Lower Limb Deformity Management in Arthrogryposis – What to Correct and When

Volume 10 | Issue 2 | May-August 2024 | Page: 00-00 | Ishani P Shah, Sujika Ranmuthuge, Varun Parnami, Anastasios Chytas 

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.000

Submitted: 18/05/2024; Reviewed: 06/06/2024; Accepted: 16/07/2024; Published: 10/08/2024

Authors: Ishani P Shah DNB Ortho. FRCS (T & O) [1], Sujika Ranmuthuge MD, FRCS (T & O) [1], Varun Parnami DNB Ortho. [1], Anastasios Chytas MD, MSc [1]

[1] Department of Paediatric Orthopaedic Surgery, Royal Manchester Children’s Hospital, Oxford Road, M13 9WL

Address of Correspondence

Dr. Ishani P Shah,
Consultant Paediatric Orthopaedic Surgeon, Royal Manchester Children’s Hospital, Oxford Road, M13 9WL.
E-mail: ishanipshah@gmail.com

Abstract

Arthrogryposis is a descriptive term involving non – progressive joint contractures of two or more joints at birth. It is associated with more than 300 diseases. Lower limb involvement is seen in about 95% of the cases with variable affection of the foot, knee and hip. Management depends on the severity, affection of number of joints and co-morbidities. Multidisciplinary management is crucial with realistic expectations. Prognosis should be discussed with parents prior to undertaking surgical intervention, especially the risk of recurrence as age advances. Deformities include soft tissue contractures, fibrotic hypoplastic muscles and in older children, deformed articular congruity. Foot is most commonly affected and Ponseti casting is the gold standard first line of treatment. Failed correction or late presentations are treated with soft tissue/bony surgery and/or fixator. Knee contractures can be flexion or extension with or without joint subluxation and patella involvement. Options for management are serial casting, soft tissue release, growth modulation, bony surgery, gradual correction with fixator or a combination of these based on the severity and age at presentation. Pterygium management is difficult due to proximity of neurovascular structures to the skin web and higher risk of recurrence. Hip contractures and dislocation when unilateral should be treated surgically. Treatment of bilateral affection is controversial and should be individualised.
Keywords: 

References

1. Bevan, W.P., et al., Arthrogryposis multiplex congenita (amyoplasia): an orthopaedic perspective. J Pediatr Orthop, 2007. 27(5): p. 594-600.
2. Hall, J.G., Arthrogryposis multiplex congenita: etiology, genetics, classification, diagnostic approach, and general aspects. J Pediatr Orthop B, 1997. 6(3): p. 159-66.
3. Sells, J.M., K.M. Jaffe, and J.G. Hall, Amyoplasia, the most common type of arthrogryposis: the potential for good outcome. Pediatrics, 1996. 97(2): p. 225-31.
4. Hall, J.G., K.A. Aldinger, and K.I. Tanaka, Amyoplasia revisited. Am J Med Genet A, 2014. 164A(3): p. 700-30.
5. Hansen-Jaumard, D., et al., A review of the orthopedic interventions and functional outcomes among a cohort of 114 children with arthrogryposis multiplex congenita. J Pediatr Rehabil Med, 2020. 13(3): p. 263-271.
6. Swinyard, C.A. and E.E. Bleck, The etiology of arthrogryposis (multiple congenital contracture). Clin Orthop Relat Res, 1985(194): p. 15-29.
7. Ooishi, T., et al., Congenital dislocation of the knee. Its pathologic features and treatment. Clin Orthop Relat Res, 1993(287): p. 187-92.
8. Hoffer, M.M., et al., Ambulation in severe arthrogryposis. J Pediatr Orthop, 1983. 3(3): p. 293-6.
9. Harold J.P. van Bosse, D.A.Z., The Orthopaedic Management of Arthrogryposis Multiplex Congenita. Journal of the Pediatric Orthopaedic Society of North America, 2021. 3(2): p. 277.
10. Carlson, W.O., et al., Arthrogryposis multiplex congenita. A long-term follow-up study. Clin Orthop Relat Res, 1985(194): p. 115-23.
11. Staheli, L.T., et al., Management of hip dislocations in children with arthrogryposis. J Pediatr Orthop, 1987. 7(6): p. 681-5.
12. St Clair, H.S. and S. Zimbler, A plan of management and treatment results in the arthrogrypotic hip. Clin Orthop Relat Res, 1985(194): p. 74-80.
13. Szoke, G., et al., Medial-approach open reduction of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop, 1996. 16(1): p. 127-30.
14. van Bosse, H.J.P., et al., Treatment of the Lower Extremity Contracture/Deformities. J Pediatr Orthop, 2017. 37 Suppl 1: p. S16-S23.
15. Wada, A., et al., Surgical treatment of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop B, 2012. 21(5): p. 381-5.
16. Yau, P.W., et al., Twenty-year follow-up of hip problems in arthrogryposis multiplex congenita. J Pediatr Orthop, 2002. 22(3): p. 359-63.
17. Nema, S.K., et al., Open reduction for hip dislocation in children with arthrogryposis multiplex congenital: Outcomes of a systematic review. J Clin Orthop Trauma, 2024. 53: p. 102434.
18. Sarwark, J.F., G.D. MacEwen, and C.I. Scott, Jr., Amyoplasia (a common form of arthrogryposis). J Bone Joint Surg Am, 1990. 72(3): p. 465-9.
19. Miao, M., et al., Early open reduction of dislocated hips using a modified Smith-Petersen approach in arthrogyposis multiplex congenita. BMC Musculoskelet Disord, 2020. 21(1): p. 144.
20. Hamdy, R.C., et al., Treatment and outcomes of arthrogryposis in the lower extremity. Am J Med Genet C Semin Med Genet, 2019. 181(3): p. 372-384.
21. van Bosse, H.J. and R.E. Saldana, Reorientational Proximal Femoral Osteotomies for Arthrogrypotic Hip Contractures. J Bone Joint Surg Am, 2017. 99(1): p. 55-64.
22. Guidera, K.J., et al., Radiographic changes in arthrogrypotic knees. Skeletal Radiol, 1991. 20(3): p. 193-5.
23. Sodergard, J. and S. Ryoppy, The knee in arthrogryposis multiplex congenita. J Pediatr Orthop, 1990. 10(2): p. 177-82.
24. Murray, C. and J.A. Fixsen, Management of knee deformity in classical arthrogryposis multiplex congenita (amyoplasia congenita). J Pediatr Orthop B, 1997. 6(3): p. 186-91.
25. Brunner, R., F. Hefti, and J.D. Tgetgel, Arthrogrypotic joint contracture at the knee and the foot: correction with a circular frame. J Pediatr Orthop B, 1997. 6(3): p. 192-7.
26. Thomas, B., et al., The knee in arthrogryposis. Clin Orthop Relat Res, 1985(194): p. 87-92.
27. Eriksson, M., et al., Gait in children with arthrogryposis multiplex congenita. J Child Orthop, 2010. 4(1): p. 21-31.
28. Palmer, P.M., et al., Passive motion therapy for infants with arthrogryposis. Clin Orthop Relat Res, 1985(194): p. 54-9.
29. Ponten, E., Management of the knees in arthrogryposis. J Child Orthop, 2015. 9(6): p. 465-72.
30. Drummond DS, S.T., Cruess RL, Management of arthrogryposis multiplex congenita. Instr Course Lect, 1974. 23: p. 79-95.
31. Ho, C.A. and L.A. Karol, The utility of knee releases in arthrogryposis. J Pediatr Orthop, 2008. 28(3): p. 307-13.
32. Palocaren, T., et al., Anterior distal femoral stapling for correcting knee flexion contracture in children with arthrogryposis–preliminary results. J Pediatr Orthop, 2010. 30(2): p. 169-73.
33. Klatt, J. and P.M. Stevens, Guided growth for fixed knee flexion deformity. J Pediatr Orthop, 2008. 28(6): p. 626-31.
34. Herzenberg, J.E., et al., Mechanical distraction for treatment of severe knee flexion contractures. Clin Orthop Relat Res, 1994(301): p. 80-8.
35. DelBello, D.A. and H.G. Watts, Distal femoral extension osteotomy for knee flexion contracture in patients with arthrogryposis. J Pediatr Orthop, 1996. 16(1): p. 122-6.
36. Yang, S.S., et al., Ambulation gains after knee surgery in children with arthrogryposis. J Pediatr Orthop, 2010. 30(8): p. 863-9.
37. Feldman, D.S., T.J. Rand, and A.J. Huser, Novel Approach to Improving Knee Range of Motion in Arthrogryposis with a New Working Classification. Children (Basel), 2021. 8(7).
38. van Bosse, H.J., et al., Treatment of knee flexion contractures in patients with arthrogryposis. J Pediatr Orthop, 2007. 27(8): p. 930-7.
39. Aman, M., et al., Comparative analysis of surgical treatment modalities for a popliteal pterygium: a meta-analysis. Arch Orthop Trauma Surg, 2024. 144(5): p. 2449-2459.
40. Curtis, B.H. and R.L. Fisher, Congenital hyperextension with anterior subluxation of the knee. Surgical treatment and long-term observations. J Bone Joint Surg Am, 1969. 51(2): p. 255-69.
41. Oetgen, M.E., et al., Functional results after surgical treatment for congenital knee dislocation. J Pediatr Orthop, 2010. 30(3): p. 216-23.
42. Shah, N.R., N. Limpaphayom, and M.B. Dobbs, A minimally invasive treatment protocol for the congenital dislocation of the knee. J Pediatr Orthop, 2009. 29(7): p. 720-5.
43. Johnson, E., R. Audell, and W.L. Oppenheim, Congenital dislocation of the knee. J Pediatr Orthop, 1987. 7(2): p. 194-200.
44. Roy, D.R. and A.H. Crawford, Percutaneous quadriceps recession: a technique for management of congenital hyperextension deformities of the knee in the neonate. J Pediatr Orthop, 1989. 9(6): p. 717-9.
45. Fucs, P.M., et al., Quadricepsplasty in arthrogryposis (amyoplasia): long-term follow-up. J Pediatr Orthop B, 2005. 14(3): p. 219-24.
46. Kowalczyk, B. and J. Felus, Arthrogryposis: an update on clinical aspects, etiology, and treatment strategies. Arch Med Sci, 2016. 12(1): p. 10-24.
47. Morcuende, J.A., M.B. Dobbs, and S.L. Frick, Results of the Ponseti method in patients with clubfoot associated with arthrogryposis. Iowa Orthop J, 2008. 28: p. 22-6.
48. Matar, H.E., P. Beirne, and N. Garg, The effectiveness of the Ponseti method for treating clubfoot associated with arthrogryposis: up to 8 years follow-up. J Child Orthop, 2016. 10(1): p. 15-8.
49. van Bosse, H.J.P., Challenging clubfeet: the arthrogrypotic clubfoot and the complex clubfoot. J Child Orthop, 2019. 13(3): p. 271-281.
50. Drummond, D.S. and R.L. Cruess, The management of the foot and ankle in arthrogryposis multiplex congenita. J Bone Joint Surg Br, 1978. 60(1): p. 96-9.
51. Niki, H., L.T. Staheli, and V.S. Mosca, Management of clubfoot deformity in amyoplasia. J Pediatr Orthop, 1997. 17(6): p. 803-7.
52. Guidera, K.J. and J.C. Drennan, Foot and ankle deformities in arthrogryposis multiplex congenita. Clin Orthop Relat Res, 1985(194): p. 93-8.
53. Chergui, S., et al., Talectomy for arthrogrypotic foot deformities: A systematic review. Foot Ankle Surg, 2023. 29(1): p. 15-21.
54. Segal, L.S., et al., Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy. Foot Ankle, 1989. 10(1): p. 12-6.
55. Eidelman, M. and A. Katzman, Treatment of arthrogrypotic foot deformities with the Taylor Spatial Frame. J Pediatr Orthop, 2011. 31(4): p. 429-34.
56. El Barbary, H., H. Abdel Ghani, and M. Hegazy, Correction of relapsed or neglected clubfoot using a simple Ilizarov frame. Int Orthop, 2004. 28(3): p. 183-6.
57. Chalayon, O., A. Adams, and M.B. Dobbs, Minimally invasive approach for the treatment of non-isolated congenital vertical talus. J Bone Joint Surg Am, 2012. 94(11): p. e73.
58. Bouchard, M., An Algorithmic Approach to the Congenital Vertical Talus. Journal of the Pediatric Orthopaedic Society of North America, 2022. 4(1): p. 398.

