Search

Purpose: The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method. Methods: The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results: Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade. Conclusion: This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the kinematics/kinetics of the ankle, knee, hip in the sagittal plane in adolescents with recurrent patellar dislocation in comparison to a healthy control. Methods: Case–control study. Eighty-eight knees (67 patients) with recurrent patellar dislocation (mean age 14.8 years ± 2.8 SD) were compared to 54 healthy knees (27 individuals, 14.9 years ± 2.4 SD). Kinematics/kinetics of ankle, knee, hip, and pelvis were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates). One cycle (100%) consisted of 51 data-points. The mean of six trials was computed. Results: The loading-response increased by 0.02 s ± 0.01SE (10.8%) with dislocations (0.98% of total gait, P < 0.01). The mid-stance-phase decreased equally (P < 0.01). Dislocation decreased knee flexion during the entire gait cycle (P < 0.01), with the largest difference during mid-stance (9.0° ± 7.2 SD vs. 18.5° ± 6.7 SD). Dislocation increased plantar-flexion during loading response 4.1° ± 0.4 SE with (P < 0.01), afterward, the dorsal-extension decreased 3.2° ± 0.3 SE, (P < 0.01). Dislocation decreased hip flexion during all phases (P < 0.01). Maximal difference: 7.5° ± 0.5 SE during mid-stance. 80% of all patients developed this gait pattern. Internal moments of the ankle increased, of the knee and hip decreased during the first part of stance. Conclusion: Recurrent patellar dislocation decreases knee flexion during the loading-response and mid-stance phase. A decreased hip flexion and increased plantar-flexion, while adjusting internal moments, indicate a compensation mechanism. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose Surgical procedures, such as medial hamstring lengthening (MHL) and femoral derotational osteotomy (FDO), can improve the gait of children with cerebral palsy (CP); however, substantial variation exists in the factors that influence the decision to perform surgery. The purpose of this study was to use expert surgeon opinion through a Delphi technique to establish consensus for indications in ambulatory children with CP. Methods A 15-member panel, all established experts with at least nine years' experience in the surgical management of children with CP, was created (mean of 20.81 years' experience). All panel members also had expertise of the use of movement analysis for the assessment of gait disorders in children with CP. The group initially focused on two of the most commonly performed procedures, MHL and FDO, in an attempt to gain consensus (> 80%). This was obtained through a standardized, iterative Delphi process. Results For MHL, a total of 59 questions were surveyed: 41 indication questions and 18 outcome questions, for which there was consensus on ten indication questions and seven outcomes. For FDO, a total of 55 questions were surveyed: 43 indication questions and 12 outcome questions, for which there was consensus on 29 indication questions and eight outcomes. Conclusion This study is the first to use an expert panel to identify best-practice indications for common surgical procedures of children with CP. The results from this study will allow for more informed evaluation of practice and form the basis for future improvement efforts to standardize surgical recommendations internationally. [ABSTRACT FROM AUTHOR]

Background: A dorsal bunion may occur in nonambulatory adolescents with cerebral palsy (CP) and a Gross Motor Function Classification System (GMFCS) level of IV or V. The deformity can cause pain, skin breakdown, and difficulty wearing shoes and braces. A consensus on the biomechanics and surgical management of dorsal bunions in persons with severe CP has not been established., Methods: This retrospective cohort study included 23 nonambulatory adolescents with CP, GMFCS level IV or V, and symptomatic dorsal bunions requiring surgery. The median age at surgery was 17 years, and the median follow-up was 56 months. Reconstructive surgery included the excision of a 2 to 3-cm segment of the tibialis anterior tendon to correct the elevation of the first metatarsal. The fixed deformity of the first metatarsophalangeal joint was managed with use of corrective arthrodesis and dorsal plate fixation. Clinical and radiographic outcomes were assessed preoperatively and postoperatively at the transition to adult services., Results: There were significant improvements in the clinical and radiographic outcome measures (p < 0.001). Pain was relieved, and there were no further episodes of skin breakdown. The elevation of the first metatarsal was corrected from a mean of 3° of dorsiflexion to a mean of 19° of plantar flexion. The deformity of the first metatarsophalangeal joint was corrected from a mean of 55° of plantar flexion to a mean of 21° of dorsiflexion. Six patients had complications, all of which were grade I or II according to the modified Clavien-Dindo system., Conclusions: The surgical reconstruction of a dorsal bunion via soft-tissue rebalancing of the first ray and corrective arthrodesis of the first metatarsophalangeal joint resulted in favorable medium-term clinical and radiographic outcomes in nonambulatory adolescents with CP., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Article Processing Charge for open access publication was funded by the Murdoch Children’s Research Institute, Melbourne. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I168)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

This study summarizes the current knowledge of the etiology of hip dysplasia in children with neuromuscular disease and the implications for management. This article is based on a review of development of the hip joint from embryology through childhood growth. This knowledge is then applied to selective case reviews to show how the understanding of these developmental principles can be used to plan specific treatments. The development of the hip joint is controlled by genetic shape determination, but the final adult shape is heavily dependent on the mechanical environment experienced by the hip joint during growth and development. Children with neuromuscular conditions show a high incidence of coxa valga, hip dysplasia, and subluxation. The etiology of hip pathology is influenced by factors including functional status, muscular tone, motor control, child's age, and muscle strength. These factors in combination influence the development of high neck-shaft angle and acetabular dysplasia in many children. The hip joint reaction force (HJRF) direction and magnitude determine the location of the femoral head in the acetabulum, the acetabular development, and the shape of the femoral neck. The full range of motion is required to develop a round femoral head. Persistent abnormal direction and/or magnitude of HJRF related to the muscular tone can lead to a deformed femoral head and a dysplastic acetabulum. Predominating thigh position is the primary cause defining the direction of the HJRF, leading to subluxation in nonambulatory children. The magnitude and direction of the HJRF determine the acetabular shape. The age of the child when these pathomechanics occur acts as a factor increasing the risk of hip subluxation. Understanding the risk factors leading to hip pathology can help to define principles for the management of neurologic hip impairment. The type of neurologic impairment as defined by functional severity assessed by Gross Motor Function Classification System and muscle tone can help to predict the risk of hip joint deformity. A good understanding of the biomechanical mechanisms can be valuable for treatment planning.

