Tarsal coalition: Systematic review of arthroscopic management.

INTRODUCTION: The standard of care in the treatment of symptomatic tarsal coalitions is open surgery. However, certain limitations exist with open surgery, which include limited visualization leading to an incomplete resection and possible recurrence of the tarsal coalition. Arthroscopic tarsal coalition resection (TCR) is an alternative that is gaining traction, primarily as the safety profile of posterior ankle and subtalar arthroscopy is more well understood. This study provides a systematic review of the outcomes of arthroscopic TCR. METHODS: PubMed and Embase were searched independently by 2 reviewers for relevant articles based on predetermined criteria. The subject heading "tarsal coalition" and its related key terms were used. RESULTS: A total of 416 studies were revealed by the initial search, out of which only 6 met our predetermined inclusion criteria. A total of 42 patients (average age: 17.6 years) were treated with arthroscopic TCR. Thirty-three (78.6%) and 9 (21.4%) patients had talocalcaneal and calcaneonavicular coalitions, respectively. The follow-up period ranged from 6 to 60 months (mean: 26 months), and no recurrence of the tarsal coalition was detected (0.0%). Complications occurred in two (4.8%) patients only, with one developing complex regional pain syndrome (CRPS), and another patient developing hyperesthesia on the medial aspect of the calcaneus. CONCLUSION: Arthroscopic TCR is a feasible and effective surgery for both CNC and TCC with minimal complications and no disease recurrence at an average of 26 months follow-up. Future high-level of evidence studies are needed to compare the outcomes of open versus arthroscopic TCR.

Operating Room Educational Environment in Canada: Perceptions of Surgical Residents.

OBJECTIVE: The educational experience in operating rooms (OR) plays a central role in the transformation of a trainee into a surgeon. As Canadian residency programs transition to competency-based medical education, and since most surgical competencies are attained in the OR, we investigated the perceptions of Canadian surgical residents about their OR learning environment. DESIGN: Cross-sectional, national survey. SETTING: An online questionnaire, including the validated 40-item operating room educational environment measure (OREEM) inventory, was sent to residency programs of all surgical specialties in Canada. The OREEM assesses the trainees' perceptions of the "trainer and training," "learning opportunities," "atmosphere in the operating room," "supervision, workload, and support," Each individual item was rated using a 5-point Likert scale ranging from "strongly disagree" (scores 1) to "strongly agree" (scores 5). The mean score of each individual item was measured, and the mean scores of each subscale and an overall score of the questions were also measured. PARTICIPANTS: Surgical residents in Canada. RESULTS: Four hundred thirty residents were included for final analysis. The overall mean OREEM score was 3.72 ± 0.4. "Atmosphere in the OR" was the subscale with the highest mean score (3.87 ± 0.5), while "supervision, workload, and support" had the lowest subscale mean score (3.49 ± 0.5). The overall OREEM mean score for junior and senior residents was 3.67 ± 0.4 and 3.80 ± 0.4, respectively (p = 0.001). No significant differences were seen in the mean OREEM score between males and females or different surgical programs. Nevertheless, general surgery had the lowest "supervision, workload, and support" subscale score (3.27 ± 0.5; p < 0.001). CONCLUSIONS: The overall educational environment in OR may be considered satisfactory as perceived by Canadian surgical residents; however, several areas for potential improvement are identified and suggestions for optimizing the learning environment are described.

Selective Dorsal Root Rhizotomy for Spastic Cerebral Palsy: A Longitudinal Case-Control Analysis of Functional Outcome.

BACKGROUND: The benefit of selective dorsal rhizotomies (SDR) on motor function relative to the cerebral palsy (CP) natural history remains unknown. OBJECTIVE: To determine the functional benefit of SDR over the longitudinal CP natural history. METHODS: Retrospective, single-center, case-control study of patients post-SDR after 1990. Inclusion criteria were the following: diagnosis of spastic CP, at least 1 preoperative and 1 postoperative Gross Motor Function Measure (GMFM-88), at least 1 yr of postoperative follow-up. GMFM-88 assessments were performed at 1, 2, 3, 5, 10, and 15 yr postoperatively and converted to GMFM-66. Cases were stratified by preoperative Gross Motor Function Classification System (GMFCS) and matched against their expected natural history using published reference centiles. After age 12, our cohort and matched controls were also fitted to published nonlinear mixed models of GMFM-66 evolution over time. RESULTS: Analysis included 190 patients. Median follow-up, 5.3 yr (range: 1-16.9), median age at surgery, 4.6 yr, and 81.6% of patients grouped as GMFCS II or III pre-op. SDR patients performed statistically significantly better than their expected natural history (P < .0005). At 21 yr old, a modeled benefit of 8.435 was observed for GMFCS I (P = .0051), 0.05 for GMFCS II (P = .9647), 6.31 for GMFCS III (P < .0001), and 1.191 for GMFCS IV patients (P = .0207). CONCLUSION: These results support the use of SDR in carefully selected spastic CP children.

