The unstable hip in children with cerebral palsy: does an acetabuloplasty add midterm stability?

PURPOSE: This study addresses whether an additional pelvic procedure is superior to a varus derotation osteotomy femur (VDRO) alone in unstable hips in children with cerebral palsy (CP). METHODS: All patients had unstable hips utilising the Melbourne Cerebral Palsy Hip Classification System (MCPHCS). We compared one group that underwent VDRO alone with one that had a combination of VDRO and Dega osteotomy (VDRO+). Measurements were taken before surgery, postoperatively, two years after surgery and at latest follow-up. Generalised estimating equations were used to account for known and unknown correlations between hips from bilateral cases. RESULTS: In total, 74 hips in 57 children fulfilled the inclusion criteria. There was no outcome difference between Gross Motor Function Classification System levels III, IV and V. Age at time of operation ranged from three to 16 years (mean 9.8 years). Mean follow-up was 49.1 months. In the VDRO group (28 hips) migration percentage (MP) changed from 61% preoperative to a final value of 35.7%. In the VDRO+ group (46 hips) the MP changed from 64.4% to 19.3%. At final follow-up 15 hips (54%) were stable in the VDRO group, 37 hips (83%) in the VDRO+ group. The odds ratio (OR) of hip stability at final follow-up was 3.5-times higher in the VDRO+ group versus the VDRO group (OR = 3.9; 95% confidence interval = 1.5 to 9.7; p = 0.004). CONCLUSION: Reconstruction of unstable hips via VDRO + Dega in children with CP provides a higher likelihood of long-term stability than an isolated VDRO. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Can pedobarography predict the occurrence of heel rocker in children with lower limb spasticity?

BACKGROUND: Pedobarography software calculates the centre-of-pressure trajectory in relation to the foot to quantify foot contact patterns. This study presents two new pedobarography measures using the centre-of-pressure trajectory to assess heel rocker. METHODS: To validate these pedobarography measures against 3D gait analysis, emed®-x and Vicon Nexus gait analysis data were captured from 25 children aged 8-16 years (11 male) with unilateral (n = 18) and bilateral (n = 7) cerebral palsy or acquired brain injury. 3D gait analysis identified whether heel rocker was intact (n = 22 feet) or absent (n = 28 feet) based on centre-of-pressure at initial contact and the ankle kinematic curve between 0 and 2% of the gait cycle. Pedobarography measures calculated from the initial centre-of-pressure point were the distance to the heel (point of initial contact) and to the most posterior point of the trajectory (rollback), reported as a percentage of foot length. FINDINGS: The median point of initial contact in limbs with an intact heel rocker was 9% (range 7-12%) and median rollback was 0% (range 0-0.2%), whereas the median point of initial contact in limbs with an absent heel rocker was 58% (range 8-78%) and rollback was 18% (range 0-40%). Point of initial contact is the more accurate method for predicting heel rocker, with a threshold of 14% of foot length identifying the correct heel rocker status in 94% of cases. INTERPRETATION: Point of initial contact can assess heel rocker with high accuracy. Both point of initial contact and rollback provide sensitive information on foot strike pattern, enhancing the utility of pedobarography.

Orthopaedic Surgery in Dystonic Cerebral Palsy.

BACKGROUND: Outcomes after orthopaedic interventions in patients with dystonic cerebral palsy (DCP) are historically regarded as unpredictable. This study aims to evaluate the overall outcome of orthopaedic surgery in children with DCP. METHOD: Children with DCP who underwent lower limb orthopaedic surgery with a minimum follow-up of 12 months were included. Data collected included age at time of surgery, surgical procedures performed, Gross Motor Function Classification System (GMFCS) level, and Barry Albright Dystonia Scale (BADS) score. The cohort was divided into 2 groups. Group 1 (GMFCS levels I to III), mean age 12 years 7 months and group 2 (GMFCS levels IV to V), mean age 10 years 7 months. Group 1 had surgery aimed at deformity correction to improve gait and mobility, and group 2 for the management or prevention of hip displacement. Outcome measures analyzed were: the incidence of unpredictable results related to surgery and early recurrence of deformity in both groups. Functional mobility scale scores were evaluated for group 1 and hip migration percentage for group 2. Linear mixed models were used to take into account repeated measures over time and correlations between measurements from the same patient. RESULTS: Group 1 (n=18); had low BADS scores and were considered to have mild dystonia. Three children experienced unpredictable results, 2 had early recurrence of deformity, 3 had a decline, and 1 child improved in the functional mobility scale.Group 2 (n=19); had high BADS scores and were considered to have moderate to severe dystonia. Nine surgical events involved bony procedures and 15 were soft tissue surgery only. One surgical event lead to unpredictable results and 2 children had early recurrence of deformity. Postoperatively, a linear trend of increasing migration percentage [0.49% (95% confidence interval, 0.23-0.74; P=0.0002)] was seen up to 21 months. There was no significant change after 21 months [-0.08% (95% confidence interval, -0.24 to +0.041; P=0.18)]. CONCLUSIONS: This study suggests that unpredictable results and early recurrence of deformity following orthopaedic surgery in children with DCP are not as common as previously regarded. Furthermore, functional mobility and hip morphology can be improved. LEVEL OF EVIDENCE: Level IV-this is a case-series.

