Management of a Proximal Femoral Central Physeal Bar in a 3-Year-Old Child Using a Novel Surgical Technique: A Case Report.

CASE: We present a proximal femoral central physeal bar secondary to femoral neck fracture management, in a 3-year-old boy. He presented with progressive femoral neck deformity and limb length discrepancy. He was managed with a novel technique of bar resection by drilling and polymethylmethacrylate interposition. After 5 years of follow-up, the hip score by Ratliff criteria was good. CONCLUSION: Screw penetration across physis during management of femoral neck fracture can cause growth arrest in a young child. Our technique is useful when physeal bar is central and linear. It can allow sufficient growth and remodeling to restore a near-normal hip both radiologically and clinically.

Evaluation of a technique of patellar tendon shortening to correct patella alta associated with severe crouch gait in cerebral palsy.

This study was undertaken to evaluate the results of patella tendon shortening to correct patella alta in the context of surgery for the management of severe crouch gait. Our aim was to ascertain whether the corrected position of the patella and improvement of the power of the quadriceps were maintained for 4 years or more. Twenty older children (mean age: 14.2 years) with long-standing crouch gait secondary to cerebral diplegia underwent surgery to correct crouch gait that included the patellar tendon shortening. The technique for plicating the tendon differed for skeletally mature and immature patients. The length of the patellar tendon was measured by the Koshino Index. The strength of the quadriceps muscle was assessed by manual muscle testing and with a dynamometer and extensor lag, if present, was measured with a goniometer. In all 40 knees, the patella was brought to a more distal position and the position was maintained for a mean duration of 84 months (Koshino Index: preoperative 1.3 ± 0.10; 3-month postoperative 0.95 ± 0.05; final follow-up 0.95 ± 0.04). The results were the same for the techniques used for skeletally mature and immature patients. The power of the quadriceps improved [Medical Research Council (MRC) grade 3 to MRC grade 4] and the improvement was maintained. The technique of patella tendon shortening was effective in correcting patella alta and improving quadriceps power. The shortened patellar tendon did not stretch over the period of follow-up. Level of evidence: III.

Hip Surveillance for Children with Cerebral Palsy: A Survey of Orthopaedic Surgeons in India.

BACKGROUND: The purpose of this study was to assess Indian orthopaedic surgeons' current practices and beliefs regarding hip surveillance for children with cerebral palsy (CP), to determine potential support for developing hip surveillance guidelines, and to identify knowledge gaps and key obstacles to guideline implementation in India. METHODS: An anonymous, cross-sectional online survey was sent to approximately 350 Paediatric Orthopaedic Society of India (POSI) members who were queried on their practices and beliefs about hip surveillance for children with CP, as well as perceived challenges and requirements for the successful implementation of hip surveillance guidelines in the Indian context. RESULTS: Out of 107 responses obtained from POSI members, almost all (96.2%) agreed that hip displacement requires standardized monitoring, using surveillance and surgery to prevent hip dislocation. Approximately half (51.5%) of respondents reported using existing hip surveillance guidelines, with most (41.2%) using the Australian guidelines. Almost all (97%) surgeons indicated that hip surveillance guidelines in India are needed, with 100% expressing interest in following guidelines specific to India. Respondents most frequently indicated late referrals to orthopaedics (81.2%), loss of patients to follow-up (78.2%), and lack of resources (43.6%) as challenges to successful hip surveillance in India. Perceived requirements for implementation included developing Indian-specific guidelines (83.2%) as well as educating surgeons (56.4%), physiotherapists/pediatricians (90.1%), and families (82.2%). CONCLUSION: Orthopaedic surgeons practicing in India understand the importance of preventing hip dislocations in children with CP through hip surveillance and timely surgical intervention. The results demonstrated strong support for the development of hip surveillance guidelines designed specifically for the Indian healthcare system. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00432-3.

Reliability of 3 Radiologic Classifications for the Severity of the Developmental Dysplasia of the Hip in Children Older Than 4 Years.

