One-stage hip reconstruction in children with cerebral palsy: long-term results at skeletal maturity

Purpose

Hip subluxation is common in children with cerebral palsy (CP). Surgery is indicated in case of pain or progressive increase of Reimers index on radiographs. Peri-iliac osteotomy combined with femoral osteotomy is one of the numerous operative techniques available, but results at skeletal maturity remain unclear. The purpose of this radiological study was to report the long-term results of this procedure.

Materials and methods

Twenty hips in 20 children were retrospectively evaluated at skeletal maturity. Mean age at surgery was 8.1 years and follow-up averaged 9.1 years. All patients underwent Dega acetabuloplasty, soft-tissue release and femoral-shortening varus derotation osteotomy without open reduction. Reimers index, acetabular angle (AA) and neck-shaft angle (NSA) were compared on preoperative, postoperative and latest follow-up radiographs.

Results

Dega osteotomy significantly improved the AA and the correction remained stable at maturity. The NSA significantly decreased postoperatively (153°–115°), but recurrence of the valgus deformity (130°) of the proximal femur was observed at maturity. Consequently, Reimers index followed the same evolution. No case of osteonecrosis was reported but one hip dislocated and one subluxated during follow-up.

Conclusion

Progressive recurrence of the valgus deformity of the proximal femur, attributable to adductors spasticity and gluteus medius weakness, led to a significant increase in the Reimers index. However, hip coverage remained >70 % at maturity in 90 % of the hips. This one-stage procedure without hip dislocation efficaciously corrected acetabulum dysplasia and successfully treated neurological hips in CP patients.

Level of evidence

IV: retrospective study.     

Cementless total hip arthroplasty for patients previously treated with femoral osteotomy for hip dysplasia: the incidence of periprosthetic fracture

Purpose

Femur deformities can make stem fixation difficult in total hip arthroplasty (THA). We report the clinical results of cementless THA using a press-fit stem in patients who had previously undergone femoral osteotomy for hip dysplasia.

Methods

The subjects included 66 hips in 64 patients, with the mean follow-up period of 7.3 years. THA was performed at a mean period of 17.1 years after intertrochanteric femoral osteotomy. Valgus osteotomy was performed in 42 hips, and varus osteotomy in 24. Clinical results were evaluated by using the Merle d’Aubigne-Postel score. Implant survival was determined with revision as the end point, and any related complications were investigated.

Results

The Merle d’Aubigne-Postel score improved from 9.4 to 16.1 at the final follow-up, without any implant loosening. However, periprosthetic femoral fractures were observed in four hips (6.0 %), one intra-operatively and three within three weeks after THA. Among these cases, three hips previously had varus osteotomy (12.5 %) and one hip had valgus osteotomy (2.3 %). Two hips were revised with full porous stems and circumferential wiring. The five and ten year cumulative survivorship rates were 97 % (range, 88.8–99.3 %) and 97 % (88.8–99.3 %), respectively.

Conclusions

Although the use of a press-fit cementless stem yielded acceptable results in most of the patients, perioperative femoral fracture was a major complication especially in the patients previously treated with intertrochanteric varus osteotomy. Careful planning and implant selection could be emphasized for these cases.

     

A balanced approach for stable hips in children with cerebral palsy: a combination of moderate VDRO and pelvic osteotomy

Background

Hip reconstructive surgery in cerebral palsy (CP) patients necessitates either femoral varus derotational osteotomy (VDRO) or pelvic osteotomy, or both. The purpose of this study is to review the results of a moderate varisation [planned neck shaft angle (NSA) of 130°] in combination with pelvic osteotomy for a consecutive series of patients.

Methods

Patients with CP who had been treated at our institution for hip dysplasia, subluxation or dislocation with VDRO in combination with pelvic osteotomy between 2005 and 2010 were reviewed.

Results

Forty patients with a mean follow-up of 5.4 years were included. The mean age at the time of operation was 8.9 years. The majority were non-ambulant children [GMFCS I–III: n = 11 (27.5 %); GMFCS IV–V: n = 29 (72.5 %)]. In total, 57 hips were treated with both femoral and pelvic osteotomy. The mean pre-operative NSA angle of 152.3° was reduced to 132.6° post-operatively. Additional adductor tenotomy was performed in nine hips (16 %) at initial operation. Reimers’ migration percentage (MP) was improved from 63.6 % pre-operatively to 2.7 % post-operatively and showed a mean of 9.7 % at the final review. The results were good in 96.5 % (n = 55) with centred, stable hips (MP <33 %), fair in one with a subluxated hip (MP 42 %) and poor in one requiring revision pelvic osteotomy for ventral instability.

