Carley Vuillermin

Severe crouch gait in spastic diplegia can be prevented: a population-based study

We studied the prevalence of severe crouch gait over a 15-year period in a defined population of children with spastic diplegia and Gross Motor Function Classification System levels II and III, to determine if there had been a decrease following changes to the management of equinus gait. These changes were replacing observational with three-dimensional gait analysis, replacing single level with multilevel surgery, and replacing gastrocsoleus lengthening with gastrocnemius recession. Of 464 children and adolescents with spastic diplegia who underwent three-dimensional gait analysis, 27 had severe crouch gait. Seventeen of these had been managed by isolated lengthening of the gastrocsoleus. Following changes in the management of equinus gait, the prevalence of severe crouch gait decreased from 25% and stabilised at a significantly lower rate, fluctuating between 0% and 4% annually (p < 0.001). We conclude that severe crouch gait in this population was precipitated by isolated lengthening of the gastrocsoleus. These findings may be relevant to other surgical populations, as severe crouch gait may be a useful way to monitor the quality of the surgical management of abnormal gait in children with cerebral palsy and spastic diplegia.

Soft Tissue Release and Bilobed Flap for Severe Radial Longitudinal Deficiency

PURPOSE To report the hand position, range of motion, functional results, and radiographic outcomes associated with treating radial longitudinal deficiency with release of constricting or deforming soft tissue and resurfacing of the radial skin deficiency with a bilobed flap. METHODS We recalled and reviewed patients with at least a 3-year follow-up who had undergone soft-tissue release and coverage with a bilobed flap. The study group consisted of 16 patients and 18 wrists. All patients underwent follow-up examination and radiographs. Outcome measures using Pediatric Outcomes Data Collection Instrument (PODCI), Disabilities of the Arm, Shoulder, and Hand (DASH), and visual analogue scale (VAS) scores were recorded. RESULTS At a mean of 9.2 years follow-up, the average final resting wrist radial deviation angle was 64° compared with 88° preoperatively. The average active wrist flexion-extension arc was 73°. Average DASH score was 27 (range, 5-54). PODCI global was 88 (range, 75-97), PODCI happiness was 86 (range, 70-100), and VAS overall satisfaction (range, 0-10) was 1.2 (range, 0-8). At final follow-up, no physeal growth arrests were noted on radiographs, and no patients to date have required ulnocarpal arthrodesis. CONCLUSIONS Soft-tissue release and coverage with a bilobed flap should be considered in the treatment algorithm for patients with radial longitudinal deficiency. Outcome measures show that these patients maintain useful active motion, and along with their parents, are satisfied with both the appearance and function. Some recurrence of radial deviation was noted, which was similar to results previously reported following centralization/radialization procedures, although with a lower inherent risk of both physeal injury to the ulna and stiffness. In addition, potential future procedures are not compromised by this surgical approach. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Flexor Digitorum Superficialis Opposition Transfer for Augmenting Function in Types II and IIIA Thumb Hypoplasia

PURPOSE To report the functional outcomes associated with the flexor digitorum superficialis (FDS) opposition transfer for types II and IIIA thumb hypoplasia and determine if there is any noteworthy difference in the outcome dependent on the pulley used. METHODS We included patients who underwent a ring FDS opposition transfer and had at least 2 years follow-up. The study group consisted of 36 patients with 40 treated thumbs. All patients underwent follow-up examination and standardized testing. Outcome functional measures were recorded using the Pediatric Outcomes Data Collection Instrument (PODCI). There were 9 type II and 31 type IIIA hypoplastic thumbs. All patients underwent a ring FDS opposition transfer and a 4-flap z-plasty for first web space deepening. The pulley for opposition was flexor carpi ulnaris in 19 and the transverse carpal ligament in 21. Thirty-six thumbs had ulnar collateral ligament reconstructions, with 5 of the 36 undergoing combined ulnar collateral ligament/radial collateral ligament stabilizations. Average follow-up was 7.6 years (range, 2-16 years). RESULTS Average postoperative Kapandji score was 8 (range, 4-10). Grip, lateral pinch, and tripod pinch strengths averaged 46%, 49%, and 48% of age- and sex-matched normal controls, respectively. There was no significant difference between surgical pulleys used. The Pediatric Outcomes Data Collection Instrument global was 91 (range, 53-100), and PODCI happiness was 87 (range, 15-100). CONCLUSIONS We found the ring FDS opposition transfer to be an effective method for providing opposition for both type II and IIIA thumb hypoplasia. At follow-up, excellent opposition function and PODCI scores were noted, with no difference related to the type of pulley used. Type II thumbs had significantly greater grip and pinch strengths when compared with type IIIA thumbs.

