Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery.

BACKGROUND: Severe crouch gait in patients with spastic diplegia causes excessive loading of the patellofemoral joint and may result in anterior knee pain, gait deterioration, and progressive loss of function. Multilevel orthopaedic surgery has been used to correct severe crouch gait, but no cohort studies or long-term results have been reported, to our knowledge. METHODS: In order to be eligible for the present retrospective cohort study, a patient had to have a severe crouch gait, as defined by sagittal plane kinematic data, that had been treated with multilevel orthopaedic surgery as well as a complete clinical, radiographic, and instrumented gait analysis assessment. The surgical intervention consisted of lengthening of contracted muscle-tendon units and correction of osseous deformities, followed by the use of ground-reaction ankle-foot orthoses until stable biomechanical realignment of the lower limbs during gait was achieved. Outcome at one and five years after surgery was determined with use of selected sagittal plane kinematic and kinetic parameters and valid and reliable scales of functional mobility. Knee pain was recorded with use of a Likert scale, and all patients had radiographic examination of the knees. RESULTS: Ten subjects with severe crouch gait and a mean age of 12.0 years at the time of surgery were studied. After surgery, the patients walked in a more extended posture, with increased extension at the hip and knee and reduced dorsiflexion at the ankle. Pelvic tilt increased, and normalized walking speed was unaltered. Knee pain was diminished, and patellar fractures and avulsion injuries healed. Improvements in functional mobility were found, and, at the time of the five-year follow-up, fewer patients required the use of wheelchairs or crutches in the community than had been the case prior to intervention. CONCLUSIONS: Multilevel orthopaedic surgery for older children and adolescents with severe crouch gait is effective for relieving stress on the knee extensor mechanism, reducing knee pain, and improving function and independence.

Lengthening and transfer of hamstrings for a flexion deformity of the knee in children with bilateral cerebral palsy: technique and preliminary results.

Between July 2000 and April 2004, 19 patients with bilateral spastic cerebral palsy who required an assistive device to walk had combined lengthening-transfer of the medial hamstrings as part of multilevel surgery. A standardised physical examination, measurement of the Functional Mobility Scale score and video or instrumented gait analysis were performed pre- and post-operatively. Static parameters (popliteal angle, flexion deformity of the knee) and sagittal knee kinematic parameters (knee flexion at initial contact, minimum knee flexion during stance, mean knee flexion during stance) were recorded. The mean length of follow-up was 25 months (14 to 45). Statistically significant improvements in static and dynamic outcome parameters were found, corresponding to improvements in gait and functional mobility as determined by the Functional Mobility Scale. Mild hyperextension of the knee during gait developed in two patients and was controlled by adjustment of their ankle-foot orthosis. Residual flexion deformity > 10 degrees occurred in both knees of one patient and was treated by anterior distal femoral physeal stapling. Two children also showed an improvement of one level in the Gross Motor Function Classification System.

Supramalleolar derotation osteotomy of the tibia, with T plate fixation. Technique and results in patients with neuromuscular disease.

Torsional deformities of the tibia are common in children, but in the majority both the torsion and the associated disturbance of gait resolve without intervention. There are, however, a significant number of children and adults with neuromuscular disease who present with pathological tibial torsion, which may require surgical correction. We conducted a prospective study in two centres, to investigate the outcome of supramalleolar derotation osteotomy of the tibia, using internal fixation with the AO-ASIF T plate. A range of outcome variables was collected, prospectively, for 57 patients (91 osteotomies), including thigh foot angle, foot progression angle, post-operative complications and serial radiographs. Correction of thigh foot angle and foot progression angle was satisfactory in all patients. Three major complications were recorded; one aseptic nonunion, one fracture through the osteotomy site after removal of the plate and one distal tibial growth arrest. We found that supramalleolar derotation osteotomy of the tibia, with AO-ASIF T plate fixation is an effective method for the correction of torsional deformities of the tibia and the associated disturbances of gait in children and adults with neuromuscular disease, with a 5.3% risk of major complications.

Walking speed in children and young adults with neuromuscular disease: comparison between two assessment methods.

Self-selected walking speed is being increasingly used as a primary outcome measure in the management of neuromuscular disease. It would be useful if the speed recorded in the gait laboratory represented the child's walking speed in the community. This study investigated the difference in self-selected walking speeds between a 10-meter walk, as measured during instrumented gait analysis, and a 10-minute walk. The authors found that self-selected walking speed during the 10-minute walk was slower than the self-selected walking speed recorded during the 10-meter walk. The former may be more representative of walking speed in the community setting. Walking speed measured during walks of 10 minutes or more should become an integral part of gait laboratory evaluation.

