Botulinum toxin A (BoNT-A) is considered a safe and effective therapy for children with cerebral palsy (CP), especially in the hands of experienced injectors and for the majority of children. Recently, some risks have been noted for children with Gross Motor Classification Scale (GMFCS) of IV and the risks are substantial for level V. Recommendations for treatment with BoNT-A have been published since 1993, with continuous optimisation and development of new treatment concepts. This leads to modifications in the clinical decision making process, indications, injection techniques, assessments, and evaluations. This article summarises the state of the art of BoNT-A treatment in children with CP, based mainly on the literature and expert opinions by an international paediatric orthopaedic user group. BoNT-A is an important part of multimodal management, to support motor development and improve function when the targeted management of spasticity in specific muscle groups is clinically indicated. Individualised assessment and treatment are essential, and should be part of an integrated approach chosen to support the achievement of motor milestones. To this end, goals should be set for both the long term and for each injection cycle. The correct choice of target muscles is also important; not all spastic muscles need to be injected. A more focused approach needs to be established to improve function and motor development, and to prevent adverse compensations and contractures. Furthermore, the timeline of BoNT-A treatment extends from infancy to adulthood, and treatment should take into account the change in indications with age.

Forty-two children with nontuberculous spondylodiscitis treated between 1966 and 1997 were reviewed, and the clinical, paraclinical, and therapeutic results are presented. The study shows the difficulties of diagnosis and understanding the pathophysiology of the disease. Additional information is provided by new imaging techniques, disc aspiration, and biopsy. The mean age at treatment was 4 years 6 months. The initial clinical presentation was often misleading and the diagnosis was often delayed (42 days average). Standard radiographs and technetium bone scans were important for diagnosis and patient follow-up. Magnetic resonance imaging and needle aspiration of the disc gave an additional reliable aid in differential diagnosis and helped to guide treatment. Bacteria were isolated in 22 of the 35 samples taken (55%Staphylococcus aureus, 27%Kingella kingae;Coxiella burnetii in one sample). The functional outcome is good if treatment is properly carried out. Disc fibrosis and occasional vertebral fusion develop inevitably in the long term. According to these results, nontuberculous spondylodiscitis is truly osteomyelitis of the spine.

Retrospective review of patients records with clinical and radiographic assessment. To evaluate the long-term result of thoracolumbar hemivertebrae resection using a double approach in a single procedure. Thoracolumbar hemivertebrae resection by a combined posterior and anterior approach has been previously described, but this is the largest series of hemivertebrae reported. From 1987 to 2003, a consecutive series of 34 congenital scoliosis or kyphoscoliosis due to thoracolumbar hemivertebrae were managed by hemivertebra resection using a combined posterior and anterior approach and short anterior and posterior convex fusion in the same day/same anesthesia. The mean age at surgery was 3.5 years. The mean follow-up period was 6.0 years. There was a mean improvement of 69.3% in the segmental curve from a mean angle of 34.8° before surgery to 10.7° at the latest follow-up assessment. The global scoliosis curve improved of 33.4% from 40.4° to 26.9°, respectively. Trunk shift was significantly improved. The mean final kyphosis was within normal values. This procedure is safe and offers a persistent correction with a short segment fusion. Surgery should be performed as early as possible to avert severe local deformities and prevent secondary structural deformities in order to avoid extensive fusions.

Although some clinical reports suggest patient-specific instrumentation in TKA may improve alignment, reduce surgical time, and lower hospital costs, it is unknown whether it improves pain- and function-related outcomes and gait. We hypothesized that TKA performed with patient-specific instrumentation would improve patient-reported outcomes measured by validated scoring tools and level gait as ascertained with three-dimensional (3-D) analysis compared with conventional instrumentation 3 months after surgery. We randomized 40 patients into two groups using either patient-specific instrumentation or conventional instrumentation. Patients were evaluated preoperatively and 3 months after surgery. Assessment tools included subjective functional outcome and quality-of-life (QOL) scores using validated questionnaires (New Knee Society Score^© [KSS], Knee Injury and Osteoarthritis Outcome Score [KOOS], and SF-12). In addition, gait analysis was evaluated with a 3-D system during level walking. The study was powered a priori at 90% to detect a difference in walking speed of 0.1 m/second, which was considered a clinically important difference, and in a post hoc analysis at 80% to detect a difference of 10 points in KSS. There were improvements from preoperatively to 3 months postoperatively in functional scores, QOL, and knee kinematic and kinetic gait parameters during level walking. However, there was no difference between the patient-specific instrumentation and conventional instrumentation groups in KSS, KOOS, SF-12, or 3-D gait parameters. Our observations suggest that patient-specific instrumentation does not confer a substantial advantage in early functional or gait outcomes after TKA. It is possible that differences may emerge, and this study does not allow one to predict any additional variances in the intermediate followup period from 6 months to 1 year postoperatively. However, the goals of the study were to investigate the recovery period as early pain and functional outcomes are becoming increasingly important to patients and surgeons. Level I, therapeutic study. See the Instructions to Authors for a complete description of levels of evidence.