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Background: Clinicians interested in assessment and outcome measurement of upper extremity (UE) function and performance in children with cerebral palsy (CP) must choose from a wide range of tools.Questions/purposes: We systematically reviewed the literature for UE assessment and classification tools for children with CP to compare instrument content, methodology, and clinical use.Methods: We searched Health and Psychosocial Instruments (HaPI), US National Library of Medicine (PubMed), and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus) databases (1937 to the present) to identify UE assessment and outcomes tools. We identified 21 tools for further analysis and searched HaPI, PubMed, CINAHL Plus, and Google Scholar ( http://scholar.google.com/schhp?tab=ws ) databases to identify all validity and reliability studies, systematic reviews, and original references for each of the 21 tools.Results: The tools identified covered ages birth to adulthood. International Classification of Functioning, Disability and Health domains addressed by these tools included body function, body structure, activities and participation, and environmental factors. Eleven of the tools were patient or family report, seven were clinician-based observations, and three tools could be used in either fashion. All of the tools had published evidence of validity. Nine of the tools were specifically designed for use in subjects with CP. Two of the tools required formal certification before use. Ten of the tools were provided free of charge by the investigators or institution who developed them.Conclusions: Familiarity with the psychometric and clinometric properties of assessment and classification tools for the UE in children with CP greatly enhances a clinician's ability to select and use these tools in daily clinical practice for both clinical decision-making and assessment of outcome. [ABSTRACT FROM AUTHOR]

Background: According to the most recent data, an estimated 17.1% of children in the United States are obese. We found no published studies documenting the prevalence of obesity in ambulatory children with cerebral palsy. The purpose of this study was to document the prevalence of obesity in ambulatory children with cerebral palsy and examine the trend in this measure over the last decade.Methods: A retrospective review was performed to analyze the age, gender, height, weight, physical classification of the cerebral palsy, and functional level as determined with the Gross Motor Function Classification System (GMFCS) of all children with cerebral palsy who had a gait analysis performed in the Motion Analysis Laboratory of our institution between January 1994 and December 2004. This information was used to determine the prevalence of obesity (a body mass index in or above the 95th percentile of the sex-specific body mass index-for-age growth chart) in this population and its relationship to age, gender, the physical classification of the cerebral palsy, and the GMFCS level.Results: When the data were grouped into three time periods (1994 to 1997, 1998 to 2002, and 2003 to 2004), a significant increase in obesity over time was noted (p = 0.017). The prevalences increased from 7.7% to 14% to 16.5% in the respective time periods. The prevalence increased over time in both males and females, those with hemiplegia and those with diplegia, and those with level-I function and those with level-II function according to the GMFCS. The association between obesity and time was significant in the female (p = 0.015), hemiplegic (p = 0.049), less than eight-year-old (p = 0.020), and GMFCS level-II (p = 0.003) groups. We found that the time period was independently associated with obesity when we controlled for age, type of cerebral palsy, and GMFCS level (p = 0.014). Children with a lesser degree of involvement (GMFCS level II) had twice the odds of becoming obese than did children with greater involvement (GMFCS level III).Conclusions: The prevalence of obesity in ambulatory children with cerebral palsy has risen over the last decade from 7.7% to 16.5%, an increase that is similar to that seen in the general pediatric population in the United States. This finding may have a major impact on the general health and functional abilities of these children as they reach adult life. [ABSTRACT FROM AUTHOR]

Background: Children with cerebral palsy who are able to walk are often managed with an ankle-foot orthosis to assist with walking. Previous studies have shown kinematic, kinetic, and energetic benefits during gait with the addition of an ankle-foot orthosis, although the mechanism of this gait improvement is unknown. The ability of orthoses to correct foot malalignment in children with cerebral palsy is not known. The current study was performed to determine the impact of orthoses on static foot alignment in children with cerebral palsy.Methods: A retrospective radiographic review was performed for 160 feet (102 patients). All patients had a diagnosis of cerebral palsy. Standing anteroposterior and lateral radiographs of the foot and ankle were made with the patient barefoot and while wearing the prescribed orthosis and were compared with use of the technique of quantitative segmental analysis of foot and ankle alignment.Results: Analysis of the foot and ankle radiographs made with the patient barefoot and while wearing the brace revealed significant changes in all measurements of segmental alignment (p < 0.05). The magnitudes of these differences were small (<6 degrees or <10%) and would be considered clinically unimportant. The coupled malalignment of equinoplanovalgus (clinical flatfoot) showed radiographic correction of at least one segment (hindfoot, midfoot, or forefoot) to within the normal range in 24% to 44% of the feet. The coupled malalignment of equinocavovarus (clinical high arched foot) showed correction of at least one segment to within the normal range in 5% to 20% of feet.Conclusions: The present study demonstrates that the use of the ankle-foot orthoses failed to improve the static foot alignment in the majority of feet in children with cerebral palsy who were able to walk.Level Of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: There is substantial controversy concerning the prosthetic management of children with unilateral congenital below-elbow deficiency. The optimal age at the time of the initial fitting, the value of intensive prosthetic training, and the preferred prosthetic design for these children have not been established.Methods: The outcomes of prosthetic management for 260 children with unilateral congenital below-elbow deficiency, treated between 1954 and 2004, were analyzed with respect to ongoing clinic attendance and self-reported prosthetic use. A successful prosthetic outcome was defined as a child and parents who continued to attend the limb-deficiency clinic and claimed at the time of the most recent follow-up that the prosthesis had been worn for any period of time. An unsuccessful prosthetic outcome was defined as a child and parents who were lost to follow-up or who claimed at the time of the most recent follow-up that the child never wore the prosthesis. Survival analysis was performed.Results: An unsuccessful prosthetic outcome was noted for 127 children (49%). Initial fitting prior to the age of three years was associated with improved prosthetic outcome (p < 0.001). With the numbers studied, there was no additional benefit noted for fitting before one year of age (p = 0.60). Improved prosthetic outcomes were noted in children who had received intensive training at the time of fitting with an active terminal device (p = 0.005). Provision of a variety of prosthetic designs over the growing years was also associated with improved prosthetic outcome (p < 0.001).Conclusions: This study supports the initial prosthetic fitting for a child with unilateral congenital below-elbow deficiency prior to the age of three years, the provision of intensive training under the direction of an occupational therapist when an active terminal device is applied, and utilization of a variety of prosthetic designs over the child's years of growth. Further analysis of outcomes for the prosthetic management of these children will require more precise definitions of outcome in multiple domains and the development and validation of specific outcome instruments. [ABSTRACT FROM AUTHOR]