This article introduces a novel concept where advanced technologies have been leveraged to produce a modular walking orthosis (MOWA) within a completely digital process chain. All processes of this new supply chain are described step-by-step. The prescription and treatment of lower leg orthoses for individuals with paralysis or muscle weakness, particularly cerebral palsy (CP), are complex. A single case study indicates successful treatment with this new orthosis (MOWA). From the authors' perspective, this innovative fitting concept is promising and will contribute to creating more efficient care within a multidisciplinary team.

Background and Objectives: Single-Event Multi-Level Surgery (SEMLS) is a complex surgical programme in which soft tissue contractures and bony torsional deformities at the ankle, knee and hip, in both lower limbs are surgically corrected during a single operative session, requiring one hospital admission and one period of rehabilitation. The aim of SEMLS is to improve gait and function in ambulant children with cerebral palsy. Utilisation of the SEMLS concept can reduce the number of surgical events, hospital inpatient stays and reduce rehabilitation requirements to a single intensive episode. Three-dimensional gait analysis is a pre-requisite to plan intervention at multiple anatomic levels to correct fixed deformities and to improve gait and function. Materials and Methods : This study was a bibliometric analysis of SEMLS in cerebral palsy using the Clarivate Web of Science Core Collection database from 1900 to 29 May 2023. Results : A total of 84 studies met the inclusion criteria. The most highly cited article was "Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery" by Rodda et al. (2006) with 141 citations. The most productive institutions by number of articles were the Royal Children's Hospital Melbourne (Australia), Murdoch Children's Research Institute (Australia) and University of Melbourne (Australia). The most productive author by number of citations was HK Graham (Australia). Conclusions : The literature base for SEMLS consists largely of retrospective cohort studies. The aforementioned three institutes in Melbourne, Australia, which frequently collaborate together, have contributed the greatest number of studies in this field.

Purpose: We compared the outcomes of arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in 31 adolescents with cerebral palsy, using three different methods of fixation: K-wires, non-locking plates, and locking plates., Methods: Clinical outcomes included time to weight-bearing, fusion rates and surgical complications. Radiographic assessment included comparing pre- and post-operative hallux valgus angles, intermetatarsal angles, interphalangeal angles, and lateral metatarsophalangeal angles. Patient-reported outcomes included pre- and post-operative visual analogue scales addressing bunion pain and concerns, difficulties with wearing shoes and braces, and difficulties with foot hygiene., Results: Of the 31 adolescents (16 male), 10 patients had K-wire fixation, 11 had a non-locking dorsal plate, and 10 had fixation with a dorsal locking plate. Mean age at surgery was 16 years (12-18 years) and mean follow-up was 4 years (2.7-6.5 years). Patients with K-wire fixation had delayed weight-bearing and had more complications than those managed by dorsal plating. There were significant improvements in radiographic parameters (except interphalangeal angle) and in patient-reported outcomes, in all groups ( p  < 0.001). However, radiographic and clinical outcomes were better in the dorsal plating groups compared to the K-wire group., Conclusion: Arthrodesis of the first metatarsophalangeal joint gave good correction of deformity with improvements in symptoms and radiographic parameters in adolescents with cerebral palsy. We recommend dorsal plating that allowed early weight-bearing and had fewer complications with better clinical and radiographic outcomes, than K-wire fixation., Level of Evidence: IV: Retrospective case series., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.Y. declares no conflicts of interest. M.C. declares no conflicts of interest. S.K.V.d.V. declares no conflicts of interest. A.K. declares no conflicts of interest. K.G. has received research support from the NHMRC-CRE-CP-Achieve outside the scope of the submitted work and is on the Surgeon’s Advisory Board of the OrthoPaediatrics Corp. E.R. declares no conflicts of interest., (© The Author(s) 2023.)

Introduction: Most classification systems for lateral discoid meniscus do not evaluate instability of the meniscal peripheral rim. Considerable variability in the prevalence of peripheral rim instability has been published, and it appears that instability is underestimated. The purpose of this study was: first, to evaluate the prevalence of peripheral rim instability and its location in the symptomatic lateral discoid meniscus, and second, to investigate if patient age or type of discoid meniscus are possible risk factors for instability., Methods: A cohort of 78 knees that underwent operative treatment due to symptomatic discoid lateral meniscus was analyzed retrospectively for the rate and location of peripheral rim instability., Results: Out of the 78 knees, 57.7% (45) had a complete and 42.3% (33) had an incomplete lateral meniscus. The prevalence of peripheral rim instability in symptomatic lateral discoid menisci was 51.3%, and with 32.5%, the anterior attachment was most commonly affected, followed by the posterior (30%) and central (10%) attachment. 27.5% of the tested menisci were unstable anteriorly and posteriorly. There was no significant difference in the prevalence of rim instability between the type of discoid menisci (complete vs. incomplete), nor was there a significant correlation for age as a risk factor for instability., Conclusion: The discoid lateral meniscus has a high prevalence and variable location of peripheral rim instability. Meniscal rim stability must be tested and addressed cautiously in all parts and in all types of discoid lateral menisci during operative treatment., (© 2023. The Author(s).)

