Aims. To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity. Methods. Five databases (CENTRAL, CINAHL, PubMed, Embase, Web of Science) were systematically screened for studies investigating split tibialis anterior or split tibialis posterior tendon transfer for spastic equinovarus foot deformity, with gait-related outcomes (published pre-September 2022). Study quality and evidence were assessed using the Methodological Index for Non-Randomized Studies, the Risk of Bias In Non-Randomized Studies of Interventions, and the Grading of Recommendations Assessment, Development and Evaluation. Results. Overall, 17 studies (566 feet) were included: 13 studies used clinical grading criteria to report a postoperative ‘success’ of 87% (75% to 100%), 14 reported on orthotic use with 88% reduced postoperative use, and one study reported on ankle kinematics improvements. Ten studies reported post-surgical complications at a rate of 11/390 feet (2.8%), but 84 feet (14.8%) had recurrent varus (68 feet, 12%) or occurrence of valgus (16 feet, 2.8%). Only one study included a patient-reported outcome measure (pain). Conclusion. Split tendon transfers are an effective treatment for children and youth with CP and spastic equinovarus foot deformities. Clinical data presented can be used for future study designs; a more standardized functional and patient-focused approach to evaluating outcomes of surgical intervention of gait may be warranted. Cite this article: Bone Jt Open 2023;4(5):283–298

Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. A retrospective analysis of medical files of 247 idiopathic CTEV patients born between 01/01/2010 - 01/01/2021 was performed. Data was collected using a REDCap database. Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 22.9% of Mitchell boot and 12.6% of Markell boot patients (X. 2. =6.9, p=0.009). The overall rate of bracing complications was 51.4%. 33.2% of parents admitted to bracing non-compliance and 31.2% of patients required re-casting during the bracing period for relapse. For patients with a minimum follow-up of age 6 years, 44.2% required tibialis anterior tendon transfer. Parents admitting to non-compliance were significantly more likely to have a child who required tibialis anterior tendon transfer (X. 2. =5.71, p=0.017). Overall rate of capsular release (posteromedial release or posterior release) was 2.0%. Neither medium nor longterm results of Ponseti treatment in the Australian and New Zealand clubfoot have been published. Globally, few publications describe specific bracing complications in clubfoot, despite this being a notable challenge for clinicians and families. Recurrent pressure sores is a persistent complication with the Mitchell boots for patients in our center. In our population of Australian clubfoot patients, tibialis anterior tendon transfer for relapse is common, consistent with the upper limit of tibialis anterior tendon transfer rates reported globally

Ponseti method has become the most common and validated initial non-operative and/or minimally invasive treatment modality of idiopathic clubfoot regardless of the severity of the deformity worldwide. Despite hundreds of publications in the literature favoring Ponseti method, the data about secondary procedures performed in the follow-up period of clubfoot and their incidence remains sparse and given as small details in the articles. The objective of this study was to analyse our incidence of secondary procedures performed in the midterm followup period of idiopathic clubfoot patients treated with Ponseti method and review of the relevant literature. For this purpose 86 feet of 60 patients with idiopathic clubfoot who were treated with original Ponseti method were enrolled in this retrospective case control study. Unilateral ankle foot orthosis (AFO) was used rather than standart bar-connected foot abduction orthosis varying from 12 months to 25 months in the follow-up period and 74 of 86 (86%) feet required percutaneous achilles tenotomy. The average age of initial cast treatment was 12.64 days (range 1 to 102 days). The mean follow-up time was 71 months (range 19 to 153 months). Thirty seven feet of 24 patients recieved secondary procedures (43%) consisting of; supramalleolary derotational osteotomy (SMDO) (1 patient/2 feet), complete subtalar release (3 patients/5 feet), medial opening lateral closing osteotomy (double osteotomy) (2 patients/3 feet), double osteotomy with transfer of tibialis anterior tendon (TTAT) (2 patients/3 feet), partial subtalar release (PSTR) (3 patients/5 feet), PSTR with SDO (1 patient/1 foot), posterior release (PR) with repeated achillotomy (1 patient/2 feet), TTAT (6 patients/10 feet), TTAT with PR (2 patients/2 feet), TTAT with Vulpius procedure (1 patient/1 foot) and TTAT with SMDO (2 patients/3 feet) respectively. The amount of percutaneous achilles tenotomy (86%) in our study correlated with the literature which ranged from 80 to 90 %. The transfer of tibialis anterior tendon continued to be the most performed secondary procedure both in our study (51%) and in the literature, but the amount of total secondary procedures in our study (43%) was determined to be higher than the literature data varying from 7 to 27 percent which may be due to unilateral AFO application after Ponseti method for idiopathic clubfoot deformity in our study

