We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 ± 1.3 v 10.7 ± 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 ± 11° internal to 3 ± 9.5° external in the proximal group and from 9 ± 14° internal to 4 ± 12.4° external in the distal group. Correction of the foot progression angle was from a mean of 10.0 ± 17.3° internal to 13.0 ± 11.8° external in the proximal group (p < 0.001) compared with a mean of 7.0 ± 19.4° internal to 10.0 ± 12.2° external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia

Over a 4 year period 27 children with cerebral palsy underwent proximal femoral derotation osteotomy resulting in a total of 42 operations performed. Each of these children had pre operative gait analysis performed followed by derotation osteotomy. The degree of derotation varied individually and was judged to be correct when the foot lay in a neutral position. Gait analysis was not repeated until 1 year after surgery to allow for complete bony union, recovery of the soft tissues and general patient rehabilitation. Pre-operative and post-operative data were compared to give a quantitative analysis of the actual derotation obtained. The mean age at the time of operation was 9.7 years (range 4.5–14.5 years). The male : female ration was 6 : 5. the mean amount of femoral derotation achieved was 26.25 degrees (minimum 7 degrees, maximum 66 degrees). The goal of the operation was to correct internal rotation and achieve a hip in a neutral position throughout the majority of the gait cycle. The average hip rotation in a normal able-bodied person is 1.72 degrees of external rotation. 84% achieved more than 75% derotation to neutral. The remainder were considered operational failures. These results quantitatively demonstrate that proximal femoral derotation osteotomy is a successful operation in cerebral palsy to correct intoeing

In this study we highlight the advantages supported by long term results of using our external fixator system for femoral derotation osteotomy as part of our management regime for developmental dysplasia of the hip. Out of all the children in the East Kent area who present with a dislocated hip each year about 4 require a femoral derotation osteotomy in order to maintain a good position after either open or closed reduction. The system has been used since 1981. 51 patients (56 hips) were reviewed with a follow up between 5 and 18 years with a mean of 11 years. The age at diagnosis ranged from shortly after birth to 42 months with a mean of 12 months. The treatment involved a protocol in which traction was applied for 4 weeks preoperatively if the hip was high and open or closed reduction was selected according to the result of an arthrogram. 33 of the 51 patients received traction and 23 patients (25 hips) had an open reduction. Following reduction the hips were immobilized in a spica for 6 weeks after which the femoral osteotomy using the fixator was performed. A second 6 week period of spica immobilization followed after which the fixator and spica were removed. We had 16 complications including 3 patients who developed AVN of the femoral head. 8 patients required an additional 16 operations. We assessed the patients clinically and radiologically using the Severin’s grading system. At final follow up over 85% of patients were assessed to have a clinical grade of 1 and 2 and over 70% a radiological grade of 1 and 2. Our technique of external fixation has several advantages over conventional methods of fixation of the femur: a) the avoidance of a 2nd open procedure to remove the implant, b) the accuracy of the femoral derotation using the goniometer and c) the achievement of femoral fixation without the need for image intensifier screening

Purpose of Study. To evaluate the results of using external fixation to stabilise femoral derotation osteotomy involved in DDH surgery. Methods and results. A retrospective analysis was performed on 44 patients undergoing 48 femoral osteotomies for DDH surgery between the years 2001 and 2009 by a single surgeon (senior author MC). The external fixator was used either during the primary procedure involving femoral shortening to aid in hip reduction (4 patients) or to correct femoral malrotation in a reduced hip as a secondary procedure(40 patients). As the external fixator frame was within the hip spica it was not a cause of concern to the parents or the child. There was no evidence of any pin tract infection and all patients eventually progressed to satisfactory bony union. One patient had delayed union which was treated successfully with conservative management and one patient had a malunion requiring a further osteotomy and extended treatment with the external fixator. Conclusion. External fixation is a viable alternative for the traditional internal fixation used for femoral osteotomy involving DDH Surgery. Our study has shown that it produces satisfactory results with minimal complications. Apart from minimising tissue scarring in the muscle and subcutaneous planes, it gives a cosmetically better scar. If there is further need for revision surgery it provides healthy tissue planes for dissection. Furthermore it eliminates the need for additional surgery required for removal of plates

