Growth dynamics in the context of pediatric sports injuries and overuse.

The onset and timing of the growth of children and adolescents occurs with considerable variability in cohorts of the same chronological age. The musculoskeletal system changes in proportion over time, and lever-arm changes, altered individual flexibility, and strength lead to age-specific injury patterns in youth sports. In sports, juniors are commonly grouped according to their chronological age. Early- and late-maturing children and adolescents might therefore not routinely be trained in relation to their biology. This not only represents a risk for overuse and injury but might limit their development in sports. To obtain information about the biological age of children is challenging. Numerous methods have been studied and validated. However, the implementation of these methods on a large scale is still to come. This report provides a brief overview of growth dynamics in relation to youth sports injuries and describes a few challenges for the future.

No adverse affect after harvesting of free fibula osteoseptocutaneous flaps on gait function.

The aim of this study was to analyze gait function and muscular strength on donor site after harvesting of a vascularized fibula osteoseptocutaneous flap. Nine patients with a mean follow-up of 33 months (range, 7-59) and a mean resection length of the middle portion of the fibula of 18.0 cm (range, 14.0-23.0) underwent an instrumented three-dimensional gait analysis to evaluate gait function. Furthermore, CYBEX II extremity system was used for muscular strength measurements. Subjective muscle strength measurements were performed according to Kendall et al. and were classified according to the British Medical Research Council. Intraindividual comparison between the operated and the nonoperated leg revealed no significant differences for gait function parameters (cadence, velocity, and stride length, P > 1.00) and for muscular strength measurements for flexion (knee: P = 0.93, ankle: P = 0.54) and extension (knee: P = 0.97, ankle: P= 0.21), respectively. In conclusion, intraindividual comparison of the operated and nonoperated sides after harvesting of the middle portion of the fibula for gaining a free fibula osteoseptocutaneous flap has no adverse affect on gait function or muscular flexion and extension strength on donor site at a mean follow-up of 33 months.

Does gender influence the long-term outcome of single-event multilevel surgery in spastic cerebral palsy?

This study compared the long-term outcome of single-event multilevel surgery in spastic diplegic cerebral palsy (CP) on the basis of sex. We hypothesized that boys would have a worse outcome than girls. Thirty-four children (19 boys and 15 girls) with diplegic spastic CP and a minimal follow-up of 10 years were included. The Gillette Gait Index was the main outcome measure. We found no differences in surgical treatment, and both groups initially benefited from the surgery. However, although girls maintained the enhanced level of walking, walking ability in boys deteriorated constantly. Such a finding suggests that sex might have an important influence on treatment outcomes in children with CP.

Pathological gait in children with Legg-Calvé-Perthes disease and proposal for gait modification to decrease the hip joint loading.

PURPOSE: Legg-Calvé-Perthes disease (LCP) severely limits the range of hip motion and hinders a normal gait. Loading of the hip joint is a major consideration in LCP treatment. The aim of this study was to evaluate gait patterns in LCP and identify gait modifications to decrease the load on the affected hip. METHODS: Forty children with unilateral LCP were divided into three groups based on the time base integral of the hip abductor moments during single stance on the affected side acquired during instrumented 3D gait analysis. X-rays of the affected hip were classified according to Herring and Catterall. RESULTS: Children in the "unloading" group spontaneously adopted a Duchenne-like gait with pelvis elevation, hip abduction and external rotation during single support phase. The "normal-loading" group showed pelvis elevation with a neutral hip position in the frontal plane. In the "overloading" group the pelvis dropped to the swinging limb at the beginning of stance accompanied by prolonged hip adduction. The time base integral of the hip abductor moments during single stance correlated positively with the X-ray classifications of Herring and Catterall, hip abduction angle and age. Older children preferred to walk in hip adduction during single stance, had more impaired hips and tended to overload them. CONCLUSION: The hip overloading pattern should be avoided in children with LCP. Gait training to unload the hip might become an integral component of conservative treatment in children with LCP.

Lengthening of the midfoot in a case of lower-extremity hemimelia.

