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.

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.

Preliminary report: resection and interposition of a deepithelialized skin flap graft in tarsal coalition in children.

Six tarsal coalitions in children were managed surgically using a deepithelialized skin flap for interposition after resection of the bony, fibrous or cartilaginous coalition. The advantage of this technique is that due to positioning the skin flap, joint motion can be preserved. The clinical results using the Ankle Hindfoot Scale of the American Orthopedic Foot and Ankle Society were excellent in two and good in four cases. The radiographs at follow-up showed no recurrences of the resected coalitions. This study shows that the use of deepithelialized skin flap interposition is effective in providing pain relief for the patients in symptomatic coalitions.

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.

[Reconstruction of humeroradial joint]. / Korrekturosteotomien suprakondylärer Fehlstellungen am Humerus.

OBJECTIVE: Reconstruction of the anatomic axis of the upper extremity and preservation or improvement of elbow function. INDICATIONS: Supracondylar axial deviation (cubitus varus/valgus). Limitation of range of motion. Cosmetic impairment. Psychological problems due to deformity. CONTRAINDICATIONS: Degenerative changes of the elbow joint in adolescents and adults due to rheumatoid/anti-inflammatory disease. SURGICAL TECHNIQUE: Three-dimensional open deformity correction of the distal humerus without wedge resection and stabilization by external fixation. POSTOPERATIVE MANAGEMENT: Early postoperative mobilization of the elbow. Average treatment time by external fixator 10-12 weeks. RESULTS: Between 1998 and 2006, ten children underwent surgery for posttraumatic supracondylar deformity. Correction was achieved by means of three-planar reorientation of the distal end of the humerus. An external fixator was used for stabilization. Preoperatively, all patients showed cosmetic or functional impairment. Follow-up was performed between 1 and 9 years (7.4 years) postoperatively. Subjective, clinical and radiologic criteria were evaluated. Three patients showed excellent, six good and one poor results. Two pin tract infections and one irritation of the ulnar nerve were observed during treatment.

[Anterior cruciate ligament reconstruction with semitendinosus tendon in children]. / Vorderer Kreuzbandersatz mit der Semitendinosussehne bei Kindern.

OBJECTIVE: To present the technique of arthroscopy-assisted anterior cruciate ligament (ACL) reconstruction in children with complete ACL rupture. INDICATIONS: The indications for surgery are intraligamentous ruptures of the ACL with persistent signs and symptoms due to instability in spite of a minimum 6-month trial with conservative management and reduction of sports activities. Other decision-making factors for surgery include secondary injuries to the menisci or limitation of daily activities due to the instability produced by the ACL rupture. The indication for surgical intervention has to be judged individually and carefully in younger children. CONTRAINDICATIONS: Poor compliance on the part of the patient to participate in postoperative rehabilitation. Overexpectations regarding the surgical outcome (ability to participate in professional sports without limitations). Younger age of the patient (Tanner stage 2 or younger maturity), without trial of conservative treatment over a period of 6 months. ACL rupture at the bone-ligament region (tibial or femoral), partial rupture or lengthening of the ACL without rupture; in these instances, the instability may improve with growth. SURGICAL TECHNIQUE: Diagnostic arthroscopy to evaluate the knee joint and to identify associated or secondary injuries to the menisci and articular cartilage. If possible, these injuries should be addressed in the same surgical session. Preparation and stripping of the semitendinosus tendon using a tendon stripper. The technique used is transepiphyseal with extraosseous fixation. Depending on the thickness, the semitendinosus tendon is either tripled or quadrupled and prepared for transplantation. Single-canal technique. The diameter of the canal has to be selected depending on the size of the child's knee (usually between 6-8 mm). The tendon transplant is placed such that the canal is also filled with the tendon in the epiphyseal part (tendon transplant length usually 7 cm). Tibial canal entry medial to the tibial tuberosity, entering the joint at the level of the anterior horn of lateral meniscus in the intercondylar notch. Optimal positioning confirmed by an intraoperative negative impingement test of the guiding pin before drilling. Femoral canal entry placed at the 10:00-10:30 o'clock position on the right side, and 01:30-02:00 o'clock position on the left side. Care must be taken to avoid injury to the perichondral ring. In younger children (Tanner stage 3 or lower), avoidance of fixation material transfixing the epiphysis - femoral fixation performed using endobutton and tibial fixation with the Suture-disc. In older children (Tanner stage 4 or above) alternative fixation methods are possible (interference screw). The fixation of the ACL tendon transplant is such that reconstruction is in minimal tension in 30 degrees flexion. POSTOPERATIVE MANAGEMENT: Postoperative treatment regimen in the first 6 weeks after surgery depends on the extent of additive surgeries (menisci, chondral injuries) performed in the same sitting. In the absence of associated injuries, weight bearing is gradually increased with the aim of achieving full weight bearing at the end of the 1st postoperative week. In case of additional meniscal sutures, knee flexion is restricted to 60 degrees maximum and non-weight bearing for 4 weeks is advised. Postoperative mobilization is performed using an adjustable knee orthesis. Between 4-6 weeks postoperatively, the permitted flexion is gradually increased to a maximum of 90 degrees and partial weight bearing is started. Full weight bearing and free movements with muscle training are started after 6 weeks. Avoidance of weight transmission on the flexed and rotated knee until 12 weeks postoperatively. Start with sports activities under supervision after 6 months, trial with professional sports activities after 9 months. RESULTS: 57 children with remaining growth potential around the knee underwent ACL reconstruction using the semitendinosus tendon at the Pediatric Orthopedic Unit, Department of Pediatric Surgery, Graz, Austria, between 2002-2007. 45 patients received ACL reconstruction with associated meniscal injuries. The described endobutton technique for fixation of the transplant has been performed since 2006. As the patients are under follow-up, the long-term effects of this technique on growth around the knee are, to date, not known. 30 patients were operated before 2006 using the bioresorbable interference screw for fixation by ACL reconstruction with the semtendinosus tendon. All these patients were at Tanner stage 4 or older. 15 of these cases were evaluated after completion of growth, and all showed a good to excellent outcome in Tegner, Lysholm and IKDC (International Knee Documentation Committee) Scores without any growth disturbances.

