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Case: A young girl without pertinent medical history presented with a leg length discrepancy and an awkward gait disturbance. After a rapid growth spurt during the following year, other symptoms became obvious, she developed an inability to sit crossed legged, and her range of motion of the left hip decreased. Hip magnetic resonance imaging demonstrated a left unilateral fibrous band between the iliac wing and the greater trochanter., Conclusion: A fibrous band is a rare cause of leg length discrepancy and gait disturbance. The gait and hip movement improved after excision of the band., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C295)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Rotationplasty can be used as an alternative to amputation when conservative treatment is not possible, for example in malignant tumours of the knee. The principle of the operation is to rotate the lower leg through 180 ° after resection of the distal femur and in this way the ankle joint replaces the knee joint. This surgical technique, although complex, allows satisfactory carcinological resection with a functional outcome superior to amputation above the knee as well as a better quality-of-life. Patients do not develop phantom pain, neuroma or stump discomfort because it is not an amputation. In addition, they can actively control their knee and having proprioception and normal contact with the ground. This results in a coordinated, harmonious and elegant gait pattern similar to the normal population. Patients are more efficient in their activities of everyday life and sports. The major disadvantage is the particular aesthetic aspect and the psychological acceptance.

Eighteen osteoporotic (Z-score at or below 2.5) nonambulatory children with cerebral palsy or a neuromuscular disorder received cyclic intravenous administration of pamidronate. One year after treatment, bone densitometry showed an improvement in all patients: a mean increase of 13% +/- 15% standard deviation (SD) (p < 10(-5)) on the global data, and a mean increase of 27% +/- 15% (p < 10(-5)) on the most significant area for each individual patient. Clinical improvement was found in all patients, with a decrease in pain on manipulation, and no new fractures. No major adverse effects were reported. Cyclic intravenous administration of pamidronate is a useful tool in the treatment of osteoporosis in these children.

Purpose of the Study: The purpose of this clinical prospective study is to better assess the efficacy of intramuscular injections of botulinum-A toxin in the treatment of spastic dynamic equinus deformities in children with cerebral palsy., Material: Ten walking children (14 feet) with cerebral palsy were treated with botulinum-A toxin (the American type, Botox) for spastic dynamic equinus, equinovalgus or equinovarus deformity of the foot. The mean age was 6 years (range 4 to 12 years of age)., Method: Two units of botulinum-A toxin per kilogram were injected in each involved extremity: the lateral and medial gastrocnemius were injected in equinus or equinovalgus foot and one more injection was done in the tibialis posterior in equinovarus foot. A clinical assessment (based on opinion of caretakers, functional evaluation of gait, detailed orthopaedic clinical evaluation and video of the gait) and a gait analysis were performed prior to the first injections and then at 1, 3 and 6 months afterwards., Results: All patients showed a clinical improvement. The functional possibilities increased in 6 out of the 10 children. Five children showed a better endurance in their walking capacities. The clinical orthopaedic exam showed improvement for 10 out of the 14 injected feet in passive dorsiflexion from 3 to 15 degrees at one month. Twelve feet improved their score on the Physician Rating Scale from 1 to 4 points. For gait analysis, 6 children (8 feet) had an improvement often minor of their curves in terms of improvement of the dorsal flexion of the ankle and the EMG of the gastrocnemius was improved in terms of decrease of spastic activity in 7 children (10 feet). The response to the injections was seen within 10 days (3 to 10 days) and lasted 3 to 6 months except in one child where it stopped already after 1 month. No side effect was noted., Discussion: All ten patients of our study showed some type of improvement even if only minor or limited in time in some of them. These data corroborate previous studies performed by other authors. Since this study, the recommended dosage has greatly increased (from 2 U/kg up to 10 U/kg or even more). The most interesting new element is that we noted that it seems to increase the endurance of the patient regarding walking distance., Conclusion: The intramuscular injection of botulinum-A toxin in spastic dynamic equinus deformities in children with cerebral palsy is an useful treatment modality, but the indications have to be respected scrupulously. The subject needs more study with the higher dosage and clinical evaluation to confirm the possible increased endurance.

The purpose of this clinical prospective study was to assess the effect of intramuscular injections of botulinum toxin A on energy cost of movement and walking endurance in 15 children with cerebral palsy, aged 4 to 13 years, by using incremental walking treadmill protocol to voluntary exhaustion. Oxygen-uptake response to exercise stress and endurance time were analyzed before and 2 and 6 months after botulinum toxin A injection. Endurance time was significantly improved 2 months after botulinum toxin A injection in 13 patients, and a residual improvement was still present 6 months after injection in some of them. The effect of botulinum toxin A on energy cost of movement was very variable. This study provides clinical evidence of the efficacy of botulinum toxin A in reducing the energy cost of movement and in improving the endurance of spastic muscles in children with cerebral palsy.

