Intramuscular psoas lengthening at the pelvic brim plus proximal lengthening of the rectus femoris as a treatment for fixed knee flexion deformity in cerebral palsy. / Tenotomía intrapélvica del psoas y alargamiento proximal del recto anterior como tratamiento del flexo fijo de rodilla en parálisis cerebral infantil.

Although the correction of knee flexion by lengthening the hamstring musculature is traditionally contemplated in cerebral palsy, literature suggests that treatment of hip flexion also improves knee extension. The aim of the study was to first show the efficacy of the sequence of intrapelvic tenotomy of the psoas followed by intramuscular lengthening of the proximal rectus anterior and, later, that of both surgical soft tissue surgeries separately. For this, a prospective study was carried out in 10 patients with a mean age of 14 years, which presented 16 fixed knee flexes with a mean of deformity of 22°. The data was analyzed through means of an ANOVA of repeated measures and to determine the effect separately of each one of the techniques, the improvements obtained with respect to the previous level were contrasted. The mean extension achieved was 12°, 7° corresponding to the intrapelvic tenotomy of the psoas and, on the remaining knee flexion, a correction of 5° after intramuscular lengthening of the anterior rectus at the proximal level. Both the sequence of proposed gestures and those that form separately, showed statistically significant differences (P <0.001) in the correction of the deformity. In conclusion, the proposed techniques applied sequentially or separately are effective in reducing knee flexion in predominantly spastic cerebral palsy, facilitating or even being able to avoid the treatment that is directly needed.

[Evaluation of function and limiting factors of gait disorder treatment in cerebral palsy: development of the Walking Abilities Levels Classification System]. / Evaluación funcional y de factores limitantes del tratamiento de los trastornos de la marcha en la parálisis cerebral infantil: desarrollo del sistema de clasificación de niveles de deambulación funcional.

INTRODUCTION: The Gross Motor Function Classification System has allowed us to stratificate cerebral palsy patients, according to their walking abilities. The lack of sensitivity about detecting changes and the absence of a global patient evaluation, justify the search of new pre-operative evaluation tools. AIMS: To present the Walking Abilities Levels Classification System (WALCS) and to show the first inter-observer agreement study that has been carried out. This system uses first a different pattern for ordering gait functional skills, and after that, evaluates the reversibility of the contextual factors that may limit the result of a gait disorder treatment. SUBJECTS AND METHODS: A new evaluation frame was built by an interdisciplinary team with an average professional experience of more than 15 years, initially focused as part of the pre-surgical patient evaluation. An inter-observer agreement study was held to gain the first insight of it. 14 participants studied the medical reports and gait lab video images of 10 cases. RESULTS: The kappa index was 0.76 for the walking ability level, 0.79 for the biological type, 0.69 psychological type and 0.64 social type of limiting factors. CONCLUSIONS: The WALCS offers a new evaluation frame gathering patient walking skills and limiting factors treatment. The initial inter-observer agreement rate endorsed more intra- and inter-studies in order to achieve a more robust validation.

TITLE: Evaluación funcional y de factores limitantes del tratamiento de los trastornos de la marcha en la parálisis cerebral infantil: desarrollo del sistema de clasificación de niveles de deambulación funcional.Introducción. El Gross Motor Function Classification System ha permitido estratificar, según su habilidad para caminar, a los pacientes que padecen parálisis cerebral infantil. La falta de sensibilidad en la detección de cambios y la ausencia de una evaluación del paciente en el contexto en el que se encuentra justifican la búsqueda de alternativas de evaluación pretratamiento. Objetivos. Presentar y mostrar la concordancia interobservador inicial del sistema de clasificación de niveles de deambulación funcional. Con él se evalúa la destreza para caminar y la necesidad de asistencia para realizar transferencias desde la silla de ruedas, y, posteriormente se analiza el escenario que la salud y el entorno del paciente ofrecen como condicionantes en la corrección de la marcha o la bipedestación asistida. Sujetos y métodos. Se describe un nuevo marco de evaluación, elaborado por un grupo interdisciplinar con más de 15 años de experiencia media, enfocado inicialmente a la toma de decisiones antes de un tratamiento quirúrgico. Como control interno, 14 participantes evaluaron la historia clínica y los vídeos de marcha de 10 casos. Resultados. Se alcanzó un índice kappa de acuerdo de 0,76 en niveles funcionales y de 0,79 en el tipo de escenario biológico, de 0,69 en el psicológico y de 0,64 en el social. Conclusiones. El sistema de clasificación de niveles de deambulación funcional ofrece un marco para la evaluación conjunta de la deambulación y de los factores limitantes en la eficacia de un tratamiento. La concordancia interobservador avala iniciar su validación.

