Glen O. Baird

Comprehensive outcomes of surgically treated idiopathic toe walkers.

Abstract: The treatment of idiopathic toe walking in children can include surgical lengthening of the gastrocnemius/soleus complex after conservative options have been ineffective. Previous outcome reports of surgery for idiopathic toe walkers have largely been limited to assessing the sagittal plane motion of dorsiflexion/plantar flexion with minimal quantitative preoperative and postoperative analysis. The purpose of this study was to comprehensively assess the outcome of idiopathic toe walkers that had been treated surgically. Fourteen children seen in our motion analysis laboratory that underwent gastrocnemius or tendo-Achilles lengthening for idiopathic toe walking were retrospectively reviewed. Preoperatively, this group had significantly greater anterior pelvic tilt than normal, decreased peak knee flexion in swing, greater external foot progression, and the expected increased plantar flexion (P < 0.01). Postoperatively, anterior pelvic tilt decreased by a mean of about 4 degrees (P < 0.01), only for the group that had tendo-Achilles lengthening because the gastrocnemius group was close to normal preoperatively, and peak knee flexion normalized. The foot progression angle of this group did not change from preoperative values and remained significantly more external than normal, although dorsiflexion in stance significantly improved after surgery (indicating the goal of the surgery was achieved). Increased external foot progression in idiopathic toe walkers is apparently due to increased external tibial torsion and/or external hip rotation but was unaffected by gastrocnemius/soleus surgical lengthening. Significant improvement occurred on an overall index of gait variables, indicating surgery can be an effective treatment of idiopathic toe walkers.

The pediatric outcomes data collection instrument detects improvements for children with ambulatory cerebral palsy after orthopaedic intervention.

The purpose of this study was to assess whether the Pediatric Outcomes Data Collection Instrument (PODCI) was able to detect changes in function, as perceived by the parents of children and adolescents with cerebral palsy who had undergone lower limb soft tissue and/or bony surgeries. This was a retrospective study of 80 ambulatory patients who were seen in the motion laboratory and classified with the Gross Motor Functional Classification System (GMFCS). Significant changes (P < 0.05) were detected in the PODCI scores for upper extremity function, transfers and mobility, physical function and sports, and global function after surgery, by approximately 4% to 5%, whereas comfort (pain-free) did not significantly change. There was a significant difference in the PODCI scores preoperatively between GMFCS levels I, II, and III for upper extremity function, transfers and mobility, physical function and sports, and global function. Postoperative improvements were of equal magnitude for each GMFCS level. This suggests that the PODCI did not have a ceiling effect for high-functioning children. Age (±10 years) and surgery (soft tissue/soft tissue plus bony) were not significant factors for any of the subcategories preoperative to postoperative. In conclusion, the PODCI detected improvement as perceived by the parents in ambulatory children with cerebral palsy after lower-limb soft tissue and/or bony surgeries in 4 areas by a magnitude of approximately 4% to 5%.

Gait analysis outcomes of percutaneous medial hamstring tenotomies in children with cerebral palsy.

Background: Hamstring lengthening procedures are commonly performed on children with cerebral palsy (CP) to improve gait. The purpose of this study was to determine the efficacy of percutaneous hamstring tenotomy surgery for children with ambulatory CP. Methods: In this retrospective study, subjects were included if they had a diagnosis of CP and had computerized gait analysis data collected before and after surgery. Subjects were not included in the study if they had any open hamstring lengthening on the same side. Other concomitant lower extremity surgeries were not exclusionary. Short- and long-term follow-up groups were established: if the time from their surgery to their gait laboratory was less than 18 months, they were placed in the short-term follow-up group, and if the time from their surgery to their gait laboratory was greater than 18 months, they were placed in the long-term follow-up group. Results: The results demonstrated that for short- and long-term groups on preoperative to postoperative analysis, there was significantly improved knee extension at initial contact, increased velocity, increased stride length, improved overall gait as indicated by a decrease in a 16 variable multivariate index (Gillette Gait Index), and a decreased popliteal angle. For the short-term group only, additional significant findings included increased peak knee extension in stance and reduced plantar flexion at initial contact. The absolute values of peak knee extension in stance and plantar flexion at initial contact were equivalent at follow-up for the short- and long-term groups. Increased anterior pelvic tilt was also significant for the short-term follow-up group only. Conclusions: The findings of this study demonstrate that the minimally invasive technique of percutaneous hamstring tenotomy is effective in improving key dynamic gait parameters for individuals with CP for a short period, and these benefits are maintained in the long term. Level of Evidence: Level IV.

