The Importance of Having a Single, Dedicated Medical Team to Treat Congenital Talipes Equinovarus Using the Ponseti Method: A Retrospective Analysis of Treatment Outcomes After 3 Years of Follow-up.

BACKGROUND: Congenital talipes equinovarus (CTEV) is a relatively common pediatric orthopaedic disorder and a frequent cause of disability in adult populations. The Ponseti method has emerged as the generally preferred for treating children with CTEV. Strict adherence to this technique's basic principles is critical to achieving favorable outcomes. In 2013, our institution decided that every case of pediatric CTEV would be treated by a single dedicated medical team. The present study aimed to compare the treatment outcomes of children with CTEV treated using the Ponseti method in period I (multiple surgeons) versus those in period II (single dedicated team). PATIENTS AND METHODS: We included respectively the children with CTEV treated using the Ponseti method in Geneva University Hospitals' pediatric units from 2007 to 2018. Data on patient demographics, clinical characteristics, and the treatment outcomes were collected. The primary outcome was the number of relapsed feet (treatment failure) after 3 years of follow-up. The 2 periods' outcomes were compared using χ 2 and independent Student t -tests. Run charts were used to report yearly rates of complications, minor and major recurrences, treatment failure, brace noncompliance, and feet that underwent tenotomy. RESULTS: A total of 48 feet (32 patients) and 42 feet (29 patients) in periods I and II were included. The periods showed similar rates for participants' characteristics. The run charts illustrated the overall improvements in treatment outcomes in period II. A total of 8 relapsed feet (5 patients) were reported, all during period I. CONCLUSIONS: Since all the pediatric CTEV patients at our institution began to be treated by a single dedicated medical team, we have observed a decrease in all recurrences and complications and an absence of treatment failure. These results highlight the importance of the continuity of care and strict adherence to the Ponseti method. LEVEL OF EVIDENCE: Level-III Retrospective comparative study.

Assessment of gait quality and efficiency after undergoing a single-event multilevel surgery in children with cerebral palsy presenting an intoeing gait pattern.

PURPOSE: The biomechanical impact of undergoing a single-event multilevel surgery (SEMLS) for children with cerebral palsy (CP) presenting an intoeing gait pattern has been widely documented. However, past studies mostly focused on gait quality rather than efficiency. Thus, there is a need to determine the impact of undergoing a SEMLS on gait quality and efficiency in children with CP presenting an intoeing gait pattern. METHODS: Data from 16 children with CP presenting an intoeing gait pattern who underwent a SEMLS were retrospectively selected. Gait kinematics was quantified before (baseline) and at least 1 year after the surgery (follow-up). Gait quality was investigated with the Gait Profile Score (GPS), hip internal rotation angle and foot progression angle (FPA). Gait efficiency was analysed using clinically accessible variables, namely the normalised gait speed and medio-lateral and vertical centre of mass excursions (COMp). Dependent variables were compared between sessions with paired t-tests. RESULTS: At the follow-up, children with CP exhibited a more outward FPA and GPS as well as a decreased hip internal rotation angle. No changes in normalised gait speed and vertical COMp excursion were observed, and medio-lateral COMp excursion was slightly decreased. CONCLUSION: Children with CP presenting an intoeing gait pattern who underwent a SEMLS exhibited an increased gait quality, but gait efficiency was only minimally improved at the follow-up compared to baseline. Further studies are needed to identify contributors of gait efficiency in children with CP, and the best treatment modalities to optimise both their gait quality and efficiency.

[New tools for movement assessment in children with motor disabilities]. / Nouveaux outils d'évaluation du mouvement chez l'enfant avec handicap moteur.

Until recently, movement analysis of children with motor disabilities has mainly relied on in-lab measurements using optoelectronic systems. The development of new tools is mainly inspired from mainstream devices, such as video cameras associated with artificial intelligence or inertial sensors. These tools have extended the assessment of movement in these children beyond traditional movement analysis laboratories, to take an interest in their movements in everyday life. Through the complementarity of these measurements (and associated tools), which the use of is becoming mainstream, a more exhaustive understanding of children's motor disorders and their impacts will allow clinicians to optimize their therapeutic management.

