To assess long and short term kinematic gait outcomes after rectus femoris transfers (RFT) in ambulatory children with cerebral palsy (CP). A retrospective review was conducted of ambulatory children with spastic diplegic CP, who had RFT plus motion analysis preoperatively and 1 year post-operatively. Those with 5 and 10 year post-operative motion analysis were also included. The primary variables were: peak knee flexion range of motion in swing (PKFSW), timing of peak knee flexion in swing as a percent of the gait cycle (PKF%GC), and knee range of motion from peak to terminal swing (KROM). Responders and non-responders were identified. Descriptive, kinematic and kinetic variables were evaluated as predictors of response. 119 ambulatory children (237 limbs) with spastic diplegic CP who had RFT were included. Mean age at surgery was 10.2 years (range 5.5 to 17.5). Sixty-seven participants were classified at GMFCS Level II and 52 at GMFCS Level III. All participants (237 limbs) had a preoperative and 1 year postoperative motion analysis. Motion analysis at 5 and 10 years post-operatively included 82 limbs and 28 limbs, respectively. Ninety-three (39%) limbs improved in both PKFSW and PKF%GC. PKFSW improved in 59% of limbs. Responders started 1.2 SD below the mean PKFSW preoperatively, and improved by an average of 1.9 SD to reach a normal range at 1 year post-operatively (p < 0.05). Improvement was maintained at 5 and 10 years postoperatively. Those at GMFCS level II were more likely [OR 1.71, CI 1.02, 2.89] to have improved PKFSW at 1 year postoperatively than those at GMFCS level III. PKF%GC improved in 70% of limbs. Responders had delayed PKF%GC, starting 10 SD above the mean (later in the gait cycle) preoperatively. Their timing improved towards normal values: 5 SD, 5.9 SD, 3.5 SD from the mean, (earlier in the gait cycle) at 1, 5 and 10 years postoperatively, respectively (p<0.05). KROM improved in only 24% of limbs. For all variables, there was a significant difference in mean preoperative values between responders and non-responders (p<0.05). RFT improves short and long-term kinematic gait outcomes. The majority of children responded to RFT with improvements in PKFSW or PKF%GC at 1, 5, and 10 years post RFT. GMFCS level is a predictor of improved PKFSW, with children at GMFCS Level II having an increased likelihood of improvement at 1 year post surgery. Children who have worse preoperative values of PKFSW, PKF%GC, and KROM have a greater potential for benefit from RFT. Characteristics associated with responders who maintain long term positive outcomes need to be identified.
Fractures through the physis account for 18–30% of all paediatric fractures, leading to growth arrest in 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients < 1 8 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators and radiographic data were collected at baseline, one and two years post-injury. A total of 167 patients had at least one year of follow-up. Average age at injury was 10.4 years, 95% CI [9.8,10.94]. Reduction was required in 51% of cases. Right-sided (52.5%) and distal (90.1%) fractures were most common. After initial reduction 52.5% of fractures had some form of residual angulation and/or displacement (38.5% had both). At one year follow-up, 34 patients (21.1%) had evidence of a bony bridge on plain radiograph, 10 (6.2%) had residual angulation (average 12.6°) and three had residual displacement. Initial angulation (average 22.4°) and displacement (average 5.8mm) were seen in 16/34 patients with bony bridge (48.5%), with 10 (30.3%) both angulated and displaced. Salter-Harris type II fractures were most common across all patients (70.4%) and in those with bony bridges (57.6%). At one year, 44 (27.3%) patients had evidence of closing/closed physes. At one year follow-up, there was evidence of a bony bridge across the physis in 21.1% of patients on plain film, and residual angulation and/or displacement in 8.1%. Initial angulation and/or displacement was present in 64.7% of patients showing possible evidence of growth arrest. The incidence of growth arrest in this patient population appears higher than past literature reports. However, plain film is an unreliable modality for assessing physeal bars and the true incidence may be lower. A number of patients were approaching skeletal maturity at time of injury and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine the true incidence and impact of growth arrest.
