Analysis of lower extremity alignment in achondroplasia: interobserver reliability and intraobserver reproducibility

This study was designed to evaluate the reliability and reproducibility of frontal plane malalignment measurements using the mechanical axis deviation method in achondroplasia and to determine whether the patient's age has any influence on these measurements. A total of 150 anteroposterior standing radiographs of the lower extremities were randomly selected for the study. Radiographs were divided into three groups according to age: group 1, younger than 6 years of age; group 2, 6 to 10 years of age; group 3, older than 10 years of age. Interobserver agreement for the medial proximal tibial angle and the lateral distal tibial angle measurements were poor (0.32 and 0.38, respectively) in group 1, but agreement increased between observers with increasing patient age. Good to excellent intraobserver reproducibility was found in all groups, except measurement of the medial proximal tibial angle in group 1, where the results were poor (0.36). Significant measurement errors in the proximal and distal tibial joint lines are possible in children less than 6 years of age with achondroplasia.     

Intraobserver reproducibility and interobserver reliability of cervical spine measurements

Lateral flexion-extension radiographs of 72 patients with Down syndrome were used to assess the interobserver reliability and intraobserver reproducibility of the atlanto-dens interval, Wiesel-Rothman measurement, occiput atlas angle, and Power's ratio in flexion and extension. The radiographs were reviewed by three blinded observers on three different occasions with at least a 1-month interval between assessments. The intraclass correlation coefficient was used to measure the reproducibility of the measurements from a given observer and the reliability between different observers. With the exception of observer one, the atlanto-dens interval had a statistically significant intraobserver agreement compared with any of the other measurements (p < 0.05). The atlanto-dens interval and the Wiesel-Rothman measurements tended to have better correlation between observers, although there was only fair agreement. The agreement, however, was statistically significant (p < 0.05) compared with Power's ratio. The degree of intraobserver reproducibility and interobserver reliability may make it difficult to base treatment protocols on these measurements.     

Limited intraobserver and interobserver reliability for the common measures of hip joint congruency used in dysplasia

Background  

A congruent hip frequently is cited in the literature as a prerequisite for performing a reconstructive pelvic osteotomy for hip dysplasia. The designation as congruent is important as incongruent joints generally are regarded as requiring a salvage-type procedure. Several measures of congruency are described in the literature, but it is unclear whether these measures are reliable.     

Older's classification of Colles' fractures: Good intraobserver and interobserver reproducibility in 185 cases

To evaluate the reliability of the Older classification, 4 observers classified 185 distal radius fractures twice with 1 month's interval. Both the intraobserver agreement and the interobserver agreement were high, with kappa values of 0.75 (0.69-0.79) and 0.69 (0.60-0.77), respectively. the agreement was especially high for type 1 and type 4 fractures. Older's method of classifying distal radius fractures can thus be recommended for clinical use.     

Development of gait in spastic children with cerebral palsy

The gait of 50 spastic children 3-16 years old was recorded and analyzed. All children showed abnormal values of both basal parameters and phases of the stride. In gait velocity and stride length, their values were lower than normal, but they increased with age, with stride length increasing in parallel with normal values. Stride frequency showed a decrease with age, the reverse of normal. Stance and swing, when normalized with regard to stride duration, showed no change with age in spastic children. Also, stance was longer than in normal children, the same tendency as shown by double support. Hemiplegic children showed clearly asymmetric phases. The decreasing stride frequency with increasing age indicates a relative slowing of movements. Most changes with age were, however, the same as in normal children. The prolonged stance and double support suggest deteriorated postural control, resulting in an increased need of support.     

Correlation between muscle shortening and derangement of the hip joint in children with spastic cerebral palsy

From clinical studies on hip derangement and measurement of muscle shortening around the hip joint in 244 patients with spastic cerebral palsy, we found that the incidence of subluxation was 17.0% and that of dislocation was 8.2%; there was no dislocation in ambulatory spastics and the incidence of hip derangement was high in non-ambulatory patients; significant shortening of the adductors was closely correlated with hip derangement; the combination of damaged flexors, hamstrings and adductors led to hip derangement; surgical intervention in the adductors, the flexors (particularly the iliopsoas muscle) and the hamstrings should be considered in the treatment of advanced hip derangement in patients with cerebral palsy.     

