Influence of gait analysis on decision-marketing for lower extremity surgery

Correlation between kinematic deviations at knee and degree of femoral anteversion in cerebral palsy


  1. 1. IRCCS Medea, Bosisio Parini, Lecco;
  2. 2. Bioengineering Department, Polytechnic of Milan, Milan, Italy

Objectives: To study the relationship between femoral anteversion and reduced knee flexion during swing phase on gait pattern in children affected by diplegic cerebral palsy (CP).

Group 1
Group 2
Group 3
KMSw(degs) Amount of delay
39.65 (6.55)
35.92 (6.75)
56.45 (5.70)
12.22 (2.82)
18.40 (3.98)
13.50 (1.52)
Hip rotaion at toe-off (degs)
11.36 (9.09)
2.85 (9.45)
-1.51 (7.37)

Design: Baseline analysis of cohort study.

Participants: Twenty-seven independent ambulators with diplegic CP (age range 3-15y; mean age 10y 5mo; 51 limbs) and 20 normally developing children (control group [CG]; age range 5-12y; mean age 9y) were evaluated in this study. The following criteria were met for CP group selection: diagnosis of CP, increased spasticity of the rectus femoris muscle, no prior orthopaedic surgery in the lower extremities, and no previous injections of botulinum toxin. All patients were independent ambulators without the assistance of walking aids.

Method: Clinical evaluation of femoral anteversion and Duncan Ely test was performed. The gait strategy of each participant was evaluated quantitatively using gait analysis (GA): an 8-camera optoelectronic system with passive markers (ELITE, BTS, Italy), two force plates (Kistler, CH), and a synchronic Video system (BTS, Italy) were used. Five trials were conducted for each patient. Some indices extracted from GA graphs of all lower limb joints were identified and calculated in order to quantify the gait strategy of analyzed participants. Statistical analysis was conducted using parametric and non-parametric tests (p<0.05).

Results: Clinical evaluation revealed that 63% of limbs (Group 1) exhibited excessive femoral anteversion while 37% (Group 2) did not present this feature. In particular, both groups were characterized by a blunt peak of knee flexion during swing phase (less than normal peak), representative of spasticity of rectus femoris muscle, 1,2 but two different gait strategies were found in terms of the timing of maximum knee flexion during swing phase (KMSw index). Group I exhibited a reduced value of the KMSw index, with its timing close to normative data and excessive hip internal rotation, represented by the hip rotation at toe-off (HTO) parameter that is correlated with increased femoral anteversion. Group 2 presented a reduced peak of knee flexion in swing and a significant delay of its timing with hip rotation close to normative data. No significant difference was exhibited with regard to other lower limb joints.

Conclusions: Results obtained in the study demonstrated that the presence of reduced peak of knee flexion in swing was associated with excessive femoral anteversion, represented by the HTO index. In the presence of reduced peak of knee flexion in swing together with a significant delay of its timing, rectus femoris spasticity may be due to rectus spasticity added to an uncorrected motor selective control. These results are crucial from a clinical viewpoint for decision-making in treatment options (i.e. derotative femoral osteotomy vs rectus transfer).


  1. 1. DeLuca PA, Davis RB, Ounpuu S, Rose S, Sirkin R. (1997)
  2. 2. Alterations in surgical decision making in patients with cerebral palsy based on three-dimensional gait analysis. J Paediatr Orthopaed 17: 608-614.\
  3. 3. Gage JR, editor. (2004) The Treatment of Gait Problems in Cerebral Palsy. Clinics in Developmental Medicine No. 164-5.
  4. 4. London: Mac Keith Press.
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