Abhay Khot

The radiological assessment of pelvic obliquity in cerebral palsy and the impact on hip development

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels. The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpes angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity. The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

The transverse Vulpius gastrocsoleus recession for equinus gait in children with cerebral palsy

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.

Subtalar fusion for pes valgus in cerebral palsy: results of a modified technique in the setting of single event multilevel surgery.

Background: We studied the use of cortico-cancellous circular allograft combined with cannulated screw fixation for the correction of dorsolateral peritalar subluxation in a series of children with bilateral spastic cerebral palsy undergoing single event multilevel surgery. Methods: Forty-six children who underwent bilateral subtalar fusion between January 1999 and December 2004 were retrospectively reviewed. Gait laboratory records, Gross Motor Function Classification System (GMFCS) levels, Functional Mobility Scale (FMS) scores, and radiographs were reviewed. The surgical technique used an Ollier type incision with a precut cortico-cancellous allograft press-fit into the prepared sinus tarsi. One or two 7.3 mm fully threaded cancellous screws were used to fix the subtalar joint. Radiographic analysis included preoperative and postoperative standing lateral radiographs measuring the lateral talocalcaneal angle, lateral talo-first metatarsal angle, and navicular cuboid overlap. Fusion rate was assessed with radiographs >12 months after surgery. Results: The mean patient age was 12.9 years (range, 7.8 to 18.4 y) with an average follow-up of 55 months. Statistically significant improvement postoperatively was found for all 3 radiographic indices: lateral talocalcaneal angle, mean improvement 20 degrees (95% CI, 17.5-22.1; P<0.001); lateral talo-first metatarsal angle, mean improvement 21 degrees (95% CI, 19.2-23.4; P<0.001); and navicular cuboid overlap, mean improvement 29% (95% CI, 25.7%-32.6%; P<0.001). FMS improved across all patients, with Gross Motor Function Classification System III children experiencing a 70% improvement across all 3 FMS distances (5, 50, and 500 m). All 3 radiographic measures improved significantly (P<0.001). Fusion was achieved in 45 patients and there were no wound complications. Conclusions: With this study, we demonstrate significant improvement in radiographic segmental alignment and overall function outcome with this modified subtalar fusion technique. We conclude that this technique is an effective complement for children with dorsolateral peritalar subluxation undergoing single event multilevel surgery. Level of Evidence Level IV.

Gastrocsoleus recession techniques: an anatomical and biomechanical study in human cadavers

Lengthening of the conjoined tendon of the gastrocnemius aponeurosis and soleus fascia is frequently used in the treatment of equinus deformities in children and adults. The Vulpius procedure as described in most orthopaedic texts is a division of the conjoined tendon in the shape of an inverted V. However, transverse division was also described by Vulpius and Stoffel, and has been reported in some clinical studies. We studied the anatomy and biomechanics of transverse division of the conjoined tendon in 12 human cadavers (24 legs). Transverse division of the conjoined tendon resulted in predictable, controlled lengthening of the gastrocsoleus muscle-tendon unit. The lengthening achieved was dependent both on the level of the cut in the conjoined tendon and division of the midline raphé. Division at a proximal level resulted in a mean lengthening of 15.2 mm (sd 2.0, (12 to 19), which increased to 17.1 mm (sd 1.8, (14 to 20) after division of the midline raphé. Division at a distal level resulted in a mean lengthening of 21.0 mm (sd 2.0, (18 to 25), which increased to 26.4 mm (sd 1.4, (24 to 29) after division of the raphé. These differences were significant (p < 0.001).

Musculoskeletal Evaluation of Children with Cerebral Palsy

Cerebral Palsy (CP) is the most common chronic disability of childhood. The problems involved are complex; not only do these children have problems of mobility, but a plethora of associated problems [1]. A recent definition of CP includes secondary musculoskeletal problems [2]. The inclusion of this in the definition recognises the significance of musculoskeletal problems and the impact these problems have on the lives of children with CP and their families. Orthopedic management of the child with CP aims to reduce the impact of these musculoskeletal problems to help the child with CP to reach his maximum potential [3]. To accurately assess children and prepare management plans, a combination of medical history, physical examination, functional assessment, medical imaging, observational and instrumented gait analysis, and assessment of patient and family goals must be interpreted [4]. A detailed annual orthopedic assessment for all children with CP is recommended [5]. For an ambulant child, more frequent assessments are required during periods of rapid growth, observed deterioration in physical examination measures, and after interventions, including gait correction surgery. For a non-ambulant child, more frequent assessments are indicated according to hip surveillance guidelines [6, 7], during periods of observed deterioration, and following interventions such as hip or spine surgery. A systematic and practiced routine is conducive to efficiency and accuracy [5]. This paper discusses the Physical Examination Protocol used by the Hugh Williamson Gait Analysis Laboratory, in Melbourne, Australia.

