Acetabular retroversion in post slipped capital femoral epiphysis deformity.

PURPOSE: While the femoral deformity in post slipped capital femoral epiphysis (SCFE) hips has been implicated in the development of femoral acetabular impingement, little has been studied about the acetabular side. The purpose of our study was to determine the frequency of morphologic changes suggestive of acetabular retroversion in patients who have sustained a SCFE. METHODS: IRB approval was obtained and the records of patients from 1975 to 2010 were searched for ICD-9 codes for SCFE. A total of 188 patients were identified for the study. Two observers evaluated AP radiographs for evidence of acetabular retroversion as characterized by the presence of either an ischial spine sign or a crossover sign. Demographic data, date of onset, and treatment were recorded. For analysis, the right hip was used in patients with bilateral involvement. RESULTS: Of the 188 patients identified, 5 patients had an incorrect diagnosis and 41 patients had missing or inadequate films, leaving 142 patients (284 hips) for review. 57 patients (114 hips) had bilateral SCFE and 85 patients had unilateral SCFE. 79 % (n = 45) of the right hips with bilateral SCFE and 82 % (n = 70) of the unilateral involved hips had at least one sign of retroversion. Uninvolved hips had at least one sign of retroversion 76 % (n = 65) of the time. CONCLUSIONS: When compared to previously published values for normal patients, patients with SCFE appear to have an increased incidence of acetabular retroversion.

A comparison of the changes in the energy cost of walking between children with cerebral palsy and able-bodied peers over one year.

For ambulatory children with cerebral palsy, the assessment of walking energy efficiency is utilized to determine functional changes following surgical, pharmacologic, or orthotic interventions. While the assessment of energy efficiency is considered a useful outcome tool, minimal information exists about the changes in energy efficiency over one year in children with cerebral palsy at different gross motor function classification system (GMFCS) levels and whether the patterns of change are similar to their able-bodied peers. The purpose of this study was to determine whether energy efficiency variables change similarly over one year in children with cerebral palsy by GMFCS level and whether they differ from their age-matched peers. Forty-five able-bodied children and 34 children with cerebral palsy, GMFCS levels I-III participated in the study. Energy efficiency variables were measured at baseline and at 12 months using a Cosmed K4b2. All subjects walked at their self-selected velocity for testing around a 33 m track. Baseline velocity and net non-dimensional cost (NNcost) differed by GMFCS level and between the able-bodied peers and all GMFCS levels. Children in GMFCS level III had the highest cost and the slowest velocity. When controlling for age and baseline values, significant differences in the magnitude of change were seen in velocity between children in GMFCS level III and children in GMFCS level I and II and their able-bodied peers. In comparison to their able-bodied peers, all GMFCS levels had an increase in NNcost over one year when controlling for age and baseline NNcost, with the difference in magnitude increasing by GMFCS level. Consistent with the literature, children with cerebral palsy had an increase in NNcost over one year in comparison to their able-bodied peers, which increased with GMFCS level. This finding demonstrates that when evaluating the change in walking energy efficiency with maturation and therapeutic intervention, comparisons should be made by GMFCS level.

Botulinum toxin type A injection in alleviating postoperative pain and improving quality of life in lower extremity limb lengthening and deformity correction: a pilot study.

BACKGROUND: The Ilizarov technique is commonly used for lengthening and deformity corrections of the lower limbs in children. Postoperative pain can be significant, affecting quality of life and functional mobility, and often requiring prolonged medication use. Several studies have investigated the antinociceptive actions of botulinum toxin type A (BtX-A), yet evidence for its use in this population is limited. The objectives were to (1) establish the feasibility of a randomized clinical trial in children undergoing limb lengthening or deformity correction and (2) provide preliminary evidence of the beneficial effects of BtX-A in this population. METHODS: Fifty-two patients with a mean age of 13.7 years (range, 5 to 21 y) were randomized to receive either BtX-A or an equivalent volume of sterile saline solution (placebo group), as a single dose during the surgical procedure. Pain, medication use, quality of life, and functional mobility outcomes were assessed in all patients. Adverse events were reported for all patients and classified as minor or major. RESULTS: Differences between groups did not reach statistical significance; however, pain at mid-distraction was found to be slightly lower in the BtX-A group, as compared with the placebo group. Patients in the BtX-A group used less parenteral pain medication in the first 4 days after the surgery, had higher quality of life scores at 3 of the 5 time points assessed, and slightly higher functional mobility scores. All adverse events were expected complications of the lengthening process. No event was considered to be a serious adverse event related to the BtX-A injection itself. There was a trend toward fewer major adverse events in the BtX-A group. CONCLUSIONS: This pilot study established the feasibility of a randomized controlled trial design for in this population. Its findings indicate that BtX-A injections appear to be safe and effective for reducing pain and improving the quality of life and functional mobility of children undergoing lengthening or deformity corrections of the lower limbs. A larger-scale study is currently underway to confirm these preliminary findings.

