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Niedzwecki C, Barbuto A, Mitchell K, Wirt S, Seymour M, Thomas S, Schwabe A. Comparison of outcomes following surgical intervention and inpatient rehabilitation stays in children with cerebral palsy. PM R 2024; 16:449-461. [PMID: 37801614 DOI: 10.1002/pmrj.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/28/2023] [Accepted: 09/01/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Literature is limited on functional outcomes in children with cerebral palsy (CP) following surgical procedures and a subsequent inpatient rehabilitation unit (IRU) stay. OBJECTIVE To compare functional outcomes and length of stay (LOS) in children with CP following a surgical procedure and IRU stay based on the surgical procedure performed, pattern of involvement, etiology, and Gross Motor Function Classification System (GMFCS) level. DESIGN Retrospective cohort study. SETTING Tertiary care pediatrics. PARTICIPANTS Pediatric patients with CP who underwent one of three surgical procedures followed by an IRU stay. INTERVENTIONS Selective dorsal rhizotomy (SDR), single-event multilevel orthopedic surgery (SEMLS), or intrathecal baclofen (ITB) pump implantation and subsequent IRU stay. MAIN OUTCOME MEASURES IRU LOS, Functional Independence Measure for Children (WeeFIM) total score, sub-scores, and efficiency. RESULTS Children undergoing SDR had a longer LOS (p ≤ .015). Children with spastic diplegia, GMFCS level II, and prematurity-based CP had higher WeeFIM efficiency scores (p ≤ .046, ≤.021, and .034 respectively). Greater changes in WeeFIM™ scores were associated with spastic diplegia, SDR, GMFCS level II, longer LOS, and higher admission scores (p ≤ .045). CONCLUSIONS Although statistically and functionally significant improvements in children with CP following surgical interventions and an IRU stay were seen, those with higher WeeFIM change scores tended to have spastic diplegia, to have undergone SDR, GMFCS level II, longer LOS, and higher admission scores.
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Affiliation(s)
- Christian Niedzwecki
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Amy Barbuto
- Department of Physical and Occupational Therapy, Texas Children's Hospital-The Woodlands, The Woodlands, Texas, USA
| | - Katy Mitchell
- Department of Physical Therapy, Texas Woman's University-Houston, Houston, Texas, USA
| | - Steven Wirt
- Department of Physical and Occupational Therapy, Texas Children's Hospital-Main Campus, Houston, Texas, USA
| | - Michelle Seymour
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Sruthi Thomas
- Departments of Physical Medicine & Rehabilitation and Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aloysia Schwabe
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
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Crecchi A, Tozzini A, Benedetti R, Maltinti M, Bonfiglio L. Case report: Intensive rehabilitation program delivered before and after single-event multilevel surgery in a girl with diplegic cerebral palsy. Front Neurol 2024; 14:1323697. [PMID: 38283677 PMCID: PMC10811248 DOI: 10.3389/fneur.2023.1323697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction Diplegic cerebral palsy (CP) is often associated with musculoskeletal disorders that contribute to worsen walking function. The standard care in these cases is single-event multilevel surgery (SEMLS) followed by rehabilitation. Our aim was to investigate whether a rehabilitation program starting even before SEML could add a benefit with respect to standard postoperative programs considered by previous research. Methods From 2 months before to 13 months after SEMLS (except for the first month after surgery), the participant underwent a motor training focused on ROM exercises with tactile and kinaesthetic feedback. Walking performance, walking capacity, and quality-of-life were assessed before and after SEMLS at different follow-up times. Results Walking capacity improved 3 months after SEMLS (i.e., earlier than in current literature) and walking performance improved 12 months after SEMLS (instead of simply returning to baseline as previously reported), with a positive impact on quality-of-life. Conclusions This case suggests that a rehabilitation program starting even before SEMLS could add benefits over walking function and quality-of-life of children with diplegic CP compared to postoperative programs only.
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Affiliation(s)
- Alessandra Crecchi
- Unit of Developmental Neurorehabilitation, Maternal and Child Department, Pisa University Hospital, Pisa, Italy
| | - Alessandra Tozzini
- Unit of Developmental Neurorehabilitation, Maternal and Child Department, Pisa University Hospital, Pisa, Italy
| | - Roberta Benedetti
- Department of Translational Research on New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Marco Maltinti
- 1st Unit of Orthopaedics and Trauma, Pisa University Hospital, Pisa, Italy
| | - Luca Bonfiglio
- Unit of Developmental Neurorehabilitation, Maternal and Child Department, Pisa University Hospital, Pisa, Italy
- Department of Translational Research on New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
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Fong MM, Gibson N, Williams SA, Jensen L. Clinical functional outcome measures for children with cerebral palsy after gait corrective orthopaedic surgery: A scoping review. Dev Med Child Neurol 2023; 65:1573-1586. [PMID: 37147852 DOI: 10.1111/dmcn.15622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 05/07/2023]
Abstract
AIM To identify the most frequently reported non-instrumented measures of gait, activity, and participation in children with cerebral palsy (CP) after undergoing gait corrective orthopaedic surgery. METHOD Four databases were searched from database inception to the 9th December 2021 for studies that evaluated functional outcomes for children with CP under 18 years undergoing gait corrective orthopaedic surgery. RESULTS Of 547 citations, 44 publications (n = 3535 participants, n = 1789 males, mean age 10 years 5 months [SD = 3 years 3 months], Gross Motor Function Classification System levels I-III at the time of surgery) were eligible for inclusion. Fourteen different outcome measures were used: one measure of gait, 10 measures of activity, and three measures of participation. Gait was measured with the Edinburgh Visual Gait Scale (EVGS; 4 out of 44). The most common activity and participation measures were the Functional Mobility Scale (FMS; 15 out of 44) and Pediatric Outcomes Data Collection Instrument (11 out of 44) respectively. No studies reported a combination of gait, activity, and participation measures. INTERPRETATION The EVGS and FMS should be considered as core outcome measures in gait corrective orthopaedic surgery, while a measure of participation is unclear. Additional considerations for developing a comprehensive suite of outcomes include identifying a combination of clinical measures and performance-reflective questionnaires that are standardized for children with CP undergoing surgery and meaningful to clinicians and families.
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Affiliation(s)
- Maxine M Fong
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Department of Physiotherapy, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Noula Gibson
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Department of Physiotherapy, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Kids Rehab WA, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Sian A Williams
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Lynn Jensen
- Department of Physiotherapy, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Raab D, Kecskeméthy A. [Clinical value of instrumental gait analysis]. Orthopadie (Heidelb) 2023:10.1007/s00132-023-04397-z. [PMID: 37286624 DOI: 10.1007/s00132-023-04397-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Instrumental gait analysis is becoming an established addition to conventional diagnostic methods for the clinical assessment of complex movement disorders. It can provide objective and high resolution motion data and contains information that is not observable with conventional clinical methods, such as muscle activation during gait. UTILISATION Instrumental gait analysis can add observer independent parameters to the treatment planning of individuals as well as provide insights into pathomechanisms with clinical research studies. Limiting factors for the use of gait analysis technology are currently the time and personnel expenditures for measurements and data processing, as well as the extensive amount of training time required for data interpretation. This article illustrates the clinical value of instrumental gait analysis and specifies its synergies with conventional diagnostic methods.
