Guided Growth of the Proximal Femur for the Management of Hip Dysplasia in Children With Cerebral Palsy.

BACKGROUND: Progressive hip displacement is one of the most common and debilitating deformities seen in children with cerebral palsy (CP). The aim of this study was to evaluate the results of temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF) using a transphyseal screw to control hip migration during growth in children with CP. METHODS: This was a retrospective study of children with CP and hip dysplasia, age 4 to 11 years and GMFCS levels III-V. There were 28 patients with 56 hips that underwent TMH-PF surgery between 2007 and 2010. Clinical and radiologic evaluation was performed preoperatively, at 6, 12, and 60 months following the index surgery. Acetabular index (AI), neck-shaft angle (NSA) and migration percentage (MP) were measured. All complications were recorded. RESULTS: All radiographic measurements were significantly improved at the final follow-up. Positive correlations were found between NSA, MP, and AI. Multiple regression analysis revealed that MP, time from surgery, and age were influenced by the decrease of the NSA. The femoral physis grew off the screw in 9 hips within 36 months. The screw head broke during attempted screw exchange in 1 hip. The remain cases (4 hips) were treated by placing a second screw parallel to the existing one. Finally, progressive subluxation occurred in 3 hips when the physis grew off the screw and were treated by skeletal reconstruction. CONCLUSIONS: TMH-PF was effective in controlling progressive subluxation of the hip in the majority of cases, obviating the need for major reconstructive surgery in these children with CP. LEVEL OF EVIDENCE: Level IV.

Impact of Orthopedic Surgery on Parents of Children Affected by Cerebral Palsy: a Preliminary Study in Greece.

BACKGROUND: Cerebral palsy (CP) is a serious disorder with an important impact not only on the affected person but also on parents and the entire family. CP children often undergo surgery with long stay hospitalization. AIM: The aim of the study was to highlight the impact of orthopedic surgery on parents of children affected by cerebral palsy in Greece. MATERIALS AND METHODS: The semi-structured interviews of 80 parents (40 fathers and 40 mothers) of nuclear and intact families were collected. All parents were of Greek nationality, belonged to the middle socio-economic class and had at least one child affected by CP candidate to orthopedic surgery. RESULTS: The majority of parents' perception was that CP is a condition requiring special education, need for specialized services and a medical problem that affects the entire family. Their expectations after orthopedic surgery were focused mainly on child's healing and hope to have a "healthy" child, while expectations from future surgery were focused on improving child's quality of life, movement and gait. CONCLUSIONS: Parents of CP children have different perceptions of the clinical condition and a variety of expectations about orthopedic surgery and its outcomes.

Effect of plano-valgus foot posture on midfoot kinematics during barefoot walking in an adolescent population.

BACKGROUND: Plano-valgus is a common alteration of the paediatric foot, characterized by valgus hindfoot, foot pronation and drop of the medial longitudinal arch. Despite their importance in the diagnosis and classification of plano-valgus foot condition, little information is available on functional alterations of the major joints spanning the medial longitudinal arch - i.e. midtarsal and tarso-metatarsal. Aim of the study was to provide objective description of the alterations in plano-valgus midfoot joints with respect to those in an age-matched normally-developed feet population. METHODS: Twenty adolescents (13.3 ± 0.8 years) with bilateral plano-valgus feet underwent clinical examination and were gait-analysed via a validated 4-segment foot model. This allowed to measure static foot posture, kinematics of the main foot joints, and medial longitudinal arch deformation during walking at comfortable speed. Range of motion and temporal profiles of joint rotations were compared to those from a control population of age-matched adolescents with normally-developed feet. RESULTS: The plano-valgus midtarsal joint was more dorsiflexed, everted and abducted than that in the control group, and showed reduced sagittal-plane RoM (plano-valgus = 15.9 degrees; control = 22.2 degrees; P <  0.01). The tarso-metarsal joint was more plantarflexed and adducted, and showed larger frontal-plane RoM. The MLA showed larger RoM and was lower throughout the stance phase of the gait cycle. CONCLUSION: Significant postural and kinematic alterations are present at the midtarsal and tarso-metarsal joints of adolescents with plano-valgus feet. Objective identification and quantification of plano-valgus foot alterations, via non-invasive gait-analysis, is relevant to improving the diagnosis of this condition and to evaluating the effect of conservative treatments and of surgical corrections by different techniques.

The Role of Taylor Spatial Frame in the Treatment of Blount Disease.

