Richard D. Beauchamp

A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy.

A randomized controlled single‐blind trial was performed to compare lumbo‐sacral selective posterior rhizotomy (SPR) followed by intensive physiotherapy, with intensive physiotherapy alone in improving motor function in children with spastic diplegic cerebral palsy. Fifteen patients were randomly assigned to each treatment modality. Patients in the SPR group had rhizotomy within 1 month, followed by intensive outpatient physiotherapy for 9 months. Patients assigned to physiotherapy alone had identical intensive physiotherapy. There was a statistically significant and clinically important difference in improvement in motor function in favor of the SPR group, with a mean increase in total Gross Motor Function Measure (OMFM) score of 11.3% at 9 months for the SPR group compared with 5.2% for the physiotherapy‐only group (P=0.007). Significant improvements in spasticity (P<0.001) and range of movement (P<0.001) were noted in the SPR group compared to the physiotherapy‐only group. The results indicate that the improvement in motor function after SPR is more than can be explained by the associated intensive physiotherapy.

Selective functional posterior rhizotomy for treatment of spastic cerebral palsy in children: review of 50 consecutive cases

Fifty consecutive children are described with spastic cerebral palsy treated with selective functional lumbar and sacral rhizotomy and followed for a minimum of 6 months. In all patients, spasticity improved postoperatively, but this was not necessarily accompanied by a functional improvement. Eighteen children who could not walk preoperatively were able to do so after rhizotomy. All 17 children who could walk preoperatively could do so following surgery, and in 15, gait was improved. Complications included transient urinary dysfunction in 4 children and sensory loss in 1. The operative procedure evolved with time: the technique of replacement laminotomy was refined; the electrophysiologic basis for selection of nerve rootlets changed after studies of nonspastic controls; smaller percentages of the L3 and L4 roots were sectioned in an attempt to prevent postoperative weakness of quadriceps, and there was a trend in the most recent patients to cut a smaller portion of all the posterior roots.

Treatment of idiopathic clubfoot utilizing botulinum A toxin: a new method and its short-term outcomes.

A pivotal point in most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of botulinum A toxin (BTX-A) in attenuating the function of the triceps surae muscle complex as an alternative to tenotomy was investigated. Fifty-one patients with 73 idiopathic clubfeet were recruited. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: group 1 (<30 days old) and group 2 (>30 days and <8 months old). Ankle dorsiflexion in knee flexion and extension remained above 20 degrees and 15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. One of the 51 patients required limited posterior release and 9 patients required repeat manipulation and casting plus or minus BTX-A injection. The use of BTX-A as an adjunctive therapy in the noninvasive approach of manipulation and casting in idiopathic clubfoot is a safe and effective treatment.

A quality assessment of randomized clinical trials in pediatric orthopaedics.

The promotion and practice of evidence-based medicine necessitates a critical evaluation of medical literature, including the criterion standard of randomized clinical trials (RCTs). Recent studies have examined the quality of RCTs in various surgical specialties, but no study has focused on pediatric orthopaedics. The purpose of this study was to assess and describe the quality of RCTs published in the last 10 years in journals with high clinical impact in pediatric orthopaedics. All of the RCTs in pediatric orthopaedics published in 5 well-recognized journals between 1995 and 2005 were reviewed using the Detsky Quality Assessment Scale. The mean percentage score on the Detsky scale was 53% (95% confidence interval, 46%-60%). Only 7 (19%) of the articles satisfied the threshold for a satisfactory level of methodological quality (Detsky >75%). Most RCTs in pediatric orthopaedics that are published in well-recognized peer-reviewed journals demonstrate substantial deficiencies in methodological quality. Particular areas of weakness include inadequate rigor and reporting of randomization methods, use of inappropriate or poorly described outcome measures, inadequate description of inclusion and exclusion criteria, and inappropriate statistical analysis. Further efforts are necessary to improve the conduct and reporting of clinical trials in this field to avoid inadvertent misinformation of the clinical community.

Soft tissue anatomy of proximal femoral focal deficiency.

The soft tissue anatomy of Aitken types A, B, C, and D proximal femoral focal deficiency (PFFD) was examined by magnetic resonance imaging (MRI). A characteristic pattern of soft tissue abnormalities is described. All muscles were present, but most were smaller than their normal counterparts. The exception was the obturator externus muscle, which was elongated and remained muscular almost up to its insertion. In type A PFFD, it is straight; in types B, C, and D PFFD, it is L-shaped. The sartorius is hypertrophied.

