Augmentation of immune response to vaccinations through osteopathic manipulative treatment: a study of procedure

CONTEXT

Anecdotal evidence suggested that osteopathic manipulative treatment (OMT) may have imparted survivability to patients in osteopathic hospitals during the 1918 influenza pandemic. In addition, previous OMT research publications throughout the past century have shown evidence of increased lymphatic movement, resulting in improved immunologic function qualitatively and quantitatively.

OBJECTIVES

The following is a description of a proposed protocol to evaluate OMT effects on antibody generation in the peripheral circulation in response to a vaccine and its possible use in the augmentation of various vaccines. This protocol will serve as a template for OMT vaccination studies, and by adhering to the gold standard of randomized controlled trials (RCTs), future studies utilizing this outline may contribute to the much-needed advancement of the scientific literature in this field.

METHODS

This manuscript intends to describe a protocol that will demonstrate increased antibody titers to a vaccine through OMT utilized in previous historical studies. Confirmation data will follow this manuscript validating the protocol. Study participants will be divided into groups with and without OMT with lymphatic pumps. Each group will receive the corresponding vaccine and have antibody titers measured against the specific vaccine pathogen drawn at determined intervals.

RESULTS

These results will be statistically evaluated. Our demonstration of a rational scientific OMT vaccine antibody augmentation will serve as the standard for such investigation that will be reported in the future. These vaccines could include COVID-19 mRNA, influenza, shingles, rabies, and various others. The antibody response to vaccines is the resulting conclusion of its administration. Osteopathic manipulative medicine (OMM) lymphatic pumps have, in the past through anecdotal reports and smaller pilot studies, shown effectiveness on peripheral immune augmentation to vaccines.

CONCLUSIONS

This described protocol will be the template for more extensive scientific studies supporting osteopathic medicine's benefit on vaccine response. The initial vaccine studies will include the COVID-19 mRNA, influenza, shingles, and rabies vaccines.

An analysis of osteopathic medical students applying to surgical residencies following transition to a single graduate medical education accreditation system

CONTEXT

Upon requests from osteopathic medical schools, the National Resident Matching Program (NRMP) Charting Outcomes were redesigned to include osteopathic medical school seniors beginning in 2018 and one joint graduate medical education (GME) accreditation system, the Accreditation Council for Graduate Medical Education (ACGME), formed in 2020.

OBJECTIVES

The goal of this study is to analyze the match outcomes and characteristics of osteopathic applicants applying to surgical specialties following the ACGME transition.

METHODS

A retrospective analysis of osteopathic senior match outcomes in surgical specialties from the NRMP Main Residency Match data from 2020 to 2022 and the NRMP Charting Outcomes data from 2020 to 2022 was performed.

RESULTS

For surgical specialties, results show matching increased as United States Medical Licensing Examination (USMLE) Step 2 CK (clinical knowledge) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level 2 CE (cognitive evaluation) scores increased along with the number of contiguous rankings (p<0.001). The greatest indication for matching looking at scores alone were those who scored greater than 230 on Step 2 CK compared to below (p<0.001) and above 650 on Level 2 CE (p<0.001). However, those who scored 240 (p=0.025) on Step 2 CK were just as likely to match as those who scored 250 (p=0.022) when compared to those who scored below those scores. Increasing research involvement had little to no significance with the likelihood of matching across most surgical subspecialties.

CONCLUSIONS

Our study demonstrates that there are unique thresholds for Step 2 CK scores, Level 2 CE scores, and the number of contiguous ranks for each surgical specialty that, when reached, are significantly associated with match success. Although certain board score delineations are linked with higher match success rates, the rates level off after this point for most surgical specialties and do not significantly increase further with higher scores. In addition, thresholds within contiguous ranks for increasing match likelihood exist and vary across surgical specialties. Overall, this study highlights that the quantitative metrics utilized to assess applicants lack the correlation reported historically, and the data presently available need to be more substantiated.

