Early Bony Hip Reconstructive Surgery for Hip Subluxation in Children With Severe Cerebral Palsy.

Hip subluxation occurs frequently in children with severe cerebral palsy. This retrospective study examined the effects of age and type of bony surgery on radiographic outcomes of children with severe cerebral palsy who were treated for hip subluxation. The study included nonambulatory children with cerebral palsy undergoing bony hip reconstructive surgery consisting of proximal femoral varus derotational osteotomy (VDRO) alone or combined with pelvic osteotomy. The migration index was recorded for preoperative, postoperative, and final follow-up (minimum 2 years) radiographs. Failure was defined as subsequent bony hip reconstructive surgery or final follow-up migration index greater than 50%. Seventy-seven hips in 40 patients younger than 6 years (55 VDRO alone, 22 combined) and 73 hips in 43 patients older than 6 years (27 VDRO alone, 46 combined) met inclusion criteria. For VDRO alone, the failure rate for patients younger than 6 years (33%) was significantly higher than for patients older than 6 years (7%). For combined procedures, failure rates between younger (0%) and older groups (9%) were not significantly different. Patients younger than 6 years undergoing combined procedures started with a significantly worse migration index than patients undergoing VDRO alone, 72% vs 46%, yet had significantly better final migration indices of 13% vs 31%, respectively. For surgeons performing bony reconstructive surgery to treat hip subluxation in younger children with severe cerebral palsy who are nonambulatory, the findings of this study support the use of combined VDRO and pelvic osteotomy. [Orthopedics. 2021;44(2):e294-e300.].

Bilateral Patellar Stress Fractures in a Skeletally Immature Athlete: A Case Report.

CASE: This report describes the divergent course and management of bilateral patellar stress fractures in a 17-year-old skeletally immature male athlete. Beginning as bilateral incomplete tension-sided patellar fractures, the right patella healed uneventfully, whereas the left progressed to a complete, mildly displaced transverse fracture that eventually healed with nonoperative treatment measures to include temporary bracing, physical therapy, and vitamin D supplementation. CONCLUSIONS: Patellar stress fractures are exceptionally rare, particularly bilateral injuries in the pediatric population. Diligent workup is necessary for appropriate diagnosis, whereas knowledge of the salient features of these injuries is useful in treatment.

Secondary Surgery Rates After Primary Fusion for Adolescent Idiopathic Scoliosis.

Instrumented spinal fusion is the gold standard treatment for surgical magnitude adolescent idiopathic scoliosis (AIS), with the goal being stable fusion without the need for additional procedures. The purpose of this study was to define the surgical return rates of AIS at a single center with respect to various instrumentation constructs used during initial spinal fusion. A retrospective chart review was performed of all patients with AIS who underwent instrumented fusion with a minimum of 2-year follow-up. Demographic information, implant type, and surgical approach for the primary surgery and all subsequent secondary operations were recorded. Four hundred eleven patients who underwent instrumented fusion for AIS during the study period met inclusion criteria. Sixty-six secondary operations were performed in 50 patients (12.2%). Symptomatic hardware, pseudarthrosis, and infection were the most common indications for secondary surgery. Posterior pedicle screw constructs had a lower secondary surgery rate (5.8%) compared with hybrid and combined fusions (P<.05). The all hook, hybrid, anterior only, and combined fusions had secondary surgery rates of 13.0%, 18.5%, 10.0%, and 20.8%, respectively, which were not statistically different. When specifically comparing pedicle screw with hook constructs, there was a statistically lower pseudarthrosis rate (P=.03) favoring pedicle screw instrumentation. Patients undergoing instrumented fusion for AIS are at some risk for subsequent surgery. To lessen that risk, pedicle screw constructs should be considered, as they have shown an overall lower secondary surgery rate and in particular a lower rate of pseudarthrosis. [Orthopedics. 2019; 42(4):235-239.].

Long term gait outcomes of surgically treated idiopathic toe walkers.