Conclusions

This approach maintains good hip abduction and reduces soft-tissue surgery. Moderate varisation in VDRO in combination with pelvic osteotomy leads to good mid-term results with stable, pain-free hips, even in patients with severe spastic quadriplegia.

     

Rotational osteotomy with submuscular plating in skeletally immature patients with cerebral palsy

Background

In cerebral palsy, intoeing gait with increased femoral anteversion is not uncommon and often requires surgical intervention. Although several conventional methods have been used, complications are common. We applied a new technique of rotational osteotomy with submuscular plating in skeletally immature patients with cerebral palsy.

Methods

Eighteen patients (26 femora, 8 bilateral) with a mean age of 8.7 years (range, 6–16) were prospectively treated with this technique. The anatomic distribution of patients was hemiplegia (n = 7), diplegia (n = 8), and asymmetric diplegia (n = 3). Percutaneous osteotomy was performed at the middle of the femoral shaft. After rotational correction, submuscular plating was done using a locking compression plate. Femoral anteversion was evaluated by a trochanteric prominence angle test (TPAT) and computed tomography.

Results

In all cases, each osteotomy healed in an average of 12 weeks (range, 10–14). The mean femoral anteversion by TPAT improved to 12° (range, 5°–30°) after surgery from 44° (range, 30°–65°) (p < 0.001). There were no complications of deep infection, implant failure, or limb length discrepancy over 1 cm.

Conclusions

In skeletally immature patients with cerebral palsy, femoral anteversion can be safely corrected using submuscular plating with a locking compression plate.     

Ischio-pubic stress fracture after peri-acetabular osteotomy in patients with hip dysplasia

Purpose

Ischio-pubic stress fracture is one of the potential complications after peri-acetabular osteotomy (PAO) in patients with hip dysplasia. The purpose of this study was to examine the prevalence of and risk factors for ischio-pubic fractures following PAO.

Methods

A total of 296 hips in 275 patients who underwent transposition osteotomy of the acetabulum between 2001 and 2012 were retrospectively reviewed. Patient characteristics and radiographic parameters were compared between patients with and without fracture.

Results

Fourteen ipsilateral hips (4.7 %) in 14 female patients had fracture of the inferior pubic ramus (11 hips) or the ischial ramus (three hips) on the same side as the surgery at an average of 4.6 weeks after PAO. Multivariate analysis indicated that younger age at operation (odds ratio of 1.43 per five years, p?=?0.0169) and greater degree of correction (odds ratio of 1.98 per five degrees, p?=?0.0005) were significantly associated with ischio-pubic fracture as independent risk factors. All fractures healed conservatively with partial weight-bearing.

Conclusions

Younger female patients and greater deformity corrections increased the risk of ischio-pubic stress fracture after PAO.     

Early Results of One-Stage Correction for Hip Instability in Cerebral Palsy

Background

We evaluated the clinical and radiological results of one-stage correction for cerebral palsy patients.

Methods

We reviewed clinical outcomes and radiologic indices of 32 dysplastic hips in 23 children with cerebral palsy (13 males, 10 females; mean age, 8.6 years). Ten hips had dislocation, while 22 had subluxation. Preoperative Gross Motor Function Classification System (GMFCS) scores of the patients were as follows; level V (13 patients), level IV (9), and level III (1). Acetabular deficiency was anterior in 5 hips, superolateral in 7, posterior in 11 and mixed in 9, according to 3 dimensional computed tomography. The combined surgery included open reduction of the femoral head, release of contracted muscles, femoral shortening varus derotation osteotomy and the modified Dega osteotomy. Hip range of motion, GMFCS level, acetabular index, center-edge angle and migration percentage were measured before and after surgery. The mean follow-up period was 28.1 months.

Results

Hip abduction (median, 40°), sitting comfort and GMFCS level were improved after surgery, and pain was decreased. There were two cases of femoral head avascular necrosis, but no infection, nonunion, resubluxation or redislocation. All radiologic indices showed improvement after surgery.

