Chris Church

A comprehensive outcome comparison of surgical and Ponseti clubfoot treatments with reference to pediatric norms

PurposeIsolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics.MethodsTwenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements.ResultsThe Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group.ConclusionsPonseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.

Comprehensive vestibular and balance testing in the dizzy pediatric population

Objective. To describe the spectrum of balance disease in a large population of children presenting to a tertiary care vestibular and balance laboratory. Study Design. Case series with chart review. Setting. Tertiary care pediatric hospital. Main Outcome Measures. Results of audiometric, vestibular, and balance tests and final diagnosis. Subjects and Methods. Retrospective review of audiometric, vestibular, balance testing, and final diagnosis from a patient database. Results. Between September 2003 and September 2007, 132 children were evaluated at the Alfred I. duPont Hospital for Children Vestibular Disorders Program. Sixty-nine of the patients were boys and 63 were girls. The average age was 9.7 ± 5.0 years (range, 1-17 years). Although not all were able to complete the entire test battery (99 children completed at least 50% of the tests in the protocol), a diagnosis was achieved in most cases. The most common diagnoses were peripheral vestibulopathy (29.5%), migraine/benign recurrent vertigo of childhood (24.2%), motor/developmental delay (10.6%), traumatic brain injury (9.8%), and central nervous system structural lesion (9.1%). Conclusions. Peripheral vestibular deficits and migraine disease account for most of the pathology in the pediatric population. With a multidisciplinary approach, diagnosis of the source of vertigo and imbalance is possible in most children.

Dynamic lower extremity alignment in children with achondroplasia.

Abstract: The purpose of this study is to analyze lower extremity dynamic malalignment during gait using a 3-dimensional kinematics and kinetics in 13 children (3-17 years old) with achondroplasia and to compare measurements of alignment and malrotation between gait, radiographic, and clinical measures. Gait analysis in the coronal plane showed a varus malalignment of the knee (19 ± 13 degrees) and variable tibial torsion abnormalities (13 [internal] ± 15.7 degrees). Radiographs also showed knee varus malalignment (16 ± 9 degrees); however, there was poor correlation with gait analysis measures (P > 0.05). In the sagittal plane, radiographs showed genu recurvatum deformity (23.5 ± 13.2 degrees), although the sagittal plane knee kinematics were normal. Kinetic analyses of the knee showed high internal knee valgus moments (external varus moments, 0.48 ± 0.25 N m/kg), which were significantly different from the normal population (P < 0.05). In conclusion, there is a 3-dimensional, complex, dynamic deformity of the lower extremity present in children with achondroplasia. We recommend a very careful assessment of the limb focusing on both the static and dynamic varus deformity and tibial torsion using a combination of radiographic, clinical, and gait analysis.

Gait pattern and lower extremity alignment in children with Morquio syndrome.

The gait in children with Morquio syndrome (MPS IV) has not been previously described. We reviewed the charts, gait analysis reports, and radiographs of nine children with no previous lower extremity surgery. Children with MPS IV had a slower walking speed, reduced cadence, and reduced stride length as compared with normal (P<0.05). There was increased knee flexion, genu valgus, and external tibial torsion during stance (P<0.05). Kinetics showed that knee varus moment was increased (P<0.05). There was a strong correlation between genu valgus measured on gait analysis and standing radiographs (r=0.89).

Persistence and Recurrence Following Femoral Derotational Osteotomy in Ambulatory Children With Cerebral Palsy