Variability and minimum detectable change for walking energy efficiency variables in children with cerebral palsy.

For individuals with neuromuscular disorders, the assessment of walking energy efficiency is useful as a clinical outcome measure. Issues surrounding data collection methodology, normalization of the data, and variability and clinical utility of energy efficiency data preclude universal application. This study examined the variability and the clinical utility of velocity, energy efficiency index (EEI), gross cost, and net nondimensional cost (NNcost) in children and adolescents with spastic diplegic cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels I to III. The energy efficiency of walking was evaluated in 23 children and adolescents (12 males, 11 females, mean age 11y 3mo [SD 3y 5mo]; range 7-17y). Day-to-day variability was similar for all energy efficiency variables, with no significant differences in magnitude of variability between GMFCS levels. Correlations between EEI and gross cost and EEI and NNcost were fairly good (r=0.65, p<0.001, and r=0.74, p<0.001 respectively). However, only gross cost and NNcost discriminated between GMFCS levels in children with CP. Gross cost required the greatest amount of change to be considered clinically significant, whereas NNcost and EEI required a similar amount of change. For cohorts of children with CP who are evaluated over time, NNcost is the best normalization method as it reduces the variability between participants of different ages, height, and weight while evaluating only the amount of energy used to ambulate.

Walking energy expenditure in able-bodied individuals: a comparison of common measures of energy efficiency.

Assessment of walking energy efficiency is potentially useful for objectively quantifying gait efficiency; however, issues regarding methodology, day-to-day variability, inter subject variability (age and size differences) and clinical relevance prevents the assessment of walking energy efficiency from being used as a standard assessment tool. Volume of oxygen (VO(2)) and heart rate were assessed to determine the intra-subject (day-to-day) variability, the impact of age and body parameters and the clinical relevance of gross cost, Net non-dimensional Cost (NNcost) and Energy Efficiency Index (EEI) in able-bodied individuals. Gross cost demonstrated the least amount of day-to-day variability, in comparison to NNcost and EEI. Age and body parameters contributed more to the variability in gross cost than NNcost and EEI. Only net non-dimensional oxygen consumption was related to the velocity of walking. EEI did not correlate with direct measures of oxygen cost. The results from this study demonstrate that utilization of NNcost, a measure that subtracts resting oxygen consumption from walking oxygen consumption and scales for body parameters, is preferable to the traditional measures for comparing individuals of different ages and sizes and is related to the speed that the individual walks.

Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy.

The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX-A) alone, casting alone, and the combination of BTX-A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty-nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo-controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX-A only (B), placebo injection plus casting (C), or BTX-A plus casting (B+C). The dosage for the BTX-A injections was 4U/kg per extremity. Assessments were performed at baseline, 3, 6, 7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1-year study indicate that BTX-A alone provided no improvement in the parameters measured in this study, while casting and BTX-A/casting were effective in the short- and long-term management of dynamic equinus in children with spastic CP.

A 2-year follow-up of outcomes following orthopedic surgery or selective dorsal rhizotomy in children with spastic diplegia.

The purpose of this study was to prospectively compare the effect of orthopedic surgery (OS) and selective dorsal rhizotomy (SDR) on muscle tone, range of motion, gait and energy efficiency in ambulatory children with spastic diplegia. Twenty-five children with a diagnosis of spastic diplegia, with a mean age of 73 months, were evaluated prior to surgery and 1 and 2 years postoperatively; however, only the preoperative and 2-year postoperative data are reported here. Eighteen children received SDR and seven received OS. Children were evaluated with the Ashworth scale for muscle tone, passive range of motion (PROM), gait analysis and oxygen consumption for energy cost. Significant improvements were seen in PROM, muscle tone, gait kinematics and oxygen cost regardless of surgical intervention. Although OS and SDR interventions influence motor function through different mechanisms, the gait and energy outcomes 2 years following OS or SDR are similar.

Comparison of three ankle-foot orthosis configurations for children with spastic diplegia.

This study compared the functional efficacy of three commonly prescribed ankle-foot orthosis (AFO) configurations (solid [SAFO], hinged [HAFO], and posterior leaf spring [PLS]). Sixteen independently ambulatory children (10 males, six females; mean age 8 years 4 months, SD 2 years 4 months; range 4 years 4 months to 11 years 6 months) with spastic diplegia participated in this study. Four children were classified at level I of the Gross Motor Function Classification System (GMFCS; Palisano et al. 1997); the remaining 12 were at level II. Children were assessed barefoot (BF) at baseline (baseline assessment of energy consumption was performed with shoes on, no AFO) and in each orthotic configuration after three months of use, using gait analysis, oxygen consumption, and functional outcome measures. AFO use did not markedly alter joint kinematics or kinetics at the pelvis, hip, or knee. All AFO configurations normalized ankle kinematics in stance, increased step/stride length, decreased cadence, and decreased energy cost of walking. Functionally, all AFO configurations improved the execution of walking/running/jumping skills, upper extremity coordination, and fine motor speed/dexterity. However, the quality of gross motor skill performance and independence in mobility were unchanged. These results suggest that most children with spastic diplegia benefit functionally from AFO use. However, some children at GMFCS level II demonstrated a subtle but detrimental effect on function with HAFO use, shown by an increase in peak knee extensor moment in early stance, excessive ankle dorsiflexion, decreased walking velocity, and greater energy cost. Therefore, constraining ankle motion by using a PLS or SAFO should be considered for most, but not all, children with spastic diplegia.