Bilateral symmetry in leg and joint stiffness in children with spastic hemiplegic cerebral palsy during gait

Deviations are often identified at individual joints in the gait analysis of patients with cerebral palsy. Previous gait studies on hemiplegic cerebral palsy (HCP) have focused mainly on deviations of the affected side. The current study aimed to quantify and compare the joint and leg stiffness, the contributions of skeletal and muscular components, and the associated joint angles and moments of the affected and nonaffected lower limbs during level walking in children with spastic HCP. A total of 12 children with spastic HCP and 12 healthy controls walked at a self-selected speed in a gait laboratory while their kinematic and forceplate data were measured and analyzed during loading response, midstance, terminal stance, and preswing. The altered joint kinematics and kinetics in the nonaffected limb in the HCP group appeared to be mainly a compensatory strategy to minimize the bilateral asymmetry in leg stiffness during the double-limb support phase and joint stiffness during the entire stance phase. The current results suggest that therapeutic planning and decision-making for children with HCP should consider not only the mechanics of the affected side but also the control of the nonaffected side.     

Older's classification of Colles' fractures. Good intraobserver and interobserver reproducibility in 185 cases

To evaluate the reliability of the Older classification, 4 observers classified 185 distal radius fractures twice with 1 month's interval. Both the intraobserver agreement and the interobserver agreement were high, with kappa values of 0.75 (0.69-0.79) and 0.69 (0.60-0.77), respectively. The agreement was especially high for type 1 and type 4 fractures. Older's method of classifying distal radius fractures can thus be recommended for clinical use.     

Appearance of spastic hip pain in cerebral palsy children]

Pain is a serious complication in the development of spastic dislocation of the hip joint, sometimes determining future of the patient, limiting the degree of his independence and comfort of his life. OBJECTIVES: Determination of 1. the frequency of appearance of lower limbs' pain among patients with subluxation and dislocation of the hip joint in the course of spastic form of cerebral palsy; 2. the influence of the surgical treatment on pain development. MATERIALS: We analysed 82 patients (126 spastic hips) treated between 1970 to 1995 with spastic form of cerebral palsy. Patients were divided into 3 groups according to the degree of hip instability and the performed method of treatment. Group 1-41 patients (77 spastic hips) without neurogenic instability of hip (mean value of migration percentage (MP) - 25%), group II - 14 patients (19 hips) with untreated dislocation of hip (MP - 100%), group III- 25 patients (30 hips) with dislocation and subluxation of hips treated by open reduction combined with Dega's pelvic osteotomy and intertrochanteric varus osteotomy of femur. METHODS: Each patient underwent clinical and radiological evaluation of hips. We assessed the value of migration percentage according to Reimers. We adopted the scale of intensity of pain according to Barie: 1) no pain, 2) sporadic pains, 3) frequent pains retreating after administration of routine analgesic drugs, 4) frequent pains persisting after administration of typical analgesics. The evaluation of pains also comprised their localisation within the hip joint and the knee joint of the same limb (projected pains). RESULTS: Group I in 11.7% of hips occurred mild pain, in 20.8% light pain and in 67.5% pain didn't occur, there was no severe pain. In group II in 73.7% appeared severe and mild pain, in 10.5% light pain and in 15.8% pain didn't appear. In group III severe and mild pain occurred in 37%, light in 33% and no pain in 30%. In all groups appearance and severity of pain depends of the degree of hip dislocation (p < 0.01 to 0.001). Appearance and aggravation of hips' pain depends on the degree of decentration of the femur's head from the acetabulum, estimated by the migration percentage (MP). Treatment and prevention demands "aggressive" operative procedure to avoid expansion of the hip's pain. Surgery decreases the frequency and intensity of pain but doesn't make patient totally free from the risk of its appearance.     

Evans' classification of trochanteric fractures: an assessment of the interobserver and intraobserver reliability

The reliability of Evans' classification of trochanteric femoral fractures was examined using κ (Kappa) statistics. Radiographs of 50 randomly chosen trochanteric fractures were evaluated by six observers. One set of radiographs was uniformly classified as a subtrochanteric fracture by all observers and was excluded from further analysis.

Only 18 per cent of the fractures were classified identical by all observers and 57 per cent when differentiating between stable and unstable fractures. The corresponding κ values showed moderate agreement ranging from 0.38 to 0.68     

Pronation and supination after forearm fractures in children: Reliability of visual estimation and conventional goniometry measurement

Background

Forearm fractures are common amongst children and often result in limited rotational function. In daily practice, pronation and supination of the arm are often visually estimated or measured using a conventional goniometer. The aim of this study was to compare the reliability of these two methods in paediatric patients who had previously sustained a forearm fracture.

Methods

Intra- and interrater reliability of visual estimation and conventional goniometry were determined in 47 children who had previously sustained a forearm fracture.

Results

Intra- and interrater reliability of visual estimation and conventional goniometry was fair to excellent, with intraclass correlation coefficients (ICCs) ranging between 0.75 and 0.94. In addition, the overall goniometer data consistently showed lower smallest detectable differences (SDDs) compared to the visual estimation data, also indicating better reliability for the goniometer method.

Conclusions

A conventional goniometer is an easy, fast and reliable method to determine the pronation and supination in a child who had sustained a forearm fracture. If an uncooperative child hinders the measurement, visual estimation is a good second choice. Measurements are more reliable when repeated by the same professional.     