Background: Excessive hip internal rotation is frequently seen in children with cerebral palsy (CP). Femoral derotational osteotomy (FDO) is effective in the short term, but factors associated with long-term correction remain unclear. The purposes of this study were to define the incidence of persistence and recurrence of hip internal rotation following FDO in ambulatory children with CP and to evaluate factors that influence outcome. Methods: Following IRB approval, kinematic and passive range of motion (PROM) variables were retrospectively evaluated in children with spastic CP who had FDO to correct hip internal rotation as part of clinical care at a children’s specialty hospital. Children included had a preoperative evaluation (Vpre), a short-term postoperative evaluation (Vshort, 1 to 3 y post), and, in some cases, a long-term postoperative evaluation (Vlong, ≥5 y post). Age at surgery, physical exam measures, and kinematics variables were evaluated as predictors for dynamic and static recurrence. Results: Kinematic hip rotation improved from 14±12 degrees (Vpre; internal positive) to 4±13 degrees (Vshort) and relapsed to 9±15 degrees long term (P<0.05 Vpre/Vshort/Vlong; 99 limbs). Hip PROM midpoint improved from 23±9 degrees (Vpre) to 8±11 degrees (Vshort) and relapsed to 14±13 degrees (P<0.01 Vpre/Vshort/Vlong). Persistent hip internal rotation was noted in 41% (kinematics) and 18% (PROM) of limbs at Vshort (105 children, 178 limbs). Of limbs that showed initial improvement at Vshort (62 children, 95 limbs), recurrence was seen in 40% (kinematic hip rotation) and 39% (hip midpoint) at Vlong. Comparing children who had recurrent hip internal rotation and those who maintained long-term correction, we saw higher levels of spasticity and lower gait velocity in the recurrent group (P<0.05). Conclusions: Although FDO is an accepted treatment in children with CP, persistence and recurrence of hip internal rotation can occur. Recurrence is associated with spasticity and slower gait velocity. Predictor variables may be useful for surgeons during preoperative discussions of expected outcome with families of FDO candidates. Level of Evidence: Level III.

Reliability and validity of Edinburgh visual gait score as an evaluation tool for children with cerebral palsy

Assessment of gait abnormalities in cerebral palsy (CP) is challenging, and access to instrumented gait analysis is not always feasible. Therefore, many observational gait analysis scales have been devised. This study aimed to evaluate the interobserver reliability, intraobserver reliability, and validity of Edinburgh visual gait score (EVGS). Video of 30 children with spastic CP were reviewed by 7 raters (10 children each in GMFCS levels I, II, and III, age 6-12 years). Three observers had high level of experience in gait analysis (10+ years), two had medium level (2-5 years) and two had no previous experience (orthopedic fellows). Interobserver reliability was evaluated using percentage of complete agreement and kappa values. Criterion validity was evaluated by comparing EVGS scores with 3DGA data taken from the same video visit. Interobserver agreement was 60-90% and Kappa values were 0.18-0.85 for the 17 items in EVGS. Reliability was higher for distal segments (foot/ankle/knee 63-90%; trunk/pelvis/hip 60-76%), with greater experience (high 66-91%, medium 62-90%, no-experience 41-87%), with more EVGS practice (1st 10 videos 52-88%, last 10 videos 64-97%) and when used with higher functioning children (GMFCS I 65-96%, II 58-90%, III 35-65%). Intraobserver agreement was 64-92%. Agreement between EVGS and 3DGA was 52-73%. We believe that having EVGS as part of the standardized gait evaluation is helpful in optimizing the visual scoring. EVGS can be a supportive tool that adds quantitative data instead of only qualitative assessment to a video only gait evaluation.

The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy.

Crouched gait is common in children with cerebral palsy (CP), and there are various treatment options. This study evaluated the effectiveness of single-event multilevel surgery including posterior knee capsulotomy or distal femoral extension osteotomy to correct knee flexion contracture in children with CP. Gait analyses were carried out to evaluate gait preoperatively and postoperatively. Significant improvements were found in physical examination and kinematic measures, which showed that children with CP and crouched gait who develop knee flexion contractures can be treated effectively using single-event multilevel surgery including a posterior knee capsulotomy or distal femoral extension osteotomy.

