Proximal femoral osteotomy in children with cerebral palsy: the perspective of the trainee

Blade plate versus locking plate fixation of proximal femoral varus osteotomy in children with cerebral palsy

The hip is commonly affected in children with cerebral palsy (CP), requiring proximal femoral varus derotational osteotomies. Novel locking plates afford a popular alternative to traditional blade plates. The purpose of this study was to compare the effectiveness of blade plate versus locking plate fixation in children with CP undergoing proximal femoral osteotomy. We conducted a retrospective review of patients who underwent proximal femoral osteotomy over an 8-year period. Incidence of healing, failure of the procedure, and loss of varus correction were compared between the two groups (blade plate vs. locking plate). Independent samples t -tests and Chi-square analysis were employed to compare differences between continuous and categorical variables, respectively. A total of 268 hips [137 right (51.1%)] met inclusion criteria. Ninety-eight hips (36.6%) were fixed with blade plates [170 (63.4%) locking plates]. Although those in the blade plate cohort were more likely to achieve complete radiographic healing by 6 weeks postoperatively (41.09% vs. 18.84%; P < 0.050), there was no significant difference ( P > 0.050) between the two groups for healing at 3, 6, and 12 months ( P > 0.050). There was no significant difference between the two cohorts regarding the number of patients experiencing migration percentage at least 50% at 6 (3.06% vs. 3.53%) and 12 (3.06% vs. 5.88%) months ( P > 0.050) or in those undergoing revision surgery at 12 (5.33% vs. 1.18%) and 24 (2.04% vs. 1.76%) months ( P > 0.050). The findings of this retrospective study show similar outcomes between blade plate and proximal femoral locking plates in proximal femoral varus osteotomy in children with CP.

Reliability of the Modified Clavien-Dindo-Sink Complication Classification System in Pediatric Orthopaedic Surgery

Background

There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases.

Methods

The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively.

Results

The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group.

Conclusions

The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

Classifying Adverse Events Following Lower Limb Orthopaedic Surgery in Children With Cerebral Palsy: Reliability of the Modified Clavien-Dindo System

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.