Effect of selective percutaneous myofascial lengthening and functional physiotherapy on walking in children with cerebral palsy: Three-dimensional gait analysis assessment.

BACKGROUND: Walking is the most affected motor function in children with cerebral palsy (CP). Orthopaedic surgery is regularly used to improve ambulation in children with CP. Selective Percutaneous Myofascial Lengthening (SPML) is considered the state-of-the art technique for surgical lengthening of spastic/contracted muscles in CP. The purpose of this study was to investigate the effect of combined SPML surgery and postoperative functional physiotherapy on gait function and characteristics of children with spastic cerebral palsy (CP). METHODS: Twenty-six children with spastic CP, aged 5-7 years, Gross Motor Function Classification System (GMFCS) levels II (n = 6), III (n = 12) and IV (n = 8) participated in a quasi-experimental one-group pretest-posttest study with a 9-month follow-up. The Global Motion Graph Deviation Index (MGDI) (including MGDI sub-indices of each joint in each plane of motion) and spatiotemporal parameters of a three-dimensional kinematic gait analysis were used to assess the gait function and characteristics, respectively. RESULTS: Nine months following SPML and functional physiotherapy, statistically significant improvements (p < 0.05) were noted in the Global MGDI, the MGDIs of sagittal plane knee and ankle motion analysis graphs, and the four most common spatiotemporal measures of gait: walking velocity, stride length, step length, and cadence. CONCLUSION: Children with spastic CP seem to gain better overall gait function following SPML procedure and functional physiotherapy, by achieving higher walking velocity, longer stride length and step length, and faster cadence. Further studies with control group and longer follow-up three-dimensional gait analyses are warranted to validate these positive results.

The Role of Taylor Spatial Frame in the Treatment of Blount Disease.

BACKGROUND: Alteration of the posteromedial part of the proximal tibia is the main characteristic of Blount's disease and if left untreated, leg alignment and normal development of the lower limbs may be compromised. AIM: To report treatment outcomes in children with Blount's disease using the Taylor Spatial Frame (TSF). MATERIALS AND METHODS: From January 2007 to December 2014, 16 young children (24 tibia) with a mean age of 7.5 years (range of 3-14 yrs) and severe Blount's disease were treated using TSF. Preoperative long standing radiographs were performed and anatomic medial proximal tibial angle (MPTA), diaphyseal-metaphyseal tibial angle (Drennan), femoro-tibial angle and leg length discrepancy (LLD) were measured. RESULTS: Post-operative improvement of all measurements was observed. MPTA increased from a mean of 71.8° (58° - 79°) to 92.5° (90° - 95°), the Drennan decreased from 16.6° (14° - 18°) to 3.6° (0° - 6°), the F-T angle changed from 15.4° (10° - 25°) of varus to 5.9° (2° - 10°) of valgus and the LLD decreased from 208 mm (150-320) to 69 mm (0- +120). Mean follow-up was 45.6 months. According to Paley's criteria pin track infection was present in 6 tibiae, while in 5 patients software changes were necessary. Recurrence was observed in 3 patients (triplets). Complete restoration of the mechanical axis was obtained at the end of the treatment. CONCLUSIONS: In the last decades, different surgical treatments have been proposed for Blount's disease (tension band plate, staples, osteotomies using external or internal fixation). External fixation using the TSF allows gradual safe correction of multiplanar deformities and is a well-tolerated technique by patients with Blount's disease.

Risk factors for and complications of distraction osteogenesis.

PURPOSE: Distraction osteogenesis is commonly used for limb deformities and reconstruction of bone defects with satisfactory outcome for the patients. However, it is associated with a risk of complications. The present study aims to assess the incidence of complications and to identify the risk factors that may predict distraction osteogenesis-related complications. MATERIALS AND METHODS: We retrospectively studied 63 patients (mean age 13.5 years; range 3-57 years) who had 74 distraction osteogenesis procedures from 2004 to 2009. A circular external fixator was used in 58 procedures, and a monolateral in 16 procedures. Fixator's time, days of treatment, lengthening percentage, bone healing index, distraction regenerate length and index, risk factors and complications were evaluated. The mean follow-up was 5 years (range 2-7 years). RESULTS: Complications occurred in 57 of the 74 procedures (77%); 70% were major complications and 30% were minor. Complications were more common in adults. Bone healing index, days of treatment and fixator's time were univariate predictors of complications. Bone healing index and adult age were the only multivariate predictors of complications. CONCLUSION: Adult age and bone healing index are the most important multivariate predictors of distraction osteogenesis-related complications. Routine follow-up after implant removal, selection of younger patients with minor risk factors and shorter fixator's time are necessary to reduce the rate of distraction osteogenesis-related complications.