Functional Gains in Children With Spastic Hemiplegia Following a Tendon Achilles Lengthening Using Computerized Adaptive Testing-A Pilot Study.

PURPOSE: This pilot study evaluated the outcomes of tendon Achilles lengthening in 12 children (mean age: 11.2 years) with spastic hemiplegia. METHODS: Cerebral Palsy Computer Adaptive Tests, the timed up-and-go, the Gross Motor Function Measure, the Gillette Functional Assessment Questionnaire, and the Pediatric Outcomes Data Collection Instrument were administered at baseline and at 6, 12, and 24 months postsurgery. RESULTS: Significant improvement at the latest follow-up (12-24 months following surgery) was seen in all domains of the Cerebral Palsy Computer Adaptive Test: activity (P = .017), lower extremity (P = .005), global (P = .005), pain (P = .005), and fatigue (P = .028), as well as in the Gross Motor Function Measure-D domain (P = .02) and the mobility domain of the Pediatric Outcomes Data Collection Instrument (P = .04). CONCLUSION: These findings indicate that the tendon Achilles lengthening improved functional outcome in these children as measured by tests of physical function, walking speed, and activity performance.

Spondyloepimetaphysial Dysplasia with Joint Laxity in Three Siblings with B3GALT6 Mutations.

Spondyloepimetaphyseal dysplasia with joint laxity type 1 (SEMDJL1) is a rare entity with a recessive inheritance. In this report, we describe 3 affected members of the same family who present with short stature, hyperlaxity with secondary spinal malalignment, ulnar subluxation, developmental dysplasia of the hips, and craniofacial alterations; one member also had learning difficulties. DNA analysis showed compound heterozygous variants in the B3GALT6 gene (c.901_921dup, c.511C>T) in all 3 patients, inherited from the parents. This family demonstrates the clinical variability of SEMDJL1.

Hip joint osteochondroma: systematic review of the literature and report of three further cases.

The aim of this study is to systematically review the literature with regards to surgical treatment of patients with hip joint osteochondromas, and to report our surgical management of three paediatric patients who had femoral neck or acetabular osteochondromas in association with acetabular dysplasia. We performed a systematic review using PubMed and Embase databases for all studies that reported surgical treatments for patients with peritrochanteric or acetabular osteochondroma with or without acetabular dysplasia. We also retrospectively reviewed three patients who were diagnosed with a hip osteochondroma in association with actetabular dysplasia. These patients were known to have hereditary multiple exostoses (HME). The systematic review revealed 21 studies that met our inclusion criteria. All studies were case reports and retrospective in nature and failed to conclude a uniform treatment plan. The three reported cases illustrate successful excision of hip osteochondromas and treatment of acetabular dysplasia. Early excision of hip osteochondromas might prevent acetabular dysplasia in HME patients. Routine radiographic pelvic survey at the time of diagnosis of HME is recommended for early detection of hip osteochondromas and acetabular dysplasia in these children.

Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy.