Introduction: Activated platelets release various growth factors, some ot which are recognize to improve nerve regeneration. The present study evaluated the effect of platelet-rich-plasma (PRP) in end to end neurorraphy. Material and method: A total of 38 Spragle-Dawley rats were used. The PRP was obteined from each rat and applicated to the same rat. The left hind limb were used as experimental, with the right as control. The animals were treated in two grups. In both groups the sciatic nerve was dissected from the sciatic notch to the bifurcation. The nerve was transected an repaired with epineural suture (ethilon 9–0). Group A (n=12): suture without PRP. Group B (n=15) suture with PRP. The rats were anestherized and electromyographic studie was performed after the following, 120,5 days for group A and 125,86 for group B. Prior to sacrifice muscular and nerve tissue harvesting was performed. The amplitude was expressed as the amplitude at the experimental sde divided by the amplitude at the contralateral, untreated side, multiplied by 100%. Recording was done in gastrocnemius and tibialis anterior muscle. Results: The stimulation was performed in supramaximal form on both groups: Group A: (without PRP). The mean of intensity was 1.49 mA and the mean of threshold was 0,56 mA. The mean of amplitude was 19,53mV for tibialis anterior and 42,83 mV for gastrocnemius. The mean of latency was 2,28ms for tibialis anterior and 2,19ms for gastrocnemius Group B: (with PRP). The mean of intensity was 1,46 mA and the mean of threshold was 0,53 mA. The mean of amplitude was 21,83mV for tibialis anterior and 19,32mV for gastrocnemius. The mean of latency was 2,43ms for tibialis anterior and 2,29ms for gastrocnemius. No stadistical difference on both groups was found. Histological studies were performed and results are no available at the moment of send this abstract. Conclusions:. No evidence has been found that the use of PRP has a beneficial effect on peripheral nerve regeneration. Further studies should be do to elucited the real role of PRP on peripheral nerve regeneration