Outcome models in peripheral nerve repair: time for a reappraisal or for a novel?

Peripheral nerve injuries are still underestimated. The complexity of assessment of outcome after nerve injury and repair has been described by many authors. Furthermore, the outcome is influenced by several factors that depend on mechanisms in the peripheral as well as the central nervous system. Appropriate formulation of a global accepted postoperative clinical protocol for peripheral nerve repair in the upper extremity remains a subject of debate. The purpose of this review is to detail the current concepts of methods of evaluation after peripheral nerves repair. Finally, we discuss the most crucial factors that determine the final hand function and we consider the challenges that need to be addressed to create a realistic clinical protocol that reflects a prognostic importance.

Results of extra-articular subtalar arthrodesis in children with cerebral palsy.

BACKGROUND: Grice-Green extra-articular subtalar arthrodesis is considered to be a valid surgical method which improves foot alignment in patients with spastic pes planovalgus deformity. The purpose of the present study was to examine the long-term results of Grice-Green procedure and whether it can achieve significant correction of each of the components of pes planovalgus deformity. METHODS: Eleven children (16 feet) with cerebral palsy who underwent Grice extra-articular subtalar arthrodesis were reviewed retrospectively. The mean age of patients at the time of surgery was 9 years and 8 months (range, 6 years 5 months to 12 years 4 months). The mean followup was 3 years and 7 months (range, 2 years 1 month to 8 years 3 months). Seven radiographic parameters of each patient before surgery, after surgery and at the latest followup were used. In addition, position of the graft relative to the weightbearing axis of the tibia was evaluated. RESULTS: Most of the examined parameters showed statistically significant correction which was maintained in the long run. Moreover, the placement of the graft along the mechanical axis seemed to play an important role for stability and preservation of correction of the planovalgus deformity. On the other hand, there were three cases where the osseous graft was absorbed and two cases where triple arthrodesis was necessary due to recurrence of the deformity. CONCLUSION: Grice-Green extra-articular subtalar arthrodesis improves foot alignment in patients with spastic pes planovalgus deformity and can achieve significant correction, postoperatively as well as on a long-term basis, of each of the components of pes planovalgus deformity.

Birth fracture of the clavicle.

Birth fracture of the clavicle occurs in approximately 0.4% to 10% of vaginal births. The most common symptom is decreased movement of the ipsilateral arm. A high index of suspicion is necessary in infants presenting without any symptoms. Although displaced clavicular fractures are relatively easily diagnosed clinically, nondisplaced fractures may be apparent only after callus formation, or if all neonates are subjected to radiography or ultrasonography, or multiple physical examinations by trained examiners. We present a case of an infant delivered with vaginal labor with a fracture of the right clavicle diagnosed after apparent callus formation and discuss the current evidence of associated factors and obstetrical care.

Hemiepiphyseal arrest in a porcine model.

BACKGROUND: Treating angular deformities with temporary hemiepiphysiodesis in skeletally immature patients can avoid the need for osteotomies. Recently, newer implants have been introduced as alternatives to the Blount staple, which was commonly used for the past 60 years. The purpose of this project was to develop a porcine model that can be used to compare various methods of temporary hemiepiphyseal arrest. In this pilot study, we compared the Blount staple and the eight-Plate. We hypothesized that the Blount staple, a fixed angle device, tethers growth immediately, whereas the eight-Plate, having mobile arms, has a certain lead time to take the slack out of the system until it can begin to tether growth. METHODS: A porcine model was selected due to its widespread availability and because its size approximates human pediatric dimensions. Thirty-day-old, 15-kg piglets underwent surgery to insert an eight-Plate in each right proximal medial tibia and a Blount staple in each left proximal medial tibia. The insertion technique was identical to the surgical procedure performed in humans, including the use of image intensification. Anteroposterior and lateral view tibial radiographs were obtained monthly until sacrifice at 3 months after insertion to measure the medial proximal tibial angle. RESULTS: At 1 month follow-up, a large varus deformity up to 30 degrees had already occurred with both devices. In some piglets, the implants were even dragged, by growth, through the epiphysis during the first two months. With further follow-up, the Blount staples frequently migrated to the proximal metaphysis. We observed rebound in four tibiae after implant migration, with partial restoration of the normal limb alignment. CONCLUSIONS: The porcine model for temporary hemiepiphysiodesis seems to have promise for future studies. However, the unusually rapid rate of growth causes us to recommend more frequent observation periods, such as weekly instead of monthly radiographic observation.

