Gait & Posture 64 (2018) 119–125

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Gait & Posture

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Full length article

Long-term outcomes over 10 years after femoral derotation osteotomy in T

ambulatory children with cerebral palsy
Ki Hyuk Sunga,1, Soon-Sun Kwonb,1, Chin Youb Chunga, Kyoung Min Leea, Gyeong Hee Choa,
⁎
Moon Seok Parka,
a
Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Gyeonggi, South Korea
b
Department of Mathematics, College of Natural Sciences, Ajou University, Gyeonggi, South Korea

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Femoral derotation osteotomy (FDO) is generally reported to be excellent for correcting the hip
Femoral derotation osteotomy rotation and foot progression angles in children with cerebral palsy (CP). However, it is unclear how long the
Cerebral palsy favorable outcomes are maintained.
Anteversion Research question: This study was performed to evaluate the long-term outcomes at more than 10 years after FDO
Gait analysis
in children with CP.
Methods: FDO, as part of single event multilevel surgery to improve gait function, was performed at the inter-
trochanteric level with the patient in the prone position. The goal of the index surgery was femoral anteversion
of 15°, measured using a modified trochanteric prominence angle test intraoperatively. All patients underwent
three-dimensional gait analysis preoperatively and at 1 year and over 10 years postoperatively.
Results: Thirty-four ambulatory patients (53 hips) with CP undergoing FDO were included. The mean age at
surgery was 7.8 years (SD = 3.0 years) and mean follow-up duration was 12.9 years (SD = 2.7 years). The mean
hip rotation decreased significantly from 9.6° preoperatively to 3.1° at 1 year postoperatively (p = 0.004), and
decreased significantly to -5.9° at the final follow-up (p < 0.001). The mean foot progression in stance de-
creased from 7.9° preoperatively to −7.4° at 1 year postoperatively (p < 0.001), and was maintained at -10.9°
at the final follow-up. The GDI significantly improved from 68.2 preoperatively to 83.4 1 year postoperatively
(p < 0.001), and was maintained at 82.3 at the final follow-up. No patients underwent revision surgery due to
recurrence of rotation deformity.
Significance: Proximal FDO performed in the prone position provides favorable long-term outcomes at more than
10 years postoperatively, without recurrence of rotation deformity. To avoid under-correction or recurrence due
to insufficient derotation, surgeons should consider not only dynamic gait analysis findings but also the mea-
surement of anatomic femoral anteversion during intraoperative derotation.

1. Introduction rotation may be a compensatory mechanism to preserve abduction

In-toeing gait due to increased femoral anteversion is the most
commonly seen transverse plane deformity in children with cerebral
palsy (CP) [1,2]. Gait problems associated with increased femoral
anteversion include excessive internal hip rotation in all gait phases,
leading to internal foot progression angle and poor foot clearance with
excessive shoe wear, which causes increased tripping and falling, as
well as a cosmetically poor gait pattern [3]. Increased femoral ante-
version decreases the abduction moment arm of the hip abductors and
this moment arm is restored with internal rotation; thus internal
capacity [4]. Femoral derotation osteotomy (FDO) is indicated to cor-
rect in-toeing gait and gait problems due to excessive femoral ante-
version in patients with CP [5].
FDO is generally reported to be excellent for correcting the hip ro-
tation and foot progression angles in children with CP [5–13]. How-
ever, it is unclear how long the favorable outcomes are maintained.
Several studies evaluating the long-term outcomes of FDO showed re-
currence rates between 0 and 39% [14–21]. The authors of these stu-
dies reported that the risk factors included the patient’s age at surgery,
greater plantar flexion, decreased hip abductor impulse and work,

⁎
Corresponding author at: Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-Gu, Sungnam, Gyeonggi, 13620, South
Korea.
E-mail address: pmsmed@gmail.com (M.S. Park).
1
Ki Hyuk Sung and Soon-Sun Kwon contributed equally to the writing of this article.