Purpose of study and background. Psychological factors are considered to play a role in development and maintenance of chronic low back pain (CLBP). Stress or anxiety can change pain sensitivity; however, this has predominantly been studied in healthy individuals with limited work in individuals with musculoskeletal pain. The objective of this study was to quantify the effect of acute exposure to a psychosocial stressor on mechanical pain sensitivity in individuals with and without CLBP. Summary of methods and results. Six individuals with CLBP and 10 individuals without CLBP performed a 10-minute computer task under conditions of low and high psychosocial stress. Psychosocial stress was manipulated using mental maths and memory tasks combined with social evaluative threat. The effect of the stressor was evaluated using blood pressure, heart rate and the state anxiety component of the Spielberger State-Trait Anxiety Index. Mechanical pressure pain threshold (PPT) was recorded on the tibialis anterior muscle using a handheld digital pressure algometer. The stress manipulation increased self-reported anxiety (p<0.001), but not blood pressure or heart rate (p>0.06). Change in PPT from low to high stress was greater in the CLBP group (median ΔPPT = −0.5 kg/cm. 2. ) than in the control group (−0.15 kg/cm. 2. ; p=0.005). Conclusion. Individuals experienced an increase in pain sensitivity after acute exposure to a stressor designed to mimic low-level workplace stressors, and this increase was greater in individuals with CLBP than asymptomatic individuals. These results indicate that this experimental model can be used to study links between pain sensitivity and psychosocial stressors and increase our understanding of their potential role in CLBP. Conflicts of Interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose. This study aimed to objectively define gait derangements and changes before and after Tibialis Anterior Tendon Transfer surgery in a group of patients treated using the Ponseti method. Methods. 21 feet in 13 patients with Ponseti treated clubfoot who showed supination in swing on clinical examination, underwent gait analysis before, and approximately 12 months after, Tibialis Anterior Tendon transfer. 3–4 weekly casts were applied prior to the surgery, which was performed by transfer of the complete TA tendon to the lateral cuneiform. A parental satisfaction questionnaire was also completed. Results. In all but one patient, increased supination in swing phase was confirmed on pre-operative gait analysis, with EMG evidence of poor Tibialis Anterior modulation through-out the gait cycle. Post-operatively all patients showed improved positioning at initial contact, with heel strike and an absence of supination, and a decrease in swing phase supination. In all patients, knees were overly flexed at initial contact, some continuing through stance phase; there was no change seen postoperatively. All parents reported marked improvements in gait and activity level post-operatively. Conclusion. Gait analysis can be useful to confirm the need for tibialis anterior tendon transfer. Improved post-operative gait patterns seen by parents and clinicians can be related to objective improvements seen during gait analysis, confirming the benefit of tibialis anterior tendon transfer in appropriate patients

We reviewed 19 patients (30 feet) with congenital vertical talus treated surgically between 1987 and 1999, 22 of them by the same surgeon. The etiological diagnosis was idiopathic in seven patients. Six patients had associated congenital abnormalities (four arthrogryposis, two digitotalar dysmorphism) and six had associated neurological abnormalities (three microcephalic, three spinal dysraphism). Only two patients had surgery after the age of 18 months. The mean age at surgery was 14.7 months (6 to 51). In 15 feet a two-stage procedure was performed. Lengthening of the extensor tendons, notably tibialis anterior, was followed six weeks later by posterior release. In 15 feet a one-stage procedure was done, with no lengthening of the extensors or transfer of tibialis anterior. The Kidner procedure was done in seven feet, but the tibialis posterior was never found to be subluxed and the procedure was abandoned. The calcaneocuboid joint was opened and pinned in eight feet. The peroneal tendons required lengthening in eight feet. At a mean follow-up of 5.8 years (2 to 13.5), results were excellent in 17 feet (normal forefoot and hind-foot). Results were good in seven feet (normal radiographs, normal hindfoot, but pronated forefoot). In four feet the result was fair (valgus hindfoot with a plantarflexion angle of the talus more than 35(). In one patient, the results in both feet were poor (uncorrected). All seven good results followed a two-stage procedure. We concluded that this was due to relative weakening of the lengthened tibialis anterior to the peroneus longus. Where necessary, plantarflexion of the talus should be corrected at operation, and this should be correlated with intra-operative fluoroscopy. Adequate reduction of the navicula inferomedially on the talar head obviates the need for tendon transfer

