Deformity In Children Research Articles

Treatment of Complex Foot Deformities in Children with the Taylor Spatial Frame

The Taylor spatial frame is a relatively new external fixator able to correct 6-axis deformities with computer accuracy using a virtual hinge. The Taylor spatial frame has gained tremendous popularity, but its use for the correction of foot deformities is still limited. Various ring configurations and a new foot program have recently become available and allow correction of the most difficult foot deformities. This article reports the results of 13 patients (15 frames) with various foot deformities treated at our institution with 3 different Taylor spatial frame configurations (standard rings construction, miter frame, and butt frame). Treatment goals were achieved in 11 patients, while mild residual deformities persisted in 2 patients. Most complications during treatment consisted of pin tract infections. One patient had premature consolidation, which was treated with additional midtarsal osteotomy; 1 had metatarsophalangeal joint subluxation, which was fixed with tendon lengthening and pining of the joint; and 1 had talar subluxation, which was reduced with residual program correction. Based on our experience, we believe the Taylor spatial frame is a very powerful and accurate surgical modality with a relatively short learning curve for the correction for most difficult foot deformities.

Modified Chuinard-Baskin Procedure for Managing Mild-to-Moderate Cavus and Claw Foot Deformity in Children and Adolescents

Nineteen ambulant patients (children and adolescents, 23 feet), with mild-to-moderate cavus and claw feet of neuromuscular etiology, underwent a modified Chuinard-Baskin operation, combining long toe extensor tendon transfer to the metatarsals with distal tenodesis onto the proximal phalanx. The technique aims to improve forefoot deformity and metatarsophalangeal dysfunction, and to enhance ankle dorsiflexion. Transcutaneous flexor tenotomies in several toes, and additional complementary surgery in the middle and hindfoot (plantar soft tissue releases, tendon lengthenings, and/or transfers and osteotomies/fusions) were also performed, when required. Selection criteria for the target procedure were mild-to-moderate cavus deformity (<45 degrees Meary's angle), restricted ankle dorsiflexion, discomforting symptoms, age span 6 years to maturity, and follow-up had to be at least 2 years. Evaluation was based on modified Frank and Johnson's clinical criteria. Radiologically, the Meary's angle on lateral standing view (long axes of talus/first metatarsal) was used. Global results at last follow-up (mean 6.91 +/- 5.43 years) were excellent in 11 feet (48%), satisfactory in 9 (39%), and unsatisfactory in 3 (13%). This retrospective study showed that satisfactory correction can be obtained in mild-to-moderate claw foot deformity in children and adolescents with this variation of Chuinard-Baskin's operation, and therefore can be used as an alternative to others that are more traditionally used.

Qualitative Versus Quantitative Radiographic Analysis of Foot Deformities in Children With Hemiplegic Cerebral Palsy

Qualitative assessments of standing plain radiographs are frequently used to determine treatment strategies and assess outcomes for the management of a wide range of foot and ankle conditions in children. A quantitative technique for such analyses would presumably be more precise and reliable. The goal of this study was to compare qualitative and quantitative techniques for the assessment of plain radiographs of the foot and ankle in children with hemiplegic type cerebral palsy (CP). Standing anteroposterior and lateral radiographs of the foot and ankle of the involved side for 49 children with hemiplegic CP were analyzed qualitatively by 2 pediatric orthopaedists, based upon a 3-segment (hindfoot, midfoot, and forefoot) foot model. Quantitative assessment of the same radiographs was performed by 2 examiners, using 6 radiographic measurements developed to describe the alignment of the foot based upon the same 3-segment model. Intraobserver and interobserver reliability was determined for both the qualitative and the quantitative techniques. The qualitative and quantitative techniques were compared to determine agreement. The qualitative technique demonstrated poor-to-fair interobserver reliability (percent agreement range, 23%-31%; weighted kappa range, 0.291-0.568). The quantitative technique demonstrated good-to-excellent intraobserver (correlation coefficient range, 0.81-0.99) and interobserver (correlation coefficient range, 0.81-0.97) reliability. Percent agreement between the quantitative and the qualitative techniques for the assessment of foot segmental alignment for each examiner ranged from 22.2% to 100% (mean agreement for examiner 1 was 51% [correlation coefficient range, 0.04-0.48]; mean agreement for examiner 2 was 65.3% [correlation coefficient range, 0.22-0.85]). Percent agreement between the quantitative technique and both observers ranged from 11.1% to 83.3% (mean agreement was 36.7% [correlation coefficient range, 0.17-0.94]). Reliable quantitative radiographic analysis of the segmental alignment of the involved foot and ankle in children with hemiplegic CP is possible and is more precise and reliable than traditional qualitative techniques. Quantitative techniques can identify a wider range of foot segmental malalignments and should facilitate deformity analysis, preoperative planning, assessment of outcome, and comparison of results between centers.