Jusqu'à récemment l'analyse du mouvement chez l'enfant avec handicap moteur s'est principalement appuyée sur des mesures détaillées effectuées en laboratoire à l'aide de systèmes optoélectroniques. Le développement de nouveaux outils de mesure s'appuie sur des dispositifs grand public, tels que les caméras vidéo associées à de l'intelligence artificielle ou les capteurs inertiels. Ces outils ont permis d'étendre le champ d'exploration du mouvement de ces enfants hors des laboratoires traditionnels d'analyse du mouvement pour s'intéresser à leurs mouvements dans la vie quotidienne. Par la complémentarité de ces mesures (et outils associés), dont l'utilisation est appelée à se démocratiser, une compréhension plus exhaustive des troubles moteurs de l'enfant et de ses impacts permettra d'optimiser leur prise en charge thérapeutique.

Self-perceived gait quality in young adults with cerebral palsy.

AIM: To explore how patients with cerebral palsy (CP) perceive their gait and evaluate associations between subjective gait perception and: objective gait parameters, endurance, pain, and fatigue. METHOD: Sixty-two patients (21 females and 41 males; mean [SD] age 20y [5y 1mo], range 15-29y) performed a clinical gait analysis. Self-selected walking speed, Gait Profile Score, and Gait Variable Score were calculated. Subjective gait perception was assessed with a visual analogue scale using the question: 'On a scale from 0 (worst) to 10 (optimal), how would you describe your walking today?'. A 6-minute walk test (6MWT) measured endurance; the 36-Item Short Form Health Survey (SF-36) evaluated quality of life. T-tests, Pearson correlations, and univariate and multiple linear regression models were used to compare and find associations between the data. RESULTS: Overall mean (SD) subjective gait perception was 7.5 (1.8) and was significantly higher for patients in Gross Motor Function Classification System (GMFCS) level I (7.9 [1.5]) than for patients in GMFCS levels II and III (5.9 [2.0]). Positive correlations were found between subjective gait perception and gait scores, walking speed, 6MWT distance, and SF-36 score. Only walking speed was a significant predictor of subjective gait perception. INTERPRETATION: Subjective gait perception was influenced by GMFCS level and linked partially with the walking speed. The gait quality did not explain subjective gait perception. It is important to combine subjective and objective gait scores to develop personalized therapeutic goals. WHAT THIS PAPER ADDS: Subjective gait perception is influenced by the physical impairment levels of patients with cerebral palsy. Subjective gait perception and objective gait scores are associated. Walking speed is the only predictor of gait perception.

What is the Best Configuration of Wearable Sensors to Measure Spatiotemporal Gait Parameters in Children with Cerebral Palsy?

Wearable inertial devices have recently been used to evaluate spatiotemporal parameters of gait in daily life situations. Given the heterogeneity of gait patterns in children with cerebral palsy (CP), the sensor placement and analysis algorithm may influence the validity of the results. This study aimed at comparing the spatiotemporal measurement performances of three wearable configurations defined by different sensor positioning on the lower limbs: (1) shanks and thighs, (2) shanks, and (3) feet. The three configurations were selected based on their potential to be used in daily life for children with CP and typically developing (TD) controls. For each configuration, dedicated gait analysis algorithms were used to detect gait events and compute spatiotemporal parameters. Fifteen children with CP and 11 TD controls were included. Accuracy, precision, and agreement of the three configurations were determined in comparison with an optoelectronic system as a reference. The three configurations were comparable for the evaluation of TD children and children with a low level of disability (CP-GMFCS I) whereas the shank-and-thigh-based configuration was more robust regarding children with a higher level of disability (CP-GMFCS II-III).

Results and complications of percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy in 54 consecutively operated GMFCS level IV and V cerebral palsy patients.

