Fever after varus derotational osteotomy is common, but not a risk factor for infection.

Postoperative fever in pediatric patients following reconstructive hip surgery is of unknown significance. This study identifies the prevalence of postoperative fever after corrective hip surgery, its relationship to infection, and whether preventative use of anti-pyretics affects patient outcomes.Overall, 222 patients who underwent a varus derotational osteotomy (VDRO) between 11/1/2004 to 8/1/2014 with minimum 6 months follow up were retrospectively identified. Variables included diagnosis, inpatient stay, daily maximum temperature, duration of fever, fever workup, and administration of scheduled anti-pyretics. Fever was defined as temperature ≥38°C.In total, 123/222 (55.4%) and 70/222 (31.5%) had postoperative fevers of ≥38°C and ≥38.5°C, respectively. Average inpatient stay was 2.7 days postoperatively. Temperature (mean = 38.0°C) was greatest on postoperative day 1 (POD1), and 43.7% of patients had T ≥38°C on POD1. Anti-pyretics did not influence the duration of fever. Anti-pyretics on the day of surgery (POD0) did not influence the incidence of fever. Acetaminophen on POD0 significantly reduced likelihood of fever on POD1 (P = .02). Average length of fevers ≥38°C and 38.5°C were 8.4 and 4.2 hours, respectively. 3/18 (16.7%) fever workups administered were positive. Postoperative fever did not predict infection. 9/222 (4/1%) patients had postoperative infection - 5/123 (4.1%) with fever ≥38°C and 4/70 (5.7%) with fever ≥38.5°C. Rates of infection in patients with and without fevers were not significantly different (P = .97 for T ≥38°C and P = .38, for T ≥38.5°C).Though common, postoperative fever does not increase risk of infection. The low prevalence of positive cultures indicates routine fever workups can safely be avoided in most patients.Level of Evidence: III, retrospective comparative study.

Impact of gait analysis on pathology identification and surgical recommendations in children with spina bifida.

BACKGROUND: Gait analysis provides quantitative data that can be used to supplement standard clinical evaluation in identifying and understanding gait problems. It has been established that gait analysis changes treatment decision making for children with cerebral palsy, but this has not yet been studied in other diagnoses such as spina bifida. RESEARCH QUESTION: To determine the effects of gait analysis data on pathology identification and surgical recommendations in children with spina bifida. METHODS: Two pediatric orthopaedic surgeons and two therapists with >10 years of experience in gait analysis reviewed clinical, video, and gait analysis data from 43 ambulatory children with spina bifida (25 male; mean age 11.7 years, SD 3.8; 25 sacral, 18 lumbar). Primary gait pathologies were identified by each assessor both before and after consideration of the gait analysis data. Surgical recommendations were also recorded by the surgeons before and after consideration of the gait analysis data. Frequencies of pathology and surgery identification with and without gait analysis were compared using Fisher's exact test, and percent change in pathology and surgery identification was calculated. RESULTS: Pathology identification often changed for common gait problems including crouch (28% of cases), tibial rotation (35%), pes valgus (18%), excessive hip flexion (70%), and abnormal femur rotation (75%). Recognition of excessive hip flexion and abnormal femur rotation increased significantly after consideration of gait analysis data (p < 0.05). Surgical recommendations also frequently changed for the most common surgeries including tibial derotation osteotomy (30%), antero-lateral release (22%), plantar fascia release (33%), knee capsulotomy (25%), 1st metatarsal osteotomy (60%), and femoral derotation osteotomy (89%). At the patient level, consideration of gait analysis data altered surgical recommendations for 44% of patients. SIGNIFICANCE: Since gait analysis data often changes pathology identification and surgical recommendations, treatment decision making may be improved by including gait analysis in the patient care process.

Advanced skeletal maturity in children and adolescents with myelomeningocele.