Efectos a medio y largo plazo sobre la marcha de un programa de ejercicio domiciliario y ortesis de uso nocturno en niños con equinismo idiopático / Medium and long-term effects on gait cycle of home-based exercise program and use of a night splint in children with idiopathic toe walking

Introducción: El equinismo idiopático es una alteración de la marcha pediátrica caracterizada por la realización de una excesiva flexión plantar del tobillo durante la marcha. No hay consenso en la literatura acerca de la mejor oferta terapéutica, coexistiendo opciones conservadoras y quirúrgicas en la práctica clínica. El objetivo de este trabajo es comprobar el impacto de un programa de ejercicios domiciliarios asociado al uso de una ortesis nocturna en el manejo del niño con equinismo idiopático. Material y métodos: Se realizó un estudio cinemático comparativo a los 6, 12 y 18 meses de 29 niños con equinismo idiopático, comparando los datos con los de 15 niños con marcha normal. La propuesta de tratamiento consistió en ejercicios domiciliarios asociados a una ortesis de uso nocturno durante 12 meses. Resultados: La propuesta terapéutica planteada ofrece normalización de los parámetros cinemáticos a los 18 meses de evolución. Se encontraron cambios estadísticamente significativos en los valores cinemáticos de la marcha estudiados (A1, A3, A5 y GDI), así como en una de las variables de la exploración física (rango de dorsiflexión). Todos los cambios se produjeron en dirección a los valores cinemáticos durante la marcha del grupo de niños sin patología. Conclusiones: El análisis del movimiento es una herramienta de monitorización de los trastornos de la marcha y control de evolución para los niños con equinismo idiopático. El ejercicio domiciliario asociado a una ortesis nocturna ofrece resultados positivos en la corrección de la marcha en niños con equinismo idiopático (AU)

Introduction: Idiopathic toe walking (ITW) is a common paediatric gait disorder characterised by excessive plantar flexion during the gait cycle. There is no consensus in the literature about the best therapeutic approach to treat ITW and different conservative and surgical options are used in clinical practice. The main objective of this study is to evaluate the clinical impact of a home-based exercise program associated with the use of a night splint (AFO) for managing gait problems in children with ITW. Material and methods: This is a comparative kinematic study. Long-term follow-ups were conducted at 6, 12, and 18 months with 29 children with ITW and 15 healthy children. The proposed treatment was a home-based exercise associated with a night splint for 12 months. Results: The therapeutic approach improved several kinematic values by the 18-month follow-up. We found statistically significant differences for gait kinematics (A1, A3, A5 and GDI) and one of the clinical examination variables (ankle passive dorsiflexion). All the differences showed a normalization of gait kinematics, with critical kinematic values close to the normalcy data. Conclusions: 3D gait analysis is an assessment tool for gait disorders and for long-term follow-up of children with ITW. Our home-based exercise associated with a night splint showed good results for gait disorders treatment in children with idiopathic toe walking (AU)

Relative fascicle excursion effects on dynamic strength generation during gait in children with cerebral palsy.

Evaluation of muscle structure gives us a better understanding of how muscles contribute to force generation which is significantly altered in children with cerebral palsy (CP). While most muscle structure parameters have shown to be significantly correlated to different expressions of strength development in children with CP and typically developing (TD) children, conflicting results are found for muscle fascicle length. Muscle fascicle length determines muscle excursion and velocity, and contrary to what might be expected, correlations of fascicle length to rate of force development have not been found for children with CP. The lack of correlation between muscle fascicle length and rate of force development in children with CP could be due, on the one hand, to the non-optimal joint position adopted for force generation on the isometric strength tests as compared to the position of TD children. On the other hand, the lack of correlation could be due to the erroneous assumption that muscle fascicle length is representative of sarcomere length. Thus, the relationship between muscle architecture parameters reflecting sarcomere length, such as relative fascicle excursions and dynamic power generation, should be assessed. Understanding of the underlying mechanisms of weakness in children with CP is key for individualized prescription and assessment of muscle-targeted interventions. Findings could imply the detection of children operating on the descending limb of the sarcomere length-tension curve, which in turn might be at greater risk of developing crouch gait. Furthermore, relative muscle fascicle excursions could be used as a predictive variable of outcomes related to crouch gait prevention treatments such as strength training.