How to Cite this Article:  Shah IP, Ranmuthuge S, Parnami V, Chytas A | Lower Limb Deformity Management in Arthrogryposis – What to Correct and When | International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 09-16.
https://doi.org/10.13107/ijpo.2024.v10.i02.184

(Article Text HTML)      (Full Text PDF)

Blount’s Disease: Review Article

Volume 10 | Issue 2 | May-August 2024 | Page: 39-48 | Yashwant Singh Tanwar, Sirazul Haque Malik, Karolina Siwicka, Nando Ferreira, Pieter Herman Maré 

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.192

Submitted: 02/05/2024; Reviewed: 29/05/2024; Accepted: 21/06/2024; Published: 10/08/2024

Authors: Sudhanshu Yashwant Singh Tanwar MS Ortho., DNB, MRCS [1], Sirazul Haque Malik MS Ortho. [2], Karolina Siwicka MD, PhD (T & O) [3], Nando Ferreira FC Orth (SA), MMed (Orth), PhD [3], Pieter Herman Maré FC Orth (SA), PhD [4]
[1] Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
[2] Department of Orthopedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Jollygrant, Uttarakhand, India.
[3] Division of Orthopedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa.
[4] Paediatric Orthopaedics Unit, Grey’s Hospital, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa.

Address of Correspondence

Dr. Yashwant Singh Tanwar
Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
E-mail: tanwar_yashwant@yahoo.co.in