Self-reported Health-related Quality of Life in Adolescents With Cerebral Palsy

BACKGROUND

Happiness, comfort, and motor function contribute to satisfaction with life for individuals with cerebral palsy (CP). Evidence-based medical care can improve motor function and physical health of youth with CP. Less is known about medical care and its relationship to health-related quality of life (HRQOL) in adolescents and young adults with CP. This study aimed to describe HRQOL among adolescents with CP to examine differences between adolescent (self) and parent (proxy) reports of HRQOL and to explore associations of pain, age, and gross motor function with HRQOL.

METHODS

This is a retrospective study including adolescents with CP classified as Gross Motor Function Classification System levels I to V, ages 11 to 20 years, reading ≥ a fourth-grade level, and who completed the self-reported Pediatric Outcomes Data Collection Instrument (PODCI). Parents completed the PODCI concurrently or within 12 months and scores were compared. In addition, self-reported scores were compared between age bands, across Gross Motor Function Classification System levels, with typically developing youth (TDY), and between youth with/without pain.

RESULTS

PODCI scores from 102 adolescents [59 males; 15.0 (SD: 2.6) years old] were examined. Scores from 50 adolescents and parents were matched. Mean self-reported scores were significantly higher than mean parent-reported scores in 4 domains: upper extremity and physical function ( P =0.018), sports and physical function ( P =0.005), happiness ( P =0.023), and global functioning ( P =0.018). All domains, except Happiness, were significantly < TDY ( P <0.01). The presence of pain was associated with lower scores in all domains ( P <0.05).

CONCLUSION

Examining HRQOL with the PODCI revealed significant limitations in physical function and higher pain in adolescents with CP compared with TDY. Self- and parent-reported PODCI results should be considered separately. Adolescents report higher HRQOL compared with parent proxy. Recognizing and validating the perspectives of youth and their parents presents an opportunity for providers to discuss different points of view with families. Such engagement can help promote self-efficacy in youth with CP as they transition to the responsibility of guiding their own care in adulthood.

LEVEL OF EVIDENCE

III, Retrospective comparative study.

A 10-Year Report on the Trends of Osteopathic Medical Students (OMS) in Osteopathic Orthopaedic Residency over the Past Decade

OBJECTIVES

Osteopathic match rates in competitive specialties, such as orthopaedics, have been under intense scrutiny. This study aimed to quantify trends in the characteristics of Osteopathic Orthopaedic Surgical Residency training and education from graduating classes of 2010-2020.

METHODS

This was a retrospective evaluation of a large, longitudinally maintained database of the American Osteopathic Association (AOA) from orthopaedic residency graduating classes of 2010-2020. Trends in characteristics were analyzed, including the resident's age at graduation from medical school and residency, gender, advanced degree status, College or School of Osteopathic Medicine (COM/SOM), residency, and residency class year.

RESULTS

Overall, the number of osteopathic orthopaedic residents had a 32.9% increase from 85 to 113 per year, graduating over the past decade. Statistical forecasting predicts a 27.8% increase in osteopathic orthopaedic residents over the next decade. The percent composition of osteopathic students entering orthopaedic residency class by gender remained relatively stable. The average percent male composition of the orthopaedic residency class was 90.5%, ranging from a maximum of 96.1% and a minimum of 83.7%. While the average percent female composition of orthopaedic residency class was 9.5% for the past decade, statistical forecasting predicts that over the next decade, the average percent composition of females in orthopaedic residency will be 5.8%. The average age of residents at graduation was 33.4 years, while across the decade, resident age at graduation decreased by 9.8%. On average, female orthopaedic residents at graduation were younger than male orthopaedic residents. Osteopathic Postdoctoral Training Institute (OPTI)-West/Community Memorial Health System Orthopaedic Surgery Residency had the highest average age at residency graduation (35.7 years), and Lake Erie COM/York Hospital Orthopaedic Surgery Residency had the youngest average age at residency graduation (32 years). Edward Via COM-Carolinas Campus had the highest average age at graduation from medical school (30.5 years), and Touro COM had the lowest average age at graduation from medical school (26.7 years). Only 3.3% of osteopathic orthopaedic residents had additional advanced degrees. Philadelphia COM produced the most significant number of orthopaedic residents (89) and trained the most female orthopaedic surgeons of any program over the ten years.

