Does Size Really Matter? Incidence of Periprosthetic Fractures After Femoral Osteotomy in Patients With Cerebral Palsy.

OBJECTIVE: Of children, 30% to 35% with cerebral palsy (CP) develop hip subluxation or dislocation and often require reconstructive hip surgery, including varus derotation osteotomy (VDRO). A recent literature review identified postoperative fractures as the most common complication (9.4%) of VDROs. This study aimed to assess risk factors for periprosthetic fracture after VDRO in children with CP. METHODS: A total of 347 patients (644 hips, 526 bilateral hips) with CP and hip subluxation or dislocation (129 females; mean age at index VDRO: 8.6 y, SD 3.4, range: 1.5 to 17.7; 2 Gross Motor Function Classification System (GMFCS) I, 35 GMFCS II, 39 GMFCS III, 119 GMFCS IV, 133 GMFCS V, 21 unavailable) were included in this retrospective, single-group intervention (VDRO) study at a tertiary referral center. Imaging and clinical documentation for patients age 18 years or younger at index surgery, treated with VDRO were reviewed to determine demographic data, GMFCS level, surgeon, type of hardware implanted, use of anticonvulsants and steroids, type of postoperative immobilization, presence of periprosthetic fractures, fracture location and mechanism, and time from surgery to fracture. Potential determinants of periprosthetic fractures were assessed using mixed effects logistic regression. RESULTS: Of 644 hips, 14 (2.2%, 95% CI: 1.3%, 3.6%) sustained a periprosthetic fracture, at a median of 2.1 years postoperatively (interquartile range: 4.6 y, range: 1.2 mo to 7.8 y). Patients with a fracture had a median age at index surgery of 7.3 years (interquartile range: 4.3, range: 2.8 to 17.8; 1 GMFCS II, 6 GMFCS IV, 7 GMFCS V). Periprosthetic fractures were not significantly related to age at index surgery ( P = 0.18), sex ( P = 0.30), body mass index percentile ( P = 0.87), surgery side ( P = 0.16), anticonvulsant use ( P = 0.35), type of postoperative immobilization ( P = 0.40), GMFCS level ( P = 0.31), or blade plate size ( P = 0.17). Only surgeon volume significantly related to periprosthetic fracture (odds ratio = 5.03, 95% CI: 1.53, 16.56, P = 0.008), with the highest-volume surgeon also using smaller blade plates ( P < 0.01). CONCLUSIONS: Periprosthetic fractures after VDRO surgery in children with CP are uncommon, and routine hardware removal appears unnecessary. The data suggest that the common dogma of putting in the largest blade plate possible to maximize fixation may increase the risk of periprosthetic fracture. Due to the overall low fracture rate, especially when contextualized relative to the risk of hardware removal, a reactive approach to hardware removal appears warranted. LEVEL OF EVIDENCE: Level III-retrospective study (targeting varus derotational osteotomies in children with cerebral palsy).

Absence of Peroneus Tertius in Split Anterior Tibialis Tendon Transfer Surgery.

Split anterior tibialis tendon transfer is a common orthopedic surgical procedure for varus foot deformities. In the absence of the peroneus tertius, the peroneus brevis may be used in the transfer. Little is known about the prevalence of each transfer type. The goal of this study is to understand trends in tendon transfer for patients who undergo split anterior tibialis tendon transfer. Records of all patients who underwent tibialis anterior tendon split transfer at our institution between January 2004 and September 2020 were reviewed. After, 337 subjects who underwent tibialis anterior tendon split transfer were included. The peroneus tertius was absent in 33.2% (112/337) of subjects. Logistic regressions showed the odds of having a missing peroneus tertius were 66.9% lower for subjects with cerebral palsy and related etiologies (odds ratio [OR]: 0.331, 95% confidence interval [CI]: 0.21, 0.53), 47% lower for white subjects (OR: 0.53, 95% CI: 0.31, 0.91), and 59.1% lower for non-Hispanic subjects (OR: 0.409, 95% CI: 0.25, 0.66). The odds of a missing peroneus tertius tendon were 2.72 times higher for subjects who identified in the other racial category (95% CI: 1.65, 4.49), and 2.41 times greater for subjects who identified as Hispanic (95% CI: 1.51, 3.84). Patients who underwent the procedure who identified as Hispanic or members of other (non-White, -Black, -Asian) racial groups had an increased likelihood of having a missing peroneus tertius tendon. Patients who identified as white, having cerebral palsy or related etiologies, or non-Hispanic had a decreased risk of having a missing peroneus tertius tendon.

