Hypertonia occurs commonly in individuals with cerebral palsy and can impair comfort, functional progress, skin integrity and caretaking. In these cases, management of hypertonia is essential to improve function and quality of life. Non-surgical management of hypertonia can be achieved through non-pharmacologic, pharmacologic and procedural interventions, and in many cases a combination of these strategies is employed to optimize function and quality of life in those with cerebral palsy.Non-pharmacologic management includes the use of orthoses, physical and occupational therapies and the inclusion of evidence-based therapeutic techniques. Pharmacologic management is the use of enteral medication to minimize generalized hypertonia. Procedural management involves targeted injection of muscle groups or of nerves or their motor points and is typically used for focal hypertonia.In summary, hypertonia management involves a multidisciplinary approach and is tailored individually based on the severity, pattern and distribution of hypertonia, functional level, goals and social context. Commonly, multiple treatment modalities are used to achieve the best outcome for the individual.
Neuromuscular scoliosis (NMS) is a progressive spinal deformity commonly seen in children with cerebral palsy (CP), particularly in those with severe functional impairment. Operative treatment is indicated for progressive deformity, functional decline, and impaired quality of life, with curve magnitude and pelvic obliquity remaining important decision-making factors. Careful preoperative multidisciplinary assessment is essential given the high burden of pulmonary, nutritional, and medical comorbidities in this population. The risk of major complications after surgery is as high as 39%, which underlines the importance of multidisciplinary management and good preoperative optimization. Although complication rates remain high, recent literature demonstrates durable radiographic correction and meaningful improvements in health-related quality of life. Continued advances in surgical techniques and perioperative optimization remain essential to further improve outcomes in this high-risk patient population.
Hypertonia in cerebral palsy, including spasticity and dystonia, contributes to progressive musculoskeletal deformity, impaired mobility, pain, and challenges with care. When conservative measures fail, surgical tone management offers targeted interventions to reduce pathologic tone and improve function, comfort, and quality of life.This article provides a practical, technique-focused review of the principal neurosurgical strategies for tone management, including intrathecal baclofen pump placement, selective dorsal rhizotomy, ventral–dorsal rhizotomy, and deep brain stimulation with consideration of both lower and upper extremity involvement. Emphasis is placed on context driven and phenotype-driven patient selection, differentiation of dynamic tone abnormalities from fixed deformities, and integration of surgical decision-making within a multidisciplinary care framework. Key operative steps, technical nuances, and procedure-specific pitfalls are highlighted.A tailored, multidisciplinary approach is essential to optimize outcomes. As surgical techniques continue to evolve, including minimally invasive and precision-based approaches, treatment paradigms are increasingly shifting toward individualized, goal-directed strategies for tone management in cerebral palsy.
Upper extremity involvement in cerebral palsy results from complex muscle imbalance, spasticity, weakness, and progressive contracture, producing characteristic deformities that may impair function, hygiene, appearance, and independence. Although nonoperative management remains the mainstay of treatment, carefully selected patients may benefit from surgical intervention based on individualized, realistic goals and comprehensive assessment of the entire upper extremity. Surgical planning should account for the dynamic interaction among the shoulder, elbow, forearm, wrist, fingers, and thumb, with single-event multilevel surgery frequently used to restore muscle balance and optimize limb positioning and function.This review describes the operative principles and techniques used to manage upper extremity deformity in cerebral palsy. Soft-tissue procedures, including musculotendinous lengthening, releases, and tendon transfers, remain central to surgical reconstruction, while hyperselective neurectomy provides an evolving option for selected patients with dynamic spasticity and preserved voluntary motor control. Osteotomy and arthrodesis may be appropriate for severe fixed deformities when soft-tissue reconstruction is insufficient. Specific operative strategies for deformities of the shoulder, elbow, forearm and wrist, and thumb-in-palm are reviewed, emphasizing appropriate patient selection, technical principles, postoperative rehabilitation, and the importance of matching the surgical approach to each patient's functional abilities and goals.
Hamstring injuries are increasingly recognized across both elite and recreational athletic populations and most commonly result from high-load eccentric contraction. Injury patterns span the musculotendinous unit, including proximal injuries at the ischial tuberosity, intramuscular tears, and distal tendon injuries at the tibia or fibula. Patients typically present with posterior thigh pain, ecchymosis, and functional weakness. Magnetic resonance imaging is the diagnostic modality of choice, allowing accurate characterization of injury location, severity, and chronicity, and assisting with treatment stratification. Management is guided by the number of tendons involved, degree of retraction, and patient-specific factors. While the majority of hamstring injuries can be treated successfully with nonoperative measures such as activity modification, structured rehabilitation, and biologic adjuncts like platelet-rich plasma, for the appropriate patient, surgery for proximal hamstring tears is a viable treatment option. Surgical intervention, performed through either open or endoscopic techniques, is generally indicated for multi-tendon avulsions with significant retraction or for persistent symptoms despite prolonged conservative management, with earlier operative repair often associated with more favorable outcomes.
