Synthetic suture tape for medial patellofemoral ligament reconstruction is an effective treatment for complex paediatric patellofemoral instability.

PURPOSE: To assess the outcomes of medial patellofemoral ligament (MPFL) reconstruction using synthetic suture tape in paediatric patients with patellofemoral instability (PFI). METHODS: This ambispective comparative study, conducted from 2014 to 2022, included paediatric patients who underwent MPFL reconstruction with synthetic suture tape and had a minimum follow-up of 1 year. Pre- and postoperative clinical and functional outcomes, patient satisfaction and complications were assessed. RESULTS: The study comprised 22 patients (29 knees), with a median age at surgery of 14.4 years (interquartile range [IQR] 10.9-16.7) and a median follow-up of 46.5 months (24.7-66). Notably, 13 knees (44.8%) had open growth plates at the time of surgery. The cohort included patients with Down syndrome (3 patients), Ehlers-Danlos (2), arthrogryposis (1), generalized joint hypermobility (8) and previous unsuccessful PFI surgeries (8). Concomitant procedures were performed on 16 knees. Postoperatively, improvements were observed in all but one patient, who reported residual pain. There were two other complications: one suture-tape rupture and one surgical wound infection. Functional scores significantly improved: Kujala, +14 points (7-29) (p < 0.001); IKDC, +10.5 points (5.2-25.3) (p < 0.001); Tegner, +2 points (0-4) (p < 0.001); Lysholm, +15 points (0-37.5) (p < 0.001). Most patients achieved excellent outcomes by Crosby-Insall criteria (21 patients, 72.4%) and reported high satisfaction (23 patients, 79.3%). CONCLUSIONS: MPFL reconstruction using synthetic suture tape is a viable and effective treatment for paediatric patients with PFI, particularly for those with connective tissue disorders, generalized joint hypermobility or past surgical failures, significantly enhancing clinical and functional outcomes with an acceptable complication rate. LEVEL OF EVIDENCE: Level IV.

Is reduction necessary in overriding metaphyseal distal radius fractures in children under 11 years: a systematic review and meta-analysis of comparative studies.

OBJECTIVE: To determine the necessity of reduction in the treatment of overriding metaphyseal distal radius fractures (DRF) in children under 11 years. METHODS: In this systematic review and meta-analysis, PubMed, Embase, and Cochrane databases were searched to retrieve studies published from inception to 2023. Two reviewers independently screened for studies with observational or randomized control design comparing two treatments for overriding metaphyseal DRF in patients under 11 years: simple casting without reduction (SC group) versus closed reduction plus casting or pin fixation (CRC/F group); with varying outcomes reported (CRD471761). The risk of bias was assessed using the ROBINS-I tool. RESULTS: Out of 3,024 screened studies, three met the inclusion criteria, 180 children (mean age 7.1 ± 0.9 years) with overriding metaphyseal DRF: SC-group (n = 79) versus CRC/F-group (n = 101). Both treatment groups achieved 100% fracture consolidation without requiring further manipulation. The SC-group showed significantly fewer complications (mean difference [MD] 0.08; 95% CI [0.01, 0.53]; I2 = 22%; P < 0.009) and trends towards better sagittal alignment (MD 5.11; 95% CI [11.92, 1.71]; I2 = 94%; P < 0.14), less reinterventions (MD 0.31; 95% CI [0.01, 8.31]; P < 0.48), and fewer patients with motion limitation at the end of follow-up (MD 0.23; 95% CI [0.03,  1.98]; P < 0.18), although these findings were not statistically significant. CONCLUSIONS: Despite a limited number of studies comparing SC versus CRC/F in overriding DRF in children under 11 years, this study suggests that anatomical reduction is not necessary. Treating these fractures with SC, even when presenting with an overriding position, leads to reduced complications, shows a trend towards fewer reinterventions, improved sagittal alignment, and less limitation in patient motion. LEVEL OF EVIDENCE: Level III, Systematic review of Level-III studies.

Post-traumatic cortical cystic lesions in children: three case reports and a systematic review of the literature.

