Will my Child Walk Funny? The Rotational Profile of Infants and Children With Classic Bladder Exstrophy

Bladder exstrophy is a rare, complex disorder that involves the urinary, reproductive, gastrointestinal, and musculoskeletal systems and is marked by an incomplete lower abdominal wall, leaving the bladder exposed to the outside world. Skeletal findings in this condition include externally rotated innominate bones. While the resulting acetabular retroversion might be expected to cause out-toeing, there is no published data on the gait parameters or rotational profile of children with classic bladder exstrophy (CBE) in isolation. This study, therefore, characterizes the rotational profile and walking age of infants and toddlers with CBE.

Patients treated at a tertiary care pediatric hospital for CBE from January 2014 to June 2023 were retrospectively reviewed. Patient history, examination, and radiographic findings-including rotational profile and age at independent ambulation-were recorded. Patients with a diagnosis of cloacal exstrophy or epispadias without exstrophy were excluded.

Out of 46 patients meeting inclusion criteria, 17 (37%) were female and 29 (63%) were male. All underwent exstrophy repair combined with iliac osteotomies (24 anterior and 22 posterior). The anterior pelvic ring was secured with suture fixation (44/46) or threaded wires (2/46). Patients were immobilized with either a spica cast (n=41, 89%) or skin traction (n=5, 11%).Preoperatively, hip internal and external rotation with the hip in extension averaged 43 and 78 degrees, respectively. Postoperatively, internal rotation initially decreased and then increased over time, while external rotation decreased over the same time. There was no difference in internal or external rotation between patients who had either anterior or posterior osteotomies ( P =0.35, 0.09, respectively).At 3 years of age, foot progression angle (n=21) averaged +8.7 degrees ±5.5 (range: 0 to 20 degrees) while thigh foot angle (n=30) averaged +2.8 degrees ±4.4 (range: 0 to 10 degrees). Despite most patients undergoing surgery before age 1, all patients walked independently on time at a mean age of 13±2.4 months (range: 11 to 18 mo).

Infants and toddlers with CBE who undergo early reconstruction walk independently at a normal age. Their rotational profile falls within normal bounds, even though their underlying pelvic anatomy may predispose them towards an externally rotated gait.

Level III-retrospective cohort study.