Functional outcomes after selective dorsal rhizotomy followed by minimally invasive tendon lengthening procedures in children with spastic cerebral palsy Many surgical options have been proposed to improve the ambulatory status of children with spastic cerebral palsy (CP), but none have focused on addressing both spasticity and lower extremity tendon contractures. The purpose of this study is to evaluate the results of selective dorsal rhizotomy (SDR) followed by minimally invasive tendon lengthening allowing immediate return to ambulation. Two hundred fifty-five spastic CP patients (who received SDR procedure at an average age of 6.9±2.6  years and tendon lengthening procedure at an average age of 7.2±2.5  years) were retrospectively reviewed. Patients were grouped by the gross motor function classification system (GMFCS) 1–3 and 4–5. Kaplan–Meier analysis and Cox proportional hazard model using a requirement for additional tendon lengthening as an end point were conducted. Tendon lengthening followed SDR at an average of 4.3±10.7  months. On an average of 4.9±1.2  years after tendon lengthening, GMFCS was improved in 28 and maintained in 213 patients, respectively. There was no difference of variables and joint angles between the two GMFCS groups. A repeat tendon lengthening was required in 19 patients. The Kaplan–Meier analysis showed 81% success rate. Cox proportional hazard model identified age at tendon lengthening [hazards ratio (HR), 0.53; 95% confidence interval (CI), 0.37–0.76] and duration between SDR and tendon lengthening of more than 6  months (HR, 2.96; 95% CI, 1.05–8.33) associated with need for a repeat tendon lengthening procedure. Our novel approach of SDR/tendon lengthening results in improved joint angles as well as stable or improved GMFCS. Longer follow-up is necessary to determine if this approach could prolong ambulatory ability and reduced need for more invasive orthopedic surgeries.

Postanesthesia alternation of lower limb contractures in children with spastic cerebral palsy The aim of this study was to clarify the effects of general anesthesia (GA) on joint range of motion (ROM) in children with spastic cerebral palsy (SCP). Eighty-four SCP cases (mean age 8.4 years) admitted for first corrective surgery were retrospectively reviewed. Lower limb ROM were measured 1 day before operation and immediately after GA. Contracture of hip, knee, and ankle joints decreased significantly after GA, with + 11.1° (39.5%) for the hip abduction angle, −3.7° (18.0%) for the Thomas test, −15.0° (19.1%) for the popliteal angle, + 6.6° (39.8%) and 7.0° (109%) for ankle dorsiflexion with knee flexion and extension, respectively (all P < 0.001). These changes were correlated positively to pre-GA contracture and body weight, negatively to age, but independent of preoperative functional level, geographic classification of SCP, or modified Ashworth scale. On the basis of these findings, routine post-GA reassessments of joint ROM before corrective surgeries were recommended for pediatric SCP cases.

Femoral derotation osteotomy in children with cerebral palsy using the pediatric proximal femoral nail We designed a pediatric proximal femoral nail (PPFN) to overcome fixation method-related complications when performing femoral derotation osteotomy in cerebral palsy patients. Preliminary results of cerebral palsy patients who underwent femoral derotation osteotomy fixed using PPFN to treat in-toeing were evaluated. Sixteen patients with a mean age of 10 years were included. Mean follow-up duration was 36 months. There was no significant difference in the follow-up neck-shaft angle and articulotrochanteric distance values (P = 0.2 and 0.3). PPFN provides stable fixation, early weight-bearing, reduces soft-tissue disruption while limiting the complications due to fixation technique.

An alternative fixation method for femoral varus derotational osteotomy in spastic cerebral palsy: the Rush rod The objective of this study is to present the clinical and radiographic data collected from patients who were treated with a varus derotational osteotomy using Rush rod fixation and compare this to published norms of outcomes using blade plate fixation. A retrospective chart and radiograph review was conducted after identifying 44 patients with 61 hips who underwent varus derotational osteotomy with Rush rod fixation at our institution between 2006 and 2016. We identified 44 patients with 61 hips who underwent the procedure. Information from follow-up clinic visits was gathered and any complications were noted. The patients’ radiographs were analyzed to measure neck-shaft angle, center-edge angle, and acetabular index. At the time of surgery, 44 patients (61 hips) also had soft tissue releases performed, 44 (61 hips) had an open reduction of the hip, and 39 (55 hips) had Dega acetabular osteotomies performed as well. The average pre-operative neck-shaft angle was measured at 163.0° (range 128–180) with average post-operative neck-shaft angles measuring 111.3° (range 85–167). The acetabular index improved from an average of 33.3° (range 16–60) to 16.4 (range 4–35). Post-operative Center-Edge Angle measured 29.7° (range 5–45). There were no infections or cases of avascular necrosis of the femoral head. We present an alternative fixation method for performing varus derotational osteotomy of the proximal femur in children with cerebral palsy using the Rush rod. In our retrospective analysis of 61 hips undergoing this procedure, we present comparable radiographic outcomes with decreased complication rates. Level of evidence: Retrospective comparative study to previously published results, Level III.