Background: The Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) is a video-based tool for the assessment of upper extremity function in children with hemiplegic cerebral palsy. This tool includes spontaneous functional analysis and dynamic positional analysis and assesses the ability to perform grasp and release. The purpose of the present study was to assess the reliability, concurrent validity, and construct validity of this instrument.Methods: The Shriners Hospital for Children Upper Extremity Evaluation studies for eleven subjects with hemiplegic cerebral palsy were selected for the evaluation of intraobserver and interobserver reliability. Concurrent validity was determined through analysis of the Shriners Hospital for Children Upper Extremity Evaluation, Pediatric Evaluation of Disability Inventory, and Jebson-Taylor Test of Hand Function scores for twenty children. Construct validity was determined through analysis of Shriners Hospital for Children Upper Extremity Evaluation scores for eighteen children before and after flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer.Results: The absolute mean differences between the two scoring sessions for three raters were 1.2 and 1.0 for the spontaneous functional analysis and the dynamic positional analysis, respectively. Although the mean differences were significantly different from 0 (p < 0.001 and p = 0.003), the differences were small and not clinically important with regard to the total possible score. There was excellent intraobserver reliability between the two sessions with regard to both spontaneous functional analysis (r = 0.99) and dynamic positional analysis (r = 0.98). Assessment of interobserver reliability revealed absolute mean differences between four raters of 3.8 and 3.7 for the spontaneous functional analysis and the dynamic positional analysis, respectively. These differences were significantly different from 0 (p < 0.001); however, the magnitudes of these differences were not important with regard to total score or clinical interpretation. There was excellent interobserver reliability for both the spontaneous functional analysis (r = 0.90) and the dynamic positional analysis (r = 0.89). There was 100% agreement within and between examiners for the grasp-and-release section. The Shriners Hospital for Children Upper Extremity Evaluation showed fair correlation with the self-care scaled score from the Pediatric Evaluation of Disability Inventory (r = 0.47) and good inverse correlation with the non-dominant total time section of the Jebson-Taylor test (r = -0.76). The Shriners Hospital for Children Upper Extremity Evaluation wrist score improved for all eighteen subjects after the flexor tendon transfer, and the mean improvement was significant (p < 0.001).Conclusions: The present study establishes the clinical reliability, concurrent validity, and construct validity of the Shriners Hospital for Children Upper Extremity Evaluation for the assessment of upper extremity function in children with hemiplegic cerebral palsy. [ABSTRACT FROM AUTHOR]

Background: Investigators have recommended aggressive use of skin-grafting in order to preserve length and proximal joint function following an acquired amputation in children. However, there is little objective evidence to either support or refute that recommendation.Methods: We performed a retrospective review of the cases of all children for whom a skin graft had been applied to the residual limb following an acquired lower-extremity amputation at our Limb Deficiency Clinic between 1984 and 2002. Skin graft dysfunction, defined as breakdown, contracture, and/or pain, was considered to be clinically relevant if it required the child to discontinue use of the prosthesis for any period of time or if it required revision surgery to facilitate continued prosthetic fitting.Results: Twenty-three children (mean age at amputation, 4.4 years) with a total of thirty-one acquired lower-extremity amputations had been treated with skin-grafting. At a mean of 6.3 years after the operation, sixteen (52%) of the thirty-one extremities had had no episodes of skin graft dysfunction. The remaining fifteen extremities (48%) had had clinically relevant skin graft dysfunction (breakdown in thirteen and contracture and pain in one extremity each). Nine of the ten extensive skin grafts underwent clinically relevant breakdown, as did thirteen of the twenty-four grafts that were located distally on the residual limb. Subsequent surgical revision of the residual limb because of inadequate function of the skin graft was performed on seven extremities (23%), with revision to a more proximal limb-segment level required in five.Conclusions: Focal skin-grafting (involving < or = 25% of the surface area) of partial-thickness soft-tissue defects in order to optimize the length of the residual limb at the time of an amputation is an effective option for children with an acquired lower-extremity amputation. Limited skin-grafting (involving 26% to 50% of the surface area) is more likely to result in skin graft breakdown, particularly when it is done distally. Extensive skin-grafting, while technically possible, frequently requires revision and rarely results in an optimally functioning limb. Alternative treatment strategies should be considered for extremities that would require extensive, distal skin-grafting. [ABSTRACT FROM AUTHOR]

Background: There are many anatomical changes during pregnancy that could potentially lead to substantial alterations in gait. Gait deviations may contribute to a variety of musculoskeletal overuse conditions associated with pregnancy, such as low-back, hip, and calf pain. Because we are aware of little research on this topic, the purpose of this study was to objectively analyze gait during pregnancy.Methods: Three-dimensional gait analysis was performed on fifteen women during the second half of the last trimester of pregnancy and again one year post partum. Selected kinematic and kinetic parameters for the pregnancy and one-year postpartum conditions were compared with use of paired t tests (95 percent significance level).Results: Overall, gait kinematics were remarkably unchanged during pregnancy. No evidence of a so-called waddling gait during pregnancy was found. Maximum anterior pelvic tilt during gait increased a mean of 4 degrees during pregnancy, although individual subject-to-subject variation (range, an increase of 13 degrees to a decrease of 10 degrees) was observed. Significant increases in hip and ankle kinetic gait parameters, however, were observed during pregnancy (p < 0.05).Conclusions: Significant increases in kinetic gait parameters during pregnancy (p < 0.05) explain how gait motion remained relatively unchanged despite increases in body mass and width as well as changes in mass distribution about the trunk. This finding indicates that during pregnancy there may be an increased demand placed on hip abductor, hip extensor, and ankle plantar flexor muscles during walking. [ABSTRACT FROM AUTHOR]