Symptomatic hallux valgus and dorsal bunion in adolescents with cerebral palsy: clinical and biomechanical factors

The prevalence of severely symptomatic deformities of the first metatarsophalangeal (MTP) joint in adolescents with cerebral palsy (CP) requiring arthrodesis is unknown. Recent literature regarding these deformities is limited. We studied the presentation of severe, symptomatic deformities of the first ray in a large population of children and adolescents with CP and their association with gross motor function, CP subtype, and other musculoskeletal deformities.

High prevalence of vitamin D deficiency in 2–17 year olds presenting with acute fractures in southern Australia

Aim To determine vitamin D deficiency risk and other lifestyle factors in children aged 2–17 years presenting with an acute fracture to Sunshine Hospital. Methods A prospective observational study was undertaken using a convenience sample data collected from children aged 2–17 years of age presenting with an acute fracture. Recruitment was undertaken over a 3-month period from February to May 2014. Risk factors for vitamin D deficiency (skin pigmentation, hours spent outdoors, sunscreen use and obesity) were identified. Patients providing consent, had measurements of serum 25-hydroxyvitamin D (25-OHD). Vitamin D deficiency was defined as < 50 nmol/L. Results Of the 163 patients recruited into this study, 134 (82%) had one or more risk factor(s) for vitamin D deficiency. Of these, 109 (81%) consented to 25-OHD testing, with a median of 53 nmol/l (range 14–110 nmol/l) obtained. A total of 57 (52% at risk, 35% of total participants) were found to be vitamin D deficient. 45 (80%) had mild deficiency (30–50 nmol/l) and 11 (20%) had moderate deficiency (12.5–29 nmol/l). Conclusions One third of all participants, and the majority participants who had one or more risk factor(s) for vitamin D deficiency, were vitamin D deficient. Based on our findings we recommend that vitamin D status be assessed in all children with risk factor of vitamin D deficiency living in urban environments at higher latitudes presenting with fractures. The effect of vitamin D status on fracture risk and fracture healing in children and teenagers is yet to be determined, as do the effects of vitamin D supplementation in vitamin D deficient paediatric patients presenting with acute fracture.

High incidence of vitamin D deficiency in 2 – 17 year olds presenting with fracture to a Melbourne suburban public hospital

To determine vitamin D deficiency risk and other lifestyle factors in children and teenagers aged 2 – 17 years presenting with fracture to Sunshine Hospital, a clinical observational study was undertaken using convenience sample data collected from children and teenagers aged 2 - 18 years of age presenting with fracture, for whom consent had been obtained to determine clinical characteristics and lifestyle factors. Recruitment was undertaken over a 4 month period from 1st February to 31st May 2014. A suburban Melbourne (latitude 38°S) teaching hospital, Sunshine Hospital provides paediatric orthopaedic services for a high proportion of children and teenagers from ethnically diverse backgrounds with an increased proportion of highly pigmented individuals, which may influence vitamin D status specifically. Proxy measures of vitamin D were used (skin pigmentation, hours spent outdoors, sunscreen use and obesity) [1] to determine patients at risk for vitamin D deficiency. Further consent was then obtained from at risk patients to take blood for 25 OH vitamin D (LIAISON®, Diasorin Assay). Of the 162 patients recruited into this study, 133 (82%) had risk factors for vitamin D deficiency. Of these 108 (81% of at risk) consented to blood testing for 25 OH vitamin D, with a median of 50nmol/l (range 14 – 110nmol/l) obtained. A total of 56 (52% at risk, 34% of total participants) were found to be vitamin D deficient and of these 45 (80% at risk) were mildly deficient (25 OH D 30 -50nmol/l) and 11 (20% at risk) had moderate deficiency (25 OH D 12.5 – 29 nmol/l). Although our study was undertaken at the end of summer, one third of the patients in our study were vitamin D deficient. Furthermore, half of those clinically deemed at risk for vitamin D deficiency were confirmed on biochemical testing. Childhood fracture incidence has been reported to be increasing, and with relatively stable genetic characteristics, any variations in childhood fracture incidence would imply environmental changes. The effect of mild to moderate vitamin D deficiency on fracture risk, healing and longer term refracture risk in children and teenagers is yet to be determined, however, based on our findings we recommend that vitamin D status be assessed in all at risk children and teenagers living in urban environments at higher latitudes presenting with fracture.