https://doi.org/10.1016/j.gaitpost.2018.06.003
Received 4 December 2017; Received in revised form 23 May 2018; Accepted 3 June 2018
0966-6362/ © 2018 Elsevier B.V. All rights reserved.
K.H. Sung et al.
decreased ankle joint impulse, greater hamstring and adductor spasti-
city, recurrence of flexed knee gait, and reduced preoperative walking
speed.
In this study, we evaluated the long-term outcomes at more than
10 years after FDO in children with CP. We hypothesized that the im-
provements in CP in children undergoing would be maintained for more
than 10 years postoperatively.
2. Materials and methods
This retrospective study was approved by the institutional review
board of our hospital, which is a tertiary referral center for patients
with CP. The need to acquire informed consent was waived due to the
retrospective nature of the study.
The inclusion criteria were: (1) consecutive ambulatory patients
with spastic CP; (2) patients who underwent single event multilevel
surgery (SEMLS) including FDO between 1995 and 2006; and (3) pa-
tients who underwent three-dimensional (3D) gait analyses pre-
operatively and at 1 year and more than 10 years postoperatively. The
exclusion criteria were: (1) patients with a history of gait-correcting
surgery and (2) patients who had incomplete or missing 3D gait ana-
lysis data. The age at the time of surgery, sex, follow-up duration, Gross
Motor Function Classification System (GMFCS) level, anatomical type
(unilateral vs. bilateral involvement) of CP, and details of concomitant
surgeries were obtained from the patients’ medical records.
2.1. Operative protocol
FDO, as part of a SEMLS to improve the patient’s gait pattern, was
performed by a single pediatric surgeon (CYC) with 28 years of ex-
perience in pediatric orthopedics. The surgical procedures were per-
formed after considering both the clinical and gait analysis findings.
The indications for FDO were in-toeing gait with increased femoral
anteversion and internal foot progression with increased hip internal
rotation.
All patients underwent FDO at the intertrochanteric level, and the
osteotomy site was internally fixated with a blade plate (Stryker,
Selzach, Switzerland). FDO was performed with the patients in the
prone position, and the goal of the index surgery was femoral ante-
version of 15° [8]. The amount of derotation was determined not by the
parameters of the gait analysis, but by an intraoperative physical ex-
amination, which was the modified trochanteric prominence angle test
(TPAT). A guide pin was inserted parallel to the femoral neck axis on a
frog-leg lateral hip radiograph. Intertrochanteric osteotomy was per-
formed with an oscillating saw, and derotation was performed until the
modified TPAT reached 15°. The modified TPAT is defined as the angle
between a vertical line and the long axis of the leg when the guide pin
was located horizontal to the ground (Fig. 1A–B).
All patients had a postoperative non-weight bearing period of 4–6
weeks, depending on the type of concomitant surgery. Subsequently,
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Gait & Posture 64 (2018) 119–125
the patients were referred to a local rehabilitation center to perform
muscle-strengthening exercises and receive gait training. Hardware
removal was performed more than 1 year after the initial operation.
2.2. Acquisition of kinematic data and gait deviation index (GDI) score
A 3D gait analysis was performed 1 or 2 days before the surgery
using a Vicon 370 system (Oxford Metrix, Oxford, UK) that was
equipped with 7 cameras and 2 force plates. Markers were placed as for
the Helen Hayes marker set, by a skillful operator with 21 years of
experience for consistent anatomical landmark identification and
marker positioning [22]. Patients walked barefoot on a 9-m
walkway > 3 times, and 3 trials that represented a patient’s typical gait
pattern were selected. The data of the 3 trials were averaged to obtain
the values of the index variables. The 3D gait analysis was repeated at
1 year and more than 10 years postoperatively. The gait deviation index
(GDI) was calculated using pelvic and hip kinematic data in all three
planes, knee and ankle data in the sagittal plane, and foot progression
with control data as described by Schwartz [23]. A GDI score > 100
denotes a non-pathological gait, and each 10-point decrement below
100 indicates 1 standard deviation from normal kinematics. Relevant
kinematic values, including the mean pelvic rotation, mean hip rota-
tion, foot progression in the stance phase, and GDI score, were the
outcome measures.
2.3. Statistical analyses
The preoperative gait kinematics and GDI score were compared
with values obtained at 1 year postoperatively and at the final follow-
up, using repeated-measures analysis of variance with a Bonferroni post
hoc test.
To consider bilateral cases, a linear mixed model (LMM) was ap-
plied for statistical analysis [24]. The annual postoperative changes in
gait kinematics and GDI were adjusted for multiple factors using the
LMM, with sex, age at the time of surgery, GMFCS level, anatomical
type, DHL and TAL or Strayer procedure as the fixed effect model, and
follow-up duration, laterality (left or right), and each subject as the
random effect model. All statistical analyses were conducted using SAS
9.4.2 (SAS Institute, Cary, NC, USA) and R version 3.2.5 (R Foundation
for Statistical Computing, Vienna, Austria); all statistics were two-
tailed, and p-values < 0.05 were considered significant.
3. Results
Between 1995 and 2006, we performed FDO in 268 children. After
applying the exclusion criteria, 234 patients were excluded and 34
children with 53 hips were finally included in the study. The majority of
the patients had bilateral involvement (25 patients), based on an ana-
tomical type; and GMFCS level II (20 patients), based on a functional
classification. The mean follow-up duration was 12.9 ± 2.8 years
Fig. 1. (A) A guide pin is inserted parallel to
the femoral neck axis on a frog-leg lateral hip
radiograph, and intertrochanteric osteotomy
and derotation are performed until the mod-
ified TPAT reaches 15°. (B) The modified TPAT
is defined as the angle between a vertical line
and the long axis of the leg when a guide pin is
located horizontal to the ground.
K.H. Sung et al. Gait & Posture 64 (2018) 119–125

