Lower Limbs In Children Research Articles

Angular Deformities of the Lower Limb in Children

Angular deformities of the lower limbs are common during childhood. In most cases this represents a variation in the normal growth pattern and is an entirely benign condition. Presence of symmetrical deformities and absence of symptoms, joint stiffness, systemic disorders or syndromes indicates a benign condition with excellent long-term outcome. In contrast, deformities which are asymmetrical and associated with pain, joint stiffness, systemic disorders or syndromes may indicate a serious underlying cause and require treatment.Little is known about the relationship between sport participation and body adaptations during growth. Intense soccer participation increases the degree of genu varum in males from the age of 16. Since, according to some investigations, genu varum predisposes individuals to more injuries, efforts to reduce the development of genu varum in soccer players are warranted. In this article major topics of angular deformities of the knees in pediatric population are practically reviewed.

An unusual cause of paralysis of the peroneal nerve—a case report

A 12-year-old boy was referred to our clinic because of progressive paresis of left peroneal nerve. Ultrasound showed a cystic mass close to the proximity of the fibula neck. Puncture revealed jelly-like fluid, but that could not relieve symptoms. Six weeks after onset of symptoms, the boy had complete paresis. Peroneal intraneural ganglia are a rare entity of paralysis of the lower limb in children; more often these symptoms occur because of exostosis. Surgical exploration showed a cystic formation involving the common peroneal nerve. Total recovery of nerve function was seen two years later. Patients with exostosis showed varying outcomes. In children with symptoms suspicious of nerve compression, fast diagnosis and immediate treatment are mandatory to regain best possible recovery.

Clinical observation on treatment of spastic cerebral palsy with tuina plus music therapy

Objective To observe the effect of tuina plus music therapy on range of motion of ankle joints and muscle spasm of lower limbs in children with spastic cerebral palsy.

Comparative multibody dynamics analysis of falls from playground climbing frames

This paper shows the utility of multibody dynamics in evaluating changes in injury related parameters of the head and lower limbs of children following falls from playground climbing frames. A particular fall case was used as a starting point to analyze the influence of surface properties, posture of the body at impact, and intermediate collisions against the climbing frame before impacting the ground. Simulations were made using the 6-year-old pedestrian MADYMO rigid body model and scaled head contact characteristics. Energy absorbing surfaces were shown to reduce injury severity parameters by up to 30–80% of those of rigid surfaces, depending on impact posture and surface. Collisions against components of a climbing frame during a fall can increase injury severity of the final impact of the head with the ground by more than 90%. Negligible changes are associated with lower limb injury risks when different surfacing materials are used. Computer reconstructions of actual falls that are intended to quantify the severity of physical injuries rely on accurate knowledge of initial conditions prior to falling, intermediate kinematics of the fall and the orientation of the body when it impacts against the ground. Multibody modelling proved to be a valuable tool to analyze the quality of eyewitness information and analyze the relative injury risk associated with changes in components influencing fall injuries from playground climbing frames. Such simulations can also support forensic investigations by evaluating alternative hypotheses for the sequence of kinematic motion of falls which result in known injuries.

Botulinum Toxin Type A Injection in Alleviating Postoperative Pain and Improving Quality of Life in Lower Extremity Limb Lengthening and Deformity Correction: A Pilot Study

The Ilizarov technique is commonly used for lengthening and deformity corrections of the lower limbs in children. Postoperative pain can be significant, affecting quality of life and functional mobility, and often requiring prolonged medication use. Several studies have investigated the antinociceptive actions of botulinum toxin type A (BtX-A), yet evidence for its use in this population is limited. The objectives were to (1) establish the feasibility of a randomized clinical trial in children undergoing limb lengthening or deformity correction and (2) provide preliminary evidence of the beneficial effects of BtX-A in this population. Fifty-two patients with a mean age of 13.7 years (range, 5 to 21 y) were randomized to receive either BtX-A or an equivalent volume of sterile saline solution (placebo group), as a single dose during the surgical procedure. Pain, medication use, quality of life, and functional mobility outcomes were assessed in all patients. Adverse events were reported for all patients and classified as minor or major. Differences between groups did not reach statistical significance; however, pain at mid-distraction was found to be slightly lower in the BtX-A group, as compared with the placebo group. Patients in the BtX-A group used less parenteral pain medication in the first 4 days after the surgery, had higher quality of life scores at 3 of the 5 time points assessed, and slightly higher functional mobility scores. All adverse events were expected complications of the lengthening process. No event was considered to be a serious adverse event related to the BtX-A injection itself. There was a trend toward fewer major adverse events in the BtX-A group. This pilot study established the feasibility of a randomized controlled trial design for in this population. Its findings indicate that BtX-A injections appear to be safe and effective for reducing pain and improving the quality of life and functional mobility of children undergoing lengthening or deformity corrections of the lower limbs. A larger-scale study is currently underway to confirm these preliminary findings.

