Bryan J. Tompkins

Safety of Percutaneous Tendoachilles Tenotomy Performed Under General Anesthesia on Infants With Idiopathic Clubfoot

Background Most patients with idiopathic clubfeet require a percutaneous tendoachilles tenotomy to correct residual equinus deformity. This procedure is typically performed with the child awake in an outpatient setting. Percutaneous tendoachilles tenotomy under general anesthesia offers the potential advantages of better pain control, the ability to perform the procedure in a more controlled manner, and the possibility of lessening the pain response of the infant. Potential disadvantages include concerns regarding the safety of general anesthesia in infants. The purpose of this study is to review the safety of this procedure performed in the operating room under general anesthesia. Methods A retrospective review was carried out of patients with idiopathic clubfoot less than 1 year of age who underwent percutaneous tendoachilles tenotomy under general anesthesia from 2000 to 2008. Patient medical records were reviewed for gestational age, age at surgery, risk factors for anesthesia, and surgical/anesthesia-related complications. To be discharged on the day of surgery, patients met the accepted criteria. Children at risk for apnea were considered for overnight observation using established criteria of postconception age under 44 weeks, premature birth, pulmonary comorbidities, and history of an apneic event. Results One hundred and thirty-seven patients underwent a total of 182 tenotomies under general anesthesia. Ninety-two tenotomies were unilateral, 45 were bilateral. The average postconception age at time of surgery was 53.9 weeks (range, 41 to 90 wk, SD 9.8 wk). Eighty-nine patients were under 3 months of age. Twenty-one patients (15.3%) met the criteria for the observation for postoperative monitoring for apnea because of postconception age under 44 weeks or gestational age under 37 weeks. Three patients were admitted overnight because of a maternal history of drug abuse. No patients had earlier apneic events or were American Society of Anesthesiologists Class III for comorbidities. No patient showed apnea or anesthesia-related complications. Conclusions Percutaneous tendoachilles tenotomy under general anesthesia can be safely performed in infants with clubfeet. No complications related to anesthesia were identified in this group and nearly all patients were discharged on the day of surgery. Level of Evidence Prognostic level 3.

Outcomes of Orthopaedic Surgery With and Without an External Femoral Derotational Osteotomy in Children With Cerebral Palsy.

Background: Ambulatory children with cerebral palsy (CP) often present with multiple deviations in all planes including increased internal hip rotation during gait. Excessive femoral anteversion is a common cause of deviation managed surgically with an external femoral derotational osteotomy (FDO). The purpose of this study was to evaluate the gait and functional outcomes of a group of subjects with CP who underwent surgical intervention that included an FDO compared with a match group with indications of internal hip rotation that did not receive an FDO. Methods: For this retrospective study, subjects were identified from the Motion Analysis Laboratory database that had orthopaedic surgery including an FDO (FDO group). A control group was established from a chart review identifying subjects that had indications for an FDO, but did not have this surgery (No-FDO group). All subjects had preoperative and postoperative gait studies. Subjects categorized as Gross Motor Function Classification System (GMFCS) levels I and II in both FDO and No-FDO groups were combined for analysis. Subjects rated as GMFCS level III were analyzed separately. Preoperative to postoperative kinematic and kinetic variables, Gait Deviation Index, net oxygen cost, and PODCI scores were analyzed with paired t tests. Results: Typical sagittal plane kinematic variables improved significantly by equivalent magnitudes for both FDO and No-FDO groups (GMFCS I/II and III). Transverse plane improvements were only seen for the FDO group (GMFCS I/II and III). The Gait Deviation Index, an overall index of kinematics, improved by a significantly greater amount for the FDO group across GMFCS levels I/II and III. Net oxygen cost improved for both FDO and No-FDO for GMFCS I/II. PODCI scores improved for FDO and No-FDO in GMFCS I/II, but only the FDO group for GMFCS III. Conclusions: For children with CP, inclusion of an FDO in the surgical intervention, when indicated, resulted in improved outcomes. Overall gait kinematic improvements were significantly greater when an FDO was included in the surgical management. Level of Evidence: Level III—retrospective comparative study.