Introduction: Hemiplegic cerebral palsy (CP) children are often treated with ankle-foot orthoses (AFO′s) in order to resist abnormal motion patterns and to restore normal function. It has been shown that AFOs are successful in improving pre-positioning of the foot for initial heel strike in CP patients. The myoelectric signal (EMG) during gait provides valuable information with respect to timing of muscular activity. The aim of this study was to evaluate changes in timing of muscle activation in children with hemipelegic CP during gait with and without wearing AFOs. Patients/Materials and Methods: Eight Children (5 boys, 3 girls; mean age 9.5±1.4 years) with mild to moderate hemiplegic CP and no prior surgeries or fixed contractures were studied. The children were tested barefoot and wearing a hinged AFO and shoes. Only children with an initial toe-strike barefoot and a physiological heel-strike with the AFO were included. All children performed a 3-dimensional gait analysis. At least six trials with clear forceplate data have to be collected for each of the two testing condition. Frontal and sagittal video recording took place. A sSurface EMG of vastus medialis/lateralis, rectus femoris, biceps fem-oris, semimembranosus/semitendinosus, gastrocnemius lateralis (only barefoot), and tibialis anterior was collected. Results: Mean ankle plantarflexion at initial foot contact was 16.1° when walking barefoot and 3.4° with the AFO. EMG data showed reduced tibialis anterior muscle activity with the AFO in all patients, especially in early to mid swing phase. Muscle activation pattern was corrected towards normal for knee extensors and hamstrings. Discussion: Our results show that tibialis anterior muscle activity is reduced by a hinged AFO with plantarflexion block in hemiplegic CP children. These results indicate that the pathological muscle activation pattern present in CP patients are not only due to spastic activation but also to a compensation for the abnormal gait pattern

Aim. 10 years after the introduction of the Ponseti casting regimen as standard treatment for idiopathic clubfoot at Alder Hey Children's Hospital, we reviewed the mid-term outcomes of the initial 2-year cohort (treated from 2002–2004). Method. 100 feet were treated in 66 patients. 61 of the 100 feet have been prospectively reviewed on an annual/ bi-annual basis since successful correction, with outcomes of the remaining feet obtained by retrospective analysis. Results. 96 feet responded to initial casting; of these, 31 had a recurrence within the first 2 years (16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, the remaining 15 requiring extensive soft tissue release). 12 feet developed recurrence after 2 years (9 of whom were successfully treated with transfer of tibialis anterior tendon and 3 of whom required extensive soft tissue release) Mean dorsiflexion at average follow-up of 9 years is 15 degrees (95% CI 12.96 to 17.04) and mean abduction 41 degrees. (95%CI 37.65 to 45.07). Conclusion. The Ponseti regimen is a successful treatment option for the management of idiopathic clubfoot. The majority of recurrences occur in the first two years and so close follow-up should be undertaken during this period. The importance of strict compliance with boots and bars must be emphasised to parents at this treatment stage. These mid-term outcomes have highlighted that, although fewer recurrences occur after the first two years, it is difficult to predict which feet might recur; consequently, we recommend following children up in an annual/bi-annual fashion until their skeletal maturity

Aim. To compare outcomes for children treated for idiopathic clubfeet with the Ponseti regimen before (2002–2004) and after (2005–2006) implementation of a dedicated Ponseti service. Method. A retrospective analysis of outcomes for all patients with idiopathic clubfeet treated in the 2 years before and after implementation of a dedicated Ponseti service was undertaken. Results were statistically analysed using Fisher's exact t-test. Results. In the original cohort treated between 2002–2004, with an ad-hoc service where children were treated in general paediatric orthopaedic clinics by a number of different consultants, 100 feet in 66 children were treated. 96 feet (96%) responded to initial casting. 85 feet (85%) required tendo-achilles tenotomy. 31 feet had a recurrence within the first 2 years (16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, the remaining 15 requiring extensive soft tissue release). Between 2005–2006, with a dedicated Ponseti service, 72 feet in 53 children were treated. 72 (100%) responded to initial casting. 60 feet (83.3%) required tendo-achilles tenotomy. Relapse of the initial deformity occurred within 2 years in 11 feet – 4 children required repeat serial casting, 3 feet required tendon of tibialis anterior transfer, 3 required repeat tenotomy of tendo-achilles and one foot required extensive soft tissue release. Conclusion. Our results have shown that a dedicated Ponseti service leads to improved outcomes in the treatment of idiopathic clubfeet. We have shown a statistically significant reduction of recurrence (p=0.02) and extensive soft tissue release (0.002) in those children treated in a specialist service compared to an earlier ad hoc treatment programme