Hemimelia of the lower limb belongs to the group of congenital deficiency disorders. The clinical spectrum ranges from minimal shortening of the long bones to severe deficiencies of the extremities. Several etiologies, such as X-rays or drugs, have been implicated to be responsible for hemimelia. In the present report the clinical course and the long-term follow-up of a patient with transverse terminal hemimelia of the left foot at the level of the basis of the metatarsals is described. Due to frequent episodes of pain, development of pressure sores, and an increasing psychological burden, operative intervention consisting of a lengthening procedure using an Ilizarov fixator was indicated. Long-term outcome was good; the patient is now able to painlessly wear conventional shoes and displays a normal gait pattern.

The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait.

AIM: Information on the timing and long-term outcome of single-event multilevel surgery in children with bilateral spastic cerebral palsy (CP) walking with flexed knee gait is limited. Based on our clinical experience, we hypothesized that older children with bilateral spastic CP would benefit more from single-event multilevel surgery than younger children. Moreover, any improvement in older children could be maintained with fewer additional surgery events. METHOD: We performed a retrospective analysis of the long-term outcomes of single-event multilevel surgery. Thirty-two children (17 males, 15 females) who had received single-event multilevel surgery between 1995 and 2000 with a mean age at the time of surgery of 10 years 6 months (range 5y 8mo-15y 6mo; SD 3y 1mo) and in Gross Motor Function Classification System level II (n=12) or III (n=20) were included in the study. The inclusion criteria required that all children were ambulatory with spastic bilateral CP, had a flexed knee gait, had a full set of data for single-event multilevel surgery preoperatively and at 1 year and 10 years postoperatively, had not had previous surgery on their lower limbs, had not had any treatment with botulinum toxin A before gait assessment, and had not received intrathecal baclofen medication. The follow-up time lasted for over 10 years until the participants reached adulthood (mean age at the last follow-up 21 years 4 months, SD 3y 4mo). Data were collected on six separate occasions: preoperatively, at 1 year, at 2 to 3 years, at 5 years, at 7 to 8 years, and at 10 or more years postoperatively. The primary outcome was the Gait Deviation Index, and the secondary outcomes were the number and type of initial and additional surgeries. A linear mixed model and Spearman's rank correlation coefficient were used to prove the hypothesis. RESULTS: The older the child was at the time of the surgery, the better the long-term result ((Age,Time) =0.15; p=0.03). We did not find any correlation between age at the time of surgery and the number of bony or soft-tissue procedures performed initially as well as during the 10 years of follow-up. INTERPRETATION: Children with CP who require single-event multilevel surgery at an older age fare better in the long term than those who are younger at the time of surgery. The pubertal growth spurt is discussed as a contributing factor to gait deterioration.

Altered functional organization of the motor system related to ankle movements in Parkinson's disease: insights from functional MRI.

Bradykinesia represents one of the cardinal and most incapacitating features of Parkinson's disease (PD). In this context, investigating the cerebral control mechanisms for limb movements and defining the associated functional neuroanatomy is important for understanding the impaired motor activity in PD. So far, most studies have focused on motor control of upper limb movements in PD. Ankle movement functional MRI (fMRI) paradigms have been used to non-invasively investigate supraspinal control mechanisms relevant for lower limb movements in healthy subjects, patients with Multiple sclerosis, and stroke. Using such an active and passive paradigm in 20 PD patients off medication (mean age 66.8 ± 7.2 years) and 20 healthy controls (HC; mean age 62.3 ± 6.9 years), we here wished to probe for possible activation differences between PD and HC and define functional correlates of lower limb function in PD. Active ankle movement versus rest was associated with a robust activation pattern in expected somatotopy involving key motor areas both in PD and HC. However, contrasting activation patterns in patients versus controls revealed excess activation in the patients in frontal regions comprising pre-supplementary motor areas (pre-SMA) and SMA proper. The extent of SMA activation did not correlate with behavioural parameters related to gait or motor function, and no differences were seen with the passive paradigm. This finding might be indicative of higher demand and increased effort in PD patients to ensure adequate motor function despite existing deficits. The missing correlation with behavioural variables and lack of differences with the passive paradigm suggests that this excess activation is not exclusively compensatory and also not hard-wired.

Dynamic versus fixed equinus deformity in children with cerebral palsy: how does the triceps surae muscle work?