Femoral neck stress injuries are an important cause of hip pain often in the setting of overuse. These injuries may be misdiagnosed because radiographs are frequently normal. Recognizing these injuries early is crucial, as prompt treatment can prevent progression of the fracture. Delays in diagnosis can lead to worsening of the condition and potentially catastrophic outcomes including a displaced fracture and osteonecrosis of the femoral head. This manuscript will review risk factors for femoral neck stress injuries and optimal evaluation and management. Magnetic resonance imaging remains the diagnostic gold standard and is essential for injury grading which determines medical or surgical management. Acute management includes cessation of activity and initiation of non-weightbearing restrictions. Definitive management of femoral neck stress injuries is based on both the grade and injury location, which will be discussed in depth. Surgical intervention may be necessary, and the authors’ preferred surgical technique will be described. Regardless of treatment modality, recovery after a femoral neck stress injury often requires 6-9 months. The modest published return to sport rates reveal the importance of physicians having realistic conversations with their patients about recovery expectations and the likelihood of return to sport.
Hip microinstability is an increasingly recognized cause of hip pain and dysfunction in young, active patients. The hip joint relies on both static stabilizers (labrum, capsule, ligamentum teres) and dynamic stabilizers (periarticular musculature) to maintain stability, with greater reliance on soft tissue structures for anterior stability due to asymmetric bony coverage. Hip microinstability is a multifactorial phenomenon that can be broadly categorized into 6 etiologies: bony abnormalities/dysplasia, connective tissue disorders, posttraumatic, microtraumatic, iatrogenic, and idiopathic. The scope of this review is to focus on microtraumatic hip anterior instability, the most common etiology that presents in the outpatient office setting of most sports medicine surgeons. The most common presenting symptoms include anterior hip pain, subjective instability with gait, and mechanical symptoms. Physical examination should include provocative maneuvers such as the anterior apprehension test, abduction-extension-external rotation test, and prone external rotation test, which together demonstrate a 95% positive predictive value for intraoperative confirmation. Imaging evaluation includes radiographs assessing the cliff sign and femoro-epiphyseal acetabular roof (FEAR) index, computed tomography (CT) for three-dimensional bony assessment, and magnetic resonance imaging (MRI) for soft tissue evaluation including capsular laxity and secondary chondrolabral lesions. The 2023 international Delphi consensus established standardized diagnostic criteria for diagnoses of hip microinstability via a combination of minor and major factors from a patient’s history, examination, and imaging. Nonoperative management with physical therapy focusing on dynamic stabilizer strengthening is first-line treatment and is generally trialed for 3 months. Surgical management includes arthroscopic or open plication, capsular reconstruction for unrepairable capsular defects, and ligamentum teres reconstruction for complete tears with multidirectional instability or in patients who have failed prior stabilization procedures.
Groin pain in athletes is diagnostically challenging due to the frequent coexistence of intra- and extra-articular pathology. Core muscle injury (CMI), also known as sports hernia or athletic pubalgia, involves dysfunction of the lower abdominal wall and adductor attachments at the pubic symphysis. Femoroacetabular impingement (FAI) syndrome is a mechanical hip disorder caused by abnormal femoral–acetabular contact. Both conditions commonly affect young, high-demand athletes and share overlapping clinical presentations, often leading to delayed or incomplete diagnosis. This manuscript reviews the anatomy, pathophysiology, diagnostic approach, treatment strategies, and outcomes associated with CMI. Restricted hip motion from FAI syndrome may increase stress across the pubic symphysis and abdominal–adductor complex, predisposing athletes to secondary CMI. Diagnosis relies on careful history, targeted physical examination, and advanced imaging to identify the primary pain generator. Initial management for both CMI and FAI syndrome emphasizes structured rehabilitation, though a subset of athletes ultimately requires surgical intervention. Available evidence demonstrates high return-to-sport rates following operative treatment of either pathology, with increasing support for combined or staged surgical management in athletes with dual pathology. A representative adolescent athlete case is presented to highlight the importance of interdisciplinary evaluation and individualized treatment planning. Early recognition of concomitant CMI and FAI syndrome and collaborative management between hip preservation and core muscle specialists are critical for durable symptom resolution and successful return to sport.
