Slide 100 — McHale procedure

Clean FRCS notes with inline figures

•XR of this skeletally immature patient showing broken Shenton's and dislocated left hip

•The acetabular index is increased, and the neck shaft angle is also increased with perhaps more anteversion noted

•Reimer migration index (RMI) is increased

•I suspect this is a neuromuscular dislocation rather than DDH as evidenced by the relatively well formed tear drop and femoral head. Also pelvis looks inlet view due to pelvic anteversion from tight rectus

•Look for VP drain

•Triradiate cartilage fuses at 11-13yo

History

Perinatal history + Birth history

•Developmental milestone (age of sitting and walking)

•Problems faced by patient him/herself

•Problems faced by carer (perineal hygiene, pain, transfer, sitting)

•Determine GMFCS level (I no restriction II stairs rails III wheelchair IV powered wheelchair V self mobility limited

•Other medical problems

•Social support

•GMFCS 3 walker, 4 sitter

•If still very young, try to prognosticate if walker or not

•Good prognosis: head control by 9mo, sit by 2 yr, hemiplegic

•Bad prognosis: Persistent primitive reflex >1yo (Bleck), lack of head control by 20 months, non ambulatory by 7 yr

Examination

•General

•IQ

•Sitting balance

•Gait – assess stance and swing phase

•Orthosis

•Specific

•Hip tone, ROM, Thomas or Staheli test for FFC, adductor tightness by Phelps test, rectus tightness by Duncan Ely, ITB by Ober

•Knee tone, ROM, popliteal angle (hamstring shift is more accurate to see if psoas contracture is contributing)

•Ankle tone, ROM, silverskiold test, any bony impingement or impending ulcers

•Spine for scoliosis

•Pelvic obliquity

•LLD

•If non-ambulatory and >1yo, perform primitive reflexes, 2 or more is poor prognosis for walking according to Bleck

•Gait analysis lab for quantitative measurements

Management

•Multi-disciplinary approach (Paed, NS, Ortho, PT, Occu, P&O, MSW, family)

•Expectation management: Ortho has role only in spastic type, not able to reverse the primary insult

•Community-based, minimize hospital admissions

•Aims: maximize patient’s function consistent with the current disease status and prevent deterioration

Patient specific aims

•Walker – want to achieve an efficient gait, as described by Gage (stability in stance phase, adequate stride length, proper preposition of foot for heel strike, enough foot clearance, energy conservation) + prevent early OA

•Sitter – Spinopelvic balance, perineal hygiene, mobile knees (flex to sit, extend to brace for transfer), plantigrade feet

Medical management of spasticity

•- Physio, analgesia, wheelchair modification

•- Oral or intrathecal baclofen

•- Botox injection (3-6 months)

Surgery:

•Timing: delay OT as long as possible (>6yo), but before tertiary issue (contain hip before dislocation, gait modification before deviation)

•SEMLS (Single event multilevel surgery) vs OSSCS [orthopaedic selective spasticity control surgery = correct lever arm dysfunction by releasing or lengthening the biarticular muscles and preserving the monoarticular antigravity muscles]

•Prevent birthday syndrome

•Components

•Balance spasticity

•Prevent contractures

•Correct lever arm dysfunction

•Hip dysplasia in CP is preventable

•Spastic, bi-articular (adductor) more spasm than mono articular (abductor) → hip out

Treatment

•Conservative + Surveillance (Xray before 3 y.o. repeat one in 6 y.o. If walker, refer ortho if abd <30, or RMI >33%)

•According to the NICE guidelines and the Swedish CPUP study

•Reimer migration index, hip abduction

Early subluxation (RMI 33-50%):

•Botox / soft tissue release by adductor tenotomy, iliopsoas lengthening +/- hamstring lengthening, nighttime abduction splint

•(adductor longus transect, protect anterior branch of obturator nerve, gracilis myotomy, adductor brevis lengthening

•Moderate subluxation (RMI>50%)

Surgery – VDRO / pelvic osteotomy

•Dislocation

Surgery – recon vs salvage

•Depends on time

•Early <1yr: recon (OR + soft tissue release + VDRO +/- shortening osteotomy +/- pelvic osteotomy: dega or triple osteotomy)

•Late >1yr: observe if no pain, if pain, salvage, Girdlestone, capsule interpositional arthroplasty, McHale procedure (subtrochanteric valgus osteotomy + femoral head excision)

So we operate if the patient has dislocated hip but asymptomatic?