Modern treatment of pathological fractures in children.

Pathological fractures in children occur from a variety of causes. The clinician has to develop an individual strategy that weighs up the pros and cons of treatment, considering the bone biology and the biomechanics at the fracture site. Determining the lesional pathology is paramount, whether it is in the form of a neoplastic or non-neoplastic entity, so that bone healing can be maximized. Time-efficient protection and reconstruction of the child's musculoskeletal system is the aim of the surgeon's intervention. The whole strategy must be individualized to every situation. Combinations of diseases, fracture sites, and children are many, whereas treatment options are fewer. Options include non-operative management with observation, and intralesional resection with or without bone grafting, and with or without internal fixation. A thoughtful, disciplined, and systematic approach will be successful most often. The goals of treating a child's pathological fracture are all based on establishing a diagnosis. Only after establishing the diagnosis with certainty can a proper treatment strategy be formulated. Fracture management is then based on five points: (a) pain relief and comfort of the child; (b) achieve Local control or containment of the pathological lesion; (c) skeletal stabilization, preservation of growth, and maintain anatomical alignment; (d) fracture union; and (e) restoration of function. Maintaining perspective will facilitate optimal patient care and minimize the confounding variables that seem to plague the treatment of pathological fractures.

Tibial lengthening over nails in children using modified Ender nails: preliminary results of a new treatment.

Tibial lengthening over nails, using modified Ender nails, was performed in nine children whose mean age at surgery was 12.8 years. The prerequisite for using this technique was the absence of axial malalignment and an indication for tibial lengthening only. Lengthening was not performed in one case due to the development of a compartment syndrome after the tibial osteotomy. Breakage of one interlocking screw without loss of alignment or length was observed in one case. Superficial pin tract infections were observed in two cases. An average of 4.1 cm (range 3-4.5 cm) lengthening of the tibia was achieved in eight of the nine cases. The modified Ender nails used permitted locking at both ends after achieving the desired distraction and permitted early removal of the external fixator. The advantage of this technique is that it permits early removal of the fixator and thus decreases the incidence of fixator related problems and facilitates early rehabilitation.

Treatment of unicameral calcaneal bone cysts in children: review of literature and results using a cannulated screw for continuous decompression of the cyst.

Nine unicameral bone cysts of the calcaneus in children were managed surgically using the technique of continuous decompression with titanium cannulated cancellous screws. The average age of the patients at surgery was 12.8 years. At follow-up a minimum of 2 years after surgery, eight cysts showed complete healing; one patient showed healing with residuals. Irritation at the screw insertion site necessitated early removal of the screw in one patient; implant-related problems were not observed in the other patients. Patients were allowed to bear weight after surgery. Implant extraction was performed after full consolidation of the cyst and was uneventful in all patients. A review of the literature and the different treatment modalities used for managing calcaneal cysts is also presented.

Treatment of femoral neck and trochanteric simple bone cysts.

INTRODUCTION: Problems associated with common treatment modalities of bone cysts located in the proximal femur include a high blood loss, infection, lack of stability, donor-site morbidity, restriction to normal activity, and high recurrence rate. MATERIALS AND METHODS: Twelve patients with a simple bone cyst of the proximal femur were treated with retrograde flexible nailing. Six showed a pathological fracture. Mean age at surgery was 10.4 years, mean follow-up was 57 months. Radiographs were classified as healed, healed with residuals, recurred, or no response. RESULTS: The mean healing period was 38.8 months. Two cysts healed completely, nine healed with residuals. There was no recurrence or non-responder. In a fractured cyst a perforation of a nail through the cyst occurred 4 months after nailing. CONCLUSION: The method is less invasive and offers early stability to the bone without the need for cast immobilization.

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.