Femoral derotation osteotomy in spastic diplegia. Proximal or distal?

We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 +/- 1.3 v 10.7 +/- 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 +/- 11 degrees internal to 3 +/- 9.5 degrees external in the proximal group and from 9 +/- 14 degrees internal to 4 +/- 12.4 degrees external in the distal group. Correction of the foot progression angle was from a mean of 10.0 +/- 17.3 degrees internal to 13.0 +/- 11.8 degrees external in the proximal group (p < 0.001) compared with a mean of 7.0 +/- 19.4 degrees internal to 10.0 +/- 12.2 degrees external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia.

Hip surveillance in children with cerebral palsy. Impact on the surgical management of spastic hip disease.

We studied prospectively the impact of a hip surveillance clinic on the management of spastic hip disease in children with cerebral palsy in a tertiary referral centre. Using a combination of primary clinical and secondary radiological screening we were able to detect spastic hip disease at an early stage in most children and to offer early surgical intervention. The principal effect on surgical practice was that more preventive surgery was carried out at a younger age and at a more appropriate stage of the disease. The need for reconstructive surgery has decreased and that for salvage surgery has been eliminated. Displacement of the hip in children with cerebral palsy meets specific criteria for a screening programme. We recommend that hip surveillance should become part of the routine management of children with cerebral palsy. The hips should be examined radiologically at 18 months of age in all children with bilateral cerebral palsy and at six- to 12-monthly intervals thereafter. A co-ordinated approach by orthopaedic surgeons and physiotherapists may be the key to successful implementation of this screening programme.

Modified technique for varus derotation osteotomy of the proximal femur in children.

BACKGROUND: The results of a study in which the Richards' intermediate hip screw and the AO (Association for the Study of Internal Fixation (ASIF)) 908 fixed-angle blade plate were compared for use in proximal femoral osteotomy in children have previously been reported. In that study loss of position at the osteotomy site was reported as a specific complication associated with the use of the Richards' intermediate hip screw. METHODS: The authors devised a simple modification of surgical technique using the Richards' intermediate hip screw to enhance the stability of the fixation. In the present article the results of a prospective study of that modified technique are reported and compared with the results of the previous study. RESULTS: During a 2-year period 24 proximal femoral osteotomies were performed on 12 children with cerebral palsy, using the modified technique by two surgeons. Only two of the 12 patients (16%) required postoperative immobilization in a hip spica cast. This represents a significant reduction in the level of spica casting when compared with the previous cohort study (61%). CONCLUSION: A simple modification of surgical technique improves the stability of fixation in proximal femoral osteotomy in children who have cerebral palsy. This resulted in a decreased need for supplementary hip spica casting and may reduce morbidity.

Isolated calf lengthening in cerebral palsy. Outcome analysis of risk factors.

We assessed the medium-term outcome of three methods of isolated calf lengthening in cerebral palsy by clinical examination, observational gait analysis and, where appropriate, instrumented gait analysis. The procedures used were percutaneous lengthening of tendo Achillis, open Z-lengthening of tendo Achillis and lengthening of the gastrosoleus aponeurosis (Baker's procedure). We reviewed 195 procedures in 134 children; 45 had hemiplegia, 65 diplegia and 24 quadriplegia. We established the incidence of calcaneus and recurrent equinus and identified 'at-risk' groups for each. At follow-up, 42% had satisfactory calf length, 22% had recurrent equinus and 36% calcaneus. The incidence of calcaneus in girls at follow-up was significantly higher (p = 0.002) while boys had an increased rate of recurrent equinus (p = 0.012). Children with diplegia who had surgery when aged eight years or younger had a 44% risk of calcaneus, while those over eight years had a 19% risk (p = 0.046). Percutaneous lengthening of tendo Achillis in diplegia was the least predictable, only 38% having a satisfactory outcome compared with 50% in the other procedures. The incidence of recurrent equinus in hemiplegic patients was 38%. Only 4% developed calcaneus. The type of surgery did not influence the outcome in patients with hemiplegia or quadriplegia. Severity of involvement, female gender, age at operation of less than eight years and percutaneous lengthening of tendo Achillis were 'risk factors' for calcaneus. Hemiplegia, male gender, and an aponeurosis muscle lengthening increased the risk of recurrent equinus.

Which implant for proximal femoral osteotomy in children? A comparison of the AO (ASIF) 90 degree fixed-angle blade plate and the Richards intermediate hip screw.