CONCLUSIONS

The number of osteopathic medical students entering orthopaedics has increased over the past decade. However, there remains a lack of a similar increasing trend of female osteopathic medical students entering osteopathic orthopaedic residency programs. Interestingly, the age of osteopathic orthopaedic residents at graduation decreased across the decade, while advanced degrees did not play a statistically significant factor in matching into orthopaedic surgery. The osteopathic medical school was the most significant predicting factor in matching into orthopaedic surgery. With such knowledge, greater efforts should aim to enhance osteopathic medical student exposure to orthopaedic programs to maintain quality candidate interest in this competitive field, including female prospects, while also increasing the holistic diversity of characteristics within the field of orthopaedic surgery.

Mortality after spinal fusion in children with cerebral palsy and cerebral-palsy-like conditions: A 30-year follow-up study

AIM

To report survival probability of a large cohort of children with cerebral palsy (CP) after spinal fusion.

METHOD

All children with CP who had spinal fusion between 1988 and 2018 at the reporting facility were reviewed for survival. Death records of the institutional CP database, institutional electronic medical records, publicly available obituaries, and the National Death Index through the US Centers for Disease Control were searched. Survival probabilities with different surgical eras, comorbidities, ages, and curve severities were compared using Kaplan-Meier curves.

RESULTS

A total of 787 children (402 females, 385 males) had spinal fusion at a mean age of 14 years 1 month (standard deviation 3 years 2 months). The 30-year estimated survival was approximately 30%. Survival decreased for children who had spinal fusion at younger ages, longer postoperative hospital stays, longer postoperative intensive care unit stays, gastrostomy tubes, and pulmonary comorbidities.

INTERPRETATION

Children with CP who required spinal fusions had reduced long-term survival compared with an age-matched typically developing cohort; however, a substantial number survived 20 to 30 years after the surgery. This study had no comparison group of children with CP scoliosis; therefore, we do not know whether correction of scoliosis affected their survival.

Advancing care and research for traumatic brain injury: a roadmap

Across all segments of society in the United States, millions of adults and children experience a traumatic brain injury (TBI) each year, which may pose lifetime health and financial burdens in the billions of dollars. Efforts have been made to advance research and care with goals to improve awareness of the causes and consequences of TBI, but gaps still remain in understanding TBI and delivering high-quality care to everyone who needs it both in military and civilian life. At the request of the Department of Defense, the National Academies of Sciences, Engineering and Medicine recently convened experts to address existing gaps in brain injury science and systems of care. Although many people who experience a TBI recover fully, others experience long-term physical, emotional, and often financial consequences to the patient and family system, and require ongoing accommodations to support their return to the communities in which they live, learn, and work. A holistic approach within the context of osteopathic medicine may be helpful and enhance contributions within the field. This article will discuss the roadmap to help guide the field, including key conclusions and recommendations for actions to advance progress over the next decade while embracing a comprehensive bio-psycho-socio-ecological model of TBI care bringing in the distinctive osteopathic approach not only to improve care and outcomes, but also to understand patient and family experiences on their TBI journey.

Recurrent hip instability after hip reconstruction in cerebral palsy children with spastic hip disease

BACKGROUND

Migration percentage (MP) is widely used to evaluate hip stability in children with spastic cerebral palsy (CP). Orthopedic surgeons need more objective information to make a proper hip reconstruction surgical plan and predict the outcome.

METHODS

Medical records and plain radiographs of children with CP who underwent the hip reconstruction procedure for dysplasia were reviewed retrospectively.