•Evidence suggests that less than 50% of asymptomatic dislocated hips will develop pain in the long run. As such, observation of asymptomatic hip can be supported

Why increased anteversion and valgus?

•Psoas spastic, hip flexed, reduced torque on proximal femur, femur cannot derotate, so anteversion. Valgus as non weight bearing

Follow-up

•Valgus ok

•But don’t understand anteversion

Cerebral Palsy:

•A neuromuscular disorder caused by non progressive insult to the immature brain. Primary neurological insult is non progressive but musculoskeletal features evolve as the child grows

Classification

•Topographically: Diplegic [bil LL more affected than bil UL], hemiplegic, quadriplegic

•Neurologically (5): spastic, hypotonic, mixed, athetoid (dyskinetic), ataxic

•Functionally: GMFCS (I – free ambulatory, II – rails with stairs, III – walking aid/ wheelchair, IV – head control, V no head control)

Issues:

•Primary deviation: loss of selective motor control, leading to muscle balance, abnormal tone and coordination

•Secondary deviation: growth related deviation that arise due to abnormal loading in the setting of primary gait deviations

•Anatomic shortening of muscle tendon unit (e.g. myostatic contractures)

•Persistent bone deformities due to HV principle (e.g. femoral anteversion)

•Joint subluxations/ dislocations

•Tertiary: compensatory deformities, become apparent when secondary is corrected

•Spasticity – velocity dependent increase in tone (due to loss of supraspinal inhibition)

•Measured with Tardieu scale (R1 R2 with different velocity)

Treatment: Global vs focal

•Global

•Selective dorsal rhizotomy (decrease afferent input from muscle spindle)

•Baclofen (GABA agonist → increase K channel opening → easy hyperpolarization)

•Gabapentin (VGCC deactivator → decrease nerve excitation and decrease neurotransmitter release)

•Focal: Botox

•Contracture – shortening of musculotendinous unit (due to slowing of growth due to lack of tensile loading) – Treatment: muscle (release or transfer), joint (release), bone (osteotomy)

•Lever arm dysfunction

•Unstable fulcrum (hip dislocation)

•Floppy lever (pes planus)

•Short lever (coxa valga)

•Malrotation (tibial ER)

Winter classification of CP gaits

•Hemiplegic gaits

•Foot drop → hinged AFO/ solid AFO

•True equinus - Gastroc soleus contracture → hinged AFO → heel cord lengthening

•Jump knee – Spastic hamstring + triceps surae → hinged AFO → no OT

•Apparent equinus – Iliopsoas contracture + gastroc weakness → solid AFO → psoas lengthening

•Diplegic gaits

•True equinus

•Jump knee

•Apparent equinus

•Crouch knee

•Recurvatum knee

•Stiff knee (swing phase problem)