Table 1 follow-up for each hip. The change in mean hip rotation was divided
Patients demographics and summary of concomitant surgeries. into 4 groups (< 5°, 5–10°, 10–15°, and > 15°) according to Dreher’s
Value method [20]. Of the 9 hips, 2 (22.2%) showed an increase less than 5°,
5 (55.6%) showed an increase between 5 and 10°, and 2 (22.2%)
Sex (male/ female) 19/ 15 showed an increase between 10 and 15°. No hip showed a recurrence of
Laterality (right/ left) 24/ 29
more than 15° of mean hip rotation and no hip underwent revision
Anatomical type (hemiplegia / diplegia) 9 / 25
GMFCS level (I / II) 14 / 20
surgery due to the recurrence of rotation deformity.
Age at surgery (years) 7.8 ± 3.0 (4.9–17.1) When evaluating the factors that affected transverse kinematics and
Age at final follow-up (years) 20.8 ± 3.8 (16.1–30.4) GDI in serial postoperative gait analyses, we found that the mean hip
Follow-up duration (years) 12.9 ± 2.7 (10.0–21.0) rotation and foot progression in stance phase significantly improved by
No. of 3D gait analysis 3 (3–5)
follow-up duration (0.85° and 0.33° per year; p < 0.001 and p = 0.016,
Concomitant surgery Limbs respectively). However, the mean pelvic rotation and GDI did not
FDO 53 (100%)
changed by follow-up duration (p = 0.490 and p = 0.268, respec-
DHL 50 (94.3%)
RFT 39 (73.6%) tively). The mean hip rotation and foot progression in stance phase
TAL or Strayer procedure 49 (92.5%) were not significantly affected by other factors including the patient’s
Adductor tenotomy 12 (22.6%) sex, age at surgery, laterality, anatomical type of CP, GMFCS level, DHL
Foot surgery 14 (26.4%) and TAL or Strayer procedure. The GDI score was significantly affected
Total 217 (4.1 per one limb)
by the anatomical type of CP (p = 0.025). The GDI score in patients
GMFCS, gross motor functional classification system; FDO, femoral derotation with hemiplegia was significantly higher than in those with diplegia, by
osteotomy; DHL, distal hamstring lengthening; RFT, rectus femoris transfer; 6.43. The mean pelvic rotation was significantly affected by the GMFCS
TAL, tendo-Achilles lengthening. level (−2.98°; p = 0.034) (Table 3).