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

Purpose. Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21 and we describe long-term outcomes following the precise use of femoral varus derotation osteotomy. Methods. 16 consecutive hips, 9 children, with Trisomy 21 aged =10 years, were identified from hospital databases. Clinical notes and radiographs from presentation to final follow-up were reviewed. Results. Mean age at first known hip dislocation was 4.1 years (range 3, 7 years). All had a femoral varus derotation osteotomy (VDRO). In 2 hips, significant intraoperative instability persisted and a periacetabular osteotomy and capsulorraphy were required. Mean Femoral neck shaft angle (NSA) fell from 166.7° (+/-6.9°) to 106.0° (+/-5.4°). Mean follow-up was 5.9 years (+/-2.9). 1 hip (6.2%) developed painful arthritis. 14 hips developed peri-trochanteric varus deformities. 2 (12.5%) developed periprosthetic fractures 4 and 8 years post-operatively. 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. In those aged =9 who have not developed hip incongruency, a VDRO with adequate varisation and minimal derotation was sufficient. Reducing the femoral NSA to approximately 100°, intraoperatively stabilised most hips. If instability persisted, a periacetabular osteotomy and capsulorraphy were performed. The 2 hips requiring additional procedures had the least corrected NSAs (115° and 122°) in our series. These patients were also older, aged 7 and 10, a factor that may have also contributed to the need for acetabular correction. 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 100-110°. This should be performed before either the age of 8 years or teardrop development. In our experience this has been effective in maintaining hip stability

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

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

Our aim in this retrospective study of 52 children with spastic hemiplegia was to determine the factors which affected the amount of residual pelvic rotation after single-event multilevel surgery. The patients were divided into two groups, those who had undergone femoral derotation osteotomy and those who had not. Pelvic rotation improved significantly after surgery in the femoral osteotomy group (p < 0.001) but not in the non-femoral osteotomy group. Multiple regressions identified the following three independent variables, which significantly affected residual pelvic rotation: the performance of femoral derotation osteotomy (p = 0.049), the pre-operative pelvic rotation (p = 0.003) and the post-operative internal rotation of the hip (p = 0.001). We concluded that there is a decrease in the amount of pelvic rotation after single-event multilevel surgery with femoral derotation osteotomy. However, some residual rotation may persist when patients have severe rotation before surgery

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

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

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

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

We describe a technique of femoral derotation osteotomy performed according to the Ilizarov principles of percutaneous corticotomy and fixation with a frame. We performed 24 femoral osteotomies in 16 patients, four with cerebral palsy and 12 with idiopathic femoral anteversion. All had rapid union and there were few complications. The advantages of the method include early ambulation, good control of rotation and axial alignment, and minimal scarring

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.

We reviewed 14 patients (16 hips) treated by open reduction and upper femoral derotation osteotomy for congenital dislocation of the hip. Nine patients with 11 treated hips had growth deformities of the proximal femur; in all of them the top screw of the fixation plate lay within the cartilaginous precursor of the greater trochanter. In the five control hips the top screw was more distal. In the nine patients (mean follow-up 10.8 years) there was an increase of 14 degrees in the neck-shaft angle (p = 0.01) and of 18 degrees in the angle between the capital femoral physis and the shaft (p = 0.01) compared to the control group. This indicates that growth disturbance of the greater trochanteric apophysis as a result of plate fixation leads to long-term deformity

We studied the results of multi-level surgical intervention for children with cerebral palsy. Thirty patients, aged 7–16 years, with spastic diplegia (n=20), or spastic hemiplegia (n=10) were studied prospectively by gait analysis. Multilevel surgery included a combination of psoas lengthening, medial hamstring lengthening, rectus femoris transfer and gastrocnemius lengthening +/− foot surgery or femoral derotation osteotomies. Gait analyses were carried out pre-op and at 6 and 24 months post-op. Children with spastic diplegia increased their walking velocity by an average of 20% at two years (p< 0.05). Mean stride length increased from 89cm pre-op to 102cm at two years (p< 0.05) with similar improvements in both groups of children. Maximum knee extension in stance improved from an average 17.5 degrees flexion pre-operatively to an average 5 degrees flexion postoperatively (p< 0.05). Peak knee flexion in swing was maintained and the timing improved. Peak ankle dorsiflexion in stance was unchanged following surgery but the timing of peak ankle dorsiflexion was normalised to late stance (from 24% of cycle pre-operatively to 48% of cycle post-operatively (norm = 48%). Average maximum hip extension in stance did not change. The mean anterior pelvic tilt did not change post-operatively. However, a number of children with spastic diplegia had increased anterior pelvic tilt post-operatively. These results are similar to those reported internationally, with most improvement seen distally at the knee and ankle and less improvement at the hip. Increased anterior pelvic tilt was seen as a consequence of hamstring lengthening in some more involved patients

