Pediatric Outcomes Data Collection Instrument Scores Within Gross Motor Function Classification Scale Levels and Functional Mobility Scale Ratings in Individuals With Cerebral Palsy.

BACKGROUND AND OBJECTIVE: The Pediatric Outcomes Data Collection Instrument (PODCI) is a patient/parent-reported outcome measure used in children with cerebral palsy (CP). PODCI score variability has not been widely examined in patients of Gross Motor Function Classification System (GMFCS) level IV or using the Functional Mobility Scale (FMS). The purpose of this study is to examine the distribution of PODCI scores within patients with CP GMFCS levels I-IV and FMS levels 1-6. METHODS: Retrospectively identified patients with CP whose parent/caregiver had completed the PODCI at their visit were grouped based on GMFCS and FMS level. One-way ANOVA with pairwise Bonferroni-adjusted post hoc tests was performed to compare the effect of GMFCS and FMS levels (1, 2-4, 5, or 6) on PODCI scores. RESULTS: Three hundred sixty-seven patients were included (128 female, 11.7 years, SD 3.6). Global, Sports, Transfer, and Upper Extremity scores differed among all GMFCS levels ( P ≤0.056) and were significantly lower for GMFCS IV compared with all other levels. Happiness, Expectations, and Pain scores did not differ significantly among GMFCS levels including level IV ( P >0.06). Similar trends were seen at all FMS distances (5, 50, and 500âm). At 50âm, Global, Sports, Transfer, and Upper Extremity scores differed significantly among all FMS levels ( P <0.001) except that Upper Extremity Scores were similar between levels 2-4 and level 5 ( P =1.00). Happiness and Pain scores were not different between FMS levels ( P >0.27). Expectations scores differed only between FMS 1 and FMS 6 with FMS 6 being higher at the 50-m distance only ( P =0.03). CONCLUSIONS: Parent-reported outcome measures are important for providing patient-centered care. Providers can examine these measures alongside functional classification systems to create a more complete clinical picture of the patient. Providers should be aware of the score trends seen in our results when evaluating the PODCI for individuals with CP to improve shared decision-making and better monitor their need for future care. LEVEL OF EVIDENCE: Level III-retrospective study.

Anterior Distal Femoral Hemiepiphysiodesis Does Not Change Pelvic Tilt in Children With Cerebral Palsy.

BACKGROUND: Anterior distal femoral hemiepiphysiodesis (ADFH) is a surgical treatment choice to correct flexed knee gait and fixed knee flexion deformities in children with cerebral palsy who are skeletally immature. Increased anterior pelvic tilt has been reported after surgeries that correct knee flexion deformities, including hamstring lengthening (HSL) and distal femoral extension osteotomies, but anterior pelvic tilt has not been studied after ADFH. We hypothesized that anterior pelvic tilt would increase after ADFH, especially when combined with HSL, and it would correlate with the change in minimum knee flexion in stance and dynamic hamstring lengths. METHODS: Thirty-four eligible participants (age: 13.0, SD: 2.0) were included. Change in mean pelvic tilt across the gait cycle was compared as a function of clinical and gait parameters using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation. RESULTS: Overall, anterior pelvic tilt increased significantly after ADFH by 4.4 degrees ( P = 0.02). Further, the analysis revealed anterior pelvic tilt only increased significantly in the group that had concurrent HSL (11.1 degrees, P < 0.001). Overall, minimum knee flexion significantly decreased (increase in knee extension) in stance (-19.1 degrees, P < 0.001) and there was an increase in maximum normalized dynamic hamstring lengths (0.03, P < 0.001). The anterior pelvic tilt increased significantly in Gross Motor Function Classification System levels III to IV (5.9 degrees, P = 0.02) but did not change significantly in Gross Motor Function Classification System I to II (2.5 degrees, P = 0.37). Change in pelvic tilt was correlated with change in maximum dynamic hamstring lengths ( r = 0.87, P < 0.0001) and change in minimum knee flexion in stance ( r = -0.71, P < 0.0001). CONCLUSIONS: Anterior distal hemiepiphysiodesis without concurrent HSL for flexion knee deformities does not result in increased anterior pelvic tilt. Surgeons should consider anterior distal hemiepiphysiodesis in patients with cerebral palsy and flexed knee gait, who preoperatively have long dynamically modeled hamstrings, are skeletally immature, and when maintenance of pelvic tilt is desired. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

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).

Hip Surgery is Not More Painful Than Spine Surgery in Children With Cerebral Palsy.

