Renjit A. Varghese

Management of severe crouch gait in children and adolescents with cerebral palsy.

Background Crouch gait in cerebral palsy is associated with spasticity and contracture of the hamstrings and weakness of the extensors of the hip and knee and ankle plantar flexors. Different treatment options have been described in the literature to deal with this difficult problem. We devised a different protocol of treatment aimed at correction of the flexion deformity of the knee, weakening of the hamstrings, and augmenting the power of the knee and hip extension, which we used on 17 children with severe crouch. Methods This surgery, performed in 2 stages, entailed shortening of the femur, plication of the patellar tendon, transfer of the semitendinous to the back of the femur, and fractional lengthening of the other hamstrings. The degree of fixed deformity, the popliteal angle, quadriceps power, range of knee motion, ambulatory status and the efficiency of gait, and the position of the patella were evaluated before surgery and again after a minimum 2-year follow-up. Results The gait improved and the power of the quadriceps and the range of knee motion increased. The flexion deformity and popliteal angle decreased significantly. Patella alta was corrected and all fragmentation of the tibial tuberosity and fractures of the patella healed. The Functional Mobility Scores and the ambulatory capacity increased in all the children. There was no evidence of damage to the sciatic nerve in any patient. Conclusions The method of treatment of severe crouch gait outlined in this study seems to be an effective and safe method of dealing with this difficult problem. Study Design Level of evidence: IV.

Evaluation of outcome of treatment of congenital clubfoot.

Abstract: The study was undertaken to determine whether existing systems of outcome evaluation of clubfoot are comparable; to determine the relationship between the shape of the foot, its function, and radiological tarsal relationships; and to identify which objective variables used in the assessment of clubfeet are reproducible. Fifty treated idiopathic clubfeet were assessed by the scoring systems of Laaveg and Ponseti, McKay, Magone, and Ghanem and Seringe. Although there was a good correlation between the scores, there was very poor agreement between the grading of feet by these different systems. The feet were also evaluated using a new scoring system that has 3 domains of evaluation, viz, morphological, functional, and radiological. Comparison of the scores in each of these domains showed that there was a correlation between morphology, function, and radiological measurements of tarsal alignment. Several of the criteria used in this new scoring system were reproducible.

The levels of evidence in pediatric orthopaedic journals: where are we now?

Background: In recent years, it has become common to publish a level of evidence grading for orthopaedic journal publications. Our primary research question is: is there an improvement in levels of evidence of articles published in pediatric orthopaedic journals over time? In addition, what is the current status of levels of evidence in pediatric orthopaedic journals? Methods: All articles in Journal of Pediatric Orthopaedics-A (JPO-A) and Journal of Pediatric Orthopaedics-B (JPO-B) for 2001, 2002, 2007, and 2008 and those in Journal of Childrens Orthopaedics (JCO) for 2007 and 2008, were collected by an independent reviewer. Of the 1039 articles identified, animal, cadaveric and basic science studies, expert opinion and review articles were excluded. Seven hundred fifty remaining articles were blinded and randomized with respect to journal, title, publication date, author, and institution. According to the currently accepted grading system, study type and level of evidence was assigned to each article. Interobserver and intraobserver reliability were investigated. Statistical analysis was carried out using SPSS software. Results: There were no statistically significant differences in study type or levels of evidence in articles published before and after 2003. Of articles published during 2007/2008, 3.0% were graded as level I, 5.0% as level II, 24.1% as level III, and 58.0% as level IV. Analysis of the separate journals for all 4 years revealed that JPO-A published 2.6% (13 of 503) level I studies, whereas JPO-B published 4.3% (7 of 163) and JCO published 1.2% (1 of 84). The intraobserver reliability was high for study type (, 0.842) and substantial for level of evidence (, 0.613).The interobserver reliability for study type and level of evidence was high ( 0.921 and 0.860, respectively). Conclusions: Since the introduction of levels of evidence to orthopaedic journals in 2003, there has been minimal change in the quality of evidence in pediatric orthopaedic publications. We note a modest increase in level III articles and a corresponding decrease in level IV articles. Articles can be reliably graded by nonepidemiologically trained individuals. Level of Evidence: Not applicable.

