Long-term outcome of hamstring lengthening versus transfer and the role of biceps femoris lengthening in patients with spastic diplegia and dynamic knee flexion in gait.

Background: Orthopedic treatment of flexed-knee gait consists of hamstring lengthening along with surgery at other levels. Transfer of the semitendinosus (hamstring transfer) was introduced to avoid increase of anterior pelvic tilt as well as reduce risk of recurrence. Methods: We retrospectively assessed children with spastic cerebral palsy and flexed-knee gait pre-operatively, 1 year post-operatively, and at a minimum of 7 years post-operatively. Results: The 39 patients were a mean 9.4 ± 3.4 years at the time of surgery, 20 subjects underwent hamstring transfer, and 19 subjects had hamstring lengthening with mean follow-up 9.1 years. Passive range of motion improved initially, but regressed at long term. Dynamic minimum knee flexion in stance decreased in both groups at the first post-operative study, and was maintained at final follow-up in 64-67% of patients. There was a small increase in anterior pelvic tilt at the 1-year follow-up which subsequently decreased to less than pre-operative in the hamstring lengthening group but remained mildly increased (5°) in the hamstring transfer group at final follow-up. Success in correcting stance knee flexion of the entire group was 69% of the Gross Motor Function Classification System grades I and II and 60% of the Gross Motor Function Classification System grade III subjects. Gait profile Score and sagittal knee Gait Variable Score both showed clinically important improvement after surgery and was mostly maintained long term for both groups. Lateral hamstring lengthening was beneficial in more severe patients, with minimal risk of adverse effects. Conclusion: Hamstring surgery as part of single event multi-level surgery (SEMLS) is effective in correcting flexed-knee gait in 60%-70% of patients with minimal effect on anterior pelvic tilt. There was no added advantage to hamstring transfer. Biceps Femoris lengthening may be beneficial and without significant additional risk. Level of evidence: level III.

3D Gait Analysis and Patient-reported Outcomes of Femoral Osteotomies for Torsional Deformity.

BACKGROUND: Idiopathic torsional deformities causing pain and/or functional difficulty is an indication for a femoral derotational osteotomy (FDRO). Past studies have focused entirely on children with internal femoral torsional deformity (IFTD). This study aims to compare gait and outcomes between children with IFTD and those with external femoral torsional deformity (EFTD) after a FDRO. METHODS: A retrospective review of all patients who underwent an FDRO between 1997 and 2020 at our institution. Data on typically developing (TD) children with no torsional deformity was used as a control group. We analyzed preoperative and postoperative standardized physical examination, 3-dimensional gait analysis, and Pediatric Outcomes Data Collection Instrument questionnaires. RESULTS: There were 54 patients in total (IFTD=37, EFTD=17) and 20 patients in the control group. The EFTD cohort was older (IFTD=11.7, EFTD=14.7, P <0.05) and had a higher body mass index both preoperatively (IFTD=21.1 kg/m 2 , EFTD=32.1 kg/m 2 , P <0.05) and postoperatively (IFTD=20.2 kg/m 2 , EFTD=34.1 kg/m 2 , P <0.05). Preoperatively, 3-dimensional gait analysis elicited mean hip rotation in stance was more internal for IFTD cohort (10.8 degrees) and external for the EFTD cohort (-17.8 degrees) in comparison to the TD (2.4 degrees, P <0.001). Postoperatively, dynamic mean hip rotation during stance was -1.4 degrees for IFTD, whereas for EFTD, it was -5.4 degrees, which was different to the TD ( P <0.05). The IFTD group's Pediatric Outcomes Data Collection Instrument improved for transfer/basic mobility, sports/physical function, global functioning, and satisfaction with symptoms ( P <0.05). The EFTD group that only reported an improvement with the satisfaction with symptoms after surgery ( P <0.05). CONCLUSIONS: Adolescents with surgically corrected IFTD show more improvement in gait and in patient-reported outcomes than those with surgically corrected EFTD. Children with EFTD persist in external rotation and have less satisfactory patient-reported outcomes after a FDRO in comparison those with IFTD. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Patient-Reported Outcome Measurement Information System (PROMIS) Scores in Pediatric Idiopathic Toe Walkers.