Serial casting in idiopathic toe-walkers and children with spastic cerebral palsy

Serial casting to stretch the plantar-flexors has been advocated for idiopathic toe-walkers (ITW) and children with spastic cerebral palsy (CP), although outcomes have not been well studied. Neuromuscular function and gait were examined in eight children with CP (mean age, 7.1 years) and eight ITW (mean age, 7.5 years) casted for 3 to 6 weeks. Baseline comparisons indicated that children with CP produced lower isometric plantar-flexor torques (p<0.02) concomitant with marked co-contraction (p<0.001). greater ankle mobility (p<0.02), and higher reflex excitability (p<0.001) than ITW. After casting, both groups increased dorsiflexion range (p<0.001), decreased resistance to passive stretch (p<0.005), and produced maximal plantar-flexor torques in dorsiflexed positions (p<0.001). Reflex excitability was reduced in CP (p<0.05). Immediately postcasting, no children toe-walked, but two with CP resumed a digitigrade pattern 6 weeks later. Gait velocity and stride length did not change (p>0.05). Serial casting yielded positive outcomes that may be longer lasting in ITW.     

The use of botulinum toxin in the treatment of spastic hip joint instability in children with cerebral palsy]

Authors present the effect of intramuscular injections of botulinum toxin A (BTX-A) in the treatment of hip instability in children with spastic cerebral palsy. MATERIAL AND METHOD: The sixty-seven non walking children (110 hips) with quadriplegia and hip instability (MP > 33% or increase of MP > 20% in the second follow-up after 12 months) were evaluated. The mean age of patients in the beginning of study was 3 years and 8 months (SD = 2 years). The patients were randomly allocated to administrations of BTX-A - group A (52 hips) or to observation - group B (58 hips). The intramuscular injections of BTX-A were performed every 3 months, bilaterally to adductors, medial hamstrings and psoas muscles. The choice of muscles for BTX-A administration was determined by the results of clinical examination consisting in dynamic assessment of joint range of motion. The groups of muscles presenting the dynamic contraction (3 and more in Ashworth Scale) were injected. The a-p radiographs were used to assess the migration percentage (MP). The average length of follow-up was 21 months. RESULTS: The mean value of MP in the group A was 38% at the beginning of treatment and 28% at the end of follow-up (difference statistically significant; p < 0.00001). The mean value of MP in the group B was 36% at the primary examination and 38% at the final examination (difference statistically significant; p < 0.00001). The mean progression (-) for the group A = 10% (improvement) and for the group B +3% (deterioration) (difference statistically significant; p < 0.00001). CONCLUSIONS: Locate specific target intramuscular injections of botulinum toxin A (BTX-A) are a useful method of prevention of the neurogenic hip dislocation in children with spastic cerebral palsy.     

Comparison of pronator tenotomy and pronator rerouting in children with spastic cerebral palsy

Forty-one patients with cerebral palsy and pronation contracture of the forearm were treated with pronator teres rerouting compared with 16 patients who were treated with pronator teres tenotomy. The mean age of patients with pronator tenotomy was 4 years 3 months compared with 7 years 3 months for patients with rerouting. Follow-up averaged 94 months for tenotomy and 21 months for rerouting. Average gain in supination was 78 degrees for rerouting and 54 degrees for tenotomy. No patient lost active range of motion during follow-up. Although pronator teres tenotomy increased active supination of the forearm, greater active supination of the forearm was afforded patients treated with pronator teres rerouting.     

Pharmacologic management of the spastic and dystonic upper limb in children with cerebral palsy

Spasticity or dystonia of the upper limb in children with CP commonly is seen as part of a more involved clinical picture. Each can cause functional problems in and can interfere with the quality of life of children with CP. Pharmacologic manipulation of the spasticity and dystonia requires a patient and ordered approach. Treatment often is performed using an open trial method, with medications introduced slowly but often being limited in their usefulness by significant side effects. Despite multiple medications being available for spasticity and dystonia management, few of the oral treatments have been assessed systematically in children with CP. Specific evaluation of the use of enteral medications in upper limb management is even rarer.     

Gait electromyographic evaluation of the long-toe flexors in children with spastic cerebral palsy

In a prospective study of the phasic activity of the long-toe flexors of patients with spastic cerebral palsy, the electrical activity of the long-toe flexors in 37 children with varus or valgus hindfoot deformity was measured by wire electrode dynamic electromyography. Although gross abnormalities in the phasic timing of the flexor hallucis longus and flexor digitorum longus were observed, these muscles could not be implicated in the etiology of hindfoot deformity. In planning gait analysis protocols for children with cerebral palsy and hindfoot deformity, electromyography of the long-toe flexors is not necessary unless toe curling is clinically evident.