Introduction: Children with cerebral palsy (CP) have high rates of foot deformity. Accurate assessment of foot morphology is crucial for therapeutic planning and outcome evaluation. This study aims to evaluate the reliability of a novel photo-based Modified Foot Posture Index (MFPI) in the evaluation of foot deformity in children with CP., Methods: Thirteen orthopaedic surgeons with neuromuscular clinical focus from 12 institutions evaluated standardized standing foot photographs of 20 children with CP, scoring foot morphology using the MFPI. Raters scored the standardized photographs based on five standard parameters. Two parameters assessed the hindfoot: curvature above and below the malleoli and calcaneal inversion/eversion. Three parameters assessed the midfoot and forefoot: talonavicular congruence, medial arch height, and forefoot abduction/adduction. Summary MFPI scores range from -10 to +10, where positive numbers connote planovalgus, whereas negative numbers connote a tendency toward cavovarus. Intra- and interrater reliability were calculated using a 2-way mixed model of the intraclass correlation coefficient (ICC) set to absolute agreement., Results: Feet spanned the spectrum of potential pathology assessable by the MFPI, including no deformity, mild, moderate, and severe planovalgus or cavovarus deformities. All scored variables showed high intrarater reliability with ICCs from 0.891 to 1. ICCs for interrater reliability ranged from 0.965 to 0.984. Hindfoot total score had an ICC of 0.979, with a 95% CI, 0.968-0.988 ( P <0.001). The forefoot total score had an ICC of 0.984 (95% CI, 0.976-0.991, P <0.001). Mean total score by the MFPI was 3.67 with an ICC of 0.982 (95% CI, 0.972-0.990, P <0.001)., Conclusions: The photo-based MFPI demonstrates high intra- and interrater reliability in assessing foot deformities in children with CP. Its noninvasive nature and ease of use make it a promising tool for both clinical and research settings. MFPI should be considered as part of standard outcomes scores in studies regarding the treatment of CP-associated foot deformities., Level of Evidence: Level V., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tendo Achilles lengthening (TAL) for the management of equinus contractures in ambulatory children with cerebral palsy (CP) is generally not recommended due to concerns of over-lengthening, resulting in weakness and plantar flexor insufficiency. However, in some cases, surgical correction of severe equinus deformities can only be achieved by TAL. The goal of this study is to assess the outcomes following TAL in these cases., Methods: A retrospective cohort study of children with CP with severe equinus contractures (ankle dorsiflexion with the knee extended of -20 degrees or worse) who underwent TAL as part of a single event multilevel surgery, with preoperative and postoperative gait analysis studies. Continuous data were analyzed by paired t test, and categorical data by McNemar Test., Results: There were 60 subjects: 42 unilateral, 18 bilateral CP; 41 GMFCS II, 17 GMFCS I; mean age at surgery was 10.6 years, mean follow-up was 1.3 years. Ankle dorsiflexion with the knee extended improved from -28 to 5 degrees (P<0.001). The ankle Gait Variable Score improved from 34.4 to 8.6 (P<0.001). The ankle moment in terminal stance improved from 0.43 to 0.97 Nm/kg (P<0.001). Significant improvements (P<0.001) were seen in radiographic measures of foot alignment following surgery. There were few significant differences in the outcome parameters between subjects with unilateral versus bilateral CP (eg, only the bilateral group showed improved but persistent increased knee flexion in mid-stance)., Conclusions: The outcomes following TAL for the management of severe equinus deformity in ambulatory children with CP were favorable 1 year after surgery, with significant improvements in all domains measured., Significance: This study does not advocate for the widespread use of TAL to correct equinus deformity in children with CP. However, it does show that good short-term outcomes following TAL are possible in properly selected subjects with severe contractures when the dosing of the surgery is optimal (correction of contracture to between 0 and 5 degrees of dorsiflexion with the knee extended) and the procedure is performed in the setting of single event multilevel surgery with subsequent proper orthotic management and rehabilitation., Competing Interests: J.R.D. is on the Editorial Board of the Journal of Pediatric Orthopaedics, has been a consultant of OrthoPediatrics Corp., and is on the Board of the Foundation for Advancing Pediatric Orthopaedics, all of which are outside the scope of the submitted work. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Crouch gait is a frequent gait abnormality observed in children with cerebral palsy. Distal femoral extension osteotomy (DFEO) with the tightening of the extensor mechanism is a common treatment strategy to address the pathologic knee flexion contracture and patella alta. The goal of this study was to review the results of a patellar tendon imbrication (PTI) strategy to address quadriceps insufficiency in the setting of children undergoing DFEO., Methods: After institutional review board approval, all patients with crouch gait treated at a single institution with DFEO and PTI were identified. Clinical, radiographic, and instrumented gait analysis data were analyzed preoperatively and at 1 year following surgery., Results: Twenty-eight patients (54 extremities) with a diagnosis of cerebral palsy and crouch gait were included. Significant improvements were appreciated in the degree of knee flexion contracture, quadriceps strength, knee extensor lag, and popliteal angle (P<0.01). Knee flexion at initial contact and during mid-stance improved significantly (P<0.0001), and knee moments in late stance were significantly reduced (P<0.01). The anterior pelvic tilt, however, significantly increased postoperatively (P<0.0001). Radiographic improvements were seen in the knee flexion angle and patellar station as assessed by the Koshino Sugimoto Index (P<0.0001). Four patients (14.2%) developed a recurrence of knee flexion contracture requiring further intervention., Conclusions: PTI is a simplified and safe technique to address quadriceps insufficiency when performing DFEO. The short-term results of patients who underwent DFEO with PTI demonstrated improvements in clinical, radiographic, and gait analysis variables of the knee. Investigating long-term outcomes, comparing techniques, and assessing quality of life measures are important next steps in research., Level of Evidence: Level IV-case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Idiopathic toe walking (ITW) is a diagnosis of exclusion and represents a spectrum of severity. Treatment for ITW includes observation and a variety of conservative treatment methods, with surgical intervention often reserved for severe cases. Previous studies reviewing treatment outcomes are often difficult to interpret secondary to a mixture of case severity. The goal of this study was to review surgical outcomes in patients with severe ITW who had failed prior conservative treatment, as well as determine differences in outcomes based on the type of surgery performed., Methods: After IRB approval, all patients with surgical management of severe ITW at a single institution were identified. Zone II or zone III plantar flexor lengthenings were performed in all subjects. Clinical, radiographic, and motion analysis data were collected preoperatively and at 1 year following surgery., Results: Twenty-six patients (46 extremities) with a diagnosis of severe ITW from 2002 to 2017 were included. Zone II lengthenings were performed in 25 extremities (mean age=9.9 y) and zone III lengthenings were performed in 21 extremities (mean age=8.6 y). At the most recent follow-up, 100% of zone III lengthening extremities and 88% of zone II lengthening demonstrated decreased severity of ITW. Six extremities required additional treatment, all of which were initially managed with zone II lengthenings., Conclusions: Severe ITW or ITW that has not responded to conservative treatment may benefit from surgical intervention. More successful outcomes, including continued resolution of toe walking, were observed in subjects treated with zone III lengthenings., Level of Evidence: Level III-case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Gait dysfunction associated with patella alta (PA) in subjects with cerebral palsy (CP) has been presumed but not objectively established clinically or through biomechanical modeling. It is hypothesized that PA is associated with increasing level of motor impairment, increasing age, obesity, and worse stance phase knee kinematics and kinetics in children with CP., Methods: Retrospective case series of 297 subjects with CP studied in our Motion Analysis Center. Data analyzed included patient demographics (age, body mass index, CP classification), patella height (Koshino-Sugimoto Index), and knee kinematics and kinetics., Results: PA was present in 180 of 297 subjects (61%), in 68 of the 146 (47%) with unilateral CP, and 112 of 151 subjects (74%) with bilateral CP. For unilateral CP, the prevalence of PA was not significantly different between Gross Motor Function Classification System (GMFCS) I and II (P=0.357). For bilateral CP, the prevalence of PA in GMFCS III was significantly greater than in GMFCS I and II (P=0.02). Regression analysis showed a significant trend between increasing age and PA in unilateral and bilateral groups (P<0.001 and 0.001, respectively). The prevalence of PA was not significantly different across body mass index categories for either unilateral or bilateral groups. There were only 2 of 10 significant correlations between PA and gait parameters for subjects with unilateral CP functioning at the GMFCS I and II levels. There were 8 of 12 significant correlations between PA and gait parameters for subjects with bilateral CP functioning at the GMFCS I, II, and III levels., Conclusions: PA is common in ambulatory children with CP across topographic types and motor functional levels. PA is well tolerated with respect to gait dysfunction in unilateral CP, but may contribute to crouch gait in bilateral CP. Gait dysfunction cannot be inferred from the radiographic assessment of patellar height, and radiographic evidence of PA by itself does not justify surgical correction with patellar tendon advancement or shortening., Level of Evidence: Level III-prognostic, retrospective series.

Background: Children's ability to control the speed of gait is important for a wide range of activities. It is thought that the ability to increase the speed of gait for children with cerebral palsy (CP) is common. This study considered 3 hypotheses: (1) most ambulatory children with CP can increase gait speed, (2) the characteristics of free (self-selected) and fast walking are related to motor impairment level, and (3) the strategies used to increase gait speed are distinct among these levels., Methods: A retrospective review of time-distance parameters (TDPs) for 212 subjects with CP and 34 typically developing subjects walking at free and fast speeds was performed. Only children who could increase their gait speed above the minimal clinically important difference were defined as having a fast walk. Analysis of variance was used to compare TDPs of children with CP, among Gross Motor Function Classification System (GMFCS) levels, and children in typically developing group., Results: Eight-five percent of the CP group (GMFCS I, II, III; 96%, 99%, and 34%, respectively) could increase gait speed on demand. At free speed, children at GMFCS I and II were significantly faster than children at GMFCS level III. At free speed, children at GMFCS I and II had significantly greater stride length than those at GMFCS levels III. At free speed, children at GMFCS level III had significantly lower cadence than those at GMFCS I and II. There were no significant differences in cadence among GMFCS levels at fast speeds. There were no significant differences among GMFCS levels for percent change in any TDP between free and fast walking., Discussion: Almost all children with CP at GMFCS levels I and II can control the speed of gait, however, only one-third at GMFCS III level have this ability. This study suggests that children at GMFCS III level can be divided into 2 groups based on their ability to control gait speed; however, the prognostic significance of such categorization remains to be determined., Level of Evidence: Diagnostic level II.