Conclusions

A single event multilevel surgery including soft tissue, pelvic and femoral side correction is effective in treating spastic dislocation of the hip in cerebral palsy.     

Does selective dorsal rhizotomy improve bladder function in children with cerebral palsy?

Purpose

To investigate the efficacy of selective dorsal rhizotomy (SDR) on urinary symptoms and bladder function in cerebral palsy children.

Methods

Selective dorsal rhizotomy was performed in 56 children with spastic cerebral palsy. Intraspinal nerve root divisions over the cauda equina from L1/2 to S1/2 levels were performed. Urinary symptoms and urodynamic study (UDS) parameters before and after SDR were analyzed.

Results

Fifty-four out of 56 children (mean age 7.7) with SDR performed had complete urinary symptoms for analysis, of which 90 % had diplegic cerebral palsy. Fifty-one children had preoperative UDS performed, and 20 children had both preoperative and postoperative UDS. All UDS were performed within 4 weeks before SDR, and the mean time from SDR to post-op UDS was 8.4 months. Before operation, 22 out of 54 (40.7 %) children had urgency or frequency, and 16 out of 54 (29.6 %) children had incontinence. Twelve out of 22 (54.5 %) children with urgency or frequency became completely asymptomatic after SDR (p = 0.013), while 9 out of the 10 children with residual urgency or frequency had significant improvement. Twelve out of 16 (75.0 %) incontinent children became continent after SDR (p = 0.013). Bladder capacity at first incontinence significantly increased from 70 to 130 ml (p = 0.016). Other parameters had no significant difference after SDR. There was a trend that S2 rootlet division had major contribution in achieving continence.

Conclusions

Selective dorsal rhizotomy significantly improved urgency, frequency, incontinence, and urodynamic bladder capacity at first incontinence in a significant proportion of spastic cerebral palsy children.     

Lesser trochanteric osteotomy in total hip arthroplasty for treating CROWE type IV developmental dysplasia of hip

Purpose

The study was designed to evaluate the efficacy and safety of lesser trochanteric osteotomy for femoral shortening in total hip arthroplasty in treatment of 28 cases of CROWE IV developmental dysplasia of the hip (DDH).

Methods

Patients underwent progressive femoral shortening at the level of lesser trochanteric to make reduction possible into the anatomical acetabulum in all hips. The results were collected and evaluated clinically and radiographically.

Results

The mean follow-up period was 55.3 months. The average postoperative leg length discrepancy was eight millimetres for unilateral THA patients. A modified Merle d’Aubigné scale was improved from 9.3 preoperatively to 15.9 postoperatively. Sciatic nerve palsy was confirmed in two hips which resolved completely in six months. The Trendelenburg sign was positive in two hips at the final follow-up. No revision surgery was required by the final follow-up.

Conclusion

Lesser trochanteric osteotomy proved to be safe and effective in femoral shortening for treatment of CROWE IV DDH without the problem of nonunion at the site of osteotomy.     

Hip displacement in relation to age and gross motor function in children with cerebral palsy

Purpose

Hip dislocation in cerebral palsy (CP) is a serious complication. By radiographic screening and prophylactic surgery of children at risk most dislocations can be prevented. CPUP, the Swedish CP registry and follow-up program, includes annual radiographic examinations of children at Gross Motor Function Classification System (GMFCS) levels III–V. Data from CPUP were analysed to assess the risk of hip displacement in relation to GMFCS levels and age.

Methods

All children at GMFCS levels III–V (N = 353) whose first radiographic screening occurred before 3 years of age were followed between the ages 2–7 years. Migration percentages (MPs) were recorded annually (1,664 pelvic radiographs) and analysed using discrete time survival analysis.

Results

The risk of hip displacement between 2 years and 7 years of age was significantly (p < 0.05) higher for children at GMFCS level V during the entire study period. The risk was highest at 2–3 years of age and decreased significantly (p < 0.001) with each year of age (OR = 0.71, 95 % CI 0.60–0.83). The cumulative risk at age 7 years for those at GMFCS V for MP ≥ 40 % was 47 % (95 % CI 37–58). The corresponding risk at GMFCS IV was 24 % (16–34) and at GMFCS III 23 % (12–42).

