Muayad Kadhim

Crouch gait changes after planovalgus foot deformity correction in ambulatory children with cerebral palsy

Ambulatory children with cerebral palsy (CP) may present with several gait patterns due to muscular spasticity, commonly with crouch gait. Several factors may contribute to continuous knee flexion during gait, including hamstring and gastrocnemius contracture. In planovalgus foot deformity, the combination of heel equinus, talonavicular joint dislocation, midfoot break and external tibial torsion also contribute to crouch gait as part of lever arm dysfunction. In this retrospective cohort study, we assessed 21 children with CP (34 feet) who underwent planovalgus foot correction as a single level surgery. Fifteen feet underwent subtalar fusion and 19 feet had lateral calcaneal lengthening. Patients who underwent knee, hip or pelvis surgeries were excluded from the study. The aim was to examine the changes in gait pattern and the correlation between the changes of knee flexion at stance phase with the other kinematic and kinetic parameters after foot surgery. Post surgery change of Maximum knee extension at stance (MKE-dif) was the outcome of interest. The magnitude of change in MKE after surgery increased (less crouch after surgery) in patients who had milder preoperative planovalgus feet and higher preoperative ankle maximum dorsiflexion at stance and ankle power. The gain of knee extension after surgery correlated with correction of ankle hyperdorsiflexion and with increase of knee extension at initial contact and knee power. Patients with high preoperative ankle maximum dorsiflexion may benefit from surgical foot deformity correction to achieve decreased ankle dorsiflexion with no knee surgical intervention.

Correlation of radiographic and pedobarograph measurements in planovalgus foot deformity.

Planovalgus foot deformity is common in children with cerebral palsy. Several pathologies contribute to the deformity. It begins with the lateral displacement of the navicular and the talar head becomes uncovered and prominent in the medial side of the midfoot. The purpose of this study was to assess the correlation between the radiographic and the pedobarographic measurements and the ability to predict foot pressure components using radiographic measurement. The patient sample included 43 patients with cerebral palsy who were ambulatory and had planovalgus foot deformity (76 feet). Medial midfoot pressure showed correlation with talonavicular uncoverage index, talonavicular angle, medial arch angle, Meary angle, and lateral talocalcaneal angle. Heel impulse showed negative correlation with talonavicular uncoverage index and talonavicular angle. Simple linear regression was used to assess the relationship between radiographic and foot pressure component measurements. For every unit change in talonavicular uncoverage index, the predicted value of medial midfoot pressure was [9.9+27 (talonavicular uncoverage index)]. This equation accounted for 17.9% of the changes in the medial midfoot pressure. Tibial foot angle and maximum knee extension also contributed to the heel impulse. The radiographic indices of the planovalgus foot can explain the changes in some foot pressure components.

Long-term Outcome of Planovalgus Foot Surgical Correction in Children with Cerebral Palsy

Pes planovalgus deformity results from changes in the anatomic relations among tarsal bones. Foot deformity and pain can affect the patients ability to ambulate and are common indications for surgery. The present study was a retrospective study aimed at assessing the effectiveness and complications of subtalar fusion and calcaneal lengthening during long-term follow-up in ambulatory children with cerebral palsy. Pedobarographic measurements, ankle range of motion, and radiographic indexes were used to assess the outcome of surgery. The functional abilities of the patients were assessed using the gross motor functional classification system. Pain complaints were reported to evaluate potential risk factors. A total of 24 patients (43 feet) were included, with mean age at surgery of 11 ± 3.2 (range 4.7 to 18.3) years and mean follow-up duration of 10.9 ± 2.7 (range 6.3 to 15.4) years. Of the 43 feet, 15 were treated with calcaneal lengthening (mostly gross motor functional classification system level I and II) and 28 with subtalar fusion (mostly gross motor functional classification system level III and IV). Improvement was observed in both surgery groups during long-term follow-up. The need for additional surgery was observed more among patients with poor ambulation who were treated with subtalar fusion. Young patients who underwent surgery were more likely to develop foot pain. Foot pain was less common among children with poor functional abilities and patients who underwent subtalar fusion. Surgical correction of planovalgus deformity has good outcomes after both subtalar fusion and calcaneal lengthening, with maintenance of the deformity correction during long-term follow-up.

Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis.

Objectives: To determine which reconstruction treatment of long bones nonunion with segmental bone defects (SBDs) is effective to restore bone length and union with good function. Data Sources: PubMed was used to identify published literature on treatment of SBD caused by fracture nonunion regardless of infection between January 1975 and December 2014. Study Selection: We included retrospective cohort studies with a minimum sample size of 10 consecutive patients with minimum follow-up of 18 months and available data on radiographic and functional outcomes. Data Extraction: Literature review revealed 24 publications with a sample size of 504 patients (395 males, 109 females). Data on bone union and functional outcome and complications were collected and analyzed based on validated classification systems. Data Synthesis: Two outcome groups were categorized for bone union and functional outcome, success, and failure. We then performed heterogeneity test to examine the variability or differences in the methods used by these studies and based on that we determined whether the fixed effect or random effect method is appropriate in examining the summary or pool estimate. Pool estimate was examined for bone union and functional outcome in each surgical modality and in each anatomic location when data were available. Conclusions: Treatment of SBD can be challenging. This quantitative evidence synthesis shows that bone union was achieved by different procedures with variable bone union and functional outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Unicameral Bone Cysts in the Humerus: Treatment Outcomes.