Abstract

Blount’s disease, or non-physiological idiopathic tibia vara, is a growth disturbance affecting the medial proximal tibial physis, leading to a progressive three-dimensional deformity characterized by varus, procurvatum, and internal rotation. While its precise etiology remains unclear, the condition has been closely linked to obesity, mechanical stress, and potential genetic predisposition. Infantile Blount’s typically presents between one and three years of age, often bilaterally, whereas late-onset forms occur in juveniles (4–10 years) or adolescents (>10 years) and are more commonly unilateral. Early differentiation from physiological bowing is essential, as untreated disease results in progressive deformity and joint instability.
Radiographic evaluation is critical in confirming the diagnosis and planning treatment. Key parameters, including the meta-diaphyseal (Drennan) angle, medial metaphyseal beak angle, and mechanical tibiofemoral axis deviation, provide objective measures to distinguish Blount’s disease from other causes of genu varum. Medial tibial plateau depression, best assessed using an arthrogram, is a key determinant in surgical planning, particularly in advanced cases.
Management strategies depend on the stage and severity of the disease. In early stages, guided growth using tension-band plating may modulate physeal development and prevent progression. However, in advanced or recurrent cases, surgical correction is required. Metaphyseal osteotomy, with or without internal fixation, remains the mainstay of treatment. In cases with significant medial plateau depression, a medial hemiplateau elevation osteotomy is indicated to restore joint congruency and knee stability. Severe or late-presenting cases may necessitate double osteotomy techniques, combining joint line realignment with metaphyseal correction. Acute correction methods, including oblique and dome osteotomies, are effective but carry risks of neurovascular compromise. In cases of complex multiplanar deformity, gradual correction using circular external fixation offers precise correction while minimizing complications.
Despite surgical intervention, recurrence remains a concern, particularly in cases with persistent medial physeal slope abnormalities. Strategies such as prophylactic lateral tibial and fibular epiphysiodesis, as well as controlled overcorrection, have been proposed to minimize recurrence risk. Perioperative considerations, including prophylactic fasciotomy and careful fibular osteotomy placement, play a role in preventing complications such as compartment syndrome and peroneal nerve palsy.
Blount’s disease is a progressive condition requiring early diagnosis and timely intervention to prevent long-term morbidity. A structured approach, incorporating clinical assessment, radiographic analysis, and stage-specific management, is essential to optimize outcomes. While current surgical techniques provide reliable correction, ongoing research into the pathophysiology and treatment of Blount’s disease remains essential to improving long-term prognosis.
Keywords: Blount’s disease, Infantile tibia vara, Adolescent tibia vara