PURPOSE: This retrospective study evaluated mid-to-long-term outcome of a minimally invasive percutaneous pelvic osteotomy (PPO) approach combined with varus derotational shortening osteotomy (VDRSO) and soft tissue release in children with severe CP. METHODS: A retrospective review was performed of all patients presenting with a diagnosis of CP with hip subluxation or dislocation treated surgically by simultaneous soft tissue release, VDRSO, and PPO between 2002 and 2015. Eligible patients included those with a diagnosis of spastic quadriplegia or CP GMFCS level IV or V with unilateral or bilateral hip subluxation or dislocation and surgical treatment of the deformity by simultaneous soft tissue release, VDRSO and PPO. All anterior-posterior (AP) radiographs of the pelvis were reviewed and Reimers migration percentage (MP) and acetabular angle (AA) were measured. RESULTS: In total, 54 children and adolescents (34 boys, 20 girls) with CP GMFCS level IV and V were treated during study period: 38 (70.4%) classified GMFCS level IV and 16 (29.6%) classified GMFCS level V. A total of 64 consecutive hips underwent simultaneous PPO associated with VDRSO. Overall, at the time of chart and radiograph review, mean age was 9.1 ± 3.3 years (range 4-16.5) and mean follow-up was 43.9 ± 19.5 months (range 3-72). Mean migration percentage improved from 66.8 ± 19.8% (range 33-100) preoperatively to 8.1 ± 16.5% (range 0-70) at last follow-up. Mean acetabular angle improved from 32.7° ± 7.1° (range 20-50) preoperatively to 14° ± 6.7° (range 0-27) at last follow-up. Only one case of bone graft dislodgment was observed. We did not observe any cases of avascular necrosis of the femoral head. All operated hips were pain free at the time of last follow-up. CONCLUSION: PPO through a less invasive surgical approach offers a valuable alternative to standard techniques as it gives similar outcome but with less muscle stripping and less time in surgery. LEVEL OF EVIDENCE: III.

[Clinical gait analysis: user guide]. / Analyse quantifiée de la marche: mode d'emploi.

Clinical gait analysis has become an indispensable medical examination for the management of patients with complex gait disorders. As its name suggests, the purpose of this examination is to assess patients whilst they are walking in a laboratory setting. Measurements include: 3 dimensional joint motion, forces applied to joints, and electromyographic muscle activity. This quantitative data allows identification of walking deviations and to deduce the likely causes of these deviations thanks to the clinical data available for each patient.

Shear fractures of the capitellum in children: a case report and narrative review.

The shear fractures of the capitellum are rare fractures in the pediatric population. Their diagnosis is challenging because of the high cartilaginous component of the growing elbow, requiring a high level of clinical suspicion especially in the case of small osteochondral or chondral fragments. The literature on capitellar shear fractures is mainly represented by case reports, which provides a patchy view of the topic. For this reason, we aimed to draw a narrative review presenting the available management strategies and their outcomes, and present two cases treated in our institution.

A 10.5-year follow-up of walking with unilateral spastic cerebral palsy.

Purpose: The purpose of this study was to describe gait evolution in patients with unilateral spastic cerebral palsy (USCP) using modified Gait Profile Score (mGPS without hip rotation), Gait Variable Score (GVS), walking speed, and the observed effects of single-level surgery (SLS) after 10 years. Methods: Fifty-two patients with USCP (Gross Motor Function Classification System I) and data from two Clinical Gait Analyses (CGAs) were included. The evolution of patients' mGPS, GVS, and walking speed were calculated. Two "no surgery" and "single-level surgery" patient categories were analyzed. Paired t-tests were used to compare the data between CGAs and as a function of treatment category. Pearson's correlations were used to examine relationships between baseline values and evolutions in mGPS and walking speed. Results: Mean ages (SD) at first and last CGAs were 9.3 (3.2) and 19.7 (6.0) years old, respectively, with an average follow-up of 10.5 (5.6) years. Mean mGPS for the patients' affected side was significantly lower at the last CGA for the full cohort: baseline = 8.5° (2.1) versus follow-up = 7.2° (1.6), effect size = 0.73, p < 0.001. Significant improvements in mGPS and GVS for ankle and foot progression were found for the SLS group. The mGPS change and mGPS at baseline (r = -0.79, p < 0.001) were negatively correlated. Conclusions: SLS patients demonstrated a positive long-term change in gait pattern over time. The group that had undergone surgery had worse gait scores at baseline than the group that had not, but the SLS group's last CGA scores were relatively closer to those of the "no surgery" group. Level of evidence: This was a retrospective comparative therapeutic study (level III).