(range: 10.0–21.0 years). The total number of surgical procedures, in-
cluding FDO, was 209 (4.1 procedures per limb). The number of 3D gait
analyses per patients ranged between 3 and 5, and 7 patients (11 limbs)
underwent 3D gait analyses more than four times (Table 1).
The mean hip rotation significantly decreased from 9.6° pre-
operatively to 3.1° at 1 year postoperatively (p = 0.004), and sig-
nificantly decreased to −5.9° at the final follow-up (p < 0.001). The
mean foot progression angle in the stance phase significantly decreased
from 7.9° preoperatively to −7.4° at 1 year postoperatively
(p < 0.001), and was maintained at −10.9° at the final follow-up
(p = 0.255). The mean pelvic rotation significantly increased from
−2.5° preoperatively to 0.3° at 1 year postoperatively (p = 0.008), and
was maintained at 1.7° at the final follow-up (p = 0.525) (Fig. 2). The
GDI significantly improved from 68.2 preoperatively to 83.4 at 1 year
postoperatively (p < 0.001), and was maintained at 82.3 at the final
follow-up (p = 0.094) (Table 2). In terms of sagittal kinematics, mean
pelvic tilt, knee flexion at initial contact, and ankle dorsiflexion at in-
itial contact were improved after SEMLS.
At final follow-up, increased hip external rotation was observed in
44 hips and, with increased hip internal rotation in 9 hips, from post-
operative 1 year. The amount of recurrence was calculated by the dif-
ference in mean hip rotation between postoperative 1 year and final
4. Discussion
In-toeing gait due to increased femoral anteversion is a common gait
deformity in ambulatory children with CP, and it is commonly treated
with FDO. Although the procedure’s short-term effectiveness is gen-
erally accepted, maintenance of long-term correction is controversial.
Therefore, we investigated the long-term outcome at more than
10 years after FDO in children with CP. We demonstrated that FDO,
performed with the patient in the prone position, provided a favorable
long-term outcome for more than 10 years, without recurrence of ro-
tation deformity, in children with CP.
A number of studies have reported that FDO has satisfactory short-
term outcomes in patients with CP (Table 4). Additionally, Ounpuu
et al. found that correction that was achieved with FDO was well-
maintained 5 years postoperatively, without the recurrence of defor-
mity [14]. However, several studies investigating the long-term out-
come of FDO showed that immediate improvement in transverse ki-
nematics deteriorated throughout the follow-up period. De Morais Filho
et al. reported that the recurrence rate after FDO was 9.5%, and re-
currence could be related to younger age [19]. They also showed that
internal hip rotation deformities were not corrected in 33.3% of pa-
tients, and it was related to iatrogenic under-correction due to the

Fig. 2. Graphs of average transverse and sagittal plane kinematics for all patients are shown. In all graphs, the solid line represents the average value, and the gray
area represents one standard deviation of normal control.

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K.H. Sung et al. Gait & Posture 64 (2018) 119–125

Table 2
Kinematic data and GDI before and after femoral derotation osteotomy.
Parameters Preoperative Postoperative Final p-value
(1 years) follow-up
Preop-1Y Preop-10Y 1Y-final RM-ANOVA

