Multi-segment foot kinematics during gait in children with spastic cerebral palsy.

BACKGROUND: Foot deformities (e.g. planovalgus and cavovarus) are very common in children with spastic cerebral palsy (CP), with the midfoot often being involved. Dynamic foot function can be assessed with 3D gait analysis including a multi-segment foot model. Incorporating a midfoot segment in such a model, allows quantification of separate Chopart and Lisfranc joint kinematics. Yet, midfoot kinematics have not previously been reported in CP. RESEARCH QUESTIONS: What is the difference in multi-segment kinematics including midfoot joints between common foot deformities in CP and typically-developing feet? METHODS: 103 feet of 57 children with spastic CP and related conditions were retrospectively included and compared with 15 typically-developing children. All children underwent clinical gait analysis with the Amsterdam Foot Model marker set. Multi-segment foot kinematics were calculated for three strides per foot and averaged. A k-means cluster analysis was performed to identify foot deformity groups that were present within CP data. The deformity type represented by each cluster was based on the foot posture index. Kinematic output of the clusters was compared to typically-developing data for a static standing trial and for the range of motion and kinematic waveforms during walking, using regular and SPM independent t-tests respectively. RESULTS: A neutral, planovalgus and varus cluster were identified. Neutral feet showed mostly similar kinematics as typically-developing data. Planovalgus feet showed increased ankle valgus and Chopart dorsiflexion, eversion and abduction. Varus feet showed increased ankle varus and Chopart inversion and adduction. SIGNIFICANCE: This study is the first to describe Chopart and Lisfranc joint kinematics in different foot deformities of children with CP. It shows that adding a midfoot segment can provide additional clinical and kinematic information. It highlights joint angles that are more distinctive between deformities, which could be helpful to optimize the use of multi-segment foot kinematics in the clinical decision making process.

The clinical value of preoperative 3D planning and 3D surgical guides for Imhäuser osteotomy in slipped capital femoral epipysis: a retrospective study.

BACKGROUND: Accurate repositioning of the femoral head in patients with Slipped Capital Femoral Epiphysis (SCFE) undergoing Imhäuser osteotomy is very challenging. The objective of this study is to determine if preoperative 3D planning and a 3D-printed surgical guide improve the accuracy of the placement of the femoral head. METHODS: This retrospective study compared outcome parameters of patients who underwent a classic Imhäuser osteotomy from 2009 to 2013 with those who underwent an Imhäuser osteotomy using 3D preoperative planning and 3D-printed surgical guides from 2014 to 2021. The primary endpoint was improvement in Range of Motion (ROM) of the hip. Secondary outcomes were radiographic improvement (Southwick angle), patient-reported clinical outcomes regarding hip and psychosocial complaints assessed with two questionnaires and duration of surgery. RESULTS: In the 14 patients of the 3D group radiographic improvement was slightly greater and duration of surgery was slightly shorter than in the 7 patients of the classis Imhäuser group. No difference was found in the ROM, and patient reported clinical outcomes were slightly less favourable. CONCLUSIONS: Surprisingly we didn't find a significant difference between the two groups. Further research on the use of 3D planning an 3D-printed surgical guides is needed. TRIAL REGISTRATION: Approval for this study was obtained of the local ethics committees of both hospitals.

Active monitoring versus an abduction device for treatment of infants with centered dysplastic hips: study protocol for a randomized controlled trial (TReatment with Active Monitoring (TRAM)-Trial).

BACKGROUND: Developmental Dysplasia of the Hip (DDH) is one of the most common pediatric orthopedic disorders, affecting 1-3% of all newborns. The optimal treatment of centered DDH is currently under debate. This randomized controlled trial aims to study the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH. METHODS: This is a multicenter, parallel-group, open-label, non-inferiority randomized controlled trial studying the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH in fourteen hospitals in the Netherlands. In total, 800 infants with centered DDH (Graf IIa-/IIb/IIc), aged 10-16 weeks, will be randomly allocated to the active monitoring or abduction treatment group. Infants will be followed up until the age of 24 months. The primary outcome is the rate of normal hips, defined as an acetabular index lower than 25 degrees on an antero-posterior radiograph, at the age of 12 months. Secondary outcomes are the rate of normal hips at the age of 24 months, complications, time to hip normalization, the relation between baseline patient characteristics and the rate of normal hips, compliance, costs, cost-effectiveness, budget impact, health-related quality of life (HRQoL) of the infant, HRQoL of the parents/caregivers, and parent/caregiver satisfaction with the treatment protocol. DISCUSSION: The outcomes of this randomized controlled trial will contribute to improving current care-as-usual for infants with centered DDH. TRIAL REGISTRATION: Dutch Trial Register, NL9714, registered September 6, 2021. https://clinicaltrialregister.nl/en/trial/29596.