RESULTS

In total, 253 operated hips (140 patients; 11.7 ± 3.3 years old) were included in this study. MP at pre-operative (T_pre) was 35.3 ± 22.5%; at immediate follow-up (T_post) was 5.9 ± 9.5%; at last follow-up (T_final) was 9.8 ± 10.8% (4.5 ± 2.3 years post-operative at age 16.3 ± 2.8 years). In hips with Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS) grade 3 (n = 78), around 30-45% had an unsatisfactory outcome at T_post and T_final. However, hips categorized as other grades showed only 2.1-9.1% of unsatisfactory outcome. In less affected hips (pre-operative MP<30%, n = 122), 109 hips (89.3%) had varus derotation osteotomy only, the other 13 hips (10.7%) were combined with a pelvic osteotomy. In more severely affected hips (pre-operative MP ≥ 30%, n = 131), 26 hips (19.8%) had varus derotation osteotomy only, the other 105 hips (80.2%) were combined with a pelvic osteotomy.

CONCLUSIONS

Hips with pre-operative MP between 15 and 29% (MCPHCS grades 3) can be a higher risk group of recurrent hip instability after hip reconstruction surgery. Multiple indications beyond MP should be considered when indicating pelvic osteotomy or hip muscle release as combined procedures with varus femoral osteotomy for hip reconstruction in this milder group to achieve a consistent long-term satisfactory outcome.

Residual Deformity and Outcome of Ambulatory Adults With Cerebral Palsy: A Long-term Longitudinal Assessment

BACKGROUND

Advances in pediatric orthopaedic care have improved mobility and function for children with cerebral palsy (CP) as mobility declines from adolescence into adulthood. The long-term effectiveness of modern orthopaedic care is not widely reported. This study aimed to report the pediatric orthopaedic surgical burden, residual deformities, and outcomes using objective evidence of mobility in ambulatory adults with CP.

METHODS

An institutional review board-approved prospective cohort study was performed in ambulatory adults with CP between 25 and 45 years, who had an adolescent gait analysis. Orthopaedic interventions were reviewed, and adolescent and adult gait analyses were compared using paired 2-tailed t tests. Adults were categorized by the presence of no, mild, or severe residual deformities in rotation, crouch, stiff knee, equinus, and foot deformity.

RESULTS

Of 106 adults with CP, Gross Motor Function Classification System (GMFCS) distribution was grade I (22%), II (50%), III (23%), and IV (5%). Sixty-one males and 45 females were tested. The average age was 30±4 years with follow-up of 13±4 years since previous analysis; 279 surgical events (1165 procedures) were performed with a mean per patient of 2.6 events and 11 procedures. Comm on procedures were gastrocsoleus complex (88%) and hamstring lengthening (79%). The mean gait deviation index at adolescent and adult visit were 72.7±13 and 72.3±13 (P=0.78). Mean gait velocity at the adolescent visit was 85±27 and 79±31 cm/s at adult visit (P=0.02). Both gait deviation index and gait velocity change were clinically insignificant. Fifty-seven adults (81 limbs, 54%) had mild residual deformities. Residual hip internal rotation, pes planovalgus, and crouch gait were common. Severe deformities impacting function or causing pain were present in 11 participants (14 limbs, 10%). Seven of the 11 adults with severe deformities were worse compared with their adolescent evaluation; 4 were unchanged.

CONCLUSIONS

Correcting deformities before adulthood has lasting stability with little functional loss in most ambulatory young adults with CP. Increasing deformity after adolescence can occur in young adults but is uncommon.

LEVEL OF EVIDENCE

Level III.

The Foot in Cerebral Palsy

Children with cerebral palsy frequently develop foot deformities, most commonly equinus contractures, which can be managed with orthotics up to age 5 to 7 years. Plantar flexor lengthening, typically around this age, should be restricted to the offending muscle only, usually with a fascia release of the gastrocnemius. Equinovarus, mainly a problem in children with unilateral cerebral palsy, often responds to plantar flexor lengthening. If further tendon transfers are needed, they should be done when the child is older to avoid overcorrection. Planovalgus mostly improves spontaneously up to age 5 years. Surgical correction is best done in adolescence.

Factors associated with walking activity in adults with cerebral palsy

BACKGROUND

This prospective study used instrumented gait analysis, patient-reported outcomes, and portable accelerometers to examine walking activity in adults with cerebral palsy (CP).

RESEARCH QUESTION

This study aimed to provide objective data and evaluate factors associated with walking activity in adults with CP.

