Overview of foot deformity management in children with cerebral palsy

Foot deformities in children with cerebral palsy are common. The natural history of the deformities of the feet is very variable and very unpredictable in young children less then 5 years old. Treatment for the young children should be primarily with orthotics and manual therapy. Equinus is the most common deformity, with orthotics augmented with botulinum toxin being the primary management in young children. When fixed deformity develops lengthening only the muscle which is contracted is preferred. Varus deformity of the feet is often associated with equinus, and can almost always be managed with orthotics until 8 or 10 years of age. Planovalgus is the most common deformity in children with bilateral lower extremity spasticity. The primary management is orthotics until the child no longer tolerates the orthotic; then surgical management needs to consider all the deformities and all should be corrected. This requires correcting the subtalor subluxation with calcaneal lengthening or fusion, medial midfoot correction with osteotomy or fusion.     

Pes planovalgus deformity surgical correction in ambulatory children with cerebral palsy

Purpose

Planovalgus foot deformity is common in diplegic and quadriplegic patients. Surgery is the definitive treatment to restore the alignment of the talus, calcaneus, and navicular bones. We aimed, in the current study, to compare the effectiveness of subtalar fusion and calcaneal lengthening, and to assess the recurrence in ambulatory children with cerebral palsy.

Methods

This is a retrospective study of 78 patients (138 feet diagnosed with planovalgus deformity) who underwent surgical correction using subtalar fusion or calcaneal lengthening. Range of motion, radiographic indices, kinematic, and pedobarographic data were used to examine the deformity and the outcome of surgery. A repeated measures analysis of variance (ANOVA) was used to test the study hypothesis.

Results

Most of the patients were diplegic (87.2 %) and the mean age at surgery was 11.9 ± 2.9 years (range from 4.7 to 18.3 years), with a mean follow-up of 5 ± 4.4 years (range from 1 to 15.4 years). Sixty-three feet were treated with calcaneal lengthening, while 75 were treated with subtalar fusion. The feet treated with subtalar fusion were more severe preoperatively. However, both surgery groups showed improvement postoperatively. Among 12 cases of recurrence, medial column fusion was the main surgery performed to correct the deformity.

Conclusions

Surgery is effective in the treatment of planovalgus deformity in ambulatory children with cerebral palsy. Severe and rigid planovalgus feet can be treated effectively with subtalar fusion. Feet with milder deformity show good results, with calcaneal lengthening. Surgery provides good correction in young patients, but there is a higher recurrence rate.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-012-0413-3) contains supplementary material, which is available to authorized users.     

Calcaneal lengthening osteotomy in spastic planovalgus feet

Purpose of StudyPlanovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters.Methods17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance.ResultsImprovement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis.ConclusionCalcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.     

Evans跟骨外侧延长术治疗距跟联合合并后足外翻畸形

目的探讨Evans跟骨外侧延长术治疗距跟联合合并后足外翻畸形的疗效。方法2014年1月—2017年10月,采取Evans跟骨外侧延长术治疗10例(13足)距跟联合合并后足外翻畸形患者。男6例(8足),女4例(5足);年龄13~18岁,平均15.8岁。病程10~14个月,平均11.5个月。患侧跟骨外翻、前足外展、足弓低平。疼痛部位:跗骨窦4足、距跟联合5足、踝关节4足。Silverskiold试验腓肠肌腱膜紧张3例(4足),跟腱挛缩7例(9足)。术前美国矫形外科足踝协会(AOFAS)踝与后足评分为(46.54±9.08)分,行走1 km后疼痛视觉模拟评分(VAS)为(6.54±0.88)分。术后采用AOFAS踝与后足评分、VAS评分,以及X线片测量距骨-第1跖列角(talar-first metatarsal angle,T1MT)、距舟覆盖角(talonavicular coverage angle,TCA)、距骨倾斜角(talar-horizontal angle,TH)、跟骨倾斜角(calcaneal pitch angle,CP)、跟骨外翻角(heel valgus angle,HV),评价手术疗效。结果术后切口均Ⅰ期愈合。10例患者均获随访,随访时间12~30个月,平均18个月。末次随访时,AOFAS踝与后足评分为(90.70±6.75)分,VAS评分为(1.85±0.90)分,均较术前明显改善(t=-23.380,P=0.000;t=35.218,P=0.000)。X线片复查示截骨均达骨性愈合,愈合时间为2~4个月,平均3个月。末次随访时,T1MT、TCA、TH、HV均较术前明显降低,CP明显提高,差异有统计学意义(P<0.05)。随访期间1例(1足)疼痛缓解不明显,1例(1足)出现腓肠神经皮支损伤症状。结论对于距跟联合合并后足外翻畸形患者,Evans跟骨外侧延长术可以有效纠正畸形、缓解疼痛。     