Spinal deformity after selective dorsal rhizotomy in ambulatory patients with cerebral palsy.

Thirty-four patients with ambulatory spastic diplegia (ages 10-19.8 years) who were part of a prospective study of selective dorsal rhizotomy (SDR) had standardized radiographs before and after SDR. Follow-up ranged from 5 to 11.6 years after surgery. Two different surgical approaches were used: laminectomy (14 patients) and laminoplasty (20 patients). Radiographs were measured for coronal and sagittal balance. Thirty patients had a spinal deformity at long-term follow-up compared with 10 patients before surgery. Seventeen patients (50%) developed lumbar hyperlordosis greater than 60 degrees. Six patients (18%) developed grade 1 spondylolisthesis, Scoliosis occurred de novo in eight patients (24%) and progressed by greater than 5 degrees in two patients with preoperative scoliosis. No significant differences were found between laminoplasty and laminectomy patients. None of the patients have undergone any surgical intervention for spinal deformity. There was a higher incidence of spinal deformity after SDR than in normals and an historical control population, which warrants clinical and radiographic long-term follow-up.

Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy.

OBJECTIVE: To compare the efficacy of selective dorsal rhizotomy (SDR) and orthopedic surgery using multidimensional (National Center for Medical Rehabilitation Research disablement framework) outcome measures. DESIGN: Prospective outcome study. SETTING: Pediatric orthopedic hospital. PARTICIPANTS: Twenty-five children with spastic diplegia. Eighteen participants (mean age, 71.3 mo) chose SDR. Seven participants (mean age, 78.6 mo) chose orthopedic surgery. INTERVENTIONS: Children were evaluated 2 days before surgical intervention and at 6 months, 1 year, and 2 years postsurgically. MAIN OUTCOME MEASURES: The Gross Motor Performance Measure, the Gross Motor Function Measure, and the Pediatric Evaluation of Disability Inventory. RESULTS: The SDR group improved significantly in quality of movement attributes 6 months postsurgically; however, gross motor skills (standing; walking, running, and jumping) gains were seen 2 years postsurgically. The orthopedic group improved significantly in select quality of movement attributes 6 months postsurgically and in standing skills within the first postsurgical year. Self-care skills, mobility, and social function gains were seen earlier and with greater frequency in the SDR group. CONCLUSIONS: Both surgical interventions demonstrated multidimensional benefits for ambulatory children with spastic diplegia. The results suggest that qualitative changes in movement, achieved by spasticity reduction, have a greater effect on the enhancement of functional skill proficiency, thus independence, than recognized.

Objective measurement of muscle strength in children with spastic diplegia after selective dorsal rhizotomy.

OBJECTIVES: To examine changes in isometric muscle strength at the elbow, knee, and ankle at 6 months and 1 year after selective dorsal rhizotomy (SDR) and to determine if SDR altered the frequency of muscle cocontraction. DESIGN: Prospective outcome study of a consecutive sample. SETTING: Children's hospital. PATIENTS: Ten children with spastic diplegia (7 independent and 3 dependent ambulators who used assistive devices) and 8 age-matched controls. INTERVENTIONS: SDR; physical and occupational therapy; elbow, knee, and ankle measured for flexion and extension strength during three 10-second isometric contractions for each muscle group; and monitored cocontraction measured via muscle electrodes. MAIN OUTCOME MEASURES: Absolute and normalized values of isometric strength; and alterations in the frequency of cocontraction at 6 months and 1 year postoperatively. RESULTS: Children with spastic diplegia showed significantly weaker knee extensors, ankle dorsiflexors, and ankle plantarflexors than age-matched controls. There were no significant differences in strength between the 2 groups in the elbow flexors, elbow extensors, and knee flexors. Isometric strength did not increase or decrease significantly after SDR. Cocontraction during knee extension was normalized after SDR, whereas cocontraction during ankle plantarflexion was unchanged by SDR in the majority of children. CONCLUSION: SDR did not result in a significant decrease in muscle strength in ambulatory children with spastic diplegia. The normalization of the electromyographic patterns at the knee and not the ankle after SDR lends support to the premise that in children with cerebral palsy cocontraction is multifaceted, representing a volitional strategy to enhance control, as well as a disorder of the mechanisms that govern patterns of muscle activity.