Aponeurotic release of semimembranosus: A technical note to increase correction gained with hamstring lengthening surgery in cerebral palsy.

OBJECTIVE: The aim of this study was to determine the intraoperative corrective effect of the aponeurotic release of semimembranosus (SM) as a single procedure or an adjunct procedure to distal myotendinous release of semitendinosus (ST) and myofascial release of SM lengthening in the correction of knee flexion deformity in cerebral palsy (CP). METHODS: In this prospective study, 46 knees of 23 consecutive ambulatory patients (15 boys and 8 girls; mean age=8.33 years; age range=5-12 years) with spastic diplegic CP with a gross motor function classification system level (GMFCS) II or III were included. The patients were then divided into 2 groups. In group I, there were 10 patients (4 boys, 6 girls; mean age=8.6±2), and combined release of ST in the myotendinous junction and SM in the myofascial junction, followed by aponeurotic release of SM were carried out. In group II, there were 13 patients (2 girls, 11 boys; mean age=8±2.35), and aponeurotic release of SM was done first and followed by the combined release of ST in the distal myotendinous junction and the myofascial release of SM. Intraoperative popliteal angle (PA) measurements were recorded in each group. RESULTS: PA was reduced from 58.1°±7.6° (range=46°-75°) to 41.2°±8.8° (range=20°-54°) in group 1 and from 59.1°±11.3° (range=40°-87°) to 42.7°±10.8° (range=24°-64°) in group 2. No significant difference was observed between the groups in terms of reduction in PA (p=0.867). In group 1, adding the aponeurotic release of SM further reduced the PA to 31.7°± 8.5° (range=14°-47°) (p=0.002). In group 2, adding the myotendinous release of ST and myofascial release of SM further reduced the PA to 32.9°±7.2° (range=16°-44°) (p=0.004). There was no significant difference between the final PA values in the 2 groups (p=0.662). There was no difference in terms of early complications. CONCLUSION: Aponeurotic release of SM is equally effective to reduce the intraoperative PA with combined myotendinous release of ST and myofascial release of SM. Combining all the 3 procedures provides a better correction without forceful manipulation or lengthening of the lateral hamstrings during the correction of knee flexion deformity in CP.

Growth Modulation for Knee Coronal Plane Deformities in Children With Nutritional Rickets: A Prospective Series With Treatment Algorithm.

To report prospectively the radioclinical outcome of guided growth surgery for coronal plane deformities around the knee in young children with nutritional rickets on the intermediate term, to assess the responsiveness of torsional deformities of the tibias to guided growth regarding function and objective clinical parameters, and to propose a treatment algorithm. Methods: Fifty children (male:female, 27:23) with knee coronal plane deformities (knees:physes, 86:99), (varum:valgum, 51:35) secondary to nutritional rickets were subjected to femoral and/or tibial temporary hemiepiphysiodesis using a two-hole 8-plate. The mean age at implantation was 3.8 ± 1.5 years (range 2.5 to 5). The mean follow-up was 2.8 years (range 2 to 4). All children received a standing full-length AP radiographs of both lower limbs in neutral rotation to measure the mechanical axis deviation, tibiofemoral angle, and joint orientation angles. Tibial torsion was objectively assessed by measuring the bimalleolar axis. Results: The radiologic measurements, tibiofemoral angle, mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle, and Hilgenreiner-epiphyseal angle, showed a highly statistically significant improvement (P ≤ 0.001). Radiographic outcomes correlated with their clinical counterparts. The mean duration of correction of the mechanical axis was 10.8 ± 2.4 months (7 to 21). The mean follow-up for rebound of the deformity was 1.5 years (range 1 to 3). Conclusion: The radioclinical outcome is rewarding with a tolerable complication profile. The mechanical complications were mostly related to lengthy implant retainment encountered in severe deformities. Internal tibial torsion seems profoundly responsive to correction of coronal plane deformity. And, derotation osteotomies are rarely justified. Our proposed algorithm may be used as a decision-taking guide for achieving the desired growth modulation in a more efficient manner.

Osteotomy around the knee: evolution, principles and results.

PURPOSE: This article summarises the history and evolution of osteotomy around the knee, examining the changes in principles, operative technique and results over three distinct periods: Historical (pre 1940), Modern Early Years (1940-2000) and Modern Later Years (2000-Present). We aim to place the technique in historical context and to demonstrate its evolution into a validated procedure with beneficial outcomes whose use can be justified for specific indications. MATERIALS AND METHODS: A thorough literature review was performed to identify the important steps in the development of osteotomy around the knee. RESULTS: The indications and surgical technique for knee osteotomy have never been standardised, and historically, the results were unpredictable and at times poor. These factors, combined with the success of knee arthroplasty from the 1980s onward, led to knee osteotomy being regarded as an irrelevant surgical option by many surgeons. Despite its fluctuating reputation, this article demonstrates the reasons for the enduring practice of osteotomy, not least because achieving the appropriate alignment is now recognised as the foundation step when planning any surgical intervention. CONCLUSIONS: With appropriate patient selection, accurate pre-operative planning, modern surgical fixation techniques and rapid rehabilitation, osteotomy around the knee is now an effective biological treatment for degenerative disease, deformity, knee instability and also as an adjunct to other complex joint surface and meniscal cartilage surgery. LEVEL OF EVIDENCE: V.