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Affiliation(s)
- Dominik Raab
- Lehrstuhl für Mechanik und Robotik, Universität Duisburg-Essen, Lotharstr. 1, 47057, Duisburg, Deutschland.
| | - Andrés Kecskeméthy
- Lehrstuhl für Mechanik und Robotik, Universität Duisburg-Essen, Lotharstr. 1, 47057, Duisburg, Deutschland
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Bonnefoy-Mazure A, De Coulon G, Lascombes P, Bregou A, Armand S. A 10.5-year follow-up of walking with unilateral spastic cerebral palsy. J Child Orthop 2023; 17:173-183. [PMID: 37034199 PMCID: PMC10080234 DOI: 10.1177/18632521231154975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 12/25/2022] [Indexed: 04/11/2023] Open
Abstract
Purpose The purpose of this study was to describe gait evolution in patients with unilateral spastic cerebral palsy (USCP) using modified Gait Profile Score (mGPS without hip rotation), Gait Variable Score (GVS), walking speed, and the observed effects of single-level surgery (SLS) after 10 years. Methods Fifty-two patients with USCP (Gross Motor Function Classification System I) and data from two Clinical Gait Analyses (CGAs) were included. The evolution of patients' mGPS, GVS, and walking speed were calculated. Two "no surgery" and "single-level surgery" patient categories were analyzed. Paired t-tests were used to compare the data between CGAs and as a function of treatment category. Pearson's correlations were used to examine relationships between baseline values and evolutions in mGPS and walking speed. Results Mean ages (SD) at first and last CGAs were 9.3 (3.2) and 19.7 (6.0) years old, respectively, with an average follow-up of 10.5 (5.6) years. Mean mGPS for the patients' affected side was significantly lower at the last CGA for the full cohort: baseline = 8.5° (2.1) versus follow-up = 7.2° (1.6), effect size = 0.73, p < 0.001. Significant improvements in mGPS and GVS for ankle and foot progression were found for the SLS group. The mGPS change and mGPS at baseline (r = -0.79, p < 0.001) were negatively correlated. Conclusions SLS patients demonstrated a positive long-term change in gait pattern over time. The group that had undergone surgery had worse gait scores at baseline than the group that had not, but the SLS group's last CGA scores were relatively closer to those of the "no surgery" group. Level of evidence This was a retrospective comparative therapeutic study (level III).
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Affiliation(s)
- Alice Bonnefoy-Mazure
- Willy Taillard Laboratory of
Kinesiology, Geneva University Hospitals and University of Geneva, Geneva,
Switzerland
- Alice Bonnefoy-Mazure, Willy Taillard
Laboratory of Kinesiology, Geneva University Hospitals and University of Geneva,
Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland.
| | - Geraldo De Coulon
- Pediatric Orthopedic Service,
Department of Child and Teenage Medicine, Geneva University Hospitals and University
of Geneva, Geneva, Switzerland
| | | | - Aline Bregou
- Pediatric Orthopedic Service,
Department of Child and Adolescent Medicine, Lausanne University Hospital and
University of Lausanne, Lausanne, Switzerland
| | - Stéphane Armand
- Willy Taillard Laboratory of
Kinesiology, Geneva University Hospitals and University of Geneva, Geneva,
Switzerland
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Bekteshi S, Monbaliu E, McIntyre S, Saloojee G, Hilberink SR, Tatishvili N, Dan B. Towards functional improvement of motor disorders associated with cerebral palsy. Lancet Neurol 2023; 22:229-43. [PMID: 36657477 DOI: 10.1016/S1474-4422(23)00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023]
Abstract
Cerebral palsy is a lifelong neurodevelopmental condition arising from non-progressive disorders occurring in the fetal or infant brain. Cerebral palsy has long been categorised into discrete motor types based on the predominance of spasticity, dyskinesia, or ataxia. However, these motor disorders, muscle weakness, hypotonia, and impaired selective movements should also be discriminated across the range of presentations and along the lifespan. Although cerebral palsy is permanent, function changes across the lifespan, indicating the importance of interventions to improve outcomes in motor disorders associated with the condition. Mounting evidence exists for the inclusion of several interventions, including active surveillance, adapted physical activity, and nutrition, to prevent secondary and tertiary complications. Avenues for future research include the development of evidence-based recommendations, low-cost and high-quality alternatives to existing therapies to ensure universal access, standardised cerebral palsy registers to harmonise epidemiological and clinical information, improved adult screening and check-up programmes to facilitate positive lived experiences, and phase 3 trials for new interventions.
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Hösl M, Schupfinger A, Klich L, Geest L, Bauer P, Bonfert MV, Afifi FK, Nader S, Berweck S. Relationship between kinematic gait quality and caregiver-reported everyday mobility in children and youth with spastic Cerebral Palsy. Eur J Paediatr Neurol 2023; 42:88-96. [PMID: 36587415 DOI: 10.1016/j.ejpn.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/09/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND 3D gait analysis (3DGA) is a common assessment in Cerebral Palsy (CP) to quantify the extent of movement abnormalities. Yet, 3DGA is performed in laboratories and may thus be of debatable significance to everyday life. AIM The aim was to assess the relationship between kinematic gait abnormality and everyday mobility in ambulatory children and youth with spastic CP. METHODS 73 paediatric and juvenile patients with uni- or bilateral spastic CP (N = 21 USCP, N = 52, BSCP, age: 4-20 y, GMFCS I-III) underwent a 3DGA, while the MobQues47 Questionnaire quantified caregiver-reported mobility. We calculated the Gait Profile Score (GPS), a metric that summarizes how far the lower limb joint angles during walking deviate from those of matched controls. RESULTS The GPS correlated well with indoor and outdoor mobility (rho = -0.69 and -0.70, both p < 0.001) and the relationships were not significantly different for USCP and BSCP. Still, mobility was lower in BSCP (p < 0.001) and more compromised outdoors (p = 0.002). Indoor mobility could be predicted by walking speed, GPS and age (adj. R2 = 0.62). Outdoor mobility was best predicted by walking speed and GPS (adj. R2 = 0.60). The additive explained variance by the GPS was even higher outdoors than indoors (17.1% vs. 11.4%). CONCLUSIONS Measuring movement deviations with 3DGA seems equally meaningful in uni- and bilaterally affected children and has considerable relevance for real-life ambulation, particurlarly outdoors, where children with spastic CP typically face greater difficulties. Therapeutic strategies that achieve faster walking and reduction of kinematic deviations may increase outdoor mobility.
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Lennon N, Gerry G, Biermann I, Beaman J, Mamula N, Gilmore A, Niiler T, Shrader MW, Owens LL. Factors Associated With Short-Term Recovery Following Single-Event Multilevel Surgery for Children With Cerebral Palsy. Pediatr Phys Ther 2023; 35:93-9. [PMID: 36638036 DOI: 10.1097/PEP.0000000000000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To examine the role of multiple factors, including therapy dose, on recovery of mobility function during post-single-event multilevel surgery (SEMLS) rehabilitation in youth with cerebral palsy. METHODS Several factors expected to influence postoperative change in Gross Motor Function Measure (GMFM) were examined: age, Gross Motor Function Classification System (GMFCS) level, cognition, number of osteotomies, surgical complications, medical comorbidities, number of therapy sessions, and preoperative measures of gait, balance, and gross motor function. RESULTS Sixty-nine youth with cerebral palsy, GMFSC levels I-IV, who had undergone SEMLS and rehabilitation had on average 2.6 osteotomies and 89 postoperative therapy sessions. Fewer osteotomies, higher therapy dose, higher preoperative GMFM, and lower GMFM at postoperative admission were significant in determining GMFM change. CONCLUSIONS The most relevant factors on post-SEMLS recovery were therapy dose, surgical burden, and level of gross motor function immediately before and after surgery.
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Visscher R, Hasler N, Freslier M, Singh NB, Taylor WR, Brunner R, Rutz E. Long-term follow-up after multilevel surgery in cerebral palsy. Arch Orthop Trauma Surg 2022; 142:2131-2138. [PMID: 33620528 DOI: 10.1007/s00402-021-03797-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/12/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Single-event multilevel surgery (SEMLS) is frequently used to correct pathological gait patterns in children with bilateral spastic cerebral palsy (BSCP) in a single session surgery. However, in-depth long-term evaluation reports of gait outcomes are limited. Therefore, we investigated if SEMLS is able to correct lower extremity joint and pelvic angles during gait towards typically developing gait patterns (TDC) in children with BSCP, and if so, if this effect is durable over a 10-year period. MATERIALS AND METHODS In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7-18.2 years at the time of SEMLS were retrospectively recruited. Three-dimensional gait data were captured preoperatively, as well as at short-, mid-, and long-term post-operatively, and used to analyze: movement analysis profile (MAP), gait profile score (GPS), and lower extremity joint and pelvic angles over the course of a gait cycle using statistical parametric mapping. RESULTS In agreement with previous studies, MAP and GPS improved towards TDCs after surgery, as did knee extension during the stance phase (ɳ2 = 0.67; p < 0.001), while knee flexion in the swing phase (ɳ2 = 0.67; p < 0.001) and pelvic tilt over the complete gait cycle (ɳ2 = 0.36; p < 0.001) deteriorated; no differences were observed between follow-ups. However, further surgical interventions were required in 8 out of 13 of the participants to maintain improvements 10 years post-surgery. CONCLUSIONS While the overall gait pattern improved, our results showed specific aspects of the gait cycle actually deteriorated post-SEMLS and that a majority of the participants needed additional surgery, supporting previous statements for the use of multilevel surgery rather than SEMLS. The results highlight that the field should not only focus on the overall gait scores when evaluating treatment outcomes but should offer additional long-term follow-up of lower extremity function.