METHODS

Participants with CP (ages 25-45 years) completed instrumented gait analysis and patient-reported outcomes, including the Patient Reported Outcome Measurement Information System (PROMIS) and Satisfaction with Life Score (SWLS), and wore a StepWatch for 8 days. Average strides per day, stratified by Gross Motor Function Classification System (GMFCS), were compared with nondisabled adults ages 30-39 years utilizing Welch's t-tests with Bonferroni corrections. Correlation coefficients and stepwise multiple linear regression analyses examined relationships between walking activity and GMFCS, gait deviation index (GDI), gait velocity, PROMIS physical function, SWLS, body mass index (BMI), and employment.

RESULTS

Participants included 109 adults with CP, ages 29 ± 4 years, classified at GMFCS levels I/II (73 %) and III/IV (27 %). Compared with nondisabled adults, daily stride count was significantly lower in both groups of adults with CP (p < 0.00025), with a progressive decline according to GMFCS level. Walking activity correlated with PROMIS physical function (r = .42), GDI (r = .48), and gait velocity (r = .58). Association for employment was lower (r = 0.27) but significant, while age, SWLS, and BMI were not individually correlated with walking activity. Stepwise, multiple linear regression modeled with Akaike information criterion explained 40.9 % of the observed variability in walking activity in this cohort of adults with CP.

SIGNIFICANCE

Physical function, as classified by GMFCS or measured by PROMIS and self-selected walking velocity, has the strongest association with and is the most significant predictor of walking activity in adults with CP. After accounting for physical function, a small amount of the variation in walking activity can be explained by GDI, employment, and age.

The impact of asymmetry on the radiographical outcomes following hip reconstruction in patients with cerebral palsy

PURPOSE

The purpose of this study was to evaluate the impact of asymmetric hip dysplasia on the outcome of hip reconstruction in patients with cerebral palsy according to preoperative migration percentage (MP).

METHODS

This study was institutional review board-approved for retrospective cohort review. From 2008 to 2018, 65 patients met inclusion criteria: Gross Motor Function Scale Classification (GMFSC) III to V with spastic hips (MP > 30%) who underwent bilateral hip reconstruction, with a follow-up > 24 months. Main exclusion criteria: children with associated syndromes or chromosomal disorders. The cohort was subdivided into three groups according to preoperative MP difference between hips: Group A > 50%, group B 20% to 50% and Group C < 20%. Subsequently, the groups were analyzed individually and then compared. The asymmetry of extended abduction of the hip was also evaluated and separated into three groups: no asymmetry (< 20° difference), mild asymmetry (20° to 50° difference) and severe (> 50° difference).

RESULTS

In total, 65 patients underwent bilateral bony reconstructive surgery (130 hips). Mean age at surgery was 10.1 years (sd 3.6; 3.6 to 18.4). Mean age at follow-up was 14.7 years (sd 3.8; 8 to 21). Preoperative GMFSC distribution was grade III (four, 6%), IV (15, 23%) and V (46, 71%). In all, 21 symmetric hips (< 20% MP difference) had a preoperative MP difference of 9% and a follow-up MP difference of 18% (p > 0.05); 32 had a preoperative MP difference of 34% and a follow-up MP difference of 16% (p < 0.0001); 12 had a preoperative MP difference of 80% and a follow-up difference of 6% (p < 0.0001). According to pre- and postoperative abduction values, the mean high hip abduction preoperatively was 34° (sd 17°), whereas low hip abduction was 23° (sd 17°).

CONCLUSION

Hips with asymmetrical dysplasia and/or abduction undergoing bilateral reconstructive surgery focused on symmetric abduction, and corrected dysplasia in patients with cerebral palsy has improved symmetry in hip abduction and MP. Obtaining this goal immediately postoperatively is maintained to medium-term follow-up.

LEVEL OF EVIDENCE

IV.

Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children With Cerebral Palsy With Stiff Knee Gait

BACKGROUND

Children with cerebral palsy (CP) often present with a stiff knee gait pattern because of rectus femoris (RF) spasticity and/or contracture. Rectus femoris transfers (RFTs) and resections are surgical procedures aimed at reducing muscle stiffness, thereby improving knee flexion during the swing phase of gait. Previous research has consistently demonstrated objective benefits of rectus transfer using instrumented gait analysis (IGA). Rectus femoris resection (RFR), a relatively simpler procedure, shows similar improvement in knee range of motion during gait. The objective of this study was to compare surgical outcomes between rectus transfers and resections using 3-dimensional IGA.

METHODS

Children with spastic CP who had RFTs or resections were retrospectively matched by walking speed and preoperative knee kinematics from 3-dimensional IGA (peak and timing of peak knee flexion in swing). Secondary outcomes included knee range of motion and maximum knee extension during gait.

RESULTS

Twenty-eight children were included in both the transfer group [age 9.4±2 y; Gross Motor Function Classification System (GMFCS) I (3 children), II (15 children), III (8 children), and IV (2 children)] and the resection group [age 10.6±2.5 y; GMFCS I (1 child), II (14 children), and III (13 children)]. Both surgical groups showed statistically significant short-term postsurgical improvements in peak knee flexion during swing (P<0.001 for the transfer group and P=0.003 for the resection group) and Duncan-Ely test (P=0.004 for the transfer group and P<0.001 for the resection group). Further analysis by GMFCS level showed children at GMFCS levels III/IV had a greater tendency to crouch after RFT when compared with children at GMFCS levels I/II. This tendency was not observed in the RFR group.

CONCLUSIONS

Both transfer and resection surgeries significantly improved gait kinematics short-term outcomes in children with spastic CP who present with stiff knee gait pattern. Further studies are required to compare long-term outcomes of both surgeries.

LEVEL OF EVIDENCE

Level III-retrospective matched-cohort study.

Single-event multilevel surgery in cerebral palsy: Value added by a co-surgeon

ABSTRACT

The aim of this study was to compare outcomes for single-event multilevel surgery (SEMLS) in cerebral palsy (CP) performed by 1 or 2 attending surgeons.A retrospective review of patients with CP undergoing SEMLS was performed. Patients undergoing SEMLS performed by a single senior surgeon were compared with patients undergoing SEMLS by the same senior surgeon and a consistent second attending surgeon. Due to heterogeneity of the type and quantity of SEMLS procedures included in this study, a scoring system was utilized to stratify patients to low and high surgical burden. The SEMLS events scoring less than 18 points were categorized as low burden surgery and SEMLS scoring 18 or more points were categorized as high burden surgery. Operative time, estimated blood loss, hospital length of stay, and operating room (OR) utilization costs were compared.In low burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 8 patients had SEMLS performed by 2 surgeons. In high burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 12 patients had SEMLS performed by 2 surgeons. For high burden SEMLS, operative time was decreased by a mean of 69 minutes in cases performed by 2 co-surgeons (P = 0.03). Decreased operative time was associated with an estimated savings of $2484 per SEMLS case. In low burden SEMLS, a trend toward decreased operative time was associated for cases performed by 2 co-surgeons (182 vs 221 minutes, P = 0.11). Decreased operative time was associated with an estimated savings of $1404 per low burden SEMLS case. No difference was found for estimated blood loss or hospital length of stay between groups in high and low burden SEMLS.Employing 2 attending surgeons in SEMLS decreased operative time and OR utilization cost, particularly in patients with a high surgical burden. These findings support the practice of utilizing 2 attending surgeons for SEMLS in patients with CP.Level of Evidence: Level III.

The effectiveness of epidural blood patch in patients with cerebral palsy treated with intrathecal baclofen implantation

BACKGROUND

Cerebrospinal fluid leak and postdural puncture spinal headache following intrathecal baclofen therapy are known complications. Although primary treatments are conservative, epidural blood patch is an alternative in patients with persistent and severe symptoms.

AIM

The purpose of this article is to review the effectiveness of epidural blood patch for the treatment of spinal headache and cerebrospinal fluid leak associated with intrathecal baclofen treatment in children with cerebral palsy.