Transphyseal Hematogenous Osteomyelitis: An Epidemiological, Bacteriological, and Radiological Retrospective Cohort Analysis.

Transphyseal hematogenous osteomyelitis (THO) is a serious condition that can affect the growing physis, yet it is insufficiently recognized in children. The aim of this study was to explore the prevalence and epidemiology of pediatric THO, and to discuss the underlying pathophysiology. All consecutive cases of acute and subacute osteomyelitis admitted to our institution over 17 years were retrospectively studied. Medical records were examined for patient characteristics, bacteriological etiology, and medical and surgical management. Magnetic resonance imaging was reviewed for all patients to identify those with transphyseal spread of infection. For positive cases, the surface area of the transphyseal lesion was estimated relative to the total physeal cross-sectional area. Fifty-four (25.7%) of the 210 patients admitted for acute or subacute osteomyelitis were diagnosed with THO. The study population's ages ranged from 1 month to 14 years old (median age 5.8 years, interquartile range 1-167 months). Fourteen (25.9%) patients were younger than 18 months old; the remaining 40 (74.1%) had a mean age of 8.5 years old. The most common sites of THO were the distal tibia (29.1%), the proximal tibia (16.4%), and the distal fibula (14.5%). Transphyseal lesions were due to acute infection in 41 cases and to subacute osteomyelitis in 14 cases. The two most frequently identified pathogens were Staphylococcus aureus (49.1%) and Kingella kingae (20.0%). An average transphyseal lesion represented 8.9% of the total physeal surface, and lesions comprised more than 7% of the physeal cross-sectional area in 51% of cases. Our study revealed that pediatric THO was more frequent than commonly thought. Transphyseal lesions were frequently above this 7% cut-off, which is of paramount importance since subsequent growth is more likely to be disturbed when more than 7% of the physeal cross-sectional area is injured. THO also affected children older than 18 months, an age at which transphyseal arterial blood supply to the epiphysis is believed to have disconnected. This finding suggests another pathophysiological reason for the transphyseal diffusion of infection, a topic deserving further studies and greater understanding.

Recovery of physical activity levels in adolescents after lower limb fractures: a longitudinal, accelerometry-based activity monitor study.