OBJECTIVES: To detect outcome measures that could help differentiate between dynamic and fixed equinus (FEQ) deformities in children with cerebral palsy, and secondary, to describe the function of the gastrocnemius and soleus (SOL) muscles when either dynamic triceps surae tightness or FEQ contracture is present. DESIGN: A group-comparison study. SETTING: Gait analysis laboratory. PARTICIPANTS: Children (N=23; 31 limbs) with cerebral palsy; 12 limbs showed a fixed contracture (FEQ group) and 19 limbs showed dynamic tightness of the triceps muscle (dynamic equinus group). Healthy children (N=12) without a neurologic or orthopedic disorder served as the control group. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Time-distance, kinematic and kinetic gait variables, muscle-tendon length, and velocity parameters. RESULTS: Maximal ankle dorsiflexion angles were decreased in both equinus groups compared with the control group. Ankle range of motion, maximal power generation of the plantar flexors, and its timing during the gait cycle were different among groups. The ankle slope parameter showed substantial differences among groups. Muscle-tendon length parameters for the SOL and the medial (MGAC) and lateral gastrocnemius muscles were abnormal in both equinus groups compared with the control group. Maximal muscle lengths of the MGAC and SOL were longer in the dynamic equinus than FEQ group. Peak lengthening velocity of the triceps surae muscle was significantly slower for all triceps surae muscles in the FEQ group than in the dynamic equinus group and occurred in the early swing phase. CONCLUSIONS: The presented results indicate that peak lengthening velocity of the triceps surae muscle might be one of the discriminating factors between FEQ and dynamic equinus deformity in children with cerebral palsy. This could help clinical decision making for treatment of an equinus gait pattern.

Genu recurvatum in cerebral palsy--part A: influence of dynamic and fixed equinus deformity on the timing of knee recurvatum in children with cerebral palsy.

The aim of the study was to confirm the hypothesis of the influence of the dynamic and fixed equinus deformity on the timing of knee recurvation (hyperextension). According to our hypothesis, dynamic equinus is linked to early and fixed equinus and to late knee hyperextension. A group 35 children with cerebral palsy (47 lower limbs) was divided into two subgroups according to the timing of maximum knee hyperextension. Clinical examination confirmed our hypothesis. Gait analysis and musculoskeletal modelling results were compared with 12 normally developing children. Both recurvatum groups had forefoot landing and neither achieved normal ankle dorsiflexion. Electromyographic examination revealed an abnormally high soleus activity in a single stance. Muscle length changes of medial gastrocnemius and soleus were in agreement with our hypothesis. Such a finding might simplify the decision as to which treatment to select for equinus deformity, present in patients with genu recurvatum.

Genu recurvatum in cerebral palsy--part B: hamstrings are abnormally long in children with cerebral palsy showing knee recurvatum.

Hyperextension of the knee in stance (knee recurvatum) is a common disorder in patients with spastic cerebral palsy (CP). A group 35 children with CP (47 lower limbs) was divided into two subgroups according to the timing of maximum knee extension during the stance phase of gait. Gait analysis and musculoskeletal modelling data were compared with a control group of 12 normally developing children. We observed no difference in kinematics between the CP groups who showed an equinus position of the foot at initial contact. Both groups showed increased external extensor moments across the knee. The muscle-tendon lengths of the hamstrings were abnormally long at initial contact, and in both recurvatum groups, contracted faster compared with the control group. Surface electromyography revealed prolonged activity of the hamstrings in stance and early activation in swing. Abnormally long hamstrings at initial contact together with equinus position of the foot are the main causes of genu recurvatum in children with CP.

Gait analysis in patients with Parkinson's disease off dopaminergic therapy.

OBJECTIVE: To compare time-distance, kinematic, and kinetic gait parameters in patients with idiopathic Parkinson's disease (PD) off dopaminergic therapy with a group of healthy control subjects. DESIGN: A group-comparison study. SETTING: Gait analysis laboratory. PARTICIPANTS: Patients with PD (n=20) and healthy age-matched controls (n=20). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Time-distance, kinematic, and kinetic gait variables. RESULTS: PD patients walked slower with shorter stride-length, comparable cadence, and longer double support times. Kinematics showed a reduction of the range of motion in the hip, knee, and ankle joints. Maximum hip extension and the ankle plantar flexion were significantly reduced. Kinetic gait parameters showed reduced push-off ankle power and lift-off hip power generation. Strong correlations between these important body advancement mechanisms and the walking velocity were observed. CONCLUSIONS: In addition to previously described dysfunctional kinematics, abnormal kinetic parameters play an important role in the characterization of gait in PD patients off therapy. Hence, these parameters could be used to document treatment effects of parkinsonian gait disorders.