Introduction. Shoes with a rocker sole are commonly prescribed following forefoot surgery to redistribute pressure towards the heel. By shifting the body weight backwards, does the rocker shoe adversely effect balance and so disturb normal muscle activity? This study investigated the effects of the Darco post-operative shoe, and the impact of a contralateral shoe raise, on forefoot pressure, posture and balance. Materials and Methods. Fourteen healthy volunteers were investigated (age 36 ±10.8 yrs 11 females) either wearing (1) left Darco shoe and right standard shoe with/without a 5cm temporary shoe raise (Algeos Ltd) (2) two standard shoes. Postural sway was measured while standing with eyes open/closed and on/off a foam block. Dynamic balance was measured while stepping forwards/backwards and walking. Measurements of foot pressure (TECSKAN Inc USA), 3D body motion (Codamotion, UK) and surface electromyography of lower limb muscles were taken. Results were analysed using a repeated measures ANOVA. Results. The rocker shoe was associated with a 84% (±14) decrease in mean peak medial forefoot pressure a posterior shift of 0.9 cm (±1) in the centre of pressure (COP) and a 223% (±127) increase in tibialis anterior activity (P<0.05). Postural sway and whole body motion while stepping did not change. The shoe raise decreased peak loading in the Darco shoe and resulted in a smaller shift in the COP. Discussion and Conclusions. The increase in tibialis anterior activity helps maintain balance by compensating for the posterior shift in the centre of pressure. In people with weakness in the anterior muscles a rocker shoe may adversely affect balance. A contralateral shoe raise reduces the posterior shift in the COP but, due to a decrease in total loading through the whole foot, forefoot offloading is similar. A contralateral shoe raise may therefore aid balance while maintaining forefoot offloading

We assessed three children who had limb salvage surgery for sarcomata of the proximal fibula. Their ages ranged from 6 to 13 years. MRI showed involvement of the anterior, lateral and deep posterior compartments. Incisional biopsy showed two osteoblastic osteosarcomata and one Ewing’s sarcoma. Preoperative angiogram confirmed that the tibialis posterior artery was the main blood supply to the foot. The surgical technique was as described by Malawer (1984): via an anterolateral incision, the anterior, lateral and deep posterior compartments were excised en bloc with the proximal fibula. The peroneal artery was sacrificed in all three patients, and the common peroneal nerve and tibialis anterior artery in two. In the patient with Ewing’s sarcoma, the tibialis anterior muscle, artery and nerve did not require excision. What remained were the tibialis posterior nerve and artery, gastrocnemius, flexor digitorum longus and most of soleus. The lateral gastrocnemius was rotated forward to fill the defect. The collateral ligament of the knee was reconstructed by suturing the lateral collateral ligament and biceps femoris to the proximal tibia. All three patients had neo-adjuvant chemotherapy. Tumour necrosis ranged from 90% to 100%. At follow-up at 2, 4 and 9 years, there was no recurrence. The Musculoskeletal Tumour Society evaluation was used and all patients scored more than 80% and were happy with the cosmetic result. Although two of the three patients required an orthotic because of weak dorsiflexion, the functional result was good