Cirugía multinivel para las alteraciones de la deambulación en parálisis cerebral infantil. Evaluación cuantitativa, funcional y de satisfacción de los resultados obtenidos / Multilevel surgery for gait disorders in cerebral palsy. Quantitative, functional and satisfaction outcomes measurement

Objetivo: Estudiar la eficacia de la cirugía en el tratamiento de los trastornos de la marcha en la parálisis cerebral infantil (PCI) utilizando análisis cuantitativo del movimiento. Material y método: Se realizó un estudio retrospectivo en 26 pacientes con edades comprendidas entre los 8 y los 17 años. El 64% de los pacientes presentaban un nivel funcional III y IV de la clasificación GMFCS (Gross Motor Function Clasification System). La corrección quirúrgica de las alteraciones esqueléticas se asoció a la cirugía de partes blandas, usando análisis de movimiento. La evolución fue de 16 meses. Resultados: Se encontraron mejorías significativas en la extensión máxima de rodilla en fase de apoyo y en el rango dinámico de la misma durante el ciclo de marcha. La mayor mejoría funcional se consiguió en la distancia de 50 metros. Cerca del 80% de los padres valoraron los resultados como buenos o excelentes. Conclusión: La cirugía osteoarticular multinivel es eficaz, objetiva y subjetivamente, en el tratamiento de las alteraciones de la marcha en la PCI (AU)

Objective: To study the efficacy of orthopaedic surgery with bone correction guided by quantitative motion analysis, for the treatment of gait disorders in cerebral palsy. Material and method: A retrospective study with 26 patients, aged between 8 and 17, and an average follow up of 16 months, was conducted. 60% of the patients were level III or IV. Surgery of the bone lever arm dysfunction was added to the to soft-tissue surgery when necessary. Gait cycle graphs, F.M.S. (Functional Mobility Scale), and a post-treatment satisfaction and gait functional questionnaire were used for proving differences. Results: Kinematic improvements were found in the gait cycle. Maximun values of extensión in stance phase and dynamic range of motion of the knee were better, showing a significant statistically difference. The greater functional improvement was reached in the 50 meters distance. In other words, the patients were able to use the wheel-chair at school less, after this surgical treatment. Around 80% of the parents considered results as good or excellent. Conclusion: The bone and articular surgey in the single multilevel surgery showed its efficacy in the treatment of gait disorders in cerebral palsy (AU)

[Guide to the comprehensive treatment of spasticity]. / Guia del tratamiento integral de la espasticidad.

AIMS AND DEVELOPMENT: Spasticity is an important medical problem with a high rate of incidence both in childhood, mainly as a result of cerebral palsy, and in adults, which is frequently brought about by traumatic brain injuries, strokes and spinal cord injuries. Spasticity is part of upper motoneuron syndrome, which gives rise to important problems, such as limited joint movement, abnormal postures that can produce pain, impaired functional capacity, aesthetic or hygiene disorders, among others. It progresses naturally towards chronicity, accompanied by static phenomena due to alterations affecting the properties of soft tissues (elasticity, plasticity and viscosity). Numerous therapeutic options are available for the treatment of spasticity, including medication, physiotherapy, orthopaedic aid, surgery, and so forth. Moreover, treatment should be individualised and realistic, with goals that have been agreed between the patient or caregiver and the medical team. The aim of the following guide is to further our knowledge of this condition, its causes, epidemiology and progression, as well as to outline an approach that is both rational and global from the point of view of pharmacological, rehabilitation and surgical treatment. CONCLUSIONS: Spasticity is a complex problem that requires specialists (neurologist, rehabilitation doctor, occupational therapist, orthopaedic surgeon, general practitioner, etc.) to work as a team in order to achieve the goals set out when treatment is begun. Early treatment is important to avoid or reduce, as far as possible, the severe complications stemming from this condition.

Guía del tratamiento integral de la espasticidad / Guide to the comprehensive treatment of spasticity

Objetivos y desarrollo. La espasticidad constituye un problema médico de incidencia y trascendencia elevada tanto en la infancia, como consecuencia principalmente de la parálisis cerebral, como en adultos, ocasionada frecuentemente por traumatismos craneoencefálicos, ictus y lesión medular. La espasticidad forma parte del síndrome de motoneurona superior que ocasiona problemas importantes, como son: limitación articular, posturas anómalas que pueden generar dolor, alteraciónde la capacidad funcional, alteraciones estéticas o de higiene, entre otras. Su evolución natural es hacia la cronicidad, acompañada de fenómenos estáticos por alteraciones de las propiedades de los tejidos blandos (elasticidad, plasticidad y viscosidad).Las opciones terapéuticas de la espasticidad son múltiples: fármacos, fisioterapia, ayudas ortopédicas, cirugía, etc.Además, el tratamiento debe ser individualizado y realista, con unos objetivos consensuados entre el paciente o cuidador y el equipo médico. El objetivo de la siguiente guía es profundizar en el conocimiento de esta patología, sus causas, epidemiologíay evolución, así como aportar una forma racional y global de abordaje desde el punto de vista del tratamiento farmacológico, rehabilitador y quirúrgico. Conclusión. La espasticidad es un problema complejo que requiere un trabajo en equipo(neurólogo, rehabilitador, terapeuta ocupacional, cirujano ortopeda, médico de familia, etc.) para conseguir los objetivos que se fijan al principio de su tratamiento. Es importante el tratamiento precoz para evitar o reducir, en la medida de lo posible, las graves complicaciones que conlleva

