Risk factors for pancreatitis after posterior spinal fusion in children with cerebral palsy.

This study reports on the prevalence and risk factors of acute pancreatitis after posterior spinal fusion for cerebral palsy scoliosis. Pancreatitis diagnosis was based on elevated amylase or lipase above three times the upper normal limit. Perioperative data were compared between patients with and without pancreatitis. We included 300 patients; 55% developed acute pancreatitis. Gastrostomy dependence was more common in the pancreatitis group (P=0.048). Perioperative data were similar between groups. Patients with pancreatitis had longer duration of hospitalization (19 vs. 13 days, P<0.001). Acute pancreatitis is common after cerebral palsy scoliosis surgery. Gastrostomy dependence increases its risk. Although no mortality was reported, hospital stay was longer.

Long-term Outcome of Internal Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: External tibial torsion (ETT) is a common bony deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome following TDO to correct ETT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ETT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, E0 MTR, E0 gait velocity, gross motor function classification system (GMFCS) score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 43 legs (with E0 and E2) and 22 legs (with E0, E1, and E2). The mean age at surgery was 10.3±3.4 years (range, 6 to 19.2 y). In the group MTR trended toward improvement moving from -26±17 degrees (E0, external negative) to -16±16 degrees (E1) and relapsed to -23±17 degrees at the long term (P=0.071, E0/E1; P=0.589, E0/E2). Improvement was also seen in the transmalleolar axis (P=0.074), mean ankle rotation, and mean foot orientation (P<0.05, E0/E2). At the long-term evaluation, 16 legs (37%) were found to be in the kinematic corrected group, 25 legs (58%) in the kinematic undercorrected group, and 2 legs (5%) in the kinematic overcorrected group. There were no significant differences between the corrected and undercorrected groups of children with respect to age at surgery, GMFCS, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although internal TDO improves ETT in the short term, recurrence is frequent with an apparent developmental trend toward external rotation of the tibia. LEVELS OF EVIDENCE: Level IV-therapeutic study.

Long-term Outcome of External Tibial Derotation Osteotomies in Children With Cerebral Palsy.

BACKGROUND: Internal tibial torsion (ITT) is a common boney deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome after external TDO performed to correct ITT in ambulatory children with CP. METHODS: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ITT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing the subjects mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, preop MTR (at E0), preop gait velocity (at E0), gross motor function classification system score, and foot deformity were evaluated to determine their influence on long-term results. RESULTS: The study sample consisted of 36 legs (with E0 and E2) and 17 legs (with E0, E1, and E2). The mean age at surgery was 7.4±2.8 (range, 4 to 16.6) years. Comparing the changes over time, kinematic MTR improved from 17±11 degrees initially (E0) to -10±14 degrees short term (E1) and progressed to -23±13 degrees long term (E2) (P<0.05 E0/E1/E2; internal rotation is positive). At E2, 16 legs (44%) were found to be in the kinematic corrected group and 20 legs (56%) in the kinematic overcorrected group. There were no significant differences between the corrected and overcorrected groups of children in respect to age of surgery, gross motor function classification system, E0 MTR, gait velocity, or foot deformity. CONCLUSIONS: Although external TDO is an accepted form of treatment in children with CP, in the long term a tendency to move into external tibial torsion is common. Therefore, caution is warranted with children who initially present with ITT to avoid overcorrection. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Scoliosis in Down's syndrome.

This study reports the recent experience in the management of scoliosis in Down's syndrome. Curve patterns, progression in brace, and surgical outcomes were recorded. Cardiac surgery history was compared between children with and without scoliosis. Out of 581 children with Down's syndrome, 62 children had scoliosis. The mean age of the children was 13.8 years. The mean magnitude was 31°. Bracing was successful in five of seven patients. Ten children had posterior spinal fusion with follow-up of 2.6 years (1-7.3). One deep wound infection was recorded with no revision. No difference was found in cardiac surgery history between children with and without scoliosis. LEVEL OF EVIDENCE: Type IV - prognostic and therapeutic study.

Hallux valgus deformity correction without fusion in children with cerebral palsy.

This study aimed to evaluate the outcomes of nonarthrodesis surgical treatment of hallux valgus (HV) deformity in children with cerebral palsy using radiographic and gait analysis parameters. There were 25 patients who had hallux valgus correction in 39 feet. The mean age at surgery was 15±2.8 years and the mean follow-up duration was 14.6 months. The first metatarsal osteotomy was performed in nine feet, bunionectomy in 25 feet, and Aiken osteotomy in 32 feet. None had metatarsophalangeal joint fusion. We observed a significant correlation between HV correction and other foot and ankle gait parameters. Our study showed correction of HV deformity at short-term follow-up without fusion of the metatarsophalangeal joint. LEVEL OF EVIDENCE: Level IV Therapeutic Studies.

Hip Reconstruction in Children With Unilateral Cerebral Palsy and Hip Dysplasia.