Calf circumferences in fetuses and neonates with and without talipes equinovares. A prospective cohort study.

OBJECTIVE: Children and adults with talipes equinovarus (TEV) have smaller calves and shorter feet compared to non-affected controls. Do these changes have a prenatal onset? METHODS: A prospective cohort study (January 2020-July 2021) was conducted with serial ultrasonographic measurements at 20 and 28 weeks gestation and measurements directly and 6 weeks after birth. Calf circumference and width, foot length and length of humerus, ulna, radius, femur, tibia and fibula were measured in TEV and were compared to a control population. Calculated sample size necessitated a minimal population of 10 cases with TEV and 50 controls. RESULTS: Twenty cases with TEV and 62 controls were included. Fetal calf circumference (p < 0.001) and width (p < 0.001) were smaller in the TEV group in comparison to the control group, which persisted after birth. Growth in foot length (p < 0.001) and calf width (p 0.003) declined prenatally over time. The bone lengths and upper leg circumference were not smaller or shorter in TEV compared to controls. CONCLUSION: This prospective cohort study demonstrated the prenatal onset of reduced calf and foot size in fetuses with TEV from 20 weeks and onwards, which persists directly after birth. To investigate whether reduction in circumference initiates TEV or is caused by TEV, further examination is needed.

Treatment of decentered developmental dysplasia of the hip under the age of 1 year: an evidence-based clinical practice guideline - Part 2.

Background and purpose: Diagnostics and treatment of developmental dysplasia of the hip (DDH) are highly variable in clinical practice. To obtain more uniform and evidence-based treatment pathways, we developed the 'Dutch guideline for DDH in children < 1 year'. This study describes recommendations for unstable and decentered hips. Materials and methods: The Appraisal of Guidelines for Research and Evaluation criteria (AGREE II) were applied. A systematic literature review was performed for six predefined guideline questions. Recommendations were developed, based on literature findings, as well as harms/benefits, patient/parent preferences, and costs (GRADE). Results: The systematic literature search resulted in 843 articles and 11 were included. Final guideline recommendations are (i) Pavlik harness is the preferred first step in the treatment of (sub) luxated hips; (ii) follow-up with ultrasound at 3-4 and 6-8 weeks; (iii) if no centered and stable hip after 6-8 weeks is present, closed reduction is indicated; (iv) if reduction is restricted by limited hip abduction, adductor tenotomy is indicated; (v) in case of open reduction, the anterior, anterolateral, or medial approach is advised, with the choice based on surgical preference and experience; (vi) after reduction (closed/open), a spica cast is advised for 12 weeks, followed by an abduction device in case of residual dysplasia. Interpretation: This study presents recommendations on the treatment of decentered DDH, based on the available literature and expert consensus, as Part 2 of the first official and national evidence-based 'Guideline for DDH in children < 1 year'. Part 1 describes the guideline sections on centered DDH in a separate article.

Treatment of centered developmental dysplasia of the hip under the age of 1 year: an evidence-based clinical practice guideline - Part 1.

Despite the high incidence of developmental dysplasia of the hip (DDH), treatment is very diverse. Therefore, the Dutch Orthopedic Society developed a clinical practice guideline with recommendations for optimal and uniform treatment of DDH. This article summarizes the guideline on centered DDH (i.e. Graf types 2A-C). The guideline development followed the criteria of Appraisal of Guidelines for Research and Evaluation II. A systematic literature review was performed to identify randomized controlled trials and comparative cohort studies including children <1 year with centered DDH. Articles were included that compared (1) treatment with observation, (2) different abduction devices, (3) follow-up frequencies, and (4) discontinuation methods. Recommendations were based on Grading Recommendations Assessment, Development, and Evaluation, which included the literature, clinical experience and consensus, patient and parent comfort, and costs. Out of 430 potentially relevant articles, 5 comparative studies were included. Final guideline recommendations were (1) initially observe 3-month-old patients with centered DDH, start abduction treatment if the hip does not normalize after 6-12 weeks; (2) prescribe a Pavlik harness to children <6 months with persisting DDH on repeated ultrasonography, consider alternative abduction devices for children >6 months; (3) assess patients every 6 weeks; and (4) discontinue the abduction device when the hip has normalized or when the child is 12 months. This paper presents a summary of part 1 of the first evidence-based guideline for treatment of centered DDH in children <1 year. Part 2 presents the guideline on decentered DDH in a separate article.