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Affiliation(s)
- Rosa Visscher
- Laboratory for Movement Biomechanics, Institute for Biomechanics, ETH Zurich, HCP H16.1, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland.
| | - Nadine Hasler
- Laboratory for Movement Biomechanics, Institute for Biomechanics, ETH Zurich, HCP H16.1, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland
| | - Marie Freslier
- Laboratory of Movement Analysis, University Children's Hospital Basel (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland
| | - Navrag B Singh
- Laboratory for Movement Biomechanics, Institute for Biomechanics, ETH Zurich, HCP H16.1, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland
| | - William R Taylor
- Laboratory for Movement Biomechanics, Institute for Biomechanics, ETH Zurich, HCP H16.1, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland
| | - Reinald Brunner
- Laboratory of Movement Analysis, University Children's Hospital Basel (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland
- Faculty of Medicine, The University of Basel, 4001, Basel, Switzerland
| | - Erich Rutz
- Laboratory of Movement Analysis, University Children's Hospital Basel (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland
- Murdoch Children's Research Insitute, Pediatric Orthopedic Department, The University of Melbourne, The Royal Children's Hospital RCH, 50 Flemington Road, Parkville, Melbourne, 3052, Australia
- Faculty of Medicine, The University of Basel, 4001, Basel, Switzerland
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Abstract
BACKGROUND Upper motor neuron (UMN) syndrome consists of muscle spasticity, weakness, and dyssynergy due to a brain or spinal cord injury. The purpose of this study is to describe the perioperative adverse events for adult patients undergoing single-event, multilevel upper extremity surgery (SEMLS) due to UMN syndrome. METHODS A retrospective case series was performed for 12 consecutive adult patients who underwent SEMLS to correct upper extremity dysfunction or deformity secondary to UMN syndrome. The evaluation consisted of primary outcome measures to identify readmission rates and classify adverse events that occurred within 30 days after surgery. RESULTS All 12 patients were functionally dependent with 50% (n = 6) men and 50% (n = 6) women at a mean age of 43.6 years (range: 21-73) with a mean of 5.92 (range: 0-16) comorbid diagnoses at the time of surgery. There were no intraoperative complications, hospital readmissions, or deaths among the 12 patients. Five patients experienced 5 minor postoperative complications that consisted of cast- or orthosis-related skin breakdown remote from the incision (n = 3), incidental surgical site hematoma that required no surveillance or intervention (n = 1), and contact dermatitis attributed to the surgical dressing that resolved with topical corticosteroids (n = 1). CONCLUSIONS With an appropriate multidisciplinary approach, there is minimal risk for developing perioperative and 30-day postoperative adverse events for adults undergoing SEMLS to correct upper extremity deformities secondary to UMN syndrome. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Peter C. Rhee
- Mayo Clinic, Rochester, MN, USA
- Travis Air Force Base, CA, USA
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Õunpuu S, Pierz K, Rethlefsen SA, Wren TAL. Cost savings for single event multilevel surgery in comparison to sequential surgery in ambulatory children with cerebral palsy. Gait Posture 2022; 96:53-9. [PMID: 35576667 DOI: 10.1016/j.gaitpost.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/20/2022] [Accepted: 05/04/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to determine the differences in billable provider charges between single event multilevel surgery (SEMLS) based on comprehensive gait analysis and a staged surgical approach (SSA) without comprehensive gait analysis for the orthopedic treatment of ambulatory children with cerebral palsy (CP). METHODS The charges associated with nine common orthopedic surgical combinations (both unilateral and bilateral, soft tissue or soft tissue plus bony) for children with CP were determined and compared between SEMLS and SSA. The charges included surgical, anesthesia, operating room, recovery room, hospital stay, physical therapy, and, for SEMLS only, comprehensive computerized gait analysis. RESULTS Total charges to complete each combination was higher for SSA than for SEMLS. The differential ranged from $10,247 to $75,069 with the percentage difference ranging from 20% to 47%. The mean difference was $43,606 (p = 0.0002). The dollar difference (r = 0.98, p < 0.0001) and percentage difference (r = 0.79, p = 0.01) were both related to the total charge of the SEMLS surgery. SIGNIFICANCE Financial costs are lower for SEMLS vs. SSA for the treatment of multilevel gait issues in children with CP. The cost of gait analysis is much smaller than the cost differential between SEMLS and SSA. Although some patients who have SEMLS may need additional orthopedic surgery with associated costs, this is also possible for SSA. Therefore, due to the many benefits of SEMLS, which also include more informed treatment decision-making as well as reduced time away from school and work (for caregivers), SEMLS guided by gait analysis is recommended over SSA for the treatment of gait disorders in children with CP.
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Abstract
Quantitative data assessment on the basis of three-dimensional gait analysis has been routinely used in the evaluation of pathological gait of children with cerebral palsy. However, a similar quantitative methodology has not been applied for spina bifida patients in whom atypical gait patterns are thought to correlate with various levels of neurological paralysis. The purpose of this study is to investigate the differences among gait patterns in spina bifida between different levels of neurological lesions using quantitative methods: Gait profile score (GPS) and gait variable scores (GVS), scoring subject's gait deviation from a reference. In this cross-sectional study, 22 children with spina bifida (11 women, 11 men; mean age 9.4 years, SD 3.8 years, range 3-17 years), were examined using three-dimensional gait analysis from 2008 to 2018. Physical examination allowed for classification of each of the 44 limbs as either L4, L5 or S1 and comparison with the GPS and GVS using a linear mixed model. GPS and the GVS of the pelvis and hip range of motion in the coronal plane were significantly higher in the L4 group than in the L5 and S1 groups (GPS, P = 0.041, P = 0.003, respectively; GVS of pelvis, P = 0.001, P = 0.001; GVS of hip, P < 0.001, P < 0.001) GVS (foot progression angle) was significantly lower in the S1 group than in L4 and L5 groups (P < 0.001, P = 0.037). We found that GPS and GVS enable us to quantitatively assess the differences among gait patterns between different neurological levels. The scoring tool showed the potential for detecting individual neurological changes.
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Affiliation(s)
- Hiroyori Fusagawa
- Department of Orthopaedics, Hokkaido Medical Center for Child Health and Rehabilitation
- Department of Orthopaedics, Sapporo Medical University
| | - Hiroki Fujita
- Department of Orthopaedics, Hokkaido Medical Center for Child Health and Rehabilitation
| | | | - Nobuaki Himuro
- Department of Public Health, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | | | | | - Paulo Selber
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
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Boyer ER, Novaczyk ZB, Novacheck TF, Symons FJ, Burkitt CC. Presence and predictors of pain after orthopedic surgery and associated orthopedic outcomes in children with cerebral palsy. Paediatric and Neonatal Pain 2022; 4:44-52. [PMID: 35546914 PMCID: PMC8975226 DOI: 10.1002/pne2.12067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/28/2021] [Accepted: 12/05/2021] [Indexed: 12/29/2022]
Abstract
While children with cerebral palsy (CP) may undergo 8‐22 orthopedic surgeries in their lifetime, little is known about the associated pain. We aimed to assess the pain presence before and one year after lower extremity orthopedic surgery, predictors of pain presence at follow‐up, and the association between pain and orthopedic outcomes related to surgery. This retrospective study included 86 children with CP (M age = 10.0 years, SD = 3.2; range = 4.1‐17.3 years, Gross Motor Functional Classification System (GMFCS) level I‐III) who underwent orthopedic surgery and had completed questionnaires at gait analyses before (M = 2.7 months; range = 0.0‐5.7) and after surgery (M = 11.8 months; range = 9.0‐14.9). Pain presence, location, and Pediatric Outcomes Data Collection Instrument (PODCI) scores were documented before and after surgery at gait analyses. Pain prevalence was 60% at baseline and 56% at follow‐up. Significant predictors of pain presence at follow‐up included (1) pain presence at baseline (range of odds ratios [OR] across any/all locations = 3.22 to 15.54), (2) older age (range of OR for any pain, back, knee, and foot pain = 1.24‐1.26), (3) female sex (decreased OR for males for ankle pain = 0.12), (4) having hip surgery (decreased OR for foot pain = 0.20), and (5) lower GMFCS level (OR for foot pain = 0.41). Changes in PODCI Sports and Physical Function scores were associated with changes in hip and knee pain (P < .03); PODCI scores worsened for patients who had pain at both time points and improved for patients who had pain at baseline but not follow‐up. Pain was present for over half of the participants before and after orthopedic surgery. Pain presence at follow‐up was predicted by pain presence at baseline. Pain and functional outcomes were correlated at follow‐up. Prospective studies examining perioperative pain experience and factors predicting pain outcomes are warranted.
