The February 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures.

Aims

The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V.

Aims

The frequency of severe femoral retroversion is unclear in patients with femoroacetabular impingement (FAI). This study aimed to investigate mean femoral version (FV), the frequency of absolute femoral retroversion, and the combination of decreased FV and acetabular retroversion (AR) in symptomatic patients with FAI subtypes.

This retrospective study was to investigate radiographic and clinical outcomes in treatment of hip instability in children and young adults undergoing periacetabular osteotomy (PAO) with or without femoral osteotomy. 19 patients (21 hips) with CP were treated with PAO with or without femoral osteotomy The mean age was 16.2 years old (7 to 28 years). Five patients (5 hips) received PAO, Six patients (7 hips) PAO with femoral derotation osteotomy, Eight patients (9 hips) PAO with varus derotational osteotomy (VDRO). Anteroposterior pelvic radiographs and CT were taken to assess the migration percentage (MP), lateral center-edge angle (LCEA), Sharp angle, femoral neck anteversion, neck-shaft angle. Gross Motor Function Classification System (GMFCS) was assessed pre- and post-surgery. Complications were recorded. The mean follow-up time was 41.2 months (range, 24 to 86 months). All hips but one were pain free at final visit. The GMFCS improved by one level in 10 of 19 patients. MP improved from a mean of 76.6% to 18.6% at the final follow-up(p<0.001). The mean pre-operative LCEA and Sharp angle were −33.5 ? and 35 ? respectively, improved to 21.5 ? and 11.8 ? at the final follow-up (p < 0.001). There were six patients (7 hips) had re-subluxation at latest follow-up. Nervus cutaneus femoris lateralis was impaired in four patients after surgery. There was no re-dislocation, AVN, or infections in this group. Satisfactory clinical and radiologic results can be obtained by PAO with or without femoral osteotomy minor complications

Aims

Periacetabular osteotomy (PAO) is an established treatment for acetabular dysplasia. It has also been proposed as a treatment for patients with acetabular retroversion. By reviewing a large cohort, we aimed to test whether outcome is equivalent for both types of morphology and identify factors that influenced outcome.

MPFL reconstruction has demonstrated a very high success rate with improved patella stability, physical function, and patient-reported outcomes. However technical error and a lack of consideration of anatomic risk factors have been shown to contribute to failure after MPFL reconstruction. Previous research has also reported a complication rate of 26% following surgery. The purposes of this study were to determine the re-dislocation rate, type and number of complications, and most common additional surgical procedures following MPFL reconstruction. Patients with symptomatic recurrent patellofemoral instability underwent an MPFL reconstruction (n = 268) and were assessed with a mean follow-up of 31.5 months (minimally 24-months). Concomitant procedures were performed in addition to the MPFL reconstruction in order to address significant anatomic or biomechanical characteristics. Failure of the patellofemoral stabilization procedure was defined as post-operative re-dislocation of the patella. Rates of complications and re-procedures were assessed for all patients. The re-dislocation rate following MPFL reconstruction was 5.6% (15/268). There were no patella fractures. A total of 49/268 patients (18.3%) returned to the operating room for additional procedures following surgery. The most common reason for additonal surgery was removal of symptomatic tibial tubercle osteotomy hardware in 24/268 patients (8.9%). A further 9.3% of patients underwent addtional surgery including revision MPFL reconstruction: with trochleoplasty 8/268 (3.0%), with tibial tubercule osteotomy 4/286 (1.5%) and with femoral derotation osteotomy 3/268 (1.1%); manipulation under anaesthesia for reduced knee range of motion 4/268 (1.5%); knee arthroscopy for pain 8/268 (3.0%); and cartilage restoration procedures 3/268 (1.1%). There was 1 case of wound debridement for surgical incision infection. MPFL reconstruction using an a la carte approach to surgical selection demonstrated a post-operative redislocation rate of 5.6%. The rate of complications following surgical stabilization was low, with the most common reason for additional surgery being removal of hardware