Evaluation of the effectiveness of botulinum toxin injections in the lower limb muscles of children with cerebral palsy. Preliminary prospective study of the advantages of ultrasound guidance

Objective The aim of this study was to evaluate the effectiveness of injecting botulinum toxin A into the lower limbs of children with cerebral palsy, according to age, dose, dilution, injection site and needle placement technique (manual or ultrasound guidance). Materials and methods Any child with cerebral palsy examined between May 2005 and May 2006 who needed botulinum toxin A injections in the adductor, hamstring, gastrocnemius and/or soleus muscles could be included. Fifty-four (54) children participated in the study, 30 of whom were injected under ultrasound guidance. The pre- and post- toxin evaluations were done through analytical clinical examination and the Gross Motor Function Measure (GMFM-88). Results We found an overall clinical effectiveness for 51% of the children. This effectiveness was significantly higher for children under 6 years old or over 12, especially when the doses were greater than 0.8 UI/kg per muscle of Botox ®, when the injected muscles were hamstrings or gastrocnemius, and when the injections were guided by ultrasound. Dilution had no effect on clinical effectiveness. Function after one month was better for 24% of the children. This functional improvement was significantly better for children under 6 years old with the injections under ultrasound control. Conclusions This study confirms that the effectiveness of botulinum toxin injections is higher in younger children, with injected doses higher than 0.8 UI/kg per muscle of Botox ® and injections guided by ultrasound.

Correlation Between Lower Limb Bone Morphology and Gait Characteristics in Children With Spastic Diplegic Cerebral Palsy

Children with spastic diplegic cerebral palsy (CP) exhibit abnormal walking patterns and frequently develop lower limb, long bone deformities. It is important to determine if any relationship exists between bone morphology and movement of the lower limbs in children with CP. This is necessary to explain and possibly prevent the development of these deformities. This study investigated the relationship between bone morphology and gait characteristics in 10 healthy children (age range, 6-13 years; mean, 8 years 7 months; SD, +/-2 years 7 months) and 9 children with spastic diplegic CP (age range, 6-12 years; mean, 9 years 2.5 months; SD, +/-1 year 10.5 months) with no previous surgery. Three-dimensional magnetic resonance images were analyzed to define bone morphology. Morphological characteristics, such as the bicondylar angle, neck-shaft angle, anteversion angle, and tibial torsion, were measured. Gait analyses were performed to obtain kinematic characteristics of CP and normal children's gait. Principal component analysis was used to reduce the dimensionality of 27 parameters (26 kinematics variables and age of the children) to 8 independent variables. Correlations between gait and bone morphology were determined for both groups of children. Results indicated that in healthy children, hip adduction was correlated with neck-shaft and bicondylar angles. In CP children, pelvic obliquity correlated with neck-shaft angle, and foot rotation with bicondylar angle. In the transverse plane, hip and pelvic rotational kinematics were related to femoral anteversion in healthy children and to tibial torsion in CP children. Different development was observed in femoral and tibial morphology between CP and healthy children. The relationship between bone shape and dynamic gait patterns also varied between these populations. This needs to be taken into account, particularly when surgical treatment is planned. Understanding the relationship between gait abnormality and bone deformity could eventually help in developing treatment regimens that will address gait deviations at the correct level and promote normal bone growth in children with CP.

Modified Sofield-Millar operation: less invasive surgery of lower limbs in osteogenesis imperfecta

We present the results of intramedullary rodding of long bones of the lower limbs in children with osteogenesis imperfecta using a modified Sofield-Millar operation. Fourteen patients (mean age at primary operation was 5 years 11 months) were treated with a modified Sofield-Millar operation which allows minimal bone exposure, preservation of the periosteum and keeping the number of osteotomies to the minimum. Union was achieved in all cases within 7 weeks. Of the 14 patients (29 bones) treated with nonelongating rods, rod revisions were needed in 13 patients (26 bones). We found no statistically significant difference between the width of the bone immediately postoperatively and at the final follow-up. The walking ability was improved in four patients. Advantages of less invasive surgery in osteogenesis imperfecta are rapid bone union, no bone atrophy or nonunion, better postoperative mobility and small scars.