Background: Progressive hip displacement is one of the most common and debilitating deformities seen in children with cerebral palsy (CP). The aim of this study was to evaluate the results of temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF) using a transphyseal screw to control hip migration during growth in children with CP., Methods: This was a retrospective study of children with CP and hip dysplasia, age 4 to 11 years and GMFCS levels III-V. There were 28 patients with 56 hips that underwent TMH-PF surgery between 2007 and 2010. Clinical and radiologic evaluation was performed preoperatively, at 6, 12, and 60 months following the index surgery. Acetabular index (AI), neck-shaft angle (NSA) and migration percentage (MP) were measured. All complications were recorded., Results: All radiographic measurements were significantly improved at the final follow-up. Positive correlations were found between NSA, MP, and AI. Multiple regression analysis revealed that MP, time from surgery, and age were influenced by the decrease of the NSA. The femoral physis grew off the screw in 9 hips within 36 months. The screw head broke during attempted screw exchange in 1 hip. The remain cases (4 hips) were treated by placing a second screw parallel to the existing one. Finally, progressive subluxation occurred in 3 hips when the physis grew off the screw and were treated by skeletal reconstruction., Conclusions: TMH-PF was effective in controlling progressive subluxation of the hip in the majority of cases, obviating the need for major reconstructive surgery in these children with CP., Level of Evidence: Level IV.

Background: Classic teaching for surgical lengthening of muscle contractures in children with cerebral palsy (CP) has emphasized complete correction of the deformity acutely, with immobilization of the targeted muscles in the fully corrected position. Clinical experience has led to the impression that the muscles are invariably weakened by this approach. We have developed an alternative technique for correction of contractures called slow surgical lengthening (SSL). The goal of the study was to determine the physical examination, kinematic, and muscle strength outcomes following SSL of the medial hamstring muscles in children with CP., Methods: The study group included 41 children with CP who underwent SSL of the medial hamstring muscles as part of a comprehensive single-event multilevel surgery, who had preoperative and 1-year postoperative evaluations in our Motion Analysis Center, which included quantitative assessment of isometric and isokinetic muscle strength., Results: All subjects were Gross Motor Function Classification System I and II. Mean age at the time of surgery was 10.8 years. The mean popliteal angle improved by 16.2 degrees (P<0.001) following SSL of the medial hamstrings. Sagittal plane kinematics following SSL of the medial hamstrings showed improvement of knee extension at initial contact of 10.2 degrees (P<0.001), decrease of peak knee flexion in mid-swing of 3.6 degrees (P=0.014), improved minimum knee flexion in stance of 4.9 degrees (P=0.002), and no significant change in mean anterior pelvic tilt (P=0.123). Mean peak isometric knee flexion torque remained unchanged from preoperative to postoperative studies (P=0.154), whereas mean peak isokinetic knee flexion torque significantly increased by 0.076 Nm/kg (P=0.014) following medial hamstring SSL., Discussion: SSL was developed based upon clinical experience and improved understanding of the pathophysiology of skeletal muscle in children with CP. The SSL technique allows the tendinous tissue to separate spontaneously at the time of recession, but does not force further acute lengthening by intraoperative manipulation, thereby minimizing the damage to the underlying muscle. It is broadly believed that muscle weakness is inevitable following surgical lengthening. The current study shows that the SSL technique does not cause weakness., Level of Evidence: Level IV-therapeutic.

Background: Few studies exist to inform the extrapolated practice of irradiating children for heterotopic ossification (HO) prevention. We report the incidence of HO formation following prophylactic preoperative compared with postoperative radiation therapy (RT) in children with neuromuscular hip dysplasia (NHD) following proximal femoral resection (PFR)., Methods: A retrospective, 2-institution chart review was performed. Eligibility was limited to patients with at least 1 year of follow-up. Evaluation included radiographic HO grading by a combined severity scale, assessment of synchronous symptoms of pain or decreased range of motion, and stratification by preoperative versus postoperative reception of RT. A control cohort included 4 nonirradiated hips with NHD after PFR., Results: Twenty-five hips in 20 children met eligibility criteria. Eleven hips were irradiated preoperatively and 14 postoperatively. Radiographic evidence of post-RT development of radiographic evidence of heterotopic ossification (rHO) was found in all 25 hips and earlier in patients irradiated preoperatively (median time to rHO was 4.0 vs. 15.7 mo, P=0.03, 95% confidence interval, 0.24-21.5). There was no statistically significant difference in the development of symptomatic HO (P=0.62) between the preoperative (45.5%) and postoperative (35.7%) groups, nor in HO grade (P=0.34). Seven (28%) of the 25 hips (5 preoperative and 2 postoperative) had documentation of rHO-free intervals after surgery, with an average duration of 5.6 months, while the remaining presented with rHO at first follow-up visit. All eligible control hips (100%) developed rHO and symptomatic heterotopic ossification., Conclusions: Perioperative RT did not prevent the formation of HO in any child with NHD after PFR. Extrapolation of evidence of the efficacy of RT for HO prevention in ambulatory adults after traumatic hip injury to a population of children with central nervous system injury and NHD may be premature. Additional studies are needed to clarify optimal prevention of HO in this population., Level of Evidence: Level III-therapeutic retrospective comparative study.

Optimal clinical decision making and surgical management of hip dysplasia in children with cerebral palsy (CP) requires an understanding of the underlying pathophysiology (pathomechanics and pathoanatomy), incidence, and natural history. The incidence of hip dysplasia in children with CP is directly related to the degree of motor impairment. A subluxated or dislocated hip in a child with CP can compromise the quality of life for both the child and their caregivers. The goal of this article is to highlight the events over the last 25 years that have had the greatest impact on the management of hip dysplasia in children with CP. It is my opinion that the 2 most significant advances during this time have been the development of a classification system based upon motor impairment (the Gross Motor Function Classification System), and the development of surveillance programs for hip dysplasia in children with CP. This article will contrast neuromuscular hip dysplasia with developmental dysplasia of the hip. It will be shown how the development and utilization of the Gross Motor Function Classification System has contributed to our understanding of the epidemiology and natural history of hip dysplasia in children with CP, and to the assessment of outcomes following surgical management. The impact of hip surveillance programs on early soft tissue surgeries, skeletal hip reconstructions, and the incidence of hip dislocations and salvage surgeries will be reviewed. Challenges in the implementation of hip surveillance programs in resource poor and decentralized health care delivery systems will be considered, and innovative approaches identified.

Background: Abnormal hip rotation is a common deviation in children with cerebral palsy (CP). Clinicians typically assess hip rotation during gait by observing the direction that the patella points relative to the path of walking, which is referred to as the knee progression angle (KPA). Two kinematic methods for calculating the KPA are compared with each other. Video-based qualitative assessment of KPA is compared with the quantitative methods to determine reliability and validity., Methods: The KPA was calculated by both direct and indirect methods for 32 typically developing (TD) children and a convenience cohort of 43 children with hemiplegic type CP. An additional convenience cohort of 26 children with hemiplegic type CP was selected for qualitative assessment of KPA, performed by 3 experienced clinicians, using 3 categories (internal, >10 degrees; neutral, -10 to 10 degrees; and external, >-10 degrees)., Results: Root mean square (RMS) analysis comparing the direct and indirect KPAs was 1.14+0.43 degrees for TD children, and 1.75+1.54 degrees for the affected side of children with CP. The difference in RMS among the 2 groups was statistically, but not clinically, significant (P=0.019). Intraclass correlation coefficient revealed excellent agreement between the direct and indirect methods of KPA for TD and CP children (0.996 and 0.992, respectively; P<0.001).For the qualitative assessment of KPA there was complete agreement among all examiners for 17 of 26 cases (65%). Direct KPA matched for 49 of 78 observations (63%) and indirect KPA matched for 52 of 78 observations (67%)., Conclusions: The RMS analysis of direct and indirect methods for KPA was statistically but not clinically significant, which supports the use of either method based upon availability. Video-based qualitative assessment of KPA showed moderate reliability and validity. The differences between observed and calculated KPA indicate the need for caution when relying on visual assessments for clinical interpretation, and demonstrate the value of adding KPA calculation to standard kinematic analysis., Level of Evidence: Level II-diagnostic test.