We reviewed the clinical and radiologic results of 164 proximal femoral osteotomies in 132 children using the AO (ASIF) 90 degree fixed-angle blade plate and the Richards intermediate hip screw to establish the clinical and radiologic outcomes, establish the incidence of complications, and determine the relative indications and contraindications for the two implants. The incidence of complication in this series was 9% (15 complications in 14 osteotomies in 13 patients) including one bursitis, one wound breakdown with exposure of the underlying plate, five infections, two peroneal nerve palsies, one fractured shaft of femur, one fractured neck of femur, two technical errors, one painful nonunion, and one loss of fixation. There were five (3%) revisions in total. Fifty-six osteotomies in 44 patients were performed using the Richards intermediate hip screw, and 108 osteotomies were performed in 88 patients using the AO 90 degree fixed-angle blade plate. We found that both implants were effective with an acceptable rate of complications and revision surgery.

Slotted acetabular augmentation: is a hip spica necessary?

Between 1988 and 1996, 16 patients who underwent a total of 18 slotted acetabular augmentation procedures were managed postoperatively without a spica cast, by using instead a protocol of limited weight bearing and restriction of hip range of motion. Postoperatively, no patients experienced hip stiffness. No patients exhibited any migration or change of position of their bone graft. Radiographic examination revealed the following: center-edge angle (CEA) averaged 3 degrees preoperatively and 54 degrees postoperatively. Acetabular index averaged 35 degrees preoperatively and 18 degrees postoperatively. No patients experienced any deleterious effects by not using a spica cast. We believe that by obviating the spica cast, we may ease the postoperative recovery for patients, avoid postoperative hip stiffness, and thereby expand the applications of this safe and reliable method of acetabular reconstruction in selected patients.

High- or low- technology measurements of energy expenditure in clinical gait analysis?

The repeatability of energy-expenditure measurements were studied in five children and four adults without disabilities using the Cosmed K4 (high technology). The ability to detect change in measurements was compared between this instrument and the Physiological Cost Index (PCI; low technology). The results of repeatability (95% range) for oxygen cost were 13.1% in children and 13% in adults. In contrast, the SD of PCI was 6 to 72% of the mean in adults and wider in children (91%; 95% range). The validity of PCI as an outcome measure was questioned. In addition, 177 children with motor disability were prospectively studied using the Cosmed K4. Previous experience with the Cosmed K2 (intermediate technology) helped to develop a practical and repeatable protocol for testing children with disability using the Cosmed K4. The protocol commenced with 5 minutes of rest to achieve baseline values of heart rate and oxygen consumption, followed by 10 minutes of continuous walking at a self-selected speed on a 10-metre level oval walking track. The test concluded with 5 minutes of rest to monitor the return to baseline values. Ninety-one percent of the children with disability quickly reached a steady-state of oxygen consumption and carbon-dioxide production. The carbon-dioxide sensor in the Cosmed K4 has enabled a new group of severely involved children with cerebral palsy (9%) to be defined. These children have been termed 'physiologically marginal ambulators'.

Vertebral osteomyelitis in an infant presenting with a posterior mediastinal mass.

A rare case of vertebral osteomyelitis and paravertebral abscess that presented as a posterior mediastinal tumour with airway compression in a 7-week-old baby is presented. The differential diagnosis and the recommended treatment are discussed.

Pes anserinus syndrome due to solitary tibial spurs and osteochondromas.

We studied 19 children with the pes anserinus syndrome due to proximal tibial exostoses. Nine children had a solitary sessile or pedunculated osteochondroma that produced a painful lump that was readily palpable. The symptoms resolved following removal of the osteochondroma. Ten children had a bone spur that was shaped like a rose thorn. It produced pain with snapping or a feeling of locking of the pes anserinus tendons. Careful palpation was required to detect the tender bone spur beneath the pes anserinus. In five children, the bone spurs were excised because of persistent symptoms, and each was shown to be an exostosis without a cartilage cap. The symptoms resolved. However, the bone spurs need not be excised if the symptoms improve with rest and do not recur following resumption of activities.

An alternative method for determination of the carpal height ratio.

Radiographs of the wrist often do not include the entire third metacarpal, so the standard method for measurement of the carpal height ratio (the carpal height divided by the length of the third metacarpal) cannot be used. In this study, the ratio of the carpal height relative to the length of the capitate was evaluated for its suitability as a reproducible alternative. The revised carpal height ratio (the carpal height divided by the capitate length) was evaluated for reproducibility and clinical utility in both in vitro and in vivo studies: it was determined from the radiographs of ten cadaveric wrists; those of 100 wrists (fifty pairs) of normal volunteers, made with controlled positioning; those of 100 wrists, drawn at random from radiographs that had been previously interpreted as showing normal findings; and those of fifty wrists of twenty-nine patients who had documented rheumatoid arthritis. The new ratio was found to be constant in the normal population, consistent bilaterally, decreased in patients who had carpal collapse, and reproducible.