BACKGROUND: In adolescents, loss of bone mineral mass usually occurs during phases of reduced physical activity (PA), such as when an injured extremity spends several weeks in a cast. We recorded the PA of adolescents with lower limb fractures during the cast immobilization, at 6 and at 18 months after the fracture, and we compared these values with those of healthy controls. METHODS: Fifty adolescents with a first episode of limb fracture and a control group of 50 healthy cases were recruited for the study through an advertisement placed at the University Children's Hospital of Geneva, Switzerland. PA was assessed during cast immobilization and at 6- and 18-month follow-up by accelerometer measurement (Actigraph(®) 7164, MTI, Fort Walton Beach, FL, USA). Patients and their healthy peers were matched for gender and age. Time spent in PA at each level of intensity was determined for each participant and expressed in minutes and as a percentage of total valid time. RESULTS: From the 50 initial teenagers with fractures, 44 sustained functional evaluations at 6 months follow-up, whereas only 38 patients were studied at 18 months. The total PA count (total number of counts/min) was lower in patients with lower limb fractures (-62.4%) compared with healthy controls (p<0.0001) during cast immobilization. Similarly, time spent in moderate-to-vigorous PA was lower by 76.6% (p<0.0001), and vigorous PA was reduced by 84.4% (p<0.0001) in patients with cast immobilization for lower limb injuries compared to healthy controls values. At 6 and 18 months after the fracture, the mean PA level of injured adolescents was comparable to those of healthy teenagers (-2.3%, and -1.8%, respectively).Importantly, we observed that time spent in vigorous PA, which reflects high-intensity forces beneficial to skeletal health, returned to similar values between both groups from the six month follow-up in adolescents who sustained a fracture. However, a definitive reduction in time spent in moderate PA was observed among patients with a lower limb fracture at 18 months, when comparing with healthy controls values (p = 0.0174). CONCLUSIONS: As cast immobilization and reduced PA are known to induce bone mineral loss, this study provides important information to quantify the decrease of skeletal loading in adolescents with limb fractures. The results of this study demonstrate that the amount of skeletal loading returns to normal values in adolescents with lower limb fractures after bone healing and is probably linked to an overall better pattern of functional recovery among this age group. When comparing both populations of adolescents, a definitive decrease in time spent in moderate-to-vigorous PA was observed among patients with a lower limb fracture at 18 months and may suggest a modification of lifestyle. The high rate of missing data (26.5%) due to above all non compliance with monitor wearing among teenagers complicates the data analysis, and requires a more cautious interpretation of the results. Future studies using accelerometer to monitor PA in adolescents should therefore include strategies for improving the rate of adherence and minimizing the ratio of missing data.

Complications of intrathecal baclofen pump treatment in children with spastic cerebral palsy. A comparative analysis of patients weighing over or under 20 kg at the time of implantation.

The purpose of this study was to investigate the incidence of complications in pediatric spastic cerebral palsy (CP) patients weighing less than 20 kg at the time of intrathecal baclofen (ITB) pump implantation and to compare it with spastic CP patients heavier than 20 kg. Twenty-seven patients with spastic CP (14 males) treated with ITB implantation at our institution between January 2002 and January 2018 were retrospectively reviewed. Eight of the 27 patients had a bodyweight below 20 kg (group A) and 19 had weight above 20 kg (group B). Group A had a significantly more important proportion of patients with the Gross Motor Function Classification System V compared to group B (88 vs. 42%). The median follow-up was respectively 2.5 (1.8-4.6) and 4.6 (1.9-10.0) years in groups A and B. Median age at the time of ITB implantation was 7.4 (2.8-12.8) and 13.7 (6.5-16.8) years in groups A and B (P = 0.002). The proportion of patients with complications or reoperation was NS between groups A and B (P > 0.05). No postoperative infections were recorded in any of the groups. During follow-up, five patients died (63%) in group A and three (16%) in group B (P = 0.049) within 3.8 years on average after ITB implantation. ITB therapy in spastic CP patients weighing less than 20 kg seems to be as well tolerated and effective as it is in heavier (>20 kg) pediatric patients.

Running capacity in children with bilateral cerebral palsy: What are the biomechanical and neuromotor differences between runners and walkers?

BACKGROUND: Running is a high-level locomotor activity requiring more from joints, muscles and a more complex interaction of the neuromuscular system than walking. High-level locomotor activity has the potential to shed light on motor function deficits that lower-level activity does not reveal. Therefore, the study aimed to compare biomechanical and neuromotor function between a group of children with bilateral cerebral palsy who are able and unable to run. METHODS: Retrospectively, children with bilateral cerebral palsy aged between 6 and 18 years who completed a clinical gait analysis between 2006 and 2019 were included. Participants were categorized as walkers or runners based on the presence of a double floating phase. Spasticity, selectivity, muscle weakness, and passive range of motion of the lower limbs were measured and dichotomized as «normal¼ or «abnormal¼ based on reference values. Functional tasks reflecting balance (standing on one leg) and power (single leg and two-legged jumps) were realized and evaluated as failure or success. FINDINGS: 75 children with bilateral cerebral palsy (53 runners/22 walkers) were included. Children classified as runners were stronger (hip flexors, p = 0.006; hip abductors, p = 0.022; knee flexors, p = 0.001; dorsiflexors, p = 0.014), had greater selectivity (hip flexors, p = 0.011; dorsiflexors, p = 0.001; plantiflexors, p = 0.043) and lower spasticity at the knee extensors (p = 0.045). No differences were observed in the passive range of motion between the two groups. Children classified as runners performed better at all tasks of balance and power (p < 0.05). INTERPRETATION: Flexors muscles strength and selectivity and knee extensor spasticity are key points for running ability in children with bilateral cerebral palsy.