References

1. Erlacher P. Deforming processes of the epiphyseal region in children. Arch Orthop trauma Surg. 1922;March(20):81–96.
2. W.P. Blount. Tibia vara: osteochondris deformans tibiae. J Bone Jt Surg. 1937;19:1–29.
3. LANGENSKIOLD A. Tibia vara; (osteochondrosis deformans tibiae); a survey of 23 cases. Acta Chir Scand. 1952 Mar 26;103(1):1–22.
4. LANGENSKIOELD A, RISKA EB. TIBIA VARA (OSTEOCHONDROSIS DEFORMANS TIBIAE): A SURVEY OF SEVENTY-ONE CASES. J Bone Joint Surg Am. 1964 Oct;46:1405–20.
5. Stricker SJ, Edwards PM, Tidwell MA. Langenskiöld Classification of Tibia Vara: An Assessment of Interobserver Variability. J Pediatr Orthop. 1994 Mar;14(2):152–5.
6. Sabharwal S, Zhao C, McClemens E. Correlation of body mass index and radiographic deformities in children with Blount disease. J Bone Joint Surg Am. 2007 Jun;89(6):1275–83.
7. ARKIN AM, KATZ JF. The effects of pressure on epiphyseal growth; the mechanism of plasticity of growing bone. J Bone Joint Surg Am. 1956 Oct;38-A(5):1056–76.
8. Mehtar M, Ramguthy Y, Firth G. Profile of patients with Blount’s disease at an academic hospital. SA Orthop J. 2091;18(9).
9. Muthuri SK, Francis CE, Wachira L-JM, Leblanc AG, Sampson M, Onywera VO, et al. Evidence of an overweight/obesity transition among school-aged children and youth in Sub-Saharan Africa: a systematic review. PLoS One. 2014;9(3):e92846.
10. Montgomery CO, Young KL, Austen M, Jo C-H, Blasier RD, Ilyas M. Increased risk of Blount disease in obese children and adolescents with vitamin D deficiency. J Pediatr Orthop. 2010 Dec;30(8):879–82.
11. Lisenda L, Simmons D, Firth GB, Ramguthy Y, Kebashni T, Robertson AJF. Vitamin D Status in Blount Disease. J Pediatr Orthop. 2016;36(5):e59-62.
12. Jansen N, Hollman F, Bovendeert F, Moh P, Stegmann A, Staal HM. Blount disease and familial inheritance in Ghana, area cross-sectional study. BMJ Paediatr Open. 2021 Apr;5(1):e001052.
13. Feldman MD, Schoenecker PL. Use of the metaphyseal-diaphyseal angle in the evaluation of bowed legs. J Bone Jt Surg. 1993 Nov;75(11):1602–9.
14. Siffert RS, Katz JF. The intra-articular deformity in osteochondrosis deformans tibiae. J Bone Joint Surg Am. 1970 Jun;52(4):800–4.
15. Maré PH, Thompson DM, Marais LC. Predictive Factors for Recurrence in Infantile Blount Disease Treated With Tibial Osteotomy. J Pediatr Orthop. 2021 Jan;41(1):e36–43.
16. Sanghrajka AP, Hill RA, Murnaghan CF, Simpson AHRW, Bellemore MC. Slipped upper tibial epiphysis in infantile tibia vara. J Bone Joint Surg Br. 2012 Sep;94-B(9):1288–91.
17. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985 Jan;67(1):39–47.
18. Wongcharoenwatana J, Kaewpornsawan K, Chotigavanichaya C, Eamsobhana P, Laoharojanaphand T, Musikachart P, et al. Medial Metaphyseal Beak Angle as a Predictor for Langenskiöld Stage II of Blount’s Disease. Orthop Surg. 2020 Dec;12(6):1703–9.
19. Davids JR, Blackhurst DW, Allen BL. Radiographic evaluation of bowed legs in children. J Pediatr Orthop. 2001;21(2):257–63.
20. Gordon JE, King DJ, Luhmann SJ, Dobbs MB, Schoenecker PL. Femoral Deformity in Tibia Vara. J Bone Jt Surg. 2006 Feb;88(2):380–6.
21. Sabharwal S, Lee J, Zhao C. Multiplanar Deformity Analysis of Untreated Blount Disease. J Pediatr Orthop. 2007 Apr;27(3):260–5.
22. Sabharwal S. Blount Disease. Orthop Clin North Am. 2015 Jan;46(1):37–47.
23. Robbins CA. Deformity Reconstruction Surgery for Blount’s Disease. Child (Basel, Switzerland). 2021 Jun 30;8(7).
24. Edwards TA, Hughes R, Monsell F. The challenges of a comprehensive surgical approach to Blount’s disease. J Child Orthop. 2017 Dec 1;11(6):479–87.
25. Jain MJ, Inneh IA, Zhu H, Phillips WA. Tension Band Plate (TBP)-guided Hemiepiphysiodesis in Blount Disease: 10-Year Single-center Experience With a Systematic Review of Literature. J Pediatr Orthop. 2020 Feb;40(2):e138–43.
26. Maré PH, Thompson DM, Marais LC. Guided growth using a tension-band plate in Blount’s disease. J Pediatr Orthop B. 2022 Mar 1;31(2):120–6.
27. Stevens PM. Guided growth for deformity correction. Oper Tech Orthop. 2011;21:197–202.
28. LaMont LE, McIntosh AL, Jo CH, Birch JG, Johnston CE. Recurrence After Surgical Intervention for Infantile Tibia Vara: Assessment of a New Modified Classification. J Pediatr Orthop. 2019 Feb;39(2):65–70.
29. Adulkasem N, Wongcharoenwatana J, Ariyawatkul T, Chotigavanichaya C, Eamsobhana P. A Predictive Score for Infantile Blount Disease Recurrence After Tibial Osteotomy. J Pediatr Orthop. 2023 Apr;43(4):e299–304.
30. Andrade N, Johnston CE. Medial epiphysiolysis in severe infantile tibia vara. J Pediatr Orthop. 2006;26(5):652–8.
31. Eamsobhana P, Kaewpornsawan K, Yusuwan K. Do we need to do overcorrection in Blount’s disease? Int Orthop. 2014 Aug;38(8):1661–4.
32. Maré PH, Thompson DM, Marais LC. Growth modulation may decrease recurrence when used as an adjunct to osteotomy in infantile Blount’s disease. SA Orthop J [Internet]. 2021 [cited 2024 Aug 31];20(2):88–92. Available from: http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2021000200007&lng=en&nrm=iso&tlng=en
33. Baraka MM, Hefny HM, Mahran MA, Fayyad TA, Abdelazim H, Nabil A. Single-stage medial plateau elevation and metaphyseal osteotomies in advanced-stage Blount’s disease: a new technique. J Child Orthop. 2021 Feb 1;15(1):12–23.
34. Feldman DS, Madan SS, Ruchelsman DE, Sala DA, Lehman WB. Accuracy of Correction of Tibia Vara. J Pediatr Orthop. 2006 Nov;26(6):794–8.
35. Nada AA, Hammad ME, Eltanahy AF, Gazar AA, Khalifa AM, El-Sayed MH. Acute Correction and Plate Fixation for the Management of Severe Infantile Blount’s Disease: Short-term Results. Strateg trauma limb Reconstr. 2021;16(2):78–85.
36. Griswold B, Gilbert S, Khoury J. Opening Wedge Osteotomy for the Correction of Adolescent Tibia Vara. Iowa Orthop J. 2018;38:141–6.
37. Mare PH, Marais LC. Gradual Deformity Correction with a Computer-assisted Hexapod External Fixator in Blount’s Disease. Strateg Trauma Limb Reconstr. 2022 May 24;17(1):32–7.
38. Maré P, Thompson D. Infantile Blount’s disease. SA Orthop J. 2020;19(3).
39. Craig JG, van Holsbeeck M, Zaltz I. The utility of MR in assessing Blount disease. Skeletal Radiol. 2002 Apr;31(4):208–13.
40. Maré PH, Thompson DM, Marais LC. The Medial Elevation Osteotomy for Late-presenting and Recurrent Infantile Blount Disease. J Pediatr Orthop. 2021 Feb;41(2):67–76.
41. van Huyssteen AL, Hastings CJ, Olesak M, Hoffman EB. Double-elevating osteotomy for late-presenting infantile Blount’s disease. J Bone Joint Surg Br. 2005 May;87-B(5):710–5.
42. Rab GT. Oblique tibial osteotomy for Blount’s disease (tibia vara). J Pediatr Orthop [Internet]. 1988/11/01. 1988;8(6):715–20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3192702
43. Rab GT. Oblique tibial osteotomy revisited. J Child Orthop [Internet]. 2010/03/18. 2010;4(2):169–72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20234769
44. Dilawaiz Nadeem R, Quick TJ, Eastwood DM. Focal dome osteotomy for the correction of tibial deformity in children. J Pediatr Orthop B. 2005 Sep;14(5):340–6.
45. Miraj F, Ajiantoro, Arya Mahendra Karda IW. Step cut “V” osteotomy for acute correction in Blount’s disease treatment: A case series. Int J Surg Case Rep. 2019;58:57–62.
46. Phedy P, Siregar PU. Osteotomy for deformities in blount disease: A systematic review. J Orthop. 2016 Sep;13(3):207–9.
47. Karuppal R, Mohan R, Marthya A, Ts G, S S. Case Report: “Z” osteotomy – a novel technique of treatment in Blount’s disease. F1000Research. 2015;4:1250.
48. Khermosh O, Wientroub S. Serrated (W/M) osteotomy: a new technique for simultaneous correction of angular and torsional deformity of the lower limb in children. J Pediatr Orthop B. 1995;4(2):204–8.
49. Gkiokas A, Brilakis E. Management of neglected Blount disease using double corrective tibia osteotomy and medial plateau elevation. J Child Orthop. 2012 Oct;6(5):411–8.
50. Gbenou AS, Assan BR, Houegban ASCR, Fiogbe MA. Compartment syndrome following an acute correction of a neglected case of Blount’s disease: What lessons can be learned? J Orthop Reports. 2022 Dec;1(4):100079.
51. Cometa MA, Esch AT, Boezaart AP. Did continuous femoral and sciatic nerve block obscure the diagnosis or delay the treatment of acute lower leg compartment syndrome? A case report. Pain Med. 2011 May;12(5):823–8.
52. Greene WB. Infantile tibia vara. J Bone Jt Surg. 1993 Jan;75(1):130–43.
53. Birch JG. Blount Disease. J Am Acad Orthop Surg. 2013 Jul 1;21(7):408–18.
54. McCarthy JJ, MacIntyre NR, Hooks B, Davidson RS. Double Osteotomy for the Treatment of Severe Blount Disease. J Pediatr Orthop. 2009 Mar;29(2):115–9.
55. Hefny H, Shalaby H, El-kawy S, Thakeb M, Elmoatasem E. A New Double Elevating Osteotomy in Management of Severe Neglected Infantile Tibia Vara using the Ilizarov Technique. J Pediatr Orthop. 2006 Mar;26(2):233–7.
56. Bar-On E, Weigl DM, Becker T, Katz K. Treatment of severe early onset Blount’s disease by an intra-articular and a metaphyseal osteotomy using the Taylor Spatial Frame. J Child Orthop. 2008 Dec 1;2(6):457–61.
57. Cerqueira F dos S, Motta GATA, Rocha de Faria JL, Pizzolatti IS, Motta DP da, Mandarino M, et al. Controlled Double Gradual Opening Osteotomy for the Treatment of Severe Varus of the Knee—Blount’s Disease. Arthrosc Tech. 2021 Sep;10(9):e2199–206.
58. Jones S, Hosalkar HS, Hill RA, Hartley J. Relapsed infantile Blount’s disease treated by hemiplateau elevation using the Ilizarov frame. J Bone Joint Surg Br. 2003 May;85-B(4):565–71.
59. Tavares JO, Molinero K. Elevation of medial tibial condyle for severe tibia vara. J Pediatr Orthop B. 2006 Sep;15(5):362–9.
60. Haddad FS, Harper GD, Hill RA. Intraoperative Arthrography and the Ilizarov Technique. J Bone Jt Surg. 1997 Sep 1;79(5):731–3.
61. Stanitski DF, Stanitski CL, Trumble S. Depression of the Medial Tibial Plateau in Early-Onset Blount Disease: Myth or Reality? J Pediatr Orthop. 1999 Mar;19(2):265–9.

How to Cite this Article:  Tanwar YS, Malik SH, Siwicka K, Ferreira N, Maré PH | Blount’s Disease: Review Article | International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 39-48. https://doi.org/10.13107/ijpo.2024.v10.i02.192

(Article Text HTML)      (Full Text PDF)

Understanding the Biomechanics of Lever Arm Disorders in Cerebral Palsy

Volume 10 | Issue 1 | January-April 2024 | Page: 09-13 | Jayanth Sampath, Taral Nagda

DOI- https://doi.org/10.13107/ijpo.2024.v10i01.172

Submitted: 01/02/2024; Reviewed: 14/02/2024; Accepted: 18/03/2024; Published: 10/04/2024

Authors: Jayanth Sampath MS Ortho [1], Taral Nagda MS Ortho [2]

[1] Department of Paediatric Orthopaedics, Rainbow Children’s Hospital, Bangalore, Karnataka, India.
[2] Department of Paediatric Orthopaedics, SRCC NH Children’s Hospital, Mumbai, Maharashtra, India

Address of Correspondence

Dr. Jayanth S. Sampath,
Rainbow Children’s Hospital, Bangalore, Karnataka, India.
E-mail: jayanthdoc@gmail.com