#	lvl	marL	indent	logical	original note line
1	0	0	0	0	XR of this skeletally immature patient showing broken Shenton's and dislocated left hip
2	0	0	0	0	The acetabular index is increased, and the neck shaft angle is also increased with perhaps more anteversion noted
3	0	0	0	0	Reimer migration index (RMI) is increased
4	0	0	0	0	I suspect this is a neuromuscular dislocation rather than DDH as evidenced by the relatively well formed tear drop and femoral head. Also pelvis looks inlet view due to pelvic anteversion from tight rectus
5	0	0	0	0	Look for VP drain
6	0	0	0	0	Triradiate cartilage fuses at 11-13yo
7	0	0	0	0	Go back to history:
8	0	228600	-228600	1	Perinatal history + Birth history
9	0	228600	-228600	1	Developmental milestone (age of sitting and walking)
10	0	228600	-228600	1	Problems faced by patient him/herself
11	0	228600	-228600	1	Problems faced by carer (perineal hygiene, pain, transfer, sitting)
12	0	228600	-228600	1	Determine GMFCS level (I no restriction II stairs rails III wheelchair IV powered wheelchair V self mobility limited
13	0	228600	-228600	1	Other medical problems
14	0	228600	-228600	1	Social support
15	0	0	0	0	GMFCS 3 walker, 4 sitter
16	0	0	0	0	If still very young, try to prognosticate if walker or not
17	1	457200	0	1	Good prognosis: head control by 9mo, sit by 2 yr, hemiplegic
18	1	457200	0	1	Bad prognosis: Persistent primitive reflex >1yo (Bleck), lack of head control by 20 months, non ambulatory by 7 yr
19	0	0	0	0	PE:
20	0	0	0	0	General
21	0	171450	-171450	1	IQ
22	0	171450	-171450	1	Sitting balance
23	0	171450	-171450	1	Gait – assess stance and swing phase
24	0	171450	-171450	1	Orthosis
25	0	0	0	0	Specific
26	0	171450	-171450	1	Hip tone, ROM, Thomas or Staheli test for FFC, adductor tightness by Phelps test, rectus tightness by Duncan Ely, ITB by Ober
27	0	171450	-171450	1	Knee tone, ROM, popliteal angle (hamstring shift is more accurate to see if psoas contracture is contributing)
28	0	171450	-171450	1	Ankle tone, ROM, silverskiold test, any bony impingement or impending ulcers
29	0	171450	-171450	1	Spine for scoliosis
30	0	171450	-171450	1	Pelvic obliquity
31	0	171450	-171450	1	LLD
32	0	0	0	0	If non-ambulatory and >1yo, perform primitive reflexes, 2 or more is poor prognosis for walking according to Bleck
33	0	0	0	0	Gait analysis lab for quantitative measurements
34	0	0	0	0	Mx:
35	0	228600	-228600	1	Multi-disciplinary approach (Paed, NS, Ortho, PT, Occu, P&O, MSW, family)
36	0	228600	-228600	1	Expectation management: Ortho has role only in spastic type, not able to reverse the primary insult
37	0	228600	-228600	1	Community-based, minimize hospital admissions
38	0	0	0	0	Aims: maximize patient’s function consistent with the current disease status and prevent deterioration
39	0	0	0	0	Patient specific aims
40	0	0	0	0	Walker – want to achieve an efficient gait, as described by Gage (stability in stance phase, adequate stride length, proper preposition of foot for heel strike, enough foot clearance, energy conservation) + prevent early OA
41	0	0	0	0	Sitter – Spinopelvic balance, perineal hygiene, mobile knees (flex to sit, extend to brace for transfer), plantigrade feet
42	0	0	0	0	Medical management of spasticity
43	0	0	0	0	- Physio, analgesia, wheelchair modification
44	0	0	0	0	- Oral or intrathecal baclofen
45	0	0	0	0	- Botox injection (3-6 months)
46	0	0	0	0	Surgery:
47	0	0	0	0	Timing: delay OT as long as possible (>6yo), but before tertiary issue (contain hip before dislocation, gait modification before deviation)
48	0	0	0	0	SEMLS (Single event multilevel surgery) vs OSSCS [orthopaedic selective spasticity control surgery = correct lever arm dysfunction by releasing or lengthening the biarticular muscles and preserving the monoarticular antigravity muscles]
49	0	0	0	0	Prevent birthday syndrome
50	0	0	0	0	Components
51	1	685800	-228600	2	Balance spasticity
52	1	685800	-228600	2	Prevent contractures
53	1	685800	-228600	2	Correct lever arm dysfunction
54	0	0	0	0	-------------------------------
55	0	0	0	0	Hip dysplasia in CP is preventable
56	0	0	0	0	Spastic, bi-articular (adductor) more spasm than mono articular (abductor) → hip out
57	0	0	0	0	Treatment
58	0	228600	-228600	1	Conservative + Surveillance (Xray before 3 y.o. repeat one in 6 y.o. If walker, refer ortho if abd <30, or RMI >33%)
59	1	628650	-171450	2	According to the NICE guidelines and the Swedish CPUP study
60	1	628650	-171450	2	Reimer migration index, hip abduction
61	0	228600	-228600	1	Early subluxation (RMI 33-50%):
