Abstract
Keywords
Dear Editor,
We read with great interest the study by Mamedov et al., which prospectively evaluated gait outcomes following combined multilevel orthopaedic surgery and guided growth in children with unilateral spastic cerebral palsy (USCP). 1 The integration of guided growth to address limb length discrepancy alongside multilevel correction represents an innovative and clinically meaningful approach. The use of instrumented gait analysis strengthens the study’s objectivity by quantifying biomechanical recovery across both involved and uninvolved limbs. However, certain methodological and interpretive considerations warrant further reflection before these results are translated into wider practice.
The study’s use of a nonrandomized design and retrospective analysis of prospectively collected data raises concerns regarding allocation bias and confounding by indication. Children selected for simultaneous guided growth might differ systematically in skeletal maturity or neuromuscular severity from those undergoing surgery alone. 2 Without matched control groups or propensity adjustment, it is difficult to isolate the specific contribution of guided growth to kinematic gains. Clinically, this uncertainty limits the precision with which surgeons can generalize timing and extent of epiphysiodesis for hemiplegic limb equalization.
While gait analysis objectively captured kinetic and kinematic improvements, the absence of patient-centred functional outcomes – such as Gross Motor Function Measure or Functional Mobility Scale – restricts interpretability. Improvements in dorsiflexion or pelvic tilt do not necessarily correspond to enhanced community ambulation or reduced energy expenditure. 3 For rehabilitation planning, it would be informative to correlate biomechanical gains with endurance, participation or quality-of-life metrics to determine whether gait normalization translates into tangible daily-life benefits.
The study’s recommendation of performing guided growth before 12 years of age is supported by radiological correction data but not by validated growth-prediction modelling. Chronologic age does not uniformly represent physeal potential in children with cerebral palsy, whose bone maturation can differ by limb or by side. 4 A more precise approach would incorporate bone-age estimation or growth-remaining algorithms to individualize surgical timing. In clinical terms, premature epiphysiodesis risks overcorrection and angular deviation, whereas delay may cause residual discrepancy and compensatory gait asymmetry.
Finally, the interpretation of uninvolved-limb ‘normalization’ warrants caution. The reported reduction in compensatory hyperflexion and pelvic obliquity could partly reflect adaptive mechanisms rather than true symmetry restoration. As gait in USCP inherently relies on asymmetrical motor strategies, excessive normalization may risk new inefficiencies or contralateral overuse syndromes. 5 Long-term kinetic follow-up beyond 2 years would clarify whether these adjustments remain beneficial or regress with growth.
In summary, this study contributes valuable quantitative evidence supporting combined multilevel surgery and guided growth in managing USCP with limb length discrepancy. Its findings suggest potential biomechanical synergy between deformity correction and equalization procedures. Nonetheless, controlled comparisons, growth-based timing protocols and inclusion of functional outcomes are essential to confirm the true rehabilitative impact of this dual-sided approach.
Supplemental Material
sj-pdf-1-cho-10.1177_18632521251405153 – Supplemental material for Letter to the Editor: High effectiveness of multilevel orthopaedic surgery and guided growth in spastic hemiplegia children
Supplemental material, sj-pdf-1-cho-10.1177_18632521251405153 for Letter to the Editor: High effectiveness of multilevel orthopaedic surgery and guided growth in spastic hemiplegia children by Shyam Sundar Sah and Abhishek Kumbhalwar in Journal of Children's Orthopaedics
Footnotes
Author contributions
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Ethical approval
Not required.
Clinical trial registration details/number
Not applicable, as this study does not report a clinical trial.
Research registry number
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Human ethics and consent to participate declarations
Not applicable as no patient data were collected or analysed in this study.
Generative AI use statement
Generative AI tools, including Paperpal and ChatGPT 5, were utilized solely for language, grammar and stylistic refinement. These tools had no role in the conceptualization, data analysis, interpretation of results, or substantive content development of this manuscript. All intellectual contributions, data analysis and scientific interpretations remain the sole work of the authors. The final content was critically reviewed and edited to ensure accuracy and originality. The authors take full responsibility for the accuracy, originality and integrity of the work presented.
Data availability statement
Not applicable, as no data were generated or analysed in this study.
References
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