Effects of minimally invasive surgery and functional physiotherapy on motor function of children with cerebral palsy: A non-randomised controlled trial.

PURPOSE: This non-randomised controlled trial investigated whether a combined programme of functional physiotherapy and minimally invasive orthopaedic surgery improves the level and degree of capacity and performance of gross motor function in children with spastic cerebral palsy (CP). METHODS: Fifty-two children with spastic CP aged 5-7 years, Gross Motor Function Classification System (GMFCS) levels II-IV, were allocated to two equal groups: experimental group (selective percutaneous myofascial lengthening [SPML] procedure and 9-month functional strengthening physiotherapy programme) and control (standard physiotherapy) groups. At baseline and at the end of the 9-month intervention, the capacity and performance of gross motor function were assessed with the Gross Motor Function Measure (GMFM) D and E subcategories and Functional Mobility Scale (FMS), respectively. The level of gross motor function was measured with the GMFCS. RESULTS: There was a statistically significant difference in the post-intervention improvements in the GMFM D (experimental mean difference = 19.63 ± 10.46; control mean difference = 2.40 ± 4.62) and E (experimental mean difference = 19.33 ± 11.82; control mean difference = 4.20 ± 6.26) between experimental and control group (p < 0.001). There was a significant improvement in the GMFCS level and each FMS distance for the experimental group (p < 0.001), but not for the control group (p > 0.05). CONCLUSION: SPML procedure combined with functional physiotherapy improves gross motor function in children with spastic CP, by raising the degree and level of motor independence.

Intrinsic passive stiffness of 2 constructs of varus proximal femoral osteotomy: external fixator or blade plate.

BACKGROUND: Despite the published clinical evidence of the implementation of external fixation of proximal femoral osteotomies, there is lack of specific laboratory justification. METHODS: Two groups of 5 adult composite femur constructs of varus proximal femoral osteotomy were tested under incremental and cyclical loading of up to 600N along the mechanical axis. Five were fixed with a blade plate and another 5 with a monolateral external fixator. Load versus displacement curves were produced, and passive stiffness of all constructs was calculated. The described loading regime aimed to simulate the initial postoperative state and provide data for the assessment of vertical intrinsic passive stiffness in partial weight-bearing conditions. RESULTS: Although the blade plate constructs showed higher average stiffness, this was not statistically significant [F(1,8)=1.712, P=0.23]. No construct failed. No failure or plastic deformation was observed under the described loading regime. CONCLUSIONS: Vertical intrinsic passive stiffness in partial weight-bearing conditions during the initial postoperative period can be considered satisfactory subsequent to unilateral external fixation of a varus intertrochanteric osteotomy. CLINICAL RELEVANCE: The results support the hypothesis that external fixation is a biomechanically sound alternative to internal fixation of varus intertrochanteric osteotomies, in selected patients.

The orthopaedic aspect of spastic cerebral palsy.

Spastic Cerebral Palsy (CP) is the most common form of CP, comprising of 80% of all cases. Spasticity is a type of hypertonia that clinically manifests as dynamic contractures. The dynamic contracture along with the reduced level of physical activity in a child with CP leads to secondary structural and morphological changes in spastic muscle, causing real musculotendinous shortening, known as fixed contractures. When fixed muscle contractures are not treated early, progressive musculoskeletal deformities develop. As a consequence, spastic CP from a static neurological pathology becomes a progressive orthopaedic pathology which needs to be managed surgically. Orthopaedic surgical management of CP has evolved from previous "multi-event single level" procedures to a "single event multilevel" procedures, with changes in selection and execution of treatment modalities. There is increasing evidence that multilevel surgery is an integral and essential part of therapeutic management of spastic CP, but more research is needed to ensure effectiveness of this intervention on all domains of physical disability in CP.

Early experience with biodegradable implants in pediatric patients.

UNLABELLED: We retrospectively studied nine children and adolescents with congenital malformations, large reconstruction after tumor excision, fractures and osteotomies of the upper extremity, and hand trauma with bone and soft tissue defects treated by internal synthesis using a biocopolymer of L- and DL-stereoisomers of lactic acid polymers and trimethylenecarbonate. A total of 52 biodegradable implants were placed in bone. At a minimum followup of 7 months (mean, 17 months; range, 7-22 months), wound healing was uncomplicated; local or systemic inflammatory tissue reactions, foreign body reactions, and infections were not observed. Bone healing was complete. Six biodegradable screws broke during insertion because of inadequate drilling and tapping, and three biodegradable screws had to be replaced because of damage to the screw head during assembly with the screwdriver. Biodegradable copolymers of poly-L-lactic-poly-DL-lactic acid and trimethylenecarbonate can be used safely and effectively for reconstruction and fixation of bone in children and adolescents. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Elastic intramedullary nailing and DBM-bone marrow injection for the treatment of simple bone cysts.