Aims. The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT. Methods. We retrospectively evaluated symptomatic patients with FAI or hip dysplasia with CT scans performed between September 2011 and September 2016. A total of 261 hips (174 patients) had a measurement of FT and TT. Their mean age was 31 years (SD 9), and 63% were female (165 hips). Patients were compared to an asymptomatic control group (48 hips, 27 patients) who had CT scans including femur and tibia available for analysis, which had been acquired for nonorthopaedic reasons. Comparisons were conducted using analysis of variance with Bonferroni correction. Results. In the overall study group, abnormal FT was present in 62% (163 hips). Abnormal TT was present in 42% (109 hips). Normal FT combined with normal TT was present in 21% (55 hips). The most frequent abnormal combination was increased FT combined with normal TT of 32% (84 hips). In the hip dysplasia group, 21% (11 hips) had increased FT combined with increased TT. The prevalence of abnormal FT varied significantly among the subgroups (p < 0.001). We found a significantly higher mean FT for hip dysplasia (31°; SD 15)° and valgus hips (42° (SD 12°)) compared with the control group (22° (SD 8°)). We found a significantly higher mean TT for hips with cam-type-FAI (34° (SD 6°)) and hip dysplasia (35° (SD 9°)) compared with the control group (28° (SD 8°)) (p < 0.001). Conclusion. Patients with FAI had a high prevalence of combined abnormalities of FT and TT. For hip dysplasia, we found a significantly higher mean FT and TT, while 21% of patients (11 hips) had combined increased TT and increased FT (combined torsional malalignment). This is important when planning hip preserving surgery such as periacetabular osteomy and femoral derotation osteotomy. Cite this article: Bone Joint J 2020;102-B(12):1636–1645

Aims. Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT. Patients and Methods. A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed. Results. We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified. Conclusion. In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218–1229

Aims

A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood.

Introduction. Version abnormalities of the femur, either retroversion or excessive anteversion, cause pain and hip joint damage due to impingement or instability respectively. A retrospective clinical review was conducted on patients undergoing a subtrochanteric derotation osteotomy for either excessive anteversion or retroversion of the femur. Methods. A total of 49 derotation osteotomies were performed in 39 patients. There were 32 females and 7 males. Average age was 29 years (range 14 to 59 years). Osteotomies were performed closed with an intramedullary saw (Figure 1). Fixation was performed with a variety of intramedullary nails. Patients requiring a varus or valgus intertrochanteric osteotomy were excluded. Pure rotational corrections only were performed. Twenty-four percent of patients had a retroversion deformity (average −8° retroversion, range +1 to −23°), 76% had excessive anteversion of the femur (average +36° anteversion, range +22° to +53°). Etiology was post-traumatic in 5 (10%), diplegic cerebral palsy in 4 (8%), fibrous dysplasia in 2 (4%), Prader-Willi Syndrome in 1 (2%) and idiopathic in 37 (76%). Previous surgery had been performed in 51% of hips. Fifty-seven percent underwent concomitant surgery with the index femoral derotation osteotomy, including hip arthroscopy in 39% (labral debridement alone or with femoral neck osteochondroplasty), a tibial derotation osteotomy in 12% and periacetabular osteotomy in 6%. Concomitant tibial osteotomies were performed to correct a compensatory excessive external tibial torsion that would be exacerbated in the correction of excessive femoral anteversion. The modified Harris Hip Score was used to assess the results in patients with a minimum of 24 months follow-up. Results. There were no non-unions. Average time to union was 3.3 months. One late infection occurred 10 months after surgery, treated successfully with hardware removal and antibiotics. Two patients, one with Prader-Willi syndrome and one with Ehlers-Danlos syndrome, were converted to total hip replacement. At an average follow-up of 6.1 years (range 2 to 19.1 years), the modified Harris Hip Score improved by 26 points (p< 0.001, Wilcoxon signed-ranks test). The results were rated as excellent in 71%, good in 22%, fair in 5% and poor in 3%. Subsequent surgery was required in 73%, 93% of which were hardware removals. Discussion and Conclusion. A closed, subtrochanteric derotation osteotomy of the femur is a safe and effective procedure to treat either femoral retroversion or excessive anteversion. Excellent or good results were obtained in 93%, despite the need for subsequent hardware removal in more than two-thirds of the patients. For figures/tables, please contact authors directly.