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Affiliation(s)
- Elizabeth R. Boyer
- Gillette Children’s Specialty Healthcare St. Paul MN USA
- Department of Orthopedic Surgery University of Minnesota Minneapolis MN USA
| | | | - Tom F. Novacheck
- Gillette Children’s Specialty Healthcare St. Paul MN USA
- Department of Orthopedic Surgery University of Minnesota Minneapolis MN USA
| | - Frank J. Symons
- Department of Educational Psychology University of Minnesota Minneapolis MN USA
| | - Chantel C. Burkitt
- Gillette Children’s Specialty Healthcare St. Paul MN USA
- Department of Educational Psychology University of Minnesota Minneapolis MN USA
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14
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de Freitas Guardini KM, Kawamura CM, Lopes JAF, Fujino MH, Blumetti FC, de Morais Filho MC. Factors related to better outcomes after single-event multilevel surgery (SEMLS) in patients with cerebral palsy. Gait Posture 2021; 86:260-265. [PMID: 33813186 DOI: 10.1016/j.gaitpost.2021.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/08/2021] [Accepted: 03/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Good outcomes have been described after single-event multilevel surgery (SEMLS) in cerebral palsy (CP); however, there is limited evidence regarding factors influencing them. RESEARCH QUESTION What were the factors related to kinematic outcomes after SEMLS in the present study? METHODS Two hundred and fifty-eight patients with spastic diplegic CP, GMFCS I-III, who underwent SEMLS and had done pre and post-operative gait analyses were included in the SEMLS Group (SEMLS-G). A second search was performed in the same database looking for patients to compose the Control Group (CG), and 88 subjects, with at least two gait analyses and with no surgical intervention between tests, were identified. Demographic data, GDI and GPS (Gait Profile Score) were analyzed in both groups, and the results compared. A second evaluation was performed in the SEMLS-G in order to identify the influence of age, gender, follow-up time, pre-operative GDI, GMFCS and gait velocity on results. RESULTS The GDI (51.3-58.4) and GPS (2.5°) improvement occurred only in SEMLS-G (p < 0.001). On sagittal plane, there was an improvement at the knee and ankle levels in SEMLS-G, whereas the pelvic alignment improved in the CG. In SEMLS-G, patients with improvement on GDI > 10 points had lower pre-operative GDI (46.15) than other groups (p < 0.001). In addition, patients with reduction on GDI after intervention had lower pre-operative gait velocity than subjects with improvement >10 points (p = 0. 01). The increase on GDI after SEMLS was greater in patients GMFCS I and II than GMFCS III (p = 0.003). There was a negative effect of GMFCS III on GDI improvement after intervention (p = 0.014). SIGNIFICANCE Lower pre-operative GDI, higher baseline gait velocity and GMFCS levels I and II were related to better outcomes after SEMLS in the present study. On the other hand, patients GMFCS III were more susceptible to deteriorate after SEMLS.
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Affiliation(s)
| | | | | | - Marcelo H Fujino
- Gait Laboratory and Cerebral Palsy Clinic, AACD, São Paulo, Brazil
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15
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Graham HK, Thomason P, Willoughby K, Hastings-Ison T, Stralen RV, Dala-Ali B, Wong P, Rutz E. Musculoskeletal Pathology in Cerebral Palsy: A Classification System and Reliability Study. Children (Basel) 2021; 8:252. [PMID: 33807084 PMCID: PMC8004848 DOI: 10.3390/children8030252] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 02/01/2023]
Abstract
This article presents a classification of lower limb musculoskeletal pathology (MSP) for ambulant children with cerebral palsy (CP) to identify key features from infancy to adulthood. The classification aims to improve communication, and to guide referral for interventions, which if timed appropriately, may optimise long-term musculoskeletal health and function. Consensus was achieved by discussion between staff in a Motion Analysis Laboratory (MAL). A four-stage classification system was developed: Stage 1: Hypertonia: Abnormal postures are dynamic. Stage 2: Contracture: Fixed shortening of one or more muscle-tendon units. Stage 3: Bone and joint deformity: Torsional deformities and/or joint instability (e.g., hip displacement or pes valgus), usually accompanied by contractures. Stage 4: Decompensation: Severe pathology where restoration of optimal joint and muscle-tendon function is not possible. Reliability of the classification was tested using the presentation of 16 clinical cases to a group of experienced observers, on two occasions, two weeks apart. Reliability was found to be very good to excellent, with mean Fleiss' kappa ranging from 0.72 to 0.84. Four-stages are proposed to classify lower limb MSP in children with CP. The classification was reliable in a group of clinicians who work together. We emphasise the features of decompensated MSP in the lower limb, which may not always benefit from reconstructive surgery and which can be avoided by timely intervention.
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Affiliation(s)
- H. Kerr Graham
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
- Hugh Williamson Gait Laboratory, Royal Children’s Hospital, Parkville, VIC 3052, Australia; (P.T.); (T.H.-I.); (P.W.)
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
- Orthopaedic Department, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - Pam Thomason
- Hugh Williamson Gait Laboratory, Royal Children’s Hospital, Parkville, VIC 3052, Australia; (P.T.); (T.H.-I.); (P.W.)
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
| | - Kate Willoughby
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
- Orthopaedic Department, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - Tandy Hastings-Ison
- Hugh Williamson Gait Laboratory, Royal Children’s Hospital, Parkville, VIC 3052, Australia; (P.T.); (T.H.-I.); (P.W.)
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
| | - Renee Van Stralen
- Department of Orthopedic Surgery, Sophia Children’s Hospital, Erasmus MC, 3015GD Rotterdam, The Netherlands;
| | - Benan Dala-Ali
- Orthopaedic Department, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK;
| | - Peter Wong
- Hugh Williamson Gait Laboratory, Royal Children’s Hospital, Parkville, VIC 3052, Australia; (P.T.); (T.H.-I.); (P.W.)
- Orthopaedic Department, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - Erich Rutz
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
- Hugh Williamson Gait Laboratory, Royal Children’s Hospital, Parkville, VIC 3052, Australia; (P.T.); (T.H.-I.); (P.W.)
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
- Orthopaedic Department, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
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16
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Edwards TA, Thompson N, Prescott RJ, Stebbins J, Wright JG, Theologis T. A comparison of conventional and minimally invasive multilevel surgery for children with diplegic cerebral palsy. Bone Joint J 2021; 103-B:192-197. [PMID: 33380192 DOI: 10.1302/0301-620x.103b1.bjj-2020-0714.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP). METHODS A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded. RESULTS In both groups, GPS improved from the preoperative gait analysis to the six-month assessment with maintenance at 12 and 24 months postoperatively. While reduced at six months in both groups, walking speed returned to preoperative speed by 12 months. The overall pattern of change in GPS and walking speed was similar over time following C-MLS and MI-MLS. There was a median of ten procedures per child as part of both C-MLS (interquartile range (IQR) 8.0 to 11.0) and MI-MLS (IQR 7.8 to 11.0). Surgical adverse events occurred in seven (37%) and 13 (36%) children, with four (21%) and 13 (36%) patients requiring subsequent surgery following C-MLS and MI-MLS, respectively. CONCLUSION This study indicates similar improvements in gait kinematics and walking speed 24 months after C-MLS and MI-MLS for children with diplegic CP. Cite this article: Bone Joint J 2021;103-B(1):192-197.