Conclusions

Children at GMFCS V have a significantly higher risk of hip displacement compared with children at GMFCS III–IV. The risk is highest at 2–3 years of age. The results support a surveillance program including radiographic hip examinations as soon as the diagnosis of severe CP is suspected.     

No association of labor epidural analgesia with cerebral palsy in children

Background

Some pregnant women avoid labor epidural analgesia because of their concerns about risk of cerebral palsy in children. Although it is believed that labor epidural does not contribute to cerebral palsy, to our knowledge no study has been published to specifically address this concern. We carried out a retrospective case–control study to investigate whether labor epidural analgesia is associated with cerebral palsy in children.

Methods

This study used data that were collected and entered into the Geisinger electronic health records between January 2004 and January 2013. During this period, 20,929 children were born at Geisinger hospitals. Among them, 50 children were diagnosed with cerebral palsy, and 20 of those were born vaginally. Each of these 20 cerebral palsy children was matched with up to 5 non-cerebral palsy children born at the same hospitals in the same timeframe using propensity scoring methods. Analgesia was classified as epidural (including epidural or combined spinal and epidural) or non-epidural. Conditional logistic regression was used to compare the percentages of deliveries with each analgesia type between the cerebral palsy and non-cerebral palsy groups.

Results

In the non-cerebral palsy group, the percentage of patients receiving labor epidural analgesia was 72 %, and in the cerebral palsy group the percentage was 45 %. There was no significant difference between non-cerebral palsy and cerebral palsy groups (odds ratio, 0.57; 95 % confidence interval, 0.14–2.24; p = 0.42).

Conclusion

We found no association between the use of labor epidural analgesia and the occurrence of cerebral palsy in children.

     

Comparative study on results of reconstructive surgery in 45 hip joints of 25 children with cerebral palsy

Purpose

Multilevel surgeries with hip reconstruction in children with cerebral palsy require low morbid surgical interventions. The aim of our study is to compare results of application of two locking plates in hip reconstructive surgeries in children with cerebral palsy (CP) from the point of view of efficiency and morbidity of the intervention.

Methods

We performed a prospective study on the results of 25 consecutive children with CP operated for hip reconstruction. The patients were divided into two groups according to the type of applied plate chosen at random. Group 1 (Synthes, LCP Pediatric Hip Plate) included 12 patients (22 hips) of an average age 6.2 years. Group 2 (Surfix, PSFE or PPSFE) included 13 patients (23 hips) of an average age 6.1 years. Thirteen acetabuloplasties were performed in group 1 and 15 acetabuloplasties in group 2. Duration of the procedure, amount of intraoperative blood loss, and hematogram indices before and in 24 h after surgery were compared. The following radiographic parameters were compared preoperatively and in 5–6 months of follow-up: acetabular index, projected neck shaft angle, Reimers index, and Wiberg angle.

Results

A statistically longer duration of surgery and more significant intraoperative blood loss were noted in group 1. Evaluation of radiograms did not reveal difference between the groups.

Conclusions

Results of hip reconstruction in children with severe forms of CP are satisfactory and reproducible in our series. Application of Surfix locking plates is associated with smaller volume of blood loss, and operation time is shorter.     

Boomerang proximal tibial osteotomy for the treatment of severe varus gonarthrosis

Purpose

The purpose of the study was to review the results of modified infratubercle displacement osteotomy in patients with severe varus gonarthrosis and to determine the factors influencing outcomes.

Methods

A total of 177 knees in 133 patients with severe varus gonarthrosis were treated with infratubercle boomerang-shaped osteotomy, stabilised with dual plates. The mean age of the patients was 63.8 years (range 43–80 years), and the mean follow-up period was 61.4 months (range 24 –139 months). The factors associated with clinical and survival outcomes were analysed including age, gender, body mass index (BMI), preoperative and post-operative femorotibial angle and femorotibial angle at one year after surgery.

Results

Using the Knee Society clinical rating system 149 knees or 84.2 % were rated as having good to excellent results and 21 knees or 15.8 % as having fair to poor results. Overall, the mean preoperative knee score of 33.6 points had improved significantly to 80.7 points at the final follow-up (p < 0.001). Using Kaplan-Meier survivorship analysis the five-year survival was 97.1 % with conversion to arthroplasty or second osteotomy as the end point and 89.2 % with a knee score of under 70 points as the end point. The anatomical femorotibial angle at one year after osteotomy had the most significant positive effect on the clinical (p < 0.001) and survival outcomes for all end points (p = 0.002 for conversion to arthroplasty or second osteotomy and p < 0.001 for knee score less than 70 points).

