Hösl Matthias, Böhm Harald, Seltmann Michaela, Dussa Chakravarthy Ugandhar, Döderlein Leonhard
Schön Klinik Bad Aibling, Hospital for Neurology and Neurological Rehabilitation, Kolbermoorer Str. 72, 83043, Bad Aibling, Germany.
Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH, Bernauer Str. 18, 83229, Aschau im Chiemgau, Germany.
Gait Posture. 2018 Feb;60:28-34. doi: 10.1016/j.gaitpost.2017.11.006. Epub 2017 Nov 10.
Patella-alta is very common in patients with Cerebral Palsy (CP). While several diagnostic x-ray indices have been developed for patella-alta in general, the specific relationship with walking dysfunction in CP is only partly understood.
33 participants with bilateral spastic CP between 4 and 20 years (GMFCS I-II without previous surgery) that underwent 3D gait analysis as well as a radiographic exam within 0.8 (SD 1.2) months were retrospectively included. The Caton-Deschamps, the Insall-Salvati and the Koshino-Index, as well as the moment-arms of the quadriceps, the pattelar-tendon length and patellar tilt angle were analyzed from x-rays. During gait, tempo-spatial parameters, the knee flexion kinematics, the knee moments and the moment impulse were calculated and correlated to x-ray parameters.
Smaller quadriceps moment-arms were related to slower walking speed (r=0.48, P=0.005) and less knee extension during stance (r=0.68 P<0.001). Smaller quadriceps moment arms and longer patellar-tendons were also significantly related to a larger knee flexion moment impulse in the second half of the stance phase (r=-0.36, P=0.045 and r=0.39, P=0.028) and hence to more abnormal knee loads. Yet, none of the traditional indices was related to any parameter of gait.
Traditional radiographic indices for patella-alta possess little to no informative value for walking dysfunction in individuals with CP suspected to have knee pathology. Smaller moment-arms are a key feature of patellofemoral pathology in CP reducing the knee extensor mechanism, an aspect which is not sufficiently picked up by traditional indices.
髌骨高位在脑瘫（CP）患者中非常常见。虽然一般已开发出多种用于诊断髌骨高位的X线指标，但与CP患者步行功能障碍的具体关系仅得到部分了解。
回顾性纳入33例4至20岁的双侧痉挛性CP患者（GMFCS I-II级，未接受过手术），这些患者在0.8（标准差1.2）个月内接受了三维步态分析以及X线检查。从X线片中分析了Caton-Deschamps、Insall-Salvati和Koshino指数，以及股四头肌的力臂、髌腱长度和髌骨倾斜角度。在步态分析过程中，计算了时空参数、膝关节屈曲运动学、膝关节力矩和力矩冲量，并将其与X线参数进行关联。
较小的股四头肌力臂与较慢的步行速度相关（r = 0.48，P = 0.005），且与站立期膝关节伸展减少相关（r = 0.68；P < 0.001）。较小的股四头肌力臂和较长的髌腱也与站立期后半段较大的膝关节屈曲力矩冲量显著相关（r = -0.36，P = 0.045和r = 0.39，P = 0.028），因此与更异常的膝关节负荷相关。然而，没有一个传统指标与任何步态参数相关。
对于怀疑有膝关节病变的CP患者，传统的髌骨高位X线指标对步行功能障碍几乎没有信息价值。较小的力臂是CP患者髌股关节病变的一个关键特征，它会降低膝关节伸展机制，而这一方面传统指标并未充分体现。