Efficacy of Spinal Instrumentation and Fusion in the Prevention of Postlaminectomy Spinal Deformity in Children With Intramedullary Spinal Cord Tumors

Postlaminectomy spinal deformity is a frequent problem after resection of a pediatric spinal cord tumor. However, the use of spinal fusion done at the time of resection in preventing the development of deformity is unknown. The purpose of our study was to assess the effectiveness of single-stage laminectomy, spinal cord decompression, and fusion for the prevention of postlaminectomy spinal deformity in children with intramedullary spinal cord tumors. Clinical charts and radiographs of 33 children with spinal cord tumors were reviewed for treatment description, preoperative spinal alignment, postoperative spinal alignment, and subsequent medical and surgical treatment. Spinal deformity was graded by predefined criteria. Significant spinal deformity developed in 10 of 17 children with laminectomy only, 3 of 4 children with laminoplasty, and 3 of 12 children with spinal fusion (2/6 with instrumentation, 1/6 with in situ fusion). Excluding patients that progressed to paraplegia, 9 of 16 patients treated with resection without fusion compared with 1 of 10 patients treated with resection and fusion developed a spinal deformity (P = 0.04). Among skeletally mature children that did not progress to paraplegia, 9 of 15 treated with resection without fusion compared with 1 of 7 patients treated with resection and fusion developed a deformity (P = 0.05). Removal of greater than 4 laminae (P = 0.03) was found to be associated with the development of postresection spinal deformity.

The Results of Tenodermodesis for Severe Chronic Mallet Finger Deformity in Children

The treatment of soft-tissue mallet fingers in children can be challenging because of delays in diagnosis and noncompliance with extension splinting or casting. The purpose of this investigation was to assess the results of tenodermodesis for the treatment of chronic soft-tissue mallet fingers in children. A retrospective analysis of 10 patients younger than 18 years was performed. All had extensor lag greater than 45 degrees, absent active distal interphalangeal joint (DIPJ) extension, and full passive DIPJ motion. All patients had failed trails of nonoperative treatment. Tenodermodesis was performed using established techniques with 4 to 6 weeks of postoperative DIPJ immobilization. Patients were evaluated for active and passive DIPJ motion, deformity, pain, limitations in activities of daily living, and the need for additional treatment. Average age at the time of surgery was 7.4 years (range, 1.4-17.8 years). At average 6.5-year follow-up (range, 1-12.8 years), all patients demonstrated restoration of active DIPJ extension and improvements in extensor lag. Two patients (20%) achieved full active DIPJ extension, whereas 8 patients (80%) had persistent extensor lag of 20 degrees or less. Seven patients (70%) maintained full active DIPJ flexion. Eight (80%) of the 10 patients reported full return to activities with no limitations. No patients required additional surgical treatment for their mallet fingers. Tenodermodesis is a safe and effective technique for the treatment of severe chronic soft-tissue mallet finger deformities in children. Although patients and families should be advised of mild persistent extensor lag and limitations in DIPJ motion, active DIPJ extension and improved clinical appearance can be achieved with this procedure.

Tenodermodesis for Chronic Mallet Finger Deformities in Children

The treatment of chronic mallet finger deformities in children can be challenging. Previously proposed for the treatment of chronic mallet fingers in adults, tenodermodesis is a reconstructive procedure that may also be applied to the pediatric population. The technique of tenodermodesis for chronic mallet finger injuries in children is presented here, featuring careful repair of the extensor mechanism and temporary transarticular Kirschner wire fixation of the distal interphalangeal joint. Preliminary clinical results with this procedure have been encouraging, with high patient/parent satisfaction and few complications. Most importantly, tenodermodesis allows anatomical reconstruction of the injured extensor mechanism while preserving skeletal growth and distal interphalangeal joint motion in children and adolescents.