BACKGROUND: Posterior spinal fusion (PSF) and hip reconstruction are commonly indicated surgeries in children with cerebral palsy (CP), particularly those functioning at GMFCS levels IV and V. These are large and often painful procedures, and previous literature suggests that hip surgery is more painful than spine surgery in this patient population. The purpose of this study is to investigate pain scores and opioid use following hip and spine surgery in a large cohort of children with CP, including many patients who have undergone both types of surgery. METHODS: A retrospective chart review was performed to identify children with CP who underwent hip reconstruction and/or PSF at a tertiary children's hospital between 2004 and 2022. Charts were reviewed for demographic data, pain scores, pain medication usage, duration of hospital stay, and complications. RESULTS: Data were collected for 200 patients (101 male, 99 female) who met inclusion criteria. Eighty-seven patients underwent hip reconstruction, 62 spinal fusion, and 51 both hip and spine surgery asynchronously. Median (interquartile range) age at the time of surgery was significantly older for spinal fusion compared with hip surgery [13.1 (4.9) vs. 8.1 (5.7) y, P<0.0001]. Length of stay was significantly longer after PSF, with a median of 6 (4) days compared with 2 (1) days after hip surgery (P<0.0001). Both maximum and average daily pain scores were similar following hip and spine surgery, with the exception that average pain scores for hip surgery were slightly higher on postoperative day 1, hip=1.73 vs. spine=1.0 (P<0.0001). The amount of opioids used, expressed as morphine milligram equivalents (MME)/kg were similar in the hip and spine surgery groups; however, it was significantly lower in the hip surgery group on postoperative day 0, hip=0.06 versus spine=0.17 (P<0.0001). For the 51 patients who underwent both hip and spine surgery, the amount of opioids used mirrored that for the entire group (similar MME/kg, though only statistically significantly less on POD 0 and 3), and pain scores were not significantly different between the 2 groups except in 2 circumstances. The 2 exceptions in these 51 patients both demonstrated lower pain scores in patients after hip surgery, including lower maximum pain scores on POD 1 (P=0.041), and lower average pain scores on POD3 (P=0.043). CONCLUSIONS: This is the largest series to date comparing postoperative pain in children with CP after hip and spine surgery, including 51 of 200 patients who underwent both types of surgery. The results of this study demonstrate that hip surgery is not more painful than spine surgery in children with CP, and conflict with the traditional belief that hip surgery is more painful. This is important information for health care providers when counseling patients and families regarding these surgeries in children with CP. LEVEL OF EVIDENCE: Level 3.

Gait Analysis Characteristics in Relapsed Clubfoot.

BACKGROUND: Relapse rates of clubfoot deformity after initial correction range between 19% and 68% regardless of treatment approach. Most studies focus on relapse before age 4. Little research has focused on late clubfoot relapse. The purpose of this study was to compare the gait characteristics of children with late clubfoot relapse (age ≥5 y) following treatment with the Ponseti method only compared with intra-articular and extra-articular surgeries. METHODS: A retrospective review was conducted of all patients with idiopathic clubfoot ≥5 years old who underwent computerized gait analysis for clubfoot relapse between 2001 and 2021. Joint range of motion, muscle strength, gait kinematics, and kinetics were compared among 3 groups based on prior clubfoot treatment: (1) Ponseti casting, (2) Extra-articular (EA) surgery, and (3) Intra-articular (IA) surgery. RESULTS: Sixty-eight subjects (107 feet) were included (39 bilateral). Thirty-one percent of feet had been treated with Ponseti casting alone; 57% had IA surgery, and 12% had EA surgery. The average age when presenting with late relapse was 8.2 years, 9.0 years and 10.7 years for the Ponseti, and IA and EA groups, respectively. The IA group had greater passive dorsiflexion than the other 2 groups (P<0.002), greater inversion weakness than the other 2 groups (P<0.0001), greater dorsiflexion during the stance phase of gait compared with the Ponseti group (P=0.001), and lower maximum power production at push-off compared with the other 2 groups (P=0.009). CONCLUSION: Late relapse can occur after all types of clubfoot correction. Consistent with existing literature, patients who have undergone posteromedial release surgery have significantly greater plantarflexor weakness resulting in poorer plantarflexor moment and power production during gait. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Variation in Functional Mobility Within Gross Motor Function Classification System Levels.