Fixation of tendon transfers about the foot in children typically involves creating a bone tunnel through which a suture is passed and tied over an external button. An internal suspension system, such as the Endobutton (Smith & Nephew) is an alternative fixation method which has demonstrated excellent fixation strength and minimal intraosseous tunnel displacement in various adult procedures. Application of the Endobutton technique has no risk of skin ulceration, does not require suture removal and may provide more secure fixation. The purpose of this study is to compare the biomechanical properties of the external button and Endobutton fixation techniques. Our primary outcome measure was intra-osseous displacement of the suture, during both static and dynamic loading, in cadaver feet. Nine adult cadaver feet were utilised. A bone tunnel was drilled in the lateral cuneiform and #1 braided non-absorbable suture was passed through the tunnel. One end was secured to a carabiner to be attached to the materials testing system and the other to the fixation device. The external button and Endobutton fixation techniques were tested once in each cadaver, randomising the order of testing to minimise bias. Each fixation technique underwent static and dynamic cyclic loading. A custom Matlab script was used to process video and materials testing system data. The relative displacement of the suture within the bone tunnel, as a function of time and load magnitude, was recorded during static and dynamic cyclic loading. Both fixation groups were analysed and compared for statistical significance using a paired T-test and an alpha value of 0.05. The Endobutton group had significantly less displacement within the bone tunnel, during both static and dynamic loading, than the external button. The average displacement during static loading was 0.42 mm for the Endobutton and 2.17 mm for the external button (p=0.0019). Similarly, during dynamic cyclic loading, the mean displacement was 0.32 mm for the Endobutton and 0.66 mm for the external button (p=0.0115). The Endobutton internal suspension technique demonstrates significantly less displacement during static and dynamic loading than the external button, during biomechanical testing in cadaver feet. The Endobutton may provide superior fixation than the traditional external button technique for tendon transfers in children. In addition, this technique avoids the risk of skin ulceration from the button and the need for suture removal.
There is currently no standardised complication grading classification routinely used for paediatric orthopaedic surgical procedures. The Clavien-Dindo classification used in general surgery was modified and validated in 2011 by Sink et al. and has been used regularly to classify complications following hip preservation surgery. The aim of this study was to adapt and validate Sink et al.'s modification of the Clavien-Dindo classification system for grading complications following surgical interventions of the upper and lower extremities and spine in paediatric orthopaedic patients. Sink et al.'s modification of the Clavien-Dindo classification system was further modified for paediatric orthopaedic procedures. The modified grading scheme was based on the treatment required to treat the complication and the long term morbidity of the complication. Grade I complications do not require deviation from standard treatment. Grade II complications deviate from the normal post-operative course and require outpatient treatment. Grade III complications require investigations, re-admission or re-operation. Grade IV complications are limb or life threatening or have a potential for permanent disability (IVa: with no long term disability and IVb: with long-term disability). Grade V complications result in death. Forty-five complication scenarios were developed. Seven paediatric orthopaedic surgeons were trained to use the modified system and they each graded the scenarios on two occasions. The scenarios were presented in a different random order each time they were graded. Fleiss' and Cohen's k statistics were performed to test for inter-rater and intra-rater reliabilities, respectively. The overall Fleiss' k value for inter-rater reliability was 0.772 (95% CI, 0.744–0.799). The weighted k was 0.765 (95% CI, 0.703–0.826) for Grade I, 0.692 (95% CI, 0.630–0.753) for Grade II, 0.733 (95% CI, 0.671–0.795) for Grade III, 0.657(95% CI, 0.595–0.719) for Grade IVa, 0.769 (95% CI, 0.707–0.83) for Grade IVb and 1.000 for Grade V (p value <0.001). The Cohen's k value for intra-rater reliability was 0.918 (95% CI, 0.887–0.947). These tests show that the adapted classification system has high inter- and intra-rater reliabilities for grading complications following paediatric orthopaedic surgery. Given the high intra- and inter-rater reliability and simplicity of this system, adoption of this grading scheme as a standard of reporting complications in paediatric orthopaedic surgery could be considered. Since the evaluation of surgical outcomes should include the ability to reliably grade surgical complications, this reproducible, reliable system to assess paediatric surgical complications will be a valuable tool for improving surgical practices and patient outcomes.