Evidence Basis for Management of Spine and Chest Wall Deformities in Children

: Review of relevant studies, including levels of evidence. : To review research on growth of the spine and chest wall and treatment of deformities. To place this knowledge in context of evidence-based assessment. : Knowledge of the growth of the spine, chest wall, and lung in the normal and deformity states has evolved among independent specialties over the past 60 years. Interest in the interrelationship has blossomed as more tools for assessment and treatment have developed. Spine-based and chest wall-based treatment options now exist, as well as options of resection versus gradual distraction. : Peer-reviewed research published on the growth of the spine, lung, chest wall, and treatment of their deformities was reviewed. Treatment methods and outcomes were compared. Ranking of the levels of evidence was performed where possible. : Most studies of these topics are Level III and IV studies, consisting of case-control studies and case series. This limitation arises because of the rarity and heterogeneity of the disorders affecting the growing spine and chest wall. The natural history of most types of spinal/chest wall deformities is not known with accuracy. Some experimental evidence informs the treatments which involve modulation of the growth of the spine. However, accurate models of the deformities themselves are lacking. Improvements in imaging and measurement offer options for more accurate patient comparison. : The natural history and results of treatment of deformities of the spine and chest wall offer much opportunity for further evidence-based research.

Isolated Cochlear Nerve Hypoplasia with Various Internal Auditory Meatus Deformities in Children

We report neuro-otological findings in isolated congenital cochlear nerve hypoplasia with various bony deformities and evaluate relationships between functional impairment and the radiologic dimensions of the internal auditory meatus (IAM). We performed imaging and functional analyses on consecutive juvenile or adolescent patients between 2001 and 2005 with "isolated" unilateral hypoplasia of the cochlear nerve, without inner ear anomaly or other deformities. Among 20 patients with unilateral profound deafness who underwent imaging studies, 10 (50%) passed the inclusion criteria. In all affected ears, auditory brain stem responses were absent and the speech discrimination score was very poor (0% to 5%). Distortion product otoacoustic emissions were good in 2 ears, fair in 1 ear, and poor in 7 ears. Caloric responses were absent in 2 ears, reduced in 3 ears, and normal in 5 ears. Inferior vestibular nerve function and facial nerve function were normal in all ears. Distortion product otoacoustic emissions and caloric responses tended to be better in ears with less severe narrowing of the IAM. The risk of co-involvement of the inner ear and superior vestibular nerve functions is higher in the presence of a narrower bony IAM. Cochlear nerve hypoplasia is proposed as one of the most important causes of juvenile unilateral deafness because of its unexpectedly high incidence.

Correlation of Body Mass Index and Radiographic Deformities in Children with Blount Disease

Background: Children with Blount disease tend to be heavier than their peers; however, the relationship between the magnitude of obesity and the severity of limb deformities in Blount disease has not been well studied. Methods: A retrospective review of the preoperative medical records and radiographs of patients with previously untreated Blount disease was conducted. Demographic information including gender, ethnicity, the age when deformity was first noted, the age at the examination, and the body mass index was recorded. Frontal and sagittal plane deformities were analyzed by one examiner using full-length standing radiographs. The association of body mass index with various demographic and deformity parameters was then analyzed. Results: Over an eight-year period, forty-five patients with sixty-five limbs affected by Blount disease were identified. Seventeen children (twenty-seven limbs) had early-onset Blount disease, and twenty-eight children (thirty-eight limbs) had late-onset disease. Fifteen of the children with early-onset disease and twenty-six of those with late-onset disease were overweight. There was no significant relationship between body mass index and gender, ethnicity, or laterality. The children with early-onset disease tended to have a lower body mass index but a greater magnitude of radiographic deformities compared with the children with late-onset disease. Greater varus malalignment (r = 0.74, p < 0.0001) and tibial procurvatum (r = -0.79, p = 0.002) were noted with an increasing body mass index in the early-onset, but not the late-onset, group of patients. Irrespective of the age at onset, the correlation of body mass index with frontal and sagittal plane deformities was stronger in extremely obese children (body mass index of ≥40). Conclusions: There is a significant relationship between the magnitude of obesity and biplanar radiographic deformities in children with the early-onset form of Blount disease and in those with a body mass index of ≥40. These clinical findings are consistent with the literature concerning the effect of compressive forces on growth at the proximal tibial physis. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Correlation of Body Mass Index and Radiographic Deformities in Children with Blount Disease