Traumatic dislocation of a native hip is an uncommon but devastating injury. Most traumatic hip dislocations are caused by high-energy mechanisms, such as motor vehicle collisions, but can also be caused by sports-related trauma or low-energy falls in elderly patients. Regardless of mechanism, hip dislocations are often accompanied by associated fractures, as well as chondral, labral, and neurovascular injuries. Advanced imaging has greatly improved the detection of subtle fractures and intra-articular pathology that can guide the choice of treatment. A comprehensive understanding of hip anatomy is crucial for achieving optimal outcomes in these patients. Dislocations can be managed nonoperatively if there is a concentric reduction with no associated intra-articular pathology or fracture. Operative indications include failed closed reductions, nonconcentric reduction secondary to fracture or intra-articular loose bodies, and certain fracture patterns. Operative options include both arthroscopic and open techniques. This narrative review summarizes the current literature on the anatomy, diagnosis, acute management, operative and nonoperative indications, and long-term outcomes of traumatic native hip dislocations in adults.
Myelomeningocele is a complex congenital condition resulting from failed neural tube closure and is associated with a wide spectrum of musculoskeletal deformities arising from paralysis, muscle imbalance, and abnormal innervation below the level of the spinal lesion. Improvements in medical care have increased survival into adulthood, leading to a growing need for thoughtful, longitudinal orthopaedic management. The chapter outlines the pathoanatomy and classification of myelomeningocele, highlighting the importance of functional neurologic level and ambulatory potential in guiding treatment. Principles of preoperative evaluation, including neurologic assessment, skin integrity, and gait analysis, are reviewed to support individualized surgical planning. Detailed discussions of operative indications and techniques are presented for common deformities of the foot, knee, hip, and lower limb rotation. Particular attention is given to achieving flexible, plantigrade, braceable feet; addressing knee contractures while minimizing postoperative stiffness; correcting clinically significant torsional malalignment; and managing hip contractures with an emphasis on function rather than radiographic reduction. Postoperative considerations unique to this population, including risks of skin breakdown, fracture, and recurrence, are also addressed. Throughout, the manuscript underscores the importance of exhausting nonoperative measures, avoiding procedures that increase rigidity in insensate limbs, and engaging in multidisciplinary care. This review aims to provide orthopaedic surgeons with practical guidance for safe, effective, and function-oriented surgical management of children with myelomeningocele. Oper Tech Orthop 35:101210 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Duchenne muscular dystrophy (DMD) is a progressive X-linked neuromuscular disorder characterized by predictable patterns of muscle weakness, contracture formation, spinal deformity, fracture risk, and cardiopulmonary decline. Although advances in medical and gene-targeted therapies have improved survival and delayed functional deterioration, orthopaedic surgery remains a critical component of comprehensive care. This manuscript provides a detailed, stage-based framework for the orthopaedic surgical management of DMD, emphasizing the integration of neuromuscular progression, functional goals, and systemic risk into operative decision-making. The chapter reviews the natural history and pathophysiology of DMD and outlines the chronological evolution of musculoskeletal pathology across ambulatory and nonambulatory stages. Surgical indications, contraindications, and technical considerations are discussed for lower extremity contracture management, fracture stabilization, and spinal deformity correction. Particular attention is given to the timing of intervention, highlighting the narrow window in which surgery can meaningfully preserve ambulation and the shift toward seating, comfort, and skin integrity once wheelchair dependence is established. Oper Tech Orthop 35:101211 Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
Cerebral palsy (CP) is characterized by a static neurologic injury with progressive musculoskeletal manifestations that evolve throughout growth and development. Operative management has shifted from reactive correction of established deformity to proactive, surveillance-guided intervention aimed at preserving function, minimizing pain, and preventing irreversible joint pathology. This article presents a contemporary operative framework for children with cerebral palsy, emphasizing hip surveillance as the foundational model, emerging knee surveillance and growth modulation strategies, coordinated spine considerations, and the integration of gait analysis to guide multilevel surgical decisionmaking. Foot and ankle deformities are addressed using a pattern-based approach that prioritizes timing, restraint, and prevention of recurrence. Throughout, we highlight the importance of multidisciplinary care, tone management, rehabilitation, and family engagement. Oper Tech Orthop 35:101209 (c) 2026 Published by Elsevier Inc.