Toe walking is a common gait deviation which in the absence of a known cause is termed idiopathic toe walking. Surgical treatment in the presence of a triceps surae contracture includes tendo-Achilles or gastrocnemius/soleus recession and has been shown to be effective in improving kinematic outcomes at a one year follow up. The purpose of this study was to assess longer term kinematic and kinetic outcomes of children with idiopathic toe walking treated surgically for gastrocnemius/soleus contractures. Eight subjects with a diagnosis of idiopathic toe walking who had surgical lengthening of the gastrocnemius/soleus and had previous motion analysis laboratory studies pre-operative and 1 year post-operative, returned for a motion analysis laboratory study greater than 5 years since surgery. Subjects completed lower extremity physical exam and 3-D computerized kinematics and kinetics. Significant improvements for mean pelvic tilt, peak dorsiflexion in stance and swing, and overall kinematics index at 1 year post-operative were maintained at 5 years post-operative. Kinetic variables of ankle moment and power were improved at 1 year and 5 years post-operative. On physical exam, dorsiflexion with knee extended was tighter from 1 to 5 year follow-up which did not correspond to the functional changes of gait. Idiopathic toe walkers who were treated surgically for triceps surae contractures showed significant improvements in key kinematic and kinetic gait analysis variables at 1 year post-operative that were maintained at 5 years post-operative. Overall, subjects were satisfied with outcomes of the surgery, unrestricted in activities, and reported minimal pain.

Lumbar spine duplication: a case report.

Duplication of the spine is a rare malformation. A neurologically intact pediatric patient with this malformation is described here. A 6-year-old girl presented to our institution for evaluation of an asymptomatic kyphotic deformity. She denied weakness, sensory changes, and bowel or bladder complaints. Physical examination revealed mild kyphosis at the thoracolumbar junction with normal gait and neurologic function. Radiographs demonstrated duplication of the lumbar spine and sacrum. Computed tomography, MRI, and abdominal ultrasound results are reported. As she is neurologically normal, we will continue to observe this patient and intervene in the case of development of neurologic impairment or worsening kyphosis.

Outcomes of Orthopaedic Surgery With and Without an External Femoral Derotational Osteotomy in Children With Cerebral Palsy.

BACKGROUND: Ambulatory children with cerebral palsy (CP) often present with multiple deviations in all planes including increased internal hip rotation during gait. Excessive femoral anteversion is a common cause of deviation managed surgically with an external femoral derotational osteotomy (FDO). The purpose of this study was to evaluate the gait and functional outcomes of a group of subjects with CP who underwent surgical intervention that included an FDO compared with a match group with indications of internal hip rotation that did not receive an FDO. METHODS: For this retrospective study, subjects were identified from the Motion Analysis Laboratory database that had orthopaedic surgery including an FDO (FDO group). A control group was established from a chart review identifying subjects that had indications for an FDO, but did not have this surgery (No-FDO group). All subjects had preoperative and postoperative gait studies. Subjects categorized as Gross Motor Function Classification System (GMFCS) levels I and II in both FDO and No-FDO groups were combined for analysis. Subjects rated as GMFCS level III were analyzed separately. Preoperative to postoperative kinematic and kinetic variables, Gait Deviation Index, net oxygen cost, and PODCI scores were analyzed with paired t tests. RESULTS: Typical sagittal plane kinematic variables improved significantly by equivalent magnitudes for both FDO and No-FDO groups (GMFCS I/II and III). Transverse plane improvements were only seen for the FDO group (GMFCS I/II and III). The Gait Deviation Index, an overall index of kinematics, improved by a significantly greater amount for the FDO group across GMFCS levels I/II and III. Net oxygen cost improved for both FDO and No-FDO for GMFCS I/II. PODCI scores improved for FDO and No-FDO in GMFCS I/II, but only the FDO group for GMFCS III. CONCLUSIONS: For children with CP, inclusion of an FDO in the surgical intervention, when indicated, resulted in improved outcomes. Overall gait kinematic improvements were significantly greater when an FDO was included in the surgical management. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