Children with Blount disease tend to be heavier than their peers; however, the relationship between the magnitude of obesity and the severity of limb deformities in Blount disease has not been well studied. A retrospective review of the preoperative medical records and radiographs of patients with previously untreated Blount disease was conducted. Demographic information including gender, ethnicity, the age when deformity was first noted, the age at the examination, and the body mass index was recorded. Frontal and sagittal plane deformities were analyzed by one examiner using full-length standing radiographs. The association of body mass index with various demographic and deformity parameters was then analyzed. Over an eight-year period, forty-five patients with sixty-five limbs affected by Blount disease were identified. Seventeen children (twenty-seven limbs) had early-onset Blount disease, and twenty-eight children (thirty-eight limbs) had late-onset disease. Fifteen of the children with early-onset disease and twenty-six of those with late-onset disease were overweight. There was no significant relationship between body mass index and gender, ethnicity, or laterality. The children with early-onset disease tended to have a lower body mass index but a greater magnitude of radiographic deformities compared with the children with late-onset disease. Greater varus malalignment (r = 0.74, p < 0.0001) and tibial procurvatum (r = -0.79, p = 0.002) were noted with an increasing body mass index in the early-onset, but not the late-onset, group of patients. Irrespective of the age at onset, the correlation of body mass index with frontal and sagittal plane deformities was stronger in extremely obese children (body mass index of > or =40). There is a significant relationship between the magnitude of obesity and biplanar radiographic deformities in children with the early-onset form of Blount disease and in those with a body mass index of > or =40. These clinical findings are consistent with the literature concerning the effect of compressive forces on growth at the proximal tibial physis. Prognostic Level II.

Recurrence Rates of Burn Contracture Ankle Equinus and Other Foot Deformities in Children Treated With Ilizarov Fixation

Recurrence Rates of Burn Contracture Ankle Equinus and Other Foot Deformities in Children Treated With Ilizarov Fixation

Recurrence Rates of Burn Contracture Ankle Equinus and Other Foot Deformities in Children Treated with Ilizarov Fixation

The purpose of this study was to determine recurrence rates of pediatric foot and ankle burn deformities treated with the Ilizarov method. A total of 19 patients with 29 foot and ankle deformities were studied. The most common deformity treated was equinus (23). Rocker-bottom and cavus foot deformities were each treated three times. The average age of the patient at the time of the burn injury was 3.2 years, and the average age at the time of fixation was 9.4 years. Equinus contractures averaged -34 degrees (34 degrees of plantarflexion) before surgery and +7 degrees (7 degrees of dorsiflexion) after treatment with the Ilizarov fixator. The recurrence rate for all 29 ankles and feet was 69% (20/29). The recurrence rate for equinus contractures was 74% (17/23). The average time to recurrence was 17.3 months. Only short-term follow-up was available on four of the six feet and ankles that did not recur. Deformity correction in burned feet and ankles is difficult to obtain by any means. The authors recommend using the Ilizarov method to obtain correction of moderate to severe foot and ankle deformities in pediatric burn patients, but the correction obtained is not stable and deformity will likely recur. Parents and patients should anticipate adjunctive nonoperative and operative procedures to keep their feet plantigrade as they grow. In young children, the possibility of having additional surgeries, including repeat Ilizarov procedures, should be discussed. Even older children should expect additional surgeries to prevent recurrent deformities.