METHODS

Our database was reviewed for epidural blood patch in 341 pediatric patients with cerebral palsy who underwent primary intrathecal baclofen treatment from 2004 to 2018 at one institution. The number of patches, time frame of treatment, and effectiveness of the epidural blood patch were collected. All patients treated with epidural blood patch were evaluated for primary and secondary intrathecal baclofen-related procedures, and subsequent treatment of intrathecal baclofen associated with cerebrospinal fluid leak and spinal headache.

RESULTS

Twenty-nine epidural blood patch procedures were performed on 26 patients who had received intrathecal baclofen procedures. Of these 26 patients, four had a secondary epidural blood patch. The incidence of spinal headache/cerebrospinal fluid leak was 31% (107/341), and 81/107 (76%) patients with spinal headache/cerebrospinal fluid leak responded to conservative treatments. Success rate for initial epidural blood patch was 79.3% (23/29). The second epidural blood patch was performed in four patients after failure of initial epidural blood patch. Second epidural blood patch success rate was 75% (3/4).

CONCLUSION

Spinal headache and cerebrospinal fluid leak are known complications after intrathecal baclofen treatment in children with cerebral palsy. When conservative treatments are unsuccessful, epidural blood patch can be used with confidence for these patients. In patients with ongoing symptoms, it is possible to obtain success by repeating the epidural blood patch to continue intrathecal baclofen treatment and avoid aggressive surgery.

What's New in Pediatric Hip?

BACKGROUND

Developmental dysplasia of the hip (DDH), which encompasses a wide spectrum of disease from mild dysplasia to frank dislocation, is one of the most common developmental deformities of the lower extremities and one of the leading causes of future osteoarthritis and hip arthroplasty. Legg-Calvé-Perthes disease (LCPD) results from a vascular insult to the growing femoral epiphysis, which in turn can create permanent morphologic changes to the hip joint. Slipped capital femoral epiphysis (SCFE) occurs when the proximal femoral physis fails allowing the epiphysis to displace in relation to the metaphysis. Infections about the hip also create significant morbidity in the pediatric hip.

METHODS

We searched the PubMed database for all studies related to DDH, LCPD, SCFE, and pediatric hip infections that were published between July 1, 2014 and August 31, 2017. The search was limited to English articles and yielded 839 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line.

RESULTS

A total of 40 papers were selected for review based upon new and significant findings. Select historical manuscripts are also included to provide sufficient background information.

CONCLUSIONS

DDH, LCPD, SCFE, and infections about the hip continue to be important topics in pediatric orthopaedics and areas of vital research. This manuscript reviews the most important recent literature on the diagnosis and treatment of these pediatric hip conditions.

LEVEL OF EVIDENCE

Level V.

Infections of Intrathecal Baclofen Delivery Systems and Ventriculoperitoneal Shunting Systems: Clinical Series Discussion

BACKGROUND/AIMS

The physiological interaction between the intrathecal baclofen (ITB) delivery system and the ventriculoperitoneal (VP) shunting system in a patient who had both systems implanted has not been reported previously. The aim of our report is to evaluate the effect that one system's infection might have on the other.

METHODS

Records of children who were followed at our institution between 2004 and 2015 for management of their ITB systems were reviewed. In this group, children who had VP shunts were identified, and those who had any of their ITB or VP systems infected were included.

RESULTS

Out of 313 children managed with ITB therapy at our institution, 31 (24%) children had VP shunts. Two patients had infection in both systems, and 3 patients had infection in 1 system.

CONCLUSION

This report suggests that if aspiration from both systems showed positive cultures, the treatment would be removal of both systems. If the primarily not infected system does not show positive cultures, it does not need to be removed. Close follow-up is recommended, and any sign of infection or malfunction of the primarily not infected device should be approached with a high level of suspicion.