BACKGROUND: Highly functioning children with unilateral cerebral palsy (CP) who have hip involvement (type IV hemiplegia) may present with hip dysplasia during their adolescence. The aim of this report is to assess the outcomes of combined femoral and acetabular reconstruction in this population. METHODS: This study is a retrospective review of all patients with unilateral CP, Gross Motor Function Classification System types I and II, who had hip reconstruction for unilateral dysplasia between 1989 and 2013. Clinical variables (pain and hip passive range of motion) were reviewed. Hip morphology was assessed radiographically according to Melbourne Cerebral Palsy Hip Classification System. Three-dimensional gait analyses were also reviewed to evaluate the effect of surgery on these patients' gaits. RESULTS: Twelve patients were included with a mean age at surgery of 14 years (range, 7 to 19 y) and follow-up mean of 4 years (range, 1 to 8 y). Nine hips were improved according to Melbourne Cerebral Palsy Hip Classification System. Migration percentage decreased significantly (P<0.001) from 45% (30% to 86%) to 15% (0% to 28%). Neck shaft angle decreased (P<0.001) from 144 degrees (range, 129 to 156 degrees) to 125 degrees (range, 114 to 139 degrees). Tonnis angle and Sharp angle also decreased significantly. All patients were pain free at the last visit. Overall level of gait function as measured by Gait Deviation Index and Gait Profile Score [78 (61 to 89) and 12 (8 to 16), respectively] for all patients was maintained without significant changes. CONCLUSIONS: In hemiplegic type IV CP, with high functional level (Gross Motor Function Classification System I and II), hip dysplasia is a rare occurrence during adolescent years. Combined hip reconstruction improves hip morphology, relieves pain, and maintains a high level of function. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Gait Pattern and Lower Extremity Alignment in Children With Diastrophic Dysplasia.

BACKGROUND: The aim of this study was to describe the dynamic lower extremity alignment in children with diastrophic dysplasia (DD) by 3-dimensional gait analyses. Our main hypothesis was that gait kinematics and kinetics are different than the age-normalized population and patellar dislocation can alter the gait in patients with DD. METHODS: A retrospective review of clinical data and radiographs was conducted for patients with DD who had gait analysis before lower extremity skeletal surgery excluding foot procedures. Lower extremity range of motion was measured. The Pediatric Outcomes Data Collection Instrument (PODCI) was administered to parents to evaluate their children's functional status. Gait laboratory data were collected to compare the hip and knee kinematics in cases with and without patellar dislocation. Anteroposterior standing radiographs were taken for all patients to assess the correlation between measurements (clinical, radiologic, and gait) for coronal knee alignment. RESULTS: Thirty lower extremities of 15 children (7 females and 8 males) were evaluated. The mean age was 7.4±3 years, the mean height was 97.7±15 cm (z=-5.1), and the mean weight was 20.6±6.2 kg (z=-0.8). The DD PODCI subscores were statistically significantly lower (P<0.05) than the average stature for developing children, except for the happiness score. Gait analysis, compared between all DD and an age-normalized average stature group, showed decreased forward velocity, step length, and stride length with an increased average forward tilt of the trunk and pelvis, hip flexion, hip adduction, and internal rotation (P<0.001). Delta hip and knee motion were also decreased (P<0.001). The patella was dislocated in 19 (63.3%) and central in 11 (36.6%) knees. Comparison of the minimum knee and hip flexion at the stance phase demonstrated increased crouch gait in the patellar dislocation group (P<0.001). Knee alignment measurements between clinical examination and gait analysis showed moderate correlation (r, 0.476; P=0.008). CONCLUSIONS: Children with DD demonstrated lower PODCI subscores except for happiness. Gait analysis showed limited lower extremity function of the children with DD in our study group. Patella dislocation group had increased crouch gait. LEVELS OF EVIDENCE: Level III-diagnostic study.

Femoral neck stress fracture in children: a case report, up-to-date review, and diagnostic algorithm.

Stress fracture of the femoral neck in skeletally immature individuals is a rare condition and generally seen as compressive type. Because the condition may lead to disastrous complications, femoral neck stress fracture must also be kept in mind in the differential diagnosis of pediatric hip pain. We present a case of compressive-type stress fracture of the femoral neck in a 10-year-old girl with left hip pain that was sustained for 4 weeks and emphasize the difficulty of early diagnosis with only a radiographic evaluation and put forward an algorithm for diagnosis and treatment.

Anatomical evaluation and stress distribution of intact canine femur.

BACKGROUND: In the biomedical field, three-dimensional (3D) modeling and analysis of bones and tissues has steadily gained in importance. The aim of this study was to produce more accurate 3D models of the canine femur derived from computed tomography (CT) data by using several modeling software programs and two different methods. METHOD: The accuracy of the analysis depends on the modeling process and the right boundary conditions. Solidworks, Rapidform, Inventor, and 3DsMax software programs were used to create 3D models. Data derived from CT were converted into 3D models using two different methods: in the first, 3D models were generated using boundary lines, while in the second, 3D models were generated using point clouds. RESULTS: Stress analyses in the models were made by ANSYS v12, also considering any muscle forces acting on the canine femur. When stress values and statistical values were taken into consideration, more accurate models were obtained with the point cloud method. CONCLUSION: It was found that the maximum von Mises stress on the canine femur shaft was 34.8 MPa. Stress and accuracy values were obtained from the model formed using the Rapidform software. The values obtained were similar to those in other studies in the literature.