Intraobserver and Interobserver Reliability of the Oberg-Manske-Tonkin (OMT) Classification: Establishing a Registry on Congenital Upper Limb Differences.

Background: The purpose of this investigation was to determine the reliability of the Oberg-Manske-Tonkin (OMT) classification system applied to patients enrolled in a prospective, multicenter cohort study of congenital upper limb differences. Our hypothesis was that the OMT classification would exhibit high intraobserver and interobserver reliability and thus would be an appropriate tool for the new Congenital Upper Limb Differences registry. Methods: Four pediatric hand surgeons independently reviewed the medical records, clinical photographs, and radiographs of 60 randomly selected patients previously enrolled in the Congenital Upper Limb Differences registry. Patient’s information was summarized and shared electronically (PowerPoint). Each rater classified each congenital anomaly according to the OMT classification system. Responses were recorded using a web-based data capture tool (REDCap). Three weeks later, the surgeons repeated the process. Intraobserver reliability for each rater was assessed using Fleiss’ &kgr;. Interobserver reliability was assessed using percent exact agreement (when all 4 raters were in agreement) as well as Fleiss’ &kgr;. Results: Using the OMT classification, intraobserver reliability for the 4 pediatric hand surgeons showed almost perfect agreement, with &kgr; values in the range of 0.89 to 0.93. Interobserver reliability demonstrated substantial agreement, with &kgr; value of 0.79 (95% confidence interval, 0.77-0.82) in the first reading and 0.80 (95% confidence interval, 0.77-0.83) in the second reading. The highest possible agreement (&kgr;=1) was seen for the following diagnoses: congenital dislocation of radial head (OMT I.A.2.v), Madelung deformity (I.A.2.vii), radial polydactyly (I.B.2.iii), triphalangeal thumb (I.B.2.iv), Kirner deformity (I.B.4.vi), and osteochondromatosis (3.B.4.i). Conclusions: The OMT classification of congenital upper limb differences exhibits substantial to almost perfect intraobserver and interobserver reliability among pediatric hand surgeons at different institutions. The OMT is therefore well-suited for classification of congenital upper limb anomalies in patients enrolled in a multicenter registry. Level of Evidence: Level II—diagnostic.

Early Outcomes of Pediatric Elbow Dislocation-Risk Factors Associated With Morbidity.

Introduction: Ulnohumeral elbow dislocation is a rare elbow injury in children. We reviewed a large cohort of pediatric ulnohumeral elbow dislocations and sought to identify risk factors associated with poor functional outcomes. Methods: Medical charts and radiographs were reviewed for all acute pediatric ulnohumeral elbow dislocations evaluated at our facility during a 7-year period. Charts were abstracted for demographics, injury characteristics, treatments, and complications. Functional outcomes were assessed at minimum 6-week follow-up using a combination of symptoms and elbow range of motion (Roberts criteria). Results: A total of 145 cases qualified for inclusion and were analyzed. The average age at injury was 11 years (range, 5 to 18 y), with equal distribution between male and female individuals. Concomitant elbow fractures were identified in 114 (80%) cases; the most common was the medial epicondyle (80/134, 60%). Treatment consisted of open reduction and fixation of associated fracture(s) in 59% of fracture cases. At an average follow-up of 3.7 months, the average range of motion was −5-degree extension to 126-degree flexion. Immobilization for longer than 2 weeks resulted in a loss of elbow extension (P<0.001). Functional outcomes as assessed by the Roberts criteria were good or excellent in 90% of cases. Risk factors associated with less than excellent functional outcomes included the presence of multiple fractures (P=0.001), the need for operative intervention (P=0.01), and the duration of immobilization (P=0.03). Complications requiring further treatment occurred in 16 cases (11%). Patients without complication resulted in a higher proportion of “excellent” functional outcomes (76%) compared with those with a complication (40%) (P<0.001). Conclusions: The majority of pediatric ulnohumeral elbow dislocations experience good to excellent functional outcomes by early follow-up. Risk factors associated with less than excellent functional outcomes include the presence of multiple associated fractures, operative intervention, and prolonged immobilization. Complications requiring operative intervention are not rare, and have a significant effect on functional outcomes. Level of Evidence: Level IV—prognostic.