Background: Although the treatment of cerebral palsy should be based on improving function as assessed by measures of impairment, activity, and participation, the standard indications for surgical treatment of upper extremity cerebral palsy (UECP) are impairment measures, primarily active and passive range of motion (ROM). Recently, validated activity measures have been developed for children with UECP. The purposes of this study were to determine the relationship between impairment and activity measures in this population, and whether measures of activity correlate with each other., Methods: A total of 37 children, ages 5 to 16 years, who met standard ROM surgical indications for UECP were evaluated with the impairment measures of active and passive ROM and stereognosis, as well as 3 activity measures [Assisting Hand Assessment (AHA), Box and Blocks test, and the Shriners Hospitals Upper Extremity Evaluation Dynamic Positional Analyses (SHUEE DPA)]. Impairment measures were correlated with activity measures using Spearman rank correlation coefficients., Results: Impairment measures showed inconsistent correlation with activity measures. Of the 12 comparisons, only 4 correlated: active forearm supination (ρ=0.47, P=0.003), wrist extension (ρ=0.55, P=0.001), and stereognosis scores (ρ=0.54, P=0.001) were correlated with AHA; and wrist extension was correlated with the SHUEE DPA (ρ=0.41, P=0.01). When the results of activity tests were compared, the AHA was correlated with the Box and Blocks tests (ρ=0.63, P<0.001), and the SHUEE DPA and Box and Blocks tests were correlated with each other (ρ=0.35, P=0.04)., Conclusions: The goal of surgery in UECP is to improve the child's ability to perform activities, and ultimately to participate in life situations. Impairment measures, such as ROM, were inconsistently correlated with validated measures of activity. Some activity measures correlated with each other, although they did not correlate with the same impairment measures. We conclude that impairment measures, including ROM, do not consistently predict functional dynamic ROM used to perform activities for children with UECP. Activity limitation measures may provide more appropriate indicators than impairment measures for upper extremity surgery for this population., Level of Evidence: Level II-diagnostic.

Background: Excessive internal or external tibial torsion is frequently present in children with cerebral palsy. Several surgical techniques have been described to correct excessive tibial torsion, including isolated distal tibial rotation osteotomy (TRO). The anatomic changes surrounding this technique are poorly understood. The goal of the study was to examine the anatomic relationship between the tibia and fibula following isolated distal TRO in children with cerebral palsy., Methods: Twenty patients with 29 limbs were prospectively entered for study. CT scans of the proximal and distal tibiofibular (TF) articulations were obtained preoperatively, at 6 weeks, and 1 year postoperatively. Measurements of tibia and fibula torsion were performed at each interval. Qualitative assessments of proximal and distal TF joint congruency were also performed., Results: The subjects with internal tibia torsion (ITT, 19 limbs) showed significant torsional changes for the tibia between preoperative, postoperative, and 1 year time points (mean torsion 13.21, 31.05, 34.84 degrees, respectively). Measurement of fibular torsion in the ITT treatment group also showed significant differences between time points (mean -36.77, -26.77, -18.54 degrees, respectively). Proximal and distal TF joints remained congruent at all time points in the study.Subjects with external tibia torsion (ETT, 10 limbs) showed significant differences between preoperative and postoperative tibial torsion, but not between postoperative and 1 year (mean torsion 54, 19.3, 23.3 degrees, respectively). Measurement of fibular torsion in the ETT treatment group did not change significantly between preoperative and postoperative, but did change significantly between postoperative and 1 year (mean torsion -9.8,-16.9, -30.7 degrees, respectively). Nine of 10 proximal TF joints were found to be subluxated at 6 weeks postoperatively. At 1 year, all 9 of these joints had reduced., Conclusions: Correction of ITT by isolated distal tibial external rotation osteotomy resulted in acute external fibular torsion. The fibular torsion alignment remodeled over time to accommodate the corrected tibial torsional alignment and reduce the strain associated with the plastic deformity of the fibula. Correction of ETT by isolated distal internal TRO resulted in acute subluxation of the proximal TF articulation in almost all cases. Subsequent torsional remodeling of the fibula resulted in correction of the TF subluxation in all cases. Acute correction of TT by isolated distal TRO occurs by distinct mechanisms, based upon the direction of rotational correction., Level of Evidence: Level II-Diagnostic.

Background: The natural history of ambulatory function in individuals with cerebral palsy (CP) consists of deterioration over time. This is thought to be due, in part, to the relationship between strength and weight, which is postulated to become less favorable for ambulation with age., Methods: The study design was prospective, case series of 255 subjects, aged 8 to 19 years, with diplegic type of CP. The data analyzed for the study were cross-sectional. Linear regression was used to predict the rate of change in lower extremity muscle strength, body weight, and strength normalized to weight (STR-N) with age. The cohort was analyzed as a whole and in groups based on functional impairment as reflected by Gross Motor Function Classification System (GMFCS) level., Results: Strength increased significantly over time for the entire cohort at a rate of 20.83 N/y (P=0.01). Weight increased significantly over time for the entire cohort at a rate of 3.5 kg/y (P<0.0001). Lower extremity STR-N decreased significantly over time for the entire cohort at a rate of 0.84 N/kg/y (P<0.0001). The rate of decline in STR-N (N/kg/y) was comparable among age groups of the children in the study group. There were no significant differences in the rate of decline of STR-N (N/kg/y) among GMFCS levels. There was a 90% chance of independent ambulation (GMFCS levels I and II) when STR-N was 21 N/kg (49% predicted relative to typically developing children)., Discussion: The results of this study support the longstanding clinically based observation that STR-N decreases with age in children with CP. This decrease occurs throughout the growing years, and across GMFCS levels I to III. Independent ambulation becomes less likely as STR-N decreases. This information can be used to support the rationale, and provide guidelines, for a range of interventions designed to promote ambulation in children with CP.

Background: Previous investigation has proven 3-dimensional (3D) computed tomography (CT) to be a poor method of assessing femoral anteversion in patients with cerebral palsy. However, new advancements in CT software yield the potential to improve upon those dated results., Methods: CT was performed on 9 femoral models with varying amounts of anteversion (20 to 60 degrees) and varying neck-shaft angles (120 to 160 degrees). Each model was scanned in 2 holding devices. One holder placed the femur in an ideal position relative to the gantry. The other placed the femur in flexion, adduction, and internal rotation simulating a common lower extremity posture in cerebral palsy. Femoral anteversion was measured on 3D reconstructions by 4 observers on 2 separate occasions. Interobserver and intraobserver reliability, accuracy, and the effect of increasing neck-shaft angle of the measurements were examined and compared with previously published data using the same models., Results: Pearson correlation coefficients between first and second measurements by the same examiner were all above 0.96 regardless of positioning of the femur in the gantry. The correlation coefficients among all examiners were 0.97 regardless of positioning of the femur in the gantry. Accuracy in measurements was comparable using 3D CT techniques with mean differences between the normal and cerebral palsy-positioned models of <3.6 degrees (SD, 3.1 to 3.3 degrees). Accuracy of the study's 3D CT technique in measuring femoral anteversion in cerebral palsy-positioned femurs was significantly more accurate than that of 2D CT (P<0.0001)., Conclusions: Recent improvements in processing software and 3D reconstruction have made assessment of femoral anteversion with 3D CT accurate through the studied range of anteversion and neck-shaft angles. Using this technique, high intraobserver and interobserver reliability in the determination of femoral anteversion can be expected regardless of neck-shaft angle or postural deformity., Level of Evidence: Level II.