Medial displacement calcaneal osteotomy versus lateral column lengthening to treat stage II tibialis posterior tendon dysfunction,a prospective randomized controlled study

PurposeAdult-acquired flatfoot deformity (AAFD) requires optimum planning that often requires several procedures for deformity correction. The objective of this study was to detect the difference between MDCO versus LCL in the management of AAFD with stage II tibialis posterior tendon dysfunction regarding functional, radiographic outcomes, efficacy in correction maintenance, and the incidence of complications.Patient and methods42 Patients (21 males and 21 females) with a mean age of 49.6 years (range 43–55), 22 patients had MDCO while 20 had LCL. Strayer procedure, spring ligament plication, and FDL transfer were done in all patients. Pre- and Postoperative (at 3 and 12 months) clinical assessment was done using AOFAS and FFI questionnaire. Six radiographic parameters were analyzed, Talo-navicular coverage and Talo-calcaneal angle in the AP view, Talo- first metatarsus angle, Talo-calcaneal angle and calcaneal inclination angle in lateral view and tibio-calcaneal angle in the axial view, complications were reported.ResultsAt 12 months, significant improvement in AOFAS and FFI scores from preoperative values with no significant difference between both groups. Postoperative significant improvements in all radiographic measurements in both groups were maintained at 12 months. However, the calcaneal pitch angle and the TNCA were better in the LCL at 12 months than MDCO, 17̊ ± 2.8 versus 13.95̊ ± 2.2 (p = 0.001) and 13.70̊ ± 2.2 versus 19.05̊ ± 3.2 (p < 0.001) respectively. 11 patients (26.2%) had metal removal, seven (16.6%) in the MDCO, and four (9.6%) in the LCL. Three (7.1%) in the LCL group had subtalar arthritis, only one required subtalar fusion.ConclusionLCL produced a greater change in the realignment of AAFD, maintained more of their initial correction, and were associated with a lower incidence of additional surgery than MDCO, however, a higher incidence of degenerative change in the hindfoot was observed with LCL.     

What are the long-term outcomes of lateral column lengthening for pes planovalgus in cerebral palsy?

BackgroundLateral column lengthening (LCL) is commonly performed on children and adolescents with cerebral palsy (CP) for correction of pes planovalgus (PPV). There are limited reports of the long-term outcomes of this procedure. The purpose of this study was to examine the long-term results of LCL for correction of PPV in individuals with CP by evaluating subjects when they had transitioned to adulthood and were entering the workforce.MethodsClinical assessments, quantitative gait analysis including the Milwaukee Foot Model (MFM) for segmental foot kinematics, and patient reported outcomes were collected from 13 participants with CP treated with LCL for PPV in childhood (average age 24.4 ± 5.7 years, average 15.3 ± 8.5 years since LCL). Additionally, 27 healthy adults average age 24.5 ± 3.6 years functioned as controls.ResultsStrength and joint range of motion were reduced in the PPV group (p < 0.05). Sixty nine percent showed operative correction of PPV based on radiologic criteria. Gait analysis showed reduced walking speed and stride length, as well as midfoot break and residual forefoot abduction. Patient reported outcomes indicated that foot pain was not the only factor that caused limited activity and participation. LCL surgery for PPV in childhood resulted in long-term operative correction. Decreased ankle passive range of motion and strength, subtalar joint arthritic changes, inefficient and less stable ambulation, and problems with participation (difficulties in physical function, education, and employment) were observed in the long-term.ConclusionThis study identified postoperative impairments and limitations to guide future clinical decision-making. These results provide clinicians and researchers the common residual and recurrent issues for these individuals as they age. The inclusion of contextual factors that influence the disease and impairments can equip these individuals with enhanced skills they need as they transition into adulthood.     

Management of spinal deformity in cerebral palsy: conservative treatment

Introduction

The incidence of scoliosis in Cerebral Palsy (CP) is directly related to the Gross Motor Function Classification System (GMFCS) level. The natural history of untreated scoliosis in patients with CP is one of progression and factors implicated in deterioration include type of involvement (quadriplegia), poor functional status (nonambulatory, GMFCS levels IV and V), and curve location (thoracolumbar). The generally accepted incidence in the overall CP population is 20–25 %.