Ankle Mortise Instability in Multiple Hereditary Exostoses.

Ankle valgus is commonly reported in patients with multiple hereditary exostoses (MHE). We report the characteristics of mortise widening in MHE, its progression over time, and the resultant ankle pain and function at skeletal maturity. Mortise medial space (M), talocrural angle (TC), and tibiotalar angle (TT) measurements were collected on preoperative and last follow-up radiographs. Operative data and complications were recorded. American Orthopaedic Foot and Ankle Society (AOFAS) and short form-36 scores at skeletal maturity were collected. A total of 16 patients (19 ankles) had MHE and mortise widening. Thirteen patients had surgery. Preoperatively, no patient complained of instability. However, 11 ankles (57.9%) were painful and 15 (78.9%) were clinically in valgus. Patients underwent surgery at a mean age of 11.8 ± 2.2 y. Operative interventions included medial distal tibia hemiepiphysiodesis for the majority of patients. There were no statistically significant differences between pre and postoperative M, TC, TT angles. Operative patients showed an improved mean M (5.17 ± 1.17 to 4.63 ± 1.06 mm) and TT (8.71 ± 5.40° to 4.54 ±7.58°), however, neither angle reached normal values. TC representing fibular length-maintained measurements within normal limits (82.2 ± 5.3° to 84.8 ±5.8°). Questionnaires were obtained for 10 (52.6%) ankles. Mean age at questionnaires collection was 19.0 ± 3.6 y. Mean AOFAS score was 74.8 ± 17.6 out of 100. Patients scored 6.5 ± 4.1 out of 10 for alignment, 33.0 ± 6.7 out of 40 for pain, 35.3 ± 9.5 out of 50 for function. All short form-36 scores were above the national mean. Improvement of M and TT angles was modest. TC angle was within normal limits but showed an overall fibular shortening and decreased lateral buttress and potential for talar shift, as reflected in AOFAS score. The underwhelming amount of mortise widening correction achieved may not provide for a stable ankle joint.

Four-in-one Extensor Realignment for the Treatment of Obligatory or Fixed, Lateral Patellar Instability in Skeletally Immature Knee.

BACKGROUND: Congenital (fixed) and obligatory (habitual) patellar dislocations in children are a complex clinical and surgical challenge. Numerous individual surgical techniques have been described. This study aims to assess results, patient satisfaction, and complications after a combined Roux-Goldthwait procedure, vastus medialis obliquus advancement, Galeazzi procedure, and extensive, lateral release (4-in-1 extensor realignment) in the skeletally immature knee with obligatory, or fixed lateral patellar instability. METHODS: Records of children with congenital fixed or obligatory patellar instability, who underwent the 4-in-1 procedure at a single institution, were reviewed. Clinical results included ability and time for the return to activities of daily living (ADL) and sport, recurrent instability and/or dislocation, and necessity of long-term bracing. Continued pain was assessed by the Kujala Score. Complications including infection, recurrent instability, and the necessity for secondary procedures were recorded. RESULTS: A total of 34 patients (46 knees) mean age 10.3±2.4 years, underwent the 4-in-1 procedure with a mean postoperative follow-up of 51.6±31.5 (range, 12 to 146) months. Sixteen patients (22 knees) responded to a phone interview and questionnaire. All 16 patients returned to ADL in a mean time of 10.3±2.4 weeks. Ninety-one percent returned to sport in a mean time of 23.1±15.5 weeks. Long-term bracing was required for 6 knees after the surgery. The mean Kujala Score was 93.0±5.2 (range, 83 to 100). Complications included 6 of 34 patients (18%) with recurrent instability at the latest follow-up and 2 with superficial wound infection. CONCLUSIONS: Patients with obligatory or fixed lateral, patellar instability who undergo the 4-in-1 procedure have good short-term results with low complication rates. Return to ADL and sporting activity with minimal pain can be expected, usually without the need for long-term bracing. The 4-in-1 procedure is a viable option for skeletally immature patients with obligatory or fixed, lateral patellar instability. LEVEL OF EVIDENCE: Level IV-Therapeutic study.

Titanium Elastic Nails Are a Safe and Effective Treatment for Length Unstable Pediatric Femur Fractures.