Introduction: Impaired hip kinematics and kinetics may incite patellar instability. This study tested the hypothesis that hip adduction and internal rotation angles during gait are higher in adolescents with recurrent patellar dislocations compared to healthy controls., Material and Methods: Case-control study. Eighty-eight knees (67 patients) with recurrent patellar dislocation (mean age 14.8 years ± 2.8 SD) were compared to 54 healthy knees (27 individuals, 14.9 years ± 2.4 SD). Peak hip, knee and pelvis kinematics and kinetics were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates) and compared between the two groups. One cycle (100%) consisted of 51 data points. The mean of six trials was computed., Results: Peak hip adduction angles and abduction moments were significantly higher in patients with recurrent patellar dislocation compared to the control group (p < 0.001 and 0.002, respectively). Peak internal hip rotation did not differ significantly., Conclusion: Elevated hip adduction angles and higher hip abduction moments in gait of adolescents with recurrent patellar dislocation may indicate an impaired function of hip abductors that contributes to patellar instability., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.M. has received research support in royalties and as a consultant for Nuvasive, has received consulting fees from Synthes, and has received royalties from Wolters-Kluwer-Health-Lippincott Williams & Wilkins, all outside of the scope of the submitted work. He has also been an unpaid consultant for OrthoPediatrics and is a board member of the Pediatric Orthopedic Society of North America. M.W.S. is a member of the Editorial Board of the Journal of the Pediatric Orthopedic Society of North America, is a member of the National Advisory Board (NIH) on Medical Rehabilitation Research, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), all outside the scope of the submitted work. K.G. has received research support from NHMRC-CRE CP-Achieve and is on the Surgeon’s Advisory Board of OrthoPaediatrics Corp. H.C. has received personal fees from OrthoPaediatrics Corp. and Allergan Corp., outside the scope of the submitted work. J.R.D. is a consultant and board member of OrthoPaediatrics Corp., outside the scope of the submitted work. J.R. has received personal fees from OrthoPaediatrics Corp., outside the scope of the submitted work and research support Smith Nephew Corp and is on Editorial Board of Gait and Posture. R.M.K. owns stock in Zimmer/Biomet, Medtronic, Pfizer, and Johnson and Johnson, is on the Editorial Board of the Journal of Pediatric Orthopedics and his son works for Intrinsic Therapeutics, outside the scope of the submitted work.

Background: When determining the dimensions of an anterior cruciate ligament (ACL) graft in children, bone age should be considered in addition to the patient's age, gender, and body height., Objectives: We aimed to determine the relationship between age, gender, and ACL dimensions as well as thickness of growth plate cartilage of the distal femur during puberty., Methods: We retrospectively analyzed MRI scans of the knee in 131 children (82 girls, 49 boys) aged 6-18 years (mean age: 14.9 ± 2.6 years). ACL length and width as well as thickness of the growth plate cartilage at the distal femoral epiphysis were measured., Results: Mean ACL length increased linearly up to the age of 12 years in females and 14 years in males; thereafter, mean ACL length remained constant. Mean ACL length was largest at the age of 12 to < 13 years (38.18 mm) in females and at 15 to < 16 years (39.38 mm) in males. Mean ACL width increased up to the age of 12 years in girls and 13 years in boys. After the age of 12 years, both the ACL length and width were significantly larger in boys than girls (p = 0.002 and p = 0.045, respectively). Mean thickness of the growth plate cartilage of the distal femur remained stable up to the age of 12 years in girls and 14 years in boys. Thickness of the growth plate cartilage changed most markedly between the age intervals of 11 to < 12 years and 12 to < 13 years in girls and between the age intervals of 13 to < 14 years and 14 to < 15 years in boys., Conclusions: ACL dimensions depended on both age and gender during the growth period. Measurement of cartilage thickness of the femoral distal growth plate proved to be an objective parameter to assess the maturation stage of local bone. This may be useful for the planning and timing of orthopedic ACL procedures., Level of Evidence: III-retrospective cohort study., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Local botulinum toxin (BTX-A, Botox ® ) injection in overactive muscles is a standard treatment in patients with cerebral palsy. The effect is markedly reduced in children above the age of 6 to 7. One possible reason for this is the muscle volume affected by the drug. Nine patients (aged 11.5; 8.7-14.5 years) with cerebral palsy GMFCS I were treated with BTX-A for equinus gait at the gastrocnemii and soleus muscles. BTX-A was administered at one or two injection sites per muscle belly and with a maximum of 50 U per injection site. Physical examination, instrumented gait analysis, and musculoskeletal modelling were used to assess standard muscle parameters, kinematics, and kinetics during gait. Magnetic resonance imaging (MRI) was used to detect the affected muscle volume. All the measurements were carried out pre-, 6 weeks post-, and 12 weeks post-BTX-A. Between 9 and 15% of the muscle volume was affected by BTX-A. There was no effect on gait kinematics and kinetics after BTX-A injection, indicating that the overall kinetic demand placed on the plantar flexor muscles remained unchanged. BTX-A is an effective drug for inducing muscle weakness. However, in our patient cohort, the volume of the affected muscle section was limited, and the remaining non-affected parts were able to compensate for the weakened part of the muscle by taking over the kinetic demands associated with gait, thus not enabling a net functional effect in older children. We recommend distributing the drug over the whole muscle belly through multiple injection sites.