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Affiliation(s)
- Tomos A Edwards
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - Nicky Thompson
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - Robin J Prescott
- Centre for Population Health Sciences, Usher Institute, Edinburgh, UK
| | - Julie Stebbins
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - James G Wright
- Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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17
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O'Sullivan R, French HP, Van Rossom S, Jonkers I, Horgan F. The association between gait analysis measures associated with crouch gait, functional health status and daily activity levels in cerebral palsy. J Pediatr Rehabil Med 2021; 14:227-235. [PMID: 33896854 DOI: 10.3233/prm-200676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The aim of this study was to examine the relationship between gait analysis measures associated with crouch gait, functional health status and daily activity in ambulant cerebral palsy (CP). METHODS Three-dimensional gait analysis was carried out on 35 ambulant participants with bilateral CP crouch gait (knee flexion at mid-stance (KFMS) ⩾ 190). KFMS, knee-flexion at initial contact, gait speed and step-lengths were extracted for analysis. Steps/day and sedentary time/day were assessed using an ActivPAL accelerometer. Functional health status was assessed using the five relevant domains of the Pediatric Outcomes Data Collection Instrument (PODCI) questionnaire. Associations between variables were assessed with correlation coefficients and multivariable linear regression. RESULTS There were no significant correlations between KFMS and PODCI domains (ρ=-0.008-0.110) or daily activity (ρ=-0.297-0.237) variables. In contrast, multivariable analysis found that step-length was independently associated with the Sports and Physical Function (p= 0.030), Transfers and Basic Mobility (p= 0.041) and Global Function (< 0.001) domains of the PODCI assessment. Gait speed was independently associated with mean steps/day (p< 0.001). CONCLUSIONS Step length and gait speed are more strongly associated with functional health status and daily activity than knee flexion during stance in children and adolescents with CP crouch gait.
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Affiliation(s)
- Rory O'Sullivan
- Gait Analysis Laboratory, Central Remedial Clinic, Dublin, Ireland.,School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Helen P French
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sam Van Rossom
- Human Movement Biomechanics Research Group, KU Leuven, Leuven, Belgium
| | - Ilse Jonkers
- Human Movement Biomechanics Research Group, KU Leuven, Leuven, Belgium
| | - Frances Horgan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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Skoutelis VC, Kanellopoulos AD, Kontogeorgakos VA, Dinopoulos A, Papagelopoulos PJ. The orthopaedic aspect of spastic cerebral palsy. J Orthop 2020; 22:553-558. [PMID: 33214743 DOI: 10.1016/j.jor.2020.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023] Open
Abstract
Spastic Cerebral Palsy (CP) is the most common form of CP, comprising of 80% of all cases. Spasticity is a type of hypertonia that clinically manifests as dynamic contractures. The dynamic contracture along with the reduced level of physical activity in a child with CP leads to secondary structural and morphological changes in spastic muscle, causing real musculotendinous shortening, known as fixed contractures. When fixed muscle contractures are not treated early, progressive musculoskeletal deformities develop. As a consequence, spastic CP from a static neurological pathology becomes a progressive orthopaedic pathology which needs to be managed surgically. Orthopaedic surgical management of CP has evolved from previous "multi-event single level" procedures to a "single event multilevel" procedures, with changes in selection and execution of treatment modalities. There is increasing evidence that multilevel surgery is an integral and essential part of therapeutic management of spastic CP, but more research is needed to ensure effectiveness of this intervention on all domains of physical disability in CP.
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Affiliation(s)
- Vasileios C Skoutelis
- Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece.,Laboratory of Neuromuscular and Cardiovascular Study of Motion, Department of Physiotherapy, School of Health and Care Sciences, University of West Attica, Egaleo, Attica, Greece.,Department of Physiotherapy, 'Attikon' University General Hospital, Chaidari, Attica, Greece
| | | | - Vasileios A Kontogeorgakos
- Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece.,First Department of Orthopaedic Surgery, 'Attikon' University General Hospital, Chaidari, Attica, Greece
| | - Argirios Dinopoulos
- Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece.,Third Department of Paediatrics, 'Attikon' University General Hospital, Chaidari, Attica, Greece
| | - Panayiotis J Papagelopoulos
- Medical School, National and Kapodistrian University of Athens, Athens, Attica, Greece.,First Department of Orthopaedic Surgery, 'Attikon' University General Hospital, Chaidari, Attica, Greece
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19
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Rutz E, McCarthy J, Shore BJ, Shrader MW, Veerkamp M, Chambers H, Davids JR, Kay RM, Narayanan U, Novacheck TF, Pierz K, Rhodes J, Shilt J, Theologis T, Van Campenhout A, Dreher T, Graham K. Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study. J Child Orthop 2020; 14:405-414. [PMID: 33204348 PMCID: PMC7666804 DOI: 10.1302/1863-2548.14.200145] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. METHODS A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. RESULTS Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). CONCLUSIONS The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Erich Rutz
- The Royal Children’s Hospital, Melbourne, Australia
| | - James McCarthy
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - M. Wade Shrader
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Matthew Veerkamp
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Jon R. Davids
- Shriners Hospitals for Children--Northern California, Sacramento, California, USA
| | - Robert M. Kay
- Children’s Hospital Los Angeles, Los Angeles, California, USA
| | | | - Tom F. Novacheck
- Gillette Children’s Specialty Healthcare, Saint Paul, Minnesota, USA
| | - Kristan Pierz
- Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Jason Rhodes
- Children’s Hospital Colorado, Aurora, Colorado, USA
| | | | | | | | | | - Kerr Graham
- The Royal Children’s Hospital, Melbourne, Australia,Correspondence should be sent to H. Kerr Graham, Department of Orthopaedic Surgery, Royal Children’s Hospital, Flemington Road, Parkville, Victoria, Australia. E-mail:
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20
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Almoajil H, Wilson N, Theologis T, Hopewell S, Toye F, Dawes H. Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review. Dev Med Child Neurol 2020; 62:1138-1146. [PMID: 32567044 DOI: 10.1111/dmcn.14599] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/07/2020] [Indexed: 11/30/2022]
Abstract
AIM To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework. METHOD This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework. RESULTS Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%). INTERPRETATION The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.
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Affiliation(s)
- Hajar Almoajil
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Department of Physical Therapy, College of Applied Medical Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nichola Wilson
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Tim Theologis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Paediatric Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Hopewell
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Francine Toye
- Physiotherapy Research Unite, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Dawes
- Centre for Movement, Occupational and Rehabilitation Sciences, Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK.,Oxford Health NHS Foundation Trust, Oxford, UK
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21
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Kuchen DB, Eichelberger P, Baur H, Rutz E. Long-term follow-up after patellar tendon shortening for flexed knee gait in bilateral spastic cerebral palsy. Gait Posture 2020; 81:85-90. [PMID: 32693350 DOI: 10.1016/j.gaitpost.2020.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/08/2020] [Accepted: 07/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Flexed knee gait is a common gait dysfunction in individuals with bilateral spastic cerebral palsy (BSCP) and is often addressed with single event multilevel surgery (SEMLS). SEMLS has been shown to have positive short-term effects especially on sagittal knee joint kinematics with less knee flexion during stance phase. However, mid- and long-term observations are rare, and results are reported in discrete parameters or summary statistics where temporal aspects are not considered. RESEARCH QUESTION Does the improved knee joint kinematics after patellar tendon shortening (PTS) as part of SEMLS persist in the long-term in individuals with BSCP? METHODS Data of instrumented gait analysis of twelve participants (females/males: 5/7, mean age: 15.3 ± 3.4 years) with BSCP treated with PTS as part of SEMLS were retrospectively analyzed. Participants had had follow-up gait analysis 1, 5 and 7 years or more after surgery. Three-dimensional lower extremity kinematics of walking at a self-selected speed were collected using a 12-camera motion capture system and 4 embedded force plates. One-dimensional statistical parametric mapping (SPM) was used for data analysis, permitting time point comparisons of continuous data. RESULTS Time point comparison revealed no significant differences in the sagittal plane for knee joint kinematics (p > 0.05) over the tree measurement time points. Hip and ankle joint kinematics as well as normalised walking speed remained stable over the observation period. SIGNIFICANCE This is the first study investigating lower extremity kinematics in patients with BSCP and flexed knee gait after SEMLS with SPM. Results demonstrate that positive effects on sagittal knee joint kinematics of PTS as part of SEMLS persist up to 9 years after surgery and progressivity does not reoccur. Thus, if clinical examination indicates an operation in individuals with BSCP, improved kinematics through SEMLS persist into adulthood. With the relatively new statistical procedure SPM gait can be displayed and analysed in established joint angle curves making them easier to understand (e.g. physiotherapists, movement scientists, physicians).