Abstract

Levers in the human body play an important role in facilitating efficient movement. Muscle forces act around the axis of movement of adjacent joints. The normal moment of a joint (M) is the product of the muscle force (F) and the length of lever arm (d). The primary neurological insult in cerebral palsy (CP) causes shortening of muscles, joint contractures, and torsional abnormalities in bones. The resulting ineffective lever arm leads to a failure to produce an appropriate torque and subsequent gait abnormalities. Therefore, the effects of lever arm dysfunction should be considered when gait improvement surgery is being offered to children with CP. This review will explain the role of levers in normal human biomechanics and the significance of lever arm dysfunction in the management of CP.
Keywords: Biomechanics, Lever arm, Disorder, Cerebral palsy

References

1. Gage JR, editor. The treatment of gait problems in cerebral palsy. 2nd ed. London: Mac Keith Press; 2004. Treatment principles for crouch gait; p 382-97.
2. Theologis T. Lever arm dysfunction in cerebral palsy gait. J Child Orthop. 2013;7(5):379-382.
3. Kalkman BM, Bar-On L, Cenni F, et al. Achilles tendon moment arm length is smaller in children with cerebral palsy than in typically developing children. J Biomech. 2017;56:48-54.
4. Õunpuu S, Solomito M, Bell K, Pierz K. Long-term outcomes of external femoral derotation osteotomies in children with cerebral palsy. Gait Posture. 2017;56(March 2016):82-88..
5. Kim HY, Cha YH, Chun YS, Shin HS. Correlation of the torsion values measured by rotational profile, kinematics, and CT study in CP patients. Gait Posture. 2017;57:241-245.
6. Saglam Y, Ekin Akalan N, Temelli Y, Kuchimov S. Femoral derotation osteotomy with multi-level soft tissue procedures in children with cerebral palsy: Does it improve gait quality? J Child Orthop. 2016;10(1):41-48.
7. Kadhim M, Miller F. Crouch gait changes after planovalgus foot deformity correction in ambulatory children with cerebral palsy. Gait Posture. 2014;39(2):793-798.
8. Kadhim M, Holmes L, Miller F. Long-term Outcome of Planovalgus Foot Surgical Correction in Children with Cerebral Palsy. J Foot Ankle Surg. 2013;52(6):697-703.
9. Kim HT, Jang JH, Ahn JM, Lee JS, Kang DJ. Early results of one-stage correction for hip instability in cerebral palsy. Clin Orthop Surg. 2012;4(2):139-148.
10. Ganjwala D. Multilevel orthopedic surgery for crouch gait in cerebral palsy: An evaluation using functional mobility and energy cost. Indian J Orthop. 2011;45(4):314..
11. Foroohar A, McCarthy JJ, Yucha D, Clarke S, Brey J. Head-shaft angle measurement in children with cerebral palsy. J Pediatr Orthop. 2009;29(3):248-250.
12. Rethlefsen SA. Causes of Intoeing Gait in Children with Cerebral Palsy. J Bone Jt Surg. 2006;88(10):2175..
13. Čobeljić G, Djorić I, Bajin Z, Despot B. Femoral derotation osteotomy in cerebral palsy: Precise determination by tables. Clin Orthop Relat Res. 2006;(452):216-224.
14. Kadhim M, Holmes L, Church C, Henley J, Miller F. Pes planovalgus deformity surgical correction in ambulatory children with cerebral palsy. J Child Orthop. 2012;6(3):217-227.
15. Aiona M, Calligeros K, Pierce R. Coronal plane knee moments improve after correcting external tibial torsion in patients with cerebral palsy. Clin Orthop Relat Res. 2012;470(5):1327-1333.
16. Davids JR, Gibson TW, Pugh LI, Hardin JW. Proximal femoral geometry before and after varus rotational osteotomy in children with cerebral palsy and neuromuscular hip dysplasia. J Pediatr Orthop. 2013;33(2):182-189.
17. Rodda JM, Sciences H. Severe Crouch Gait in the Sagittal Gait Patterns of Spastic Diplegic Cerebral Palsy : the Impact of Single Event Multilevel Surgery. 2005;(November).
18. Inan M, Altinta F, Duru I. The evaluation and management of rotational deformity in cerebral palsy. Acta Orthop Traumatol Turc. 2009;43(2):106-112.
19. Heimkes B, Stotz S, Heid T. Pathogenesis and prevention of spastic hip dislocation. Z Orthop Ihre Grenzgeb. 1992;130(5):413-418.
20. Pirpiris M, Trivett A, Baker R, Rodda J, Nattrass GR, Graham HK. Femoral derotation osteotomy in spastic diplegia. J Bone Jt Surg. 2003;85(2):265-272.

How to Cite this Article:  Sampath J, Nagda T | Understanding the Biomechanics of Lever Arm Disorders in Cerebral Palsy | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 09-13 . https://doi.org/10.13107/ijpo.2024.v10i01.172

(Article Text HTML)      (Full Text PDF)

Upper Limb in Cerebral Palsy

Volume 10 | Issue 1 | January-April 2024 | Page: 39-49 | Praveen Bhardwaj, Vigneswaran Varadharajan, Mukil Venthan S, S Raja Sabapathy 

DOI- https://doi.org/10.13107/ijpo.2024.v10i01.177

Submitted: 28/01/2024; Reviewed: 16/02/2024; Accepted: 11/03/2022; Published: 10/04/2024

Authors: Praveen Bhardwaj MS Ortho [1], Vigneswaran Varadharajan MS Ortho [1], Mukil Venthan S MS Ortho [1], S Raja Sabapathy MS Ortho [2]

[1] Department of Hand & Reconstructive Microsurgery Ganga Hospital, Coimbatore, Tamil Nadu, India
[2] Department of Plastic, Hand & Reconstructive Microsurgery Ganga Hospital, Coimbatore, Tamil Nadu, India

Address of Correspondence

Dr. Praveen Bhardwaj,
Consultant- Hand & Reconstructive Microsurgery Ganga Hospital, 313- Mettupalayam Road Sai Baba Colony Coimbatore, Tamil Nadu, India
E-mail: drpb23@gmail.com

Abstract

Cerebral palsy (CP) is a complex neuromuscular disorder characterized by impaired movement and coordination, often resulting in significant gait abnormalities. The spectrum of motor function impairment varies greatly among individuals with CP, influenced by muscle control issues and specific types of cerebral palsy, including spasticity and ataxia. Gait analysis, comprising both observational and instrumented techniques, is essential for assessing gait patterns and identifying abnormalities. While observational gait analysis provides qualitative insights, instrumented gait analysis offers a detailed and objective assessment through motion capture technology, allowing for comprehensive evaluation of joint angles(Kinematics) and forces(Kinetics).
Understanding gait patterns is crucial for making informed clinical decisions regarding therapeutic interventions such as surgery and orthotic management. Literature has demonstrated that gait analysis significantly improves surgical recommendations and outcomes, highlighting the importance of incorporating detailed gait data into treatment planning. However, limitations such as variability in data accuracy, the complexity of methods, and hesitancy among some orthopaedic surgeons to adopt these techniques need to be addressed. The integration of gait analysis into clinical practice represents a paradigm shift in the management of cerebral palsy, transitioning treatment from an art to a science. It enables clinicians to tailor interventions based on individual biomechanical profiles, ultimately enhancing the functional ability and quality of life for patients. Continued research and standardized practices are essential to maximize the effectiveness of gait analysis in this population, ensuring that children withe cerebral palsy receive the most appropriate and effective care.
Keywords: Gait Analysis, Cerebral Palsy, Instrumented Gait Lab