Complex vascular injuries of lower limbs in children

Background: Pediatric vascular trauma is rare and there is scarcity of data available to direct optimal care of these patients. Even rarer are reports of long term venous function after complex vascular repairs of lower extremities. Purpose of article is to evaluate the long term arterial and venous function after complex vascular repairs with interposition vein graft, vein by-pass graft or modified veno-venous saphenous vein by-pass graft. A prospective cohort study of children with combined lower extremity vessel injuries (arterial and venous) treated during 10-year period (1995–2005). All patients were followed up in regular six months intervals by color flow duplex ultrasound imaging. Six months after injury radioisotopic phlebography was performed. In selected cases arteriography was performed and isotopic phlebography repeated. Patients: Seventeen patients (range 3–16 years, 15 male) were followed up (range 6 months – 10 years) after complex trauma of lower extremities (traffic-related injuries 15 cases, farming machines-related injuries 2 cases). By all patients there were associated injury of bone structures and other associated injuries. There were 10 patients with extensive laceration of superficial femoral artery and vein. Both vessels were reconstructed with an interposition vein graft (great saphenous vein). There were 7 patients with extensive popliteal artery and vein laceration and associated injuries to crural vessels. Vessels were reconstructed (arterial part) with reversed vein by-passes (three cases of additional popliteo-pedal bypass) and with veno-venous saphenous vein by-passes (venous part) with H interponat. Results: All repairs were patent, with no evidence of deep venous thrombosis. There were no signs of chronic venous insufficiency. By three patients with veno-venous by-pass varicose veins developed. There were no disturbances in limb growth. Conclusions: Long term patency of venous repair in presented group of patients is excellent. Complex venous were repairs in this particular group in majority of patients not associated with functional changes consistent with chronic venous insufficiency.

Use of videographic examination for analysis of efficacy of botulinum toxin in the lower limbs in children with cerebral palsy

The objective of this study was to test the interobserver and intraobserver reproducibility of videographic gait analysis in paediatric cerebral palsy patients following botulinum toxin type-A injections. Standardized videos according to gait-specific functional criteria were assessed for 1 h. For intraobserver reproducibility, 13 of 17 items showed good/moderate correlation, one mediocre and three poor correlation. For interobserver reproducibility, 12 of 17 items showed excellent, good or moderate agreement, five items showed poor agreement. Overall, 9 of 17 items showed good intraobserver or interobserver reproducibility. Mean interobserver scores for sagittal plane items were slightly lower than mean intraobserver scores (kappa=0.509 and 0.536, respectively). In conclusion, video analysis of children with cerebral palsy based on functional criteria is useful.

The aetiology of angular deformities of the lower limb in children in Malawi: a review of 35 patients

The aetiology of 35 Malawian children with angular deformities of the lower limb, including 18 with varus,13 with valgus and four with windswept deformities, was assessed prior to surgical correction by proximal tibial or distal femoral osteotomies. Among the varus limbs, the aetiologies were ligamentous laxity of the knee (7), lesions of the medial tibial metaphysis (3), bowing of the femora and tibiae (3), and there were two girls with the end stage of Blount's disease. Among the valgus patients, eight had extremes of physiological knock knee and five had valgus bowing of the femora or tibiae.

Passive and dynamic rotation of the lower limbs in children with diplegic cerebral palsy

Rotation characteristics in gait and passive rotation of the lower limbs were evaluated retrospectively in 105 patients with diplegic cerebral palsy (65 males, 40 females; mean age 13y [SD 6y 9mo]; range 4y 4mo-40y 5mo). Of 105 patients, 22 (20.9%) required crutches, sticks, tripods, or a K-walker for their daily ambulation. Twelve (11.5%) patients used a wheelchair or buggy for community distances, e.g. shopping. Significant differences in rotational characteristics were found at the pelvis, hip, knee, and foot between left and right legs. Patients who were more affected on the right (group R, n=33) or the left side (group L, n=39) were re-evaluated. There was also a group of patients who were not asymmetrically affected (group S, n=33). In group L, maximum passive internal rotation was significantly greater on the left side, while no difference between the sides was found in group R. Peak internal rotation in gait was significantly higher on the right side in group R, but did not differ significantly between the sides in group L. Right hindfoot-thigh angle and transmalleolar axis were more external on the right, irrespective of which leg was more affected. These findings may have implications for the early non-operative management of limb posture in infants with diplegia and the surgical management of established lower extremity malrotation.