A comparison of cell salvage strategies in posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To compare the efficacy of 3 blood management strategies in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) in reducing donor blood transfusion. SUMMARY OF BACKGROUND DATA: Although intraoperative cell salvage and predonated banked blood may be effective in reducing donor blood transfusion in the perioperative period, the optimal blood management strategy is unclear. A combined cell salvage strategy holds several potential advantages but has not yet been investigated. METHODS: Patients who underwent isolated PSF for AIS (n=167) were subdivided into 3 groups by perioperative blood management strategy: (1) intraoperative retransfusion of shed blood (cell saver) and predonated autologous banked blood (n=51); (2) cell saver alone (n=33); and (3) combined cell saver and postoperative collection and retransfusion of drained blood (Retransfusion drain) (n=83). Data collected included age, sex, diagnosis, body weight, number of levels fused, operative time, intraoperative and postoperative blood loss and retransfusion, preoperative and postoperative (72 h) hemoglobin and hematocrit (Hct), and amount of autologous and donor blood transfused in the perioperative period. RESULTS: Fewer patients in the cell saver and predonated blood (3.9%) and cell saver and retransfusion drain (1.2%) groups received donor transfusions than did those managed with cell saver alone (33%). There was no significant difference in the donor transfusion rate between cell saver/predonated blood and retransfusion groups. Mean postoperative Hct (72 h) was higher in the retransfusion group 3 than in the other 2 (group 3: 29.3%, group 1: 25.4%, group 2: 26.1%). There was no significant difference in the mean change in hemoglobin and Hct after surgery between the 3 groups. CONCLUSIONS: The present study demonstrates the efficacy of a combined intraoperative and postoperative cell salvage strategy in PSF for AIS, significantly reducing perioperative donor blood transfusions, maintaining physiological Hct, and conserving blood bank resources.

Gait outcomes of patients with severe slipped capital femoral epiphysis after treatment by flexion-rotation osteotomy.

BACKGROUND: Flexion-rotational osteotomy of the proximal femur is an accepted intervention in the management of severe deformity and femoral acetabular impingement secondary to slipped capital femoral epiphysis (SCFE). The impact of this surgical intervention on gait kinematics and kinetics, validated functional questionnaires, and patient outcomes has not been well studied. The purpose of this study was to analyze the changes in standard gait parameters of patients with moderate to severe SCFE who were treated with a flexion-rotational osteotomy. METHODS: This study is a retrospective review of 8 patients treated for a unilateral moderate and severe SCFE with a flexion-rotational osteotomy. All patients had 3-D computerized gait analysis studies completed preoperatively and 1-year postoperatively. Additional data analyzed preoperatively and postoperatively included: anterior/posterior hip radiographs, standard physical examination measures, and Pediatric Outcomes Data Collection Instrument (PODCI), completed by parents. RESULTS: The Gait Deviation Index, a composite of gait kinematics, showed a significant improvement from 64.9 to 88.0 (P<0.001). Radiographically, significant improvement toward normal values were found in the epiphyseal-shaft angle on the AP view from 123 to 139 degrees (P=0.005) and on the frog lateral view from 61 to 16 degrees (P=0.00001). Hip abduction range of motion on physical examination increased from 15 to 27 degrees and hip external rotation decreased from 51 to 25 degrees after surgery (P<0.05). The PODCI significantly improved in the categories of basic mobility, sports function, and global function (P<0.05). CONCLUSIONS: Longstanding deformity as a result of a severe SCFE may lead to osteoarthritis of the hip, disabling pain, and functional deficits. Although radiographic evidence of degenerative disease may take years to develop, changes in gait parameters can be immediately evident in this population. A flexion-rotation osteotomy in the adolescent and young adult population can improve gait kinematics, radiographic measures, range of motion, and short-term functional outcome scores. It is felt that normalization of these parameters may reduce the risk of long-term hip deterioration and its related sequelae. LEVEL OF EVIDENCE: Level IV.

Outcomes of rectus femoris transfers in children with cerebral palsy: effect of transfer site.