Few series on reflex sympathetic dystrophy syndrome (RSDS) have included children. The present series reviewed 10 affected children. The group consisted of 9 girls and one boy with an average age at onset of 11 years (5 years to 16 years). The diagnosis was based on the clinical findings of pain, dysesthesia and autonomic system dysfunction. All patients underwent x rays and bone scans. Their results showed great variation. Minor trauma was the most common trigger factor. The lower extremities were more often involved. The treatment consisted of pain relief and progressive mobilization. Less conventional treatments in children, such as calcitonin and bisphosphonate were also used. The severity and duration of the disease varied greatly among these children. Moderate pain and sympathetic dysfunction persisted often up to two years after onset. Reflex sympathetic dystrophy is more common in children than previously thought. There are differences with the adult form in presentation and clinical course: the diagnosis is often delayed, the lower extremities are more often involved, girls are affected more often and idiopathic forms are frequent. Significant emotional dysfunction is found in a majority of patients and they are best treated as inpatients by a multidisciplinary team.

The authors insist on the importance of a careful clinical examination of newborn's hips, and on the necessity of an early diagnosis of congenital hip dislocation, in order to optimize the probability of therapeutic success. They don't consider hip dislocations resulting from neuromuscular diseases or from complex malformations (e.g. arthrogryposis) included in a wider context with very different prognosis and treatment.

We reviewed the clinical records and the radiographs of 188 patients who had adolescent idiopathic scoliosis. Our purpose was to determine whether part-time and full-time bracing had been equally effective in preventing progression of the curve. Full-time bracing had been used for ninety-eight patients; part-time bracing, for forty-nine; and electrical stimulation, for forty-one. Eighty-eight patients had had a curve of less than 30 degrees and 100 patients, a curve of 30 to 40 degrees. The treatment was considered a failure if the curve had increased 5 degrees or more. The curve progressed 5 degrees or more in thirteen (36 per cent) of the thirty-six patients who had had full-time bracing for a curve of less than 30 degrees, in thirteen (41 per cent) of the thirty-two who had had part-time bracing for such a curve, and in fourteen (70 per cent) of the twenty who had had electrical stimulation for such a curve. Compared with electrical stimulation, both full-time and part-time bracing prevented progression significantly more effectively (p < 0.02 and p < 0.04, respectively). With the numbers available, the difference in progression between the groups that had had full-time and parttime bracing was not significant (p < 0.18). The curve progressed 5 degrees or more in thirty-six (58 per cent) of the sixty-two patients who had had full-time bracing for a curve of 30 to 40 degrees, in ten of the seventeen who had had part-time bracing for such a curve, and in eighteen (86 per cent) of the twenty-one who had had electrical stimulation for such a curve. The difference in progression between each bracing program and electrical stimulation was significant (p < 0.03 for the full-time program and p < 0.05 for the part-time program). With the numbers available, the difference in progression between full-time and part-time bracing was not significant (p < 1.14).

The purpose of this study was to examine the outcome of treatment of clubfeet distal to a lower extremity constriction band. Eighteen patients with 21 clubfeet distal to a lower extremity constriction band were treated during the years 1946 to 1992. Three types of bands (I to III) were defined. Three grades of feet (A to C), based on the severity of the deformity, were recognized. After treatment, the feet were classified as good, fair, or poor. At follow-up, six of 18 feet were classified as good, six as fair, and nine as poor. These results were correlated with the type of band and the grade of the foot. A grade A foot associated with type III band had the best result.

Massive deep-frozen bone allografts were implanted in 13 patients after en bloc tumor resection. Patients were followed up for 14 months to 17 years. Most of the reconstructive procedures included a segmental bone allograft with knee or ankle fusion. Graft infections were the most critical complications in regard to the end results, finally requiring amputation in two cases. There were three stress fractures; two of which were successfully treated without further complication. Graft incorporation was assessed by bone scintimetry in four cases. Isotope uptake by the center of the graft was found to be superior to control bone segments at only 15 years after surgery. Two recovered allograft specimens were available for a microradiographic study. Creeping substitution was a very slow process, initiated at the outer surface of the graft and characterized at 2-3 years after implantation by large, incompletely filled osteons. The present investigation demonstrates that massive bone allografts are very slowly revascularized and are intimately anchored by the host bone. Provided that tumor control is effective and graft infection is avoided, reconstructive surgery with massive bone allografts represents a successful alternative to prosthetic implants in young adult with a long life expectancy.