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Affiliation(s)
| | | | - Heiner Baur
- Bern University of Applied Sciences, Health Department, Bern, Switzerland
| | - Erich Rutz
- University Children's Hospital, UKBB, Basel Switzerland and the University of Basel, Switzerland; Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Melbourne, Australia; The Royal Children's Hospital, Orthopaedic Department, Parkville, Melbourne, Australia
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Van Rossom S, Kainz H, Wesseling M, Papageorgiou E, De Groote F, Van Campenhout A, Molenaers G, Desloovere K, Jonkers I. Single-event multilevel surgery, but not botulinum toxin injections normalize joint loading in cerebral palsy patients. Clin Biomech (Bristol, Avon) 2020; 76:105025. [PMID: 32402900 DOI: 10.1016/j.clinbiomech.2020.105025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many patients with cerebral palsy present a pathologic gait pattern, which presumably induces aberrant musculoskeletal loading that interferes with natural bone growth, causing bone deformations on the long term. Botulinum toxin interventions and single-event multilevel surgeries are used to restore the gait pattern, assuming that a normal gait pattern restores musculoskeletal loading and thus prevents further bone deformation. However, it is unknown if these interventions are able to restore musculoskeletal loading. Hence, we investigated the impact of botulinum toxin injections and single-event multilevel surgery on musculoskeletal loading. METHODS Gait data collected in 93 children with bilateral cerebral palsy, which included pre- and post multi-level botulinum toxin (49 children) and single-event multilevel surgery (44 children) assessments, and 15 typically developing children were retrospectively processed using a musculoskeletal modelling workflow to calculate joint angles, moments, muscle and joint contact force magnitudes and orientations. Differences from the typically developing waveform were expressed by a root-mean square difference were compared using paired t-tests for each intervention separately (alpha <0.05). FINDINGS Botulinum toxin induced significant changes in the joint angles, but did not improve the muscle and joint contact forces. Single-event multilevel surgery induced significant kinematic and kinetic changes, which were associated with improved muscle and joint contact forces. INTERPRETATION The present results indicate that botulinum toxin injections were not able to restore normal gait kinematics nor musculoskeletal loading, whereas single-event multilevel surgery did successfully restore both. Therefore, single-event multilevel surgery might be protective against the re-occurrence of bone deformation on the longer term.
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23
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Edwards TA, Prescott RJ, Stebbins J, Wright J, Theologis T. What is the functional mobility and quality of life in patients with cerebral palsy following single-event multilevel surgery? J Child Orthop 2020; 14:139-144. [PMID: 32351627 PMCID: PMC7184646 DOI: 10.1302/1863-2548.14.190148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To report functional mobility in patients with diplegic cerebral palsy (CP) at long-term follow-up after single-event multilevel surgery (SEMLS). The secondary aim was to assess the relationship between functional mobility and quality of life (QoL) in patients previously treated with SEMLS. METHODS A total of 61 patients with diplegic CP, mean age at surgery 11 years, eight months (sd 2 years, 5 months), were included. A mean of eight years (sd 3 years, 10 months) after SEMLS, patients were contacted and asked to complete the Functional Mobility Scale (FMS) questionnaire over the telephone and given a weblink to complete an online version of the CP QOL Teen. FMS was recorded for all patients and CP QOL Teen for 23 patients (38%). RESULTS Of patients graded Gross Motor Function Classification System (GMFCS) I and II preoperatively, at long-term follow-up the proportion walking independently at home, school/work and in the community was 71% (20/28), 57% (16/28) and 57% (16/28), respectively. Of patients graded GMFCS III preoperatively, at long-term follow-up 82% (27/33) and 76% (25/33) were walking either independently or with an assistive device at home and school/work, respectively, while over community distances 61% (20/33) required a wheelchair. The only significant association between QoL and functional mobility was better 'feelings about function' in patients with better home FMS scores (r = 0.55; 95% confidence interval 0.15 to 0.79; p = 0.01). CONCLUSION The majority of children maintained their preoperative level of functional mobility at long-term follow-up after SEMLS. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Tomos Aled Edwards
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK,Correspondence should be sent to Tomos Aled Edwards, 12 Brewery Lane, Collingwood, Melbourne, VIC, 3066, Australia. E-mail:
| | - Robin John Prescott
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, UK
| | - Julie Stebbins
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - James Wright
- Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim Theologis
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
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Abstract
PURPOSE Assessment of surgical treatments on gait in patients with bilateral cerebral palsy (CP) is often performed in short-term studies. The purpose of this study was to analyze the influence of single-event multilevel surgery (SEMLS) on long-term evolution of gait using gait deviation index (GDI) and walking speed. METHODS In all, 28 patients with bilateral CP (Gross Motor Function Classification System I to III) with two clinical gait analyses (CGA) were included (mean age: 9.0 years (sd 2.9) at the first CGA, 19.6 years (sd 4.1) at the last, all of them at skeletal maturity). GDI, walking speed and their changes were calculated. Statistical analysis was performed to observe differences between baseline and follow-up CGA. Pearson's correlations were conducted to evaluate the associations between GDI and walking speed changes with: GDI at baseline and walking speed at baseline. GDI and walking speed evolution have been analyzed for two groups of patients: with and without SEMLS. RESULTS Regardless of the treatment, GDI was significantly higher at follow-up CGA (baseline: 73.1 (sd 13.1) versus follow-up: 80.1 (sd 13.2); p = 0.014). Significant negative correlations were found between GDI change and GDI at baseline (r = -0.52; p = 0.004) and between walking speed change and walking speed at the baseline (r = -0.70; p < 0.001). Regarding the group of patients with or without SEMLS, only significant improvement of GDI was found for patients with SEMLS (at baseline: 69.0 (sd 12.1) versus follow-up: 77.8 (sd 11.2); p < 0.05). CONCLUSION Analysis at skeletal maturity showed a gait quality maintained for patients without SEMLS and an improvement for patients with SEMLS. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alice Bonnefoy-Mazure
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Geneva, Switzerland,Correspondence should be sent to Alice Bonnefoy-Mazure, Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland. E-mail:
| | - Geraldo De Coulon
- Paediatric Orthopaedic Service Department of Child and Teenagers, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Pierre Lascombes
- Paediatric Orthopaedic Service Department of Child and Teenagers, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Stéphane Armand
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Geneva, Switzerland
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van Bommel EEH, Arts MME, Jongerius PH, Ratter J, Rameckers EAA. Physical therapy treatment in children with cerebral palsy after single-event multilevel surgery: a qualitative systematic review. A first step towards a clinical guideline for physical therapy after single-event multilevel surgery. Ther Adv Chronic Dis 2019; 10:2040622319854241. [PMID: 31308923 PMCID: PMC6613059 DOI: 10.1177/2040622319854241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 05/08/2019] [Indexed: 11/18/2022] Open
Abstract
Background: The aim of this study was to review available evidence for physical therapy
treatment (PTT) after single-event multilevel surgery (SEMLS), and to
realize a first step towards an accurate and clinical guideline for
developing effective PTT for children with cerebral palsy (CP) after
SEMLS. Methods: A qualitative systematic review (PubMed, Medline, Embase, CINAHL, and the
Cochrane Library) investigating a program of PTT after SEMLS in children
aged 4–18 years with CP classified by Gross Motor Function Classification
System level I–III. Results: Six articles meeting the inclusion criteria were selected. The selected
studies provide only incomplete descriptions of interventions, and show no
consensus regarding PTT after SEMLS. Neither do they show any consensus on
the outcome measures or measuring instruments. Conclusions: Based on the results of this literature review in combination with our best
practice, we propose a preliminary protocol of PTT after SEMLS.