BACKGROUND: Distal rectus femoris transfer is a widely accepted and effective treatment for children with cerebral palsy presenting with stiff knee gait. Previous research has reported improvement in knee arc of motion regardless of transfer site; however, sample sizes and patient function were unmatched in these studies. The purpose of this study was to compare the outcomes of children with cerebral palsy treated with a distal rectus femoris transfer for stiff knee to 1 of 3 sites: medial to the semitendinosus (ST), medial to the sartorius (SR), or lateral to the iliotibial band (ITB). Sample sizes in the 3 groups were equal and matched by gross motor function of the subjects. METHODS: The motion analysis laboratory database was queried for subjects who had a rectus femoris transfer with preoperative and postoperative gait studies. The ITB group, 14 subjects (20 limbs), was the smallest group of subjects identified. The ITB group established the sample size for SR and ST groups, which originally had larger sample sizes, but were matched to reflect similar proportions of Gross Motor Functional Classification System Level to the ITB group. RESULTS: There were no significant differences between the 3 rectus femoris transfer groups preoperatively on knee gait variables (P>0.05). Comparison of preoperative to postoperative data demonstrated significant gait improvements in knee arc of motion for the ITB, SR, and ST groups (11 , 12, and 12 degrees, respectively) (P<0.05). There were also significant improvements in timing of peak knee flexion in swing phase and knee extension at initial contact for all 3 groups, but no significant difference was seen between preoperative and postoperative when groups were compared against one another for these measures. CONCLUSIONS: Distal rectus transfer continues to be an effective procedure for treating stiff knee gait in cerebral palsy. The location site of the transfer resulted in equally beneficial outcomes; therefore, the transfer site location can be based on surgeon preference and concomitant procedures. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

Gross motor development in babies with treated idiopathic clubfoot.

PURPOSE: To investigate the effect of treated clubfoot disorder on gross motor skill level measured by the Alberta Infant Motor Scale (AIMS). METHODS: Fifty-two babies participated: 26 were treated for idiopathic clubfoot (12 with the Ponseti treatment method, 9 with the French physical therapy technique, and 5 with a combination of both methods); 26 were babies who were typically developing and without medical diagnoses. The AIMS was administered at 3-month intervals. RESULTS: No significant differences in AIMS scores were found between the clubfoot and control groups at 3 and 6 months, but at 9 and 12 months the clubfoot group scored significantly lower. Babies who were typically developing were significantly more likely to be walking at 12 months than babies with clubfoot. CONCLUSIONS: Treated clubfoot was associated with a mild delay in attainment of gross motor skills at 9 and 12 months of age.

Safety of percutaneous tendoachilles tenotomy performed under general anesthesia on infants with idiopathic clubfoot.

BACKGROUND: Most patients with idiopathic clubfeet require a percutaneous tendoachilles tenotomy to correct residual equinus deformity. This procedure is typically performed with the child awake in an outpatient setting. Percutaneous tendoachilles tenotomy under general anesthesia offers the potential advantages of better pain control, the ability to perform the procedure in a more controlled manner, and the possibility of lessening the pain response of the infant. Potential disadvantages include concerns regarding the safety of general anesthesia in infants. The purpose of this study is to review the safety of this procedure performed in the operating room under general anesthesia. METHODS: A retrospective review was carried out of patients with idiopathic clubfoot less than 1 year of age who underwent percutaneous tendoachilles tenotomy under general anesthesia from 2000 to 2008. Patient medical records were reviewed for gestational age, age at surgery, risk factors for anesthesia, and surgical/anesthesia-related complications. To be discharged on the day of surgery, patients met the accepted criteria. Children at risk for apnea were considered for overnight observation using established criteria of postconception age under 44 weeks, premature birth, pulmonary comorbidities, and history of an apneic event. RESULTS: One hundred and thirty-seven patients underwent a total of 182 tenotomies under general anesthesia. Ninety-two tenotomies were unilateral, 45 were bilateral. The average postconception age at time of surgery was 53.9 weeks (range, 41 to 90 wk, SD 9.8 wk). Eighty-nine patients were under 3 months of age. Twenty-one patients (15.3%) met the criteria for the observation for postoperative monitoring for apnea because of postconception age under 44 weeks or gestational age under 37 weeks. Three patients were admitted overnight because of a maternal history of drug abuse. No patients had earlier apneic events or were American Society of Anesthesiologists Class III for comorbidities. No patient showed apnea or anesthesia-related complications. CONCLUSIONS: Percutaneous tendoachilles tenotomy under general anesthesia can be safely performed in infants with clubfeet. No complications related to anesthesia were identified in this group and nearly all patients were discharged on the day of surgery. LEVEL OF EVIDENCE: Prognostic level 3.