Mean pelvic rotation (˚)a

−2.5 ± 7.7 0.3 ± 5.4 1.7 ± 6.2 0.008 0.004 0.525 < 0.001
Mean hip rotation (˚) a 9.6 ± 12.2 3.1 ± 9.3 −5.9 ± 8.1 0.004 < 0.001 < 0.001 < 0.001
Mean foot progression in stance (˚) a 7.9 ± 16.3 −7.4 ± 11.3 −10.9 ± 11.3 < 0.001 < 0.001 0.094 < 0.001
Mean pelvic tilt (˚) 18.2 ± 6.6 17.2 ± 4.9 14.5 ± 5.5 0.997 0.005 0.002 < 0.001
Knee flexion at initial contact (˚) 32.9 ± 12.0 22.2 ± 9.0 23.6 ± 10.2 < 0.001 < 0.001 0.666 < 0.001
Ankle dorsiflexion at initial contact (˚) −6.5 ± 10.5 3.7 ± 6.6 1.5 ± 7.4 < 0.001 < 0.001 0.044 < 0.001
GDI 68.2 ± 8.7 83.4 ± 8.5 82.3 ± 9.5 < 0.001 < 0.001 1.000 < 0.001

a
Negative value indicates external rotation; GDI, gait deviation index; RM-ANOVA, repeated measures analysis of variance.

amount of correction undertaken. Dreher et al. reported that the mean
hip rotation and foot progression angles significantly improved at
1 year postoperatively, but both kinematic parameters deteriorated by
5° at the 6-year follow-up [20]. Furthermore, 15% of legs showed se-
vere deterioration or complete recurrence of internally rotated gait.
Kim et al. reported that recurrence of in-toeing gait in CP patients oc-
curred in 33.3% of femurs 5 years after correction, and patients un-
dergoing surgery before the age of 10 were more likely to show dete-
rioration than older patients [15]. Boyer et al. found that internal hip
rotation recurred after FDO in 12% of cases, of which half were con-
sidered problematic [21]. Church et al. reported that the improvement
after FDO recurred in 39% of limbs during long-term follow-up (7.2
years) and that recurrence was associated with higher spasticity of the
hamstring and adductor and lower gait velocity [16]. In the current
study, no hips showed a recurrence of internal rotation of more than 15°
at 13 years of follow-up. Our analysis showed than mean hip rotation
and foot progression angle in the stance phase were not significantly
affected by age at surgery. There was no significant difference in age,
sex, anatomical type of CP and GMFCS level between children who
showed a recurrence of mean hip rotation and those who showed no
recurrence of mean hip rotation. However, other factors such as,
hamstring and adductor spasticity and walking speed were not included
in our model because of retrospective nature of study. Therefore, we
think that additional long-term follow-up study with a larger cohort is
needed to delineate risk factors for the recurrence of hip internal ro-
tation deformity.
It is commonly accepted that deterioration can be expected during
the development of children with CP, especially during the pubertal
growth spurt [25]. However, the present study showed that recurrence
of deformity did not occur postoperatively at an average of 13 years,
although most of the included patients were beyond the pubertal
growth spurt phase at the final follow-up. Ounpuu et al. reported that
improvement in the mean hip rotation in stance phase and the mean
foot progression angle after FDO in children with CP were also main-
tained throughout the follow-up period, and that only 9% of hips
showed a recurrence of internal hip rotation of > 15° [18]. Svenningsen
et al. found in a prospective study that the mean increase in femoral
anteversion after FDO in children without neuromuscular disease was
minimal: only 6° during 9 years’ follow-up (0.7° per year) [26].
Determining the amount of intraoperative derotation is critical
when performing FDO. The derotation angle can be determined ana-
tomically with the femoral anteversion or hip rotation angle or dyna-
mically with the hip rotation or foot progression angle during the stance
phase of a gait analysis. In most previous studies, the amount of dero-
tation was determined using a neutral clinical midpoint between pas-
sive internal and external rotation [27] or by gait analysis findings.
Niklasch et al. reported that determining the derotation amount using
gait analysis had a superior outcome compared to clinical examination
[28]. Braatz et al. found that there was a weak correlation (r = 0.317)
between the extent of intraoperative derotation and the changes in the
mean hip rotation in stance phase [10]. They reported that only 60% of
the intraoperative extent of derotation was reflected in the findings of
3D gait analysis; thus, determining the intraoperative extent of dero-
tation according to the mean hip rotation in stance phase seems to give
the best results. Dreher et al. showed that there was a high rate of over-
and under-correction after FDO in less-involved limbs considering the
clinical midpoint, and reported that the degree of derotation should be
determined more conservatively by including gait analysis data, espe-
cially to avoid overcorrection [5]. However, they reported only the 1-
year short-term outcome after FDO and included all patients who un-
derwent proximal or distal femoral osteotomy. Therefore, we think that
these findings are not generally applicable.
Kim et al. showed that the amount of correction for the foot pro-
gression angle and hip rotation after FDO was only about half of the
surgical derotation angle [12]. Lee et al. reported that femoral ante-
version and tibial torsion accounted for only 24.7% of the foot pro-
gression angle [29]. Other structural factors such as trunk muscle bal-
ance, spinal deformity, balance between the external and internal
rotators, and selective motor control could affect rotational gait pro-
blems. Therefore, determining the derotation angle using only a dy-
namic gait analysis such as the hip rotation or foot progression angle
may result in under-correction of femoral anteversion or recurrence of