Care Pathway for Foetal Joint Contractures, Foetal Akinesia Deformation Sequence, and Arthrogryposis Multiplex Congenita.

INTRODUCTION: The majority of arthrogryposis multiplex congenita (AMC) and lethal forms of AMC such as foetal akinesia deformation sequence (FADS) cases are missed prenatally. We have demonstrated the additional value of foetal motor assessment and evaluation in a multidisciplinary team for the period 2007-2016. An applied care pathway was developed for foetuses presenting with joint contracture(s) in one anatomic region (e.g., talipes equinovarus [TEV]), more than one body part with non-progressive contractures and motility (AMC) and with deterioration over time (FADS). METHODS: The multidisciplinary team of Amsterdam University Medical Centre Expertise Centre FADS and AMC developed the care pathway. Additional tools are provided including a motor assessment by ultrasound examination and a post-mortem assessment form. RESULTS: An eight-step care pathway is presented with a proposed timing for prenatal sonographic examination, genetic examinations, multidisciplinary meetings, prenatal and postnatal counselling of the parents by a specialist also treating after birth, and the follow-up of prenatal and postnatal findings with counselling for future pregnancies. DISCUSSION/CONCLUSION: The scheduled serial structural and motor sonograpahic assessment together with follow-up examinations and genetic analysis should be tailored per prenatal centre per available resources. The multidisciplinary care pathway may pave the way to increase the detection rate and diagnosis of isolated contracture(s), TEV with underlying genetic causes, and the rare phenotypes AMC/FADS and prompt treatment after birth within expertise teams.

[Teenagers with torticollis]. / Tieners met een torticollis.

Teenagers with torticollis In this article we describe three cases of children with torticollis. A 17-year-old patient who appears to have Klippel-Feil syndrome and is treated conservatively. An 11-year-old-patient with torticollis, present since a fall two days earlier and attributed to a subluxation of C1-C2. Ultimately, she had to be treated surgically with an atlantoaxial spondylodesis and has made a good recovery. Finally, a 15-year-old who presents with torticollis which has been present from early childhood. The diagnosis neglected congenital muscular torticollis is made. Because of increasing discomfort she is treated surgically with release of the sternocleidomastoideus. Postoperative, the patient has fewer symptoms. Physicians should be aware of different causes when there is persistent torticollis. Furthermore, children presenting with posttraumatic torticollis require a strict follow-up because atlanto-axial subluxation can lead to permanent deformity.

Fetal akinesia deformation sequence, arthrogryposis multiplex congenita, and bilateral clubfeet: Is motor assessment of additional value for in utero diagnosis? A 10-year cohort study.

OBJECTIVE: The diagnosis of fetal akinesia deformation sequence (FADS) is a challenge. Motor assessment is of additional value to advanced ultrasound examinations (AUE) for in utero FADS diagnosis before 24 weeks of gestation. METHODS: All consecutive fetuses with greater than or equal to two contractures on the 20 week structural anomaly scan (2007-2016) were included. Findings at AUE, including motor assessment were analysed and related to outcome. RESULTS: Sixty-six fetuses fulfilled the inclusion criteria. On the basis of the first AUE, FADS was suspected in 13 of 66, arthrogryposis multiplex congenita (AMC) in 12 of 66, bilateral pes equinovares (BPEV) in 40 of 66, and Holt-Oram syndrome in one of 66. On the basis of the first motor assessment, the suspected diagnosis changed in 19 of 66, in 13 of 66 worsening to FADS, six of 66 amelioration from FADS, and confirmed FADS in seven of 13. The result was 20 FADS, seven AMC, and 38 BPEV. Second AUE in 44 fetuses showed additional contractures in two of eight FADS, and one intrauterine fetal death (IUFD). The second motor assessment changed the diagnosis in three of 43, one worsening from BPEV into FADS, two ameliorations from FADS, and confirmed FADS in seven by deterioration of motility. The result was nine FADS, six AMC, and 29 BPEV. CONCLUSION: The results suggest that motor assessment has additional value to distinguish between FADS, AMC, and BPEV.

Outcome of medial hamstring lengthening in children with spastic paresis: A biomechanical and morphological observational study.