Range of motion measures under anesthesia compared with clinical measures for children with cerebral palsy.

The purpose of this study was to determine whether there is a difference in range of motion at the ankle and knee when measured in the clinic versus under anesthesia for ambulatory children with cerebral palsy. Dorsiflexion and popliteal angle were measured on 70 limbs in the clinic and under surgical anesthesia with the assessor blinded. For the group of patients under 11 years of age, dorsiflexion with the knee flexed significantly increased a mean of 9.5 degrees (P<0.05) and with the knee extended significantly increased 8.5 degrees when patients were under anesthesia compared with the clinical measures. Dorsiflexion angles did not change significantly between the two conditions for the group of patients older than 11 years of age. Mean popliteal angle did not change significantly between the two conditions for either age group.

Gait analysis outcomes of percutaneous medial hamstring tenotomies in children with cerebral palsy.

BACKGROUND: Hamstring lengthening procedures are commonly performed on children with cerebral palsy (CP) to improve gait. The purpose of this study was to determine the efficacy of percutaneous hamstring tenotomy surgery for children with ambulatory CP. METHODS: In this retrospective study, subjects were included if they had a diagnosis of CP and had computerized gait analysis data collected before and after surgery. Subjects were not included in the study if they had any open hamstring lengthening on the same side. Other concomitant lower extremity surgeries were not exclusionary. Short- and long-term follow-up groups were established: if the time from their surgery to their gait laboratory was less than 18 months, they were placed in the short-term follow-up group, and if the time from their surgery to their gait laboratory was greater than 18 months, they were placed in the long-term follow-up group. RESULTS: The results demonstrated that for short- and long-term groups on preoperative to postoperative analysis, there was significantly improved knee extension at initial contact, increased velocity, increased stride length, improved overall gait as indicated by a decrease in a 16 variable multivariate index (Gillette Gait Index), and a decreased popliteal angle. For the short-term group only, additional significant findings included increased peak knee extension in stance and reduced plantar flexion at initial contact. The absolute values of peak knee extension in stance and plantar flexion at initial contact were equivalent at follow-up for the short- and long-term groups. Increased anterior pelvic tilt was also significant for the short-term follow-up group only. CONCLUSIONS: The findings of this study demonstrate that the minimally invasive technique of percutaneous hamstring tenotomy is effective in improving key dynamic gait parameters for individuals with CP for a short period, and these benefits are maintained in the long term. LEVEL OF EVIDENCE: Level IV.

The pediatric outcomes data collection instrument detects improvements for children with ambulatory cerebral palsy after orthopaedic intervention.

The purpose of this study was to assess whether the Pediatric Outcomes Data Collection Instrument (PODCI) was able to detect changes in function, as perceived by the parents of children and adolescents with cerebral palsy who had undergone lower limb soft tissue and/or bony surgeries. This was a retrospective study of 80 ambulatory patients who were seen in the motion laboratory and classified with the Gross Motor Functional Classification System (GMFCS). Significant changes (P < 0.05) were detected in the PODCI scores for upper extremity function, transfers and mobility, physical function and sports, and global function after surgery, by approximately 4% to 5%, whereas comfort (pain-free) did not significantly change. There was a significant difference in the PODCI scores preoperatively between GMFCS levels I, II, and III for upper extremity function, transfers and mobility, physical function and sports, and global function. Postoperative improvements were of equal magnitude for each GMFCS level. This suggests that the PODCI did not have a ceiling effect for high-functioning children. Age (+/-10 years) and surgery (soft tissue/soft tissue plus bony) were not significant factors for any of the subcategories preoperative to postoperative. In conclusion, the PODCI detected improvement as perceived by the parents in ambulatory children with cerebral palsy after lower-limb soft tissue and/or bony surgeries in 4 areas by a magnitude of approximately 4% to 5%.

Comprehensive outcomes of surgically treated idiopathic toe walkers.