Background: Several treatment modalities have been described for the treatment of unicameral bone cysts (UBC). The aim of this study was to examine the outcome of various treatment modalities of UBC in a specific anatomic location, the humerus. Methods: This study is a retrospective case-only study of patients with humeral UBC with minimum follow-up of 1 year. Medical records and radiographs were assessed and UBC healing status was determined based on most recent follow-up radiographs and divided into 3 groups (healed, partially healed, and not healed). Descriptive statistics were utilized to summarize study outcome. Results: Sixty-eight patients (54 boys and 14 girls) with humeral UBC comprised the study population. Sixty-four cases (94.1%) presented with a pathologic fracture. Fifty-one cases were in the proximal metaphysis and 17 were in the diaphysis. Mean age at diagnosis was 9.2±3.7 years, and mean follow-up was 4.0±2.6 years. Twenty-five patients were treated with observation, 38 by injection (27 with steroids and 11 with bone marrow), and 5 by open surgery. Patients who underwent open surgery had relatively larger cyst length, width, and cyst index, and all healed or partially healed at last follow-up. UBC persistence was observed in 29% of diaphyseal and 27.5% of metaphyseal cysts. Of the 19 patients with persistence, 8 were treated with observation, 9 with steroid injection, and 2 with bone marrow injection. Inner wall disruption before injection was performed in 17 patients (24% did not heal), whereas 21 patients did not have inner wall disruption (33% did not heal). Twenty patients received >1 injection. Eleven patients complained of pain at the last visit (8 had a persistent cyst, 2 were partially healed, and 1 had a healed UBC). Conclusions: Complete healing of humeral UBC is challenging to achieve irrespective of treatment modality. UBCs treated with open surgery tended to heal better. Unhealed cysts were more likely to be associated with pain. Level of Evidence: Level III—a retrospective comparative study.

Prevalence of scoliosis in patients with Fontan circulation

Objective To examine the prevalence of scoliosis in patients with Fontan circulation. Design Retrospective cohort (case-only), level IV study. Setting A comprehensive paediatric centre. Methods We examined the radiographs of 194 patients who underwent Fontan completion surgery between 1998 and 2011 at a median age of 1.3 years. Main outcome measure We collected data on the age at the last available radiograph and when scoliosis was diagnosed; we used the first available radiograph with scoliosis. We also measured the magnitude and direction of the spinal curve in patients with scoliosis. Results Median age at radiography was 3.4 years. Nineteen patients (9.8%) developed scoliosis; none of them underwent thoracotomy. Most of the patients with scoliosis were older than 5 years of age at scoliosis diagnosis and the female to male ratio was 5 : 3. The major curve was right thoracic in 12 patients (63.2%), left thoracic in four patients (21.1%) and high thoracic in three patients (15.8%). For every 1 year increase in age there was a 27% increased risk of developing scoliosis. Conclusions There was a high prevalence of scoliosis in patients with Fontan circulation. We recommend interdisciplinary monitoring of these patients to diagnose spinal curve deformities in a timely manner.

Scoliosis Surgery in Children With Congenital Heart Disease.

Study Design. Retrospective cohort study. Objective. To describe preoperative evaluation, anesthetic and perioperative management, and complications in patients with congenital heart disease (CHD) who underwent surgery to correct a spine deformity. Summary of Background Data. Patients with surgically palliated or repaired CHD may have nearly normal circulation or may have important residual abnormalities that affect the planning and conduct of surgery to correct a spine deformity. Methods. We examined the records of 21 patients with spine deformity who had previous surgical intervention for CHD. Three types of spine surgery and instrumentation were examined, posterior spinal fusion with instrumentation (PSFI), growing rod (GR) instrumentation, and vertical expandable prosthetic titanium rib instrumentation (VEPTR). To objectify the degree of preoperative cardiac physiological derangement, patients were classified into 3 groups: single ventricle physiology and Fontan circulation (S), two ventricles with no residual abnormal cardiac physiology condition (2N), and two ventricles with residual cardiac physiology problem (2R). Results. Subjects were 8 boys and 13 girls with mean age of 11.1 ± 5.2 years. Sixteen patients underwent surgery to correct scoliosis, 1 to correct kyphosis, and 4 did not undergo surgery. Total number of surgical procedures was 23 (16 PSFI, 5 GR, and 2 VEPTR). On the basis of cardiac physiology, 2 patients belonged 2N, 11 were 2R, and 8 were group S. Mean estimated blood loss was 1685 mL during PSFI, 515 mL during GR, and 150 mL during VEPTR. Mean volume of blood transfusion was 44 mL/kg for PSFI, 19 mL/kg for GR, whereas no transfusion was administered during VEPTR. Median intensive care unit stay was 2 days ranging from hours to 78 days. Median hospital length of stay was 7 days ranging from 3 to 93 days. There were no deaths. Conclusion. Given meticulous multidisciplinary planning and execution, major spine surgery can be safely and successfully performed in patients with significant residua of CHD. Level of Evidence: 4