The long-term function of the knee in patients with fibular hemimelia and anterior cruciate ligament deficiency

Most patients (95%) with fibular hemimelia have an absent anterior cruciate ligament (ACL). The purpose of this study was to assess the long-term outcome of such patients with respect to pain and knee function. We performed a retrospective review of patients with fibular hemimelia and associated ACL deficiency previously treated at our institution. Of a possible 66 patients, 23 were sent the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire and Lysholm knee score to complete. In all, 11 patients completed the MODEMS and nine completed the Lysholm score questionnaire. Their mean age was 37 years (27 to 57) at review. Five patients had undergone an ipsilateral Symes amputation. There was no significant difference in any subsections of the Short-Form 36 scores of our patients compared with age-matched controls. The mean Lysholm knee score was 90.2 (82 to 100). A slight limp was reported in six patients. No patients had episodes of locking of the knee or required a supportive device for walking. Four had occasional instability with sporting activities. These results suggest that patients with fibular hemimelia and ACL deficiency can live active lives with a similar health status to age-matched controls.

Gross Motor Development in Babies With Treated Idiopathic Clubfoot

Purpose: To investigate the effect of treated clubfoot disorder on gross motor skill level measured by the Alberta Infant Motor Scale (AIMS). Methods: Fifty-two babies participated: 26 were treated for idiopathic clubfoot (12 with the Ponseti treatment method, 9 with the French physical therapy technique, and 5 with a combination of both methods); 26 were babies who were typically developing and without medical diagnoses. The AIMS was administered at 3-month intervals. Results: No significant differences in AIMS scores were found between the clubfoot and control groups at 3 and 6 months, but at 9 and 12 months the clubfoot group scored significantly lower. Babies who were typically developing were significantly more likely to be walking at 12 months than babies with clubfoot. Conclusions: Treated clubfoot was associated with a mild delay in attainment of gross motor skills at 9 and 12 months of age.

A comparison of cell salvage strategies in posterior spinal fusion for adolescent idiopathic scoliosis.

Study Design: Retrospective case-control study. Objective: To compare the efficacy of 3 blood management strategies in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) in reducing donor blood transfusion. Summary of Background Data: Although intraoperative cell salvage and predonated banked blood may be effective in reducing donor blood transfusion in the perioperative period, the optimal blood management strategy is unclear. A combined cell salvage strategy holds several potential advantages but has not yet been investigated. Methods: Patients who underwent isolated PSF for AIS (n=167) were subdivided into 3 groups by perioperative blood management strategy: (1) intraoperative retransfusion of shed blood (cell saver) and predonated autologous banked blood (n=51); (2) cell saver alone (n=33); and (3) combined cell saver and postoperative collection and retransfusion of drained blood (Retransfusion drain) (n=83). Data collected included age, sex, diagnosis, body weight, number of levels fused, operative time, intraoperative and postoperative blood loss and retransfusion, preoperative and postoperative (72 h) hemoglobin and hematocrit (Hct), and amount of autologous and donor blood transfused in the perioperative period. Results: Fewer patients in the cell saver and predonated blood (3.9%) and cell saver and retransfusion drain (1.2%) groups received donor transfusions than did those managed with cell saver alone (33%). There was no significant difference in the donor transfusion rate between cell saver/predonated blood and retransfusion groups. Mean postoperative Hct (72 h) was higher in the retransfusion group 3 than in the other 2 (group 3: 29.3%, group 1: 25.4%, group 2: 26.1%). There was no significant difference in the mean change in hemoglobin and Hct after surgery between the 3 groups. Conclusions: The present study demonstrates the efficacy of a combined intraoperative and postoperative cell salvage strategy in PSF for AIS, significantly reducing perioperative donor blood transfusions, maintaining physiological Hct, and conserving blood bank resources.