BACKGROUND AND OBJECTIVE: Variation in walking performance within Gross Motor Function Classification System (GMFCS) levels for patients with cerebral palsy (CP) is often unrecognized. The Functional Mobility Scale (FMS) rates mobility at household, school, and community distances. This study evaluated the variability of walking performance within GMFCS levels as measured by the FMS. METHODS: Retrospective review of gait analysis records for ambulatory patients with CP. FMS rating distribution at each distance was examined for GMFCS levels I-IV within age groups (below 12 or above 12 y) and compared among levels using χ2 tests. RESULTS: A total of 788 patients (499 male; age 11.2, SD 3.9 y) were included. FMS score distribution differed significantly among GMFCS levels for all distances (P<0.001). GMFCS LEVEL: I-Children walked independently on all surfaces at home and school distances at all ages. In all, 5% to 7% used wheeled mobility in the community. II-Most walked at home and school distances. Some younger children crawled at home, and 5% to 8% of all subjects used walls and furniture. Approximately 50% of subjects in both age groups used some form of walking aids or a stroller/wheelchair in the community. III-Twenty-five percent to 30% walked unaided at home, requiring walking aids or wheeled mobility at school or in the community. Forty-five percent of younger and 18% of older subjects crawled at home. Eight percent of younger and 28% of older subjects used wheelchairs at school. Seventy-three percent to 75% of all subjects used strollers/wheelchairs in the community. IV-Sixty-two percent of younger and 43% of older subjects crawled at home. Approximately 15% of all subjects did some aided walking at home. Twenty-seven percent of younger children did some aided walking at school, while only 1 older subject did so. All used strollers/wheelchairs in the community. CONCLUSION: Mobility function varies within each GMFCS level with the most variability in GMFCS II at school and community distances and GMFCS III at household distances. These findings highlight the importance of using both the GMFCS and FMS when assessing functional mobility in children with CP. LEVEL OF EVIDENCE: Level III-retrospective study.

Calcaneal Sliding Osteotomy Versus Calcaneal Lengthening Osteotomy for Valgus Foot Deformity Correction in Children With Cerebral Palsy.

BACKGROUND: Medial calcaneal sliding (CS) osteotomy and lateral column lengthening (LCL) are often performed to relieve pain and improve transverse plane alignment and gait stability for children with cerebral palsy (CP) and valgus foot deformities. The purpose of this study was to examine the effectiveness of these procedures in this population. METHODS: Retrospective medical record review (including 3D gait analysis data) of patients with CP who underwent LCL (26 subjects, 46 limbs) or CS (46 subjects, 73 limbs). Data extraction included complications (modified Clavien-Dindo system), change in standing foot position (modified Yoo system), and change in gait kinematics and kinetics preoperatively to postoperatively. Groups were compared using paired t tests, Fisher exact test, and survivorship analysis using Cox proportional hazard models. RESULTS: Subjects were 57% male, average age at surgery 11.1 (SD 2.5) years. Average length of follow-up was 3.2 (SD 2.8) years, and was longer in the LCL group (P=0.0004). Complications were minor with similar rates between groups (P=0.14). Prolonged pain and plantar hypersensitivity occurred only in the CS group. Successful maintenance of deformity correction was achieved in 52/73 limbs (71%) in the CS group and 16/44 limbs (36%) in the LCL group (P<0.001). Recurrent pes valgus and need for repeat foot surgery were more common after LCL (P=0.003 and 0.001, respectively). Recurrent pes valgus never occurred when talonavicular fusion was done concomitantly with CS. After accounting for the between group difference in length of follow-up, there was no difference in the rates of recurrent valgus or repeat foot surgery between LCL and CS. None of the variables predicted development of pes varus (P>0.20). Ankle kinematics and kinetics during gait were unchanged in both groups. CONCLUSIONS: CS and LCL have similar effectiveness in providing long-lasting correction of valgus foot deformities. Concomitant talonavicular fusion is key to success of CS for lower functioning patients with severe deformities, and obligate brace wearers. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Incidence of Pin Tract Infections and Septic Arthritis in Percutaneous Distal Femur Pinning.