Background: Intoeing gait is frequently seen in developing children, and in most cases it resolves with growth. However, persistent, extreme intoeing gait, due to increased internal tibial torsion, may disrupt gait function. At our institution, children with symptomatic intoeing gait are evaluated per a standardized protocol, which includes quantitative gait analysis. When the primary cause is increased internal tibial torsion, surgical correction by supramalleolar tibial rotational osteotomy is recommended., Methods: The study design was a retrospective case series, with normative controls (31 children), of typically developing children with symptomatic intoeing gait who were treated by isolated supramalleolar tibial rotation osteotomy (28 children, with 45 treated extremities). Preoperative and 1-year postoperative physical examination, kinematic, kinetic, and pedobarographic data were compared. Patient-reported and parent-reported outcomes in functional and satisfaction domains were assessed by items on a 7-point questionnaire., Results: Internal tibial torsion, foot progression angle, and knee rotation were normalized following tibial rotation osteotomy. Compensatory external hip rotation and external knee progression angle were significantly improved but not normalized following tibial rotation osteotomy. An increased coronal plane knee varus moment was significantly decreased following surgery. Increased sagittal and transverse plane knee moments were significantly decreased but not normalized following surgery. Significant improvements were observed with respect to tripping, falling, foot/ankle pain, and knee pain following surgery., Conclusions: Children with symptomatic intoeing gait because of increased internal tibial torsion have characteristic primary and compensatory kinematic gait deviations that result in increased loading about the knee during the stance phase of gait. Correction of the internal tibial torsion by rotation osteotomy improves, but does not normalize, all the kinematic and kinetic gait deviations associated with intoeing gait. The association between increased internal tibial torsion and degenerative arthritis of the knee in adults may be a consequence of longstanding increased loading of the knee joint due to the kinematic gait deviations seen with intoeing gait., Level of Evidence: Therapeutic intervention, level III.

Background: Central polydactyly is the least common form of foot polydactyly, and the intercalary location of the duplicated ray makes the surgical exposure, excision, and closure more complex. For these reasons there is little consensus concerning the optimal technique for surgical management., Methods: A retrospective case series of 22 patients with 27 feet with central polydactyly, treated surgically by the dorsal and plantar advancement flap technique, was performed. Change in width of the forefoot was measured from radiographs by the metatarsal gap ratio. Functional outcomes were assessed by the Foot and Ankle Ability Measure., Results: Signficant narrowing of the forefoot, as measured radiographically by the metatarsal gap ratio, was achieved after surgery (P<0.0001). This radiographic narrowing was maintained with growth after a mean follow-up of 8 years (P=0.0001). In 7 of the unilateral cases, the mean forefoot radiographic width of the affected side, after surgical resection and reconstruction of the central polydactyly, was 2% greater than the contralateral, uninvolved side. Persistent clinical widening of the forefoot after surgery was reported in the majority (82%) of cases. The Foot and Ankle Ability Measure results showed near-normal functional outcomes in itemized activities of daily living, itemized sports, and overall function categories. The few reports of less than normal foot function were related to shoe wear issues and incisional scarring that was painful or cosmetically unappealing., Conclusions: The radiographic and functional outcomes after surgical management of central polydactyly with the dorsal and plantar advancement flap technique are excellent. The technique successfully narrows the forefoot on radiographs, and this narrowing is maintained with growth over time. However, families should be advised that persistent perceived widening of the forefoot relative to normal is common, despite successful radiographic narrowing after surgery., Level of Evidence: IV.

Background: The level of amputation in the pediatric population requires appropriate planning to provide an optimal residual limb for prosthetic fitting and must include long-term strategies to accommodate future growth of the extremity., Methods: A retrospective review over a 15-year period was performed of all Boyd procedures (calcaneotibial fusion) in the pediatric limb deficiency population at a single institution. A chart review and radiographic analysis was performed to identify the indications, surgical outcomes, complications, need for additional surgical intervention, and nature of the postoperative prosthetic management. Optimal positioning of the calcaneotibial fusion and the growth-dependent changes in the morphology of the fusion site were determined by radiographic analysis., Results: A total of 109 children (117 limbs) were identified for inclusion in the study. The average age at the time of the Boyd procedure was 2.8 years. The most common indication for the Boyd procedure was a diagnosis of postaxial limb bud deficiency, which accounted for 66% of cases. Concomitant procedures were performed in 24% of cases and included proximal tibial epiphyseodesis, tibial osteotomy, or knee fusion in the majority of cases. Additional procedures were required in 33% of cases either for treatment of complication (9%) or optimization of the residual limb (24%). For the entire cohort, the complication rate was 14%. Complications were most common when the Boyd procedure was used as a treatment strategy for congenital pseudoarthrosis of the tibia. Prosthetic management utilizing supramalleolar suspension with complete end-bearing through the residual limb was possible for the majority of cases., Conclusions: The Boyd procedure is an effective treatment for various conditions of the lower extremity. Concomitant or additional procedures after the initial intervention may be required for complete optimization of the residual limb., Level of Evidence: Level IV.

Purpose: The differential diagnosis in children who walk on their toes includes mild spastic diplegia and idiopathic toe walking (ITW). A diagnosis of ITW is often one of exclusion. To better characterize the diagnosis of ITW, quantitative gait analysis was utilized in a series of patients with an established diagnosis of ITW., Study Design: Patients with an established diagnosis of ITW were analyzed by quantitative gait analysis. Data were recorded as each subject walked in a self-selected toe-walking pattern. The subject was then asked to ambulate making every effort to walk in a normal heel-toe reciprocating fashion. Data were collected to determine if this group of idiopathic toe walkers was able to normalize their gait. Datasets were compared with each other and with historical normal controls., Results: Fifty-one neurologically normal children (102 extremities) with ITW were studied in the Motion Analysis Laboratory at a mean age of 9.3 years. In the self-selected trials, significant deviations in both kinematics and kinetics at the level of the ankle were identified. Disruption of all 3 ankle rockers and a plantar flexion bias of the ankle throughout the gait cycle were most commonly seen. When asked to attempt a normal heel-toe gait, 17% of the children were able to normalize both stance and swing variables. In addition, 70% were able to normalize some but not all of the stance and swing variables., Conclusion: Quantitative gait analysis is an effective tool for differentiating mild cerebral palsy from ITW. Kinematic and kinetic distinctions between the diagnoses are evident at the knee and ankle. The ability to normalize on demand at least some of the kinematic and kinetic variables associated with toe walking is seen in most children with ITW.