MRI changes in calf muscles of two children with cerebral palsy following Botulinum Toxin Type A injections: a preliminary report.

Intramuscular injections of Botulinum Toxin Type A (BoNT-A) in children with spastic cerebral palsy (CP) have been introduced in clinical practice with the aim of reducing muscle tone, preventing muscle contractures and, ultimately, improving function. The aim of this study was to evaluate prospectively the MRI changes in the calf muscles, gastrocnemius (GN) and soleus (S) of two children with unilateral spastic CP (US-CP), prior and more than 1-year following BoNT-A injections. Two male patients with US-CP were injected at the level of the GN and S muscles. Patients underwent a first lower extremity MRI prior to the first BoNT-A injection at the level of GN and S muscles of the affected side. A second MRI was perfomed 34 and 22 months after the index procedure, respectively. Both legs were investigated together symmetrically, to allow a precise comparison between muscles and structures. The MRI protocol included three sequences: axial-T2 weighted tse, SPACE and axial-T1 weighted. We found that BoNT-A injected GN and S muscles had increased signal intensity on the MRI performed 22 and 34 months after index procedure, when compared to the contralateral, not placebo injected (NaCl) leg. To the best of our knowledge, no previous studies have investigated the changes induced in muscle structures in ambulatory children with US-CP managed by BoNT-A injections. Level of evidence: II.

What can we learn from the relationship between gait deviations and clinical impairments when comparing two databases?

BACKGROUND: Several previous studies have tried to determine the relationship between gait and clinical impairments in children with Cerebral Palsy (CP). The heterogeneity of the population and the methodology used could explain the discrepancy within the results. Recently, Papageorgiou et al. (2019) used a Statistical Parametric Mapping (SPM) analysis to investigate this relationship, allowing to test across the kinematic waveforms parameters. RESEARCH QUESTION: Are we able to replicate the results of Papageorgiou et al. (2019) on a population of children with CP from another center? METHODS: Retrospectively, youth with spastic unilateral (uCP) or bilateral (bCP) CP (3-18 years of age) who underwent a clinical gait analysis at the Geneva University Hospitals (HUG) were screened. Following Papageorgiou et al. 2019, the same inclusion and exclusion criteria as well as the same methodology were applied. Mann-Whitney-U test was used to compare the impairments score between the two centers. A Student T-Test using SPM was applied to compare the kinematic waveforms from the two centers. A canonical correlation analysis using SPM was realized to assess the relationship between clinical impairments and the combined sagittal motion of the pelvis, hip, knee and ankle. RESULTS AND SIGNIFICANCE: A total of 211 patients were included with 131 uCP (10 [8-14] years old) and 80 bCP (11 [7-14] years old). The distribution of the Gross Motor Function Classification System levels and the proportion of previous treatment differs between centers. In both CP groups, significant differences were observed in the composite score and lower limb kinematics, reflecting less impaired patients with CP at HUG compared to Papagergiou et al. (2019). While similar associations between spasticity and kinematic were observed in both centers, the association with muscle weakness, selectivity, and range of motion differed.

Are Clinical Impairments Related to Kinematic Gait Variability in Children and Young Adults With Cerebral Palsy?