Hip displacement is the second most common musculoskeletal deformity in children with cerebral palsy. Hip surveillance programs have been implemented in many countries to detect hip displacement early when it is usually asymptomatic. The aim of hip surveillance is to monitor hip development to offer management options to slow or reverse hip displacement, and to provide the best opportunity for good hip health at skeletal maturity. The long-term goal is to avoid the sequelae of late hip dislocation which may include pain, fixed deformity, loss of function and impaired quality of life. The focus of this review is on areas of disagreement, areas where evidence is lacking, ethical dilemmas and areas for future research. There is already broad agreement on how to conduct hip surveillance, using a combination of standardised physical examination measures and radiographic examination of the hips. The frequency is dictated by the risk of hip displacement according to the child's ambulatory status. Management of both early and late hip displacement is more controversial and the evidence base in key areas is relatively weak. In this review, we summarise the recent literature on hip surveillance and highlight the management dilemmas and controversies. Better understanding of the causes of hip displacement may lead to interventions which target the pathophysiology of hip displacement and the pathological anatomy of the hip in children with cerebral palsy. We have identified the need for more effective and integrated management from early childhood to skeletal maturity. Areas for future research are highlighted and a range of ethical and management dilemmas are discussed.

Background: Gastrocsoleus lengthening (GSL) is the most common surgical procedure to treat equinus deformity in ambulant children with cerebral palsy (CP). Foot drop, where the ankle remains in plantarflexion during swing phase, can persist in some children post-operatively. There is currently limited understanding of which children will demonstrate persistent foot drop after GSL., Research Question: Which children develop persistent foot drop after GSL surgery for equinus?, Methods: We conducted a retrospective cohort study on ambulant children with CP who had GSL surgery for fixed equinus deformity. The aims of the study were: to determine the frequency of persistent foot drop post-operatively and to compare outcome parameters from physical examination and three-dimensional gait analysis for children with hemiplegia or diplegia., Results: One hundred and ten children functioning at GMFCS Levels I/II/III of 28/75/7 met the inclusion criteria for this study. There were 71 boys and mean age was 9.1 years at time of GSL surgery. The overall frequency of persistent foot drop was 25%, with a higher frequency of persistent foot drop in children with hemiplegia (42%) than children with diplegia (19%). There were significant improvements in dorsiflexor strength and in selective motor control in children with diplegia but not in children with hemiplegia. Mean (SD) pre-operative mid-swing ankle dorsiflexion for children with hemiplegia was - 14.0° (9.9°) and improved post-operatively to - 1.6° (5.5°). For children with diplegia, the pre-operative mid-swing ankle dorsiflexion was - 12.1° (12.9°) and improved post-operatively to + 4.2° (6.9°)., Significance: Foot drop is present following GSL surgery for fixed equinus deformity in a significant number of children with hemiplegia and to a lesser extent in children with diplegia, which may reflect a difference in the central nervous system lesion between these groups. New management approaches are required for this important and unsolved problem., Competing Interests: Declarations of Interest The authors declare no financial or personal conflict of interest with respect to this study. No external funding was received in support of this study. Kerr Graham received non-financial support from NHMRC, CP-Achieve., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Hip dislocation in cerebral palsy can lead to pain, pressure sores and difficulty with perineal hygiene. Hip surveillance programs have been implemented to identify patients who might benefit from early intervention and preventive strategies. Surgical techniques used to treat hip dislocation include soft tissue procedures, guided growth, osteotomies and salvage procedures. A search was conducted using Clarivate Web of Science Core Collection on 18 October 2022, to identify all studies of bony or soft tissue surgery for hip pathology in children with cerebral palsy. Fifty-nine original studies and reviews with at least 20 citations were included in this bibliometric analysis. We found that there has been an increase in studies over the decades, with the most studies being published in the Journal of Pediatric Orthopaedics . The United States of America was the most productive country, with Boston Children's Hospital and Harvard University publishing the most articles. The Methodological Index for Non-randomized Studies (MINORS) scoring system was used to analyse the methodological quality of included cohort studies, with the median score being 11 out of 18; many studies had no prospective calculation of study size and lacked control groups. Overall, the literature on this topic appears to be preferentially published in the Journal of Pediatric Orthopaedics , and influential papers by Hagglund 2005 and 2014 continue to be highly cited.