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Affiliation(s)
- Esther E H van Bommel
- Department of Pediatric Rehabilitation, Sint Maartenskliniek, Hengstdal 3, 6574 NA Ubbergen, The Netherlands
| | - Marieke M E Arts
- Rehabilitation Specialists, Klimmendaal, Arnhem, The Netherlands
| | - Peter H Jongerius
- Department of Pediatric Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands
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Schwarze M, Horoba L, Block J, Putz C, Alimusaj M, Wolf SI, Dreher T. Wearing Time of Ankle-Foot Orthoses with Modular Shank Supply in Cerebral Palsy: A Descriptive Analysis in a Clinically Prospective Approach. Rehabil Res Pract 2019; 2019:2978265. [PMID: 31380119 DOI: 10.1155/2019/2978265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/07/2019] [Accepted: 06/19/2019] [Indexed: 11/23/2022] Open
Abstract
Objective To date there is only limited knowledge about the wearing time of orthoses. Ankle-foot orthoses (AFOs) have not been studied with this research question. Additional influences of the orthotic design as well as weekdays and the weekend are also unknown. Design Monocentric, clinically prospective intervention study. Patients Inclusion of 10 patients with bilateral spastic cerebral palsy. Methods Equipment of all subjects with a dynamic ankle-foot orthosis (DAFO) and modular shank supply (MSS, dynamic elastic shank adaptation or ground reaction AFO). Integration of temperature sensors for recording the wearing time for a period of 3 months. Results The actual wearing time was below the recommendations on actually worn days as well as the average of the entire study period. In addition, the actual usage in terms of days and hours was well below the recommendations. The wearing time showed differences between weekdays and weekend. Differences between DAFO and MSS were not detectable. Conclusion The actual usage behavior of ankle-foot orthoses differs from the recommendations of the prescriber. This applies to both DAFOs and modular use with shank supplies. Environmental factors may have a significant impact on wearing times on weekdays and the weekend.
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Davids JR, Cung NQ, Sattler K, Boakes JL, Bagley AM. Quantitative Assessment of Muscle Strength Following "Slow" Surgical Lengthening of the Medial Hamstring Muscles in Children With Cerebral Palsy. J Pediatr Orthop 2019; 39:e373-9. [PMID: 30570590 DOI: 10.1097/BPO.0000000000001313] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Classic teaching for surgical lengthening of muscle contractures in children with cerebral palsy (CP) has emphasized complete correction of the deformity acutely, with immobilization of the targeted muscles in the fully corrected position. Clinical experience has led to the impression that the muscles are invariably weakened by this approach. We have developed an alternative technique for correction of contractures called slow surgical lengthening (SSL). The goal of the study was to determine the physical examination, kinematic, and muscle strength outcomes following SSL of the medial hamstring muscles in children with CP. METHODS The study group included 41 children with CP who underwent SSL of the medial hamstring muscles as part of a comprehensive single-event multilevel surgery, who had preoperative and 1-year postoperative evaluations in our Motion Analysis Center, which included quantitative assessment of isometric and isokinetic muscle strength. RESULTS All subjects were Gross Motor Function Classification System I and II. Mean age at the time of surgery was 10.8 years. The mean popliteal angle improved by 16.2 degrees (P<0.001) following SSL of the medial hamstrings. Sagittal plane kinematics following SSL of the medial hamstrings showed improvement of knee extension at initial contact of 10.2 degrees (P<0.001), decrease of peak knee flexion in mid-swing of 3.6 degrees (P=0.014), improved minimum knee flexion in stance of 4.9 degrees (P=0.002), and no significant change in mean anterior pelvic tilt (P=0.123). Mean peak isometric knee flexion torque remained unchanged from preoperative to postoperative studies (P=0.154), whereas mean peak isokinetic knee flexion torque significantly increased by 0.076 Nm/kg (P=0.014) following medial hamstring SSL. DISCUSSION SSL was developed based upon clinical experience and improved understanding of the pathophysiology of skeletal muscle in children with CP. The SSL technique allows the tendinous tissue to separate spontaneously at the time of recession, but does not force further acute lengthening by intraoperative manipulation, thereby minimizing the damage to the underlying muscle. It is broadly believed that muscle weakness is inevitable following surgical lengthening. The current study shows that the SSL technique does not cause weakness. LEVEL OF EVIDENCE Level IV-therapeutic.
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Amirmudin NA, Lavelle G, Theologis T, Thompson N, Ryan JM. Multilevel Surgery for Children With Cerebral Palsy: A Meta-analysis. Pediatrics 2019; 143:peds.2018-3390. [PMID: 30918016 DOI: 10.1542/peds.2018-3390] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP). OBJECTIVE To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP. DATA SOURCES Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched. STUDY SELECTION Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected. DATA EXTRACTION Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events. RESULTS Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: -0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: -0.01 to 0.25) but did improve gait (SMD: -0.80; 95% CI: -0.95 to -0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies. LIMITATIONS Data were largely from cohort studies. CONCLUSIONS Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.
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Affiliation(s)
- Noor Amirah Amirmudin
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Grace Lavelle
- Department of Clinical Sciences, Brunel University London, London, United Kingdom; and
| | - Tim Theologis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Nicky Thompson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jennifer M Ryan
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; .,Department of Clinical Sciences, Brunel University London, London, United Kingdom; and
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Amen JFH, El-Mikkawy DME, Yosry AH, El-Gebely MA, El-Sherbini MHA. Outcome of intensive rehabilitation following single-event multilevel surgery for crouch gait in children with cerebral palsy. Egypt Rheumatol Rehabil 2019. [DOI: 10.4103/err.err_3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gendy S, ElGebeily M, El-Sobky TA, Khoshhal KI, Jawadi AH. Current practice and preferences to management of equinus in children with ambulatory cerebral palsy: A survey of orthopedic surgeons. SICOT J 2019; 5:3. [PMID: 30816087 PMCID: PMC6394235 DOI: 10.1051/sicotj/2019003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 01/19/2019] [Indexed: 12/28/2022] Open
Abstract
Introduction: The consensus among orthopedic surgeons on the management of equinus deformity in cerebral palsy (CP) children has not been reported previously despite being a prevalent deformity. The goals of this study were to examine the orthopedic surgeons’ current practice regarding the management of equinus deformity in children with ambulatory CP, and analyze variations in current practice between general orthopedic and pediatric orthopedic surgeons. Methods: We implemented a brief cross-sectional self-reported questionnaire that addressed the areas of clinical examination and decision-making skills of management of equinus deformity in CP children. We targeted a convenience sample of 400 participants. Surgeons that provided complete responses to the questionnaire were 223 with a response rate of 56%, of which 123 (55%) were general orthopedic surgeons, whereas 100 (45%) were pediatric orthopedic surgeons. The target population consisted of orthopedic surgeons who were further sub-classified in accordance with practice age, general versus pediatric, and exposure to children’s orthopedics during the last three years of their practice. For analytical statistics, the Chi-Square test and Fisher’s exact test were used to examine the relationship between two qualitative variables. Results: The overall clinical practice preferences of all survey participants were unimpressive with discordant survey responses. Pediatric orthopedic surgeons generally demonstrated a statistically significant difference regarding clinical assessment skill items of the survey, in contrast to general orthopedic surgeons. However, we found no differences between pediatric orthopedic and general orthopedic surgeons regarding most of the decision-making/knowledge items. Discussion: Generally, there are insufficient clinical practice trends of both general and pediatric orthopedic surgeons regarding equinus treatment in CP children. This may indicate a knowledge–practice gap with potential risks to CP children undergoing surgery for equinus. There is a need for a more competent exposure to CP in orthopedic surgeons’ educational curricula and an updated health referral system.
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Affiliation(s)
- Samuel Gendy
- Department of Orthopedic Surgery, Hurghada General Hospital, Hurghada, Egypt
| | - Mohamed ElGebeily
- Division of Pediatric Orthopaedics and Limb Reconstruction Surgery, Department of Orthopaedic Surgery, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Tamer A El-Sobky
- Division of Pediatric Orthopaedics and Limb Reconstruction Surgery, Department of Orthopaedic Surgery, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Khalid I Khoshhal
- Department of Orthopedics, College of Medicine, Taibah University, Almadinah Almunawwarah, Saudi Arabia
| | - Ayman H Jawadi
- Department of Pediatric Orthopedic Surgery, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Schwarze M, Block J, Kunz T, Alimusaj M, Heitzmann DWW, Putz C, Dreher T, Wolf SI. The added value of orthotic management in the context of multi-level surgery in children with cerebral palsy. Gait Posture 2019; 68:525-530. [PMID: 30623847 DOI: 10.1016/j.gaitpost.2019.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/28/2018] [Accepted: 01/04/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of cerebral palsy includes an interdisciplinary concept and in more severe cases the well-established multi-level surgery (MLS). Different kinds of orthoses are typically part of postoperative treatment but there is a lack of knowledge about their additional benefit. RESEARCH QUESTION Do ankle foot orthoses lead to an additional, measurable improvement of gait after MLS? METHODS 20 children with bilateral spastic cerebral palsy (9 retrospective, 11 in a postoperative clinical routine) were included. All had a preoperative gait analysis before MLS. Postoperatively, they were fitted with different ankle foot orthoses (AFO), depending on their individual needs. Dynamic ankle foot orthoses (DAFO), combined DAFO with additional dynamic, elastic shank adaptation (DESA) and ground reaction force AFOs (GRAFO) were used. Patients underwent a second gait analysis 1.5 (± 0.6) years postoperatively barefoot and with orthoses. Data analysis included testing for normal distribution (Shapiro-Wilk-Test) and further nonparametric statistical testing on basis of a Wilcoxon Single-Rank Test. RESULTS The operation produced changes in the hip, knee and ankle joint, and the pelvis. Spatiotemporal parameters showed significant changes due to additional use of the orthoses. Further, additional kinematic changes occurred at the hip, knee and ankle joint as well as the foot. The Gillette Gait Index (GGI) improved significantly by supplementary orthoses, but not by surgery alone. The Gait Profile Score (GPS) and Gait Deviation Index (GDI) rather showed changes due to the surgery. SIGNIFICANCE MLS significantly improves GPS and GDI more than a year after surgery, which can be interpreted as an improvement in gait pattern. In contrast, the GGI is improved by additional postoperative orthotic treatment, which implies that walking ability itself has improved, rather than the gait pattern. Orthoses show a positive additional effect on surgical results at different anatomical levels. Spatiotemporal parameters are positively influenced solely by additional orthotic support.
