Frank M. Chang

Fibular hemimelia : Comparison of outcome measurements after amputation and lengthening

Background: Treatment of fibular hemimelia includes either Syme or Boyd amputation with early prosthetic fitting or tibial lengthening. Numerous studies have documented the success of both procedures. The purpose of our study was to compare the outcome after amputation with that after tibial lengthening, specifically with regard to activity restrictions, pain, satisfaction, complications, number of procedures, and cost, in children with fibular hemimelia. Methods: Thirty limbs in twenty-five patients treated with either an amputation or a lengthening procedure and followed for at least two years were studied. Fifteen patients underwent amputation, and ten patients underwent lengthening of the tibia. The mean age was 1.2 years at the time of amputation and 9.7 years at the time of initial lengthening. The mean duration of follow-up was 6.9 years after the amputations and 7.1 years after the lengthening procedures. Results: The patients who underwent amputation were able to perform more activities than those who had a lengthening (mean activity score, 0 compared with 1.2 points; p < 0.05), and they had less pain (mean pain score, 0.2 compared with 1.2 points; p = 0.091), were more satisfied and had a lower complication rate (0.37 compared with 1.91; p < 0.05). The patients who underwent amputation also had fewer procedures (1.9 compared with 7.0; p < 0.05), at a lower cost (

AUTOGRAFT VERSUS ALLOGRAFT FOR BENIGN LESIONS IN CHILDREN

7016 compared with

The Role of Gait Analysis in Treating Gait Abnormalities in Cerebral Palsy

26,900; p < 0.05), than those who had a lengthening. Lengthening was successful in equalizing limb lengths; the mean limb-length discrepancy, assessed in nine of eleven limbs, was 0.7 centimeter. Conclusions: This study demonstrated that children who undergo early amputation are more active, have less pain, are more satisfied, have fewer complications, undergo fewer procedures, and incur less cost than those who undergo lengthening. This was true even though good results were obtained with the lengthening procedures and most patients achieved limb-length equality, were able to walk, had minimal pain, and were quite active.

High reoperation rates after early treatment of the subluxating hip in children with spastic cerebral palsy.

Benign bone lesions in children are often so large in size that there is not an adequate amount of bone available for an autograft to fill the resultant cavity after surgical curettage. This study compared autografts and allografts with respect to the time required and the success of graft incorporation. Fifty-four patients with 61 lesions were studied. Lesions were classified as small volume (less than 60 cc) or large volume (more than 60 cc) and were separated into four groups: small-volume autograft, large-volume autograft, small-volume allograft, and large-volume allograft. Allografts appeared comparable to autografts when small-volume lesions were treated. The healing time was slightly longer for allografts with an average period of 21 months versus 27 months for autografts. Autografts were superior to allografts in rate and completeness of healing for solitary large lesions. This increased efficacy presumes a somewhat older child in which an adequate amount of bone is available for an autograft. A young child with multicentric or polyostotic lesions can still achieve successful incorporation with allografts. In this study, 38% healed completely and 29% healed partially. Allografts have a distinct place in the treatment of benign bone lesions in children.

The success of closed reduction in the treatment of complex developmental dislocation of the hip

Individuals with cerebral palsy (CP) cannot take a normal activity like walking for granted. CP is the most common pediatric neurologic disorder, with an incidence of 3.6 per 1000 live births. The current trend in the treatment of individuals with CP is to perform a thorough evaluation including a complete patient history from birth to present, a comprehensive physical examination, appropriate radiographs, consultation with other medical specialists, and analysis of gait.

Limb-Lengthening versus Amputation for Fibular Hemimelia

Abstract: Hip subluxation and dislocation are well-recognized complications of spastic cerebral palsy. Alternatives for treatment include observation, bracing, or surgery. The purpose of this study is to compare the rates of reoperation and acetabular development after early soft tissue procedures with those of varus derotational osteotomies performed to maintain reduced hips in severely involved children. A series of 60 patients with spastic cerebral palsy and hip subluxation younger than 6 years who underwent primary bilateral hip surgery at one hospital between 1980 and 1996, with a minimum of 4 years of follow-up, were retrospectively reviewed. Fifty-two patients had spastic tetraplegia and 47 were nonambulators. Measures of proximal femoral and acetabular development were made via radiographic analysis. Twenty-two patients underwent primary bilateral soft tissue procedures. At a mean 6-year follow-up, there was modest improvement seen in mean femoral head coverage and little improvement seen in mean indices of acetabular development. Seventeen of these 22 patients (77%) underwent reoperation. Thirty-eight patients underwent primary bilateral varus derotational osteotomies. At a mean follow-up of 5 years, there was also modest improvement noted in mean femoral head coverage with little change in the mean indices of acetabular development. Twenty-eight of these 38 patients (74%) underwent reoperation. In this population of severely involved patients with spastic cerebral palsy, the reoperation rate was high. Acetabular remodeling did not reliably occur as a result of either early soft tissue or proximal femoral procedures when performed at an average age of 4 years.

The Relationship of Gross Motor Functional Classification Scale Level and Hip Dysplasia on the Pattern and Progression of Scoliosis in Children With Cerebral Palsy

The purpose of our study was to determine the efficacy of closed reduction in the treatment of complex developmental dislocation of the hip. We identified two factors, the cone of stability and the limbus type, through the use of arthrography and gentle examination under anesthesia, which are useful guidelines in the management of complex developmental dislocation of the hip. We feel as a result of this study we can select those cases of complex developmental dislocation of the hip that are amenable to closed reduction and separate them from those other cases for which we recommend open reduction.