62	1	685800	-228600	2	Botox / soft tissue release by adductor tenotomy, iliopsoas lengthening +/- hamstring lengthening, nighttime abduction splint
63	1	457200	0	1	(adductor longus transect, protect anterior branch of obturator nerve, gracilis myotomy, adductor brevis lengthening
64	0	228600	-228600	1	Moderate subluxation (RMI>50%)
65	1	685800	-228600	2	Surgery – VDRO / pelvic osteotomy
66	0	228600	-228600	1	Dislocation
67	1	685800	-228600	2	Surgery – recon vs salvage
68	1	685800	-228600	2	Depends on time
69	2	1143000	-228600	3	Early <1yr: recon (OR + soft tissue release + VDRO +/- shortening osteotomy +/- pelvic osteotomy: dega or triple osteotomy)
70	2	1143000	-228600	3	Late >1yr: observe if no pain, if pain, salvage, Girdlestone, capsule interpositional arthroplasty, McHale procedure (subtrochanteric valgus osteotomy + femoral head excision)
71	0	0	0	0	So we operate if the patient has dislocated hip but asymptomatic?
72	0	0	0	0	Evidence suggests that less than 50% of asymptomatic dislocated hips will develop pain in the long run. As such, observation of asymptomatic hip can be supported
73	0	0	0	0	Why increased anteversion and valgus?
74	0	171450	-171450	1	Psoas spastic, hip flexed, reduced torque on proximal femur, femur cannot derotate, so anteversion. Valgus as non weight bearing
75	0	0	0	0	FU:
76	0	0	0	0	Valgus ok
77	0	0	0	0	But don’t understand anteversion
78	0	0	0	0	==============================================
79	0	0	0	0	Cerebral Palsy:
80	0	171450	-171450	1	A neuromuscular disorder caused by non progressive insult to the immature brain. Primary neurological insult is non progressive but musculoskeletal features evolve as the child grows
81	0	171450	-171450	1	Classification
82	1	628650	-171450	2	Topographically: Diplegic [bil LL more affected than bil UL], hemiplegic, quadriplegic
83	1	628650	-171450	2	Neurologically (5): spastic, hypotonic, mixed, athetoid (dyskinetic), ataxic
84	1	628650	-171450	2	Functionally: GMFCS (I – free ambulatory, II – rails with stairs, III – walking aid/ wheelchair, IV – head control, V no head control)
85	0	0	0	0	Issues:
86	0	228600	-228600	1	Primary deviation: loss of selective motor control, leading to muscle balance, abnormal tone and coordination
87	0	228600	-228600	1	Secondary deviation: growth related deviation that arise due to abnormal loading in the setting of primary gait deviations
88	1	628650	-171450	2	Anatomic shortening of muscle tendon unit (e.g. myostatic contractures)
89	1	628650	-171450	2	Persistent bone deformities due to HV principle (e.g. femoral anteversion)
90	1	628650	-171450	2	Joint subluxations/ dislocations
91	0	228600	-228600	1	Tertiary: compensatory deformities, become apparent when secondary is corrected
92	0	0	0	0	Spasticity – velocity dependent increase in tone (due to loss of supraspinal inhibition)
93	0	0	0	0	Measured with Tardieu scale (R1 R2 with different velocity)
94	0	0	0	0	Treatment: Global vs focal
95	1	628650	-171450	2	Global
96	2	1085850	-171450	3	Selective dorsal rhizotomy (decrease afferent input from muscle spindle)
97	2	1085850	-171450	3	Baclofen (GABA agonist → increase K channel opening → easy hyperpolarization)
98	2	1085850	-171450	3	Gabapentin (VGCC deactivator → decrease nerve excitation and decrease neurotransmitter release)
99	1	628650	-171450	2	Focal: Botox
100	0	0	0	0	Contracture – shortening of musculotendinous unit (due to slowing of growth due to lack of tensile loading) – Treatment: muscle (release or transfer), joint (release), bone (osteotomy)
101	0	0	0	0	Lever arm dysfunction
102	1	628650	-171450	2	Unstable fulcrum (hip dislocation)
103	1	628650	-171450	2	Floppy lever (pes planus)
104	1	628650	-171450	2	Short lever (coxa valga)
105	1	628650	-171450	2	Malrotation (tibial ER)
106	0	0	0	0	Winter classification of CP gaits
107	0	0	0	0	Hemiplegic gaits
108	0	228600	-228600	1	Foot drop → hinged AFO/ solid AFO
109	0	228600	-228600	1	True equinus - Gastroc soleus contracture → hinged AFO → heel cord lengthening
110	0	228600	-228600	1	Jump knee – Spastic hamstring + triceps surae → hinged AFO → no OT
111	0	228600	-228600	1	Apparent equinus – Iliopsoas contracture + gastroc weakness → solid AFO → psoas lengthening
112	0	0	0	0	Diplegic gaits
113	0	228600	-228600	1	True equinus
114	0	228600	-228600	1	Jump knee
115	0	228600	-228600	1	Apparent equinus
116	0	228600	-228600	1	Crouch knee
117	0	228600	-228600	1	Recurvatum knee
118	0	228600	-228600	1	Stiff knee (swing phase problem)