Factors associated with unaffected foot deformity in unilateral cerebral palsy The aim of this study was to assess the angular components of the affected foot associated with valgus deformity of the unaffected foot and to redefine the actual leg-length inequality in unilateral cerebral palsy. We retrospectively reviewed the medical records and radiologic images of 76 patients with unilateral cerebral palsy. Weight-bearing plain radiography of both feet of each subject was obtained. Angular measurements focused on the collapse of the longitudinal arch, hind foot valgus and forefoot abduction. Patients were divided into two groups: with and without valgus deformity of the unaffected side. Leg-length discrepancy and pelvic obliquity angle were measured Among 76 patients, 40 (52%) had valgus deformities of the unaffected side. Independent t-test revealed no significant differences in age, affected side, type of deformity on the affected side, or application of bilateral biomechanical foot orthosis between patients with or without valgus deformity of the unaffected side. Patients with valgus deformity had significantly increased voluntary ankle dorsiflexion greater than neutral on the affected side, leg-length discrepancy and lateral talocalcaneal angle (P < 0.05). Laterally measured foot angles of both feet were significantly correlated. The optimal cut-off points for predicting valgus deformity were leg-length discrepancy >10 mm or affected limb/unaffected limb-length index <0.98. Leg-length discrepancy and lateral talocalcaneal angle of the affected foot were significantly increased in patients with valgus deformity of the unaffected side. The optimal cut-off point for predicting valgus deformity of the unaffected foot would be useful in clinical practice.

Comparison of two different methods in preoperative planning of the amount of lengthening in Z achilloplasty technique Achilles tendon lengthening (ATL) surgery is a technique that is frequently used in the surgical treatment of contracture of the Achilles tendon seen in many pediatric orthopedic problems such as cerebral palsy, clubfoot, pes planovalgus and myelomeningocele. It is important to appropriately adjust the amount of ATL. However, the literature on the preoperative calculation of the required amount of tendon lengthening is limited. The aim of the study was to compare the reliability of the two different methods of predicting the amount of ATL. Eighteen feet of 16 patients who underwent ATL with Z-plasty technique were included in the study. The required amount of ATL was calculated as double blind according to the Cosine theorem and a method that was described by Garbarino et al. in 1985 and compared with the amounts of ATL applied during the operation. The mean amount of lengthening was 25.24 mm during surgery. The required amount of lengthening was 41.55 ± 11.0 mm, according to the Garbarino’s method. The required amount of lengthening was 23.93 ± 9.03 mm, according to the Cosine theorem. The quantities calculated according to the Cosine theorem showed excellent agreement with the amount of lengthening during surgery. The quantities calculated according to the Garbarino’s method showed poor agreement with the amount of lengthening during surgery. The calculation of the amount of ATL required in the treatment of the equinus deformity before surgery is possible by Cosine Theorem. The method of Cosine theorem is more reliable than the previous method described by Garbarino et al.

Physeal fractures of the distal femur: does a lower threshold for surgery lead to better outcomes? Distal femur physeal fractures are known to have a high incidence of complications. Our previous reported experience (pre-2007) showed a 40% complication risk, which prompted changes in our approach. The purpose of this study was to evaluate and compare the complication rate and outcome after implementation of these changes. This is a retrospective study of children with distal femur physeal fractures treated at a level 1 pediatric trauma center between 2007 and 2016. Patient demographics, fracture patterns, treatment and outcomes including complications and its risk factors were recorded and analyzed. We compared current results with our previously reported multicenter cohort (n = 73). Patients were male in majority (57/70) with a mean age of 13 ± 4 years. Fractures were most commonly Salter–Harris Type 2 (49/70) and displaced (59/70) on presentation, although neither characteristic was associated with complications. Most patients (63/70) were treated surgically, and the overall complication incidence was 36% (25/70), including growth arrest in 20 patients. The pre-2007 cohort was statistically significantly younger (P < 0.001) and was more commonly treated nonoperatively (P < 0.001). However, there was no statistically significant difference in complication incidence between studies (36% versus 40%, respectively, P = 0.751). Despite a lower threshold for surgery for distal femur physeal fractures in the past decade, the complication rate is still high and unchanged at 40%, and presenting patients are older. There were no new prognostic factors that showed statistically significant association with subsequent complications; however, patients with high-energy injury mechanisms and greater fracture displacements did have higher complication rates. These results demonstrate the inherent high complication risk for these injuries. Level of Evidence: III.