Distal Tibial Rotation Osteotomies Normalize Frontal Plane Knee Moments

BACKGROUND Torsional deformities of the lower extremity are common in children and are often corrected with rotational osteotomy. The effects of torsional abnormalities, and the effects of corrective osteotomy, are not well understood. A study of children with isolated idiopathic tibial torsional pathology undergoing a single corrective procedure may assist in understanding the biomechanics of torsional deformities and the effect of surgical correction. METHODS Preoperative and postoperative gait analyses were performed for eight subjects (eleven sides) with idiopathic excessive inward tibial torsion and ten subjects (fourteen sides) with excessive outward tibial torsion. Sagittal ankle and frontal knee moments were assessed and compared with those for age-matched controls. RESULTS Preoperatively, subjects exhibited abnormal frontal knee moments at push-off. Subjects with inward tibial torsion demonstrated excessive internal valgus moments, and subjects with outward tibial torsion demonstrated reduced internal valgus or relative internal varus moments compared with the control subjects. Ankle power was significantly reduced in the inward torsion group but not in the outward torsion group. Surgical correction of the torsional deformities normalized frontal plane knee moments in both inward and outward torsion groups and restored ankle power in the inward torsion group. CONCLUSIONS In the present study, excessive tibial torsion adversely affected frontal knee moments and was associated with other kinematic and kinetic abnormalities. Corrective osteotomies improved all variables studied here and restored many to the values found in the control group.

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.

Proximal rectus femoris release surgery is not effective in normalizing hip and pelvic variables during gait in children with cerebral palsy.

The purpose of this study was to determine the efficacy of the proximal rectus femoris release to treat hip flexor contractures and hip and pelvic gait deviations in children with spastic cerebral palsy. This study was a retrospective repeated-measures analysis of data collected on two matched groups of patients, those with and without proximal rectus femoris release surgery, seen in our Motion Analysis Laboratory. Proximal rectus release surgery did not improve hip extension, did not decrease anterior pelvic tilt, and did not improve temporal-distance measures of gait in children with cerebral palsy. A multivariate measure, the Hip Flexor Index, was also unchanged. The group of patients without any hip flexor surgery was not different from the rectus femoris release group on hip or pelvic variables before or after surgery. The findings of this study offer no evidence that the proximal rectus femoris release is successful in achieving desired gait outcomes at the hip and pelvis in children with cerebral palsy.

Modified Goal Attainment Scale outcomes for ambulatory children: With and without orthopedic surgery

AIM The purpose of this study was to determine if mobility goals were met when set and rated by the family using a modified Goal Attainment Scale following lower extremity orthopedic surgery or on follow-up without surgery. METHODS Parents were asked to establish the top three goals for their childs mobility during a visit to the Motion Analysis Laboratory. Three groups of subjects were established: (1) 25 children with CP who had surgery, (2) 13 children with CP who did not have surgery and (3) 13 children without CP who had surgery. Goals were rated at the follow-up visit to the Motion Analysis Laboratory a mean of 12.4 months after initial visit using a non-criterion reference scale. The PODCI, Gait Deviation Index and Gillette FAQ were additional standardized tools used to measure outcomes. Data were reviewed retrospectively. RESULTS Both groups that had surgery on average met their goals. The group that did not have surgery did not, on average, meet their goals (overall, no change). Significant improvements were noted in both surgery groups on the PODCI and Gait Deviation Index while no changes were found for the group without surgery. CONCLUSION Generally, goals are met following orthopedic surgery when set and rated by the family using a modified Goal Attainment Scale in the Motion Analysis Laboratory. However, goals are not universally met which presents an opportunity to improve the goal setting and evaluation process. Goals identified in this study are specific and unique to the family and agree with other standardized outcome tools.