Brunner R, Krauspe R, Romkes J
Neuroorthopädische Abteilung, Kinderorthopädische Universitäts-Klinik, Universitäts-Kinderspital beider Basel, Schweiz.
Orthopade. 2000 Sep;29(9):808-13. doi: 10.1007/s001320050530.
Patients with spastic cerebral palsy often develop torsional deformities at the level of hip, shank or foot. The abnormal muscle activity such as spasticity or the increase of tone are considered as the major cause. The present study shows that the gait pattern is another cause which may lead to deformities. The study is based on gait analysis of 13 patients and 8 normal controls. The major and significant differences in gait kinematics were toe walking, toeing-in and internal rotation at the hip in the patients whereas the unaffected control group had a physiological heel-toe gait. The difference in torsional moments at the hip, knee and ankle were statistically significant. At the knee and the ankle a decrease in the internal rotation moment was found, whereas at the hip a paradoxical curve pattern with a more externally directed rotation moment was seen. These differences in torsional moments can explain the external rotation at the foot and/or shank as well as the increase in femoral anteversion, although they might be primarily caused by the deformity itself. Because a constantly acting force, however, changes the bony form and/or shape, the abnormal moments can be considered as a factor leading to deformities. A heel-toe gait seems to be mandatory for an efficient prophylaxis. Torsional deformities at the shank require a corrective osteotomy which is performed at the supramalleolar site and fixed by an unilateral, external fixator. Malrotations at the hip usually show two components: the functional part can be corrected by lengthening and weakening the tensor fasciae latae and the ventral parts of the glutei, using stretching exercises, botulinum toxin A or operative lengthening and releases. The increased femoral anteversion needs to be corrected by a femoral derotation osteotomy. Patients with cerebral palsy show a reduced control of their legs; therefore, balance internal torsion should not be corrected to neutral and overcorrection must be avoided. A remaining slight internal rotation after correction will help to spontaneously stabilize the leg if it gives way at initial contact, by "falling underneath the centre of gravity". If the leg is in neutral or external rotation, the patient needs to realign the centre of gravity over the dynamically unstable leg, showing a trunk-lean over the leg, the Duchenne limp.
痉挛型脑瘫患者常在髋部、小腿或足部出现扭转畸形。异常的肌肉活动，如痉挛或肌张力增加，被认为是主要原因。目前的研究表明，步态模式是另一个可能导致畸形的原因。该研究基于对13例患者和8名正常对照者的步态分析。患者在步态运动学方面的主要且显著差异为足尖行走、内收足和髋关节内旋，而未受影响的对照组则呈现生理性的足跟到足尖步态。髋、膝和踝关节扭转力矩的差异具有统计学意义。在膝关节和踝关节处，内旋力矩减小，而在髋关节处，出现了一种矛盾的曲线模式，即外旋力矩更大。这些扭转力矩的差异可以解释足部和/或小腿的外旋以及股骨前倾增加，尽管它们可能主要由畸形本身引起。然而，由于持续作用的力会改变骨骼的形态和/或形状，异常力矩可被视为导致畸形的一个因素。足跟到足尖步态似乎是有效预防的必要条件。小腿的扭转畸形需要在踝关节上部位进行截骨矫正，并通过单侧外固定器固定。髋关节旋转不良通常表现为两个部分：功能性部分可通过拉伸运动、肉毒杆菌毒素A或手术延长及松解来延长和减弱阔筋膜张肌及臀肌前部来矫正。增加的股骨前倾需要通过股骨旋转截骨术来矫正。脑瘫患者对其腿部的控制能力下降；因此，不应将平衡内旋矫正至中立位，必须避免过度矫正。矫正后仍残留的轻微内旋，如果在初始接触时腿部发软，通过“向重心下方掉落”，将有助于自发稳定腿部。如果腿部处于中立位或外旋位，患者需要将重心重新调整到动态不稳定的腿部上方，表现为躯干向腿部倾斜，即杜兴氏跛行。