Purpose: The use of allografts for anterior cruciate ligament (ACL) reconstruction has gained increased popularity. The major benefits of allograft for ACL replacement include decreased morbidity, easier patient rehabilitation and include ease of surgical procedure, decreased harvest site morbidity and easier patient rehabilitation. Further, allografts have improved appeal because of better sterilization techniques, improve graft availability and decreased hospital costs.|The objective of this study was to perform mechanical testing on various types of allograft. Specimens for allograft reconstruction of the anterior cruciate ligament included tibialis anterior tendon, tibialis posterior tendon, Achilles tendon and bone patella tendon tissues. Methods: The allografts tested were used for deployment in patients suffering with anterior cruciate ligament disruptions. A total of fifty grafts were analyzed. The breakdown of graft types included 15 tibialis anterior tendon, 15 tibialis posterior tendon, 10 Achilles tendon and 10 bone patella tendon tissues. The test techniques included: cutting the tendons to a set thickness and length. The tendons were then mounted in a cryogrip and frozen with liquid Nitrogen to below zero. They were mounted into a servo-hydraulic testing machine and pre-loaded and pre-conditioned. The specimens were then stretched to failure at a set strain rate. Results: No difference was found between the mechanical/material properties of the various tendon allografts – these included tensile strength and a high stress linear modulus assessments. The mechanical (structural properties) of the allografts were more dependant on the cross sectional area of the allograft than the type of allograft tissue.The greater the cross-sectional area of the allograft, the greater the strength and stiffness of the graft. Conclusions: These findings have considerable clinical applicability in choosing an allograft for anterior cruciate ligament reconstruction

We evaluated 28 patients, 52 feet with flaccid paraparesis (27 MMC, 1 neonatal paraplegia) in which a posterior transference of the tibialis anterior was performed for talus deformities. Between 1987 and 2001 in two institutions. Mean age at surgery 6+6 ( from 0+4 to 12+10) 16 males, 12 females,. Neurological last level functioning was 1 Toracic, 2 lower lumbar, 25 sacral. Technique: through minimal incisions the muscle is transferred posteriorly opening bluntly the interosseous membrane and weaved to the aquiles tendon if present and fixed to the top of the os calcis in 10° of equinus. There where 23 bilateral cases. Asociated surgeries 17 extension calcaneal osteotomies 5 peroneal z plasties, 4 short peroneal to posterior tibialis transfer, 2 vertcal talus correction, 2 Evans lenghtenings, 1 IF arthrodesis. Follow up in 25 patients (3 lost) was 3+11 (0+3 to 12+1). Complications: 1 late calcaneal osteomielitis, ,2 severe valgus feet in a vertical talus. Results: we measured calcaneal pich in 26 feet in a lateral xray. Mean preop measure 34*(20 to 50 ) postp 21* (15 to 25). All patients were independent walkers at follow up. Conclusion: Posterior transfer of the tibialis anterior is an excellent operation that prevents talus progression in the absence of planta flexors alone or in conjuction with extension calcaneal osteotomy in older children, the better position lessens trhe chance for the habitual skin lesions in this patients

Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior tendon transfer as an endpoint. Methods. A prospectively collated database was used to identify all patients treated in the Ponseti clinic at the Royal Manchester Children's Hospital between 2002 and 2005 with idiopathic clubfoot who had not received any treatment prior to their referral. Rate of tibialis tendon transfer as well as the patient's presenting Pirani score were noted. Feet were grouped for analytical purposes into a mild clubfoot (Pirani score <4) and a severe clubfoot (Pirani score 4) category depending on initial examination. Clinic records were reviewed retrospectively to identify patients who were poorly compliant at wearing boots and bars and were categorised into having “good” or “bad” compliance with orthosis use. Results. 132 feet in 94 children were included in the study. 30 (23%) tibialis tendon transfers were performed at a mean of 4.2 years (range 2.3–5.5 years). Children with severe clubfoot had a significantly higher rate of tendon transfer compared with those with mild clubfoot (28% vs. 6%; p=0.0001). 81% of patients were classified as being “good” boot wearers. Tibialis tendon transfer rates in those who were poorly compliant with boot usage were significantly higher compared with those with good compliance (52% vs. 16%; p=0.0003). There was a significantly higher tendon transfer rate in those with severe disease and poor compliance compared with good compliance (69% vs. 20%; p=0.0002). There was no association between boot compliance and tendon transfer rates in those with mild disease. Conclusion. This study shows that late recurrences, requiring tibialis anterior tendon transfer, are associated with severity of disease at presentation and compliance with use of orthoses. Tendon transfer rates are higher for those with severe disease. We have confirmed previous reports that compliance with orthotic use is associated with recurrence. However, the novel findings regarding recurrence rates in mild clubfeet may have implications regarding usage of orthoses in the management of mild idiopathic clubfeet after initial manipulation using the Ponseti method