BACKGROUND: Controversy exists regarding the treatment of length unstable pediatric femoral shaft fractures. The purpose of this study was to investigate the outcomes of skeletally immature children with length unstable femur fractures treated with titanium elastic nails (TENs). METHODS: A retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from April 2006 to January 2018. Patients with femoral shaft fractures treated with TEN and minimum 6 months follow-up were included. Exclusion criteria were age 11 years or above, weight >50 kg, pathologic fracture, and neuromuscular disorders. Femur fractures were categorized into 2 groups: length unstable (spiral, comminuted, or long oblique fractures) versus length stable (transverse and short oblique). Complications and reoperations were compared between the groups. RESULTS: A total of 57 patients with 58 femoral shaft fractures were included. The mean age was 5±2 (1 to 11) years and mean follow-up was 20.4±18.1 (6.0 to 81.2) months. The mean weight was 22.9±7.7 (11.0 to 40.5) kg. There was no difference in age (P=0.32), weight (P=0.28) or follow-up length (P=0.57) between patients with length unstable fractures and those with length stable fractures. A total of 32/58 (55%) fractures were length unstable and 26/58 (45%) were length stable. Mean time to union was 4.6 months, and there was no significant difference in mean time to union between the 2 groups (P=0.71). Thirty-one complications occurred in 27 patients. There was no difference between groups in the incidence of major complications requiring revision surgery (P=0.68) and minor complications that did not require revision surgery (P>0.99). CONCLUSIONS: In children with femoral shaft fractures treated with TEN, there was no difference in the incidence of complications or reoperations between those with length unstable fractures and those with length stable fractures. TEN are a safe and effective choice for operative fixation of length unstable femoral shaft fractures in children. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Cervical Spine Deformities in Children With Rhizomelic Chondrodysplasia Punctata.

BACKGROUND: Cervical spine deformity in rhizomelic chondrodysplasia punctata (RCDP) has been described with different findings reported in the literature. However, available literature provides limited data from a few cases with magnetic resonance imaging (MRI) of the cervical spine. Our report describes the MRI findings in a group of children with RCDP, aiming to reach a better understanding of this pathology. METHODS: An Institutional Review Board-approved RCDP Registry was created at our institution with the goal of identifying pertinent medical issues over the lifespan of individuals with RCDP. Records of children within the registry were evaluated, and magnetic resonance images obtained between 2004 and 2015, were available for review. The levels of spinal canal stenosis were recorded and the severity of the stenosis was decided based on adults' parameters. Cord compression and myelomalacia were confirmed on the axial images. Sagittal lumbar spine magnetic resonance images were also evaluated when available, and the presence of tethered cord and fatty filum was recorded. RESULTS: Twenty-six children (15 boys and 11 girls) were identified in the RCDP Registry. Eleven children (6 boys and 5 girls) had sagittal MRI of the cervical spine available for review. Age at the time of MRI study was variable (1 wk to 32 mo). All patients except 1 had stenosis of the cervical spinal canal. Myelomalacia of the cord was noted only in this patient. CONCLUSIONS: This study suggests that, in children with RCDP, cervical spinal stenosis and cord compression are a real risk, and children with this diagnosis should have monitoring for these issues. Tethered cord is also a possible finding that needs to be evaluated. Full sagittal spine MRI is necessary to detect the possible deformities at the cervical and lumbar levels.

Valgus Hip Osteotomy in Children With Spondyloepiphyseal Dysplasia Congenita: Midterm Results.

BACKGROUND: Coxa vara has been frequently reported in spondyloepiphyseal dysplasia congenita (SEDC), and proximal femoral osteotomy has been described as a useful treatment. The aim of this study was to discuss the clinical, radiographic, and gait outcomes after valgus extension osteotomy of the proximal femur. Changes of lumbar lordosis, associated with coxa vara correction, are reported as well as the outcome differences between different ages. METHODS: Records of children with SEDC, who were followed at our institution between 2004 and 2014, were reviewed; and children had hip surgery were identified. Hip pain and passive range of motion, radiographic neck shaft angle (NSA), and Hilgenreiner trochanteric (H-T) angle, sagittal spinopelvic parameters, and gait data were recorded. Preoperative and last follow-up data were compared. Outcomes were also compared between 3 age groups. RESULTS: Of the 79 children with SEDC, 26 children (12 boys and 14 girls) had hip osteotomy in 48 hips. Mean age at surgery was 9.6 years and the mean follow-up was 5 years. Preoperative hip pain was noted in 30 hips. At the last follow-up, 3 hips were painful at the extreme range of motion. Passive range of motion, NSA, and H-T improved postoperatively. Although NSA was maintained over the follow-up, H-T deterioration was noted. Spinopelvic measurements changed significantly and gait data remained stable except pelvic tilt that reduced significantly after surgery. The changes of radiographic measurements in each age group were similar to the total group of patients. CONCLUSIONS: In children with SEDC, surgical correction of coxa vara, by proximal femoral valgus osteotomy, is an effective treatment that improves hip pain and range of motion in addition to the radiographic alignment of the proximal femur and the sagittal spinopelvic alignment. Children are expected to maintain their level of function after surgery and to have good results over the midterm regardless of their age at surgery. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Thoracic Lordosis, Especially in Males, Increases Blood Loss in Adolescent Idiopathic Scoliosis.

