Aim of study: To assess ankle dorsiflexion of operated pedes equinovari congenitales in both clinical examination and gait analysis.

Introduction: Mac Kay subtalar release corrects mostly perfectly deformed feet. Operated feet show however stiffness not only in subtalar but as well as in ankle joint. The range of motion in ankle joint was not yet studied systematically at all. Gait analysis offers the possibility to follow the motion in ankle joint dynamically.

Material: Thirty six consecutively operated feet were examined by clinical as well as by gait analysis examination. All were operated by Mac Kay procedure at least one year before examination (range 1–7 years). Feet were examined in lying and stance positions. Gait analysis was based on use of Oxford foot model (8 cameras motion capture system).

Results: Dorsiflexion/plantiflexion of the foot estimated by clinical examination was compared with maximum dorsiflexion in phase of mid-stance (second rocker)/maximum plantiflexion in pre-swing phase (third rocker). Differences individually for each patients in dorsiflexion/plantiflexion were calculated. Mean of difference between dorsiflexion in clinical examination and dorsiflexion in gait analysis x = 14.3°. Mean of diference between plantiflexion in clinical examination and plantiflexion in gait analysis x= 5,4°. Using T-paired test these differences were found statistically significant (p=0,01). Normal maximum dorsiflexion of the children’ foot in gait analysis is about 20°. From this point 14 operated feet out from 36 did not fulfill this criterion. On the other hand only 4 operated feet showed in gait analysis dorsiflexion less than 10°.

Discussion: Dorsiflexion of the foot is important for smooth gait. The diference between dates from clinical examination and dates from gait lab can be explained by weight - bearing force pushing the foot into dorsiflexion during second rocker or by secondary adaptive intrinsic bending of the foot

Conclusion: Operated feet showed moderate/severe stiffnes of ankle joint. Despite of it, the gait cycle was not significantly impaired.

Aim: To analyse retrospectively patients after subtalar extra-articular arthrodesis in CP patients.

Material and methods: The operation was designed to correct pronated valgus foot. Followed cohort involved 43 patients with 72 affected and operated feet. Subtalar arthrodesis was based on insertion of bicortical graft obtained from iliac wing in the corrected position of the foot. Immobilisation in POP cast continued for 6 weeks postoperatively. Patients were followed clinically and radiographically in standing position before the operation, and after that at regular intervals. Clinical examination involved estimation of heel valgus, foot-prints, videodocumentation. Lateral talo-calcaneal angle (TC) and calcaneal-bottom angle (CB) were measured on radiographs. Moreover qualitative-descriptive classification was used (good, fair, poor).

Results: The median of preoperative TC angle was 44,5° at right foot and 48,0° at left foot. The median of postoperative angle changed to 29,5° at right foot and 29,0° at left foot. The difference in TC angles before and after operation was statistically significant. The median of preoperative CB angle was 7,5° at right foot and 7,0° at left foot. The median of postoperative CB angle was 10,5° at right foot and 7,5° at left foot. The difference in CB angles before and after operation was not statistically significant. Operation failed in two cases due to collapse or migration of the graft. Significant improvement in this study was found in 59 (82%) of cases.

Discussion: Plenty of reports concerning the use of classical Grice-Green operation in different modifications were reported. This study is based on the use of bicortical cortico-cancellous graft, which provided good stability as well as a smooth incorporation to the neighbouring bones. The correction in TC angle dominated over change in CB angle.

Conclusion: Subtalar extra-articular arthrodesis showed in mid-term follow up very good results.

Aim: To introduce a mini-invasive surgical treatment for lengthening of knee flexors in cerebral palsied children.

Material and methods: Operation is performed in prone position under tourniquet control. The trocar (4mm) is introduced from middle thirds of dorsal surface of the thigh in the direction caudally from small incision. By means of the trocar soft tissues are separated from the superficial fascia and a working tunnel is created. Then optical system is introduced and gas (CO2) is pushed in. Under the guidance of the videoscopic system another two small incision are done, one medially one laterally. By means of the knife blade and arthroscopic scissors the superficial fascia is divided and musculotendinous junction of gracilis and semitendinosus is found and muscular recession is done. The aponeurosis of semi-membranosus is isolated and transversely cut. When necessary, from second mini-incision the aponeurosis of biceps femoris is isolated and cut. Operation method was prepared on a cadaver study, concerning the learning curve, for the operation were selected patients with only moderate flexion contracture, Bleck angle between 50–60°.

Results: In 5 operated legs videoscopic tenotomy resulted in full correction of fixed flexion. Small incisions healed uneventfully. No vascular or neurological complications were registered.