Introduction. The rate of total hip arthroplasty (THA) surgery continues to dramatically rise in the United States, with over 300,000 procedures performed in 2010. Although a relatively safe procedure, THA is not without complications. These complications include acetabular fracture, heterotopic ossification, implant failure, and nerve palsy to name a few. The rates of neurologic injury for a primary THA are reported as 0.7–3.5%. These rates increase to 7.6% for revision THA. The direct anterior total hip arthroplasty (DATHA) is gaining popularity amongst orthopedic surgeons. Many of these surgeons elect to use the Hana® table during this procedure for optimal positioning capability. Although intraoperative mobility and positioning of the hip joint during DATHA improves operative access, select positions of the limb put certain neurologic structures at risk. The most commonly reported neurologic injuries in this regard are to the sciatic and femoral nerves. To our knowledge, the use of neuromonitoring during DATHA, especially those using the Hana® table, has not been described in the literature. Methods. The patient was a 60-year-old male with long standing osteoarthritis of the right hip and prior left THA. Somatosensory evoked potential (SSEP) leads were placed bilaterally into the hand (ulnar nerve) as well as the popliteal fossae (posterior tibial nerve). Unilateral electromyography leads were placed into the vastus medialis obliquus, biceps femoris, gastrocnemius, tibialis anterior, and abductor hallucis of the operative limb (Fig. 1). Once the patient was sterilely draped, a direct anterior Smith-Peterson approach to the hip was used. Results. After the patient completed standard pre-operative protocol, neuromonitoring leads were placed as described above. There were no complications, neuromonitoring remained stable from baseline, and the patient tolerated the procedure well. Moreover, the senior author routinely uses a prophylactic cable around the calcar, particularly in patients with osteoporotic bone, as was the case with this patient. The patient's post-operative course has been without complications as well. Conclusion. There are a few studies that have examined the pressure changes around the femoral nerve during a DATHA and found that the nerve was at most danger with misplacement of a retractor near the anterior lip of the acetabulum. Furthermore, the popularity of DATHA and the Hana® table make neuromonitoring more amenable for use since the whole limb does not need to be sterilely prepped as with other approaches to the hip. The reported rates of neurologic injury during any THA along with those developed from passage of prophylactic cerclage cables and the goals of reducing surgical complications make this novel technique intriguing. It allows the surgeon yet another safe and effective tool to decrease the likelihood of neurologic injury during DATHA. For any figures or tables, please contact the authors directly