BACKGROUND: Intraoperative blood loss during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been reportedly associated with multiple factors. This study aims to investigate the effect of thoracic kyphosis on blood loss in AIS spinal fusion. METHODS: Patients with AIS who underwent posterior-only procedures for Lenke I and II type curves were identified. All included patients had intraoperative tranexamic acid. Difference in estimated blood loss per blood volume (EBL/BV) was identified between hypokyphotic curves (-), normal curves (N), and hyperkyphotic curves (+) classified based on Lenke sagittal modifier. Regression analysis was then performed with EBL/BV as dependent variable. Independent variables included radiographically measured T5-T12 kyphosis and calculated 3D T5-T12 kyphosis in addition to sex, body mass index (BMI), operative time, number of fused vertebrae, number of Ponte osteotomy levels, and main thoracic coronal curve. RESULTS: In total, 837 patients were included. For female patients: EBL/BV was significantly higher for (-) (18%) compared with (N) (16%) and (+) (14%). A total of 29 female patients had T5-T12≤0 (-15 to 0 degree). EBL/BV was not significantly higher than patients with T5-T12>0 degree (18%±9% vs. 16%±11%; P=0.212). For male patients: EBL/BV was significantly higher in (-) (23%) compared with (+) (16%). In total, 14 male patients had T5-T12≤0 (-13 to 0) degree. EBL/BV was significantly higher than patients with T5-T12>0 degree (32%±18% vs. 18%±13%; P=0.015). Significant factors in predicting EBL/BV were sex, BMI, number of fused levels, and both 2D and 3D T5-T12 kyphosis. Male sex as well as every fused-level predicted an increase in EBL/BV~2%. Every 10-unit decrease in BMI predicted an increase in EBL/BV of 7%. Every 10-degree decrease in 2D or 3D T5-T12 kyphosis predicted an increase in EBL/BV~1%. The impact of the number of Ponte osteotomy levels was not significant. CONCLUSIONS: This study supports the role of sagittal thoracic alignment in affecting EBL/BV in AIS surgery. Male patients with severe thoracic lordosis (T5-T12≤0 degree) are the highest risk group for intraoperative bleeding. These findings are helpful in predicting the intraoperative blood loss for patients with AIS undergoing posterior spinal fusion. In addition to sex and number of fused levels, decreased thoracic kyphosis is associated with increased blood loss. LEVEL OF EVIDENCE: Level III-prognostic study.

Infections of Intrathecal Baclofen Delivery Systems and Ventriculoperitoneal Shunting Systems: Clinical Series Discussion.

BACKGROUND/AIMS: The physiological interaction between the intrathecal baclofen (ITB) delivery system and the ventriculoperitoneal (VP) shunting system in a patient who had both systems implanted has not been reported previously. The aim of our report is to evaluate the effect that one system's infection might have on the other. METHODS: Records of children who were followed at our institution between 2004 and 2015 for management of their ITB systems were reviewed. In this group, children who had VP shunts were identified, and those who had any of their ITB or VP systems infected were included. RESULTS: Out of 313 children managed with ITB therapy at our institution, 31 (24%) children had VP shunts. Two patients had infection in both systems, and 3 patients had infection in 1 system. CONCLUSION: This report suggests that if aspiration from both systems showed positive cultures, the treatment would be removal of both systems. If the primarily not infected system does not show positive cultures, it does not need to be removed. Close follow-up is recommended, and any sign of infection or malfunction of the primarily not infected device should be approached with a high level of suspicion.

Magnetic Resonance Imaging in Symptomatic Children With Hereditary Multiple Exostoses of the Hip.