BACKGROUND: Retrograde percutaneous pinning often involves intra-articular pin placement. Classic teaching has cautioned about the risk of septic arthritis with intra-articular pins, although an incidence has not been reported for this complication. The purpose of this study was to determine the incidence of pin tract infections and septic arthritis following retrograde percutaneous pinning of the distal femur. METHODS: A retrospective review identified patients who underwent retrograde percutaneous pinning of the distal femur for osteotomy or physeal fracture fixation at a tertiary pediatric hospital from 2006 to 2017 and had at least 3 months follow-up. The incidence of pin site infections and septic arthritis was determined. RESULTS: In total, 163 patients met criteria, 142 patients with osteotomies and 21 with physeal fractures. The mean pin duration was 33.2±9.0 days (range: 18 to 68 d). Pin duration of ≥30 days was associated with an increased rate of pin tract infections (11.2% vs. 1.4%, P=0.01). The incidence of pin tract infections was 6.7% (11/163), including 9.5% (2/21) in those with fractures and 6.3% (9/142) following osteotomy (P=0.64). There were no cases of septic arthritis. Of the 11 patients with pin tract infections, 9 were treated successfully with oral antibiotics and 2 patients (1.2%) underwent surgical intervention for infection. Treatment of pin infections with oral antibiotics alone was successful in all 7 patients whose pins were removed within 35 days of surgery, but in only 2 of 4 whose pins were removed later (P=0.11). Of the 2 patients who required irrigation and debridement, one had a superficial pin site infection and retained subcutaneous pin and the other had a pin tract abscess and osteomyelitis at the osteotomy site. CONCLUSIONS: Of 163 patients who underwent retrograde percutaneous pinning of the distal femur, no patient developed septic arthritis and the incidence of pin site infections was 6.7% (11/163). Intra-articular retrograde percutaneous pinning of the distal femur is a safe technique with a low risk of septic arthritis. LEVEL OF EVIDENCE: Level III-case-control study.

Rectus Femoris Transfer Surgery Worsens Crouch Gait in Children With Cerebral Palsy at GMFCS Levels III and IV.

BACKGROUND: Previous study has shown that children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels III and IV do not benefit from distal rectus femoris transfer (DRFT) due to lack of improvement in stance knee extension. The fate of knees in such subjects who do not undergo DRFT is unknown. The purpose of this study was to compare knee kinematic outcomes in patients with CP and stiff knee gait who underwent single-event multilevel surgery with and without DRFT. METHODS: Preoperative and postoperative gait analysis data were retrospectively reviewed for ambulatory (GMFCS levels I to IV) patients with CP with crouch and stiff knee gait whom underwent single-event multilevel surgery, including hamstring lengthening either with DRFT (N=34) or without DRFT (N=40). Statistical analyses included t tests and χ tests, and multiple regression analysis was performed to adjust for covariates. Data were stratified by GMFCS level groups I/II and III/IV. RESULTS: Improved maximum knee extension in stance was seen for both the DRFT (P=0.0002) and no DRFT groups (P≤0.0006) at GMFCS levels I/II, and the no DRFT group at GMFCS levels III/IV (P=0.02). Excessive stance knee flexion persisted for those at GMFCS level III/IV after DRFT. Maximum knee flexion in swing was maintained after DRFT, but significantly decreased in the no DRFT group (P<0.002) for both GMFCS groups. Change in total knee range of motion improved after DRFT only in the GMFCS I/II group subjects with unilateral involvement (P=0.01). Timing of maximum knee flexion in swing improved for all patients regardless of DRFT or GMFCS level group (P<0.0001). CONCLUSIONS: In patients with CP functioning at GMFCS levels III and IV, DRFT results in persistent crouch postoperatively. Given the importance of maintaining upright posture in these patients, we do not recommend DRFT in patients functioning at GMFCS levels III and IV. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Percutaneous Hamstring Lengthening Surgery is as Effective as Open Lengthening in Children With Cerebral Palsy.

BACKGROUND: Surgical lengthening of the hamstrings is often performed to correct crouch gait in children with cerebral palsy (CP). Previous studies have demonstrated the effectiveness of open hamstring lengthening (oHSL) in improving knee extension static and dynamic range of motion; however, literature regarding percutaneous hamstring lengthening (pHSL) is limited. The purpose of this study was to investigate the effect of open versus pHSL for improving crouch gait and knee function in children with CP. METHODS: This retrospective cohort study included 87 ambulatory children with CP who underwent HLS surgery with both preoperative and postoperative gait analysis (mean time, 29.4±19.9 mo after surgery) testing between 1997 and 2015. In total, 65 patients underwent oHLS surgery (mean age, 8.5±2.5 y) and 22 patients underwent pHSL surgery (mean age, 8.3±2.3 y). Lower extremity three-dimensional kinematic data were collected while subjects walked at a self-selected speed. Outcome variables for operative limbs were compared within and between groups using t tests, χ tests, and multiple regression analysis. RESULTS: Significant postoperative decreases in knee flexion at initial contact were seen for both open (Δ12.7±13.4 degrees; P<0.001) and percutaneous (Δ19.1±13.1 degrees; P<0.001) groups. Increased postoperative maximum knee extension in stance was found for both open (Δ8.2±16.8 degrees; P=0.001) and percutaneous (Δ14.4±16.5 degrees; P=0.001) groups. No significant differences between open and percutaneous groups were found when comparing postoperative changes in kinematic variables between groups after adjusting for covariates. Postoperative changes in static range of motion were similar between lengthening groups. CONCLUSIONS: pHSL is as effective as open lengthening in improving stance phase knee kinematics during gait in children with CP. This is the first study to compare the kinematic effects of open versus pHSL in the pediatric population. Percutaneous lengthening is tolerated well by patients, and as it allows for rapid rehabilitation it may be preferable to the open procedure. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Foam Padding in Postoperative Lower Extremity Casting: An Inexpensive Way to Protect Patients.