Background. Administration of Botulinum toxin type A (BTX-A) in patients with spastic cerebral palsy aims to improve mobility by increasing joint range of motion and decreasing passive resistance. However, our recent animal experiments indicated that BTX-A can decrease muscle”s length range of force exertion (Lrange), and increase its passive forces and extracellular matrix (ECM) collagen content. Moreover, BTX-A injected into the tibialis anterior (TA) was shown to spread into non-injected synergistic muscles in the whole anterior crural compartment. These effects that contradict the treatment aims deserve further investigation. Aim. To test in a rat model if: (1) BTX-A injected into the medial and lateral gastrocnemius (GM&GL) muscles spreads into the synergistic soleus (SOL) as well as antagonistic TA and extensor digitorum longus (EDL). (2) The muscles exposed show a wider Lrange, decreased muscle passive force and reduced ECM collagen. Methods. 2×0.1U/20µl of BTX-A (BTX-A group, n=6) or only 2×20µl of saline (Control group, n=6) were prepared and each was injected into the mid-belly of the GM and GL separately. 5 days post injection, forces of all muscles were measured in passive state and also on activation. The GM&GL length was changed whereas; all other muscles were kept at constant length. After biomechanical testing, the muscles were histologically analyzed using Gomori trichrome stain to detect ECM collagen. Two-way ANOVA (factors: GM&GL length and animal group) was used to assess BTX-A effects on forces, and the Kruskal-Wallis test was used to test the change in proportion of collagenous tissue for each muscle. Differences were considered significant at p<0.05. Results. Injected muscles: ANOVA showed significant main effects of both factors on GM&GL total forces and a significant interaction. Force reductions are more pronounced at shorter lengths (increase from 80.8% to 88.4% with decreasing length). Lrange decreased (by 24.1%). ANOVA showed significant main effects of only muscle length on GM&GL passive forces and no significant interaction. Non-injected muscles: ANOVA showed significant main effects of both factors (for SOL), or only of BTX-A (for TA and EDL) only on muscle total forces, but no significant interaction. Force drops for the SOL (89.8%) and anterior crural muscles (57.0% and 51.0% for TA and EDL) do indicate spread of BTX-A intra- and extra-compartmentally. Histological analyses showed increased ECM collagen contents of BTX-A group for the GM&GL, TA, and EDL. Conclusion. Narrowed Lrange and increased ECM collagen content are not in accord with the clinical purpose of the treatment. BTX-A did not reduce passive forces, but did not cause an increase either. Remarkably, the results show that BTX-A leakage is a major issue that can affect muscles of even antagonistic muscle compartments. Hence, our animal experiments indicate much more complex BTX-A effects than considered, which requires further testing in patients

To evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10–35 years; mean 16.8 years). None had received botulinum toxin A injections or surgery in the preceding six and 12 months respectively. All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (± 5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 nineteen patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.25, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p = 0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. However, distinguishing between the natural history of CP and interventions and isolating the effects of one intervention from others in multilevel surgery are well recognised difficulties in cohort studies in CP. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP

There are numerous causes of cavovarus feet, the most common of which are the hereditary motor and sensory peripheral neuropathies. Regardless of the underlying aetiology, cavovarus feet are caused by muscle imbalance. Often the imbalance is between a relatively strong tibialis posterior acting against a weaker peroneus brevis, and a relatively weak tibialis anterior being over powered by peroneus longus. Intrinsic muscle weakness and gastro-soleal tightness is common. After the failure of non-operative management, flexible deformity can be corrected with a combination of tendon transfers and osteotomies. Frequently surgical management of cavovarus feet involves a combination of calcaneal and first metatarsal osteotomies, peroneus longus to brevis transfer, transfer of tibialis posterior through the interosseous membrane to the dorsum of the foot, tendo-Achilles and plantar fascia lengthening and correction of toe deformities. The post-operative recovery is slow, but most patients achieve good functional results and report improvements in their activities of daily living

To assess outcomes following a radical approach to cases of compartment syndrome in which a significant degree of muscle necrosis is found, 4 paediatric and adolescent patients with a delayed diagnosis of compartment syndrome in which muscle necrosis in single or multiple compartments were treated by radical debridement of necrotic tissue and reconstruction of the anterior compartment through transfer of peroneus brevis to extensor digitorum and hallucis longus tendons. Where suitable, a free vascularised and innervated gracilis muscle transfer to the tibialis anterior tendon stump was carried out with anastomosis of the nerve to gracilis to the deep peroneal nerve. Free gracilis muscle transfer was functional in one of the two patients whilst peroneus brevis transfer to extensor digitorum and hallucis tendons was functional in all three patients. In one patient, radical debridement resulted in loss of the entire anterior compartment requiring permanent ankle foot orthosis. All others had recovery of protective foot sensation and at minimum follow-up of 12 months were walking unaided. Infection was not seen in any patient. Prompt fasciotomy, debridement and reconstruction for late diagnosis of compartment syndrome proved limb-saving in our patients