BACKGROUND: Magnetic resonance imaging (MRI) is useful in evaluating nontraumatic hip pain. It provides information about associated injuries like labral/chondral tears or ischiofemoral impingement (IFI). However, in hereditary multiple exostoses (HME) there has been no report about MRI findings in symptomatic children with hip involvement. METHODS: Records of children with HME and hip osteochondromas, who had hip MRI/magnetic resonance arthrography, were reviewed. The presence of chondral lesions and labral tears, as well the presence of IFI, was recorded. IFI was defined as edema or fatty replacement/atrophy in the quadratus femoris muscle or decrease of the space for this muscle between the ischium and the proximal femur. The measurements used to determine the space included the ischiofemoral space, the quadratus femoris space, and the minimum ischiofemoral space (MIFS). All measurements were performed on axial T1-weighted images. RESULTS: Ten children were included (4 males, 6 females). In 2 patients, MRI was unilateral, therefore a total of 18 hips were analyzed. The indication for MRI was hip pain. Mean age, when MRI was performed, was 11.7 years. Labral tears were found in 44% (8/18) and chondral lesions in 33% (6/18) of the hips. The mean ischiofemoral space was 17.2 mm (SD, 7.3), the mean quadratus femoris space was 14.9 mm (SD, 5.3), and the mean MIFS was of 12.8 mm (SD, 5.9). IFI was seen in 44% (8/18) of hips. Two patients had bilateral IFI. MIFS was <10 mm in all hips with IFI (8/8). Of these hips, 88% (7/8) had edema of the quadratus femoris muscle and 38% (3/8) had fatty replacement/atrophy in the muscle. Osteochondromas were seen in the lesser trochanter in all hips with IFI (8/8) and in the ischium in 50% of them (4/8). CONCLUSIONS: In symptomatic children with HME of the hip, MRI is helpful in detecting the source of pain. A high percentage of these children have IFI and intra-articular lesions. These findings can play an important role in the indication and planning of the surgical approach. LEVEL OF EVIDENCE: Level IV-diagnostic study.

Radiographic Analysis of the Pediatric Hip Patients With Hereditary Multiple Exostoses (HME).

BACKGROUND: This study aimed to report the radiographic presentation of involved hips in children with hereditary multiple exostoses (HME). This included radiographic hip measurements, osteochondromas location, and relationship with hip subluxation. METHODS: Anteroposterior pelvis radiographs of children with HME, seen between 2003 and 2014, were retrospectively reviewed. Only patients who were skeletally immature at the first visit were included. One radiograph per patient per year was reviewed. Radiographs were examined for the presence of osteochondromas and their locations. Different parameters were evaluated: femoral neck-shaft angle, Reimer migration percentage (MP), Sharp acetabular angle, Wiberg angle, femoral head-neck ratio (coronal plane), and Shenton line. All measured radiographs were divided into 3 age groups:≤8,>8 and <13, and ≥13 years. Differences of the measured parameters with age were evaluated. Children with hip subluxation were identified and any relationship with osteochondromas locations, as well as MP changes over time, was recorded. Radiographs of children with a minimum 2-year follow-up were identified and changes of their hip measurements and osteochondromas' presence over time were recorded. RESULTS: A total of 51 children (102 hips) with HME were identified. In most locations, there was an overall increase of the occurrence of osteochondromas in the older age groups. However, in the medial femoral neck, a significantly less numbers of osteochondromas were found after 13 years of age (P=0.018). There was a decrease in MP with age (P<0.05). There was also an increase in Sharp and Wiberg angles in the older patients (P<0.05). Hips with broken Shenton line decreased in number with age (P 0.028). Hip subluxation was encountered in 23 hips. No specific location of osteochondromas was found to have a relationship with subluxation. Thirty-six children had a minimum follow-up of 2 years (mean age at first visit 8.5 y and at last visit 13.1 y). In these children, an increased occurrence of lesions was found in medial femoral neck and ischium (P<0.05) between the first and the last visit. CONCLUSIONS: In children with HME, radiographic evaluation of the hip is necessary based on the high percentage of hip involvement. When hip osteochondromas are found, radiographic surveillance is recommended to detect hip subluxation. Surgery may certainly be necessary for symptomatic osteochondromas. However, given the possibility of improvement in hip parameters with age, early surgical treatment to improve hip longevity does not seem to be warranted. LEVEL OF EVIDENCE: Level IV-prognostic study.

What's New in the Management of Foot Deformities in Children With Cerebral Palsy.