OBJECT: Large-scale natural history studies of gross motor development have shown that children with spastic cerebral palsy (CP) plateau during childhood and actually decline through adolescence. Selective dorsal rhizotomy (SDR) is a well-recognized treatment for spastic CP, but little is known about long-term outcomes of this treatment. The purpose of this study was to assess the durability of functional outcomes in a large number of patients through adolescence and into early adulthood using standardized assessment tools. METHODS: The authors analyzed long-term follow-up data in children who had been evaluated by a multidisciplinary team preoperatively and at 1, 5, 10, and 15 years after SDR. These evaluations included quantitative, standardized assessments of lower-limb tone (Ashworth Scale), Gross Motor Function Measure (GMFM), and performance of activities of daily living (ADLs) by the Pediatric Evaluation of Disability Inventory in children who had been stratified by motor severity using the Gross Motor Function Classification System (GMFCS). In addition, group-based trajectory modeling (GBTM) was used to identify any heterogeneity of response to SDR among these treated children, and to find which pretreatment variables might be associated with this heterogeneity. Finally, a chart review of adjunct orthopedic procedures required by these children following SDR was performed. RESULTS: Of 102 patients who underwent preoperative evaluations, 97, 62, 57, and 14 patients completed postoperative assessments at 1, 5, 10, and 15 years, respectively. After SDR, through adolescence and into early adulthood, statistically significant durable improvements in lower-limb muscle tone, gross motor function, and performance of ADLs were found. When stratified by the GMFCS, long-lasting improvements for GMFCS Groups I, II, and III were found. The GBTM revealed 4 groups of patients who responded differently to SDR. This group assignment was associated with distribution of spasticity (diplegia was associated with better outcomes than triplegia or quadriplegia) and degree of hip adductor spasticity (Ashworth score < 3 was associated with better outcomes than a score of 3), but not with age, sex, degree of ankle plantar flexion spasticity, or degree of hamstring spasticity. In a sample of 88 patients who had complete records of orthopedic procedures and botulinum toxin (Botox) injections, 52 (59.1%) underwent SDR alone, 11 (12.5%) received only Botox injections in addition to SDR, while 25 patients (28.4%) needed further lower-extremity orthopedic surgery after SDR. CONCLUSIONS: In the majority of patients, the benefits of SDR are durable through adolescence and into early adulthood. These benefits include improved muscle tone, gross motor function, and performance of ADLs, as well as a decreased need for adjunct orthopedic procedures or Botox injections. The children most likely to display these long-term benefits are those in GMFCS Groups I, II, and III, with spastic diplegia, less hip adductor spasticity, and preoperative GMFM scores greater than 60.

Dega osteotomy for the correction of acetabular dysplasia of the hip: a radiographic review of 21 cases.

BACKGROUND: The Dega osteotomy is a versatile procedure that is widely used to treat neuromuscular hip dysplasia. There is a paucity of the English language literature on its use in acetabular dysplasia seen in developmental dysplasia of the hip (DDH). METHODS: A retrospective radiographic and chart review was performed for all patients diagnosed with DDH who underwent a modified Dega osteotomy between March 1995 and December 2008 at the Shriners Hospital for Children or the Montreal Children's Hospital (Montréal, Canada) by 2 orthopaedic surgeons. Radiographic parameters were measured at the preoperative, immediate postoperative, and final follow-up time points. These parameters included the acetabular index, center edge angle, Reimer's extrusion index, Shenton line, and grading by the Severin classification. RESULTS: A total of 20 patients (21 hips), of which 18 were female, underwent a modified Dega osteotomy at an average age of 55.6 months (range, 20 to 100 mo). Of the 21 hips (1 bilateral and 19 single cases), 9 hips involved the right side and 12 hips involved the left side. Before surgery, 9 patients had a subluxated hip, 7 patients had a dislocated hip, and 5 patients had a dysplastic hip. Ten hips underwent concomitant procedures including 10 open reductions with capsulorraphy. The acetabular index improved from 37 degrees (SD 8) preoperatively to 19 degrees (SD 8) on the date of last visit. The center edge angle improved from 2 (SD 17) to 25 degrees (SD 12). CONCLUSIONS: The results of this study demonstrate that the modified Dega osteotomy produces near-normal lateral coverage parameters in children with DDH. LEVEL OF EVIDENCE: Therapeutic study, clinical case series: level IV.

Determinants of responsiveness to botulinum toxin, casting, and bracing in the treatment of spastic equinus in children with cerebral palsy.