Post-traumatic cortical cystic lesions are rare radiolucent lesions that appear as a complication of low-severity fractures in children. Their relevance lies in the fact that few cases of these lesions have been described to date, so they are little known among clinicians caring for children. Three case reports of well-circumscribed cortical lytic lesions detected at 2-4 months during the follow-up of non-displaced distal radius fractures in children aged 9, 7, and 2 years are presented. The consistent clinical history and typical radiological features allowed the accurate diagnosis of post-traumatic cortical cystic lesion, without the need for advanced imaging tests or biopsy. At 12-, 8- and 11-month follow-ups, respectively, the lesions either disappeared or decreased in size. This benign and self-limited lesion should be correctly recognized to avoid confusion with other diagnoses, advanced imaging tests or biopsies, and unnecessary parental concerns.

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies.

Purpose: To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Methods: Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Results: Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Conclusions: Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level of evidence: Level III, Systematic review of level III studies.

Scoliosis in Adolescent Patients With Down Syndrome: Correlation Between Curve Magnitude and Functional Level.

STUDY DESIGN: This is a retrospective, observational comparative study. OBJECTIVE: The aim of this study is to determine whether a relationship exists between the functional level and spinal deformity in patients with Down syndrome (DS). SUMMARY OF BACKGROUND DATA: Patients with DS have a higher incidence of scoliosis than the general population; however, it is unknown whether functional level influences the characteristics and severity of the deformity. MATERIALS AND METHODS: Of 649 patients with DS included in a pediatric referral center database, we identified 59 with a diagnosis of scoliosis (59.32% female; mean age, 14.19±1.82 y); the 46 patients who met the inclusion criteria comprised the study cohort. According to their functional gait skills and gross motor skills, they were classified into 2 levels. Different coronal and sagittal parameters were measured using full-spine standing radiographs. The need for surgical treatment and history of thoracotomy were recorded as well. Finally, a multivariate association analysis was performed between radiologic parameters and functional level. RESULTS: Twenty-two patients had a functional level consistent with level I and 24 with level II. Twelve curves were thoracic, 10 thoracolumbar, and 24 lumbar. A statistically significant relationship was found between functional level I and II and curve magnitude: 18.9 degrees (6.8) versus 36.9 degrees (20.3) ( P =0.001) with a cutoff point at 22.3 degrees (area under the curve=0.919, P <0.005, sensitivity=0.917 and specificity=0.818). The relationship between patients who required surgery and level II was also significant ( P =0.016). No relationship was found between functional level and coronal and sagittal balance, nor with other radiologic parameters or with curve location, or between the history of thoracotomy and thoracic curves. CONCLUSIONS: DS adolescents with poorer functional level were associated with larger curves and greater risk for surgery. These findings may provide valuable guidance for the follow-up of scoliosis in patients with DS based on their functional level. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Long-term Impact of Planovalgus Foot on Activities of Daily Living in Patients With Down Syndrome.

INTRODUCTION: Planovalgus foot (PVF) is the most common orthopaedic abnormality in children with Down syndrome (DS), and as a result these patients rarely develop an adequate plantar arch in adulthood. The present study aims to evaluate the impact of PVF on activities of daily living and participation in sports among young adults with DS and determine whether this impact is related to the degree of foot deformity based on clinical and imaging studies. METHODS: Observational analytical study examining a database of 649 patients with DS from a pediatric referral center, identifying those individuals over age 20 years at the time of the study with a childhood diagnosis of PVF. Finally, 51 patients (102 feet) were evaluated based on clinical and imaging studies, and function was assessed using the The Foot and Ankle Outcome Score (FAOS) and the Visual Analogue Scale (VAS) pain scale. A correlation analysis was performed to determine the clinical and radiographic variables associated with functional outcomes. Linear regression models were obtained to quantify the impact of these variables on function. RESULTS: Patients had a mean age of 26.14±3.88 years and body mass index of 24.51±4.57. Clinically, 63.65% presented grade 3 or 4 PVF, and most were flexible. Radiographically, midfoot flattening was mild-moderate in 92.16%, 58.82% had medial talo-navicular uncoverage, and 30.39% had an increased hallux valgus (HV) angle. Mean scores for all FAOS subscales were between 65 and 71% and the mean VAS score was 1.45±1.96. An association analysis revealed a tendency toward lower scores on all FAOS subscales and greater pain according to the VAS scale in more severe PVF and in cases of moderate HV with asymmetry between feet. Linear regression models showed that major contributors to functional scores were radiographic evidence of hindfoot valgus, midfoot abduction, and flattening, and HV. CONCLUSIONS: Young adults with DS who are diagnosed with PVF in childhood have acceptable functional scores and low pain. Alteration of radiographic parameters toward flatter, more valgus and abducted feet and greater and asymmetric HV tend to be associated with worse long-term functional scores in activities of daily living and sports participation and increased pain. Therefore, non-operative management of these patients is justified, although individualized treatment is recommended. LEVEL OF EVIDENCE: Level IV, Case series.