BACKGROUND: Foot deformities have been frequently reported in cerebral palsy (CP), and numerous diagnostic modalities and treatment options have recently been developed to achieve a better level of management for children with CP. METHODS: A thorough search of the English literature, published between January 2013 and March 2016, was performed. A summary of the new findings that had not previously described was reported. The review included recent advances regarding clinical and gait evaluation, orthotic management, botulinum toxin A treatment, and surgical correction. RESULTS: The review summarized new findings reported in 46 articles and abstracts that were published between January 2013 and March 2016. Older articles were included and cited when an original description was mentioned, or when a change or development of some findings was discussed. CONCLUSIONS: Foot deformity forms an essential part of evaluating children with CP. Dramatic advances have been achieved in gait assessment, conservative management, and surgical correction. Promising results have been reported with the goal to reach a higher level of orthopaedic care and optimize the functional potentials for children with CP. LEVEL OF EVIDENCE: Level IV-literature review.

Knee Deformities in Children With Down Syndrome: A Focus on Knee Malalignment.

BACKGROUND: Patellofemoral instability (PFI) has been the most reported knee abnormality in people with Down syndrome. Other reported knee abnormalities have been associated with PFI and different management approaches have been described with variable outcomes. The aim of this study was to describe the anatomic variations of the knee in children with Down syndrome. A comparison between knees with and without PFI was performed and our experience in treating knee abnormalities in Down syndrome was also reported. METHODS: Records of all children with Down syndrome were reviewed. Two groups were identified (knees with and without PFI). Radiographic measurements included the mechanical and anatomic lateral distal femoral angles, medial proximal tibial angle, angle of depression of medial tibial plateau, lateral tibial translation, and distal femoral physis-joint angle. On the lateral view, Insall-Salvati and Blackburne-Peel ratios were measured. The sulcus angle was measured on the tangential view. Measurements were compared between the 2 groups (with and without PFI).Knees with PFI were divided into 3 subgroups based on their treatment (group A: surgical valgus correction, group B: surgical soft tissue procedures for PFI, and group C: conservative treatment). Preoperative radiographs were used for the surgical group and last available radiographs were used for the conservative group. Clinical and radiographic data were compared between the groups. For groups A and B, clinical and radiographic data were also compared between preoperative and last visits. RESULTS: Of the 581 children with Down syndrome, 5% (31 children: 22 females, 9 males) had PFI in 56 knees. Mean age at diagnosis was 11.5±3.5 years. Of the remaining 550 children, 75 children had radiographs for 130 knees. Knees with PFI had significantly more valgus and a larger distal femoral physis-joint angle. Depression of the medial tibial plateau and lateral tibial translation were noted in knees with PFI. Insall-Salvati ratio was higher and the sulcus angle was larger in the PFI group.Of the 56 knees with PFI; 10 knees were in group A, 11 knees in group B, 33 knees in group C, and the remaining 2 knees had combined procedures. Preoperative mechanical and anatomic lateral distal femoral angles were smaller in group A than in group B or C. Grades of PFI improved in group B after surgery. This improvement was not noted in group A. CONCLUSIONS: In children with Down syndrome, different variations of the knee anatomy can be found. Although PFI might be the most evident knee abnormality, other underlying deformities are common. Treatment of the PFI should be planned through a comprehensive anatomic approach that addresses all aspects of knee deformity. LEVEL OF EVIDENCE: Level IV-prognostic and therapeutic study.

Long-term Outcome of Internal Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: External tibial torsion (ETT) is a common bony deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome following TDO to correct ETT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ETT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, E0 MTR, E0 gait velocity, gross motor function classification system (GMFCS) score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 43 legs (with E0 and E2) and 22 legs (with E0, E1, and E2). The mean age at surgery was 10.3±3.4 years (range, 6 to 19.2 y). In the group MTR trended toward improvement moving from -26±17 degrees (E0, external negative) to -16±16 degrees (E1) and relapsed to -23±17 degrees at the long term (P=0.071, E0/E1; P=0.589, E0/E2). Improvement was also seen in the transmalleolar axis (P=0.074), mean ankle rotation, and mean foot orientation (P<0.05, E0/E2). At the long-term evaluation, 16 legs (37%) were found to be in the kinematic corrected group, 25 legs (58%) in the kinematic undercorrected group, and 2 legs (5%) in the kinematic overcorrected group. There were no significant differences between the corrected and undercorrected groups of children with respect to age at surgery, GMFCS, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although internal TDO improves ETT in the short term, recurrence is frequent with an apparent developmental trend toward external rotation of the tibia. LEVELS OF EVIDENCE: Level IV-therapeutic study.