AIM: The objective was to determine whether specific intrinsic (age, pattern of cerebral palsy [CP], child's motivation) and extrinsic (number of treatments, parenting stress) characteristics were associated with responsiveness to botulinum toxin A (BoNT-A) injections in children with CP 3 months after injection into the gastrocnemius muscle. METHOD: Children with hemiplegia or diplegia recruited from a BoNT-A programme were evaluated before and 3 months following injection of BoNT-A into the gastrocnemius. Outcome measures included muscle tone, range of motion, gait pattern, level of ambulation, gross motor function, and functional independence. Determinants of responsiveness to BoNT-A considered were age, number of treatments, distribution of CP, parenting stress, and motivation. RESULTS: Thirty-one children were recruited (17 males, 14 females)--22 with hemiplegia and nine with diplegia. Twenty-eight were classified at Gross Motor Function Classification System (GMFCS) level I and three at level III. The mean age was 6 years 4 months (SD 2y 11mo). Younger age (p=0.015) and fewer number (p=0.024) of BoNT-A treatments were associated with greater change in gross motor function. Child's motivation and parenting stress were significantly associated with improvements in muscle tone (p=0.006-0.017), passive range of motion (p=0.008-0.033), gait pattern (p=0.005-0.042), level of ambulation (p=0.001-0.043), and functional independence (p=0.004-0.027). INTERPRETATION: The results indicate that child, family, and treatment characteristics influence the degree of responsiveness to BoNT-A treatment. The contribution of contextual factors (personal and environmental) on responsiveness may be underappreciated in children with CP.

Spinal deformities following selective dorsal rhizotomy.

OBJECT: Selective dorsal rhizotomy (SDR) has been shown to provide considerable benefit to children with spastic cerebral palsy (CP). The authors sought to evaluate the risks of postoperative spinal deformities in patients following SDR. METHODS: All patients who underwent SDR at McGill University between 1991 and 2001 were identified. Hospital charts and radiographic spinal studies (both preoperative and the latest postoperative) were systematically reviewed. Univariate and multivariate regression analyses were conducted to test all independent variables of potential interest to determine risk factors more likely to be associated with spinal deformity. There were 98 patients whose mean age at surgery was 5.1 years; the mean radiographic follow-up duration was 5.8 years. Thirty-nine (44.8%) of 87 patients in whom postoperative weight-bearing radiographs were obtained had mild scoliosis, and 17 in whom standing radiographs were acquired had hyperlordosis. In all, 18 of 94 patients (19.1%) who had postoperative radiographs on which the lumbosacral junction was visible were found to have spondylolisthesis. Regression analysis identified the severity of preoperative CP as an important predictor, and less ambulatory patients were more likely to have scoliotic curves. Younger age at surgery and male sex were factors associated with a lower rate of hyperlordosis. Spondylolisthesis developed only in ambulatory children. None of the patients experienced clinically significant deficits. CONCLUSIONS: There was a high rate of radiologically documented deformities in patients with CP who underwent SDR. Ambulatory function, CP severity, age at surgery, and sex may be contributing factors.

Clinical outcome of pediatric calcaneal fractures treated with open reduction and internal fixation.

The results of displaced intra-articular calcaneal fractures treated with open reduction and internal fixation in skeletally immature children at one institution were reviewed. Six children with seven displaced intra-articular calcaneal fractures treated with open reduction and internal fixation were reviewed at an average of 30 months after surgery (range 18-48 months). All children were treated by one of two surgeons and followed by the same surgeon. The preoperative workup included computed tomography scans, which showed that all had displaced intra-articular fractures and five had comminuted fractures. At follow-up all children were pain-free with normal activities. All were able to return to full activities at an average of 10 months after surgery. All had normal ankle range of motion, but five had decreased subtalar range of motion. There were no postoperative complications, shoe wear problems, or peroneal tendinitis. This study demonstrates that open reduction and internal fixation for displaced intra-articular fractures in children yields encouraging results.

Impact of selective posterior rhizotomy on fine motor skills. Long-term results using a validated evaluative measure.

Suprasegmental effects following selective posterior rhizotomy have been frequently reported. However, few studies have used validated functional outcome measures to report the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term impact of lumbosacral dorsal rhizotomy on fine motor skills. The study population comprised children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively, at 6 months and 1 year postoperatively. Quantitative standardized assessments of upper extremity function were obtained using the fine motor skills section of the Peabody Developmental Motor Scales (PDMS) test. Of 70 patients who met the entry criteria for the study, 45 and 25 completed the 3- and 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in grasping, hand use, eye-hand coordination, and manual dexterity at 1 year after SPR. More importantly, all improvements were maintained at 3 and 5 years following SPR. This study supports that significant improvements in upper extremity fine motor function using the PDMS evaluative measure are present after SPR and that these suprasegmental benefits are durable.