Table 3
Factors affecting GDI score and transverse kinematics of 3-dimensional gait analysis after femoral derotation osteotomy.
Mean hip rotation (°) Foot progression in stance (°) Mean pelvic rotation (°) GDI

Estimation SE p-value Estimation SE p-value Estimation SE p-value Estimation SE p-value

Follow up (year) −0.85 0.14 < 0.001 −0.33 0.13 0.016 0.06 0.09 0.490 −0.12 0.11 0.268
Sex (Male) 0.85 2.01 0.686 −6.41 3.84 0.100 −0.34 1.21 0.778 2.19 2.13 0.308
Age at surgery 0.41 0.35 0.243 −0.43 0.64 0.509 −0.11 0.22 0.610 −0.56 0.36 0.132
Side (Rt) −1.86 1.66 0.278 0.241 1.72 0.892 2.14 1.08 0.063 0.18 1.28 0.888
Anatomical type (Hemiplegia) −0.88 3.27 0.788 −2.72 5.85 0.643 −2.52 1.66 0.134 6.43 2.75 0.022
GMFCS level (I) 3.51 2.29 0.130 2.02 4.16 0.630 −2.98 1.37 0.034 3.47 2.40 0.154
DHL 6.65 4.91 0.181 −7.67 8.14 0.350 −4.91 3.13 0.122 6.38 5.04 0.210
TAL or Strayer −2.6 3.6 0.472 8.22 7.52 0.279 4.81 2.14 0.028 −6.45 4.33 0.141

GDI, gait deviation index; SE, standard error; GMFCS, gross motor functional classification system; DHL, distal hamstring lengthening; TAL, tendo-Achilles
lengthening.

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 K.H. Sung et al.
Table 4
Previous studies investigating the outcomes after femoral derotation osteotomy.
Author No. of Ostesotomy site Age at surgery (years) Follow-up duration Mean hip rotation (°) Foot progression (°) Mean pelvic rotation
Hips (years)
pre post p-value pre post p-value pre post p-value

Church [16] 99 Proximal 10 ± 4 7.2 ± 3.2 14 ± 12 4 ± 13(2.1Y) < 0.001 13 ± 17 −1 ± 14 < 0.001
9 ± 14 < 0.05 0 ± 14 > 0.05
Niklasch [17] 90 (sustained) Proximal or distal 10.9 ± 3.2 8.0 ± 2.2 25 ± 11 1 ± 12(1.1Y) < 0.05
3 ± 12 > 0.05
32 7.6 ± 2.1 8.5 ± 2.2 26 ± 28 4 ± 10(1.1Y) < 0.05
(recurrence) 22 ± 10 < 0.05
Dreher [20] 59 10.5 ± 3.6 8.6 ± 1.8 17 ± 14 −1 ± 11(1Y) < 0.001 17 ± 16 −3 ± 10 < 0.001 0±8 1±6 > 0.05
4 ± 13 0.004 3 ± 11 0.001 1±7 > 0.05
Kim [15] 45 Distal 9.2 6.5 27 ± 12 9 ± 10(1Y) < 0.001 20 ± 21 −4 ± 14 < 0.001
17 ± 11 0.013 −2 ± 14 0.862
Ounpuu [14] 27 Proximal (19) or distal (8) 8.1 ± 3 5.2 20 ± 8 2 ± 10(1Y) < 0.05 5 ± 17 −11 ± 16 < 0.05 −5 ± 7 −2 ± 6 > 0.05
4 ± 14 > 0.05 −12 ± 14 > 0.05 −2 ± 8 > 0.05
Dreher [5] 30 (more involved) Proximal (12) or distal (45) 10 ± 2.9 0.9 24 ± 10 1±9 < 0.05 15 ± 17 −6 ± 9 < 0.05 −1 ± 7 −2 ± 7 > 0.05
123

