Ignacio Martínez-Caballero

IntroductionNeuromuscular scoliosis (NMS) in children poses significant challenges, including postural instability, pain, mobility limitations, and respiratory issues. Sensory dynamic orthosis (SDO) garments provide dynamic compression and proprioceptive feedback aimed at improving alignment and function. This pilot study explored the feasibility and preliminary effectiveness of SDO garments in the management of NMS.MethodsA single-group pre-post, multicentre pilot study was conducted in 30 paediatric patients who used the SDO® Advanced orthosis for six months. Radiographic outcomes (Cobb angle, coronal balance, pelvic obliquity) and functional assessments (FLACC-R scale, Barthel Index) were recorded at baseline and after the intervention. Caregiver-reported satisfaction and perceived functional changes were gathered through a custom-designed questionnaire.ResultsOf the 30 participants, 25 completed the study (median age 13 [IQR 10-15]). Statistically significant within-subject reductions in Cobb angle were observed during SDO use at baseline (median difference -2.6°, p<0.001) and at final evaluation (median paired difference -4.0°, p<0.001). Similar within-subject improvements in coronal balance were observed at both time points (baseline median paired difference -2.1 cm, p<0.001; final -1.8 cm, p=0.005). Pelvic obliquity and Barthel Index scores showed no significant changes. Most caregivers reported slight to moderate improvements in functional domains and high satisfaction. No serious adverse events were observed, and adherence was high.ConclusionsThis pilot study suggests that SDO garments may contribute to short-term postural spinal alignment and balance during wear and perceived functional benefits in children with NMS. These preliminary findings support further research through controlled trials with longer follow-up to clarify clinical relevance and durability of effects.

This commentary is on the original article by Howard et al. on pages 1703‐1711 of this issue.

Introduction Patients with neuromuscular diseases frequently develop hip displacement (HD) and scoliosis, creating complex challenges in determining the optimal treatment strategy and sequence. This study aims to assess the frequency of new hip problems, including pain and HD progression, as well as the need for additional hip surgery following scoliosis correction in neuromuscular patients, and to identify predictive factors for these issues. Methods This retrospective study included 71 neuromuscular patients (142 hips) who underwent posterior spinal fusion (PSF) at a specialized center between 2015 and 2022. Clinical data such as age, sex, underlying pathology, ambulatory status, and prior hip surgeries were collected. Radiological parameters, including curve characteristics, coronal imbalance, Cobb angle, pelvic obliquity (PO), and migration percentage (MP), were measured pre- and post-operatively. Descriptive, comparative, and multivariate analyses, including logistic regression, were performed to identify significant predictors and determine optimal cutoff points. Results The mean age of patients was 15 ± 2 years, with 59% female and 84.5% nonambulatory. After scoliosis surgery, 15.5% of hips developed new hip problems: 20 hips experienced pain and 9 had HD progression, with 7 requiring additional surgery (3 reconstructive and 4 palliative). Factors including a preoperative up-hip and increased MP, with a cutoff > 25%, were strong predictors of hip pain. HD progression was linked to a postoperative up-hip and increased MP, with MP > 60% emerging as a critical predictor. The need for additional hip surgery was associated with cerebral palsy (CP) and with increased MP. Conclusions Approximately 1 in 7 hips developed new-onset problems following PSF in neuromuscular patients. Factors including a preoperative up-hip and increased MP were significant predictors of adverse outcomes, underscoring the importance of thorough preoperative assessment, personalized surgical planning, and proactive counseling regarding potential postoperative complications. Level of evidence Level IV, retrospective cohort study.

Case report: A 10-year-old boy with arthrogryposis multiplex congenita (AMC) presented in a “Buddha position” with severely limited mobility, including bilateral hip, severe knee flexion, and clubfoot deformities. Surgical correction involved (1) bilateral femoral derotation and shortening osteotomies, knee capsulotomies, and soft-tissue releases; (2) gradual left knee extension using an external fixator; and (3) distal femoral extension osteotomies and Verebelyi-Ogston procedures for clubfoot correction. Postoperative recovery involved intensive rehabilitation and orthotic support. Improved lower limb alignment enabled the patient to transition from non-ambulatory to assisted walking with knee-ankle-foot orthosis. Conclusions: This proximal-to-distal approach significantly enhances autonomy in AMC patients with severe deformities.