Rate of Correction and Recurrence of Ankle Valgus in Children Using a Transphyseal Medial Malleolar Screw.

To The Editor: We read with interest the article “Fibular Hemimelia: Comparison of Outcome Measurements After Amputation and Lengthening” (2000;82:1732-5), by McCarthy et al. The conclusion, “children who undergo early amputation for the treatment of fibular hemimelia are more active, have less pain, are more satisfied with the result of the treatment, have fewer complications, undergo fewer procedures, and incur less cost than those who undergo lengthening. . . . even though good results can be obtained with lengthening procedures,” warrants closer scrutiny. First, the number of patients who underwent limb-lengthening in this study is very small (eleven limbs in ten patients). Only six patients were treated with the Ilizarov method, and five were treated with the older Wagner method, which is associated with more complications and poorer results1. The mean age at the time of amputation was 1.2 years (range, seven months to 2.3 years) compared with a mean age of 9.7 years (range, 5.5 to 18.3 years) at the time of the initial lengthening procedure. The children in the lengthening group were followed until an average age of 16.8 years in comparison with the children in the amputation group, who were followed until an average age of 8.1 years. The patients in the lengthening group were therefore treated later, making treatment more difficult2, especially that involving large leg-length discrepancies that require as many as three lengthening procedures or two such procedures and one epiphysiodesis. It is more difficult to obtain and maintain correction of foot deformities that are not treated at an early age2. The two groups in the study by McCarthy et al. are therefore disparate; use of a case-matched control format would have produced a more scientifically valid study. When the children in the amputation group, who were followed until …

Acetabular Remodeling After a Varus Derotational Osteotomy in Children With Cerebral Palsy

PURPOSE The primary aim of the study was to determine whether progression and magnitude of scoliosis were related to the Gross Motor Functional Classification Scale (GMFCS) and whether laterality (and associated pelvic obliquity) of the spinal curvature affected severity of recurrent hip subluxation in patients with cerebral palsy who had undergone varus derotational osteotomy (VDRO). METHODS A total 115 patients underwent VDRO surgery at a single institution between 1980 and 2001. Adequate radiographs were available for 98 patients. Average age at time of VDRO was 6.5 years and follow-up post-VDRO was 8.2 years. Children were divided into lower severity (GMFCS 1-3; 13 patients), high severity (GMFCS 4; 42 patients), and highest severity (GMFCS 5; 43 patients). A single observer measured all spine radiographs using standardized technique. A separate observer measured hip migration index on all pelvis radiographs. RESULTS There was a significant increase in coronal deformity over time in each GMFCS category (p < .0001). The GMFCS 1-3 and GMFCS 4 groups had nearly identical time trends, each increasing at roughly 1° to 2° annually, whereas the GMFCS 5 group increased by 3.5°/year (p = .0153). Increasing Cobb angle was not a significant predictor of severity of recurrent subluxation. Furthermore, there was no significant difference in severity of recurrent hip subluxation when hips were evaluated based on whether they were on the same side as the concavity or convexity of the scoliosis (ie, high or low side of pelvic obliquity). CONCLUSIONS The relationship between GMFCS and rate of scoliosis progression differed between groups. Severity of hip subluxation did not increase significantly over time after VDRO, nor was it significantly related to magnitude or laterality of scoliosis in children in this cohort. SIGNIFICANCE Treatment decisions regarding hip subluxation and scoliosis in patients with cerebral palsy may be made independent of each other.

Outcomes of Isolated Varus Derotational Osteotomy in Children With Cerebral Palsy Hip Dysplasia and Predictors of Resubluxation.

Background: Transphyseal medial malleolar screw (TMMS) hemiepiphysiodesis is an effective treatment for ankle valgus in children. There is limited evidence on the effect of age and diagnosis on the rate of correction as well as the deformity recurrence after screw removal. The purpose of this study was to determine (1) the rate of correction of ankle valgus after hemiepiphysiodesis using a TMMS, (2) the effects of clinical diagnosis and age at surgery on the rate of correction, and (3) the rate of valgus recurrence after TMMS removal. Methods: In this retrospective study we included 16 male and 21 female patients (63 ankles) with an average age at surgery of 11.0 years (range, 5.4 to 14.8 y) who underwent TMMS hemiepiphysiodesis for the treatment of ankle valgus. There was a mean radiographic follow-up of 1.6 years (range, 0.4 to 4.9 y) before screw removal. For subjects who received screw removal (43 ankles), the average time from insertion to removal of the screw was 1.4 years (range, 0.4 to 5.2 y). Valgus deformity was assessed on anteroposterior ankle radiographs by measurement of tibiotalar angle. Linear mixed effects models were used to determine rates of correction and valgus recurrence. Results: The average rate of correction in tibiotalar angle was 0.37±0.04 degrees per month (P<0.001). Clinical diagnosis and age at surgery significantly affected the amount of postoperative correction in tibiotalar angle (P<0.05). Eighteen of 22 ankles (81.8%) demonstrated recurrence of ankle valgus after screw removal. The average recurrence rate in patients who underwent screw removal was 0.28±0.08 degrees per month (22 ankles, P=0.002). Conclusions: This study supports the effectiveness of the TMMS hemiepiphysiodesis for treating pediatric ankle valgus, but the effects of additional skeletal growth should be considered as the ankle may rebound into valgus after correction and screw removal. The results from this study can help with surgical planning to predict the amount of correction that may be achieved depending on underlying diagnosis and age at surgery. Level of Evidence: Level IV—retrospective study.