Intrinsic gait variability (GV), i.e., fluctuations in the regularity of gait patterns between repetitive cycles, is inherent to the sensorimotor system and influenced by factors such as age and pathology. Increased GV is associated with gait impairments in individuals with cerebral palsy (CP) and has been mainly studied based on spatiotemporal parameters. The present study aimed to describe kinematic GV in young people with CP and its associations with clinical impairments [i.e., passive range of motion (pROM), muscle weakness, reduced selective motor control (selectivity), and spasticity]. This retrospective study included 177 participants with CP (age range 5-25 years; Gross Motor Function Classification System I-III) representing 289 clinical gait analyses [n = 172 for unilateral CP (uCP) vs. 117 for bilateral CP (bCP)]. As variability metrics, Root Mean Square Deviation (RMSD) for nine lower-limb kinematic parameters and Gait Standard Deviation (GaitSD) - as composite score of the kinematic parameters - were computed for the affected (unilateral = uCP) and most affected side (bilateral = bCP), respectively, as defined by clinical scores. GaitSD was then computed for the non/less-affected side for between leg comparisons. Uni- and multivariate linear regressions were subsequently performed on GaitSD of the affected/most affected side with all clinical impairments (composite scores) as independent variables. Highest RMSD were found in the transverse plane (hip, pelvis), for distal joints in the sagittal plane (knee, ankle) and for foot progression. GaitSD was not different between uCP and bCP (affected/most affected side) but higher in the non-affected vs. affected side in uCP. GaitSD was associated with age (p < 0.001), gait deviation index (GDI) (p < 0.05), muscle weakness (p < 0.001), selectivity (p < 0.05), and pROM (p < 0.001). After adjustment for age and GDI, GaitSD remained associated with muscle weakness (uCP: p = 0.003, bCP: p < 0.001) and selectivity (bCP: p = 0.024). Kinematic GV can be expressed as global indicator of variability (GaitSD) in young people with CP given the strong correlation of RMSD for lower-limb kinematic parameters. In terms of asymmetry, increased variability of the non-affected vs. affected side may indicate contralateral compensation mechanisms in uCP. Notably muscle weakness (uCP, bCP) and selectivity (bCP) - but not spasticity - were associated with GaitSD. Further studies need to explore the clinical relevance of kinematic GV in CP to support the interpretation of clinical gait analyses and therapeutic decision-making.

Cervical spine sagittal alignment variations following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis.

The aim of this study is to quantify the changes in the sagittal alignment of the cervical spine in patients with adolescent idiopathic scoliosis following posterior spinal fusion. Patients eligible for study inclusion included those with a diagnosis of mainly thoracic adolescent idiopathic scoliosis treated by means of posterior multisegmented hook and screw instrumentation. Pre and post-operative anterior-posterior and lateral radiographs of the entire spine were reviewed to assess the changes of cervical sagittal alignment. Thirty-two patients (3 boys, 29 girls) met the inclusion criteria for the study. The average pre-operative cervical sagittal alignment (CSA) was 4.0° ± 12.3° (range -30° to 40°) of lordosis. Postoperatively, the average CSA was 1.7° ± 11.4° (range -24° to 30°). After surgery, it was less than 20° in 27 patients (84.4%) and between 20° and 40° in 5 patients (15.6%). The results of the present study suggest that even if rod precontouring is performed and postoperative thoracic sagittal alignment is restored, improved or remains unchanged after significant correction of the deformity on the frontal plane, the inherent rigidity of the cervical spine limits changes in the CSA as the cervical spine becomes rigid over time.

Analysis of concave and convex rib-vertebral angle, angle difference, and angle ratio in patients with lenke type 1 main thoracic adolescent idiopathic scoliosis treated by observation, bracing or posterior fusion, and instrumentation.