Conclusions

The boomerang osteotomy can create adequate valgus alignment in severe varus gonarthrosis. The one-year post-operative knee alignment of 11° valgus provided the most satisfactory results and that between six and 15° valgus the longest survival time.     

Prevalence of developmental dysplasia of the hip in preterm infants with maternal risk factors

Purpose

The aim of this study was to determine the prevalence of developmental dysplasia of the hip (DDH) in preterm infants with maternal risk factors.

Methods

A prospective review of the medical records and ultrasound (US) scans of all preterm infants at one tertiary-care children’s hospital was completed to identify all premature infants without any infantile risk factors at a particular time frame. We consecutively evaluated 421 babies (842 hips) who satisfied the criteria for inclusion. Hip US images were classified according to Graf.

Results

Overall, one hip was diagnosed as DDH (Graf type 2c). Female infants had significantly lower alpha angles (70.2 ± 6.6 and 71.4 ± 4.4 for females and males, respectively) (P = 0.033). There was no correlation between oligohydramnios and alpha and beta angles and hip sides (P = 0.345 and P = 0.789 for left and right hips, respectively). US examination of the infants revealed no differences between the alpha and beta angles of the hips and birth weight and age at gestation. Although it was statistically not significant, US evaluation of left hips among singletons demonstrated one immature hip (P = 0.864) and that of right hips demonstrated one immature hip for both singletons and twins (P = 0.904).

Conclusions

Prematurity with or without maternal risk factors does not have an effect on DDH.     

Shortening subtrochanteric osteotomy and cup placement at true acetabulum in total hip arthroplasty of Crowe III–IV developmental dysplasia: results of midterm follow-up

Introduction

The anatomic abnormalities in developmental dysplasia of hip (DDH) often make total hip replacement (THR) inevitable at a younger age. However, there is no universal gold standard technique of THR for high dislocated dysplastic hips.

Materials and methods

Here we present the outcomes of midterm follow-up after THR in patients diagnosed with DDH Crowe type III and IV hospitalized in a tertiary center in Iran for whom placement of a cup in true acetabulum and selective transverse subtrochanteric osteotomy was performed. Pre- and postoperative Harris Hip Score, leg length discrepancy and postoperative complications were evaluated.

Results

A total of 48 patients with DDH Crowe type III and IV (uni- or bilateral which made 52 hips) were studied. Mean age of patients was 41 years with minimum follow-up ranging from 12 months to 3 years. Mean Harris Hip Score significantly improved from 41.70 preoperatively to 88.1 at last follow-up postoperatively. Leg length discrepancy of less than 2 cm was observed which was well tolerated using shoe lifts. Regarding postoperative complications, two patients had transient peroneal nerve palsy in early postoperative period which recovered within 2 months. No other major complication was encountered.

Conclusion

THR in patients with DDH (Crowe III and IV) with a cup positioned in true acetabulum and transverse subtrochanteric osteotomy is a safe successful procedure.

     

Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy

Purpose

The purpose of this study was to evaluate the results of distal femur extension osteotomy and medial hamstring lengthening in the treatment of fixed knee flexion deformity in patients with spastic diparetic cerebral palsy.

Methods

A retrospective study was done in a group of 12 diparetic cerebral palsy patients. A distal femur extension osteotomy was performed as part of multilevel surgery on lower limbs. The fixed knee flexion deformity was measured during physical examination, whereas hip and knee flexion in the stance phase and anterior pelvic tilt were both analyzed at kinematics. The pre- and post-surgery results were compared and analyzed statistically. A medical record review was done in order to identify the complications. The mean follow-up was 28 months.

Results

A significant reduction of fixed knee flexion deformity at physical examination and knee flexion in the stance phase at kinematics was observed, but with no decrease in hip flexion. As a non-desired effect, there was an increase in anterior pelvic tilt after surgical procedures. With regard to complications, a single patient had skin breakdown at a calcaneous area on one side and the recurrence of deformity was seen in 27% of cases.

Conclusions

In this study, in which fixed knee flexion deformity did not exceed 40° before surgery, the distal femur extension osteotomy was effective in increasing knee extension in the stance phase. However, an increase in anterior pelvic tilt, deformity recurrence and necessity for walking aids are possible complications of this procedure.     