Surgical correction of juvenile hallux valgus (JHV) by soft tissue balancing or skeletal realignment is associated with a high rate of recurrence of the deformity. An alternative treatment strategy for the management of symptomatic or progressive JHV, consisting of lateral hemiepiphyseodesis of the great toe metatarsal physis, has been used at our institution since 1996. A review of these cases was performed to determine the outcomes in the technical and patient satisfaction domains. Preoperative and follow-up radiographs of the foot were analyzed to measure the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the proximal metatarsal articular angle (PMAA), and the metatarsal length ratio. Repeated measures of the radiographs were performed to determine intraobserver reliability. The medical records were reviewed to determine the children's age at presentation, chief complaints, age at surgery, tourniquet time of the surgical procedure, length of follow-up, the need for subsequent foot surgeries, and complications. Follow-up clinic or telephone interviews were performed to determine patient satisfaction. Seven children with 11 feet treated for JHV were available for study. Mean age at the time of the index surgery was 10 years 4 months (range, 9 years 7 months-11 years 1 month). Mean follow up after surgery was 4 years 2 months (range, 1 year 7 months-7 years 6 months). The mean improvement in the IMA was 2.32 degrees (range, 0-5 degrees; P < 0.0001). The mean improvement in the HVA was 3.45 degrees (range, 0-9 degrees; P = 0.027). Significant correction of both the IMA and the HVA was achieved in 6 (55%) of 11 of the feet. In no case did either of the measures worsen. The mean change in the PMAA in the anteroposterior plane was 5.09 degrees (range, 0-11 degrees; P = 0.001). The mean change in the PMAA in the lateral plane was 1.00 degree (range, 0-3 degrees; P = 0.008). The mean change in the metatarsal length ratio was 0.01 (range, 0.07-0.11), which was not statistically significant (P = 0.65). Lateral hemiepiphyseodesis of the great toe metatarsal was effective at halting the progression of the JHV deformity in all cases and achieved significant correction of both the IMA and the HVA in more than 50% of the feet. Lateral hemiepiphyseodesis of the great toe metatarsal is a reasonable alternative for the management of symptomatic or progressive JHV, given the high recurrence rate associated with other soft tissue and skeletal surgical procedures.

A retrospective review of all cerebral palsy (CP) patients with resistant or recurrent knee flexion contractures treated with serial stretch casting was performed. The protocol consisted of sequential wedging (5 degrees per week) of fiberglass casts until maximum knee extension had been achieved. Measurements were made prior to the initiation of casting, at completion of the casting, and at 1 year after the casting. Forty-six subjects, with 75 involved extremities, met the study inclusion criteria. Mean age at the time of initiation of casting was 12.7 years. Using radiographic measurements, the mean initial degree of knee flexion contracture was -17.6 degrees. At the completion of casting, the mean knee flexion angle was -8.1 degrees. The mean duration of casting was 30 days. At 1 year after completion of the casting, the mean knee flexion angle was -12.2 degrees. Initial correction to within 10 degrees of full extension was achieved in 76% of extremities. Age less than 12 years and initial flexion contracture of less than -15 degrees were statistically significant factors related to maintenance of correction at 1 year. Complications included soft tissue compromise in 13 extremities (17%), transient neurapraxia in 9 extremities (12%), and tibial subluxation in 1 extremity (1%). Serial stretch casting was successful in correcting resistant knee flexion contractures in the majority of cases. Casting was less effective in teenagers and those with larger contractures. Complications were minimized by proper casting technique and controlled rate of correction.

Clinical decision-making for the management of foot deformities in children is primarily based upon the analysis of weight-bearing radiographs of the foot and ankle. However, a comprehensive quantitative technique for the analysis of such radiographs has not been described. Ten radiographic measurements were developed and applied to the foot and ankle radiographs of a normal foot and ankle in 60 children (mean age 10 years, range 5-17 years). Intraobserver variability and interobserver variability were determined for 10 cases. Mean values for the 10 measurements were calculated from the entire study group. Intraobserver variability was excellent, with correlation coefficients for the 10 measurements ranging from 0.89 to 0.99. The absolute value of the mean differences in angular measurements ranged from 0.8 to 2.5 degrees. Interobserver variability was also excellent, with correlation coefficients ranging from 0.86 to 0.99. The absolute value of the mean differences in angular measurements ranged from 0.5 to 3.2 degrees. The mean values, standard deviations, and ranges for the 10 radiographic parameters from the 60 normal feet have been determined. Clinically acceptable variability of 10 selected radiographic measurements of the foot and ankle was achieved, and normal values and ranges for these measurements were determined. Quantitative segmental analysis of foot and ankle alignment, using these 10 radiographic measurements, can be used to describe common malalignment patterns, and this may assist in clinical decision-making and assessment of outcome.

Tibia vara is a condition characterized by progressive deformity of the proximal tibia resulting in varus malalignment of the lower extremity. An alternative treatment strategy involving lateral hemiepiphyseodesis of the proximal tibia in the skeletally immature has been utilized at our institution for the last 10 years. The study group consisted of 23 patients (16 male, seven female) with 33 involved extremities. The median age at surgery was 11.8 years (range, 7.0-17.3). The median follow-up was 3.1 years (range, 0.8-6.2). Of the patients, 82.6% had a weight greater than the 95th percentile. The preoperative mechanical axis had a median value of 18.0 degrees (range, 5.0-31.0) and at the most recent follow up, a median value of 7.0 degrees (range, -12.0 to 46.0). In 18 (54.5%) extremities, the mechanical axis improved by more than 5 degrees . There was no progression of the overall deformity in 11 (33.3%) extremities. Four (12.1%) extremities had worsening of the deformity. At the time of latest follow up, nine (27.2%) extremities had required corrective osteotomy. Twenty-four (72.7%) were skeletally mature and had not required any further treatment. Goals of hemiepiphyseodesis in adolescent tibia vara or late sequelae of infantile tibia vara include (1) correction of deformity to avoid need for osteotomy, and (2) prevention of progression of the deformity to facilitate subsequent surgery. In this series of patients, 87.8% had either improvement or stabilization of the degree of their deformity.

Seventeen amputations (in 14 children) with established overgrowth were treated by capping of the residual limb with a polytetrafluoroethylene (PTFE) felt pad. Average age at the time of the procedure was 7 years 10 months. Mean follow-up was 4 years 9 months. Statistical comparisons were made to historical controls, treated by resection revision or biologic capping, from a prior overgrowth study from the authors' institution. Revision surgery was necessary in 86% of resection revisions, 29% of biologic caps, and 29% of PTFE caps. Kaplan-Meier analysis estimated survival times of 3 years 3 months for resection revision, 6 years 1 month for biologic caps, and 7 years 2 months for PTFE caps. PTFE and biologic caps were both statistically better than resection revision with regard to need for subsequent operation and survivorship, but were not statistically different from each other. Complications associated with PTFE capping and biologic capping were distinct.

This is a study of the time required to return to preoperative functional levels after proximal femoral osteotomy in children with cerebral palsy. Seventy-one consecutive children who underwent proximal femoral osteotomy to treat an unstable hip secondary to cerebral palsy are retrospectively reviewed. All children returned to their preoperative ambulatory function within 30 months of the procedure. Children who were community or household ambulators returned to their preoperative function at a mean of 7 months after osteotomy, while wheelchair and therapeutic ambulators required a mean of 10 months. Children who had regular visits with a licensed therapist tended to return to function more quickly than those who had exercises preformed by their parents or care-takers after instruction by a therapist. The authors conclude that families should be advised that rehabilitation after osteotomy requires on average 7-10 months, but times up to 30 months are possible.

Clubfoot and hip dislocations are common conditions seen by pediatric orthopedists. In the evaluation of a child with clubfoot, most texts recommend a hip screening radiograph to rule out occult hip dysplasia. Between 1983 and 1998, 349 patients were treated for idiopathic clubfoot. Almost all feet required surgical correction. The average follow-up was 8.4 years. Of these patients, 127 had hip screening x-rays during their treatment of clubfoot. The remaining 222 patients were followed clinically for an average of 9.6 years. Of the 127 patients with hip screening x-rays, 1 was found to have hip dysplasia (0.8%). Of the 222 without hip screening x-rays, none developed signs or symptoms of hip pathology during their clinical follow-up period. The overall rate of hip dysplasia in the idiopathic clubfoot population in this series was less than 1.0%. Screening hip radiographs in the idiopathic clubfoot population are probably not warranted.