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study is to describe the radiologic changes in rib-vertebral angles (RVAs), rib-vertebral angle differences (RVADs), and rib-vertebral angle ratios (RVARas) in patients with Lenke type 1 main thoracic adolescent idiopathic scoliosis treated by observation, bracing, or posterior fusion and instrumentation, and to compare these with normal individuals. SUMMARY OF BACKGROUND DATA: The RVA measurement has been shown to be a valid and reproducible method and its asymmetries are related to age, sex, and laterality patterns of the curvature. However, studies of RVA and RVAD in patients with adolescent idiopathic scoliosis are scarce and there are no data regarding the assessment of the ratio between concave and convex RVA. METHODS: A retrospective chart and radiograph review was carried out for 66 consecutive adolescent female patients with Lenke type 1 main thoracic idiopathic scoliosis and 14 normal counterparts. Patients were divided into 5 groups: normal individuals (group 1); scoliotic patients with Cobb angle <30 degrees (group 2A); scoliotic patients with Cobb angle more than 30 degrees (group 2B), scoliotic patients treated by bracing (group 3), and scoliotic patients treated by posterior fusion and instrumentation (group 4). RESULTS: Overall values (mean ± SD) of the RVAs on the concave side were 90.5 ± 17 degrees in group 1, 90.3 ± 15.8 degrees in group 2A, 88.8 ± 15.4 degrees in group 2B, 87.5 ± 13.3 degrees in group 3, and 86.7 ± 17 degrees in group 4. On the convex side, values were 90.0 ± 17.3 degrees in group 1, 86.3 ± 13.7 degrees in group 2A, 80.7 ± 14.4 degrees in group 2B, 82.9 ± 13.2 degrees in group 3, and 81.7 ± 16.2 degrees in group 4. Overall values (mean ± SD) of the RVADs at all levels were 0.5 ± 0.7 degrees in group 1, 4 ± 4.8 degrees in group 2A, 8 ± 4 degrees in group 2B, 4.7 ± 5.6 degrees in group 3, and 5.1 ± 5.2 degrees in group 4. The RVARa values (mean ± SD) at all levels were 1.008 ± 0.012 degrees in group 1, 1.041 ± 0.061 degrees in group 2A, 1.102 ± 0.151 degrees in group 2B, 1.056 ± 0.078 degrees in group 3, and 1.061 ± 0.071 degrees in group 4. CONCLUSIONS: Convex RVA was smaller than concave RVA between T1 and T10 in all groups of patients. RVAD and RVARa values in the scoliotic segment were greater in patients with untreated scoliosis more than 40 degrees than in patients with an untreated deformity of <25 degrees or in patients, treated by bracing or surgery, with a residual curve of <25 degrees. These measurements are a useful tool in the armamentarium of the surgeon treating spinal deformities and could be used to better characterize the deformity and/or to evaluate effects of brace or surgical treatment.

Talonavicular arthrodesis for the treatment of neurological flat foot deformity in pediatric patients: clinical and radiographic evaluation of 29 feet.

BACKGROUND: Patients with cerebral palsy, syndromes, myopathies, and other forms of neurological impairment can develop planovalgus foot deformity of variable degrees of severity. Several techniques have already been described to resolve the deformity with variable results. Talonavicular arthrodesis is a well-known technique in adult patients, but to our knowledge, it has not been described in children with neurological impairment. METHODS: We performed a retrospective chart and radiographic review of 18 neurological patients (10 boys, 8 girls) with a mean age of 11.3 ± 2.6 years (range, 7 to 19 y) who underwent talonavicular arthrodesis for flat foot deformity between 1998 and 2009, at our center. RESULTS: Of a total of 29 feet, talonavicular arthrodesis was judged satisfactory in 28 feet, whereas 1 had unsatisfactory results according to the Yoo clinical outcome scoring scale. Subjective observations reported that 3 feet from 2 patients were painful preoperatively and none after last follow-up. Functionally, 2 of 13 patients were able to stop using braces after surgery. The significant improvement achieved postoperatively in radiographic measurement angles was maintained at last follow-up without any loss of angle correction. CONCLUSIONS: Talonavicular arthrodesis seems to achieve a reliable hind foot fixation in flat foot in patients with neurological impairment. LEVEL OF EVIDENCE IV: Case series.

Moraxella lacunata Subacute Osteomyelitis in a Child.

Moraxella lacunata is a rare coccobacillus associated with eye and upper respiratory tract infections. It may also have an affinity for bone and joint tissue. We report on 1 case of subacute osteomyelitis of the patella due to M. lacunata that presented as an osteolytic bone lesion in a child.