Physiologic parameters that affect pulse transit time difference between the upper and lower limbs in children

Pulse wave velocity (PWV) is a known parameter that is related to arterial distensibility. However, its potential is hampered by the absence of appropriate techniques to estimate it noninvasively. PWV can be used as an assessment of increased arterial stiffness that is linked to systolic hypertension, excess cardiovascular morbidity and mortality.(1,2)

Factors Predicting the Efficacy of Botulinum Toxin-A Treatment of the Lower Limb in Children With Cerebral Palsy

Botulinum toxin A is widely used for spasticity management in children with cerebral palsy, although outcomes are unpredictable. The aim of this study was to identify criteria for selecting patients most likely to benefit from botulinum toxin A treatment. Fifty-five subjects, aged 2.5 to 18 years, were recruited. The assessment covered measures of spasticity (Modified Ashworth Scale), function (using the Gross Motor Function Measure and the Physician's Rating Scale), selective motor control, static range of motion at the ankle with knee extended and flexed, range of motion of the knee flexors, central and peripheral vision, and cognitive ability. Outcomes at 3 months were compared with baseline values. All of the scales showed significant differences between pre- and postinjection values. Significantly increased Gross Motor Function Measure scores were found in children aged 48 months or under and in those able to walk with support. Greater improvements in selective motor control and Physician's Rating Scale were seen in those with a less severe pattern of paralysis, lower levels of impairment, the ability to walk (with or without support), normal visual acuity, and normal or borderline cognition. We identified factors that mark out patients as most likely to achieve functional gains: young age, hemiplegia or diplegia, slight to moderate disability, walking with support, normal or borderline cognition, and normal or borderline visual acuity.

Efficacy of bracing the lower limbs and ambulation training in children with myelomeningocele

Orthotics and physical therapy are offered to children with myelomeningocele, often without objective evidence of efficacy. Bracing of the lower limbs in children with myelomeningocele can be categorized into three groups based on the degree and extent of muscle weakness. Children with lesions at the thoracic and upper-lumbar level lack strength in hip extensors, hip abductors, knee flexors, knee extensors, ankle plantarflexors, and ankle dorsiflexors. They require the support of an orthosis such as a parapodium (standing frame), parawalker, reciprocating gait orthosis, or hip-knee-ankle-foot orthosis. Children with a low-lumbar level of paralysis lack strength in hip extensors, ankle plantarflexors, and ankle dorsiflexors and may need a solid ankle–foot orthosis to stabilize the ankle and assist knee extension in the stance phase of gait. Children with lesions at the sacral level either need no bracing or may need a foot orthosis to compensate for weak intrinsic foot muscles.

Limb lengthening and correction of deformity in the lower limbs of children with osteogenesis imperfecta

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI.

Botulin Toxin A-Treatment of Spastic Cerebral Palsy

Aim: To determine the effectiveness of botulin toxin A- (BTXA) treatment of spasticity in lower limbs of children with cerebral palsy (CP), and compare results with the traditional treatment. Patients and Methods: Study sample: 12 patients per group. Selection criteria: ambulatory patients of both sexes (age range, 2–8 yrs), with spastic diparetic or hemiparetic CP diagnosis, increased myostatic reflex and improved motor prepositioning and positioning of the feet, 1+ and 3 scores (modified Ashworth Scale) in the muscle groups under study (gemellus, 10 patients, and internal rectus, 1 patient). Design: Randomized clinical trial. Treatment: Patients received 5 U/kg BTXA injections per muscle (maximum dose: 400 U) at the beginning of the study and 16 weeks later. The informed consent of the patients was required in all instances. Variables evaluated: Functional improved prepositiong and positioning of the feet, evaluated by the modified Ashworth Scale, joint range of motion, active foot dorsiflexion, ambulation speed, step length and size, motor function (GMFM test), percentage of foot support, myostatic reflex and parents′ opinion. Results: Results from 17 patients (11 treated and 6 controls) who completed the study period are presented, age-range 2.25 – 7.33 yrs (x= 4.5 yrs). Ten cases corresponded to diparesis and 7 to hemiparesis. Follow-up: 32 weeks. The injection of gemellus resulted in improved Asworth scale scores (1 score), increased passive mobility (especially in quick movements) and increased plantar support. The myostatic reflex changed from 16.7 (95% CI, 8–25) at the beginning to –8 ( 95% CI, -26 – -10) 32 weeks later (p=0.002). There were no significant changes in the patient who received BTXA in the internal rectus. Parents from patients of the intervention group valued the marked (9 patients) and moderate (1 patient) improvements obtained. Conclusion: The use of BTXA is as effective as the traditional treatment for dynamic equinus gait. The results obtained in this long-term clinical randomized trial are promising but not conclusive, especially with reference to functional assessments.

