Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to satisfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession.

The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning.

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BackgroundBone marrow-derived mesenchymal stromal cells (BM-MSCs) play an important role in modern tissue engineering, while distinct variations of culture media compositions and supplements have been reported. Because MSCs are heterogeneous regarding their regenerative potential and their surface markers, these parameters were compared in four widely used culture media compositions.MethodsMSCs were isolated from bone marrow and expanded in four established cell culture media. MSC yield/1000 MNCs, passage time and growth index were observed. In P4, typical MSC surface markers were analysed by fluorescence cytometry. Additionally, chondrogenic, adipogenic and osteogenic differentiation potential were evaluated.ResultsGrowth index and P0 cell yield varied importantly between the media. The different expansion media had a significant influence on the expression of CD10, CD90, CD105, CD140b CD146 and STRO-1. While no significant differences were observed regarding osteogenic and adipogenic differentiation, chondrogenic differentiation was superior in medium A as reflected by GAG/DNA content.ConclusionsThe choice of expansion medium can have a significant influence on growth, differentiation potential and surface marker expression of mesenchymal stromal cells, which is of fundamental importance for tissue engineering procedures.

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Aim We investigated the long‐term efficacy and safety of multilevel surgery (MLS) in ambulatory children with bilateral spastic cerebral palsy (CP). Method Two hundred and thirty‐one children were evaluated at short term (1.1y, SD 0.4) and long term (9.1y, SD 3.0) follow‐up using clinical examination and gait analysis. MLS was investigated by studying changes in the Gait Profile Score (GPS) referenced to the minimally important clinical difference. Results Ambulatory children aged 10 years and 7 months (SD 2y 11mo) at MLS in Gross Motor Function Classification System levels I (19), II (144), and III (68) showed a decrease (improvement) in preoperative GPS from 16.3° (SD 4.8) to 11.3° (SD 3.2) at short‐term follow‐up, an improvement of 5°. At long‐term follow‐up, GPS was maintained at 11.4° (SD 3.1). Overall, 177 (76.6%) children maintained their improvement in GPS after 9 years. Interpretation Multilevel surgery is a safe and effective surgical intervention, which leads to a significant improvement in gait kinematics in children with bilateral spastic CP. This study improves our understanding of MLS in the long term and will help to inform families and children when planning for MLS. What this paper adds Largest study of multilevel surgery (MLS) for children with bilateral spastic cerebral palsy, with longest follow‐up. MLS resulted in significant long‐term improvements in gait function. Minor adverse events were common, while events requiring intervention were uncommon (4% of children). Thirty‐nine per cent of children required additional surgery during follow‐up. ‘Single‐event multilevel surgery’ was changed to the more realistic term ‘multilevel surgery’.

Tibialis posterior tendon transfer was effective at correcting the foot drop component of cavovarus foot deformity in patients with Charcot-Marie-Tooth disease, with the transfer apparently working as an active substitution. Although passive plantar flexion was not limited after surgery, active plantar flexion at push-off was significantly reduced and it is unknown whether this reduction was the result of a tenodesis effect or calf muscle weakness.

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