27 (less involved) 10 ± 8 0 ± 14 < 0.05 13 ± 12 −1 ± 9 < 0.05 1±7 2±7 > 0.05
Kay [7] 27 Proximal or distal 9.7 ± 3.1 1.6 11 ± 11 −10 ± 16 0.02 16 ± 21 −3 ± 32 < 0.05
51 8.6 ± 2.4 14 ± 12 −4 ± 15 0.001 18 ± 12 −3 ± 16 0.0007
Kwon [8] 50 Proximal 6.8 ± 1.5 1.0 ± 0.2 9±2 3±1 0.004 −1 ± 2 −10 ± 2 < 0.001
MacWilliams [9] 46 12.2 ± 2.8 1.0 ± 0.3 7±9 −6 ± 10 < 0.001 7±7 −6 ± 8 < 0.001
Braatz [10] 56 Proximal (15) or distal (41) 11.6 ± 2.9 1.1 ± 0.2 14 ± 15 0 ± 10 < 0.001 11 ± 16 −1 ± 8 < 0.001
Saglam [13] 175 6.2 ± 3.1 6.3 ± 3.7 −14 ± 4 6±3 0.01 8 ± 13 −17 ± 11 0.005 0±1 −1 ± 1 0.336
Boyer [21] 131 Proximal 7.3 ± 1.8 5.3 14 ± 9 3 ± 10(1.8Y) < 0.05
4 > 0.05
McMulkin [11] 77(GMFCS I &II) proximal or distal 12.1 1.1 14 −2.0 < 0.05 11.3 −5 < 0.05 −6.2 −7.2 −2 < 0.05
21(GMFCS III) 10.1 1 13 −4 < 0.05 8 −11 < 0.05 −5 > 0.05
Kim [12] 18 (bilateral) Distal 13.2 3.8 16 ± 20 1 ± 12 < 0.05 −2 ± 12 −14 ± 11 < 0.05 0 ± 11 1 ± 13 > 0.05
10 (unilateral) 7±8 1±6 < 0.05 3 ± 11 −10 ± 6 < 0.05 1±8 0±7 > 0.05
Ounpuu [18] 27 proximal (18) or distal (9) 8 ± 3.3 11.3 ± 1.9 21 ± 9 0 ± 9(1.6Y) < 0.001 9 ± 16 −14 ± 13 < 0.001 −2 ± 6 0±6 > 0.05
1±8 > 0.05 −13 ± 16 > 0.05 1±8 > 0.05
Chung [34] 34 proximal 8.0 1.8 11 ± 2 4±2 < 0.001 1±2 −14 ± 2 < 0.001 −9 ± 1 −2 ± 1 < 0.001
Current study 43 Proximal 7.8 ± 3.0 12.9 ± 2.8 10 ± 12 3 ± 9(1.2Y) < 0.001 8 ± 16 −7 ± 11 < 0.001 −3 ± 8 0±5 0.008
−6 ± 8 < 0.001 −11 ± 11 0.255 2±6 0.525

Negative value indicates external rotation.