Fracture of the Lumbar Vertebral Apophysis

Three cases of vertebral apophyseal fracture and displacement presenting with back pain are reported. Literature review revealed 11 other such cases, and these are compared. Computed tomography scan was found to be an excellent tool to confirm this diagnosis.

Extraarticular subtalar arthrodesis: the dowel method.

Summary: The technique and results of extraarticular subtalar arthrodesis using the dowel method during the 10‐year period between 1976 and 1986 were reviewed retrospectively. Fifty feet in 30 children underwent extraarticular subtalar arthrodesis for valgus deformity for diagnoses including meningomyelocele, idiopathic flatfoot, and cerebral palsy. The aims of the procedure were to correct the deformity, obtain a solid arthrodesis, and improve ambulation by reducing bracing requirements and eliminating pain. Results were excellent in 28 cases (56%), satisfactory in 15 (30%), and unsatisfactory in seven (14%). Intraoperative positioning error and simultaneous perineal tendon lengthening in children with cerebral palsy were the major sources of unsatisfactory results.

A kinematic description of dynamic midfoot break in children using a multi-segment foot model

Midfoot break (MFB) is a foot deformity that occurs most commonly in children with cerebral palsy (CP), but may also affect children with other developmental disorders. Dynamic MFB develops because the muscles that cross the ankle joint are hypertonic, resulting in a breakdown and dysfunction of the bones within the foot. In turn, this creates excessive motion at the midfoot. With the resulting inefficient lever arm, the foot is then unable to push off the ground effectively, resulting in an inadequate and painful gait pattern. Currently, there is no standard quantitative method for detecting early stages of MFB, which would allow early intervention before further breakdown occurs. The first step in developing an objective tool for early MFB diagnosis is to examine the difference in dynamic function between a foot with MFB and a typical foot. Therefore, the main purpose of this study was to compare the differences in foot motion between children with MFB and children with typical feet (Controls) using a multi-segment kinematic foot model. We found that children with MFB had a significant decrease in peak ankle dorsiflexion compared to Controls (1.3 ± 6.4° versus 8.6 ± 3.4°) and a significant increase in peak midfoot dorsiflexion compared to Controls (15.2 ± 4.9° versus 6.4 ± 1.9°). This study may help clinicians track the progression of MFB and help standardize treatment recommendations for children with this type of foot deformity.

Ground reaction forces in gait in children with clubfeet — a preliminary study

Abstract The purpose of this preliminary study was to examine the relationship between clinical range of motion measurements and ground reaction forces during walking in children with clubfeet. The childrens feet were clinically examined, measuring ankle and subtalar range of motion, and heel position on stance. Ground reaction force data were collected with three trials for each foot for each subject. Multiple regression analysis showed that the vertical moment impulse correlated strongly with subtalar ROM and heel position ( r = 0.84). A more rigid, varus foot produced a greater internal torque. The net anterior-posterior impulse correlated ( r = 0.78) with ankle plantarflexion. This small study showed that decreased plantarflexion results in decreased ability to propulse forward at push-off. Limited propulsion found in the children with clubfeet may be caused by the current standard of treatment of the clubfoot, which includes lengthening the Achilles tendon. A larger study of this population would be important to further establish consistent differences between clubfeet and normal feet.

Reliability of retrospective assignment of gross motor function classification system scores.

Objectives: To assess “alternate forms” reliability and inter-rater reliability of Gross Motor Function Classification System (GMFCS) scores. Methods: Fifty randomly selected children with cerebral palsy were divided into two groups: (1) GMFCS score assigned during gait assessment (“GMFCS previously assigned”) and (2) no GMFCS score assigned. Using database information, two physiotherapists independently determined GMFCS scores for 25 children from the “previously assigned” group, and 25 from the “no score assigned” group. Therapists compared their recently assigned scores for the “previously assigned” group, discussing discrepancies until attaining agreement. This groups consensus scores were compared to GMFCS scores assigned at time of actual assessment to calculate “alternate forms” reliability. Results: Between-therapist agreements were kappa = 0.84 for “GMFCS previously assigned” group and 0.95 for “no GMFCS assigned” group. Kappa agreement between direct assessment and retrospectively assigned scores for the “GMFCS previously assigned” group was 0.79. Conclusions: Retrospective GMFCS scores can be reliably assigned.