BACKGROUND: Simple or unicameral bone cysts are common benign fluid-filled lesions usually located at the long bones of children before skeletal maturity. METHODS: We performed demineralized bone matrix and iliac crest bone marrow injection combined with elastic intramedullary nailing for the treatment of simple bone cysts in long bones of 9 children with a mean age of 12.6 years (range, 4 to 15 years). RESULTS: Two of the 9 patients presented with a pathological fracture. Three patients had been referred after the failure of previous treatments. Four patients had large lesions with impending pathological fractures that interfered with daily living activities. We employed a ratio to ascertain the severity of the lesion. The extent of the lesion on the longitudinal axis was divided with the normal expected diameter of the long bone at the site of the lesion. The mean follow-up was 77 months (range, 5 to 8 years). All patients were pain free and had full range of motion of the adjacent joints at 6 weeks postoperatively. Review radiographs showed that all 7 cysts had consolidated completely (Neer stage I) and 2 cysts had consolidated partially (Neer stage II). Until the latest examination there was no evidence of fracture or re-fracture. CONCLUSION: Elastic intramedullary nailing has the twofold benefits of continuous cyst decompression, and early immediate stability to the involved bone segment, which permits early mobilization and return to the normal activities of the pre-teen patients.

Optimal treatment of fibrodysplasia ossificans progressiva with surgical excision of heterotopic bone, indomethacin, and irradiation.

A case report is presented of an 18-year-old boy with advanced fibrodysplasia ossificans progressiva. The patient's right hip was ankylosed in 35 degrees of flexion. Excision of the heterotopic bone from the right hip was followed by a combination of a single fraction irradiation (7Gy) given in the first postoperative day, and an 11-day treatment with indomethacin (25 mg, three times daily, orally). One year postoperatively, the patient ambulates nearly normally and he is able to sit and stand up without significant difficulty. Radiographs of the right hip showed a small amount of heterotopic bone formation at the operative site. In contrast with the results published in the literature, the clinical result of the operation is considered satisfactory. Further investigation of the combined use of indomethacin and single fraction irradiation as a preventive measure after surgical excision of heterotopic bone in patients with fibrodysplasia ossificans progressiva FOP should be performed.

Flexible intramedullary nailing of pediatric unstable forearm fractures.

In the pediatric population, the majority of displaced 2-bone forearm fractures can be reduced and stabilized by conservative means. In this article, we report on a retrospective study of 23 patients with unstable or open forearm fractures treated with closed reduction and percutaneous stabilization with flexible titanium nails. All fractures healed without complication, and final functional results were excellent.

Distal locking of femoral nails under direct vision through a cortical window.

We present a salvage technique for distal femoral interlocking under direct vision through a window in the anterior femoral cortex in a subgroup of six patients, among those presented to our institution during the last 10 years with a femoral shaft fracture treated with reamed, locked intramedullary nailing. The common characteristic of these patients was the performance of distal locking under direct vision through a small window in the anterior femoral cortex because of intraoperative dysfunction of the image intensifier. Screw insertion was successful in all cases. All fractures and all cortical windows healed uneventfully. No postoperative fractures occurred through the cortical defect. This technique, despite being a salvage one, has proven a safe alternative to the common distal targeting techniques. It can be used when an image intensifier is unavailable without jeopardizing the excellent clinical and radiographic outcome of reamed locked nailing of femoral shaft fractures.

Triplane fracture of the proximal tibia.

We report a case of successful treatment of a very rare triplane fracture of the proximal tibia in an adolescent boy. The fracture was internally fixed using cannulated Herbert screws. The final result was excellent.

A technical note on improved instrumentation for Blount staple insertion.