Outcomes of rectus femoris transfers in children with cerebral palsy: effect of transfer site.

Background: Distal rectus femoris transfer is a widely accepted and effective treatment for children with cerebral palsy presenting with stiff knee gait. Previous research has reported improvement in knee arc of motion regardless of transfer site; however, sample sizes and patient function were unmatched in these studies. The purpose of this study was to compare the outcomes of children with cerebral palsy treated with a distal rectus femoris transfer for stiff knee to 1 of 3 sites: medial to the semitendinosus (ST), medial to the sartorius (SR), or lateral to the iliotibial band (ITB). Sample sizes in the 3 groups were equal and matched by gross motor function of the subjects. Methods: The motion analysis laboratory database was queried for subjects who had a rectus femoris transfer with preoperative and postoperative gait studies. The ITB group, 14 subjects (20 limbs), was the smallest group of subjects identified. The ITB group established the sample size for SR and ST groups, which originally had larger sample sizes, but were matched to reflect similar proportions of Gross Motor Functional Classification System Level to the ITB group. Results: There were no significant differences between the 3 rectus femoris transfer groups preoperatively on knee gait variables (P>0.05). Comparison of preoperative to postoperative data demonstrated significant gait improvements in knee arc of motion for the ITB, SR, and ST groups (11 , 12, and 12 degrees, respectively) (P<0.05). There were also significant improvements in timing of peak knee flexion in swing phase and knee extension at initial contact for all 3 groups, but no significant difference was seen between preoperative and postoperative when groups were compared against one another for these measures. Conclusions: Distal rectus transfer continues to be an effective procedure for treating stiff knee gait in cerebral palsy. The location site of the transfer resulted in equally beneficial outcomes; therefore, the transfer site location can be based on surgeon preference and concomitant procedures. Level of Evidence: III, Retrospective Comparative Study.

Long term gait outcomes of surgically treated idiopathic toe walkers.

Toe walking is a common gait deviation which in the absence of a known cause is termed idiopathic toe walking. Surgical treatment in the presence of a triceps surae contracture includes tendo-Achilles or gastrocnemius/soleus recession and has been shown to be effective in improving kinematic outcomes at a one year follow up. The purpose of this study was to assess longer term kinematic and kinetic outcomes of children with idiopathic toe walking treated surgically for gastrocnemius/soleus contractures. Eight subjects with a diagnosis of idiopathic toe walking who had surgical lengthening of the gastrocnemius/soleus and had previous motion analysis laboratory studies pre-operative and 1 year post-operative, returned for a motion analysis laboratory study greater than 5 years since surgery. Subjects completed lower extremity physical exam and 3-D computerized kinematics and kinetics. Significant improvements for mean pelvic tilt, peak dorsiflexion in stance and swing, and overall kinematics index at 1 year post-operative were maintained at 5 years post-operative. Kinetic variables of ankle moment and power were improved at 1 year and 5 years post-operative. On physical exam, dorsiflexion with knee extended was tighter from 1 to 5 year follow-up which did not correspond to the functional changes of gait. Idiopathic toe walkers who were treated surgically for triceps surae contractures showed significant improvements in key kinematic and kinetic gait analysis variables at 1 year post-operative that were maintained at 5 years post-operative. Overall, subjects were satisfied with outcomes of the surgery, unrestricted in activities, and reported minimal pain.

Gait outcomes of patients with severe slipped capital femoral epiphysis after treatment by flexion-rotation osteotomy.