Gait & Posture 64 (2018) 119–125

K.H. Sung et al.
in-toeing gait.
Accurately assessing the amount of femoral derotation in-
traoperatively is difficult. FDO can be performed in patients in the su-
pine or prone position. In the supine position, two Kirschner wires that
are placed on each side of the osteotomy site can be served as guides to
provide rotation control. This technique can control the amount of
derotation, but assessing postoperative femoral anteversion is difficult.
However, performing the FDO procedure in the prone position allows
for the evaluation of hip internal and external rotation while the hip is
in extension and the knee in flexion. Furthermore, femoral anteversion
after FDO can be assessed easily using the TPAT, which has been proved
to be a clinically relevant method for evaluating femoral anteversion
[30]. At our institution, we routinely perform FDO with patients in the
prone position, and the goal of FDO is femoral anteversion of 15°. The
amount of derotation was determined not by the parameters of a gait
analysis, but by an intraoperative physical examination with the mod-
ified TPAT. Therefore, we think that performing FDO in the prone po-
sition may result in uniform surgical outcomes regarding femoral
anteversion.
Compensatory external pelvic rotation is associated with internal
rotation of hip deformities [31]. Pelvic retraction can be secondary to
biomechanical problems such as muscular shortening, and may even be
a voluntary response to internal rotation of the lower limb to improve
the foot progression angle [32]. Our study showed that the mean pelvic
rotation was significantly improved from −2.5° to 0.3° after FDO,
which was consistent with the results of previous studies [14,33,34].
Our result indicates that compensated pelvic retraction was corrected in
patients with hemiplegia after FDO. Furthermore, the maintenance of
pelvic rotation at more than 10 years postoperatively indicates that the
correction of in-toeing gait was also maintained, without recurrence.
This study has some limitations. First, this was a retrospective study;
therefore, the follow-up intervals varied. Therefore, we used an LMM to
overcome the unbalanced structure of our data set and focused on the
multiple factors that could influence the improvement and annual
change in transverse kinematics after FDO. Second, the outcomes after
FDO were evaluated with a 3D gait analysis. Although functional im-
provements after FDO are important, these objective measures may not
correlate well with functional and psychosocial outcomes [35]. There-
fore, further studies are required to evaluate the functional and health-
related quality of life outcomes. Thirds, there might be a selection bias
because about 87% of patients who underwent FDO met exclusion
criteria. In addition, this study included only patients with GMFCS level
I and II because patients with GMFCS level III who underwent FDO
were excluded. Further study with a largeer cohort including patients
with GMFCS level III is required. Fourth, 94.3% of patients underwent
distal hamstring lengthening and 92.5% underwent triceps surae sur-
gery (TAL or Strayer procedure) concomitant with FDO in this study.
DHL and triceps surae surgery could influence the transverse kine-
matics. However, our analysis showed that the mean hip rotation and
foot progression in stance phase were not significantly affected by DHL
and triceps surae surgery. Further study is required to investigate the
effect of DHL and TAL or Strayer procedure on transverse kinematics.
However, the strengths of this study were: (1) most of the patients
experienced skeletal maturity during over 10-year follow-up period and
(2) all patients underwent a uniform surgical technique: proximal in-
tertrochanteric osteotomy in the prone position with the goal of femoral
anteversion of 15°.
In conclusion, proximal FDO performed in the prone position pro-
vided a favorable long-term outcome at more than 10 years post-
operatively, without recurrence of rotation deformity in children with
CP. To avoid undercorrection or recurrence of deformity due to in-
sufficient derotation, surgeons should consider not only dynamic gait
analysis findings, but also the measurement of anatomic femoral ante-
version during intraoperative derotation.
124
Gait & Posture 64 (2018) 119–125
Conflict of interest
There were no conflicts of interest in the preparation of this study.
Acknowledgments
This work was supported by the Technology Innovation Program of
the Ministry of Trade, Industry and Energy (MOTIE) of Korea
(10049785), by Projects for Research and Development of Police sci-
ence and Technology under Center for Research and Development of
Police science and Technology and Korean National Police Agency of
the Ministry of Science, ICT and Future Planning (Grant no. PA-
C000001-2015-202), and by SNUBH research fund (Grant no. 02-2012-
033). We thank Young Choi, MD for the illustration.
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