Evaluation of the hemi-Cincinnati incision for posteromedial soft-tissue release in clubfoot

Posteromedial soft-tissue release operations were performed on 42 idiopathic clubfeet in children younger than 2 years of age through the medial half of the Cincinnati incision (the hemi-Cincinnati incision). This incision gave adequate exposure to all structures to be released. Wound closure was possible in all 42 feet without having to hold the foot in plantarflexion or inversion. Wound healing was satisfactory in the majority of instances and 81% of the scars, assessed 9 months after the operation, were graded as excellent or good. The scar is located in an area of the foot that can be concealed easily and should a more radical soft-tissue operation be needed later, the same incision can be extended easily. The authors recommend this incision as the incision of choice for performing posteromedial soft-tissue release operations on clubfeet in children younger than 2 years of age.

The use of CT in the development and implementation of a preoperative protocol to aid in pedicle screw placement during scoliosis surgery.

Scoliosis surgical constructs, using pedicle screws, provide increased fixed penetrable points for rod attachment. This allows improved curve correction and increases hardware stability. We have implemented a multidetector CT evaluation of the spine with post-process image manipulation to aid pedicle screw placement for deformity correction. Preoperative scanning was done with a Philips Brilliance 16 multislice CT scanner. The created image dataset provided valuable preoperative information regarding pedicle morphology, suitability for screw placement and preoperative screw planning. Projected intraoperatively, the images increased the surgeon’s confidence during screw placement, especially in large deformities with severe rotation. Improving pre- and intraoperative pedicle information is a valuable tool in operative management of children with spinal deformity.

Levels of evidence at the Pediatric Orthopaedic Society of North America annual meetings.

Background Since 2003, levels of evidence have been used in the orthopaedic literature to inform the reader of the study quality and its relative significance. Our primary research question was to identify if, since their introduction, there has been an improvement in the levels of evidence of the scientific papers presented at Pediatric Orthopaedic Society of North America (POSNA) meetings. Methods The abstract of every paper presented orally at the POSNA annual meeting were identified for the years 2001, 2002 (pre-2003) and 2007, 2008 (post-2003). In all, 364 abstracts were identified by an independent reviewer who then excluded cadaver, animal, and basic science studies. The 307 included abstracts were then independently blinded and randomized. Two nonepidemiologically trained pediatric orthopaedic fellows independently assigned a study type and level of evidence to each abstract based on the primary research question. The first reviewer reanalyzed 50 randomly selected abstracts. Disagreement was resolved by consensus opinion with an epidemiologically trained pediatric orthopaedic surgeon. The interobserver and intraobserver reliability was calculated for the assignment of study type and levels of evidence. Changes in the study types and levels of evidence were analyzed to compare papers presented pre-2003 and post-2003. Results For study type and levels of evidence the interobserver reliability between the authors showed substantial agreement (&kgr; 0.755 and 0.647, respectively). The intraobserver reliability also showed substantial agreement (&kgr; 0.806 and 0.789, respectively). Comparing pre-2003 and post-2003 studies there were no significant differences between the types of study presented. An increase in the number of level III studies was identified. A decrease in level I and level IV studies was identified. Conclusions There has been no significant improvement in the scientific quality of studies presented at POSNA Annual Meetings as measured by levels of evidence since their introduction. We have shown substantial agreement between nonepidemiologically trained orthopaedic surgeons when categorizing abstracts using this system. Study types and levels of evidence can be difficult to assign from the current abstract format due to their brevity and structure. Level of Evidence Not applicable.

Congenital aplasia of the patella and the distal third of the quadriceps mechanism.

Congenital absence of the patella and aplasia of the muscles are very rare anomalies. We describe a 4-year-old boy with bilateral congenital aplasia of the patella and agenesis of the distal third of the quadriceps muscle who was unable to walk owing to the lack of active knee extension. The features of this child differed from all other conditions associated with patellar aplasia. The continuity of the quadriceps mechanism was restored and he began walking normally. This appears to be the first report of the combination of aplasia of the patella and the distal third of the quadriceps that was successfully treated.