Functional outcome of botulinum toxin A injections to the lower limbs in cerebral palsy

We evaluated gross motor function following botulinum toxin A (BTX‐A) injections in the lower limbs of children with spastic cerebral palsy in a randomized clinical trial, using a cross‐over design. Forty‐nine children (24 males, 25 females, age range 22 to 80 months) were randomly allocated to two groups: group 1 received BTX‐A and physiotherapy, and group 2 received physiotherapy alone for 6 months. At the end of this period, group 2 received BTX‐A and physiotherapy and group 1 continued with physiotherapy alone. Assessment measures were the Gross Motor Function Measure (GMFM), the Vulpe Assessment Battery (VAB), joint range of movement, the Modified Ashworth Scale, and a parental questionnaire. Sustained gains in gross motor function were found in both groups of children but the only additional benefit found in group 1 was a significant increase in fine motor rating on the VAB. By contrast, parents rated the benefit of treatment highly. It is likely that assessment at 3 and 6 months post injection was too late to demonstrate peak gross motor function response and that changes in GMFM are not sustained over 6 months with a single dose. Further studies should investigate changes over shorter time periods and consider covariables such as BTX‐A dosage, number of injection sites, and the role of repeated injections combined with other interventions such as casting.

Current evidence for the use of botulinum toxin type A in the management of children with cerebral palsy: a systematic review.

Management of children with cerebral palsy (CP) is the focus of considerable resources in many countries, so that evaluation of the efficacy for new and established treatments is imperative. Botulinum toxin type A (BTX-A) is a relatively new method of spasticity management in children with cerebral palsy. It has been the focus of extensive research since its application to cerebral palsy 10 years ago. In a systematic review relating to the management of the lower limb in cerebral palsy 156 papers were identified. These were categorized according to Sackett and the World Health Organisation International Classification of Impairments, Disabilities and Handicaps model. We identified 10 randomized trials evaluating the use of BTX-A in the lower limb in children with cerebral palsy in a systematic review. A meta-analysis showed the pooled risk difference between BTX-A and placebo in three trials was 0.25 (95% CI 0.13, 0.37) and 0.23 (95% CI -0.06, 0.53) for two trials of BTX-A and casting using the physicians rating scale. These represent moderate treatment effects that are dosage-dependent. Outcomes were also compared for function in five studies. The type of evidence for BTX-A was graded by each treatment indication and directions for future research were then drawn from the available evidence.

Growth prediction in extendable tumor prostheses in children.

Limb salvage procedures for malignant bone tumors of the lower limb in children usualy involve resection of at least one growing physis. To achieve equal leg length, reconstruction relies on accurate prediction of the remaining growth potential of the child. The current authors present the results of predicted growth versus actual prosthetic elongation observed in a group of 15 children fitted with extendable tumor endoprostheses of the lower limb who subsequently have reached skeletal maturity. All patients had at least one of the distal femoral or proximal tibial physes resected for a primary malignant bone tumor. Eight patients underwent distal femoral resection, four patients underwent proximal tibial resection, and three patients had total resection of the femur. All patients received custom-made Howmedica extendable prostheses. In two patients, a newly developed automatic elongation module was used. At followup, between 70 and 158 months, the patients achieved a mean elongation of the surgically treated limb of 10.4 cm (range, 1.1-19.5 cm), which exceeded the predicted growth by 24.3%. Final leg length discrepancies did not exceed 1 cm. Using incremental extendable tumor endoprostheses, individual adaptation of the elongation procedures could be achieved for equalization of leg length discrepancies in children after resection of primary malignant bone tumors of the lower limb.