Introduction: Hip reconstruction is an established procedure in pediatric patients with neurogenic hip dislocation. An open triradiate cartilage provides the advantage of a high plasticity of the bone which prevents an intraarticular fracture and postoperative adaptation of shape. Some patients with dislocated hips, however, arrive late. A hip reconstruction is still feasible as shown earlier but the long-term risk for osteoarthritis, and recurrence of dislocation, and functional outcome is unknown. It is the aim of our investigation to evaluate long-term clinical and radiological outcomes of hip reconstruction by Dega type pelvic osteotomy performed after fusion of the triradiate epiphyseal cartilage in patients suffering from cerebral palsy., Material and Methods: We retrospectively analyzed 43 hips in 37 patients with a hip reconstruction for correction of hip dislocation or subluxation. In all patients, the triradiate cartilage was fused before surgery. Age at surgery was 15 years and 2 months on average and follow-up time was mean 13 years 5 months., Results: Mean Kellgren Lawrence score at final follow-up was significantly higher than at preoperative investigation (P < 0.00001). At long-term follow-up 3 of 43 hips had developed pain, and 1 of them required arthroplasty. Reimers´ migration index was stable over the years and was not higher at last follow-up compared to the index observed shortly after surgery (P = 0.857), so was the Sharp angle (P = 0.962). We found no significant reduction in the range of motion of the hip in the sagittal plane., Conclusion: We noted mild radiological signs of osteoarthritis which possibly occur due to an intraarticular acetabulum fracture during bending down the acetabulum. Nevertheless, hip reconstruction in patients with cerebral palsy and closed triradiate cartilage remains a valuable option as it results in a stable, painless hip for more than a decade., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement., Method: A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022., Results: There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates., Conclusion: The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research., Level of Evidence: level V., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Introduction: Single-event multilevel surgery (SEMLS) is frequently used to correct pathological gait patterns in children with bilateral spastic cerebral palsy (BSCP) in a single session surgery. However, in-depth long-term evaluation reports of gait outcomes are limited. Therefore, we investigated if SEMLS is able to correct lower extremity joint and pelvic angles during gait towards typically developing gait patterns (TDC) in children with BSCP, and if so, if this effect is durable over a 10-year period., Materials and Methods: In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7-18.2 years at the time of SEMLS were retrospectively recruited. Three-dimensional gait data were captured preoperatively, as well as at short-, mid-, and long-term post-operatively, and used to analyze: movement analysis profile (MAP), gait profile score (GPS), and lower extremity joint and pelvic angles over the course of a gait cycle using statistical parametric mapping., Results: In agreement with previous studies, MAP and GPS improved towards TDCs after surgery, as did knee extension during the stance phase (ɳ 2  = 0.67; p < 0.001), while knee flexion in the swing phase (ɳ 2  = 0.67; p < 0.001) and pelvic tilt over the complete gait cycle (ɳ 2  = 0.36; p < 0.001) deteriorated; no differences were observed between follow-ups. However, further surgical interventions were required in 8 out of 13 of the participants to maintain improvements 10 years post-surgery., Conclusions: While the overall gait pattern improved, our results showed specific aspects of the gait cycle actually deteriorated post-SEMLS and that a majority of the participants needed additional surgery, supporting previous statements for the use of multilevel surgery rather than SEMLS. The results highlight that the field should not only focus on the overall gait scores when evaluating treatment outcomes but should offer additional long-term follow-up of lower extremity function., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Purpose: Benign lesions of the proximal femur region, such as simple bone cysts, aneurysmal bone cysts, and fibrous dysplasia, are common in children. Benign lesions may cause pathologic fractures, limb length inequities, and growth disturbances. Differential diagnoses, e.g., malignant bone tumors and osteomyelitis, are sometimes difficult to rule out., Objective: We aimed to evaluate outcomes in children with benign lesions of the proximal femur treated with curettage, bone grafting, and plate fixation., Methods: In this retrospective study, we included 30 children (median age 10.5 years; range 1.1-17.8 years) suffering from bone cysts and tumor-like lesions of the proximal femur region treated between 2002 and 2018. We analyzed plain X-ray images and CT scans in all children and obtained MRI scans in a selected group of children (63.3%). We examined histopathologic biopsy results for all bone lesions before initiating treatment. Surgical management comprised tumor curettage with adjuvant high-speed drilling and allogenic bone grafting supplemented by bone graft substitutes before plate fixation. Median follow-up interval was 87 months (range 24-156 months). We evaluated the healing of lesions according to Capanna's classification and rated functional outcomes according to Merle d'Aubigné and Postel score., Results: Overall, 25 of 30 (83.3%) patients were admitted to hospital because of a pathologic fracture. We diagnosed simple bone cysts in 15 (50.0%) patients, aneurysmal bone cysts in 7 (23.5%) patients, and fibrous dysplasia in 8 (26.5%) patients. Bone consolidation was achieved in 22 of 30 (73.3%) patients after a mean of 5 months (range 3-7 months). The main complication was recurrence of the lesion in 4 of 30 (13.3%) patients. With respect to the Merle d'Aubigné and Postel scores, 17 of 30 (56.7%) patients obtained an excellent result (18 points), while 12 (40.0%) patients had a good result (15-17 points) and only 1 (3.3%) patient had a fair result (14 points)., Conclusion: Surgical treatment of bone cysts and tumor-like lesions of the proximal femur by local resection or destruction of the lesion, followed by filling the defect with bone graft material and internal stabilization represents a safe and effective treatment option in children., Level of Evidence: Therapeutic, retrospective comparative study-Level III., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique., Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached., Results: Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment., Conclusion: The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy., Level of Evidence: V., Competing Interests: Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.M. has received research support in royalties and as a consultant for Nuvasive. W.S. is a member of the Editorial Board of the Journal of the Pediatric Orthopaedic Society of North America, is a member of the National Advisory Board (NIH) on Medical Rehabilitation Research, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), all outside the scope of the submitted work. H.C. has received personal fees from OrthoPediatrics Corp. and Allergan Corp., outside the scope of the submitted work. J.R.D. is a consultant and board member of OrthoPediatrics Corp., outside the scope of the submitted work. R.K. owns stock in Zimmer/Biomet, Medtronic, Pfizer, and Johnson and Johnson, is on the Editorial Board of the Journal of Pediatric Orthopaedics and his son works for Intrinsic Therapeutics, outside the scope of the submitted work. J.R. has received personal fees from OrthoPediatrics Corp., outside the scope of the submitted work and research support Smith Nephew Corp and is on Editorial Board of Gait and Posture. K.G. has received research support from NHMRC-CRE CP-Achieve and is on the Surgeon’s Advisory Board of OrthoPediatrics Corp. E.R. is supported by the Bob Dicken’s Fellowship in Paediatric Orthopaedics. The other authors declare no conflict of interest., (© The Author(s) 2022.)