References

1. Makki D, Duodu J, Nixon M. Prevalence and pattern of upper limb involvement in cerebral palsy. J Child Orthop. 2014 May;8(3):215-9. doi: 10.1007/s11832-014-0593-0. Epub 2014 May 14. PMID: 24824566; PMCID: PMC4142879.
2. Bhardwaj P, Sabapathy SR. Assessment of the hand in cerebral palsy. Indian J Plast Surg. 2011 May;44(2):348-56. doi: 10.4103/0970-0358.85356. PMID: 22022045; PMCID: PMC3193647.
3. Van Heest AE, Bagley A, Molitor F, James MA. Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Joint Surg Am. 2015 Apr 1;97(7):529-36. doi: 10.2106/JBJS.M.01577. PMID: 25834076.
4. Libberecht K, Sabapathy SR, Bhardwaj P. The relation of patient satisfaction and functional and cosmetic outcome after correction of the wrist flexion deformity in cerebral palsy. J Hand Surg Eur Vol. 2011 Feb;36(2):141-6. doi: 10.1177/1753193410384691. Epub 2010 Oct 8. PMID: 20935023.
5. Chaudhry S, Bhardwaj P, Venkatramani H, Sabapathy SR. The Spastic Upper Extremity in Children: Multilevel Surgical Decision-making. J Am Acad Orthop Surg. 2021 May 1;29(9):e416-e426. doi: 10.5435/JAAOS-D-20-00719. PMID: 33883454.
6. Tonkin MA. The growing hand. In: Gupta A, Kay SPJ, Scheker LR, editors. The upper limb in cerebral palsy. London: Mosby; 2000. pp. 447–59.
7. Yong LY, Wong CHL, Gaston M, Lam WL. The Role of Selective Peripheral Neurectomy in the Treatment of Upper Limb Spasticity. J Hand Surg Asian Pac Vol. 2018 Jun;23(2):181-191. doi: 10.1142/S2424835518500182. PMID: 29734901.
8. Leclercq C, Mertens P. Trends and insights review. Nerve procedures in the management of upper limb spasticity. J Hand Surg Eur Vol. 2024 Jun;49(6):802-811. doi: 10.1177/17531934241238885. Epub 2024 Mar 27. PMID: 38534081.
9. De Lepeleere B, Fitoussi F. Elbow Flexor Release Combined With Selective Neurectomy of Musculocutaneous Nerve for Spastic Elbow Flexion Deformity in Children and Adolescents. J Pediatr Orthop. 2024 Sep 1;44(8):e738-e743. doi: 10.1097/BPO.0000000000002729. Epub 2024 May 21. PMID: 38770666.
10. Cambon-Binder A, Leclercq C. Anatomical study of the musculocutaneous nerve branching pattern: application for selective neurectomy in the treatment of elbow flexors spasticity. Surg Radiol Anat. 2015 May;37(4):341-8. doi: 10.1007/s00276-014-1371-x. Epub 2014 Sep 6. PMID: 25193328.
11. Zancolli E. 2nd ed. Philadelphia: Lippincott; 1979. Structural and dynamic bases of hand surgery; pp. 263–83.
12. Arnaout A, Leclercq C. Fractional Lengthening of the Forearm Flexor Muscles: Anatomic Study. J Hand Surg Am. 2022 Aug;47(8):792.e1-792.e5. doi: 10.1016/j.jhsa.2021.07.015. Epub 2021 Sep 3. PMID: 34489137.
13. Patterson JM, Wang AA, Hutchinson DT. Late deformities following the transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis in children with cerebral palsy. J Hand Surg Am. 2010 Nov;35(11):1774-8. doi: 10.1016/j.jhsa.2010.07.014. PMID: 20888146.
14. Schibli S, Fridén J. Rebalancing the Spastic Wrist by Transposition of Antagonistic Muscle-Tendon Complex. Tech Hand Up Extrem Surg. 2022 Jun 1;26(2):127-130. doi: 10.1097/BTH.0000000000000371. PMID: 34711790.
15. Gschwind C, Tonkin M. Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity. J Hand Surg Br. 1992 Aug;17(4):391-5. doi: 10.1016/s0266-7681(05)80260-8. PMID: 1402264.
16. Manske PR. Redirection of extensor pollicis longus in the treatment of spastic thumb-in-palm deformity. J Hand Surg Am. 1985 Jul;10(4):553-60. doi: 10.1016/s0363-5023(85)80082-4. PMID: 4020069.
17. Lawson RD, Tonkin MA. Surgical management of the thumb in cerebral palsy. Hand Clin. 2003 Nov;19(4):667-77. doi: 10.1016/s0749-0712(03)00042-8. PMID: 14596557.
18. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in palm deformity in cerebral palsy. J Bone Joint Surg Am. 1981 Feb;63(2):216-25. PMID: 7462278.
19. Carlson MG. Green’s operative hand surgery. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, editors. Cerebral palsy. Philadelphia: Churchill Livingstone; 2005. pp. 1197–234.
20. Carlson EJ, Carlson MG. Treatment of swan neck deformity in cerebral palsy. J Hand Surg Am. 2014 Apr;39(4):768-72. doi: 10.1016/j.jhsa.2014.01.039. Epub 2014 Mar 6. PMID: 24613587.
21. Swanson AB. Treatment of the swan-neck deformity in the cerebral palsied hand. Clin Orthop Relat Res. 1966 Sep-Oct;48:167-71. PMID: 5957466.
22. Wei DH, Terrono AL. Superficialis Sling (Flexor Digitorum Superficialis Tenodesis) for Swan Neck Reconstruction. J Hand Surg Am. 2015 Oct;40(10):2068-74. doi: 10.1016/j.jhsa.2015.07.018. Epub 2015 Aug 29. PMID: 26328902.
23. Samilson RL, Morris JM. Surgical improvement of the cerebral-palsied upper limb. Electromyographic studies and results in 128 operations. J Bone Joint Surg Am. 1964 Sep;46:1203-16. PMID: 14214354.

How to Cite this Article:  Bhardwaj P, Varadharajan V, Venthan SM, Sabapathy SR | Upper Limb in Cerebral Palsy | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 39-49 . https://doi.org/10.13107/ijpo.2024.v10i01.177

(Article Text HTML)      (Full Text PDF)

Role of Gait Analysis in Management of Cerebral Palsy

Volume 10 | Issue 1 | January-April 2024 | Page: 34-38 | Chasanal Rathod

DOI- https://doi.org/10.13107/ijpo.2024.v10i01.176

Submitted: 13/01/2024; Reviewed: 05/02/2024; Accepted: 21/03/2024; Published: 10/04/2024

Authors: Chasanal Rathod MS Ortho [1,2]

[1] Department of Paediatric Orthopaedic Surgery, SRCC Children’s Hospital, Mumbai, Maharashtra, India.
[2] Xavier’s Gait Lab, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Chasanal Rathod,
Paediatric Orthopaedic Surgeon, SRCC Children’s Hospital, Mumbai, Maharashtra, India. Xavier’s Gait Lab Mumbai, Maharashtra, India.
E-mail: chasanal@gmail.com