Pre-operative walking activity in youth with cerebral palsy

BACKGROUND No data are available regarding level of walking activity for youth with cerebral palsy (CP) before undergoing orthopeadic surgery. The goals of this study were to quantify pre-operative walking activity, and determine whether pre-operative values are different from previously defined levels of walking activity in youth with CP. PROCEDURES This study retrospectively evaluated pre-operative walking activity in youth with spastic CP, GMFCS levels I-IV. Walking activity was monitored using the StepWatch™. Outcome variables included mean daily strides, percent of day active, and percent of active time at high activity. Differences between GMFCS levels were examined and comparisons were made to published data. RESULTS Pre-operative walking activity data from 126 youth with CP were included. All variables demonstrated higher walking activity in youth at GMFCS levels I/II compared to those at GMFCS levels III/IV. When compared to previously defined walking activity levels, pre-operative walking activity was lower. CONCLUSIONS Walking activity among pre-operative youth with CP is significantly lower than published data for ambulatory youth with CP. Results suggest that youth with CP who are surgical candidates have less walking activity than youth with CP without surgical needs. Therefore this study should encourage the effort to collect and analyze individual pre-operative data for comparison and evaluation of post-operative functional recovery.

Long-term Outcome of Internal Tibial Derotation Osteotomies in Children With Cerebral Palsy.

Background: External tibial torsion (ETT) is a common bony deformity in children with cerebral palsy (CP). The current recommended treatment is tibial derotation osteotomy (TDO) to improve gait biomechanics. Satisfactory short-term results after TDO have been reported but long-term results have not been studied. The purpose of this study was to evaluate the long-term outcome following TDO to correct ETT in ambulatory children with CP. Methods: Following IRB approval, gait kinematics and passive range of motion measurements were retrospectively evaluated in children with spastic CP who underwent TDO due to ETT comparing preoperative (E0), short-term postoperative (E1; 1 to 3 y post), and long-term postoperative (E2; >5 y post) results. Limbs were categorized as corrected, undercorrected, or overcorrected at both E1 and E2, by comparing mean tibial rotation (MTR) in gait to a group of typically developing children. Age at surgery, E0 MTR, E0 gait velocity, gross motor function classification system (GMFCS) score, and foot deformity were evaluated to determine their influence on long-term results. Results: The study sample consisted of 43 legs (with E0 and E2) and 22 legs (with E0, E1, and E2). The mean age at surgery was 10.3±3.4 years (range, 6 to 19.2 y). In the group MTR trended toward improvement moving from −26±17 degrees (E0, external negative) to −16±16 degrees (E1) and relapsed to −23±17 degrees at the long term (P=0.071, E0/E1; P=0.589, E0/E2). Improvement was also seen in the transmalleolar axis (P=0.074), mean ankle rotation, and mean foot orientation (P<0.05, E0/E2). At the long-term evaluation, 16 legs (37%) were found to be in the kinematic corrected group, 25 legs (58%) in the kinematic undercorrected group, and 2 legs (5%) in the kinematic overcorrected group. There were no significant differences between the corrected and undercorrected groups of children with respect to age at surgery, GMFCS, E0 MTR, gait velocity, or foot deformity. Conclusions: Although internal TDO improves ETT in the short term, recurrence is frequent with an apparent developmental trend toward external rotation of the tibia. Levels of Evidence: Level IV—therapeutic study.

Reliability and minimal detectable change in foot pressure measurements in typically developing children

BACKGROUND In pedobarography, clinically meaningful comparison of measurements within or between subjects is limited by data variability and measurement error. This study aims to determine the components of the minimal detectable change (MDC) in impulse across all foot regions and the reliability of these measures. METHODS A convenience sample of foot pressures from 108 visits by normal, healthy subjects aged 2-17 years was studied. Each subject had three pedobarograph measurements taken per foot, with six subjects returning for a second visit for assessment of day-to-day variability. Using a five-region mask, segmental impulses were determined, and from these we obtained the coronal plane pressure index (CPPI). Inter-rater, intra-rater, and day-to-day data were analyzed using intraclass correlation coefficients (ICC) to quantify reliability. Variability of the data was analyzed to quantify the MDC. RESULTS Inter- and intra-rater reliability was high for all measurements while variability was low, indicating small direct measurement error. Generally, the largest contributing factor to the MDC was day-to-day variability. Step-to-step variability was more dependent on foot segment than age although minor age-related changes were noted. Finally, the high relative variability in the CPPI and the medial mid foot impulse resulted in very high MDCs for these measures.