Management of severe congenital flexion deformity of the knee using Ilizarov method The aim of this study was to examine the effectiveness of Ilizarov method in severe congenital flexion deformity of the knee. This was a retrospective study of eight consecutive bilateral cases (five girls and three boys, with mean age of 4 years, involving 16 knees) with minimum 2-year follow-up. Four patients had multiple congenital contractures and two patients each had popliteal pterygium syndrome and complete tibial hemimelia. All patients were treated with Ilizarov fixator and gradual correction (additional soft tissue releases in three knees). Six patients had bilateral foot and ankle deformity treated with the same fixator, and cases with tibial hemimelia had centralization of fibula and quadriceps reconstruction. Flexion deformity could be corrected in all cases. Mean duration of dynamic phase was 78.5 (55–108) days, that of static phase was 42.4 (7–100) days, and total duration of external fixation was 120.9 (87–186) days. At mean follow-up of 34.5 (23–60) months, flexion deformity improved from the preoperative value of 74.9° (50°–130°) to 13.7° (10°–16°), and passive arc of motion of knee improved from the preoperative value of 38.8° (20°–55°) to 83.6° (55°–110°). Both were statistically significant (P < 0.0001). All patients (previously nonambulatory) were ambulatory with brace and support. All patients faced pin-tract and skin complications that were successfully managed. Ilizarov method is effective in severe congenital flexion deformity of the knee in improving ambulatory status. Realignment of quadriceps mechanism and limb mechanical axis (including ankle and foot deformities) must be given due importance. Minor recurrences of deformity must be expected in all cases.

Comparison of plate and screw constructs versus screws only for anterior distal femoral hemiepiphysiodesis in children The study aim was to compare methods of anterior distal femoral hemiepiphysiodesis (ADFH) for treatment of fixed knee flexion deformities in ambulatory children with neuromuscular conditions and flexed knee gait. This is a retrospective review of 47 children (14 female, 33 male, age at surgery: 12.1 ± 2.7 years) who underwent ADFH between 2009 and 2016. Subjects were grouped by ADFH construct: one transphyseal screw (N = 11), two transphyseal screws (N = 28) or plates and screws (P/S group, N = 8). Clinical/radiographic variables were analyzed using paired t tests, χ2 tests, multiple regression and analysis of covariance. Participants experienced significant reduction in knee flexion contractures (Δ12°, P < 0.006), with no difference among groups (P = 0.43). Postoperative knee pain was significantly more prevalent in the P/S group (5/8, 63%) than the 1-SCR group (0/11, 0%) and the 2-SCR group (2/28, 7%) (P = 0.002). ADFH results in significant reduction of knee flexion deformity and improved knee extension during gait. Plate and screw constructs, the 1 and 2 transphyseal screw techniques are equally effective, but plate and screw constructs may be associated with a higher risk of persistent postoperative knee pain.

Tension band plate-guided growth of knee-flexion deformity in arthrogryposis multiplex congenita in which metaphyseal funnelization induced screw encroachment upon the neurovascular bundle Knee-flexion deformity in arthrogryposis multiplex congenita is treated by serial casting into extension, distal femoral osteotomies, distal femoral-guided growth, hemiepiphysiodesis, external fixation, capsulotomy, and soft-tissue releases. We are aware of four cases treated by distal anterior femoral-guided growth with tension band plates in which an unreported complication occurred: the screws of the tension band plates penetrated the posterior cortex of the femur during remodeling with metaphyseal funnelization risking the neurovascular bundle. Inclusion criteria were cases with arthrogryposis multiplex congenita and knee-flexion deformity, treatment at our institution by distal anterior femoral-guided growth with tension band plates, and radiographic evidence of posterior cortex screw penetration during remodeling from growth. Six knees (four cases) met the inclusion criteria. The average age at the distal anterior femoral-guided growth with tension band plate operation was 5.8 years. Radiographs after 6.6 years of follow-up showed that the screws of the tension band plates, which at surgery were intrametaphyseal, had penetrated the posterior cortex of the femur. Four knees (two cases) had diffuse pain around the knee to lower leg area, and instrumentation removal alleviated the symptoms. During distal anterior femoral-guided growth with tension band plate operation for knee-flexion deformity in arthrogryposis multiplex congenita, we found that the screws of the tension band plates, which were initially located inside the metaphysis, may protrude through the posterior bone cortex during metaphyseal funnelization with growth, and may encroach upon the neurovascular tissues. Level of evidence: Level IV – case series.