Percutaneous epiphysiodesis using transphyseal screws (PETS) has been developed for the treatment of lower limb discrepancies with the aim of replacing traditional open procedures. The goal of this study was to evaluate its efficacy and safety at skeletal maturity. A total of 45 consecutive patients with a mean skeletal age of 12.7 years (8.5 to 15) were included and followed until maturity. The mean efficacy of the femoral epiphysiodesis was 35% (14% to 87%) at six months and 66% (21% to 100%) at maturity. The mean efficacy of the tibial epiphysiodesis was 46% (18% to 73%) at six months and 66% (25% to 100%) at maturity. In both groups of patients the under-correction was significantly reduced between six months post-operatively and skeletal maturity. The overall rate of revision was 18% (eight patients), and seven of these revisions (87.5%) involved the tibia. This series showed that use of the PETS technique in the femur was safe, but that its use in the tibia was associated with a significant rate of complications, including a valgus deformity in nine patients (20%), leading us to abandon it in the tibia. The arrest of growth was delayed and the final loss of growth at maturity was only 66% of that predicted pre-operatively. This should be taken into account in the pre-operative planning.

Purpose of the study: Clinical assessment of the upper limb in the cerebral palsy child remains difficult, and minimally reproducible. Thus many authors use for the upper limb, as for the lower limb, movement analysis to aid in decision making and obtain an objective measurement of postoperative results.

Material and method: Kinematic analysis and EMG were performed with the Vicon system in 27 cerebral palsy children with a spastic upper limb. The patients were compared with data obtained in a control population of 12 children. Eight patients had a second assessment after treatment. The experimental protocol followed the recommendations of the International Society of Biomechanics. The muscles targeted by the treatment were the pronator teres, the flexor carpi ulnaris, and the adductor pollicis (lengthening, transfer, toxin injection).

Results: Significant kinematic anomalies (p< 0.05) found were: excessive homolateral inclination and flexion/extension of the trunk, excessive abduction and external rotation of the arm/trunk, excessive elbow flexion, excessive pronation of the forearm, and flexion and ulnar inclination of the wrist. There was significant improvement postoperatively in the group of treated patients (p< 0.05) regarding the kinematics of the trunk, shoulder and elbow, as well as the EMG behaviour of the biceps/triceps couple despite the fact that the procedure had not affected these muscles or joints.

Discussion: Kinematic and EMG anomalies involving the trunk, shoulder and elbow represent motor strategies compensating for distal anomalies: – recruitment of the biceps allows improved supination, pulls the elbow in flexion. Since the patient cannot extend the elbow to achieve a task, compensation with the trunk increases the amplitude of the flexion-extension movement; – ‘extrinsic’ supination is achieved via an increase in external rotation of the arm in relation to the trunk and homolateral inclination of the trunk.

Conclusion: These observations have therapeutic implications: clinical, kinematic or EMG anomalies involving the trunk, shoulder, and elbow should not be treated per se but reevaluated after treatment of more distal anomalies.

Objective: To evaluate the effectiveness of distal rectus femoris (RF) release versus transfer to treat gait abnormalities of the knee in ambulatory children with cerebral palsy.

Methods: Ninety-three children were included in this study. Thirty-two patients underwent RF transfer at a mean age of 11.8 years and sixty-one underwent distal RF release at a mean age of 12.5 years. Indications for surgery included RF contractures, abnormal RF activity during swing phase (EMG) and kinematic characteristics of stiff-knee gait. All patients had pre–and postoperative 3D gait analysis and EMG at one year follow up. To evaluate outcomes, patients were grouped by pre-operative knee kinematics (swing-phase peak knee flexion (PKF) < 50º or PKF > 50º occurring later than 77% of the cycle). All data was analyzed statistically.

Results: For the group of patients with PKF< 50º, this value increased significantly after RF transfer (p=.005) and after RF release (p=.03). Children with PKF later than 77% of the cycle also showed significant improvement after both procedures (p=.001; p=.02). All patients experienced a significant decrease of muscle contractures.

Discussion: According to the results of this study, both RF transfer and release brought significant results. We opt for distal RF release, since is technically easier, particularly when one-stage multilevel procedures are being performed.

Aim: To evaluate the effectiveness of distal rectus femoris (RF) release versus transfer to treat gait abnormalities of the knee in ambulatory children with cerebral palsy.

Patients & Methods: Thirty-nine children were included in this study. Thirty patients (55 limbs) underwent RF transfer at a mean age of 11.8 years. and nine (16 limbs) underwent distal rectus release at a mean age of 12.5 years. Indications for surgery included RF contracture and abnormal activity during swing phase in dynamic electromyography (EMG), whether with the presence of kinematic characteristics of stiff-knee gait or not. All patients had pre- and postoperative gait analysis and EMG. To evaluate functional outcomes, patients were grouped by pre-operative knee kinematics (normal; swing-phase peak knee flexion (PKF) < 50°; and peak knee flexion > 50° happening later than 77% of the cycle). All data was analyzed statistically.

Results: For the group of patients with PNF< 50°, this value increased significantly after rectus transfer (p=.005). Children with PNF> 50° and later than 77% of the cycle, showed significant improvement in timing after both procedures (p=.001; p=.02). When kinematic parameters were normal before surgery, they did not improved, although patients experienced a significant decrease of muscle contractures.

Conclusions: According to the results of this study, RF transfer would be the preferred procedure for those patients with preoperative swing-phase knee flexion < 50°. For the rest of patients, both procedures brought similar results. We opt for distal RF release since is technically easier, particularly when one-stage multilevel procedures are being performed.

Objective: To identify the demographics, risk factors and guidelines for treatment in a population of cerebral palsy (CP) children with fractures.

Materials and Methods: One hundred and fifty children with CP received treatment for fractures from 1948 through 2000. To identify changes in demographics, patients treated before 1992 were compared to those treated after 1992. The latter group was matched by age and gender to a group of CP children without fractures and compared for: CP pattern, bone density, ambulatory status, presence of G-tube, weight for height-age Z score, surgical procedures during the previous year, presence of contractures in the proximity of the fracture and seizure medications. All data was analyzed statistically.

Results: 67% of patients had a spastic quadriplegic pattern of CP and 89% were non-ambulatory; 78% of fractures occurred in lower limbs, 48% of the fractures were delayed in diagnosis, and 62% of patients showed osteo-penia. Children treated after 1992 had higher incidence of multiple fractures, less contractures, and less surgical procedures. The risk factors identified for increased fracture risk were: the use of seizure medication (p=.001), quadriplegic CP pattern (p=.005), decreased ambulatory status (p=.001), and lower bone density (p=.001). Most fractures were treated with soft bulky dressing.

Conclusions: Ambulatory status and the presence of seizure medication are the greatest risk factors for fracture in children with CP. As a consequence, a low bone density occurs. Future research should focus on underlying fracture mechanisms and prevention.