Materials and methods

We recently published our short term results for 31 children treated with a short lumbar brace. In cases of a "positive hands up test" we recommend a short lumbar brace, and in patients with scoliosis with a Cobb angle >20° a double shelled brace.

Results

In our study, there was a correction of 37 % for the lumbar Cobb angle and 39 % for the thoracic Cobb angle at a mean follow-up of 28 months.

Conclusion

The incidence of scoliosis in the overall CP population is 20–25 % and is directly related to the GMFCS level. Therefore, we recommend early treatment and prescribe a short lumbar brace in patients with dynamic instability of the trunk, and in scoliosis with a Cobb angle >20° a double shelled brace.     

Surgical treatment of swan-neck deformity in hemiplegic cerebral palsy

PURPOSE: Previously described surgical treatments for dynamic swan-neck deformity in cerebral palsy are technically difficult and time consuming. Typically only a few fingers could be addressed at one sitting, and postoperative swelling and stiffness were often incurred. An easy procedure of central slip tenotomy is described that allows for multiple fingers to be addressed, with minimal postoperative morbidity. METHODS: Fifteen patients (33 fingers) with hemiplegic cerebral palsy and dynamic swan-neck deformities of their fingers were treated. Only swan-neck deformities of greater than 20 degrees were considered for treatment. Pre- and postoperative measurements of swan-neck deformity were recorded. A central slip tenotomy was performed through a transverse incision proximal to the proximal interphalangeal joint. The joint was pinned in 10 degrees of flexion for 4 weeks, and then active extension was allowed to 10 degrees short of full extension and blocked with an oval-8 splint. Average patient age was 16 years (range 5-44 years). All patients had concurrent procedures performed on the extremity. Average follow-up evaluation was 23 months (+/-12 months). RESULTS: Improvement in dynamic swan-neck deformity averaged 32 degrees . Preoperative swan-neck deformity averaged 38 degrees and postoperative swan-neck deformity averaged 6 degrees . No swan-neck deformity was worse than its preoperative state, and no patient developed boutonniere deformity. No patient lost active or passive flexion after the procedure. All patients would repeat the procedure. CONCLUSION: Central slip tenotomy is a reliable treatment for dynamic swan-neck deformity in cerebral palsy in patients without dynamic metacarpophalangeal flexion deformity. Because of the simplicity of the procedure, it can easily be added to the treatment of the entire upper extremity in cerebral palsy.     

Stair-shaped Achilles tendon lengthening in continuity — A new method to treat equinus deformity in patients with spastic cerebral palsy

Background

Equinus of the ankle is a common deformity in spastic cerebral palsy. Achilles tendon lengthening is one of the effective options for the treatment of equinus deformity.

Comparison of hamstring lengthening with hamstring lengthening plus transfer for the treatment of flexed knee gait in ambulatory patients with cerebral palsy

Purpose

Children with spastic diplegic and hemiplegic cerebral palsy frequently ambulate with flexed knee gait. There has been concern that hamstring lengthening used to treat this problem may weaken hip extension. This study evaluates the primary outcome of hamstring transfer plus lengthening in comparison with traditional hamstring lengthening in treating flexed knee gait in ambulatory patients with cerebral palsy.

Methods

A total of 47 children (67 lower limbs) ranging in age from 5 to 17 years old were included in this study. All subjects underwent a variety of additional surgeries at the time of the hamstring surgery as part of a multilevel treatment plan. All patients who met the inclusion criteria were divided into two groups, the hamstring lengthening alone group (HSL) and the hamstring transfer plus lengthening group (HST). Full gait analysis studies were done for all subjects pre-operatively and 1 year post-operatively.

Results

There were 25 patients (35 limbs) in the HSL group and 22 patients (32 limbs) in the HST group. There was no significant difference in age, gender, or the time from surgery to post-operative gait analysis between groups. On physical examination, both HSL and HST groups showed improvement in passive knee extension, popliteal angle, and straight leg raise. Maximum knee extension in stance phase was improved in both groups. The maximum hip extension in late stance phase was significantly improved only in the HST group. The peak hip extension power in stance phase showed significant improvement only in the HST group and a significant decrease for the HSL group.

Conclusions

The findings of this study demonstrated that both the HSL and HST procedures resulted in similar amounts of improvement in passive range of motion of the knee, as well in knee extension in stance during gait at 1 year post-operatively. However, with the HST procedure, there was better preservation of hip extension power and improved hip extension in stance. The HST procedure should be considered when hamstring surgery is performed.     

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.     

Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow-up

Background

Overactivity or contractures of the hamstring muscles in ambulatory children with cerebral palsy (CP) can lead to either a jump gait (knee flexion associated with ankle plantar flexion) or a crouch gait (knee flexion associated with ankle dorsiflexion). Hamstring lengthening is performed to decrease stance knee flexion. However, this procedure carries the potential risk of weakening hip extension power as well as recurrence over time; therefore, surgeons have adopted a modified procedure wherein the semitendinosus and gracilis are transferred above the knee joint, along with lengthening of the semimembranosus and biceps femoris.

Purpose

The purpose of our study is to evaluate the differences between hamstring lengthening alone (HSL group) and hamstring lengthening plus transfer (HST group) in the treatment of flexed knee gait in ambulatory children with CP. We hypothesized that recurrence of increased knee flexion in the stance phase will be less in the HST group at long-term follow-up, and hip extensor power will be better preserved.

Methods

Fifty children with CP who underwent hamstring surgery for flexed knee gait were retrospectively reviewed. All subjects underwent a pre-operative gait study, a follow-up post-operative gait study, and a long-term gait study. The subjects were divided into two groups; HSL group (18 subjects) or HST group (32 subjects). The mean age at surgery was 9.9 ± 3.3 years. The mean follow-up time was 4.4 ± 0.9 (2.7–6.3) years.

Results

On physical examination, both groups showed improvement in straight leg raise, knee extension, popliteal angle, and maximum knee extension in stance at the first post-op study, and maintained this improvement at the long-term follow-up, with the exception of straight leg raise, which slightly worsened in both groups at the final follow-up. Both groups improved maximum knee extension in stance at the initial follow-up, and maintained this at the long-term follow-up. Only the HST group showed significant (p < 0.05) improvement in the peak hip extension power in stance at the first post-op study, and this increased further at the final follow-up. In the HSL group, there was an initial slight decrease in the hip extension power, which subsequently increased to pre-operative values at the long-term study. Only the HST group showed increase of the average anterior pelvic tilt at the long-term follow-up study, although this was small in magnitude. There were two subjects who developed knee recurvatum at the post-op study, and both were in the HST group.

Conclusions

There is no clear benefit in regards to recurrence when comparing HST to HSL in the long term. In both HSL and HST, there was reduction of stance phase knee flexion in the long term, with no clear advantage in either group. Longer follow-up is needed for additional recurrence information. There was greater improvement of hip extension power in the HST group, which may justify the additional operative time of the transfer.

Significance

This study helps pediatric orthopedic surgeons choose between two different techniques to treat flexed knee gait in patients with CP by showing the long-term outcome of both procedures.     

Recurrence after surgery for equinus foot deformity in children with cerebral palsy: assessment of predisposing factors for recurrence in a long-term follow-up study

Background  

Despite the large number of studies on the recurrence after surgery for equinus foot deformity in cerebral palsy (CP) patients, only a few investigations have reported long-term recurrence rates. Furthermore, little is known on the interval between the recurrent surgeries and the factors that lead to early recurrence. This study aimed to assess the overall recurrence after surgery for equinus foot deformity in patients with CP and to assess the factors associated with recurrence. We also aimed to determine the predisposing factors for early recurrence.     

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.

     

Development of the hip joints in unoperated children with cerebral palsy: A radiographic study of 76 patients

Background?The aims of the present study were to assess the development of hip dysplasia in children with bilateral spastic cerebral palsy and to evaluate the factors that influence the progression.

Patients and methods?76 children, 42 with spastic quadriplegia and 34 with diplegia, were included in the study. Their mean age at the first radiographic examination was 3.5 (1–11) years. The patients were followed up until operative treatment (54 subjects) or until the most recent radiograph in those who did not undergo hip surgery. The mean length of follow-up was 4.8 (1–13) years. On the initial and most recent radiographs, the migration percentage (MP) was measured, which is the percentage of the femoral head lateral to the acetabular rim.

Results?The mean MP of the side with the largest displacement was 25% (-18–66) at the initial radiographic examination and 51% (9–100) at the last follow-up. The mean increase in MP was 7% (-2–33) per year. Linear multiple regression revealed that gait function and age were the most important variables that influenced the rate of MP progression. Children who could not walk had significantly greater MP progression per year (12%) than those who walked with or without support (2%). In the quadriplegics, the maximal yearly increase in MP was 13% under 5 years of age and 7% in older children. This difference was statistically significant, whereas no significant difference in relation to patient age was seen in the diplegics.

Interpretation?There is a pronounced trend towards displacement of the hips in quadriplegic CP patients who are under 5 years of age and cannot walk. Because hip dislocation may lead to severe problems, close follow-up is important in finding the appropriate time for hip surgery in order to avoid progression towards dislocation. The risk of severe hip dysplasia is considerably less in spastic diplegia.??     