BACKGROUND: Alteration of the posteromedial part of the proximal tibia is the main characteristic of Blount's disease and if left untreated, leg alignment and normal development of the lower limbs may be compromised. AIM: To report treatment outcomes in children with Blount's disease using the Taylor Spatial Frame (TSF). MATERIALS AND METHODS: From January 2007 to December 2014, 16 young children (24 tibia) with a mean age of 7.5 years (range of 3-14 yrs) and severe Blount's disease were treated using TSF. Preoperative long standing radiographs were performed and anatomic medial proximal tibial angle (MPTA), diaphyseal-metaphyseal tibial angle (Drennan), femoro-tibial angle and leg length discrepancy (LLD) were measured. RESULTS: Post-operative improvement of all measurements was observed. MPTA increased from a mean of 71.8° (58° - 79°) to 92.5° (90° - 95°), the Drennan decreased from 16.6° (14° - 18°) to 3.6° (0° - 6°), the F-T angle changed from 15.4° (10° - 25°) of varus to 5.9° (2° - 10°) of valgus and the LLD decreased from 208 mm (150-320) to 69 mm (0- +120). Mean follow-up was 45.6 months. According to Paley's criteria pin track infection was present in 6 tibiae, while in 5 patients software changes were necessary. Recurrence was observed in 3 patients (triplets). Complete restoration of the mechanical axis was obtained at the end of the treatment. CONCLUSIONS: In the last decades, different surgical treatments have been proposed for Blount's disease (tension band plate, staples, osteotomies using external or internal fixation). External fixation using the TSF allows gradual safe correction of multiplanar deformities and is a well-tolerated technique by patients with Blount's disease.

An Epidemiological Study of Non-specific Low Back Pain in Non-professional Female Greek Classic Ballet Dancers.

AIM: Epidemiological study of the incidence of mechanical low back pain (LBP) in non-professional female Greek classic ballet dancers over a year and therapeutic interventions required to address symptoms. MATERIALS AND METHODS: Forty-six female classic ballet dancers members of preprofessional schools, aged 16-37 years (mean 28.8 ±5.44 yrs) practicing and training in classic dance for 6-40 hours/week (mean 10.8±6.68) and 2-27 years experience (mean 11.9±4.20 yrs) participated in an epidemiological study concerning the incidence of LBP episodes within the last year, the treatment they received, as well as the period of absence of training and performance due to LBP. A selfadministered questionnaire was employed. Information regarding incidence, duration, and intensity of mechanical low back pain was gathered as well as length of time away from practice or performance. A secondary aim was to investigate the type of conservative treatment that participants in this study received. RESULTS: Thirty-one (67.4%) participants in the study experienced 1-10 (mean 3.26±1.7) episodes of mechanical LBP in the previous 12 months. They had to refrain from dancing activities from 2 to 90 days (mean 16.9±16.22). Twenty one of the participants received some kind of conservative treatment. CONCLUSION: The incidence of LBP was found to be high among Greek amateur classic ballet dancers resulting in absence from dancing activities for a considerable length of time and raising the need for therapeutic intervention for a considerable percentage of the studied population. Effective prevention strategies of LBP are of vital importance, particularly in younger dancers.

Can we prevent hip dislocation in children with cerebral palsy? Effects of postural management.

BACKGROUND: Hip dislocation is common in children with cerebral palsy (CP). At birth they do not have musculoskeletal deformities but they develop over time due to the combined effects of the movement disorder and impaired gross motor function. Early detection and treatment of a hip at risk is needed to modify the natural of hip development in CP. AIM: The aim of this study was to determine the effect of postural management treatment on hip displacement's progression in children CP. DESIGN: Prospective comparative non-randomized study. SETTING: Rehabilitative outpatient unit. POPULATION: Fifty-one children with CP were studied; the treated group (N.=30) was compared to a control group (N.=21). METHODS: The treated group followed a two year's long combined treatment program consisting a neurodevelopment treatment (NDT) two times a week and a 5 hours daily siège moulé postural program. The control group underwent only NDT twice a week for two years. Hip radiographs were measured with the migration percentage (MP) method at baseline, at 1 and 2 years of follow-up. RESULTS: A significant difference has been observed in the MP (%) trend (P<0.001) between treatment and control groups. At 2 years, there was a marked worsening (MP from 23.0 to 37.7) in the control group, compared to the stability (from 28.8 to 26.8) in the treatment group. CONCLUSIONS: This study supports the evidence that conservative postural management of hip deformity is useful to prevent the natural progression of hip dislocation. CLINICAL REHABILITATION IMPACT: Hip radiographic follow up program together with NDT and postural management program is useful to modify the natural progression of hip dislocation in children with CP.

Intra-observer and inter-observer errors in CT measurement of torsional profiles of lower limbs: a retrospective comparative study.