Cerebral Palsy: Classification, Etiology and Evolution of Spine Deformity in Children and Adolescents

Cerebral palsy (CP) is a static encephalopathy affecting the immature brain and leading into a permanent motor disability. There is a spectrum of causative factors, which may be congenital in origin, or can be related to incidences occurring in the perinatal or postnatal period. The development of spine deformity constitutes a common orthopaedic problem with an increased incidence in children with spasticity. The prevalence of spine deformity is directly proportionate to the degree of neurological impairment, and inversely proportionate to the ambulatory capacity. Scoliosis in this group of severely disabled children decreases their sitting tolerance, causes pain from impingement of their pelvis against the rib cage on the concavity of scoliosis, and creates cardiopulmonary complications. Patients with walking function gradually lose their ability to ambulate and become wheelchair-dependent. Spinal arthrodesis is indicated in children with progressive curve size and rigidity, which interferes with their level of function. Spine surgery in patients with severe neurological compromise and complex medical problems is associated with technical difficulties and an increased risk of life-threatening complications. However, there is a documented positive impact on these children by correcting the deformity and maintaining a good coronal and sagittal spinal balance. Spinal fusion is the only surgical procedure that has such a high satisfaction rate among parents and caregivers, especially for quadriplegics. With improved medical management, life expectancy for this group is higher than previously reported and operative procedures to correct the spine have a definitive effect in improving the patients` quality of life. The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

Foot Deformities in Children With Hereditary Motor and Sensory Neuropathy

The authors reviewed 104 feet from 52 consecutive children with hereditary motor and sensory neuropathy (HMSN) seen for the first time in clinics in two pediatric institutions between 1996 and 2003. Sixty-nine feet had a cavovarus deformity, 23 feet had a planovalgus deformity, and 12 feet had no significant deformity. All cases with deformity had bilateral involvement, and of those with deformity, only 45% had symmetric involvement. In HMSN I, III, IV, V, and X-linked HMSN, cavovarus was the most common deformity. However, in HMSN II, 55% of feet had a planovalgus deformity, 36% had a cavovarus deformity, and 9% had no deformity. In all, 43 feet underwent surgery of some type. Surgery, and in particularly combined bony and soft tissue procedures, was performed much more frequently on feet with cavovarus than planovalgus deformities. Soft tissue surgery alone was performed at an earlier age than combined bony and soft tissue surgery.

Glenohumeral deformity in children with internal rotation contractures secondary to brachial plexus birth palsy: intraoperative arthrographic classification.

To evaluate, with intraoperative arthrography, joint morphology in children undergoing surgical treatment of residual paralysis of the shoulder resulting in brachial plexus birth palsy and to correlate the morphology with the degree of passive external rotation. In 64 children (age range, 7 months to 13 years 6 months), an orthopedic surgeon performed intraoperative arthrography and measured passive external rotation while the patient received a general anesthetic. The orthopedic surgeon and three radiologists reviewed arthrograms and in consensus classified glenohumeral joints in one of four categories: concentric, with the humeral head well centered on the glenoid fossa; flat, with flattening of the posterior glenoid; biconcave, with the humeral head in articulation with the posterior of two concavities, which were in the same plane; and pseudoglenoid, with the humeral head in articulation with the more posterior of two concavities, with retroversion and in a plane different from that of the anterior concavity. Kruskal-Wallis test was used to compare preoperative external rotation with four appearances of glenoid. Twenty-one children had concentric glenohumeral joints; seven children, flat glenohumeral joints; 19 children, biconcave glenoid; and 17 children, pseudoglenoid. Median passive external rotation was -20 degrees for patients with pseudoglenoid, -10 degrees for those with flat or biconcave glenoids, and 0 degrees for those with concentric glenoids. Presence and type of glenoid deformity were significantly associated with severity of internal rotation contracture (P <.001). Consistent patterns of glenohumeral joint deformity in brachial plexus birth palsy were identified and correlated with severity of internal rotation contracture.

Use of the Ilizarov method to correct lower limb deformities in children and adolescents.

The introduction to the West in the early 1980s of the Ilizarov circular external fixator and method resulted in rapid advances in limb lengthening, deformity correction, and segmental long-bone defect reconstruction. The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov's contribution. The most common indications for children and adolescents are limb lengthening and angular deformity correction. Surgical application and postoperative management of the device require diligent attention to detail by both patient and surgeon. Also required of the surgeon is a thorough appreciation of the basic principles of the apparatus, mechanical axial realignment, potential complications, and biologic response to stretching.