Abstract

Cerebral palsy (CP) is a complex neuromuscular disorder characterized by impaired movement and coordination, often resulting in significant gait abnormalities. The spectrum of motor function impairment varies greatly among individuals with CP, influenced by muscle control issues and specific types of cerebral palsy, including spasticity and ataxia. Gait analysis, comprising both observational and instrumented techniques, is essential for assessing gait patterns and identifying abnormalities. While observational gait analysis provides qualitative insights, instrumented gait analysis offers a detailed and objective assessment through motion capture technology, allowing for comprehensive evaluation of joint angles(Kinematics) and forces(Kinetics).
Understanding gait patterns is crucial for making informed clinical decisions regarding therapeutic interventions such as surgery and orthotic management. Literature has demonstrated that gait analysis significantly improves surgical recommendations and outcomes, highlighting the importance of incorporating detailed gait data into treatment planning. However, limitations such as variability in data accuracy, the complexity of methods, and hesitancy among some orthopaedic surgeons to adopt these techniques need to be addressed. The integration of gait analysis into clinical practice represents a paradigm shift in the management of cerebral palsy, transitioning treatment from an art to a science. It enables clinicians to tailor interventions based on individual biomechanical profiles, ultimately enhancing the functional ability and quality of life for patients. Continued research and standardized practices are essential to maximize the effectiveness of gait analysis in this population, ensuring that children withe cerebral palsy receive the most appropriate and effective care.
Keywords: Gait Analysis, Cerebral Palsy, Instrumented Gait Lab

References

1. Bell KJ, Ounpuu S, DeLuca PA, et al. Natural progression of gait in children with cerebral palsy. J Pediatr Orthop. 2002;22:677–682
2. Gage JR, The neurological control system for normal gait. Gait Analysis in Cerebral Palsy. 1991 London MacKeith Press:37–60
3. Read HS, Hazlewood ME, Hillman SJ, Prescott RJ, Robb JE. Edinburgh visual gait score for use in cerebral palsy. J Pediatr Orthop. 2003 May-Jun;23(3):296-301. PMID: 12724590
4. Harris GF, Wertsch JJ. Procedures for gait analysis. Arch Phys Med Rehabil. 1994 Feb;75(2):216-25. PMID: 8311681.
5. Gage JR. Gait analysis. An essential tool in the treatment of cerebral palsy. Clin Orthop Relat Res. 1993 Mar;(288):126-34. PMID: 8458125.
6. Rodda J, Graham HK. Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm. Eur J Neurol. 2001 Nov;8 Suppl 5:98-108. doi: 10.1046/j.1468-1331.2001.00042.x. PMID: 11851738.
7. DeLuca, Peter; Davis, Roy; Õunpuu, Sylvia; Rose, Sally; Sirkin, Robert. Alterations in Surgical Decision Making in Patients with Cerebral Palsy Based on Three-Dimensional Gait Analysis. Journal of Pediatric Orthopaedics 17(5):p 608-614, September 1997.
8. Lofterød B, Terjesen T. Results of treatment when orthopaedic surgeons follow gait-analysis recommendations in children with CP. Dev Med Child Neurol. 2008 Jul;50(7):503-9. doi: 10.1111/j.1469-8749.2008.03018.x. PMID: 18611199.
9. Rutz E, Gaston MS, Tirosh O, Brunner R. Hip flexion deformity improves without psoas-lengthening after surgical correction of fixed knee flexion deformity in spastic diplegia. Hip Int. 2012 Jul-Aug;22(4):379-86. doi: 10.5301/HIP.2012.9453. PMID: 22878968.
10. Mallet C, Simon AL, Ilharreborde B, Presedo A, Mazda K, Penneçot GF. Intramuscular psoas lengthening during single-event multi-level surgery fails to improve hip dynamics in children with spastic diplegia. Clinical and kinematic outcomes in the short- and medium-terms. Orthop Traumatol Surg Res. 2016 Jun;102(4):501-6. doi: 10.1016/j.otsr.2016.01.022. Epub 2016 Mar 31. PMID: 27050557.
11. Dreher T, Wolf SI, Maier M, Hagmann S, Vegvari D, Gantz S, Heitzmann D, Wenz W, Braatz F. Long-term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in spastic diplegic cerebral palsy. J Bone Joint Surg Am. 2012 Oct 3;94(19):e142(1-10). doi: 10.2106/JBJS.K.01300. PMID: 23032593.
12. Végvári D, Wolf SI, Heitzmann D, Klotz MC, Dreher T. Does proximal rectus femoris release influence kinematics in patients with cerebral palsy and stiff knee gait? Clin Orthop Relat Res. 2013 Oct;471(10):3293-300. doi: 10.1007/s11999-013-3086-4. Epub 2013 Jun 5. PMID: 23737262; PMCID: PMC3773150.
13. Molenaers G, Desloovere K, Fabry G, De Cock P. The effects of quantitative gait assessment and botulinum toxin a on musculoskeletal surgery in children with cerebral palsy. J Bone Joint Surg Am. 2006 Jan;88(1):161-70.
14. Cook R, Schneider I, Hazlewood E, et al. Gait analysis alters decision making in cerebral palsy. J Pediatr Orthop 2003; 23:292–295.
15. Kay R, Dennis S, Rethlefsen S, et al. The effect of preoperative gait analysis on orthopaedic decision making. Clin Orthop Relat Res 2000; 372:217–222.
16. Chang FM, Seidl AJ, Muthusamy M, et al. Effectiveness of instrumented gait analysis in children with cerebral palsy: comparison of outcomes. J Pediatr Orthop 2006; 26:612–616.
17. Kay RM, Dennis S, Rethlefsen S, Skaggs DL, Tolo VT. Impact of postoperative gait analysis on orthopaedic care. Clin Orthop Relat Res. 2000 May;(374):259-64. doi: 10.1097/00003086-200005000-00023. PMID: 10818985
18. Schutte LM, Narayanan U, Stout JL, Selber P, Gage JR, Schwartz MH et al (2000) An index for quantifying deviations from normal gait. Gait Posture 11:25–31
19. Schwartz MH, Rozumalski A (2008) The Gait Deviation Index: a new comprehensive index of gait pathology. Gait Posture 28:351–357
20. Baker R, McGinley JL, Schwartz MH et al (2009) The gait profile score and movement analysis profile. Gait Posture 30:265–269
21. Noonan K, Halliday S, Browne B, et al. Interobserver variability of gait analysis in patients with cerebral palsy. J Pediatr Orthop 2003; 23:279 – 287.
22. States RA, Krzak JJ, Salem Y, Godwin EM, Bodkin AW, McMulkin ML. Instrumented gait analysis for management of gait disorders in children with cerebral palsy: A scoping review. Gait Posture. 2021 Oct;90:1-8. doi: 10.1016/j.gaitpost.2021.07.009. Epub 2021 Aug 3. PMID: 34358847.
23. Wren TA, Gorton GE 3rd, Ounpuu S, Tucker CA. Efficacy of clinical gait analysis: A systematic review. Gait Posture. 2011 Jun;34(2):149-53. doi: 10.1016/j.gaitpost.2011.03.027. Epub 2011 Jun 8. PMID: 21646022.
24. Narayanan UG. The role of gait analysis in the orthopaedic management of ambulatory cerebral palsy. Curr Opin Pediatr. 2007 Feb;19(1):38-43. doi: 10.1097/MOP.0b013e3280118a6d. PMID: 17224660.