Aims

Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate.

The purpose of the study was to identify risk factors that are associated with re-displacement of the hip after surgical reconstruction in cerebral palsy. Retrospective review of children with cerebral palsy who had hip reconstruction with proximal femoral varus derotation osteotomy (VDRO) and Dega-type pelvic osteotomy, between 2005–2012, at a UK and European institution, was performed. Patient demographics, GMFCS, clinical and radiological outcome were assessed as well as the presence of pelvic obliquity and significant scoliosis (Cobb angle > 10 degrees). Redisplacement was defined as Reimer's Migration Index (MI) >30% at final follow-up. Logistic regression analysis was used to assess which factors were predictive of redisplacement and adjusted for clustered variables (α = 0.05). Eighty hips were identified in 61 patients. The mean age at surgery was 8.8 years (± 3.3). Mean MI pre-op was 68% (± 23%) and post-op was 8% (± 12%). At a mean follow-up, of 3.2 years (± 2.0), 23 hips had a MI >30%. Of these; five were symptomatic, and one had required a salvage procedure. Metalwork removal was undertaken in 14 hips. Logistic regression demonstrated that the pre-operative MI and the percentage of acute correction were significant predictors of re-displacement. If the pre-operative MI was greater than 65 percent, the odds ratio (OR) for redisplacement was 5.99 (p = 0.04). If correction of the MI was less than 90% of the pre-operative MI, the OR for re-displacement was 4.6 (p = 0.03). Age at the time of surgery, GMFCS, pelvic obliquity and scoliosis were not predictive of re-displacement. These results, firstly, highlight the importance of hip surveillance in children with cerebral palsy to allow timely intervention to ensure adequate radiological outcomes. Secondly, as in developmental hip dysplasia, full concentric reduction is essential to reduce the risk of re-displacement, with its associated clinical consequences

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles.

Cite this article: Bone Joint J 2015;97-B:564–71.

Proximal femoral varus osteotomy improves the biomechanics of the hip and can stimulate normal acetabular development in a dysplastic hip. Medial closing wedge osteotomy remains the most popular technique, but is associated with shortening of the ipsilateral femur.

We produced a trigonometric formula which may be used pre-operatively to predict the resultant leg length discrepancy (LLD). We retrospectively examined the influence of the choice of angle in a closing wedge femoral osteotomy on LLD in 120 patients (135 osteotomies, 53% male, mean age six years, (3 to 21), 96% caucasian) over a 15-year period (1998 to 2013). A total of 16 of these patients were excluded due to under or over varus correction. The patients were divided into three age groups: paediatric (< 10 years), adolescent (10 to 16 years) and adult (> 16 years). When using the same saw blades as in this series, the results indicated that for each 10° of angle of resection the resultant LLD equates approximately to multiples of 4 mm, 8 mm and 12 mm in the three age groups, respectively.

Statistical testing of the 59 patients who had a complete set of pre- and post-operative standing long leg radiographs, revealed a Pearson’s correlation coefficient for predicted versus radiologically observed shortening when using a wedge of either 10° or 20° of 0.93 (p <  0.001). The 95% limits of agreement from the Bland–Altman analysis for this subgroup were –3.5 mm to +3.3 mm. It has been accepted that a 10 mm discrepancy is clinically acceptable.

This study identified a geometric model that provided satisfactory accuracy when using specific saw blades of known thicknesses for this formula to be used in clinical practice.