Hereditary motor sensory neuropathies (HMSN) are a group of hereditary, chronic, distal mixed motor and sensory polyneuropathies with variable presentations, disease courses and underlying genetic causes. Most commonly, the clinical manifestations present in adolescence with distal extremity weakness, loss of deep tendon reflexes (DTR), and foot deformity. Careful history may reveal relatives with similar findings, although phenotypic presentation is variable even with comparable genotype. Workup should include electrophysiology testing, which will primarily demonstrate either prolonged nerve conduction velocity (NCV) in demyelinating forms or decreased signal amplitude in axonal forms. Genetic testing confirms diagnosis, with the most common variant being a duplication of PMP22. For the managing orthopaedic surgeon, careful evaluation of the feet, hips, spine and hands is recommended. The most common musculoskeletal manifestation requiring surgery is cavovarus foot deformity; acetabular dysplasia and scoliosis are less common clinical manifestations. Oper Tech Orthop 35:101214 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Congenital myopathies (CMs) represent a heterogeneous group of inherited muscle disorders that typically present in infancy or early childhood with hypotonia, weakness, and distinctive myopathologic features observable on muscle biopsy. While primarily considered neuromuscular disorders, CMs often lead to significant orthopaedic complications including spinal deformity, hip instability, joint contractures, and ambulatory decline. These musculoskeletal manifestations frequently require surgical intervention, making orthopaedic management an essential component of care. The purpose of this article is to provide a comprehensive review of the classification, pathophysiology, and genetics of congenital myopathies, emphasizing implications for orthopaedic surgeons. Operative strategies for spine and hip deformities, contracture management, perioperative considerations, rehabilitation, and emerging genetic therapies are discussed. Primary sources are cited throughout to provide evidence-based recommendations. Oper Tech Orthop 35:101212 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Spinal muscular atrophy (SMA) is a rare autosomal recessive neuromuscular degeneration of motor neurons within the anterior horn of the spinal cord, leading to muscle weakness, and significant musculoskeletal complications. The clinical spectrum of SMA ranges from severe infantile-onset disease with limited survival to milder adult-onset forms. The severity of SMA is closely linked to the quantity of functional SMN protein available, which is partially determined by the SMN2 gene, a paralog of SMN1. Recent advances in disease-modifying therapies have dramatically altered survival and functional outcomes, necessitating a reassessment of traditional orthopaedic management strategies. This chapter reviews the epidemiology, genetic basis, and classification of SMA, with a focused discussion on contemporary orthopaedic manifestations and interventions. Common orthopaedic complications include hip instability and spinal deformities, particularly in non-ambulatory patients with SMA Types I and II. Emphasis is placed on the importance of early surveillance, multidisciplinary care, and individualized treatment planning to optimize function, comfort, and quality of life. Non-operative strategies such as structured hip surveillance, bracing for symptomatic support, and rehabilitative interventions are discussed alongside surgical options, including guided growth, osteotomies, growth-friendly spinal instrumentation, and definitive spinal fusion. The evolving natural history of SMA in the era of disease-modifying therapies presents new challenges and opportunities for orthopaedic care. Improved motor function and extended life expectancy have expanded the role of orthopaedic intervention while underscoring the need for longitudinal data to guide evidence-based decision-making. Ongoing collaboration between orthopaedic surgeons, neurologists, rehabilitation specialists, and families remains essential to address the complex and changing needs of individuals with SMA. Oper Tech Orthop 35:101213 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Spinal muscular atrophy (SMA) and Duchenne muscular dystrophy (DMD) are among the most common pediatric genetic neuromuscular disorders encountered in contemporary orthopaedic and multidisciplinary practice. Historically associated with progressive disability and reduced life expectancy, both conditions have undergone a profound shift in clinical trajectory with the advent of disease-modifying therapies (DMTs). This manuscript reviews the mechanisms, indications, efficacy, and limitations of current DMTs for SMA and DMD, with particular emphasis on their implications for musculoskeletal care and surgical decision-making. For SMA, therapies targeting survival motor neuron (SMN) protein deficiency-including intrathecal antisense oligonucleotides, oral splicing modifiers, and gene replacement therapy-have significantly improved survival and motor milestone attainment, especially when initiated early. In DMD, corticosteroids remain foundational, complemented by newer agents such as dissociative steroids, exon-skipping therapies, histone deacetylase inhibitors, and emerging gene therapies aimed at restoring dystrophin expression or mitigating downstream muscle degeneration. While these therapies slow disease progression and extend ambulation, their benefits vary by genotype, age at treatment initiation, and disease stage. As survival and functional longevity improve, orthopaedic manifestations such as scoliosis, contractures, hip pathology, and bone health disorders are evolving in both prevalence and presentation. These changes necessitate updated surveillance strategies, thoughtful timing of orthopaedic interventions, and close coordination between neurology, orthopaedics, rehabilitation, pulmonology, and cardiology. Understanding the scope and limitations of DMTs is essential for optimizing long-term musculoskeletal outcomes and aligning orthopaedic goals with the altered natural history of SMA and DMD in this rapidly advancing therapeutic era. Oper Tech Orthop 35:101215 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