PURPOSE: Atypical skeletal development is common in youth with myelomeningocele (MM), though the underlying reasons have not been fully elucidated. This study assessed skeletal maturity in children and adolescents with MM and examined the effects of sex, age, sexual development, ethnicity, anthropometrics and shunt status. METHODS: Forty-three males and 35 females with MM, 6-16 years old, underwent hand radiographs for bone age determination. The difference between bone age and chronological age was evaluated using Wilcoxon sign rank tests. Relationships between age discrepancy (skeletal-chronological) and participant characteristics were assessed using multiple linear regression with forward selection. RESULTS: Overall, forty percent (31/78) of MM participants had an advanced bone age of 1 year or greater (median: 2.5 years), while 47% (37/78) were within 1 year above or below their chronological age (-0.001 years) and 13% (10/78) were delayed by more than 1 year (-1.4 years). Bone age was advanced compared to chronologic age in both males and females (p⩽ 0.024). Advanced bone age was observed in early to late puberty and after maturation (p⩽ 0.07), as well as in Hispanic participants (p= 0.003) and in those with a shunt (p= 0.0004). Advanced bone age was positively correlated with height, weight and body mass index (BMI) percentiles (p= 0.004). In multiple linear regression analysis, advanced bone age was most strongly associated with higher Tanner stage of sexual development, and higher weight, height or BMI percentile. CONCLUSIONS: Advanced skeletal maturity is common in children/adolescents with MM over 8 years of age who have reached puberty (65%), particularly those who are overweight (80%). Hormonal effects associated with adiposity and sexual maturity likely influence skeletal maturation. Clinicians may use Tanner stage and weight or BMI to gain insight into skeletal maturity.

Fasting serum blood measures of bone and lipid metabolism in children with myelomeningocele for early detection of cardiovascular and bone fragility risk factors.

OBJECTIVE: This study examined serum levels in children with myelomeningocele to identify the prevalence of pre-clinical signs of disease. DESIGN: A prospective, cross-sectional study. SETTING: Patients were actively recruited from multidisciplinary care clinics at tertiary children's hospitals from 2010-2012. The control comparison group was recruited by word-of-mouth. PATIENTS: Twenty-eight children with myelomeningocele (93% Hispanic; 17 males; 10.0 ± 2.1 years) and 58 controls (84% Hispanic; 30 males; 10.4 ± 2.4 years) provided ≥ 8-hour fasting blood samples with concomitant dual-energy x-ray absorptiometry measurements of body fat. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The serum analysis included a lipid panel (cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein), insulin, glucose, leptin, aspartate aminotransferase, alanine transaminase, alkaline phosphatase, albumin, creatinine, calcium, phosphatase, parathyroid hormone, and vitamin D. RESULTS: Children with myelomeningocele had higher body fat (35.2% versus 29.9%, p=0.01) and altered lipid profiles (lower high-density lipoprotein levels, 43.9 mg/dL versus 51.6 mg/dL, P = 0.03) suggesting elevated risk of metabolic syndrome. They also had a higher prevalence of vitamin D deficiency (43% versus 17%, p=0.02) and significantly lower levels of calcium (9.4 mg/dL versus 9.7 mg/dL, P = 0.003) and alkaline phosphatase (187.0 U/L versus 237.0 U/L, P = 0.003). Unexpectedly children with myelomeningocele had lower parathyroid hormone levels (14.5 pg/mL versus 18.4 pg/mL, P = 0.02) than controls despite lower calcium, vitamin D and alkaline phosphatase levels. This suggests an alteration in the sensing mechanism or response of the parathyroid gland to normal physiological stimuli in patients with myelomeningocele. CONCLUSIONS: Children with myelomeningocele have abnormal biochemical markers for cardiovascular disease, insulin resistance and bone and mineral metabolism. Early recognition and monitoring of these risk factors in patients with myelomeningocele may help prevent later complications.

Walking activity during daily living in children with myelomeningocele.