BACKGROUND: Tonnis, International Hip Dysplasia Institute (IHDI), and lateral metaphyseal height (LMH) are commonly used classifications for grading the severity of the developmental dysplasia of the hip. The reliability of these classifications is not widely studied in older children. The aim of the study was to evaluate the reliability of these 3 radiologic classifications in children older than 4 years and compared with children younger than 4 years and evaluate the cases with varied inter-rater reliability. METHODS: A purposeful sample of 40 children with untreated developmental dysplasia of the hip with ages between 6 months to 8 years was studied for the assessment of the severity grading according to all 3 classifications. Six pediatric orthopaedic surgeons classified all hips for all 3 categorical classifications as per the original description. Inter-rater and intrarater reliability was calculated according to the intraclass correlation coefficient. The cases with different ratings were assessed in detail to evaluate the reasons for the varied rating. RESULTS: The interobserver and intraobserver reliability of all 3 classifications were excellent [intraclass correlation coefficient (ICC): 0.935, 0.820, and 0.935 for IHDI, Tonnis, and LMH classification, respectively]. The excellent reliability was also observed in younger and older children. Interobserver reliability of only dysplastic hips (52 hips) was good for Tonnis (ICC: 0.741) and excellent for IHDI (ICC: 0.911) and LMH classification (ICC-0.9). The main reason for the varied rating was because of the varied perception of the superolateral margin of the acetabulum in few hips. CONCLUSION: The inter-rater and intrarater reliability of all 3 classifications (IHDI, Tonnis, and LMH) is excellent. All classifications can be used till the age of 8 years. The difficulty in selecting the superolateral margin of the acetabulum is a major cause of inter-rater variability. LEVEL OF STUDY: Level III.

Management of the Knee Problems in Spastic Cerebral Palsy.

Two common knee problems in cerebral palsy are increased knee flexion during stance phase and reduced knee flexion during the swing phase of gait. We reviewed the recent literature and based on that, we formed this review. Hamstring spasticity, quadriceps weakness, soleus weakness, and lever-arm dysfunction are few factors which lead to increased knee flexion during stance phase. Rectus spasticity diminishes knee flexion in the swing. Resulting gait-stiff knee gait interferes with ground clearance. Both gait patterns result into esthetically poor gait and increased energy consumption. Knee flexion gait may lead to pain in the knee. Natural history of knee flexion gait suggests deterioration over time. In the early stage, these gait abnormalities are managed by nonoperative treatment. Cases in which nonoperative measures fail or advance cases need surgical treatment. Various variables which are taken into consideration before selecting a particular treatment option are described. We also present an algorithm for decision-making. Nonsurgical options and surgical procedures are discussed.

Ensuring precision in lower limb deformity correction through a combination of temporary external fixation followed by internal fixation: Results of a retrospective study.

BACKGROUND: It is important to plan preoperatively when contemplating internal fixation following deformity correction. Surgeons often find it difficult to retain the achieved correction till the end of internal fixation. To maintain precise correction we used hybrid technique which uses both external and internal fixation. The objective of the study was to evaluate the effectiveness of this hybrid technique in achieving and retaining desired correction. MATERIALS AND METHODS: In this retrospective study, we evaluated the magnitude of deformity with radiological parameters. We compared correction which was planned and correction which was achieved. The technique was used during surgery for corrective osteotomies. Before carrying out the osteotomy, rail fixator with two swivel clamps was applied. After osteotomy swivel clamps were loosened. Desired correction was achieved. While fixator held the fragments in corrected position, definitive internal fixation was carried out. External fixator was removed after completion of internal fixation. Position of mechanical axis ratio, mechanical lateral distal femoral angle and mechanical medial proximal tibial angle were measured before and 12 weeks after surgery. Student t-test was used to analyze the difference between correction which was planned and correction which was achieved. RESULTS: There was no statistical difference between the desired correction and the correction achieved. CONCLUSIONS: Temporary use of external fixator while correcting angular deformities of lower limb allows to achieve accurate correction.

Multilevel orthopedic surgery for crouch gait in cerebral palsy: An evaluation using functional mobility and energy cost.

BACKGROUND: The evidence for the effectiveness of orthopaedic surgery to correct crouch gait in cerebral diplegic is insufficient. The crouch gait is defined as walking with knee flexion and ankle dorsiflexion through out the stance phase. 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. We retrospectively evaluated the effect of surgery on the mobility and energy consumption at one year or more with the help of validated scales and scores. MATERIALS AND METHODS: 18 consecutive patients with mean age of 14.6 years with cerebral diplegia with crouched gait were operated for multilevel orthopaedic surgery. Decisions for surgery were made with the observations on gait analysis and physical examination. The surgical intervention consisted of lengthening of short muscle-tendon units, shortening of long muscles and correction of osseous deformities. The paired samples t test was used to compare values of physical examination findings, walking speed and physiological cost index. Two paired sample Wilcoxon signed rank test was used to compare functional walking scales. RESULTS: After surgery, improvements in functional mobility, walking speed and physiological cost index were found. No patient was able to walk 500 meters before surgery while all were able to walk after surgery. The improvements that were noted at one year were maintained at two years. CONCLUSIONS: Multilevel orthopedic surgery for older children and adolescents with crouch gait is effective for improving function and independence.