Reliability and validity of Edinburgh visual gait score as an evaluation tool for children with cerebral palsy

Assessment of gait abnormalities in cerebral palsy (CP) is challenging, and access to instrumented gait analysis is not always feasible. Therefore, many observational gait analysis scales have been devised. This study aimed to evaluate the interobserver reliability, intraobserver reliability, and validity of Edinburgh visual gait score (EVGS). Video of 30 children with spastic CP were reviewed by 7 raters (10 children each in GMFCS levels I, II, and III, age 6-12 years). Three observers had high level of experience in gait analysis (10+ years), two had medium level (2-5 years) and two had no previous experience (orthopedic fellows). Interobserver reliability was evaluated using percentage of complete agreement and kappa values. Criterion validity was evaluated by comparing EVGS scores with 3DGA data taken from the same video visit. Interobserver agreement was 60-90% and Kappa values were 0.18-0.85 for the 17 items in EVGS. Reliability was higher for distal segments (foot/ankle/knee 63-90%; trunk/pelvis/hip 60-76%), with greater experience (high 66-91%, medium 62-90%, no-experience 41-87%), with more EVGS practice (1st 10 videos 52-88%, last 10 videos 64-97%) and when used with higher functioning children (GMFCS I 65-96%, II 58-90%, III 35-65%). Intraobserver agreement was 64-92%. Agreement between EVGS and 3DGA was 52-73%. We believe that having EVGS as part of the standardized gait evaluation is helpful in optimizing the visual scoring. EVGS can be a supportive tool that adds quantitative data instead of only qualitative assessment to a video only gait evaluation.

Evaluation of intrathecal baclofen delivery system malfunction by computed tomography scan

AIM

To describe the computed tomography (CT) findings encountered when catheter patency is questionable. The role of CT in directing treatment is evaluated.

METHOD

Records of children with intrathecal baclofen pump management were reviewed. Only patients with CT evaluation who had revision pump/catheter surgery were included.

RESULTS

From 295 patients, 27 had CT contrast study; in three of them, baclofen could not be aspirated and the procedure was stopped, eight had normal scan and did not need surgery and 16 patients were reported. Four patients had normal CT (free contrast formed a perfect crescent shape), and had surgery because the pump battery was close to expiration. Five patients had inadequate fluid pooling (fluid was seen without a crescent shape). Five patients had fluid leak (fluid was seen around the pump or in the lumbar canal below catheter entrance level or outside the canal in the lumbar region). Two patients had catheter occlusion (fluid loculation around the catheter tip with no free flow).

INTERPRETATION

CT contrast study is safe and effective for locating defects in intrathecal baclofen delivery system. When catheter patency is questionable, CT plays an important role in directing the next step of management.

Delayed Abdominal Compartment Syndrome as a Complication of Spinal Surgery: Literature Review and Case Report

Posterior spinal fusion surgery for neuromuscular scoliosis is associated with favorable outcomes and high caregiver satisfaction scores. However, these patients represent a medically fragile patient population prone to complications. One of the more unpredictable complications is abdominal compartment syndrome (ACS), the etiology of which is not fully understood. This case report represents the first case report of delayed ACS to develop 3 days after spinal fusion in a patient with no history of previous abdominal surgeries undergoing correction for neuromuscular scoliosis. This case outlines the clinical course, risk factors for ACS, and indications for urgent surgical decompression of the abdomen. Given the high mortality, it is important for orthopedic surgeons to understand prevention, presentation, and timely management associated with ACS.

Overview of foot deformity management in children with cerebral palsy

Foot deformities in children with cerebral palsy are common. The natural history of the deformities of the feet is very variable and very unpredictable in young children less then 5 years old. Treatment for the young children should be primarily with orthotics and manual therapy. Equinus is the most common deformity, with orthotics augmented with botulinum toxin being the primary management in young children. When fixed deformity develops lengthening only the muscle which is contracted is preferred. Varus deformity of the feet is often associated with equinus, and can almost always be managed with orthotics until 8 or 10 years of age. Planovalgus is the most common deformity in children with bilateral lower extremity spasticity. The primary management is orthotics until the child no longer tolerates the orthotic; then surgical management needs to consider all the deformities and all should be corrected. This requires correcting the subtalor subluxation with calcaneal lengthening or fusion, medial midfoot correction with osteotomy or fusion.