BACKGROUND: Although postoperative cast immobilization is routinely used in children, it is not without complications. Few studies have focused on interventions to decrease their frequency. The purpose of this study was to determine if foam padding in postoperative lower extremity casts decreased the rate of cast complications. METHODS: A retrospective review of patients who underwent lower extremity casting after elective surgery at a tertiary pediatric hospital from 2006 to 2013 was conducted. Postoperative casts were classified by type (A-frame, short leg, long leg, spica) and the presence of foam. Charts were reviewed for skin complications, cast splits for apparent neurovascular deficits, cast splits for patient complaints, unplanned outpatient returns for cast-related issues, and compartment syndrome. RESULTS: In total, 920 patients with 2,481 casts were included. In total, 612 (24.7%) casts had foam placed during casting. The incidence of skin complications was significantly lower in A-frame casts with foam (4.5%, 5/112) than without (13.4%, 11/82) (P=0.03) and long leg casts with foam (0.9%, 2/225) than without (4.3%, 19/444) (P=0.02). Patients with static encephalopathy casted with foam had a lower incidence of skin complications (0.7%, 2/279) than those without (3.6%, 22/615) (P=0.01). There was no difference in the overall incidence of skin complications in casts with and without foam (P=0.44), short leg casts (P=0.37), and spica casts (P=0.34). Patients with skin complications (20.3±7.1 kg/m) had a higher body mass index than those without (18.9±5.4 kg/m) (P=0.04). Postoperative A-frame casts with foam (0.0%, 0/112) were split less often for apparent neurovascular deficits than those without foam (4.5%, 3/67) (P=0.05). The cast split rates for apparent neurovascular deficits in casts with and without foam (P=0.58), long leg casts (P=0.67), short leg casts (P=0.63), and spica casts (P=1.0) were comparable. CONCLUSIONS: The use of foam in postoperative lower extremity casting is an effective intervention to reduce the incidence of skin complications in patients with static encephalopathy, in an A-frame cast, or in a long leg cast. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Prevalence of specific gait abnormalities in children with cerebral palsy revisited: influence of age, prior surgery, and Gross Motor Function Classification System level.

AIM: To examine the impact of age, surgery, and Gross Motor Function Classification System (GMFCS) level on the prevalence of gait problems in children with cerebral palsy (CP). METHOD: Gait analysis records were retrospectively reviewed for ambulatory patients with CP. Gait abnormalities were identified using physical exam and kinematic data. Relationships among age, sex, previous surgery, GMFCS level, and prevalence of gait abnormalities associated with crouch and out-toeing, and equinus and in-toeing were assessed using univariable and multivariable logistic regression. RESULTS: One-thousand and five records were reviewed. The most common gait problems were in-toeing, excessive knee flexion, stiff knee, hip flexion, internal rotation, adduction, and equinus (all >50%). Odds ratios (OR) for various gait problems associated with crouch and out-toeing increased (OR 1.07-1.32), and those associated with equinus and in-toeing decreased (OR 0.80-0.94) significantly with increasing age for patients in GMFCS levels I to III. The same trends were seen with prior surgery (OR for crouch and out-toeing: 1.86-7.14; OR for equinus and in-toeing: 0.16-0.59). INTERPRETATION: The prevalence of gait abnormalities varies by GMFCS level, but similarities exist among levels. The study results suggest that in younger children, particularly those in GMFCS levels III and IV, treatments for equinus and in-toeing should be undertaken with caution because these problems tend to decrease with age even without orthopedic intervention. Such children may end up with the 'opposite' deformities of calcaneal crouch and out-toeing, which tend to increase in prevalence with age.