Discussion: Videoscopic technique firstly was used in our institution for correction of fixed equinus in CP patients. Concerning good results and acquired operation technique, obtained experience was used for correction of fixed flexion contracture.

Conclusion: Videoscopic correction of fixed knee flexion in CP seems to be a safe and reliable operation method.

Juvenile hip instability is associated with many conditions. Most of them belong to the group of neuromuscular diseases. Generally following categories can be enumerated: 1. Cerebral palsy, 2. Myelomeningocele, 3. Spinal cord injury, 4. Paraplegia following spine surgery, 5. Poliomyelitis, 6. Inflammatory hip disease, 7. Idiopathic instability, 8. Recurrent post-traumatic hip instability. In the groups 1–5 a chronic muscle imbalance is the reason of the displacement of the femoral head. Inflammatory joint disease produces displacement through cartilage and bone destruction and increased intra-articular pressure. Very rare idiopathic instability is usually associated with generalised hypermobility. For the early diagnosis a careful clinical examination is necessary involving range of motion, testing of the hip stability by the Palmén’s test in the same way like in new-borns. Routine x-ray screening at least once per year is mandatory. For the groups 1–5 a muscle imbalance has to be corrected first. Elimination of muscles contractures or muscles transfers respectively, showed a high efficiency if these surgical corrections were performed early. Femoral osteotomy alone does not provide reliable results. Any form of pelvic osteotomy is necessary to correct acetabular insufficiency. For the inflammatory hip disease early active surgical treatment is best prevention of displacement. Idiopathic hip instability has to be differentiated from common snapping hip. No treatment is necesary. Recurrent hip dislocation can be cured by a posterior capsulorrhaphy.

Aims: Several authors reported better results after combined tenotomy of hip flexors and adductors in cerebral palsied (CP) children than by isolated tenotomy of adductors. Prospective study involving 45 children (90 hips) was performed in this research project. Methods: 45 children with spastic form of CP in the age range of 2–13 years (preoperative Reimer’s index in 25 hips 0–24%, in 38 hips 25–39%, in 18 hips 40–59%, in 9 hips over 60%) were submitted to combined adductor and flexor release. All patients were postoperatively immobilised in broomstick POP cast for 6 weeks and cured by night splinting for at least 6 months postoperatively. Routine x-rays were taken before operation, after removal of POP cast and 3–5 years after operation, all in strictly neutral position. Results: Mean Reimer’s index correction was 16%, maximally 49% in 76 out from 90 affected hip joints. CE angle correction ranged from 3 to 48 degrees. Postoperative changes of both parameters were statistically siginificant. Using Vojta kinesiologic grading 41 children (91%) became improved. The proportion of walkers/non walkers changed from 9/36 to 27/18. Conclusions: In this cohort the correction of Reimer’s index under 39% was achieved in 96% of all treated patients. Many patients benefited from the operation becoming walkers. Adequate soft tisue procedure offers a very good possibility how to reduce the rate of osteotomies in CP patients.

Retrospectively to analyse factors contributing to the development of hyperextension deformity after distal surgical lengthening of hamstrings in cerebral palsy. In the cohort of 51 diparetic patients (98 operated knees ) surgically treated for fixed flexion deformity at least five yers before this study was contemplated, the range of of hyperextension of the knee was measured.

According to surgical technique two subgroups were differentiated:

A./ Simple cutting of gracilis and semitendinosus, followed by fractional lengthening of semimembranosus and biceps femoris.

B./ Proximal stumps of gracilis and semitendinosus after its transverse division were anchored to fractionally lengthened semimembranosus.

Assessment involved: Measurement of hyperextension of the knee in lying and standing position and by walking using video-documentation. Values of Bleck popliteal angle before and after operation were estimated. This cohort did not involve any case with residual fixed plantar flexion of the foot. Both surgical subgroups were compared for occurence of hyperextension deformity > 5° in lying, standing positions and by walking. Testing by Fisher exact test did not show any statistical difference in all three compared situations (p > 0,05). The occurence of hyperextension > 5°in lying position was found in 5 knees ( 5,1 %), in standing position in 8 knees ( 8,2 %) and by walking during stance phase in 12 knees (12,3 %). In no case hyperextension of the knee exceeded 15°. Statistical testing between the postoperative Bleck popliteal angle ( stratified into classes below 20° and over 20°) and the occurence of hyperextension deformity did not show in Fisher exact test any statistical significance. On the other side the testing between postoperative Bleck popliteal angle ( stratified as above) and the type of surgery showed statistical significancy in Fisher exact test. Simple cutting of gracilis and semitendinosus brought about oftener the lower values of Bleck popliteal angle below 20°.

It seems that the role of type of treating superficial flexors in the ways used in this study was not so much decisive for development of hyperextension deformity.