Long-term Outcome of External Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: Internal tibial torsion (ITT) is a common boney deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome after external TDO performed to correct ITT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ITT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing the subjects mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, preop MTR (at E0), preop gait velocity (at E0), gross motor function classification system score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 36 legs (with E0 and E2) and 17 legs (with E0, E1, and E2). The mean age at surgery was 7.4±2.8 (range, 4 to 16.6) years. Comparing the changes over time, kinematic MTR improved from 17±11 degrees initially (E0) to -10±14 degrees short term (E1) and progressed to -23±13 degrees long term (E2) (P<0.05 E0/E1/E2; internal rotation is positive). At E2, 16 legs (44%) were found to be in the kinematic corrected group and 20 legs (56%) in the kinematic overcorrected group. There were no significant differences between the corrected and overcorrected groups of children in respect to age of surgery, gross motor function classification system, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although external TDO is an accepted form of treatment in children with CP, in the long term a tendency to move into external tibial torsion is common. Therefore, caution is warranted with children who initially present with ITT to avoid overcorrection. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Upper Cervical Fusion in Children With Spondyloepiphyseal Dysplasia Congenita.

BACKGROUND: Paraplegia or death secondary to upper cervical spine instability and spinal cord compression are known consequences of spondyloepiphyseal dysplasia congenita (SEDC). Stabilization and occasionally decompression of the upper cervical spine are indicated to treat upper cervical instability and stenosis. The purpose of this study was to report the results of upper cervical spine fusion in children with SEDC who had upper cervical instability. METHODS: Twenty children (17 females and 3 males) with SEDC who underwent upper cervical spine fusion at a mean age of 72 months were retrospectively analyzed. Three of these children were under the age of 2. Fifteen children had posterior instrumentation and fusion whereas 5 children had posterior in situ fusion without use of any implant. Thirteen of 20 children had iliac crest autograft. Radiographic and clinical results were reported. RESULTS: The average follow-up period was 8 years and 8 months. All children with instrumentation achieved fusion. Three of 5 children who had no instrumentation had nonunion (1 child had a stable nonunion and did not need revision; 1 had a single noninstrumented revision and ended up with a stable nonunion without further intervention; and the third one had a noninstrumented revision and had to have a second, instrumented, revision to achieve fusion). Six children had thoracolumbar scoliosis or kyphoscoliosis which required surgical management.No postoperative neurological deficits were observed. Two of the 3 children with a preoperative neurological deficit showed full recovery and the third one remained unchanged. Pseudarthrosis is the main complication for the noninstrumented group. Distal junctional instability after successful fusion is seen at long-term follow-up (average=6 y) for 13% of patients in instrumented group. CONCLUSIONS: Instrumentation and iliac bone grafting results in 100% upper cervical fusion for SEDC children who demonstrated instability before surgery. LEVEL OF EVIDENCE: Level IV-therapeutic.

Persistence and Recurrence Following Femoral Derotational Osteotomy in Ambulatory Children With Cerebral Palsy.

BACKGROUND: Excessive hip internal rotation is frequently seen in children with cerebral palsy (CP). Femoral derotational osteotomy (FDO) is effective in the short term, but factors associated with long-term correction remain unclear. The purposes of this study were to define the incidence of persistence and recurrence of hip internal rotation following FDO in ambulatory children with CP and to evaluate factors that influence outcome. METHODS: Following IRB approval, kinematic and passive range of motion (PROM) variables were retrospectively evaluated in children with spastic CP who had FDO to correct hip internal rotation as part of clinical care at a children's specialty hospital. Children included had a preoperative evaluation (Vpre), a short-term postoperative evaluation (Vshort, 1 to 3 y post), and, in some cases, a long-term postoperative evaluation (Vlong, ≥5 y post). Age at surgery, physical exam measures, and kinematics variables were evaluated as predictors for dynamic and static recurrence. RESULTS: Kinematic hip rotation improved from 14±12 degrees (Vpre; internal positive) to 4±13 degrees (Vshort) and relapsed to 9±15 degrees long term (P<0.05 Vpre/Vshort/Vlong; 99 limbs). Hip PROM midpoint improved from 23±9 degrees (Vpre) to 8±11 degrees (Vshort) and relapsed to 14±13 degrees (P<0.01 Vpre/Vshort/Vlong). Persistent hip internal rotation was noted in 41% (kinematics) and 18% (PROM) of limbs at Vshort (105 children, 178 limbs). Of limbs that showed initial improvement at Vshort (62 children, 95 limbs), recurrence was seen in 40% (kinematic hip rotation) and 39% (hip midpoint) at Vlong. Comparing children who had recurrent hip internal rotation and those who maintained long-term correction, we saw higher levels of spasticity and lower gait velocity in the recurrent group (P<0.05). CONCLUSIONS: Although FDO is an accepted treatment in children with CP, persistence and recurrence of hip internal rotation can occur. Recurrence is associated with spasticity and slower gait velocity. Predictor variables may be useful for surgeons during preoperative discussions of expected outcome with families of FDO candidates. LEVEL OF EVIDENCE: Level III.