Comparison of Ponseti versus surgical treatment for idiopathic clubfoot: a short-term preliminary report.

UNLABELLED: The Ponseti method of treatment for congenital clubfeet has gained widespread clinical acceptance. We have used manipulation, serial casting, and surgery to treat congenital clubfeet for almost 3 decades. Considering the Ponseti method of treatment to replace our traditional treatment method, we conducted a randomized, controlled trial evaluating the short-term outcome of the two treatment protocols. We evaluated foot function and applied a standardized measure of health status for children with orthopaedic problems. Nineteen patients (28 feet) were included in the trial. Nine infants (12 feet) were assigned to the Ponseti treatment group, and 10 (16 feet) were assigned to a group with initial casting and posteromedial release at the age of 6 to 8 months. The minimum followup was 3.3 years (mean, 3.5 years; range 3.3-3.8 years). Outcome measures included the Functional Rating System of Laaveg and Ponseti, the Pediatric Outcomes Data Collection Instrument (PODCI), and standardized radiographic measurements. At last followup the mean Functional Rating score was higher in the Ponseti group. Passive dorsiflexion and passive inversion-eversion were better in the Ponseti group. PODCI scales were comparable and radiographic outcome measures were similar in both groups. This trial has documented a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Pin tract infection with external fixation of pediatric fractures.

BACKGROUND: This study aimed to evaluate the incidence and severity of pin tract infections in a series of pediatric trauma patients. METHODS: All pediatric trauma patients with external fixation who were treated at our institution between 1998 and 2003 were included. The charts of 30 children (20 males; 10 females; mean age, 13.2 years; range, 7-19 years) with 37 episodes of external fixation were reviewed. The average duration of external fixation was 17.5 weeks (range, 1-94 weeks). Pin tract infections were graded using the Dahl classification. Bacterial cultures were obtained in case of drainage from the pin site. RESULTS: In 18 (48%) of 37 external fixations, no signs of infection occurred during the treatment period. In the remaining 19 (52%) external fixations, 35 episodes of infection were documented. Most infections were mild or moderate, whereas only 3 (9%) severe deep infections were noted (grade 5). Six (17%) infections healed with local application of rifamycin, whereas 27 (77%) of 35 infections were successfully treated with systemic antibiotics (cefuroxime, clindamycin). The remaining 2 infections (6%) required removal of a pin. CONCLUSIONS: Pin tract infection occurred in half of the patients who were treated with external fixations. Most of the pin site infections in the present series were mild and could be managed by local or systemic application of antibiotics. The occurrence of pin tract infections did not require a change of the method of stabilization.

Classification of equinus in ambulatory children with cerebral palsy-discrimination between dynamic tightness and fixed contracture.

In this study a generalised dynamic neural network (GDNN) was designed to process gait analysis parameters to evaluate equinus deformity in ambulatory children with cerebral palsy. The aim was to differentiate dynamic calf muscle tightness from fixed muscle contracture. Patients underwent clinical examination and had instrumented gait analysis before evaluating their equinus under anaesthesia and muscle relaxation at the time of surgery to improve gait. The performance of the clinical examination, the subjective interpretation of gait analysis results, and the application of the neural network to assess ankle function were compared to the examination under anaesthesia. Evaluation of equinus by a Neural Network showed high sensitivity and specificity values with a likelihood ratio of +14.63. The results indicate that dynamic calf muscle tightness can be differentiated from fixed calf muscle contracture with considerable precision that might facilitate clinical decision-making.

Medial hamstring lengthening in the presence of hip flexor tightness in spastic diplegia.

This study evaluated the effects of medial hamstring lengthening on gait in patients with diplegic cerebral palsy. A group of patients who underwent medial hamstring lengthening and distal rectus transfer was compared to a group of patients who underwent intramuscular psoas lengthening as well. Patients who underwent a psoas lengthening showed an increased anterior pelvic tilt and a tendency towards genu recurvatum, features that could indicate postoperative hamstring weakness. These results underline the importance of medial hamstrings for pelvis and knee motion in the sagittal plane during walking. In additional the limitations of the popliteal angle as a clinical measure to evaluate hamstring length in the presence of hip flexor tightness are discussed.