How to Cite this Article:  Rathod C | Role of Gait Analysis in Management of Cerebral Palsy | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 34-38. https://doi.org/10.13107/ijpo.2024.v10i01.176

(Article Text HTML)      (Full Text PDF)

Lever Arm Disorders of the Feet in Cerebral Palsy

Volume 10 | Issue 1 | January-April 2024 | Page: 26-33 | Atul Bhaskar

DOI- https://doi.org/10.13107/ijpo.2024.v10i01.175

Submitted: 11/02/2024; Reviewed: 26/02/2024; Accepted: 13/03/2024; Published: 10/04/2024

Authors: Atul Bhaskar MS Ortho, FRCS Ortho, MCH, DNB [1,2,3]

[1] Department of Orthopaedics, Apollo Hospital, Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, SRCC NH Hospital, Mumbai, Maharashtra, India.
[3] Department of Orthopaedics, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Atul Bhaskar,
Paediatric Orthopaedic Surgeon, Department of Orthopaedics, Apollo Hospital, SRCC NH Hospital, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India.
E-mail: arb_25@yahoo.com

Abstract

The key for optimum management for progressive musculoskeletal deformities in cerebral palsy patients is understanding the causative mechanisms. The impact of muscle shortening and contracture on the long bones and joints leads to lever arm problems in the foot and ankle and the associated deformities.
Management of each deformity is considered separately although many of these can occur concurrently and the severity my vary in an individual.
Keywords: Lever, Cerebral palsy, Foot & Ankle

References

1) Theologis T. Lever arm dysfunction in cerebral palsy gait. J Child Orthop. 2013 Nov;7(5):379-82. doi: 10.1007/s11832-013-0510-y. Epub 2013 Aug 14. PMID: 24432098; PMCID: PMC3838510.
2) Dudeney, S. and Stephens, M., 1998. Foot deformities in children with cerebral palsy. Journal of Pediatric Orthopaedics, 18(6), pp.743-747
3) Min, J.J., Kwon, S.S., Sung, K.H., Lee, K.M., Chung, C.Y. and Park, M.S., 2020. Progression of planovalgus deformity in patients with cerebral palsy. BMC musculoskeletal disorders, 21(1), pp.1-8.
4) Bennet, G.C., Rang, M. and Jones, D., 1982. Varus and valgus deformities of the foot in cerebral palsy. Developmental Medicine & Child Neurology, 24(5), pp.499-503.
5) Kadhim M and Miller F. Pes planovalgus deformity in children with cerebral palsy: review article. J Pediatr Orthop B 2014; 23(5): 400–405.
6) MacInnes P, Lewis TL, Griffin C, et al. Surgical management of pes planus in children with cerebral palsy: a systematic review. PROSPERO2021 CRD42021239285, https://www.crd.york. ac.uk/prospero/display_record.php?ID=CRD42021239285 (2021, accessed 22 December 2021).
7) Lee SH, Chung CY, Park MS, Choi IH, Cho TJ. Tibial torsion in cerebral palsy: validity and reliability of measurement. Clin Orthop Relat Res. 2009 Aug;467(8):2098-104. doi: 10.1007/s11999-009-0705-1. Epub 2009 Jan 22. PMID: 19159112; PMCID: PMC2706340.
8) Andrisevic E, Westberry DE, Pugh LI, Bagley AM, Tanner S, Davids JR. Correction of Tibial Torsion in Children With Cerebral Palsy by Isolated Distal Tibia Rotation Osteotomy: A Short-term, In Vivo Anatomic Study. J Pediatr Orthop. 2016 Oct-Nov;36(7):743-8. doi: 10.1097/BPO.0000000000000525. PMID: 27603097.
9) Sung K.H., Chung C.Y., Lee K.M., Lee S.Y., Park M.S. Calcaneal lengthening for planovalgus foot deformity in patients with cerebral palsy. Clin Orthop Relat Res. 2013;471(5):1682–1690. [PMC free article] [PubMed] [Google Scholar]
10) Zeifang F, Breusch SJ and Döderlein L. Evans calcaneal lengthening procedure for spastic flexible flatfoot in 32 patients (46 feet) with a followup of 3 to 9 years. Foot Ankle Int 2006; 27(7): 500–507
11) Mosca VS. Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot. J Bone Joint Surg Am 1995; 77: 500–512.
12) Andreacchio A, Orellana C, Miller F, et al. Lateral column lengthening as treatment for planovalgus foot deformity in ambulatory children with spastic cerebral palsy. J Pediatr Orthop 2000; 20: 501–505
13) Grice D.S. An extra-articular arthrodesis of the subastragalar joint for correction of paralytic flat feet in children. J Bone Joint Surg Am. 1952;34(1):927–940. [PubMed] [Google Scholar]
14) Güven M., Eren A., Akman B., Unay K., Ozkan N.K. The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy. Acta Orthop Traumatol Turcica. 2008;42(1):31–37. Jan-Feb. [PubMed] [Google Scholar]
15) Rathjen K.E., Mubarak S.J. Calcaneal-cuboid-cuneiform osteotomy for the correction of valgus foot deformities in children. J Pediatr Orthop. 1998;18(6):775–782. [PubMed] [Google Scholar]
16) Ahmed AH, Hanna AA, Arafa AS, et al. Prospective comparison of subtalar arthroereisis with calcaneal lengthening in the management of planovalgus feet of ambulatory children with spastic cerebral palsy? Foot Ankle Spec. Epub ahead of print 3 December 2020. DOI: 10.1177/1938640020974886.
17) Suh DH, Park JH, Lee SH, et al. Lateral column lengthening versus subtalar arthroereisis for paediatric flatfeet: a systematic review. Int Orthop. 2019;43:1179-1192.
18) Turriago CA, Arbeláez MF and Becerra LC. Talonavicular joint arthrodesis for the treatment of pes planus valgus in older children and adolescents with cerebral palsy. J Child Orthop 2009; 3: 179–183
19) Elbarbary HM, Arafa AS, Said ABZ, et al. Clinical and Radiological Outcomes of Subtalar Arthroereisis for Management of Planovalgus Foot in Children With Cerebral Palsy: 3-Year Follow-up. Foot & Ankle Specialist. 2022;15(6):536-544. doi:10.1177/1938640020980911
20) Vlachou M, Demetriades D and Hager I. Subtalar arthrodesis with the combined Batchelor–Grice technique. Foot Ankle Surg 2004; 10: 79–84.
21) Dussa CU, Döderlein L, Forst R, Böhm H, Fujak A. Management of Severe Equinovalgus in Patients With Cerebral Palsy by Naviculectomy in Combination With Midfoot Arthrodesis. Foot & Ankle International. 2017;38(9):1011-1019. doi:10.1177/1071100717709577
22) Ireland, M.L. and Hoffer, M., 1985. Triple arthrodesis for children with spastic cerebral palsy. Developmental Medicine & Child Neurology, 27(5), pp.623-627. O’Connell, P.A., D’Souza, L.
23) Aiona M, Calligeros K, Pierce R. Coronal plane knee moments improve after correcting external tibial torsion in patients with cerebral palsy. Clin Orthop Relat Res. 2012 May;470(5):1327-33.
24) Stefko RM, de Swart RJ, Dodgin DA, Wyatt MP, Kaufman KR, Sutherland DH, Chambers HG. Kinematic and kinetic analysis of distal derotational osteotomy of the leg in children with cerebral palsy. J Pediatr Orthop. 1998 Jan-Feb;18(1):81-7. PMID: 9449107.
25) Cidambi EO, Farnsworth CL, Jeffords ME, Hughes JL, Parvaresh KC, Sullivan TB, Yaszay B, Edmonds EW. Distal tibial osteotomy to address internal tibial torsion: Should the fibula be cut? Clin Biomech (Bristol, Avon). 2022 Jan;91:105536. doi: 10.1016/j.clinbiomech.2021.105536. Epub 2021 Nov 20. PMID: 34920237.
26) T.L. Lewis, K. Patel, K.L. Shepherd, P. MacInnes, R. Ray, M. Kokkinakis, Hallux valgus surgery in children with cerebral palsy: A systematic review, Foot and Ankle Surgery,Volume 28, Issue 4,

How to Cite this Article:  Bhaskar A | Lever Arm Disorders of the Feet in Cerebral Palsy | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 26-33.
https://doi.org/10.13107/ijpo.2024.v10i01.175

(Article Text HTML)      (Full Text PDF)