Aims and development. Spasticity is an important medical problem with a high rate of incidence both in childhood,mainly as a result of cerebral palsy, and in adults, which is frequently brought about by traumatic brain injuries, strokes and spinal cord injuries. Spasticity is part of upper motoneuron syndrome, which gives rise to important problems, such as limitedjoint movement, abnormal postures that can produce pain, impaired functional capacity, aesthetic or hygiene disorders, among others. It progresses naturally towards chronicity, accompanied by static phenomena due to alterations affecting the properties of soft tissues (elasticity, plasticity and viscosity). Numerous therapeutic options are available for the treatment ofspasticity, including medication, physiotherapy, orthopaedic aid, surgery, and so forth. Moreover, treatment should be individualised and realistic, with goals that have been agreed between the patient or caregiver and the medical team. The aimof the following guide is to further our knowledge of this condition, its causes, epidemiology and progression, as well as to outline an approach that is both rational and global from the point of view of pharmacological, rehabilitation and surgicaltreatment. Conclusions. Spasticity is a complex problem that requires specialists (neurologist, rehabilitation doctor, occupational therapist, orthopaedic surgeon, general practitioner, etc.) to work as a team in order to achieve the goals set outwhen treatment is begun. Early treatment is important to avoid or reduce, as far as possible, the severe complications stemming from this condition

Polectomía abierta frente a percutánea en el tratamiento de la tenosinovitis estenosante del pulgar en el niño / Open versus percutaneous surgery for trigger thumbs in children

Objetivo. Comparar la técnica quirúrgica abierta con la percutánea para el tratamiento de la tenosinovitis estenosante del pulgar en la infancia. Material y método. Se realizó un estudio retrospectivo donde se revisaron 108 pacientes (135 pulgares) con un período de seguimiento medio de 24 meses, comparando ambas técnicas quirúrgicas. Resultados. Seis pacientes de 92 (6,52%) presentaban incapacidad para la extensión completa de la articulación interfalángica del primer dedo tras cirugía abierta. Mediante cirugía percutánea la recidiva ocurrió en 15 pulgares de 43 intervenidos (34,8%). No aparecieron complicaciones relacionadas con déficit de sensibilidad, dolor residual, ni alteraciones de la movilidad del primer dedo en ninguna de las dos series comparadas. Conclusiones. El porcentaje de recidiva acontecido tras el tratamiento percutáneo del pulgar en resorte justifica no recomendar su utilización en la población infantil (AU)

Purpose. To compare open versus percutaneous surgery in the treatment of stenosing tenosynovitis in a pediatric population. Materials and methods. A retrospective study was performed comparing both surgical techniques by reviewing 108 patients (135 thumbs) with a follow-up period of 24 months. Results. Six patients out of 92 (6.52%) were incapable of complete extension of the interphalangeal joint of the thumb after open surgery. When percutaneous surgery was performed there was recurrence in 15 thumbs of the 43 that underwent surgery (34.8%). No complications were seen related to lack of sensitivity, residual pain, nor alterations of thumb mobility in any of the patients in the two compared series. Conclusions. Due to the percentage of recurrences seen, percutaneous surgery for trigger thumb is not recommended in a pediatric population (AU)

Kingella kingae como causa de infección en dos niños menores de dos años / Kingella kingae infections in two children younger than two years old

Kingella kingae es un cocobacilo gramnegativo, aerobio, pertenenciente a la familia de las Neisseriaceae. Presentamos dos casos clínicos de infección por Kingella kingae: bacteriemia y artritis séptica, diagnosticados en nuestro centro en el intervalo de un mes. Kingella kingae forma parte de la flora orofaríngea habitual, pudiendo ser la puerta de entrada de las infecciones sistémicas. Desde la administración de la vacuna frente a Haemophilus influenzae tipo b, Kingella kingae está siendo la principal bacteria gramnegativa implicada en infecciones osteoarticulares en niños menores de tres años. Kingella kingae es muy sensible a los antibióticos que normalmente se utilizan de forma empírica. Las infecciones por Kingella kingae habitualmente siguen un curso clínico benigno, y se han descrito casos de resolución espontánea. Queremos hacer hincapié en el hecho de que este microorganismo no es sospechado o buscado en infecciones en pacientes pediátricos. Kingella kingae es un microorganismo de difícil aislamiento, poco resistente en condiciones adversas, por lo que es importante inocular la muestra de sangre o líquido articular en frasco de hemocultivo (AU)