BACKGROUND: The purpose of this study was to determine errors in measurement of torsional profiles (TP) (torsional femoral angle, torsional tibial angle, and femoral ankle angle) among four orthopedic surgeons, experts, and non-experts in measurement, and the learning curve. METHODS: Twenty-six lower extremities of 13 patients with spastic diplegia candidates for femoral/tibial derotational osteotomy had preoperative bilateral computer tomography (CT) scan grams to establish the TP. Each measurement was done by four orthopedic surgeons, two experienced clinicians and interpreters of CT imaging and two with limited clinical and imaging assessment experiences. Images were blinded and the surgeons made three determinations at least 5 days apart; the three angles were measured each time for each limb. Intra-observer and inter-observer variability were determined using bias, standard deviation, and interclass correlation coefficient. RESULTS: Significant inter-observer variability and bias were noted between experts and non-experts (average variability: ICC experts: 0.88 ± 0.15; ICC non-experts: 0.91 ± 0.09). For non-experts, excessive bias (25° and 14°) was observed. An associated improvement in bias with additional measurement experience indicated a potential significant learning curve for interpreting these studies. Less inter-observer variability was observed between experts. CONCLUSIONS: Measurement of TP is a reliable tool when used by experienced personnel, and their use as a preoperative tool should be reserved to ones with experience with such image assessments. Non-experts' measurements produced a weak agreement when compared to experts'.

Modifying the Rizzoli foot model to improve the diagnosis of pes-planus: application to kinematics of feet in teenagers.

BACKGROUND: A number of multi-segment foot protocols have been proposed to obtain measurements of clinical value. In the clinical assessment of foot pathologies and deformities, such as in the pes-planus, the frontal-plane alignment of the calcaneus and the dynamic properties of the medial longitudinal arch are critical parameters though often neglected by the majority of foot protocols. The aim of the present work is to modify an established foot protocol to obtain static and kinematic measures more consistent with corresponding clinical observations. Moreover, while many papers have reported kinematic data from varying populations, few investigations have focussed on young participants from same-age cohorts. METHODS: A 6-camera motion capture system was employed to track the shank, rear-, mid- and fore-foot segments in the left and right leg of 10 children (13.1 ± 0.8 years) during gait. Three markers were attached to each segment thus allowing for triplanar motion of five joints to be described according to the Rizzoli Foot Model. An additional marker was attached to the posterior bottom of the calcaneus to enhance measurement of frontal-plane orientation. Description of the medial longitudinal arch angle was redefined to be more consistent with rearfoot orientation and to common clinical assessments. A novel 3-marker description of the hallux segment was implemented to improve robustness in calculating 1(st) metatarso-phalangeal joint rotations. RESULTS: Foot segments kinematics showed good inter- participant repeatability and overall consistency with previous similar reports. 15 out of 20 feet showed neutral or slightly valgus orientation of the calcaneus. Relatively large medial longitudinal arch angles (mean 186 ± 16 deg) were found in the present young population. Both measurements were reasonably in accordance with the relevant clinical observations of these feet. CONCLUSIONS: Modifications to a widely used multisegmental foot kinematic model were implemented to improve robustness and consistency with relevant clinical observations. A detailed description of foot joints motion during barefoot walking in a population of 13-year old children with apparent flat feet has been presented, which may provide useful information to investigate the development of gait in children and the diagnosis of flexible flat foot.

Tendon structure and extracellular matrix components are affected by spasticity in cerebral palsy patients.

We studied the effect of spasticity-induced overload on tendons from the gracilis and semitendinosus muscles from cerebral palsy (CP) and healthy subjects (CT) stained with haematoxylineosin, Sirius red and Alcian blue. Vascularity was also characterized using an anti-CD34 antibody. Light microscopy analysis of haematoxylin-eosin stained sections revealed that the overall structure of tendons was maintained, characterized by parallel and slightly wavy collagen fibers in both CT and CP tendons. However, hypercellularity, cell rounding, increased vascularity and lipoid degeneration were observed in CP samples. Sirius red stained collagen fibers were more evident in CP tendons, suggesting an increased collagen content induced by spasticity. Alcian blue staining revealed an overall increase of glycosaminoglycans in CP tendons as observed in tendinopathy. Our results suggest that CP-induced spasticity may be considered as a chronic, persisting and repetitive loading of tendons, inducing ECM remodeling as adaptive response to increased functional demand. At the same time, the evidence of some tendinopathic-like markers in CP tendons suggests that the chronic nature of the CP condition could represent a pathologic condition, possibly leading to a transient weakness of the tissue making it more susceptible to damage from cumulative loading until an overt tendinopathy develops.

Growth of the acetabular lateral cartilage in relation to congenital and developmental dysplasia of the hip. An histological study.

There are no clear explanations for the spectrum of hip dysplasia nor for the observation that in normal and dysplastic hips, final development may be unpredictable with or without treatment. Immunohistochemical and histological studies of a three month old child's acetabulae were performed. Multiple inclusions were found in the lateral ring epiphysis and in the three flanges of the triradiate cartilage. These inclusions may represent cartilage vessel systems pre-destined to form the secondary centres of ossification. Damage to the primary acetabular growth plates may occur congenitally and help to explain the spectrum of acetabular dysplasia. Damage to one or more of these centres, whether due to instability, displacement or iatrogenic injury, may cause failure of late acetabular development. Hips at risk of damage to the acetabular cartilages should be followed up longer.