Purpose: The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique., Methods: The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest 2 ratings., Results: For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and smaller (<30 degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture., Conclusion: Anterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery., Level of Evidence: V., Competing Interests: Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.M. has received research support in royalties and as a consultant for NuVasive, has received consulting fees from Synthes, and has received royalties from Wolters-Kluwer-Health—Lippincott Williams & Wilkins, all outside of the scope of the submitted work. Dr J.M. has also been an unpaid consultant for OrthoPediatrics and is a board member of the Pediatric Orthopaedic Society of North America. M.W.S. is a member of the Editorial Board of the Journal of the Pediatric Orthopaedic Society of North America, is a member of the National Advisory Board (NIH) on Medical Rehabilitation Research, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), all outside the scope of the submitted work. K.G. has received research support from NHMRC-CRE CP-Achieve and is on the Surgeon’s Advisory Board of OrthoPediatrics Corp. The other authors declare no conflict of interest. H.C. has received personal fees from OrthoPediatrics Corp. and Allergan Corp., outside the scope of the submitted work. J.R.D. is a consultant and board member of OrthoPediatrics Corp., outside the scope of the submitted work. J.R. has received personal fees from OrthoPediatrics Corp., outside the scope of the submitted work and research support Smith & Nephew Corp. and is on Editorial Board of Gait & Posture. R.M.K. owns stock in Zimmer/Biomet, Medtronic, Pfizer, and Johnson & Johnson, is on the Editorial Board of the Journal of Pediatric Orthopaedics and his son works for Intrinsic Therapeutics, outside the scope of the submitted work., (© The Author(s) 2022.)

Abstract: Cervical spine (C-spine) fractures in young children are very rare, and little information on treatment modalities and functional, radiographic, and patient-reported outcome exists. In this 2-center, retrospective case series, we assessed subjective and functional mid-term outcomes in children aged ≤5 years whose C-spine fractures were treated nonoperatively.Between 2000 and 2018, 6 children (median age at injury: 23.5 months; range: 16-31 months) with C1 or C2 injuries were treated with Minerva cast/brace or soft collar brace at 1 of the 2 study centers. Two patients suffered C1 fractures, and 4 patients had lysis of the odontoid synchondrosis. Overall, 3 children had sustained polytrauma. One child died due to the consequences of massive head injury.For the primary outcome parameter, we recorded subjective symptoms such as pain and functional restrictions due to the sequelae of C-spine injuries at follow-up.Based on medical records, we also assessed the causes of injury, diagnostic procedures, treatments and complications, and time to fracture consolidation.Median follow-up of the 5 surviving children was 51 months (range: 36-160 months). At the latest follow-up, 4 of 5 children did not complain of any pain. One child who sustained an open head injury in combination with a subluxation of the odontoid and undisplaced fracture of the massa lateralis reported occasional headache. All patients experienced complete fracture healing and normal range of motion of the cervical spine.Median duration of cast/brace treatment was 8.5 weeks. Fracture healing was confirmed by computed tomography in all patients.All C-spine injuries were managed with either Minerva cast/Halo brace or soft collar brace without complications.In our retrospective case series, nonoperative treatment of atlas fractures and dislocations or subluxations of the odontoid in young children using Minerva casts or prefabricated Halo braces resulted in good subjective and functional outcomes at mid-term. We observed no complications of conservative treatment of C1 and C2 injuries in young children., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP., Methods: A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process., Results: Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS)., Conclusions: The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research., Level of Evidence: V., (Copyright © 2020, The author(s).)

Purpose: In adolescent patients with recurrent patellar dislocation, the Green's quadricepsplasty stabilizes the patella in a combination of a lateral release, a transfer of the medial head of the quadriceps onto the lateral part of the patella and an imbrication of the medial patellar retinaculum and joint capsule. This study aimed to evaluate the long-term performance, considering re-dislocations and functional outcomes. We hypothesized a high failure rate in the long term., Methods: In this single surgeon and single center study 26 knees in 23 patients (mean age 14.2 years; 4-22 years, 18 females) with recurrent patellofemoral dislocation underwent a vastus medialis transfer, medial reefing and lateral release as it was described by Green in 1965 with a mean follow-up 10.8 years (6-24 years). Clinical assessment was carried out with an IKDC-score (international knee documentation committee) and a self-assessment for each knee separately. The radiologic evaluation included measurement of the patella height, the grade of trochlear dysplasia and the sulcus angle., Results: In 12 of 26 cases (46.2%) the patella did not re-dislocate after vastus medialis transfer and lateral release. In 11 of 26 cases (42.3%), the patients described the function of their knees as normal or nearly normal according to IKDC after the surgical treatment without any re-dislocation. In 14 of 26 cases (53.8%), the patella re-dislocated. 7 of these 14 cases underwent a revision operation. Re-dislocations occurred after a mean interval of 21 months after the index procedure. In only 2 of 26 cases (7.7%) the patients returned to sports., Conclusion: Green's procedure to stabilize patellofemoral instabilities results in a high failure rate on the long-term and low subjective assessments. We do not recommend performing vastus medialis transfer, medial imbrication and lateral release as a standalone technique., Level of Evidence: IV.

Purpose: To investigate if a trochleoplasty increases knee flexion angles and extensor moments in the gait of patients with patellar instability and to compare postoperative gait to a healthy control group., Methods: A bilateral dislocation group (6 patients) and a unilateral dislocation group (14 patients) were treated with bilateral and unilateral trochleoplasty, respectively. Kinematics and kinetics of the lower extremity were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, plug-in-gait, two force plates). The mean of six trials was computed. The gait cycles were compared pre to postoperatively for each group. The gait of the two groups was compared to each other and the gait of a healthy population (54 knees)., Results: After trochleoplasty, the knee flexion angles and knee extensor moments only increased in the bilateral dislocation group, whereas the gait pattern of the unilateral dislocation group remained unchanged. Compared to the healthy population, the postoperative gait pattern of the bilateral dislocation group did not differ. In contrast, knee flexion angles and extensor moments of the unilateral dislocation group were still lower., Conclusion: In adolescents with bilateral recurrent patellar dislocations, trochleoplasty of both knees increases knee flexion angles and knee extensor moments comparable to normal gait. Unilateral symptomatic patients undergoing a unilateral trochleoplasty did not achieve normal walking. These findings point out that patellar instability should be considered as a bilateral problem, even in patients with unilateral dislocations., Level of Evidence: III.

