Objectives: To evaluate overgrowth after internal fixation for pediatric femur fracture and to identify any factors related with overgrowth in terms of fracture type and fixation method. Design: Retrospective comparative study. Setting: Multicenter, children's hospital and general hospital. Patients/Participants: Eighty-seven children between 4 and 10 years of age were included. Length-stable fracture was noted in 49 children, and length-unstable fracture was found in 38 children. Intervention: Thirty-six children were treated by minimal invasive plate osteosynthesis (MIPO), and elastic stable intramedullary nail fixation (ESIN) was used in 51 children. Main Outcome Measurements: The degree of overgrowth after internal fixation compared to fracture type, fracture site, and surgical method. Multivariable logistic regression analysis was conducted to identify factors related with overgrowth. Results: The average overgrowth of the femur was 10.5 ± 7.3 mm. There was no patient who required correction for final leg length discrepancy (>2 cm). There was no significant difference in overgrowth between ESIN (9.9 ± 7.2 mm) and MIPO (11.2 ± 7.6 mm) (P = 0.417). Overgrowth was similar among length-unstable fractures (12.3 ± 7.4 mm) and length-stable fractures (9.2 ± 7.0 mm), although it was statistically greater in length-unstable fractures (P = 0.048). In the MIPO group, length-unstable fractures were associated with an increased log odds of 6.873 for overgrowth of the femur (P = 0.042). Conclusions: Femur overgrowth after internal fixation seems to not be a clinically significant problem, regardless of whether that be for length-stable or length-unstable fractures and whether they were treated by MIPO or ESIN. Length-unstable fracture may be a risk factor for overgrowth in children. However, the difference is very small, and the postoperative overgrowth would likely not be a significant factor in deciding the surgical plan. Level of Evidence: Therapeutic Level III. See Instructions for authors for a complete description of levels of evidence.

Although there have been advancements of surgical techniques to correct gait abnormalities seen in patients with cerebral palsy, the crouch gait remains one of the most difficult problems to treat. The purpose of this retrospective study was to examine our results of distal femoral shortening osteotomy (DFSO) and patellar tendon advancement (PTA), performed in patients with crouch gait associated with severe knee flexion contracture. A total of 33 patients with a mean fixed knee contracture of 38° were included in the study. The mean age at the time of surgery was 12.2 years and the mean follow-up was 26.9 months. The measurements of clinical, radiological, and gait parameters were performed before and after surgery. The mean degrees of knee flexion contracture, Koshino index of patella height, and Gait Deviation Index were found to be significantly improved at the time of final follow-up. The maximum knee extension during the stance phase improved by an average of 25°, and the range of knee motion during gait increased postoperatively. On the other hand, the mean anterior pelvic tilt increased by 9.9°. Also, the maximum knee flexion during the swing phase decreased and the timing of peak knee flexion was observed to be delayed. We conclude that combined procedure of DFSO and PTA is an effective and safe surgical method for treating severe knee flexion contracture and crouch gait. However, the surgeons should be aware of the development of increased anterior pelvic tilt and stiff knee gait after the index operation.

No previous studies have suggested a reliable criterion for determining the addition of a concomitant pelvic osteotomy by using a large patient cohort with quadriplegic cerebral palsy and a homogenous treatment entity of femoral varus derotational osteotomies (VDRO). In this retrospective study, we examined our results of hip reconstructions conducted without a concomitant pericapsular acetabuloplasty in patients with varying degrees of hip displacement. We wished to investigate potential predictors for re-subluxation or re-dislocation after the index operation, and to suggest the indications for a simultaneous pelvic osteotomy. We reviewed the results of 144 VDROs, with or without open reduction, in 72 patients, at a mean follow-up of 7.0 (2.0 to 16.0) years. Various radiographic parameters were measured, and surgical outcomes were assessed based on the final migration percentage (MP) and the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS) grades. The effects of potential predictive factors on the surgical outcome was assessed by multivariate regression analysis. A receiver operating characteristic (ROC) curve analysis was also performed to determine whether a threshold of each risk factor existed above which the rate of unsatisfactory outcomes was significantly increased. In total, 113 hips (78.5%) showed satisfactory results, classified as MCPHCS grades I, II, and III. Thirty-one hips (21.5%) showed unsatisfactory results, including six hip dislocations. Age at surgery and preoperative acetabular index had no effects on the results. Lower pre- and postoperative MP were found to be the influential predictors of successful outcomes. The inflection point of the ROC curve for unsatisfactory outcomes corresponded to the preoperative MP of 61.8% and the postoperative MP of 5.1%, respectively; these thresholds of the pre- and postoperative MP may serve as a guideline in the indication for a concomitant pelvic osteotomy. Our results also indicate that the severely subluxated or dislocated hip, as well as the hip in which the femoral head is successfully reduced by VDRO but is still contained within the dysplastic acetabulum, may benefit from concomitant pelvic osteotomy.

Pelvic retraction during walking is a common finding seen in patients with spastic hemiplegia. However, potential factors related to this condition have not been comprehensively examined in a systemic manner in previous studies. The purpose of this study was to elucidate any clinical and gait parameters related to pelvic retraction in patients with hemiplegic cerebral palsy. A total of 212 independent ambulatory patients were enrolled in the study. Group I consisted of 113 patients who had persistent pelvic retraction, and Group II of 99 with a normal range of pelvic rotation throughout the gait cycle as evidenced by kinematic analysis. A multivariate logistic regression analysis using a clustering technique was performed, with use of eight gait factors and five clinical factors. Decreased ankle dorsiflexion, increased hip internal rotation, increased anterior pelvic tilt, the Winters classification type II, and asymmetrical posturing of the upper extremity during gait were found to be related to pelvic retraction. This is the only study including a broader array of assessment domains of both clinical and gait parameters with a considerably large and homogenous population with hemiplegia. Further studies will be needed to see whether the rectification of those parameters may improve abnormal gait and pelvic retraction in hemiplegia.