To improve gait in children with spastic paresis due to cerebral palsy or hereditary spastic paresis, the semitendinosus muscle is frequently lengthened amongst other medial hamstring muscles by orthopaedic surgery. Side effects on gait due to weakening of the hamstring muscles and overcorrections have been reported. How these side effects relate to semitendinosus morphology is unknown. This study assessed the effects of bilateral medial hamstring lengthening as part of single-event multilevel surgery (SEMLS) on (1) knee joint mechanics (2) semitendinosus muscle morphology and (3) gait kinematics. All variables were assessed for the right side only. Six children with spastic paresis selected for surgery to counteract limited knee range of motion were measured before and about a year after surgery. After surgery, in most subjects popliteal angle decreased and knee moment-angle curves were shifted towards a more extended knee joint, semitendinosus muscle belly length was approximately 30% decreased, while at all assessed knee angles tendon length was increased by about 80%. In the majority of children muscle volume of the semitendinosus muscle decreased substantially suggesting a reduction of physiological cross-sectional area. Gait kinematics showed more knee extension during stance (mean change ± standard deviation: 34±13°), but also increased pelvic anterior tilt (mean change ± standard deviation: 23±5°). In most subjects, surgical lengthening of semitendinosus tendon contributed to more extended knee joint angle during static measurements as well as during gait, whereas extensibility of semitendinosus muscle belly was decreased. Post-surgical treatment to maintain muscle belly length and physiological cross-sectional area may improve treatment outcome of medial hamstring lengthening.

Analysis of gait patterns pre- and post- Single Event Multilevel Surgery in children with Cerebral Palsy by means of Offset-Wise Movement Analysis Profile and Linear Fit Method.

Gait analysis is used for the assessment of walking ability of children with cerebral palsy (CP), to inform clinical decision making and to quantify changes after treatment. To simplify gait analysis interpretation and to quantify deviations from normality, some quantitative synthetic descriptors were developed over the years, such as the Movement Analysis Profile (MAP) and the Linear Fit Method (LFM), but their interpretation is not always straightforward. The aims of this work were to: (i) study gait changes, by means of synthetic descriptors, in children with CP that underwent Single Event Multilevel Surgery; (ii) compare the MAP and the LFM on these patients; (iii) design a new index that may overcome the limitations of the previous methods, i.e. the lack of information about the direction of deviation or its source. Gait analysis exams of 10 children with CP, pre- and post-surgery, were collected and MAP and LFM were computed. A new index was designed asa modified version of the MAP by separating out changes in offset (named OC-MAP). MAP documented an improvement in the gait pattern after surgery. The highest effect was observed for the knee flexion/extension angle. However, a worsening was observed as an increase in anterior pelvic tilt. An important source of gait deviation was recognized in the offset between observed tracks and reference. OC-MAP allowed the assessment of the offset component versus the shape component of deviation. LFM provided results similar to OC-MAP offset analysis but could not be considered reliable due to intrinsic limitations. As offset in gait features played an important role in gait deviation, OC-MAP synthetic analysis was proposed as a novel approach to a meaningful parameterisation of global deviations in gait patterns of subjects with CP and gait changes after treatment.

Guideline on the diagnosis and treatment of primary idiopathic clubfoot.

- A delegation of 6 pediatric orthopedic surgeons from the Dutch Orthopedic Association (NOV) and 2 members of the board of the Dutch Parents' Association for children with clubfoot created the guideline "The diagnosis and treatment of primary idiopathic clubfeet" between April 2011 and February 2014. The development of the guideline was supported by a professional methodologist from the Dutch Knowledge Institute of Medical Specialists. This evidence-based guideline process was new and unique, in the sense that the process was initiated by a parents' association. This is the first official guideline in pediatric orthopedics in the Netherlands, and to our knowledge it is also the first evidence-based guideline on clubfoot worldwide. The guideline was developed in accordance with the criteria of the international AGREE instrument (AGREE II: Appraisal of Guidelines for Research and Evaluation II). The scientific literature was searched and systematically analyzed. In the second phase, conclusions and recommendations in the literature were formulated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Recommendations were developed considering the balance of benefits and harms, the type and quality of evidence, the values and preferences of the people involved, and the costs. The guideline is a solid foundation for standardization of clubfoot treatment in the Netherlands, with a clear recommendation of the Ponseti method as the optimal method of primary clubfoot treatment. We believe that the format used in the current guideline sets a unique example for guideline development in pediatric orthopedics that may be used worldwide. Our format ensured optimal collaboration between medical specialists and parents, and resulted in an important change in clubfoot care in the Netherlands, to the benefit of medical professionals as well as parents and patients. In this way, it is possible to improve professional collaboration between medical specialists and parents, resulting in an important change in clubfoot care in the Netherlands that will benefit medical professionals, parents, and patients. The guideline was published online, and is freely available from the Dutch Guideline Database ( www.richtlijnendatabase.nl ).