A new method is introduced quantifying the velocity-dependent muscle response during gait in spastic muscles of children with Cerebral Palsy. The velocity-dependent muscle activation Index is calculated during a 3-dimensional gait analysis using segment angular velocity and the Instantaneous Mean Frequency calculated from surface electromyography. Typical developed children (n = 11) and children with hemiplegia (n = 11) aging from 8 to 19 years participated in the study. The rectus femoris and the medial gastrocnemius were assessed by calculating the velocity dependent muscle activation Index and the modified Ashworth Scale. Greater velocity-dependent muscle activation Index values for both medial gastrocnemius and rectus femoris muscles were associated with greater Ashworth Scale. Post hoc analysis revealed significant lower velocity-dependent muscle activation Index means in the Typical developed group compared with Ashworth Scale scores of 1, 2, 3, and 5. In addition, velocity-dependent muscle activation Index for Ashworth Scale 0, 1, and 2 were significantly lower than for Ashworth Scale 3 and 5. The velocity dependent muscle activation Index showed negative low correlation with walking speed and cadence. Findings show that spastic muscles can be quantified during dynamic functional task such as walking. Future studies should investigate the reliability of the velocity-dependent muscle activation Index that may be used for the assessment of spasticity management such as Botulinum toxin A interventions., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Rationale: In the recent years, growing interest is focused on the use of platelet-rich plasma (PRP) in wound healing and tissue regeneration. There are a number of papers regarding the usefulness of PRP in the healing of ulcerations, skin injures, bone loss or distraction osteogenesis. Most authors emphasize the safety of PRP usage due to its authogenic nature., Patient Concerns: We present a case of a 14 -year-old boy admitted to our department due to simple bone cyst of the distal tibia, qualified for injection of PRP into the cyst. PRP was separated with the use of Magellan Autologous Platelet Separator System (Arteriocyte Medical Systems Hopkington, MA) according to the manufacturers' manual. Immediately after separation during short-term IV anaesthesia, 3 mL of PRP was installed to the bone cyst under image intensifier control., Diagnoses: Within the first 24 hours after exposure to PRP, the skin rash appeared. Physical examination revealed the small red papular, regionally purpuric eruptions, mainly concentrated on the upper extremities and on more warmed regions of skin, in association with pharyngitis, tonsillar enlargement, mucopurulent discharge in the posterior pharynx and swelling of the eyelids., Interventions: As the patient received calcium citrate with the PRP injection additional calcium citrate test were performed. Skin prick testing (negative) was and an intradermal test was positive (10×13 mm). Treatment included Claritine (Loratidinum) and Clemastin (Clemastinum)-both antihistaminic drugs., Outcomes: All symptoms withdrew and the patient was released home after 4 days. The patient is in 6 years follow-up without any symptoms of allergic disease., Lessons: Our case shows that safety of use of PRP is not absolutely sure. The pure autologous tissue is safe, but preparation for its use can substantially decrease this safety. In our patient, only limited skin reaction to calcium citrate was observed, but general reaction leading to anaphylactic shock cannot be excluded. In order to reduce the risk of side effects skin test should be performed but as there were no records of allergic diseases on family and patients medical history this should apply to all patients.

Background: Solitary trochleoplasty for recurrent patellar dislocation offers a unique benefit in that it addresses the most important factor in patellar instability: the trochlear dysplasia., Description: The trochlea is visualized through a lateral arthrotomy of the knee joint. An osteochondral layer is peeled off with curved chisels and extended into the intercondylar notch. A triangular bone block is removed from the subchondral bone to form the new groove. A new groove is begun with a chisel and smoothed with a high-speed burr. Also, the osteochondral layer is thinned out and fixed back transosseously in the new groove with 2 Vicryl (polyglactin) bands. The bone block is used to lengthen the lateral condyle by placing it under the osteochondral layer at the proximal extension of the lateral femoral condyle with an overlap of 1 cm., Alternatives: Nonsurgical alternatives include a knee or patellar brace, taping of the patella, and physiotherapy for strengthening of the vastus medialis obliquus of the quadriceps muscle. Surgical alternatives include reconstruction of the medial patellofemoral ligament; several femoral and tibial osteotomies, such as rotational osteotomies of the femur and tibia or medialization of the tibial tuberosity; and several soft-tissue interventions, such as medial reefing, relocation of the patellar tendon as described by Goldthwait 1 , and proximal realignments according to the method described by Insall et al. 2 or Green et al. 3 ., Rationale: Most patients with recurrent patellar dislocation have a dysplastic trochlea 4 , which is considered to be the primary reason for a recurrence. While interventions such as reconstruction of the medial patellofemoral ligament or femoral and tibial osteotomies also provide stability of the patella, they do not change the most essential factor of the instability-the trochlear dysplasia. The trochleoplasty addresses this underlying condition and reshapes the trochlea.

Septic arthritis is the result of bacterial infection of the hip joint and is often found in infants and toddlers. It is the most common septic joint condition during growth and may cause the most devastating complications without prompt and proper treatment. Early diagnosis and intervention are required to avoid irreversible complications. This review documents the systematic approach to diagnosis and management of septic arthritis in children.