Subtrochanteric shortening osteotomy combined with cemented total hip arthroplasty for Crowe group IV hips

Background

Total hip arthroplasty (THA) is a challenging surgical procedure that can be used to treat severely dislocated hips. There are few reports regarding cemented THAs involving subtrochanteric shortening osteotomy (SSO), even though cemented THAs provide great advantages because the femur is generally hypoplastic with a narrow, deformed canal.

Purposes

We evaluated the utility of cemented THA with SSO for Crowe group IV hips, and assessed the relationship between leg lengthening and nerve injury. Our goal was to describe surgical techniques for optimizing surgical outcomes while minimizing the risk of nerve injury.

Methods

We retrospectively reviewed 34 cases of cemented THAs with transverse SSO for Crowe group IV. Prior to surgery, mean hip flexion was 93.1° (40°–130°). The mean follow-up period was 5.2 years (3–10 years).

Results

Bone union took an average of 7.7 months (3–24 months). Mean leg lengthening was 40.5 mm (15–70 mm) and was greater in patients without hip flexion contracture. None of the patients experienced any nerve injuries associated with leg lengthening, and radiographic evidence of loosening was not observed at the final follow-up.

Conclusions

SSO combined with cemented THA is an effective treatment for severely dislocated hips. Leg lengthening is not necessarily associated with nerve injuries, and the likelihood of this surgical complication may be related to the presence of hip flexion contracture.     

The effect of renal function on surgical outcomes of intracapsular hip fractures with osteosynthesis

Background

Chronic kidney disease (CKD) affects many physiologic systems, including bone quality, nutrition, and cardiovascular condition. Femoral neck fractures in patients on dialysis are associated with frequent complications and a high risk of mortality. However, the effect of CKD on clinical outcomes of patients with hip fractures treated with osteosynthesis remains unclear.

Methods

One hundred and thirty patients with 130 femoral neck fractures treated with internal fixation were divided into two groups and the data were then analyzed. Group 1 consisted of 98 patients (98 hip fractures) with normal renal function (estimated glomerular filtration rate, or eGFR, ≥60 ml/min/1.73 m²). Group 2 was composed of 32 patients (32 hip fractures) with CKD (eGFR <60 ml/min/1.73 m²) without dialysis. Clinical outcomes as well as early and late complications were recorded for each group. Survivorship analysis was performed, and the mortality and complication rates for the groups were then compared.

Results

In Group 1, 32 complications (32.6 %) occurred in 98 hips, including 5 cases of nonunion and 16 cases of osteonecrosis. In Group 2, 24 complications (75 %) developed in 32 hips; these included 8 cases of nonunion and 3 cases of osteonecrosis. The mean duration of follow-up was 32 months. The overall mortality rate was 11.5 %. No difference was noted in early, late, or overall mortality rate between two groups. Patient with CKD had a higher nonunion rate (OR = 5.9, P = 0.023). Meanwhile, CKD and displaced fracture pattern were independent predictors for revision surgery (OR = 3.0, P = 0.032; OR = 6.9, P = 0.001, respectively).

Conclusions

Osteosynthesis is a safe and effective treatment for femoral neck fractures; however, patients with femoral neck fracture and CKD have a higher risk of nonunion and subsequent surgical revision.

Level of relevance

Prognostic studies, Level III.     

Comparison of open lateral release and transarticular lateral release in distal chevron metatarsal osteotomy for hallux valgus correction

Purpose

The aim of this study was to investigate the difference in clinical and radiographic outcomes between conventional open lateral soft tissue release (OLSTR) and transarticular lateral soft tissue release (TLSTR) in patients undergoing distal chevron metatarsal osteotomy (DCMO) for hallux valgus (HV) correction.

Methods

This study included weight-bearing anteroposterior radiographs of 138 patients (185 feet) with HV that underwent DCMO and Akin phalangeal osteotomy at a mean age of 51.7 years (21–74) with a mean 26 months of follow-up between June 2004 and June 2010. Patients were classified into two groups: OLSTR as group 1 (84 feet) and TLSTR as group 2 (101 feet). We evaluated clinical and radiographic outcomes between the two groups using the American Orthopaedic Foot and Ankle Society hallux score, visual analogue scale pain score, hallux valgus angle, intermetatarsal angle and complications, pre- and post-operatively.