PURPOSE: To quantify the walking activity of children with myelomeningocele during daily living. METHOD: Walking activity was measured using a StepWatch activity monitor over one week in 47 children with myelomeningocele (27 males; 9 years 11 months SD 2 years 7 months; 18 sacral, 9 low lumbar, 20 mid-high lumbar) and seven children with typical development (5 males; 11 years 1 month SD 1 year 11 months) in a prospective, cross-sectional study. Average total steps per day, number of steps and minutes spent at low, medium and high intensity stepping were evaluated. Groups were compared using t-tests and chi-squared tests with Bonferroni post-hoc adjustment. RESULTS: Children with sacral and low lumbar myelomeningocele exhibited no significant differences in demographic characteristics or walking performance compared to typically developing children. Children with mid-high lumbar myelomeningocele exhibited higher BMI percentile than the control group (p = 0.04) and took fewer total steps per day than all other groups (p ≤ 0.04). Children with mid-high lumbar myelomeningocele also spent significantly less time taking steps at all intensity levels, particularly medium-intensity, than the sacral and low lumbar groups (p ≤ 0.04). CONCLUSIONS: Children with sacral and low lumbar myelomeningocele had walking performance similar to typically developing children despite a common need for braces and assistive devices. Children with mid-high lumbar myelomeningocele were less active, which may lead to heightened risk for secondary health conditions in addition to those associated with myelomeningocele. Implications for Rehabilitation Obesity, muscle weakening and disuse osteoporosis are issues for those with myelomeningocele, all of which are affected by walking activity. Understanding walking activity and intensity in children and adolescents with myelomeningocele may aid in developing focused rehabilitation interventions and strategies. Real world walking activity as an objective and quantified measure has the potential to help guide therapists and surgeons to more effective treatments.

Differentiating Transient Synovitis of the Hip from More Urgent Conditions.

A variety of traumatic and infectious processes can cause acute onset of hip pain and difficulty walking. Without a history of trauma, a common cause is transient (or "toxic") synovitis, but serious infectious causes, such as septic arthritis of the hip or osteomyelitis, must be ruled out. Differentiating between septic arthritis of the hip (a true emergency) and transient synovitis of the hip (a much more benign inflammatory process) can be difficult. The Kocher criteria have proven to be helpful in making the distinction between these two conditions, and they are reviewed in this article. In addition, imaging studies, especially hip ultrasound, are extremely helpful in the evaluation of the painful hip. [Pediatr Ann. 2016;45(6):e209-e213.].

Quantitative Analysis of Lower Leg Adipose Tissue Distribution in Youth with Myelomeningocele.

Children with myelomeningocele have a high prevalence of obesity and excess fat accumulation in their lower extremities. However, it is not known if this is subcutaneous or intramuscular fat, the latter of which has been associated with insulin resistance and metabolic disorders. This study quantified lower leg bone, muscle, and adipose tissue volume in children with myelomeningocele, classifying adipose as subcutaneous or muscle-associated. Eighty-eight children with myelomeningocele and 113 children without myelomeningocele underwent lower leg computed tomographic scans. Subcutaneous and muscle-associated adipose were classified based on location relative to the crural fascia. No differences were seen in subcutaneous adipose. Higher level disease severity was associated with increased muscle-associated adipose volume and decreased muscle volume. Bone volume tended to decrease with higher levels of involvement. Increases in lower leg adiposity in children with myelomeningocele are primarily attributable to accumulation of muscle-associated adipose, which may signify increased risk for metabolic disorders.

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.

Fat distribution in children and adolescents with myelomeningocele.