Purpose: The primary purpose of this study was to retrospectively assess the incidence of bioabsorbable screw failure in skeletally immature patients treated for osteochondritis dissecans (OCD) of the knee. The second purpose was to assess implant degradation, focusing on differential breakdown of the intraosseous and extraosseous parts of the screw on magnetic resonance imaging (MRI)., Methods: In this retrospective study, 24 patients (30 knees) with MRI-confirmed OCD were treated with a total of 61 biodegradable screws and followed up for a minimum of 2 years or until the onset of new symptoms. MRI scans were performed every 6 months to assess differences in signal intensity between the head and body of the screw. The angle between the surface of the head and the body of the screw was measured, with an angle greater than 90° interpreted as indicating a broken screw (i.e., failed implant)., Results: Seven screws (all 2.7 mm, 11.5% of all screws) in 5 patients were considered broken screws. The implant failed completely in an additional 4 patients with breakage of 7 of 9 screws; 3 patients were considered late failures, occurring after more than 6 months. Altogether, 14 of a total of 61 screws (23%) were broken., Conclusions: Screw breakage is a surprisingly frequent cause of failure in resorbable OCD fixation in skeletally immature patients. MRI data showed differential decomposition of the screw within and outside of bone as a possible cause., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to compare meniscal stabilization alone with screw fixation in restoring subjective and objective knee function and structural cartilage integrity in skeletally immature patients with osteochondritis dissecans (OCD) of the knee., Methods: This study comprised 28 patients (32 knees) with magnetic resonance imaging (MRI)-confirmed OCD. Unstable menisci were treated with either stabilization (15 patients, 16 knees) or screw fixation (13 patients, 16 knees; control group). Patients were assessed by functional scoring (Hughston, International Knee Documentation Committee [IKDC]) and MRI for a minimum follow-up period of 2.5 years., Results: In the meniscus stabilization group, the Hughston score improved from 1.4 to 3.8 (P < .01). There was improvement in the IKDC grade, from grade C preoperatively to grade A in 14 knees and grade B in 2 (P < .01). Of 16 knees, 15 had complete defect resolution on MRI by 1 year. There were 3 complications: 1 wound infection, 1 case of trauma requiring reoperation, and 1 revision because of treatment failure at 6 months. In the screw fixation group, the Hughston score improved from 1.4 to 3.6 (P < .01). There was a significant improvement in IKDC grade, from grade C preoperatively to grade A in 11 knees and grade B in 5 (P < .01). At 2 years postoperatively, no differences in these variables were found between the groups., Conclusions: Meniscal suturing alone for the treatment of an OCD of the knee shows good or excellent results in terms of clinical scoring and MRI assessment at almost 3 years' follow-up. The results are comparable with those of screw fixation but with a faster recovery in the postoperative course., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

A misdiagnosed septic arthritis (SA) of the paediatric hip is a nightmare for many physicians. The authors tried to trace the most recent information about this problem. A Medline search, using PubMed interface, was focused on the period from 01.01.2002 to 31.08. 2012. A total of 53 papers were included in the study. They led to the following statement, among others, about the differential diagnosis between SA and transient synovitis: "CRP > 20 mg/L, non-weight-bearing, temperature >38.5 degrees C and peripheral white blood cell count > 12 x 10(9) cells /L offers a predictive probability for septic arthritis of 87%". As soon as the clinical data point to septic arthritis, a diagnostic needle aspiration becomes mandatory : for cell count, Gram stain and culture. Immediately afterwards, antibiotics should be started, knowing that they need to be adapted to the antibiogram as soon as it is available. If the clinical picture and the CRP improve within 24 hours, antibiotics are continued, classically for 3 to 3.5 weeks. If not, some kind of surgical intervention becomes necessary: arthrotomy, or daily repeated ultrasound-guided aspiration and irrigation, or arthroscopic irrigatiop and drainage. A diagnostic and therapeutic algorithm is presented. Finnish current literature proposes to reduce the aggressiveness of the treatment of SA, at least in previously healthy children with a short medical history (less than 5 days) : antibiotic therapy of less than two weeks and avoidance of a surgical intervention, apart from a diagnostic needle aspiration, might be justifiable in these cases.

Treatment with an unconventional double osteotomy of the pelvis in a 9-year-old girl with recurrent anterior hip subluxation after hip reconstruction in cerebral palsy is presented. Classical Pemberton or Salter osteotomy is effective for superolateral acetabular dysplasia, but corrections in the anterior or posterior direction are limited. In this case, double osteotomy of the pubic and iliac bone allowed better coverage in the anterior part of the acetabulum. The bone provided sufficient elasticity to achieve the desired correction without an ischial cut, therefore providing more stability of the pelvis.

Discoid menisci without tears and before surgical intervention may be an aetiological factor in the development of osteochondritis dissecans (OCD). We present the case of a massive OCD lesion in the lateral femoral condyle of a 12-year-old boy who presented with relatively few symptoms despite the size of the lesion. This was treated with meniscoplasty and rim stabilization, which has become established as the gold standard treatment for symptomatic discoid menisci. This was combined with bioabsorbable screw fixation of the OCD lesion, resulting in rapid resolution of symptoms and a return to normal magnetic resonance image appearances after 6 months. It is likely that instability of discoid menisci is a key causal component when present concurrently with OCD lesions. Therefore, stabilization of this is required as well as saucerization of the meniscus. OCD lesions which are of a sufficient size such that if they became unstable or dislocated would result in a significant defect should also be stabilized. We believe that bioabsorbable screw fixation presents a good solution for fixation in these cases and this combination of treatment should result in a satisfactory outcome.