Ulna Growth Patterns After Soft Tissue Release With Bilobed Flap in Radial Longitudinal Deficiency

Background: Centralization is commonly utilized for treating the severely deviated wrist in radial longitudinal deficiency (RLD). Individuals with RLD have congenital shortening of the ulna and previous studies have shown that traditional centralization, in particular with notching of the carpus, results in additional ulnar growth retardation. At our institution, we use a technique of soft tissue release with bilobed flap. We examined if this technique preserves the growth potential of the distal ulna, therefore, avoiding an additionally shortened forearm. Methods: We retrospectively reviewed serial radiographs of 16 patients with 18 wrists who had at least 3 years of follow-up after a soft tissue release with bilobed flap. Radiographic lengths were measured using the method described by Heikel. Percentage of normal growth was calculated using normative data published by Maresh. Comparisons were made with preoperative, postoperative, and final follow-up studies. Results: The average length of follow-up was 9.2 years (range, 3 to 16.3 y) with an average age of 11.6 years (range, 5.2 to 17.5 y). The average age at the time of surgery was 27 months (range, 14 to 48 mo). A minimum of 3 radiographic studies were available for each subject. The average ulna length preoperatively was 63.9% of age-matched normal length (51.4% to 75.3%). The average ulna length at final follow-up was 61.9% of age-matched normal length (48.5% to 70.3%). The difference was not statistically significant. In addition, there were no distal ulnar physeal arrests. Conclusions: Soft tissue release with bilobed flap does not affect ulna growth like traditional centralization procedures can. This procedure has previously been shown to retain motion and have similar recurrence rates to formal centralizations. Therefore, we advocate that it be considered more widely for use in patients with RLD and significant wrist deviation to maximize growth and improve hand position. Soft tissue release with bilobed flap can be safely used on young children and preserve ulnar growth. Level of Evidence: Level IV—therapeutic.

Lower extremity growth and deformity

The pediatric lower extremity has well known growth patterns. When deformities or growth disturbances occur, there are several methods to measure and predict the resulting discrepancy, including the Green-Anderson, Moseley, and Multiplier methods. Many techniques exist to correct leg length discrepancy and deformity such and temporary epiphysiodesis, permanent epiphysiodesis, external fixators, and internal lengthening devices. All of these methods have numerous complications and limitations; however, with careful planning and patient selection, length and alignment can be improved with high patient satisfaction.

Catastrophic failure of a low profile metal-backed glenoid component after total shoulder arthroplasty.

Context: The longevity of the glenoid component in total shoulder arthroplasty (TSA) continues to be problematic. All polyethylene glenoid components have been most widely used, but loosening rates with time and the need for revision has resulted in high-profile metal-backed components with the potential for a more stable prosthesis bone interface and liner exchange. High revision rates in the high profile metal backed designs led us to evaluate a low profile metal backed component. Aims: To examine the rate and mode of failure of a TSA in a single surgeon consecutive series that has been identified by the Australian National Joint Replacement Registry to have a higher than anticipated rate of revision. Materials and Methods: This is a single surgeon retrospective consecutive series of 51 arthroplasties undertaken in 50 patients (18 males and 32 females) with an average age of 70.4 ears (range 51-90) and mean follow-up of 5.5 years (range 3.7-8.1). Results: We observed a very high (29%) rate of revision of the metal-backed glenoid components in this series. The primary mode of failure was glenoid baseplate nonintegration which with a well-fixed central cage screw led to bone resorption and implant breakage or disassembly. Conclusion: Analysis of the mode of failure of implants identified by robust registries is essential for the development of new prostheses and the pursuit of prosthesis longevity. This low profile metal backed prosthesis has been withdrawn, but without a published mechanism of failure. We feel that any prosthesis withdrawal should be accompanied by appropriate published mechanisms to prevent future component design errors based on similar design problems.

Radiologic Evaluation of Femur Fractures

Femur fractures in children and adolescents are injuries that require careful management in order to achieve optimum outcome. Most femoral fractures in the pediatric age group are the result of high-energy trauma in the adolescent or a twisting injury or simple fall in the ambulatory toddler [1]. When this history is absent, pathologic and non-accidental fractures should be considered. Appropriate diagnosis and treatment of a femur fracture nearly always requires some form of imaging evaluation. Imaging plays a pivotal role in determining the extent of the fracture, evaluating the degree of comminution and displacement, and evaluating for damage to critical structures such as the physis and surrounding vascular structures. Imaging also plays a critical role in evaluating for post-traumatic or post-operative complications of femur fracture, such as avascular necrosis and growth disturbance. This chapter focuses on imaging techniques most commonly employed in the diagnosis and management of children with femur fractures, including a brief overview of the various imaging modalities.

Boston Children's Hospital approach to brachial plexus birth palsy.

The treatment of infants with brachial plexus birth palsy (BPBP) continues to be a focus at Boston Children’s Hospital. Over the last 15 years, there have been many developments in the treatment of infants with BPBP. Some of the greatest changes have emerged through technical advances such as the advent of distal nerve transfers to allow targeted reinnervation as well as through research to understand the pathoanatomical changes that lead to glenohumeral dysplasia and how this dysplasia can be remodeled. This review will discuss our current practice of evaluation of the infant with BPBP, techniques for microsurgical reconstruction, and prevention and treatment of secondary glenohumeral dysplasia.