#	semantic level	section?	rewritten line
1	0		XR of this skeletally immature patient showing broken Shenton's and dislocated left hip
2	1		The acetabular index is increased, and the neck shaft angle is also increased with perhaps more anteversion noted
3	1		Reimer migration index (RMI) is increased
4	1		I suspect this is a neuromuscular dislocation rather than DDH as evidenced by the relatively well formed tear drop and femoral head. Also pelvis looks inlet view due to pelvic anteversion from tight rectus
5	1		Look for VP drain
6	1		Triradiate cartilage fuses at 11-13yo
7	0	yes	History
8	0	yes	Perinatal history + Birth history
9	1		Developmental milestone (age of sitting and walking)
10	1		Problems faced by patient him/herself
11	1		Problems faced by carer (perineal hygiene, pain, transfer, sitting)
12	1		Determine GMFCS level (I no restriction II stairs rails III wheelchair IV powered wheelchair V self mobility limited
13	1		Other medical problems
14	1		Social support
15	1		GMFCS 3 walker, 4 sitter
16	1		If still very young, try to prognosticate if walker or not
17	1		Good prognosis: head control by 9mo, sit by 2 yr, hemiplegic
18	1		Bad prognosis: Persistent primitive reflex >1yo (Bleck), lack of head control by 20 months, non ambulatory by 7 yr
19	0	yes	Examination
20	1		General
21	1		IQ
22	1		Sitting balance
23	1		Gait – assess stance and swing phase
24	1		Orthosis
25	1		Specific
26	1		Hip tone, ROM, Thomas or Staheli test for FFC, adductor tightness by Phelps test, rectus tightness by Duncan Ely, ITB by Ober
27	1		Knee tone, ROM, popliteal angle (hamstring shift is more accurate to see if psoas contracture is contributing)
28	1		Ankle tone, ROM, silverskiold test, any bony impingement or impending ulcers
29	1		Spine for scoliosis
30	1		Pelvic obliquity
31	1		LLD
32	1		If non-ambulatory and >1yo, perform primitive reflexes, 2 or more is poor prognosis for walking according to Bleck
33	1		Gait analysis lab for quantitative measurements
34	0	yes	Management
35	1		Multi-disciplinary approach (Paed, NS, Ortho, PT, Occu, P&O, MSW, family)
36	1		Expectation management: Ortho has role only in spastic type, not able to reverse the primary insult
37	1		Community-based, minimize hospital admissions
38	1		Aims: maximize patient’s function consistent with the current disease status and prevent deterioration
39	0	yes	Patient specific aims
40	1		Walker – want to achieve an efficient gait, as described by Gage (stability in stance phase, adequate stride length, proper preposition of foot for heel strike, enough foot clearance, energy conservation) + prevent early OA
41	1		Sitter – Spinopelvic balance, perineal hygiene, mobile knees (flex to sit, extend to brace for transfer), plantigrade feet
42	0	yes	Medical management of spasticity
43	1		- Physio, analgesia, wheelchair modification
44	1		- Oral or intrathecal baclofen
45	1		- Botox injection (3-6 months)
46	0	yes	Surgery:
47	1		Timing: delay OT as long as possible (>6yo), but before tertiary issue (contain hip before dislocation, gait modification before deviation)
48	1		SEMLS (Single event multilevel surgery) vs OSSCS [orthopaedic selective spasticity control surgery = correct lever arm dysfunction by releasing or lengthening the biarticular muscles and preserving the monoarticular antigravity muscles]
49	1		Prevent birthday syndrome
50	1		Components
51	2		Balance spasticity
52	2		Prevent contractures
53	2		Correct lever arm dysfunction
54	0		——
55	1		Hip dysplasia in CP is preventable
56	1		Spastic, bi-articular (adductor) more spasm than mono articular (abductor) → hip out
57	0	yes	Treatment
58	1		Conservative + Surveillance (Xray before 3 y.o. repeat one in 6 y.o. If walker, refer ortho if abd <30, or RMI >33%)
59	2		According to the NICE guidelines and the Swedish CPUP study