PURPOSE: Temporary hemiepiphysiodesis has gained increasing popularity after the introduction of the eight-Plate Guided Growth System. Since its introduction, the eight-Plate has largely supplanted the traditional Blount staple. The eight-Plate offers better purchase in the bone and a more precise insertion technique. However, the Blount staple is less expensive than the various guided growth plates. Further, some surgeons feel that the Blount staple may work faster, making it more appropriate for children who are approaching skeletal maturity. Unfortunately, the original instrumentation and technique for inserting the Blount staple is over 50 years old and has not been updated. METHODS: The purpose of this study was to develop new instrumentation to make Blount staple insertion as accurate and minimally invasive as eight-Plate insertion. We developed wire/drill guides to accommodate all three sizes of the Blount staple. Two wires are inserted through the wire guide under image intensifier control. After confirming the accurate position of the guidewires, a 3.2-mm cannulated step drill is used to drill over the wires to a depth of 5 mm. This creates two pilot holes for the two tines of the Blount staple. The final insertion is guided under an anteroposterior image intensifier view. We also developed a small staple holder that permits insertion through a small incision. RESULTS: We developed a working prototype of the new instrumentation and used it in three clinical cases. CONCLUSIONS: With the new staple inserter and instrumentation, Blount staples can now be inserted through a smaller incision with similar accuracy as eight-Plate insertion.

Temporary hemiepiphysiodesis with blount staples and eight-plates in pigs.

Temporary hemiepiphysiodesis is a relatively minor surgical procedure in the growing child to allow guided growth to correct angular deformities. Blount staples (Stryker Howmedica, Kiel, Germany) have been used effectively for the past 50 years for physeal stapling; their limitations are poor mechanical purchase and easy extrusion from bone, implant breakage, and potential for physeal damage and permanent closure. Recently, an alternative device to Blount staples called the eight-Plate (Orthofix, McKinney, Texas) has been presented for hemiepiphysiodesis and guided growth. Their theoretical advantages over Blount staples include higher stability, faster correction of the deformity, and fewer complications.We performed a study in a pig model to compare the rate of angular deformity correction and implant extrusion after hemiepiphysiodesis with Blount staples and eight-Plates. In all animals, medial hemiepiphysiodesis was performed in the right proximal tibia with the eight-Plate and the left proximal tibia with the Blount staple. The medial slope angle, medial tibial plateau angle, proximal implant angle, distal implant angle, and distance of the body of the implant from the medial tibial cortex were measured on radiographs of the knee joints performed every 4 weeks. The angles of correction showed statistically significantly earlier effect on physeal guided growth of the eight-Plates compared to the Blount staples. Implant displacement/extrusion was statistically significantly lower for the eight-Plate. In this animal model, eight-Plates are significantly more effective than Blount staples for guided growth after temporary hemiepiphysiodesis.

Selective percutaneous myofascial lengthening of the lower extremities in children with spastic cerebral palsy.

Children with spastic cerebral palsy commonly acquire lower extremity musculoskeletal deformities that at some point may need surgical correction. The authors present 58 children with spastic cerebral palsy who underwent selective percutaneous myofascial lengthening of the hip adductor group and the medial or the lateral hamstrings. All the patients were spastic diplegic, hemiplegic, or quadriplegic. The indications for surgery were a primary contracture that interfered with the patients' walking or sitting ability or joint subluxation. Gross motor ability and gross motor function of the children were evaluated using the gross motor function classification system (GMFCS) and the gross motor function measure (GMFM), respectively. The mean time of the surgical procedure was 14 minutes (range, 1 to 27 minutes). All patients were discharged from the hospital setting the same day after the operation. There were no infections, overlengthening, nerve palsies, or vascular complications. Three patients required repeat procedures for relapsed hamstring and adductor contractures at 8, 14, and 16 months postoperatively. At 2 years after the initial operation, all the children improved on their previous functional level; 34 children improved by one GMFCS level, and 5 children improved by two GMFCS levels. The overall improvement in mean GMFM scores was from 71.19 to 83.19.

A guide frame for the Taylor Spatial Frame.

The Taylor Spatial Frame (TSF) is a versatile multiplanar external fixator that combines ease of application with computer accuracy to effectively reduce fractures and correct all aspects of deformity in reconstructive orthopaedic surgery. However, postapplication adjustments depend on adequate anteroposterior and lateral radiographic measurements to yield the most accurate output from the program. These radiographs need to be taken in an orthogonal plane to the reference ring. We describe a noninvasive technique using a specifically designed radiolucent frame that can be attached to the TSF to guide the surgeon and radiologist in obtaining lateral and anteroposterior radiographs, with the reference ring perfectly orthogonal in single exposures for each radiographic view. By using this guiding frame, reproducible and consistent x-rays oriented orthogonally to the reference ring at different points in the correction may be achieved, thus eliminating the need for repeat radiographs and radiation exposure for patients, radiologists, and surgeons. In this manner, the mounting parameters and the orientation of the bony deformity will be consistent. This should lead to enhanced accuracy of the TSF correction.