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

Background: Only a few studies have investigated the change in energy cost and functional ability after lower limb bone surgeries in children with cerebral palsy (CP). Research Objectives: To examine the effect of intervention (surgery) in the operated group over time on: Energy cost values, Walking functions, and on Functional mobility. Setting: Motion analysis laboratory and the child development and rehabilitation center at Assaf Harofeh Medical Center. Methods: Participants in the study consisted of 41 children with CP. The study consisted of two groups: one that had undergone surgery (the operated group) and a control group. The operated group consisted of 20 children with CP who were candidates for Femoral Derotation Osteotomy (FDO) or Tibial Derotation Osteotomy (TDO), or both. They were examined three times: the first was one day prior to surgery; the second was six months after surgery; and the third was about a year after surgery. Each examination included: anthropometric measurements, energy cost measurement using the Heart beat cost index (HBCI) in the stair climbing test, assessment of function during walking using the Functional assessement questionnaire (FAQ) and assessment of motor function using the Gross motor functional classification system (GMFCS). Control group consisted of 21 children with CP in ages compatible to the operated group, who had not been operated during the passing year. The control group was examined two times, the second a year after the first. The examination was the same as in the operated group. Main Results: In the operated group, a significant change (p< 0.0076) was observed in energy cost values over time following surgical intervention. The change was indicated in decreasing energy cost values from measurement to measurement (from value of 0.91 to value of 0.48). Significant decrease was found in the third measurement, as compared to the first measurement (p=0.0026). In the control group, a decrease, although not significant (p=0.062) was observed in energy cost values. Angles values measured in both hip and tibia a year after surgery were changed significantly (p< 0.004). Angles values after surgery were measured within normal range. Conclusions: This study indicates that the FDO and TRO have effected over time on the energy cost values in the operated group

Introduction: Hurler syndrome (mucopolysaccharidosis type I) is an autosomal recessive disorder with characteristic progressive musculoskeletal manifestations termed dysostosis multiplex. These include dorsolumbar kyphosis with gibbus deformity, deficient femoral head ossification and acetabular dysplasia, valgus deformity of the knee, broad hands prone to carpal tunnel syndrome, pes planus and generalised joint contracture. Untreated, death occurs early in childhood. Therapeutic bone marrow transplantation (BMT) has improved life expectancy and now patients attain skeletal maturity. BMT, however, appears to have little influence on skeletal outcome, and optimum orthopaedic management is as yet uncertain. Methods: Nineteen patients treated by BMT at a mean of 10 months (range 3–19 months), have been followed over a mean of 93 months (range 3–196 months). Five patients are now adolescent. We describe the clinical and radiological features of these patients and detail orthopaedic procedures and their outcome. Descriptive statistical analysis is used, displaying mean values and standard deviation where appropriate. Results: All patients demonstrate characteristic acetabular dysplasia and failure of ossification of the superolateral femoral head. Nine have undergone bilateral pelvic and femoral derotation osteotomies at a mean of 48 months (range 24–105 months); mean acetabular angle preoperatively was 33 ± 3.8°. Five patients had pelvic osteotomy only. IN the remaining five patients, mean acetabular angle is 25 ± 3.3°. Genu Valgum of variable severity due to failure of ossification of the lateral aspect of the proximal tibial metaphysis is observed early. Four patients underwent medial epiphyseal stapling at a mean of 105 months. While most patients demonstrate thoracolumbar vertebral anomalies peculiar to Hurler syndrome, only five had had progressive scoliosis, two having had anterior spinal fusion at 37 and 72 months. Most patients experience symptoms of carpal tunnel syndrome from about 48 months. Only one patient has significant difficulty mobilising independently. Conclusions: Our findings reflect the variability of musculoskeletal problems seen in Hurler syndrome. This cohort represents one of the largest available for study, and ongoing review will clarify the natural outcome of the disease and help determine if and when orthopaedic intervention is appropriate