BACKGROUND: Idiopathic toe walking (ITW) can result in early contact with the health care system and be distressing for patients and their families. The natural history of ITW is poorly characterized. Deciding how and when to intervene can be difficult.Patient-reported outcomes are utilized in the clinical setting to assess patient factors and indications that may better inform treatment plans. Patient-Reported Outcomes Measurement Information System (PROMIS) is an instrument designed to collect patient-reported outcomes. Minimum clinically important differences in PROMIS metrics have been established to facilitate clinical relevance and utility of these metrics. The purpose of this study was to characterize the patient perspective of ITW by utilizing the PROMIS scores. METHODS: Retrospective chart review was performed to identify children aged 5 to 17 with a diagnosis of ITW treated at a single tertiary care center between 2017 and 2020. Inclusion criteria were a diagnosis of ITW and completion of a PROMIS questionnaire. Exclusion criteria were neurologic disease, autism, and previous surgical treatment. Demographic, physical exam, treatment, and available motion analysis data were collected. PROMIS scores for the following domains were available: Mobility, Peer Relationships, and Pain Interference. RESULTS: Forty-five children were enrolled. Seventy-three percent of PROMIS scores were patient reported while the remainder were parent reported. PROMIS score means for the cohort by domain were Mobility: 45.2±8.2 ( P <0.000); Peer Relationships: 46.4±11.6 ( P =0.047); and Pain Interference: 47.4±9.5 ( P =0.67). Motion analysis data, available for 11 children, noted age-matched gait velocity negatively correlated ( rs =-0.652, P =0.03) with Peer Relationships. No correlations were found between other aspects of gait, body mass index, or limitations in dorsiflexion and PROMIS domains. Parents reported lower Mobility scores than children did. There were no other significant differences between patient-reported and parent-reported PROMIS scores. PROMIS scores did not differ significantly between those <10 years and those ≥10 years. CONCLUSION: In this cohort of 45 otherwise healthy children without other neurologic diagnoses, there are both clinically and statistically significant differences in PROMIS means between our cohort and the healthy age-matched population. These differences manifested in worse peer relationships and mobility scores. LEVEL OF EVIDENCE: Level IV.

The Effects of Lower Extremity Rotational Malalignment on Pediatric Patient-reported Outcomes Measurement and Information System (PROMIS) Scores.

BACKGROUND: There is sparse literature demonstrating the relationship between lower limb pediatric idiopathic rotational malalignment (IRM) and patient-reported outcomes measurement information system (PROMIS) scores. Our goal is to determine and quantify the amount that IRM deformities, as measured with the 3D gait analysis, affect childrens' pain interference, mobility, and peer relationship PROMIS domains. Secondary outcomes include investigating the potential relationships between IRM and various subgroups (Pediatric Outcomes Data Collection Instrument (PODCI), gender, Body Mass Index (BMI), femur Versus tibia). We also examine whether the PROMIS domains correlate with PODCI in this population. METHODS: This study was a retrospective cohort, single institution, and consecutively recruited cases series. We identified 47 children over a 3-year period who were evaluated at the motion analysis center at our tertiary care hospital, with increased torsion of the femur or tibia. After exclusions, 25 children with IRM, documented PROMIS data and gait analysis were considered. RESULTS: Femoral malrotation had a significant relationship with female gender ( P =0.001) and increased BMI ( P <0.001). Femoral malrotation had a correlation with PROMIS pain interference ( P =0.016), whereas tibial rotation did not achieve significance ( P =0.084). In the ANOVA regression analysis, there was a strong prediction of the PROMIS mobility domain when both malrotation and pain interference were present ( P =0.007). There were Pearson Correlations of PROMIS and PODCI domains for Mobility Versus Sports ( P =0.007) and Pain Interference Versus Comfort/Pain ( P =0.004), respectively. CONCLUSION: The evident relationship between lower limb rotational malalignment and PROMIS scores signifies the likelihood for gait and pain disturbance. This in turn could show us that children are likely to be more debilitated and thus may benefit from timely correction. We aim to conduct this as a multicentre trial to confirm our findings. LEVEL OF EVIDENCE: Level IV.

Gastric infarction following gastric bypass surgery.

Gastric infarction is an extremely rare occurrence owing to the stomach's extensive vascular supply. We report an unusual case of gastric infarction following gastric bypass surgery. We describe the imaging findings and discuss possible causes of this condition.