Is There a Relationship Between the Functional Level of Juvenile and Adolescent Patients With Down Syndrome and Hip Dysplasia?

BACKGROUND: The prevalence of hip dysplasia among patients with Down syndrome (DS) is higher than in the general population. We hypothesize that a relationship may exist between functional level and hip dysplasia in DS, but this has not been studied to date. The aim of this study is to evaluate whether there is a relationship between functional level and radiographic parameters of hip dysplasia or other measures. METHODS: Retrospective cross-sectional comparative study of 652 patients with DS from a pediatric referral center database. Patients over 8 years of age with an anteroposterior pelvis radiograph and with no exclusion criteria were selected, totaling 132 patients (264 hips; 54.55% females; mean age 12.96 ± 2.87 y). Several radiographic parameters of the acetabulum [Sharp angle (SA), Tönnis angle (TA), Wiberg center-edge angle (W-CEA), extrusion index (EI), and acetabular retroversion signs], the proximal femur [neck shaft angle (NSA)], and joint congruence [Shenton line (SL)] were assessed. Patients were classified into 2 levels based on functional skills. A multivariate association analysis was performed between radiographic parameters and functional level. RESULTS: Sixty-one patients were compatible with a functional level I and 71 with a level II. Forty-six hips were dysplastic and 60 were borderline according to the W-CEA. A statistically significant relationship was found between the categorical distribution of certain radiographic measurements of hip dysplasia (EI, SA, TA, W-CEA, SL, and classification by functional level ( P < 0.0005). A significant receiver operating characteristic curve was obtained for W-CEA with a cutt-off point at 26.4 degrees for level I (area under the curve = 0.763; P < 0.005; sensitivity = 0.800 and specificity = 0.644). There was a fairly high correlation between EI and TA (0.749; P < 0.0005), EI and W-CEA (-0.817; P < 0.0005), and TA and W-CEA (-0.748; P < 0.0005). Numerous hips showed signs of acetabular retroversion, with no significant differences found between functional levels or association with hip dysplasia measures. CONCLUSIONS: The present study reveals a relationship between an increased risk of hip dysplasia and reduced functional levels in DS children older than 8 years. These findings may guide individualized clinical follow-up of hip development in DS children considering their functional level. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Parálisis del nervio radial neonatal: relato de un caso / Isolated radial nerve palsy in a newborn: case report

La parálisis radial neonatal aislada (PRNA) es un cuadro clínico infrecuente que debe distinguirse de otras entidades más frecuentes, como la parálisis braquial obstétrica (PBO). Debemos sospechar una PRNA en neonatos que presentan incapacidad para la extensión de muñeca y de dedos, pero mantienen intacta la función del deltoides, del bíceps, y del tríceps, así como la flexión de muñeca y de dedos. Mientras la PBO tiene una evolución clínica variable dependiendo de la extensión de la lesión neurológica, la PRNA presenta una resolución espontánea, independientemente del grado de afectación inicial. Presentamos el caso de un recién nacido con PRNA cuyo diagnóstico inicial fue de PBO.

Isolated radial nerve palsy (IRNP) in the newborn is a rare clinical condition that must be distinguished from entities that are more common, such brachial plexus birth palsy (BPBP). It should be suspected in newborns presenting with absent wrist and digital extension but intact deltoid, biceps, and triceps function, as well as wrist and digital flexor function. Whereas BPBP is highly variable depending on the extent of the neurological involvement, IRNP resolves spontaneously, regardless of the severity of the initial presentation. We herein present a case of newborn with IRNP whose initial diagnosis was of BPBP.

Long-term Outcomes of Talonavicular Arthrodesis for the Treatment of Planovalgus Foot in Children With Cerebral Palsy.

