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Orthopaedic surgical consensus in children with CP

...when should hamstrings lengthening and femoral derotation osteotomy be performed?

Background

Surgical procedures such as femoral derotation osteotomies (FDO) and medial hamstrings lengthening (MHL) are crucial in the treatment of ambulatory children with CP. They can improve the children’s walking ability and function. However, there is a great variation in factors that influence the decision to perform these surgeries. This leads to both under- as well as overuse of these procedures in these children.

Both surgical procedures are commonly part of single-event multilevel surgeries (SEMLS) where multiple surgical procedures are included in one surgery to avoid repeat episodes of anaesthesia, hospitalisation, and rehabilitation. Unfortunately, the combination of procedures in SEMLS makes the evaluation of surgical indications and outcomes very challenging, especially in this heterogeneous population of children with CP.

 

Consensus for MHL

Most surgeons relied on 3-D gait analysis data as indicators of shortened hamstrings; excessive knee flexion at initial contact or terminal swing and decreased pelvic tilt. They agreed that knee flexion contractures of more than 10 degrees should be surgically addressed during surgery or beforehand. They also concluded that the popliteal angle should not be vigorously tested under anaesthesia to avoid stretch injuries to the sciatic nerve.

Consensus for FDO

The surgeons agreed that excessive hip internal rotation during 3-D gait analysis was an important contributor, specifically if it was increased by 15 degrees. On physical examination, 30 degrees of increased femoral anteversion and 60 degrees of increased hip internal rotation were established as indicators for FDO. However, they raised that the physical exam should be carefully considered due to repeatability problems. Many experts also recommended to incorporate a mild overcorrection in younger children with CP.

> From: McCarthy et al., J Child Orthop 14 (2020) 50–57 . All rights reserved to The Author(s). Click here for the online summary.

Want to read deeper into this topic? A free version of the full text article is available online for free. You can find it here!

Expert opinion

It is almost impossible to evaluate surgical outcomes after SEMLS in ambulatory children with CP, due to the heterogeneity of the group and the heterogeneity of SEMLS. This makes it difficult to decide which surgical procedures should be used and results in a great variability between surgical recommendations.

This article is therefore a great start to address this problem and find consensus. However, I feel the consensus remains vague and could be more precise. More articles with a similar approach would be very helpful.

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