent reliability.Thresholds for a true change were between 3.78 and 5.98. 3D CT scan indexes,evaluated in five studies (mean Q= 74) had greater reliability.The measure of neck shaft angle using X-rays, evaluated in three studies (meanQ = 74.6) showed excellent concurrent validity with measures from 3D CTreformatted slices and excellent reliability. Ninety percent of the measures hadbeen reported to be within 108 of error.Slightly less than 20 years ago we started our experience with multi-site surgeryin children with cerebral palsy. Our first surgery was performed in March 1995.Since then, until December 2010, we performed 477 multisite procedures,mostly in spastic diplegic children, but 40 times in hemiplegic children. Wewould like to share this experience.We followed the experience of J. Gage who justifies this type of care because itlimits the number of procedures and rehabilitation stays, avoiding the birthdaysyndrome, because it decreases the cost of care, and especially because itallows obtaining better results than before.Excepting one iliac artery wound sutured without sequelae, we have not had anymajor complications. No transfusions have been required (femoral osteotomieswere performed with a Esmach band at the proximal part of the limb supportedon an iliac pin). The only complications leading to supplementary surgery werenonunions after femoral and mostly tibial derotation osteotomies only in olderadolescents (all healed after new surgery). No child had a worsened functionallevel.Our results are similar to those reported in the literature in terms of improvedfunction, GGI, and quality of life. The development of multisite surgery hasbeen accompanied by the development of criteria assessing treatment outcomein these children.This type of surgery is only possible: if a full assessment has been applied, particularly with gait analysis, and if theindication is discussed by a multidisciplinary team; if the operation can be practiced with a double team (in the diplegic patient); if joint mobilization is started within days after surgery; and if weight bearing is started very early (2 weeks).</p><p>http://dx.doi.org/10.1016/j.rehab.2012.07.560</p><p>CO04-002-e</p><p>Validity and reliability of radiological methods assessingthe proximal hip geometry in children with cerebral palsy:A systematic reviewC. Pons *, B. Medee, S. BrochardRegarding femoral anteversion, one study (Q score = 89) found excellentcorrelation between the 2D CT scan and trochanteric prominence angle test andexcellent reliability. Two others showed less evidence for the use of other CTscan or ultrasound based techniques.Discussion. Once the limits of use are recongnized, hip migration, acetabulardysplasia and neck-shaft angle can be measured using X-ray. If needed, 3D CTscan can also be used reliably for acetabular dysplasia. Further evidence isrequired regarding the validity of 3D CT-scan and non-irradiative methods asultrasounds and MRI.</p><p>http://dx.doi.org/10.1016/j.rehab.2012.07.561</p><p>CO04-003-e</p><p>Influence of pelvic kinematics on lower limb rotationaldeviations during gaitA.L. Simon *, C. Mallet, A. Presedo, B. Ilharreborde, K. Mazda, G.-F. Pennecot</p><p>Service de chirurgie infantile traumatologique et orthopedique du Pr. Mazda,</p><p>hopital Robert Debre, 48, boulevard Serrurier, 75019 Paris, France</p><p>*Corresponding author.E-mail address: annelaure_simon@hotmail.com.</p><p>Keywords: Cerebral palsy; Spastic diplegia; Lower limb rotational deviation;</p><p>Pelvic kinematics</p><p>Introduction. Lack of normalization of foot progression angle after correctionof lower limb torsional troubles raised the question about the influence of pelvicrotation on lower limb rotation during gait. Pelvic rotation abnormalities aredifficult to predict by physical examination. The aim of the study was to explorethe influence of pelvic kinematics on foot progression angle deviations.Methods and subjects. We retrospectively reviewed kinematic data of 188children with spastic diplegia without any previous surgery. Data, recorded atmid stance phase, were: pelvic rotation, hip rotation, ankle rotation and footprogression angle.Results. Abnormal pelvic rotation was noticed in 255 of 376 lower limbs(68%). Among 231 patients with internal foot progression angle, internal pelvicrotation was associated to other transverse plan kinematic deviations in 98 cases(42%). For 78 patients who showed external foot progression angle, externalpelvic rotation represented a combined cause in 22 cases (28%).Discussion. Pelvic rotation is difficult to analyse by means of observationalgait analysis alone. This kinematic parameter can represent an isolated cause ofabnormal foot progression angle but it is often combined with other transverseplan deviations. A detailed kinematic analysis of interaction between planes isan essential step when making surgical planning, particularly when footprogression angle has to be corrected.</p><p>http://dx.doi.org/10.1016/j.rehab.2012.07.562</p><p>CO04-004-e</p><p>Lower limb torsional profile in children with spasticdiplegiaA.-L. Simon *, E. Litzelmann, C. Mallet, B. Ilharreborde, A. Presedo, K. Mazda</p><p>Service de chirurgie infantile traumatologique et orthopedique du Pr. Mazda,</p><p>hopital Robert-Debre, 48, boulevard Serrurier, 75019 Paris, France</p><p>*Corresponding author.E-mail address: annelaure_simon@hotmail.com.</p><p>Keywords: Spastic diplegia; Children; Lower limb rotational profile</p><p>Introduction. Lower limbs rotational troubles in spastic diplegic CP childrenare frequent and difficult to identify by physical examination alone. Thesetroubles modified level arms length and they are important to be treated. Theaim of the study was to put in evidence patterns of lower limbs rotationaltroubles on kinematic data.Material and methods. Hundred and eighty-eight spastic diplegic CP children,without any previous surgical procedure, were retrospectively reviewed.Kinematic data analysed pelvic, hip and ankle rotation with foot progressionangle.</p></li></ul>