60	2		Reimer migration index, hip abduction
61	0	yes	Early subluxation (RMI 33-50%):
62	2		Botox / soft tissue release by adductor tenotomy, iliopsoas lengthening +/- hamstring lengthening, nighttime abduction splint
63	1		(adductor longus transect, protect anterior branch of obturator nerve, gracilis myotomy, adductor brevis lengthening
64	1		Moderate subluxation (RMI>50%)
65	2	yes	Surgery – VDRO / pelvic osteotomy
66	3		Dislocation
67	2	yes	Surgery – recon vs salvage
68	3		Depends on time
69	3		Early <1yr: recon (OR + soft tissue release + VDRO +/- shortening osteotomy +/- pelvic osteotomy: dega or triple osteotomy)
70	3		Late >1yr: observe if no pain, if pain, salvage, Girdlestone, capsule interpositional arthroplasty, McHale procedure (subtrochanteric valgus osteotomy + femoral head excision)
71	0	yes	So we operate if the patient has dislocated hip but asymptomatic?
72	1		Evidence suggests that less than 50% of asymptomatic dislocated hips will develop pain in the long run. As such, observation of asymptomatic hip can be supported
73	0	yes	Why increased anteversion and valgus?
74	1		Psoas spastic, hip flexed, reduced torque on proximal femur, femur cannot derotate, so anteversion. Valgus as non weight bearing
75	0	yes	Follow-up
76	1		Valgus ok
77	1		But don’t understand anteversion
78	0		——
79	0	yes	Cerebral Palsy:
80	1		A neuromuscular disorder caused by non progressive insult to the immature brain. Primary neurological insult is non progressive but musculoskeletal features evolve as the child grows
81	0	yes	Classification
82	2		Topographically: Diplegic [bil LL more affected than bil UL], hemiplegic, quadriplegic
83	2		Neurologically (5): spastic, hypotonic, mixed, athetoid (dyskinetic), ataxic
84	2		Functionally: GMFCS (I – free ambulatory, II – rails with stairs, III – walking aid/ wheelchair, IV – head control, V no head control)
85	0	yes	Issues:
86	1		Primary deviation: loss of selective motor control, leading to muscle balance, abnormal tone and coordination
87	1		Secondary deviation: growth related deviation that arise due to abnormal loading in the setting of primary gait deviations
88	2		Anatomic shortening of muscle tendon unit (e.g. myostatic contractures)
89	2		Persistent bone deformities due to HV principle (e.g. femoral anteversion)
90	2		Joint subluxations/ dislocations
91	1		Tertiary: compensatory deformities, become apparent when secondary is corrected
92	1		Spasticity – velocity dependent increase in tone (due to loss of supraspinal inhibition)
93	1		Measured with Tardieu scale (R1 R2 with different velocity)
94	0	yes	Treatment: Global vs focal
95	2		Global
96	3		Selective dorsal rhizotomy (decrease afferent input from muscle spindle)
97	3		Baclofen (GABA agonist → increase K channel opening → easy hyperpolarization)
98	3		Gabapentin (VGCC deactivator → decrease nerve excitation and decrease neurotransmitter release)
99	2		Focal: Botox
100	1		Contracture – shortening of musculotendinous unit (due to slowing of growth due to lack of tensile loading) – Treatment: muscle (release or transfer), joint (release), bone (osteotomy)
101	1		Lever arm dysfunction
102	2		Unstable fulcrum (hip dislocation)
103	2		Floppy lever (pes planus)
104	2		Short lever (coxa valga)
105	2		Malrotation (tibial ER)
106	0	yes	Winter classification of CP gaits
107	1		Hemiplegic gaits
108	1		Foot drop → hinged AFO/ solid AFO
109	1		True equinus - Gastroc soleus contracture → hinged AFO → heel cord lengthening
110	1		Jump knee – Spastic hamstring + triceps surae → hinged AFO → no OT
111	1		Apparent equinus – Iliopsoas contracture + gastroc weakness → solid AFO → psoas lengthening
112	1		Diplegic gaits
113	1		True equinus
114	1		Jump knee
115	1		Apparent equinus
116	1		Crouch knee
117	1		Recurvatum knee
118	1		Stiff knee (swing phase problem)

100. McHale procedure