Cite this article: Bone Joint J 2014;96-B:1124–9

The February 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: flexible plasters; dual 8-plate or ablation for knee epiphysiodesis; ultrasounds for pulled elbow; leg length without the radiation; Boyd amputation in limb deficiencies; gold standard club foot treatment; quadrupled semitendinosis graft effective in paediatric ACL reconstruction; and predicting complications following cerebral palsy hip reconstruction

We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome. We present the history and operative management. The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate. No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged. To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position

We reviewed the long-term radiological outcome, complications and revision operations in 19 children with quadriplegic cerebral palsy and hip dysplasia who underwent combined peri-iliac osteotomy and femoral varus derotation osteotomy. They had a mean age of 7.5 years (1.6 to 10.9) and comprised 22 hip dislocations and subluxations. We also studied the outcome for the contralateral hip. At a mean follow-up of 11.7 years (10 to 15.1) the Melbourne cerebral palsy (CP) hip classification was grade 2 in 16 hips, grade 3 in five, and grade 5 in one. There were five complications seen in four hips (21%, four patients), including one dislocation, one subluxation, one coxa vara with adduction deformity, one subtrochanteric fracture and one infection. A recurrent soft-tissue contracture occurred in five hips and ten required revision surgery. In pre-adolescent children with quadriplegic cerebral palsy good long-term outcomes can be achieved after reconstruction of the hip; regular follow-up is required. Cite this article: Bone Joint J 2013;95-B:259–65

The October 2012 Children’s orthopaedics Roundup. 360. looks at: magnetic growing rods and scoliosis correction; maintaining alignment after manipulation of a radial shaft fracture; Glaswegian children and swellings of obscure origin; long-term outcome of femoral derotation osteotomy in cerebral palsy; lower-leg fractures and compartment syndrome in children; fractures of the radial neck in children; management of the paediatric Monteggia fracture; and missing the dislocated hip in Western Australia

Background. Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21. We describe long-term outcomes following precise use of the femoral varus derotation osteotomy to achieve and maintain hip stability and community ambulation. Methods. All individuals with Trisomy 21, who had hip surgery at Toronto's Hospital for Sick Children between 1998 and 2008, were searched using the hospital databases. 16 hips in 9 children aged less than 10 years, were identified. All had a femoral varus derotation osteotomy (VDRO) with a target femoral neck shaft angle (NSA) of 105° and less than 20° external rotation. All were performed by the senior author JHW. The clinical notes and radiographs were reviewed from presentation to final follow up. Continuous variables were assessed for normality with the d'Agostino Pearson test. Normally distributed variables are presented as means with 95% confidence intervals. Pre and postoperative means were compared using the student's t-test for paired samples. Results. Mean age at first known hip dislocation was 4.56 years (3.98, 5.15), mean age at surgery 6.07 years (5.15, 7.0) and mean follow-up 5.4 years (3.75, 7.06). Mean femoral neck shaft angle (NSA) fell from 166.7° (162.2°, 171.1°) to 106.0° (103.1°, 110.2°). In 2 hips, significant intraoperative instability persisted and periacetabular osteotomies with capsulorraphies were required. All patients developed an asymptomatic waddling gait postoperatively. 14 hips developed peritrochanteric varus deformities, mean 20.7° (15.96°, 25.4°)2 (12.5%) sustained periprosthetic fractures 4 and 8 years postoperatively. 1 hip (6.2%) developed painful arthritis. None re-dislocated at latest follow up. Conclusion. Prevention of long term disabling pain from habitually dislocating or recurrently subluxed hips, in patients with Trisomy 21, requires surgical intervention to increase hip containment. We believe surgical management of habitually subluxed or dislocated Trisomy 21 hips allows for a predictable result. We recommend a varus producing proximal femoral osteotomy to correct the NSA to 105° with less than 20° of external rotation. This technique was successful at restoring and maintaining hip stability in 16 hips with a mean follow-up of 5.4 years, whilst maintaining the patient's ability to remain community ambulators. It should be performed before aged 8 or signs of a widened or V-shape teardrop develops. In our experience this has been effective in maintaining hip stability. However, little is known about the natural history of habitual hip dislocation in these children. Patients with Trisomy 21 are living longer with hips that are at continuous risk. Thought should be given to the potential benefits of periodic screening of this treatable hip condition