Impact of multilevel joint contractures of the hips, knees and ankles on the Gait Profile score in children with cerebral palsy.

BACKGROUND: Children with cerebral palsy are at risk of developing muscle contractures, often contributing to pain, structural deformities and mobility limitations. With the increasing use of gait indices to summarise the findings of three dimensional gait analysis (3DGA), the purpose of this study is to determine whether there is a relationship between multilevel joint contractures and the Gait Profile Score in children with cerebral palsy. METHODS: The Gait Profile Score, calculated from 3D gait analysis, and passive range of motion, strength and spasticity of the hips, knees and ankles in the sagittal plane were measured in 145 children with cerebral palsy (mean age:11 years,4 months; SD:2 years,10 months) (83 males) enrolled in the NSW Paediatric Gait Analysis Service Research Registry from 2011 to 2016. The relationships between these physical measures and the Gait Profile Score were explored using bivariate and multivariate correlations. FINDINGS: Reduced hip extension, knee extension and ankle dorsiflexion (knee extended) range of motion were correlated with a higher (worse) Gait Profile Score (r = -0.348 to -0.466, p < .001). Children with all joints contracted had a significantly higher Gait Profile Score (mean 17.5°, SD 6.2°) than those with no contractures (mean 11.0°, SD 2.3°) or ankle contractures only (mean 12.8°, SD 5.1°) (p < .05). Knee flexion weakness, reduced hip extension and ankle dorsiflexion (knee extended) range of motion predicted 47% of the Gait Profile Score. INTERPRETATION: The Gait Profile Score is a sensitive measure for demonstrating the relationship between multilevel sagittal plane joint contractures and kinematic gait. Clinically, this supports the use of the Gait Profile Score as a simplified measure to understand the contribution of contractures to functional gait limitations. Monitoring knee flexion strength, and hip extension and ankle dorsiflexion (knee extended) range of motion may assist clinicians in prioritising interventions to improve gait in this population.

How does rectus femoris fibrosis affect gait?

We report on a female patient with stiff-knee gait resulting from rectus femoris fibrosis, following multiple injections into the quadriceps musculature. Treatment planning and outcome were aided by instrumented three-dimensional gait analysis. One year after surgery, improvements were found in walking speed, step length, anterior pelvic tilt, knee flexion in swing, and ankle dorsiflexion in swing. Instrumented three-dimensional gait analysis was a useful tool for characterizing gait impairments and detecting changes after surgical intervention. Intramuscular injections into the rectus femoris muscle should be avoided to prevent stiff-knee gait and associated disability.

Normative reference values for lower limb joint range, bone torsion, and alignment in children aged 4-16 years.

Normative reference values are essential to identify deviation from normal and evaluate response to treatment. As joint range of motion datasets specific to the pediatric population are infrequently reported in the literature, we determined lower limb passive joint range of motion and bone torsion values from 53 typically developing children aged 4-16 years. Our reference values were consistent with previously published norms, although for some measures, large variability in the literature exists. A clear correlation between joint range and age was observed in most measures. Our results highlight the importance of applying age-matched norms when attempting to identify deviation from normal in the growing child.

Pasteurella canis osteoarticular infections in childhood: review of bone and joint infections due to pasteurella species over 10 years at a tertiary pediatric hospital and in the literature.

BACKGROUND: Pasteurella spp. are important bacterial pathogens in both animals and humans. Most reported Pasteurella infections in humans involve skin and soft tissues, often after an animal bite, scratch, or lick to an open wound. Infections involving bone and joints are well recognized, but have not been previously reported due to Pasteurella canis without a history of penetrating dog bite. METHODS: We report a case of P. canis osteomyelitis in a 14-month-old girl and a case of P. canis septic arthritis in a 19-month-old girl, both occurring without any preceding penetrating injury. Review of all osteoarticular infections due to Pasteurella spp. at our tertiary pediatric hospital over the past 10 years was performed by obtaining the patient records of all children with positive bacterial cultures from any site for Pasteurella spp. as identified through our microbiology laboratory database. A MEDLINE and EMBASE database search was then performed to identify published pediatric cases in the literature since 1950. RESULTS: In addition to the cases of P. canis osteomyelitis and septic arthritis outlined, we identified 8 children with positive cultures for Pasteurella spp. from the hospital's microbiology database. Two of these children had deep tissue contamination involving bone and/or joints secondary to animal bites. Ten further published cases were identified from the literature since 1950. CONCLUSIONS: : Established Pasteurella osteomyelitis and septic arthritis secondary to animal bites can be largely prevented through appropriate wound management at the time of injury. However, the potential for deep tissue infection with this organism, including the species P. canis, without prior penetrating injury should be recognized. LEVEL OF EVIDENCE: Level IV-case series.