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Affiliation(s)
- M Schwarze
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany.
| | - J Block
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany
| | - T Kunz
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany
| | - M Alimusaj
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany
| | - D W W Heitzmann
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany
| | - C Putz
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany
| | - T Dreher
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany; Pediatric Orthopaedics and Traumatology, University Children's Hospital Zurich, Zurich, Switzerland
| | - S I Wolf
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200, 69118, Heidelberg, Germany
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Edwards TA, Theologis T, Wright J. Predictors affecting outcome after single-event multilevel surgery in children with cerebral palsy: a systematic review. Dev Med Child Neurol 2018; 60:1201-1208. [PMID: 30073667 DOI: 10.1111/dmcn.13981] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2018] [Indexed: 12/01/2022]
Abstract
AIM To review the potential predictors of outcome after single-event multilevel surgery (SEMLS) in children with cerebral palsy (CP). METHOD A literature search using the following criteria was performed in six electronic databases: (1) children with cerebral palsy; (2) analysed potential predictors of outcome after SEMLS; (3) minimum 12 months follow-up. The potential predictors were predefined: sex; topographical distribution; socio-economic status; Gross Motor Function Classification System (GMFCS) level; preoperative kinematic summary statistic; age at surgery. Study quality was appraised with the methodological index for non-randomized studies (MINORS) and the Oxford Centre for Evidence-Based Medicine scale. RESULTS Of the seven studies identified, the MINORS scores ranged from 9 to 11 and all were graded 2b on the Oxford Centre for Evidence-Based Medicine scale. There was little or no evidence to support sex, topographical distribution, or socio-economic status as predictive factors after SEMLS. Preoperative Gait Profile Score (GPS) was the best measure of expected improvement in gait kinematics. Parent-reported satisfaction and GPS were best after SEMLS in children graded GMFCS II. The best long-term results were seen in those aged between 10 years and 12 years of age. INTERPRETATION The candidate who might expect to realize the most improvement from SEMLS is aged between 10 years and 12 years, is in GMFCS level II, and has a poor preoperative GPS. WHAT THIS PAPER ADDS Children aged 10 to 12 years, in Gross Motor Function Classification System level II, with a poor preoperative Gait Profile Score might expect to realize the most improvement after single-event multilevel surgery.
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Affiliation(s)
- Tomos A Edwards
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - Tim Theologis
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - James Wright
- Botnar Research Centre, University of Oxford, Oxford, UK
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Givon U. Gait research in cerebral palsy: should we zoom in or zoom out? Dev Med Child Neurol 2018; 60:738-739. [PMID: 29600510 DOI: 10.1111/dmcn.13742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Uri Givon
- Pediatric Orthopedics Department, Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Putz C, Blessing AK, Erhard S, Fiethen K, Geisbüsch A, Niklasch M, Döderlein L, Wolf SI, Dreher T. Long-term results of multilevel surgery in adults with cerebral palsy. Int Orthop 2019; 43:255-60. [PMID: 29922840 DOI: 10.1007/s00264-018-4023-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Deterioration of gait in adolescent and adult patients with cerebral palsy can be associated with multiple factors. Multilevel surgery (MLS) is one option in adults with cerebral palsy to improve gait function with encouraging short-term results. It is a question whether these improvements are maintained over time. METHODS In a retrospective consecutive cohort study, adults with bilateral spastic cerebral palsy (BSCP) treated with MLS between 1995 and 2011 were scanned for potential inclusion. Patients needed to fulfill the following inclusion criteria: age at MLS > 17, standardized three-dimensional gait analysis (3D-GA) including clinical examination at pre-operative (E0), a short-term follow-up (E1) and at least seven years (E2) after the index MLS. Twenty adults (10 women, 10 men) with a Gross Motor Function Classification Level (GMFCS) I-III and a mean age at MLS of 24.8 years were included in this study. The average long-term follow-up was 10.9 years. The Gait Profile Score (GPS) was used as primary outcome measure. RESULTS The GPS improved significantly from 13.8° before surgery to 11.2° at short-term (p = 0.007) and to 11.3° at long-term follow-up (p = 0.002). Mean GPS showed a slight deterioration between E1 and E2 due to a minority of six patients (30%) who showed a significant loss of correction. CONCLUSION Surgical treatment in adults with BSCP was feasible and effective in the long-term. Significant improvement of gait and function was maintained in the majority of patients, while some patients were prone to develop crouch gait, hip flexion contractures, or pain.
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Davids J. The Gait Outcomes Assessment List (GOAL): a new tool to assess cerebral palsy. Dev Med Child Neurol 2018; 60:541. [PMID: 29574696 DOI: 10.1111/dmcn.13732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jon Davids
- Shriners Hospital - Orthopaedics, Sacramento, CA, USA
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Zhou L, Willoughby K, Strobel N, Thomason P, Gallagher C, Harambasic M, Khot A, Graham HK. Classifying Adverse Events Following Lower Limb Orthopaedic Surgery in Children With Cerebral Palsy: Reliability of the Modified Clavien-Dindo System. J Pediatr Orthop 2018; 38:e604-9. [PMID: 30036291 DOI: 10.1097/BPO.0000000000001233] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The modified Clavien-Dindo (MCD) system is a reliable tool for classifying adverse events (AEs) in hip preservation surgery and has since been utilized in studies involving lower limb surgery for ambulant and nonambulant children with cerebral palsy (CP). However, the profile of AEs recorded in children with CP compared with typically developing children is different, and the reliability of the MCD in CP is unknown. This study aimed to evaluate the interrater and intrarater reliability of the MCD system for classifying AEs following lower limb surgery in children with CP. METHODS Eighteen raters were invited to participate, including clinicians from surgical, nursing, and physical therapy professions, and individuals with CP. Following a MCD familiarization session, participants rated 40 clinical scenarios on 2 occasions, 2 weeks apart. Fleiss' κ statistics were used to calculate interrater and intrarater reliability. RESULTS The overall Fleiss' κ value for interrater reliability in the first rating was 0.70 (95% confidence interval, 0.61-0.80), and increased to 0.75 (95% confidence interval, 0.66-0.84) in the second rating. The average Fleiss' κ value for intrarater reliability was 0.78 (range, 0.48 to 1.00). Grading of more severe AEs (MCD III to V) achieved near perfect agreement (κ, 0.87 to 1.00). There was a lower level of agreement for minor AEs (MCD I-II) (κ, 0.53 to 0.55). A κ score of 0 to 0.2 was deemed as poor, 0.21 to 0.4 as fair, 0.41 to 0.6 as good, 0.61 to 0.8 as very good, and 0.81 to 1.0 as almost perfect agreement. CONCLUSIONS The MCD System demonstrates a very good interrater and intrarater reliability following lower limb surgery in children with CP. The MCD can be used by clinicians from different health care professions with a high level of reliability. The MCD may improve standardization of AE recording with a view to accurate audits and improved clarity in outcome studies for CP. LEVEL OF EVIDENCE Level II-diagnostic.
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