Accessory Navicular is Associated With Wider and More Prominent Navicular Bone in Pediatric Patients by Radiographic Measurement.

BACKGROUND: Accessory navicular (AN) is a common anatomic variant that is known to cause medial foot pain. Surgery may be required for excision if conservative measures fail. Often, the medial border of the navicular is excised in addition to the AN during surgery. The purpose of this radiographic study is to determine if the presence of an AN is associated with a wider or more prominent navicular in pediatric patients compared with normal controls. METHODS: This study included pediatric patients who received an initial plain anteroposterior foot radiograph between January 1, 2004 and December 31, 2012 and were between the ages of 10 and 20 years. Feet with an AN were compared with those without, while controlling for age. Male and female patients were analyzed independently. Feet with fractures, deformities, or previous surgeries were excluded. Radiographic measurements included the navicular width and the protrusion of the navicular bone medially. RESULTS: A total of 592 feet were included. An AN was identified in 73 feet. Male patients were analyzed separately from females. Cases with 1 AN bone had similar-sized native navicular bones in the contralateral normal foot compared with controls with 2 normal feet (P>0.05). The presence of an AN was associated with a larger navicular width (male: P=0.02, female: P=0.02) and a larger medial protrusion percent (male: P<0.01, female: P<0.01). Age was controlled for. CONCLUSION: On radiographic examination, feet with an AN had wider native navicular bones that protruded more medially than feet without an AN. LEVEL OF EVIDENCE: Level IV-diagnostic.

Variability of the Anterior Humeral Line in Normal Pediatric Elbows.

BACKGROUND: The anterior humeral line (AHL) is considered a valuable radiographic tool in the assessment of pediatric elbow sagittal plane alignment following injury. However, few studies exist that examine the validity of the AHL. The purpose of this study is to report the variability of the AHL in skeletally immature children with normal elbows. METHODS: A total of 124 true lateral elbow radiographs of normal pediatric elbows were retrospectively identified and examined for the relationship of the AHL to the capitellum. The percentage of AHLs falling outside the middle third of the capitellum was compared among different age and sex groups using Fisher exact tests. RESULTS: In 100% of patients, the AHL touched the ossific nucleus of the capitellum. In 100% (52/52) of patients ≥5 years the AHL goes through the middle third of the capitellum, but this is significantly different from patients less than 5 years of age in whom 25% (18/72) of patients the AHL fell outside of the middle third of the capitellum (P<0.001). In children less than 2 years of age, the AHL was in the anterior third in 30% of the cases. CONCLUSIONS: Traditional teaching that the AHL touches the capitellum on a lateral radiograph of a normal elbow in a child is correct, so if the AHL does not touch the capitellum it is appropriate to look for pathology. Similarly, in children 5 years and older the AHL goes through the middle third of the capitellum in all patients, so if it does not, it is appropriate to look for pathology. However, with decreasing age variability increases, with the AHL touching the anterior third of the capitellum in almost 1/3 of children. LEVEL OF EVIDENCE: Level III.

Foam padding in casts accommodates soft tissue swelling and provides circumferential strength after fixation of supracondylar humerus fractures.

BACKGROUND: Varying casting techniques are used after surgical treatment of pediatric supracondylar humerus fractures. The goals are to maintain fracture reduction, while accommodating soft tissue swelling and minimizing the risk of compartment syndrome. METHODS: A retrospective chart review of consecutive patients aged 0 to 14 years who underwent surgical treatment of supracondylar humerus fractures over a 9½-year period at a pediatric trauma center was performed. A new method of casting, in which one half inch sterile foam is applied directly to the skin and overwrapped by circumferential fiberglass, is presented and compared with traditional casts. RESULTS: A total of 541 consecutive patients were included. Foam had been used in 35% (190/541) of patients. Foam was used significantly more frequently in Gartland type 3 fractures (133/314 patients, 42%) than in type 2 fractures (57/227 patients, 25%) (P<0.001). Foam was also used more often in patients with preoperative neurovascular deficits (34/57, 60%) than in those without (156/484, 32%) (P<0.001). No patient in either group developed compartment syndrome postoperatively. Both patients in the study who required revision closed reduction and pinning were casted without foam, and one of these casts had been split. Reoperation was not associated with cast splitting (P=0.216) or foam use (P=0.543). CONCLUSIONS: For postoperative immobilization of supracondylar humerus fractures we present a new method of placing foam directly on the skin, followed by circumferential fiberglass casting. This method offers the theoretical advantage of the strength of a circumferential cast, plus the benefit of allowing for swelling. Although the novel foam and cast combination was used in more severe fractures, results were comparable to traditional casts and may reduce the need for cast splitting. LEVEL OF EVIDENCE: Therapeutic-Level III.