AIM: To evaluate fat distribution in children and adolescents with myelomeningocele using dual-energy X-ray absorptiometry (DXA). METHOD: Cross-sectional DXA measurements of the percentage of fat in the trunk, arms, legs, and whole body were compared between 82 children with myelomeningocele (45 males, 37 females; mean age 9y 8mo, SD 2y 7mo; 22 sacral, 13 low lumbar, 47 mid lumbar and above) and 119 comparison children (65 males, 54 females; mean age 10y 4mo, SD 2y 4mo). Differences in fat distribution between groups were evaluated using univariate and multivariate analyses. RESULTS: Children with myelomeningocele had higher total body fat (34% vs 31%, p=0.02) and leg fat (42% vs 35%, p<0.001) than comparison children, but no differences in trunk or arm fat after adjustment for anthropometric measures. INTERPRETATION: Children with myelomeningocele have higher than normal total body and leg fat, but only children with higher level lesions have increased trunk fat, which may be caused by greater obesity in this group. Quantifying segmental fat distribution may aid in better assessment of excess weight and, potentially, the associated health risks.

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.

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.

Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination?

BACKGROUND: Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury. METHODS: A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study. RESULTS: Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100). CONCLUSIONS: In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations. LEVEL OF EVIDENCE: Level I prognostic study.

Heterogeneity of muscle fat infiltration in children with spina bifida.

Children with spina bifida have well recognized functional deficits of muscle, but little is known about the associated changes in muscle anatomy and composition. This study used water-fat magnetic resonance imaging (MRI) to measure fat infiltration in the lower extremity muscles of 11 children with myelomeningocele, the most severe form of spina bifida. MRI measurements of muscle fat fraction (FF) were compared against manual muscle test (MMT) scores for muscle strength. The FF measurements were objective and reliable with mean inter-rater differences of <2% and intraclass correlation coefficients>0.98. There was a significant inverse relationship between muscle FF and MMT scores (P ≤ 0.001). Surprisingly, however, muscles with negligible strength (MMT 0-1) exhibited a bimodal distribution of FF with one group having FF>70% and another group having FF<20%. The MRI also revealed striking heterogeneity amongst individual muscles in the same muscle group (e.g., 4% fat in one participant's lateral gastrocnemius vs. 88% in her medial gastrocnemius), as well as significant asymmetry in FF in one participant with asymmetric strength and sensation. These results suggest that quantitative water-fat MRI may serve as a biomarker for muscle degeneration which may reveal subclinical changes useful for predicting functional potential and prognosis.

Differences in implementation of gait analysis recommendations based on affiliation with a gait laboratory.

This study examined the extent to which gait analysis recommendations are followed by orthopedic surgeons with varying degrees of affiliation with the gait laboratory. Surgical data were retrospectively examined for 95 patients with cerebral palsy who underwent lower extremity orthopedic surgery following gait analysis. Thirty-three patients were referred by two surgeons directly affiliated with the gait laboratory (direct affiliation), 44 were referred by five surgeons from the same institution but not directly affiliated with the gait laboratory (institutional affiliation), and 18 were referred by 10 surgeons from other institutions (no affiliation). Data on specific surgeries were collected from the gait analysis referral, gait analysis report, and operative notes. Adherence to the gait analysis recommendations was calculated by dividing the number of procedures where the surgery followed the gait analysis recommendation (numerator) by the total number of procedures initially planned, recommended by gait analysis, or done (denominator). Adherence with the gait analysis recommendations was 97%, 94%, and 77% for the direct, institutional, and no affiliation groups, respectively. Procedures recommended for additions to the surgical plan were added 98%, 87%, and 77% of the time. Procedures recommended for elimination were dropped 100%, 89%, and 88% of the time. Of 81 patients who had specific surgical plans prior to gait analysis, changes were implemented in 84% (68/81) following gait analysis recommendations. Gait analysis influences the treatment decisions of surgeons regardless of affiliation with the gait laboratory, although the influence is stronger for surgeons who practice within the same institution as the gait laboratory.

Orthopaedic issues in children and adolescents with central nervous system tumors.