The treatment of idiopathic toe walking in children can include surgical lengthening of the gastrocnemius/soleus complex after conservative options have been ineffective. Previous outcome reports of surgery for idiopathic toe walkers have largely been limited to assessing the sagittal plane motion of dorsiflexion/plantar flexion with minimal quantitative preoperative and postoperative analysis. The purpose of this study was to comprehensively assess the outcome of idiopathic toe walkers that had been treated surgically. Fourteen children seen in our motion analysis laboratory that underwent gastrocnemius or tendo-Achilles lengthening for idiopathic toe walking were retrospectively reviewed. Preoperatively, this group had significantly greater anterior pelvic tilt than normal, decreased peak knee flexion in swing, greater external foot progression, and the expected increased plantar flexion (P < 0.01). Postoperatively, anterior pelvic tilt decreased by a mean of about 4 degrees (P < 0.01), only for the group that had tendo-Achilles lengthening because the gastrocnemius group was close to normal preoperatively, and peak knee flexion normalized. The foot progression angle of this group did not change from preoperative values and remained significantly more external than normal, although dorsiflexion in stance significantly improved after surgery (indicating the goal of the surgery was achieved). Increased external foot progression in idiopathic toe walkers is apparently due to increased external tibial torsion and/or external hip rotation but was unaffected by gastrocnemius/soleus surgical lengthening. Significant improvement occurred on an overall index of gait variables, indicating surgery can be an effective treatment of idiopathic toe walkers.

Proximal rectus femoris release surgery is not effective in normalizing hip and pelvic variables during gait in children with cerebral palsy.

The purpose of this study was to determine the efficacy of the proximal rectus femoris release to treat hip flexor contractures and hip and pelvic gait deviations in children with spastic cerebral palsy. This study was a retrospective repeated-measures analysis of data collected on two matched groups of patients, those with and without proximal rectus femoris release surgery, seen in our Motion Analysis Laboratory. Proximal rectus release surgery did not improve hip extension, did not decrease anterior pelvic tilt, and did not improve temporal-distance measures of gait in children with cerebral palsy. A multivariate measure, the Hip Flexor Index, was also unchanged. The group of patients without any hip flexor surgery was not different from the rectus femoris release group on hip or pelvic variables before or after surgery. The findings of this study offer no evidence that the proximal rectus femoris release is successful in achieving desired gait outcomes at the hip and pelvis in children with cerebral palsy.

Findings of fibular hemimelia syndrome with radiographically normal fibulae.

We have noted a number of patients with features of fibular hemimelia with radiographically normal fibulae. This study was undertaken to further define this group. A review of hospital records and radiographs over a 72-year period identified 149 limbs in 123 patients with features of fibular hemimelia syndrome. Sixteen limbs in fourteen patients had findings of fibular hemimelia with radiographically normal fibulae. Thirteen of 16 had absent lateral rays with either ball and socket ankle joint, tarsal coalition or both. Six of the 13 had limb shortening. Three limbs in three patients did not have absent lateral rays, but had at least two other features of fibular hemimelia syndrome. All of these three limbs had ball and socket ankles and tarsal coalitions and two had shortening. These patients represent a mild subset of fibular hemimelia syndrome and we propose that they be classified as type 0 fibular hemimelia.

Lateral subtalar dislocation in a 19-month-old female.

We report a lateral subtalar dislocation in a female 19-month-old after a minor fall. Review of the literature reveals no prior report of this injury in a patient of this age. This case illustrates the importance of thoroughly examining the pediatric patient. When fracture is not diagnosed and a child refuses to use the affected extremity, examination to rule out occult fracture or dislocation must be included.

Association of fibular hemimelia and clubfoot.

This study was designed to determine the incidence of clubfoot in our fibular hemimelia population. A retrospective review of fibular hemimelia patients treated at our institution over the past seventy years was conducted. We identified twenty-three cases of clubfoot in 121 patients with 147 involved limbs. Nineteen of twenty-three limbs retained the foot, four were converted to Syme's amputation because a plantigrade functional foot could not be obtained. Hindfoot coalitions were present in eighteen limbs and nineteen had one or more missing lateral rays. In summary, the association of clubfoot deformity with fibular hemimelia is more common than previously reported. It was not always evident to the surgeon treating these patients that fibular hemimelia syndrome was present in addition to clubfoot deformity. The presence of a coalition is a relatively constant finding in this condition and should be anticipated by the treating clubfoot surgeon.