Knee Moment-Angle Characteristics and Semitendinosus Muscle Morphology in Children with Spastic Paresis Selected for Medial Hamstring Lengthening.

To increase knee range of motion and improve gait in children with spastic paresis (SP), the semitendinosus muscle (ST) amongst other hamstring muscles is frequently lengthened by surgery, but with variable success. Little is known about how the pre-surgical mechanical and morphological characteristics of ST muscle differ between children with SP and typically developing children (TD). The aims of this study were to assess (1) how knee moment-angle characteristics and ST morphology in children with SP selected for medial hamstring lengthening differ from TD children, as well as (2) how knee moment-angle characteristics and ST morphology are related. In nine SP and nine TD children, passive knee moment-angle characteristics and morphology of ST (i.e. fascicle length, muscle belly length, tendon length, physiological cross-sectional area, and volume) were assessed by hand-held dynamometry and freehand 3D ultrasound, respectively. At net knee flexion moments above 0.5 Nm, more flexed knee angles were found for SP compared to TD children. The measured knee angle range between 0 and 4 Nm was 30% smaller in children with SP. Muscle volume, physiological cross-sectional area, and fascicle length normalized to femur length were smaller in SP compared to TD children (62%, 48%, and 18%, respectively). Sixty percent of the variation in knee angles at 4 Nm net knee moment was explained by ST fascicle length. Altered knee moment-angle characteristics indicate an increased ST stiffness in SP children. Morphological observations indicate that in SP children planned for medial hamstring lengthening, the longitudinal and cross-sectional growth of ST muscle fibers is reduced. The reduced fascicle length can partly explain the increased ST stiffness and, hence, a more flexed knee joint in these SP children.

Satisfaction and pain levels after proximal femoral valgus osteotomy according to Schanz in patients with cerebral palsy and hip dislocation.

Outcome after Schanz osteotomy in the treatment of chronic hip dislocation in children with cerebral palsy was evaluated. Medical charts and questionnaires were used to assess pain, functional outcome and satisfaction. A total of 24 children, with a mean age of 13.8 years (± 8.9), were included in the study, out of which 11 were classified with Gross Motor Function Classification System (GMFCS) level IV and 13 with GMFCS level V. Current pain was comparable to patients without chronic hip dislocation, and satisfaction was intermediate. Functional outcome improved in several domains. Longer postoperative time was associated with improved pain and satisfaction. The Schanz osteotomy allowed improvement in pain levels; however, it did not completely meet caregiver's expectation and has high reoperation rates.

Malunion of distal radius fractures in children.

BACKGROUND AND PURPOSE: Distal forearm fractures in children have excellent remodeling potential. The current literature states that 15° is the maximum acceptable angulation limit, though studies focusing on remodeling capacity above this value are lacking. We present data on the remodeling process in children with distal radius malunions with an angulation of ≥ 15°. PATIENTS AND METHODS: Retrospectively, we radiographically evaluated the remodeling in 33 children (aged 3-14 years) with 40 distal radius fractures healed in ≥ 15° angulation in the dorsovolar (DV) plane (n = 32) and/or the radioulnar (RU) plane (n = 8). Malunion angulation at the start and at last follow-up was measured on AP and lateral-view radiographs. Mean follow-up time was 9 (3-29) months. RESULTS: All fractures showed remodeling. Mean DV malunion angulation was 23° (15-49) and mean RU malunion angulation was 21° (15-33). At follow-up, this had remodeled to mean 8° (-2 to 21) DV and 10° (3-17) RU. Mean remodeling speed (RS) was 2.5° (0.4-7.6) per month. There was a negative correlation between RS and remodeling time (RT) and a positive correlation between RS and malunion angulation. The relationship between RS and RT was exponential. RS was not found to be related to age or sex. INTERPRETATION: Remodeling speed decreases exponentially over time. Its starting value depends on the amount of angulation of distal radius fractures. This compensates for the increased need for remodeling in severely angulated fractures.

Retrospective radiographic evaluation of treatment results of developmental dysplasia of the hip in walking-age children.