Results

There were no significant differences between the two groups except for post-operative complications such as first metatarsophalangeal joint (MTPJ) stiffness (group 1) and post-operative hallux varus (group 2).

Conclusions

Clinical and radiographic outcomes between OLSTR and TLSTR in HV correction using DCMO were not significantly different except for post-operative limitation of motion of the first MTPJ and hallux varus tendency. Different precautions should be taken into account when choosing the type of lateral soft tissue release due to possible complications associated with each technique.     

Major perioperative complications after spine surgery in patients with cerebral palsy: assessment of risk factors

Purpose

A prospective, longitudinal cohort was studied to determine the incidence, consequences, and risk factors of major perioperative complications in patients with cerebral palsy (CP) treated with spinal fusion. There is a wide variety of data available on the complications of spine surgery; however, little exists on the perioperative complications in patients with CP.

Methods

A prospective multicenter dataset of consecutive patients with CP treated with spinal fusion was evaluated. All major perioperative complications were identified and stratified into categories: pulmonary, gastrointestinal, other medical, wound infection, neurological, instrumentation related, and unplanned staged surgery. Univariate and multivariate analyses were performed to identify various risk factors for major perioperative complications.

Results

127 patients were identified with a mean age of 14.3 ± 2.6 years. Overall, 39.4 % of the patients had a major perioperative complication. Occurrence of a complication [no complication (NC), yes complication (YC)] resulted in significantly increased intensive care unit (ICU) (NC = 3.2 days, YC = 7.8 days, p < 0.05) and hospital stays (NC = 7.7 days, YC = 15.6 days, p < 0.05). Variables associated with greater risk of a complication included: increased estimated blood loss (EBL) (p < 0.001), larger preoperative kyphosis (p = 0.05), staged procedures (p < 0.05), a lack of antifibrinolytic use (p < 0.05), and a trend toward lower body mass index (BMI) (p = 0.08). Multivariate regression analysis revealed an increased EBL as independently associated with a major perioperative complication (p < 0.05).

Conclusions

In this cohort of patients with CP who underwent spinal fusion, 39.4 % experienced a major perioperative complication, with pulmonary being the most common. The occurrence of a major perioperative complication lengthened both ICU and hospital stay. Risk factors for major perioperative complications included greater preoperative kyphosis, staged procedures, a lack of antifibrinolytic use, and increased EBL, with the latter being an independent predictor of a major perioperative complication.

Level of evidence

2.

     

Incidence and risk factors for injuries to the recurrent laryngeal nerve during neck surgery in the moderate-volume setting

Purpose

Total lobectomy is currently recommended also in benign thyroid disease in order to reduce the risk of goitre recurrence, an approach claimed not to increase post-operative morbidity. The aim of the study was to analyse risk factors for recurrent laryngeal nerve (RLN) palsy during neck surgery, with particular interest in complications after total lobectomy and subtotal resection, respectively.

Methods

All consecutive patients operated for thyroid and parathyroid diseases at one institution between 1984 and 2011 were prospectively recorded, and 1,322 patients were included. Patients with permanent post-operative RLN palsy were re-examined in 2011.

Results

The risk of permanent RLN palsy after parathyroid surgery was 0.3 %. Patients operated for thyroid cancer had a 5.9 % risk of permanent nerve injury, higher than that of patients with benign thyroid disease (1.4 %; P?=?0.029). Independent risk factors for RLN paralysis after benign thyroid surgery were intrathoracic goitre (odds ratio (OR), 3.57; 95 % confidence interval, 1.70–7.48), ipsilateral redo-surgery (OR, 3.64; 1.00–13.28) and total lobectomy (OR, 2.41; 1.05–5.55). At long-time follow-up (median, 10 years), 7 of 12 patients with permanent RLN palsy still suffered moderate or severe symptoms.

Conclusions

RLN paralysis is an infrequent complication after neck surgery, but with major negative impact on patients’ well-being when permanent. Hemithyroidectomy/total thyroidectomy is increasingly preferred over subtotal resection in multinodular goitre. This is supported by an increased risk of RLN injury during redo-surgery for recurrency but should be carefully weighed against individual risk factors for nerve palsy, including surgical experience and volume.