Correction of Tibial Torsion in Children With Cerebral Palsy by Isolated Distal Tibia Rotation Osteotomy: A Short-term, In Vivo Anatomic Study

Distal tibial osteotomy to address internal tibial torsion: Should the fibula be cut?

Background Rotational tibial osteotomy seeks to address pathologic tibial torsion. Inclusion of fibular osteotomy during this procedure remains controversial. This study aimed to determine how external rotation through a tibial osteotomy, with or without a fibular osteotomy, would influence tibiofibular joint congruity. Methods Eight cadaveric legs underwent distal tibial osteotomies. Pins were placed to designate neutral, 10°, 20°, 30° of external rotation. Computed tomography (CT) imaging was performed at each rotation without, then with a fibular osteotomy. Magnetic Resonance Imaging was performed prior to fibular osteotomy to confirm that ligaments remained intact. Custom software calculated tibial torsion using CT scan 3D reconstructions. Proximal tibiofibular joint rotation, distal tibiofibular gapping and ankle mortise were measured on each CT exam. Groups without and with fibular osteotomy were compared. Findings There was no difference between tibial osteotomy rotation magnitude with or without the fibular osteotomy (P = 0.2). The group without the fibular osteotomy had greater proximal fibular rotation at the tibiofibular joint at 20°, 30° (P < 0.05), greater posterior distal tibiofibular gap at 10°, 20°, 30° (P < 0.05) and less anterior distal tibiofibular gap at 20°, 30° (P < 0.05). The medial tibiotalar space was narrowed without the fibular osteotomy at 20°, 30° (P < 0.05) compared to pre-rotation. Interpretation Deformity at the proximal tibiofibular and ankle joints become most pronounced at >20° of tibial rotation without a fibular osteotomy. The first joint to be affected is the distal tibiofibular joint. To limit ankle and proximal tibiofibular articular deformation during tibia rotational osteotomy, a fibular osteotomy is recommended when correcting over 20° of rotation.

Improvement of the gait pattern after selective dorsal rhizotomy derives from changes of kinematic parameters in the sagittal plane

OBJECTIVE

Selective dorsal rhizotomy (SDR) can decrease spasticity in children suffering from spastic cerebral palsy (SCP) and thus improve their moving ability when supplemented with the post-operational rehabilitation program. In this case, the study aims to investigate the gait changes in children with mild SCP after SDR in short-term follow-up.

METHODS

The information of ambulatory SCP cases who underwent SDR in our center was retrospectively reviewed, and comparisons of changes in spasticity, motor function and data of gait analysis before and after SDR were analyzed.

RESULTS

In total, 32 cases were included in this study, with a mean age of 5.9 ± 2.1 years old. Noticeable decrease was found in the median value of the pre-operational MAS score after SDR at last follow-up in both sides of adductors, gastrocnemius, soleus, and left hamstrings. The Gross Motor Function Measure-66 score increased from 70.6 ± 9.2 to 73.4 ± 8.2, and the gait deviation index increased after SDR compared with the pre-operational data (right side: 65.8 ± 8.8 vs. 60.1 ± 10.7; left side: 63.5 ± 10.1 vs. 57.0 ± 9.9). Noticeable changes were found that the maximum angle of affected ankles in the sagittal plane (the dorsal-flexion angle) increased from 2.5° to 8.2°, the angles at initial contact (1% gait cycle) of affected knees in the sagittal plane decreased from 34.0° to 27.8°, and the angles at the end of swing phase (100% gait cycle) of affected knees in the sagittal plane decreased from 35.8° to 28.3°.

CONCLUSION

In short-term follow-up, SDR can lower spasticity in children with SCP. Post-operational gait analysis showed improvements in gross motor function and gait, which derived from the changes in the sagittal plane (ankle and knee). A longer follow-up duration is thus needed to clarify the long-term outcome.

Differences between Two Methods to Stabilize Supramalleolar Osteotomies in Children-A Retrospective Case Series

Supramalleolar osteotomy (SMO) in pediatric patients can be fixed in various ways. We analyzed the records of 77 pediatric patients (124 SMOs) aged ≤16 years. In 56 patients (96 SMOs), K-wires were used to stabilize SMOs (WF group), while 21 patients (28 SMOs) were treated with locking compression plates (LCPs; PF group). We recorded time to radiographic consolidation, rate of complications, length of hospital stay (LOS), and time to implant removal. Mean time to radiographic consolidation of SMOs was 7.2 weeks in the WF group and 11.1 weeks in the PF group. Complication rate in the WF group was 10.7%. LOS was similar in the two groups (7.0 days in the WF group vs. 7.3 days in the PF group). K-wire stabilization resulted in a shortened interval until consolidation of osteotomies, but children were required to use a cast. Stabilization of SMOs with LCPs facilitated early mobilization and functional rehabilitation with no need to apply a cast. In conclusion, both methods provided safe fixation of SMOs with a low rate of complications. K-wire stabilization combined with a cast achieves fast consolidation of SMOs. We recommend SMO stabilization with angular stable LCPs in patients with muscular weakness or spasticity in whom early mobilization and physiotherapy are necessary to prevent loss of muscle power, muscle function, and bone mass.

Orthopedic treatment of the lower limbs in spastic paralysis

Spastic paralysis of the limb mainly results from the central lesion, in which spastic cerebral palsy is the common cause. Due to durative muscle spasm in spastic cerebral palsy, it is often accompanied by the formation of secondary musculoskeletal deformities, resulting in limb motor disability. Based on its pathogenesis, surgical treatment is currently applied: selective posterior rhizotomy (SPR) or orthopedic surgery. The primary purpose of early orthopedic surgery was simply to correct limb deformities, which usually led to the recurrence of deformity as a result of the presence of spasticity. With the application of SPR, high muscle tone was successfully relieved, but limb deformity was still present postoperatively. Therefore, this study aimed to elaborate on the management of orthopedic surgery, common deformities of the lower limb, and orthopedic operative methods; discuss the relationship between SPR and orthopedic procedure for limb deformity; and focus on the indications, timing of intervention, and postoperative outcome of different surgical methods.

What's New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis

BACKGROUND

Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment.

METHODS

A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review.

RESULTS

The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis.

CONCLUSIONS

Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance.

LEVEL OF EVIDENCE

Level IV-literature review.