Musculoskeletal deficits remain significant impediments to the function and independence of children and adolescents following successful treatment of Central Nervous System Tumors (CNS) tumors. The sequelae often impair the function of the upper and lower extremities and manifest themselves as difficulties in gross and fine motor skills, which encompasses self care and walking. Overall, the five-year survival rate for children younger than 15 years with brain tumors is between 60 to 90 percent. Approximately two-thirds of survivors have long term neurological deficits. These neurologic deficits often manifest themselves as musculoskeletal abnormalities. It is essential to recognize the potential consequences of a CNS tumor and its associated treatments in an effort to prevent disability. Following the initial neurosurgical and oncologic treatment, the acute and chronic stages of the orthopaedic care for these patients differ significantly. Many of the rehabilitation and treatment principles for brain tumor patients have evolved from the principles used in stroke and traumatic brain injury. Orthopaedic treatment specifically includes preventing, identifying, and treating spasticity, contractures, bony and spinal deformities, and gait abnormalities.

Increased incidence of sacroiliac joint infection at a children's hospital.

BACKGROUND: Pyogenic sacroiliitis (PSI) is an uncommon type of osteoarticular infection. A study is undertaken to confirm an observed increase in incidence of PSI at our pediatric institution and to evaluate any associations with increasing incidence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection and other factors. METHODS: All inpatients with osteoarticular infection were identified from the periods of 1992 to 1996 and 2004 to 2007. Patients with surgical site infection, immunologic deficits, decubiti, or other predisposing factors were excluded. Demographic, microbiologic, and clinical factors were analyzed for comparison. RESULTS: Overall 362 cases were included: 205 with osteomyelitis alone and 157 with pyarthrosis, of which 15 were PSI cases. The incidence of PSI increased from the periods of 1992 to 1996 and 2004 to 2007 (0.8 vs. 2.8 cases/y, P=0.03), along with osteomyelitis at pelvic and spinal sites (ie, axial sites; 1.6 vs. 5.0 cases/y; P=0.03), whereas the incidence of osteoarticular infection at other sites remained stable. CA-MRSA was isolated in 1 (6.7%) PSI case. In the second time period, CA-MRSA did not form a higher proportion of S. aureus isolates at sacroiliac or other axial sites (CA-MRSA: 17% of S. aureus in PSI and axial osteomyelitis vs. 45% of S. aureus at nonaxial sites, P=0.08). Patients were older in the second time period (4.5 y vs. 7 y; P<0.0001), and patients with PSI (10.5 y) and axial osteomyelitis (8.5 y) were older than those with osteoarticular infection at other sites (5.3 y; P<0.0001). CONCLUSIONS: The emergence of CA-MRSA does not explain the increasing incidence of PSI. The incidence of PSI and osteomyelitis involving the axial skeleton are increasing, predominantly in older patients. These trends should be prospectively investigated. LEVEL OF EVIDENCE: III, Prognostic Study.

Classification systems in cerebral palsy.

Because of increasing interest in conducting large-scale, multicenter investigations into the epidemiology of cerebral palsy and its prevention and treatment, efforts have been made to establish a standard definition and classification systems for cerebral palsy. In recent years there has also been increased focus on measurement of functional status of patients and new classifications for gross and fine motor function have been developed. The purpose of this article is to update the orthopaedic community on the current classification systems for patients with cerebral palsy. This information will be of value to surgeons in determining patients' suitability for certain treatments and will also assist them in reviewing current literature in cerebral palsy.

Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy.

A retrospective review was performed of 46 consecutive ambulatory children with cerebral palsy and tibial torsion who underwent 72 distal tibial derotational osteotomies without concomitant fibular osteotomy. The average amount of derotation measured at surgery was 21 +/- 5 degrees. The average change in thigh-foot angle at follow-up was 21 +/- 9 degrees. There were eight perioperative complications (11%): three delayed unions, three superficial wound dehiscences, one case of osteomyelitis, and one superficial pin tract infection. There were no incidences of malunion or nonunion. Preoperative and postoperative three-dimensional gait analysis data were used to determine the effect of distal tibial osteotomy on foot progression angle in seven subjects (11 limbs). Foot progression improved significantly. This study shows that distal tibial osteotomy alone (without concomitant fibular osteotomy) is an effective and safe procedure for correcting and maintaining correction of tibial torsion in patients with cerebral palsy.