The effect of tuning ankle foot orthoses-footwear combinations on gait kinematics of children with cerebral palsy: A case series

Study designCase series.BackgroundAFOs are a commonly prescribed medical device given to children with cerebral palsy (CP) in an attempt to improve their gait. The current literature is equivocal on the effects AFOs have on the gait of children with CP. The vast majority of AFOs issued are not subject to AFO-FC tuning. There are emerging studies investigating the effects tuning AFO-FCs has on the gait of children with CP. However, the research is limited, and there is a lack of quantitative data.ObjectiveTo compare the kinematics of tuned versus non-tuned gait in children with CP.MethodsGait analysis assessment of five children aged between 7–11 years with a diagnosis of CP (one hemiplegic and four diplegic participants, two female, three male, with a Gross Motor Functional Classification System (GMFCS) of 2) at a Gait Analysis Laboratory.ResultsIn comparison to barefoot and non-tuned gait, walking with a tuned AFO-FC produced improvements in several key gait parameters. Including hip flexion and extension, posterior pelvic tilt and knee extension. Results also indicated that the type of gait pattern demonstrated by the participant affected the outcomes of tuning.ConclusionsTuning the AFO-FC of children with CP has the potential to improve hip function, pelvic function, knee extension in stance phase and knee flexion during swing phase and that a non-tuned AFO-FC can potentially decrease hip function, posterior pelvic tilt and increase knee extension.Clinical RelevanceWhilst AFO-FC tuning has been recommended for routine clinical practice, there still remains a paucity of research on the kinematic effects of using a tuned AFO-FC compared to a non-tuned. This paper provides a comparison of kinematics on children with CP, during barefoot, non-tuned and tuned AFO-FC walking with a view to inform clinical practice.     

Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review

Purpose:In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement.Method:A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022.Results:There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates.Conclusion:The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research.Level of evidence:level V.     

Tibial tubercle osteotomy to improve exposure in complex knee fractures: A cadaveric study and case series

Adequate exposure is fundamental to safely and correctly perform open procedures around the knee. Tibial tubercle osteotomy (TTO) has previously been described as a method to improve exposure, particularly in complex primary elective knee arthroplasty or revision surgery. We describe a tibial tubercle osteotomy technique to improve exposure in complex knee fractures and a cadaveric study and trauma case series.MethodsA cadaveric study using 8 knee specimens was conducted using a lateral subvastus approach to the knee. Standardised pictures were taken of the exposure, the tibial tubercle osteotomy was performed and pictures were taken of the new exposed area. These images were compared using a computer program that calculated the area of exposure before and after tibial tubercle osteotomy and the results analysed. The technique was then used in a case series of 6 different complex knee fractures including three distal femoral, one periprosthetic distal femur and two tibial plateau fractures. The outcomes of these patients were followed clinically and radiologically.ResultsAll specimens in the cadaveric study demonstrated an increase in area of exposure after the TTO with a mean increase of 148%. All tibial tubercle osteotomies performed in the trauma case series were united by 6 months without complication.ConclusionsTibial tubercle osteotomy is a recognised technique for improving exposure to the knee. This has been demonstrated in a cadaveric study and in a case series of six complex fractures around the knee. If performed properly, this technique can be extended to appropriate trauma cases with good results.     

Surgical treatment of equinus deformity in cerebral palsy by aponeurosis lengthening and Z-lengthening

Abstract Surgical treatment of equines deformity in cerebral palsy can be carried out successfully by Achilles tendon lengthening and gastrocnemius aponeurosis lengthening. From 1993 to 1998, we performed 59 operations in 37 cerebral palsied patients with equinus deformity using Z-lengthening in 30 cases and a modified Bakers procedure in 29 cases. The operations, associated with other hip and knee procedures in 65% of patients, were followed by postoperative use of casts and by a 12-month intensive kinesitherapeutic protocol. On preoperative evaluation, besides pattern deformity and the condition of proximal joints, we considered also age, clinical diagnosis, nature of tone and muscle strength. In most cases, the retrospective analysis showed the correction of deformity and a functional improvement. We observed 9 recurrences in six of the younger patients without relationship with topographic pattern of cerebral palsy. Overcorrection of equines deformity occurred in one diplegic child who had phasic hypertonia and low muscle strength. We believe that the evaluation of patients, the preoperative planning and the effective kinesitherapeutic program are necessary to reduce the risk of complications related to surgery.