Evaluation of intrathecal baclofen delivery system malfunction by computed tomography scan.

AIM: To describe the computed tomography (CT) findings encountered when catheter patency is questionable. The role of CT in directing treatment is evaluated. METHOD: Records of children with intrathecal baclofen pump management were reviewed. Only patients with CT evaluation who had revision pump/catheter surgery were included. RESULTS: From 295 patients, 27 had CT contrast study; in three of them, baclofen could not be aspirated and the procedure was stopped, eight had normal scan and did not need surgery and 16 patients were reported. Four patients had normal CT (free contrast formed a perfect crescent shape), and had surgery because the pump battery was close to expiration. Five patients had inadequate fluid pooling (fluid was seen without a crescent shape). Five patients had fluid leak (fluid was seen around the pump or in the lumbar canal below catheter entrance level or outside the canal in the lumbar region). Two patients had catheter occlusion (fluid loculation around the catheter tip with no free flow). INTERPRETATION: CT contrast study is safe and effective for locating defects in intrathecal baclofen delivery system. When catheter patency is questionable, CT plays an important role in directing the next step of management.

Factors predicting postoperative complications following spinal fusions in children with cerebral palsy scoliosis.

PURPOSE: The purpose of this study was to review the postoperative complications after posterior spinal fusion (PSF) in cerebral palsy (CP) scoliosis and identify the predictive preoperative risk factors. METHODS: All PSFs consecutively performed for CP scoliosis between 2004 and 2013 were reviewed. Preoperative risk score (ORS) and postoperative complications score (POCS) were used as measures of all recorded preoperative risk factors and postoperative complications, respectively. RESULTS: The review included 303 children with a mean age of 14.6 ± 3.0 years. Mean hospitalization was 16 days. Dependence on G-tube feeding was associated with higher POCS (P = 0.027). Postoperative fever, seizures, and septicemia were associated with higher ORS (P < 0.01). Specifically, postoperative pancreatitis and deep wound infections were more common in children with G-tube. CONCLUSION: This study suggests that G-tube dependence is a predictive risk factor of complications after PSF in CP scoliosis. Children with G-tube need special perioperative care. No other specific preoperative risk factor predicted postoperative complications.

Hip Instability in Down Syndrome: A Focus on Acetabular Retroversion.

BACKGROUND: The aim of this study is to compare acetabular anteversion between children with Down syndrome with or without hip instability. The second aim is to report the surgical experience at our institution in treating unstable hips for this population. METHODS: All children with Down syndrome who were seen at our institution between 2004 and 2014 were reviewed, and those who had pelvic axial computed tomographic or magnetic resonance imaging scans were identified. Acetabular anteversion was compared between 2 groups: those with hip instability as a single hip pathology and those without hip instability. For patients who had surgery for their unstable hips, demographic, clinical, and surgical data were recorded. Preoperative and last visit radiographs were reviewed. Extrusion index and Tonnis, Sharp, lateral center edge, and neck shaft angles were measured. Presence of Shenton's line disruption, crossover, and posterior wall signs were recorded. Independent and paired t test, Wilcoxon signed-rank test, and χ test were used with a significance level at 0.05. RESULTS: Out of 308 children with Down syndrome, there were 10 patients with 13 unstable hips and 13 patients with 26 stable hips who had computed tomographic or magnetic resonance imaging scans. Age and sex distributions were similar (P>0.3) with no difference in acetabular anteversion (P=0.926) between them. Twelve patients (6 boys and 6 girls) had reconstruction for 17 hips. The mean age was 9 years (3 to 15 y) and the mean follow-up was 7 years (1.2 to 17.6 y). Five hips were painful preoperatively and 1 hip was painful at last visit. Radiographic measurements improved significantly (P<0.05). Shenton's line disruption was found in fewer hips (P=0.001) at last visit with no difference in the crossover and posterior wall signs (P=0.177). CONCLUSIONS: This report suggests that a wide range of acetabular anteversion measurements exist in children with Down syndrome. After detailed anatomic study of the hip, good results with a low complication rate can be expected over the intermediate term after hip reconstruction. LEVEL OF EVIDENCE: Level IV-prognostic and therapeutic study.