Long-term ambulatory change after lower extremity orthopaedic surgery in children with cerebral palsy: a retrospective review.

BACKGROUND: Long-term studies of lower extremity orthopaedic surgery in children with cerebral palsy (CP) tend to focus on gait kinematics and kinetics, with little to no emphasis on gross motor ambulatory function. The current study was undertaken to examine the long-term impact of surgery on ambulatory function in patients with CP enrolled in a government-funded, outpatient therapy program. METHODS: Retrospective medical record review was conducted of 127 children with CP, Gross Motor Function Classification System (GMFCS) levels I to IV, followed up to 14 years after lower extremity orthopaedic surgery. Data were extracted from medical/operative records and routine physical therapy evaluations performed over the course of follow-up. Functional Mobility Scale (FMS) scores were assigned based on gross motor function information contained in each 6- to 12-month physical therapy evaluation. Data were compared statistically among GMFCS levels. RESULTS: Average length of follow up was 11.8±4 years. Subjects underwent 0.61±0.43 surgical procedures per person-year in 0.16±0.09 operative sessions per person-year with no differences between GMFCS levels. Subjects at GMFCS level I improved significantly in community (P=0.02) but not household ambulation, reflecting the ceiling effect of the FMS. Subjects at GMFCS levels II to IV showed statistically significant improvements at all distances. Subjects at level III gained more in household than long-distance ambulation (P=0.002). Subjects functioning at GMFCS level II improved by 1 FMS level for household and school distances, and 2 FMS levels for community distances (P<0.02). Subjects at level IV exhibited small ambulatory gains at all distances (P<0.04). CONCLUSIONS: Significant long-term improvement in functional ambulation is seen after surgery for children at all GMFCS levels. Children with more independence tend to make gains in long-distance ambulation, whereas those who use assistive devices tend to improve more in short-distance ambulation. This information may be useful to clinicians when counseling patients and their families regarding potential for ambulatory improvement after lower extremity orthopaedic surgery. LEVEL OF EVIDENCE: Level IV: case series.

Knee Pain and Patellofemoral Symptoms in Patients With Cerebral Palsy.

BACKGROUND: Knee pain in cerebral palsy (CP) is associated with increased patellofemoral forces present when walking with flexed knees. In typically developing children, knee pain and patellofemoral dysfunction are associated with obesity, genu valgum, femoral anteversion, and external tibial torsion. These problems are also common in CP, and may contribute to knee problems in this population. The purposes of this study were to define the prevalence of knee pain and patellofemoral dysfunction in children with CP, and to identify physical and gait characteristics (using 3-dimensional gait analysis data) that predispose them to such problems. METHODS: Retrospective review of 121 children with CP, Gross Motor Function Classification System level I to IV, who underwent computerized gait analysis testing. Demographics, range of motion, body mass index and hip, knee, and ankle kinematics were compared between subjects with and without knee pain. RESULTS: Twenty-five of 121 subjects (21%) reported knee pain at the time of testing. Three of 121 subjects (2%) had a history of patellar subluxation/dislocation. Age and sex were significantly related to presence of knee pain. The likelihood of knee pain was almost 5 times higher in females (odds ratio=4.9, [95% confidence interval, 1.8-13.3], P=0.002), with a prevalence of 40% (17/42) in females versus 10% (8/79) in males. The likelihood of knee pain increased with age by approximately 13% per year (odds ratio=1.13, [95% confidence interval, 1.00-1.28], P=0.058). Malignant malalignment syndrome showed a potential relationship to more severe knee pain (P=0.05), which warrants further investigation. Body mass index, pes valgus, and degree of stance knee flexion showed no statistically significant relationships to knee pain (P>0.16). CONCLUSIONS: The prevalence of knee pain in ambulatory patients with CP is approximately 21%. Patellar subluxation (2%) and dislocation are rare in these patients. Knee pain is not always related to crouch, femoral anteversion, external tibial torsion, genu valgum, or pes valgus. Knee pain in these patients is more prevalent in females, and increases with increasing age. LEVEL OF EVIDENCE: Level III-case-control study.

A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows.