UNLABELLED: We evaluated treatment results of 22 children (32 hips) with idiopathic hip dislocation after walking age in two Dutch academic hospitals. The Tönnis classification was used preoperatively. Outcome was measured using the Severin and Kalamchi classification. The mean age at treatment was 24 months and the mean follow-up was 6.8 years. In 24 hips (73%), a perfect outcome was found (Kalamchi score≤1 and Severin score of 1). A fair or a poor outcome according to Severin (≥3) was found in five hips (15%). Treatment of a hip dislocation beyond 18 months of age usually results in adequate hip development with limited avascular necrosis. LEVEL OF EVIDENCE: Level III.

Progressive slip after removal of screw fixation in slipped capital femoral epiphysis: two case reports.

INTRODUCTION: In slipped capital femoral epiphysis the femoral neck displaces relative to the head due to weakening of the epiphysis. Early recognition and adequate surgical fixation is essential for a good functional outcome. The fixation should be secured until the closure of the epiphysis to prevent further slippage. A slipped capital femoral epiphysis should not be confused with a femoral neck fracture. CASE PRESENTATION: Case 1 concerns a 15-year-old boy with an adequate initial screw fixation of his slipped capital femoral epiphysis. Unfortunately, it was thought that the epiphysis had healed and the screw was removed after 11 weeks. This caused new instability with a progressive slip of the femoral epiphysis and subsequently re-fixation and a subtrochanteric correction osteotomy was obligatory. Case 2 concerns a 13-year-old girl with persistent hip pain after screw fixation for slipped capital femoral epiphysis. The screw was removed as lysis was seen around the screw on the hip X-ray. This operation created a new unstable situation and the slip progressed resulting in poor hip function. A correction osteotomy with re-screw fixation was performed with a good functional result. CONCLUSION: A slipped epiphysis of the hip is not considered 'healed' after a few months. Given the risk of progression of the slip the fixation material cannot be removed before closure of the growth plate.

Kaposiform (spindle cell) hemangioendotelioma in a child with an unusual presentation.

We describe a male child with multifocal kaposiform hemangioendothelioma in the right and left cervical region with development of Kasabach-Merritt syndrome. Treatment with interferon-alpha resulted in a good but only temporary clinical response.He relapsed 3 times with regrowth of the right cervical tumor. Involvement of the liver is suspected, because normalization of the liver size followed after the treatment with interferon-alpha. The question remains whether the multiple osteolytic bone lesions also reflect kaposiform hemangioendothelioma localization.

The results of downgrading moderate and severe slipped capital femoral epiphysis by an early Imhauser femur osteotomy.

PURPOSE: Patients with moderate and severe slipped capital femoral epiphysis (SCFE) develop osteoarthritis earlier in life in association with mechanical impingement. METHODS: To correct deformity and diminish impingement, we performed epiphysiodesis combined with an Imhauser intertrochanteric osteotomy (ITO) in moderate and severe slipped capital femoral epiphysis. We downgraded the angle of the head relative to the acetabulum into an angle corresponding to a mild slip or even an anatomical position. Our hypothesis is that the avoidance of anterior impingement at an early stage can prevent the development of osteoarthritis. RESULTS: The results of 28 patients (32 hips) were evaluated. Outcome parameters were SF-36, Harris Hip Score, range of motion, Kellgren-Lawrence score, chondrolysis and avascular necrosis. After a median follow-up of 8 (range 2-25) years, the group was clinically, functionally and socially performing well. Radiologically, there was no sign of chondrolysis or avascular necrosis, and more than 80% of the patients did not show any signs of osteoarthritis. CONCLUSIONS: Based on these results, we conclude that a one-stage Imhauser ITO combined with epiphysiodesis performed on patients with moderate and severe SFCE gives satisfactory results.

Unilateral hypoplasia of the trapezius muscle in a 10-year-old boy: a case report.

We present a 10-year-old boy with a partial absence of or a hypoplastic right trapezius. At present, his only concern is shoulder asymmetry. No family history of significance and no history of trauma exist. His radiographs confirm changes in bony anatomy secondary to the altered balance of muscle forces on the skeleton. We have not identified any other clinical report of a partial or total absence of the trapezius although it has been defined in cadaveric cases. Similarly, some papers have described an absence of trapezius in combination with other abnormalities. In these cases, an abnormal blood supply has been described in contrast to the normal neurovascular anatomy identified in the cadaveric cases with partial absence. If this patient develops painful disability, the Eden-Lange procedure may be an appropriate treatment as for patients with spinal accessory nerve palsies.