Background: Flexion-rotational osteotomy of the proximal femur is an accepted intervention in the management of severe deformity and femoral acetabular impingement secondary to slipped capital femoral epiphysis (SCFE). The impact of this surgical intervention on gait kinematics and kinetics, validated functional questionnaires, and patient outcomes has not been well studied. The purpose of this study was to analyze the changes in standard gait parameters of patients with moderate to severe SCFE who were treated with a flexion-rotational osteotomy. Methods: This study is a retrospective review of 8 patients treated for a unilateral moderate and severe SCFE with a flexion-rotational osteotomy. All patients had 3-D computerized gait analysis studies completed preoperatively and 1-year postoperatively. Additional data analyzed preoperatively and postoperatively included: anterior/posterior hip radiographs, standard physical examination measures, and Pediatric Outcomes Data Collection Instrument (PODCI), completed by parents. Results: The Gait Deviation Index, a composite of gait kinematics, showed a significant improvement from 64.9 to 88.0 (P<0.001). Radiographically, significant improvement toward normal values were found in the epiphyseal-shaft angle on the AP view from 123 to 139 degrees (P=0.005) and on the frog lateral view from 61 to 16 degrees (P=0.00001). Hip abduction range of motion on physical examination increased from 15 to 27 degrees and hip external rotation decreased from 51 to 25 degrees after surgery (P<0.05). The PODCI significantly improved in the categories of basic mobility, sports function, and global function (P<0.05). Conclusions: Longstanding deformity as a result of a severe SCFE may lead to osteoarthritis of the hip, disabling pain, and functional deficits. Although radiographic evidence of degenerative disease may take years to develop, changes in gait parameters can be immediately evident in this population. A flexion-rotation osteotomy in the adolescent and young adult population can improve gait kinematics, radiographic measures, range of motion, and short-term functional outcome scores. It is felt that normalization of these parameters may reduce the risk of long-term hip deterioration and its related sequelae. Level of Evidence: Level IV.

Lumbar spine duplication: a case report.

Duplication of the spine is a rare malformation. A neurologically intact pediatric patient with this malformation is described here. A 6-year-old girl presented to our institution for evaluation of an asymptomatic kyphotic deformity. She denied weakness, sensory changes, and bowel or bladder complaints. Physical examination revealed mild kyphosis at the thoracolumbar junction with normal gait and neurologic function. Radiographs demonstrated duplication of the lumbar spine and sacrum. Computed tomography, MRI, and abdominal ultrasound results are reported. As she is neurologically normal, we will continue to observe this patient and intervene in the case of development of neurologic impairment or worsening kyphosis.

Gait findings in the adolescent subject with a stiff hip.

Background: Adolescent subjects with severe unilateral hip disease are often stiff and painful yet have limited surgical options. Although hip fusion has been used successfully to minimize pain, acquired gait compensations after arthrodesis are factors felt to lead to knee and back pain over time. However, these gait compensations may already be present in a person with a stiff hip. The purpose of this study was to describe the quantitative gait findings of the adolescent subject with a unilateral stiff hip and to determine whether these findings are similar to those of subjects presenting after arthrodesis. Methods: This study was a retrospective review of 6 subjects seen in a motion analysis laboratory between 2005 and 2009 (age 13 to 17 y). All adolescents had been referred to the motion analysis laboratory for a routine clinical gait study. Subjects were selected for this study based on kinematic sagittal plane hip motion found to be <25 degrees (mean 16.2 degrees). Diagnoses included: Legg-Calvé-Perthes (3) and hip avascular necrosis (3). Results: Compared with laboratory-based normative data, the following findings were significant: increased arc of trunk and pelvic motion (sagittal, coronal); involved side—decreased arc of hip and knee motion (sagittal), decreased peak hip abduction in swing; contralateral side—increased arc of hip and knee motion (sagittal); and increased peak hip abduction in swing. Conclusions: Gait compensations in multiple planes and joints were identified in adolescent subjects with a unilateral stiff hip. These compensations are necessary for these subjects to generate forward progression in gait and are similar to deviations found after hip arthrodesis. Subjects with a stiff hip may already be at risk to develop pain and/or arthrosis in adjacent motion segments due to these obligatory gait characteristics. Hip fusion may not increase these risks (in this patient population) since the compensations are already present and requisite, but may provide an opportunity to decrease pain and improve function. Level of Evidence: Level IV, Case Series.