Previously described techniques for surgical resection of the subtalar coalitions are technically demanding, with poor outcomes related to incomplete resection and recurrence of the coalition. A new technique, involving complete excision of the involved portion of the sustentaculum tali, has been developed at the authors' institution. A retrospective review of 10 patients with 12 coalitions was performed. The index procedure was performed at an average age of 12.7 years, with a mean follow-up of 5.1 years. Preoperative CT scans obtained to assess the extent of the coalition were analyzed. The AOFAS Hindfoot Questionnaire was used postoperatively to assess the patients' overall outcome and satisfaction with the procedure. Overall, there were eight excellent results and three good results. The postoperative mean AOFAS score was 90 compared with a preoperative score of 46. There have been no recurrences of the coalition or progressive foot malalignment in this series of patients.

Clinical assessment of femoral anteversion (FA) in children with cerebral palsy (CP) is frequently determined by the trochanteric prominence angle test (TPAT). Limited three-dimensional volumetric imaging by axial tomography of the femur was performed before surgery for 35 hips in 20 children with CP. The TPAT was performed before the imaging study for 31 hips in 18 children. The TPAT angle was within 10 degrees of the FA as determined from the computed tomography scans (Murphy technique) for 17 femurs (55%). The most prominent portion of the greater trochanter was located anterior to the femoral neck axis (mean 27 degrees, range 0 degrees-52 degrees) on the three-dimensional images in 34 of 35 hips. A simulated TPAT, measured from the imaging studies, consistently underestimated the FA as determined by the Murphy technique (mean 10 degrees, range 0 degrees-18 degrees). Accurate clinical assessment of FA by the TPAT in children with CP presumes that the prominence of the greater trochanter lies perpendicular to the axis of the femoral neck. Three-dimensional imaging showed the prominence to be anterior, to a variable degree, to the femoral neck axis, which in addition to clinical factors such as obesity compromises the accuracy of this clinical maneuver.

Summary: The authors hypothesized that the ratio of the femoral to tibial metaphyseal-diaphyseal angles (femoral-tibial ratio [FTR]) more accurately differentiates physiologic bowing from infantile tibial vara than the tibial metaphyseal-diaphyseal angle (TMDA). The purpose of this study was threefold: to determine the false-negative and false-positive error rate of the FTR and TMDA; to determine to the effect of rotation on the FTR and TMDA; and to determine the reliability of the FTR and TMDA measurements. An FTR < 1 resulted in a false-negative error rate of 10% and a false-positive error rate of 7%, whereas a TMDA > 13 degrees resulted in a false-negative error rate of 23% and a false-positive error rate of 10%. The difference between internal and external rotation was not significant for the FTR, whereas it was for the TMDA. The FTR was found to have good interobserver and intraobserver reliability (0.78 and 0.98, respectively).

Radiographic screening is widely used to distinguish between Blount disease (infantile tibia vara) and physiologic bowing. Thirteen children with Blount disease, evaluated before 3 years of age, with initial radiographs showing no sign of Langenskiold changes, were compared with 50 children with physiologic bowing, also evaluated before 3 years of age with similar radiographic studies. Screening test accuracy was determined retrospectively for measurement of the mechanical axis, the tibial metaphyseal-diaphyseal angle (TDMA), and the epiphyseal-metaphyseal angle (EMA). A radiographic screening method combining the TMDA and the EMA, using cutoff values of 10 degrees and 20 degrees respectively, exhibited the best combination of sensitivity, specificity, and positive predictive value, correctly identifying all cases of Blount disease and 40 of 50 cases of physiologic bowing. Our data suggest that children between 1 and 3 years of age with TMDA <10 degrees, or TMDA > or =10 degrees and EMA < or =20 degrees, are at less risk for development of Blount disease. Children with TMDA > or =10 degrees and EMA >20 degrees are at greater risk for development of Blount disease and should be followed closely.

Twenty-six cases of hallux valgus deformity, in 16 children with cerebral palsy, were managed with great toe metatarsophalangeal (MTP) arthrodesis. Mean age at the time of surgery was 16 years (range, 10 years and 11 months to 21 years and 11 months), and mean follow-up was 4 years and 11 months (range, 2 years and 1 month to 10 years). Significant improvement in the hallux valgus angle (preoperative, 36.3 degrees; follow-up, 9.6 degrees; p < 0.05), the intermetatarsal angle (preoperative, 12.3 degrees; follow-up, 8.4 degrees; p < 0.05), and lateral metatarsophalangeal angle (preoperative, 4.8 degrees; follow-up, 25.8 degrees; p < 0.05), were achieved and maintained after MTP arthrodesis. Functional outcome was documented by significant improvement in the modified American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (preoperative mean score, 46.2; follow-up mean score, 90.9; p < 0.05). Patient/ parent/caregiver satisfaction (as determined by a questionnaire), with improvements in cosmesis, footwear, hygiene, activity, and pain were high, ranging from 81% to 100%. Hallux valgus deformity in children with cerebral palsy is best managed by MTP arthrodesis, in conjunction with other surgical procedures that address segmental foot malalignment and dynamic gait deviations.

Early radiographic screening and/or referral to a clinical specialist are often used to distinguish between physiologic bow leg deformity and infantile tibia vara disease in young children. These practices are a consequence of the clinician's inability (based upon the clinical examination) to distinguish between the deformities associated with physiologic and pathologic bow legs. Because the great majority of these children have physiologic bowing, routine radiographic screening and referral are not cost effective and expose children to unnecessary radiation. This study describes and evaluates the efficacy of a simple clinical examination technique, the 'cover up' test, to identify young children with bow legs who are at high risk for having infantile tibia vara. The 'cover up' test qualitatively assesses the alignment of the proximal portion of the shank or lower leg relative to the thigh or upper leg. Obvious valgus alignment is considered a negative test and is indicative of physiologic bowing. Neutral or varus alignment is considered a positive test and suggests that the child is at greater risk for having infantile tibia vara. Eighteen children with infantile tibia vara, evaluated initially prior to 3 years of age, and followed to the time of surgical correction, were compared with 50 children with physiologic bowing, also evaluated initially prior to 3 years of age and followed to resolution (mean follow-up 3 years and 10 months). All of the children with infantile tibia vara had a positive 'cover up' test (sensitivity = 1.00). Eighteen of 25 children with a positive 'cover up' test actually had or developed infantile tibia vara (positive predictive value = 0.72). Forty-three of 50 children with physiologic bowing had a negative 'cover up' test (specificity = 0.86). All of the children with a negative 'cover up' test actually had physiologic bowing (negative predictive value = 1.00). We conclude that the 'cover up' test is an effective screening tool for the assessment of bow legs in children between 1 and 3 years of age. Children with a negative 'cover up' test do not require radiographic evaluation and should be followed clinically for resolution of the bowing. Children with a positive 'cover up' test should have radiographic evaluation of the lower extremities or be referred to a specialist for further evaluation and treatment.

Wrist arthrodesis was performed on 19 upper extremities in 18 children with cerebral palsy to correct volar flexion and ulnar deviation deformities. Mean age at the time of surgery was 15.8 years, and mean follow-up was 4.7 years. Review of medical records and radiographs and follow-up clinical examination, including standardized functional testing and a child/parent questionnaire, were performed to assess outcome in technical, functional, and satisfaction domains. Technical domain outcomes were best when arthrodesis was performed by proximal row carpectomy with plate fixation. Functional improvement, as documented by the House scale, averaged 1.8 levels, with 14 children (83.3%) showing improvement. Child/parent satisfaction with cosmetic, hygienic, and functional outcomes was high, ranging from 72 to 94%. Wrist arthrodesis, when combined with appropriate procedures for the forearm, fingers, and thumb, provided excellent technical, functional, and satisfaction domain outcomes for children with cerebral palsy, particularly those with more severe upper extremity involvement, dyskinetic type cerebral palsy, or poor motivation for rehabilitation.