Effect of Pamidronate Treatment on Vertebral Deformity in Children with Primary Osteoporosis

Objective: Bisphosphonates are effectively used in treatment for primary osteoporosis in children. In the present study, we quantitatively evaluated the effect of pamidronate treatment on lumbar vertebrae in children with primary osteoporosis using radiographic morphometry. Methods: Paired lateral radiographs of the lumbar spine were obtained before and after pamidronate treatment in 5 children with primary osteoporosis. To characterize vertebral deformities, specific morphometrical ratios were calculated for vertebral bodies L1–L4. Results: Significant reshape of lumbar vertebrae was observed: the concavity index (middle-anterior ratio) decreased from 55 to 36% (p = 0.006), and the anterior-posterior ratio (used as a surrogate of wedge deformity) decreased from 25 to 11% (p = 0.001). Conclusions: Pamidronate treatment significantly influences the restoration of vertebral fractures in children with primary osteoporosis. The present study demonstrates that radiographic morphometry is a suitable tool for quantitative assessment of the vertebral deformities in childhood.

Cavus foot deformity in children.

A cavus deformity of the foot is easily recognizable, but appropriate neurologic assessment can help to determine the etiology. Cavovarus, the most frequent type of cavus foot, presents with an elevated medial longitudinal arch, first ray plantarflexion, and, if rigid, a fixed heel varus. Common causes include progressive motor sensory conditions, typically Charcot-Marie-Tooth disease, and nonprogressive conditions such as cerebral palsy and poliomyelitis. A calcaneocavus foot may be seen in poliomyelitis, spinal dysraphism, and peripheral neuropathy. Initially, the cavus deformity is flexible, but if left untreated, it becomes a fixed bony deformity. Physical examination should include the cavovarus block test, which assesses flexibility of the hindfoot deformity and can direct surgical treatment. Standing radiographs of the feet and spine, magnetic resonance imaging, and electrodiagnostic studies may be useful. Management goals are to obtain a plantigrade, mobile, pain-free, stable, motor-balanced foot. Surgical options include soft-tissue and plantar fascia releases for a flexible deformity, osteotomy for a fixed deformity, and tendon transfers to restore muscle balance. Triple arthrodesis has poor long-term results in patients with progressive deformity and sensory impairment.

Variability of Radiographic Measurements of Bowleg deformity in Children: A new method for Metaphyseal Diaphyseal Angle (MDA)

Purpose : We investigate a new measurement method for bowleg deformity in children to reduce intra-observer and inter-observer error and to assess change in the angles measured with respect to the rotation of the lower leg. Material and Method: Fifty-one children younger than 3 years old with bow leg were analyzed. To assess the intra-observer and interobserver error of the Metaphyseal-Diaphyseal Angle, Intermetaphyseal-metaphyseal angle and Tibio-Femoral angle measurements, supine view antero-posterior radiographs of the lower legs were taken at the neutral rotation, at and at internal rotation positions. Also, the effect of the rotation of lower legs upon the measured angle was assessed by comparing and analyzing the angle values with respect to rotations of the lower leg. esults : TInter-observer error showed statistically significant difference (p

Long-Term Follow-up of Surgery for Equinovarus Foot Deformity in Children With Cerebral Palsy

The factors associated with failed operative intervention in the treatment of equinovarus foot deformity in children with cerebral palsy (CP) were evaluated after long-term follow-up. One hundred eight children with CP who had surgery on the posterior tibialis tendon (split tendon transfer, intramuscular lengthening, or Z-lengthening) on 140 feet were reviewed at a mean age of 16.8 years with 7.3 years of follow-up. The surgery was considered a failure when a 10 degrees or greater varus or valgus hindfoot deformity was present or if an additional operative intervention was required or planned. Involvement of CP, age at operation, and preoperative status of ambulation were significant factors in the outcome of the surgery. Hemiplegic patients demonstrated the best results, regardless of age or surgical procedure. Seventy-five percent of diplegic and quadriplegic patients who were younger than 8 years or who were not capable of community ambulation failed operative intervention, and surgery on the posterior tibialis tendon is not recommended in this group of patients.