BACKGROUND: Planovalgus foot (PVF) in cerebral palsy (CP) tends toward progression and rigidity in adolescence, especially in patients with greater functional impairment. Deformity at the talonavicular joint justifies the use of talonavicular arthrodesis as a corrective surgical technique. This study aims to assess patient or caregiver functional satisfaction and radiographic outcomes of talonavicular arthrodesis for PVF in CP patients with assisted ambulation in the long-term. METHODS: Retrospective comparative study of level III and level IV pediatric CP patients who underwent talonavicular arthrodesis for PVF between 1999 and 2010 as part of multilevel surgery and with a minimum follow-up of 10 years. Radiologic correction at 10 years was compared with preintervention values, and functional impact at 10 years was measured by the foot function index (FFI); correlation between radiologic measurements and FFI were obtained, and complications were recorded. RESULTS: Forty-nine PVFs in 25 patients with CP (72% level III and 28% level IV) were included; 52% were male. The patients had a median age of 12 years at the time of surgery (range: 11 to 15) and 23 years at the time of the study (21 to 26). Significant (P<0.01) pre-post radiologic improvements were obtained in Meary angle (37.86±10.7/8.37±5.5 degrees), calcaneal pitch (3.20±8.1/13.22±5.6 degrees), lateral talocalcaneus angle (42.18±12.1/25.29±2.9 degrees), Moreau-Costa-Bartani angle (167.04±8/146.12±7.1 degrees), talus-first metatarsal angle (27.92±13.9/9.69±4.4 degrees), anteroposterior talocalcaneal angle (37.61±7.4/22.61±2.4 degrees), and talus coverage angle (37.04±11.11/2.45±2.5 degrees). At 10 years postoperatively, functional outcome measured with the FFI was satisfactory (33.9±15.2%) and the mean maximum pain was 3.04; 56% of cases had mild pain. All patients were able to wear an ankle-foot orthosis and 8 no longer needed the device. A significant correlation was found between the talofirst metatarsal angle and the FFI (P=0.024). There were 8% of cases with screw protrusion and 14% presented pseudarthrosis, most of them asymptomatic. CONCLUSIONS: The adequate functional outcome, as well as the persistence of long-term radiologic correction and acceptable number of complications, enables us to recommend talonavicular arthrodesis as an alternative treatment to consider in level III and level IV CP patients with PVF. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

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 / Evaluation of function and limiting factors of gait disorder treatment in cerebral palsy: development of the Walking Abilities Levels Classification System

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

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

Prolonged stretching of the ankle plantarflexors elicits muscle-tendon adaptations relevant to ankle gait kinetics in children with spastic cerebral palsy.

Tissue related ankle hyper-resistance has been reported to contribute to equinus gait in children with spastic cerebral palsy. Hence, ankle plantarflexor stretching programs have been developed in order to restore passive ankle dorsiflexion. Despite high quality evidence on the limited effects of stretching on passive joint mobility, further muscle-tendon adaptations have been reported which may impact gait performance. As such, children with spastic cerebral palsy subject to long-term manual static stretching achieved dorsiflexion gains through the reduction of muscle and fascicle strain whilst preserving tendon strain, and prolonged use of ankle-foot orthoses achieved similar dorsiflexion gains through increased tendon strain whilst preserving muscle and fascicle strain. The latter concurred with normalization of early stance plantarflexor moment yet reductions in push-off plantarflexor moment given the increase in tendon compliance. Therefore, similar limited gains in passive ankle joint mobility in response to stretching may be achieved either by preserving/restoring optimal muscle-tendon function, or at the expense of muscle-tendon function and thus contributing gait impairments. The largest increase in ankle passive joint mobility in children with SCP has been obtained through prolonged plantarflexor stretching through ankle casting combined with botulinum neurotoxin type A. However, to our knowledge, there are no published studies on muscle-tendinous adaptations to ankle casting combined with botulinum toxin type A and its effect on ankle joint gait kinetics. Therefore, we hypothesized that ankle casting elicits muscle-tendon adaptations which concur with altered ankle joint kinetics during the stance phase of gait in children with SCP. More information is needed about the relationships between muscle structure and function, and the effect of specific interventions designed to alter muscle properties and associated functional outcomes in children with spastic cerebral palsy.