BACKGROUND: The radiocapitellar line (RCL) is a routinely referenced radiographic measurement for evaluating injury of the pediatric elbow, such as a Monteggia fracture. It is most commonly described as a line drawn along the radius that should intercept the center of the capitellum in a normal elbow. However, the RCL has not been rigorously defined or validated in young children. METHODS: The RCL was drawn out on the anteroposterior and lateral radiographs of 116 normal pediatric elbows by 3 examiners. On each radiograph, lines were drawn along the longitudinal center of the radial neck as well as the radial shaft. The distance from each of these lines to the center of the capitellum was defined as the line-capitellar distance (LCD). The LCD was standardized to the patient size and correlated with patient variables. RESULTS: Of the 2052 RCLs drawn, 50% (1029/2052) fell outside the middle third of the capitellum and 8.6% (176/2052) missed the capitellum completely. Lines drawn along the radial neck in the anteroposterior and lateral views missed the capitellum less frequently (1.2% vs. 12.7%, P<0.0001) and passed through its central third less (77.8% vs. 44.7%, P<0.0001) when compared with lines drawn using the radial shaft. Lines along the radial neck intersected the capitellum significantly more often on the lateral view than on the anteroposterior view (98.8% vs. 96.8%, P=0.06) and were more likely to pass through the center third of the capitellum (77.8% vs. 55.5%, P<0.0001). With both techniques of drawing the RCL, the percent of measurements falling within the middle third of the capitellum was higher in patients above 5 years of age (P<0.001). The RCL is more reliable in older patients and shows considerable variation in infants. CONCLUSIONS: The RCL does not invariably bisect or fall within the middle third of the capitellum in normal pediatric elbows. Therefore, an abnormal RCL is suggestive but not pathognomonic for injury such as Monteggia fracture. An RCL drawn along the radial shaft will miss the capitellum in 15.6% of elbows. The most consistent RCL is drawn along the radial neck on the lateral view. Patient variables such as age and sex should be considered in the ability of the RCL to identify elbow injury. LEVEL OF EVIDENCE: Diagnostic Level 3.

Drop Foot With Posterior Tibialis Weakness Treated With Peroneus Longus Transfer in a Child: A Case Report.

CASE: An 8-year-old girl with a history of acute flaccid paralysis presented with chronic valgus drop foot causing tripping and falling. Traditionally surgical correction of this deformity is accomplished by transferring the posterior tibialis tendon to enhance dorsiflexion. The authors describe a new technique which transfers the peroneus longus tendon to the dorsum of the foot in a patient with weakness of the posterior tibialis muscle. The patient's drop foot and gait were improved at the 22-month follow-up. CONCLUSION: Successful transfer of the peroneus longus was accomplished with improved limb clearance during gait and coronal alignment in stance.

Update on the reliability of gait analysis interpretation in cerebral palsy: Inter-institution agreement.

BACKGROUND: Studies have shown good reliability for gait analysis interpretation among surgeons from the same institution. However, reliability among surgeons from different institutions remains to be determined. RESEARCH QUESTION: Is gait analysis interpretation by surgeons from different institutions as reliable as it is for surgeons from the same institution? METHODS: Gait analysis data for 67 patients with cerebral palsy (CP) were reviewed prospectively by two orthopedic surgeons from different institutions in the same state, each with > 10 years' experience interpreting gait analysis data. The surgeons identified gait problems and made treatment recommendations for each patient using a rating form. Percent agreement between raters was calculated for each problem and treatment, and compared to expected agreement based on chance using Cohen's kappa. RESULTS: For problem identification, the greatest agreement was seen for equinus (85% agreement), calcaneus (88%), in-toeing (89%), and out-toeing (90%). Agreement for the remaining problems ranged between 66-78%. Percent agreement was significantly higher than expected due to chance for all issues (p ≤ 0.01) with modest kappa values ranging from 0.12 to 0.51. Agreement between surgeons for treatment recommendations was highest for triceps surae lengthening (89% agreement), tibial derotation osteotomy (90%), and foot osteotomy (87%). Agreement for the remaining treatments ranged between 72-78%. Percent agreement for all treatments was significantly higher than the expected values (p ≤ 0.002) with modest kappa values ranging from 0.22 to 0.52. SIGNIFICANCE: Previous research established that computerized gait analysis data interpretation is reliable for surgeons within a single institution. The current study demonstrates that gait analysis interpretation can also be reliable among surgeons from different institutions. Future research should examine reliability among physicians from more institutions to confirm these results.