Introduction: The progression of neurologic cavovarus (NCV) and equinocavovarus (NECV) foot deformities during growth can eventually lead to non-reducible severe talonavicular (TN) and subtalar (ST) joint rotational malalignments. This study aimed to describe a technique to correct severe, resistant inversion deformity of the ST joint complex as the foundational procedure in comprehensive reconstruction of multi-segmental NCV and NECV deformities in pediatric patients and to analyze mid-term radiologic, functional, and satisfaction outcomes. Methods: This prospective study included children with severe NCV and NECV foot deformities who underwent TCNR between 2019 and 2022, with a minimum follow-up of 2 years. Talocalcaneal angle, talus-1 metatarsal angles, and TN coverage angle were measured in preoperative and postoperative weight-bearing foot radiographs. The foot and ankle disability index, foot function index, and Maryland foot score evaluated functionality. Qualitative questions assessed perceived improvement, satisfaction, and expectations of patients/caregivers. Descriptive, comparative pre-post, subgroup, correlation, and satisfaction analysis were performed. Results: Twenty-six patients (36 feet: 16 unilateral and 10 bilateral) were included; 50% were female, median age was 12.1 years (IQR, 3.21) and median follow-up was 32.9 months (IQR, 18.7). Fifty-four percent had cerebral palsy, and 23% had charcot-marie-tooth disease; 84.6% were ambulatory. Significant improvements were found in radiologic parameters and functional outcomes (P0.05). Correlations between radiologic parameters or functional scales with age were generally low. Most reported significant functional improvements, outcomes exceeding expectations, and high satisfaction; they would recommend the surgery and undergo the procedure again. There were 3 minor complications: hypersensitivity, partial recurrence, and undercorrection. Conclusions: The TCNR technique enables realignment of severe, resistant inversion deformity of the ST joint complex in NCV and NECV foot deformities. When combined with procedures to correct the other foot deformities and muscle imbalances, functional outcomes are enhanced, high patient/caregiver satisfaction is achieved, and low complication rates are possible. This approach represents an important modification and extension of an already described technique, the deep plantar-medial release. Level of Evidence: Level III, therapeutic prospective cohort study.

Retrospective analytical study that aims to evaluate the kinematic and kinetic results obtained after percutaneous lengthening with an intramuscular needle (PLIN) of gastrocsoleus complex (GSC) zones I, II, and III, performed outside the operating room between 2018 and 2019, in pediatric patients with equinus gait resistant to non-operative treatment. Gait analysis was performed prior to treatment and 6 months post treatment in 48 ankles (30 patients), with a median patient age of 10.11 (2.85) years. Twelve patients had a diagnosis of idiopathic equinus, twelve spastic hemiplegia, and six spastic diplegia. Statistical analysis included pre–post comparison, correlation, and linear regression of critical kinematic and kinetic ankle values. Significant improvement was observed for the following parameters: ankle angle at initial contact, −4.57(10.31)/0.05(3.04)°; maximum ankle dorsiflexion in the stance phase (mADFStP), 3.70(7.56)/10.42(4.52)°; and maximum ankle dorsiflexion in the swing phase (mADFSwP), −6.54(8.41)/−0.35(6.17)°. In addition, an inversely proportional correlation with pre-intervention values was obtained for those parameters, with rho values of −0.864, −0.755, and −0.696, respectively (p < 0.0005). No significant changes in ankle kinetics were evidenced. Linear regression equations allowed for estimation of the post mADFStP, with a standard error (SE) = 1.82; R² = 0.797 (p < 0.0005), and the post mADFSwP, with an SE = 2.376; R² = 0.829 (p < 0.0005). To conclude, the addition of the GSC in patients with resistant equinus significantly improves ankle initial contact, mADFStP, and mADFSwP, with greater changes occurring with worse initial values. The regression formulas used to estimate post-procedure results will allow therapeutic indications to be adjusted.

A retrospective study that aims to analyze the safety and efficacy of single-event multilevel surgery (SEMLS) involving bifocal femoral osteotomy (BFO) performed in nine non-ambulatory children with neuromuscular diseases (NMD), with a median age of 12.86 years, to resolve both hip subluxation and ipsilateral knee flexion contracture that impaired standing, and to evaluate patient and caregiver satisfaction. Results: Median surgical time was 4 h 15 min (2 h 35 min–5 h 50 min). Hip flexion deformity improved by a median of 30° (15–35), while median improvement in knee flexion deformity was 30° (20–50). Only two patients could use a standing frame prior to surgery, although with increasing difficulty, while all children could use it following SEMLS. Mean follow-up was 27.47 months (24.33–46.9). Significant blood loss requiring transfusion was the only complication recorded (8/9). All caregivers reported slight, moderate, or significant improvement in all domains of the questionnaire, and all would undergo the procedure again and recommend it to others, as nearly all (8/9) were very satisfied. Conclusion: The findings of this study suggest that SEMLS including BFOs in non-ambulatory children with NMD can correct hip, knee, and foot deformities and simultaneously realign lower limbs to restore functional standing and wheelchair transfer. The functional results, safety, and degree of satisfaction achieved justify offering this strategy to families.