Single Event Multilevel Surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study

Factors Associated with Enhanced Gross Motor Progress in Children with Cerebral Palsy: A Register-Based Study

AIM

To examine associations between interventions and child characteristics; and enhanced gross motor progress in children with cerebral palsy (CP).

METHODS

Prospective cohort study based on 2048 assessments of 442 children (256 boys, 186 girls) aged 2-12 years registered in the Cerebral Palsy Follow-up Program and the Cerebral Palsy Register of Norway. Gross motor progress estimates were based on repeated measures of reference percentiles for the Gross Motor Function Measure (GMFM-66) in a linear mixed model. Mean follow-up time: 2.9 years.

RESULTS

Intensive training was the only intervention factor associated with enhanced gross motor progress (mean 3.3 percentiles, 95% CI: 1.0, 5.5 per period of ≥3 sessions per week and/or participation in an intensive program). Gross motor function was on average 24.2 percentiles (95% CI: 15.2, 33.2) lower in children with intellectual disability compared with others. Except for eating problems (-10.5 percentiles 95% CI: -18.5, -2.4) and ankle contractures by age (-1.9 percentiles 95% CI: -3.6, -0.2) no other factors examined were associated with long-term gross motor progress.

CONCLUSIONS

Intensive training was associated with enhanced gross motor progress over an average of 2.9 years in children with CP. Intellectual disability was a strong negative prognostic factor. Preventing ankle contractures appears important for gross motor progress.

Long-term development of gait after multilevel surgery in children with cerebral palsy: a multicentre cohort study

AIM

We investigated the long-term efficacy and safety of multilevel surgery (MLS) in ambulatory children with bilateral spastic cerebral palsy (CP).

METHOD

Two hundred and thirty-one children were evaluated at short term (1.1y, SD 0.4) and long term (9.1y, SD 3.0) follow-up using clinical examination and gait analysis. MLS was investigated by studying changes in the Gait Profile Score (GPS) referenced to the minimally important clinical difference.

RESULTS

Ambulatory children aged 10 years and 7 months (SD 2y 11mo) at MLS in Gross Motor Function Classification System levels I (19), II (144), and III (68) showed a decrease (improvement) in preoperative GPS from 16.3° (SD 4.8) to 11.3° (SD 3.2) at short-term follow-up, an improvement of 5°. At long-term follow-up, GPS was maintained at 11.4° (SD 3.1). Overall, 177 (76.6%) children maintained their improvement in GPS after 9 years.

INTERPRETATION

Multilevel surgery is a safe and effective surgical intervention, which leads to a significant improvement in gait kinematics in children with bilateral spastic CP. This study improves our understanding of MLS in the long term and will help to inform families and children when planning for MLS.

WHAT THIS PAPER ADDS

Largest study of multilevel surgery (MLS) for children with bilateral spastic cerebral palsy, with longest follow-up. MLS resulted in significant long-term improvements in gait function. Minor adverse events were common, while events requiring intervention were uncommon (4% of children). Thirty-nine per cent of children required additional surgery during follow-up. 'Single-event multilevel surgery' was changed to the more realistic term 'multilevel surgery'.

Screening and referral for children with physical disabilities

The clinical care of children with physical disabilities is a major priority for paediatricians and paediatric orthopaedic surgeons. Cerebral palsy (CP) is the prototypical condition and remains the most common cause of physical disability in developed countries. The incidence is approximately 2 per 1000 live births, translating to between 600 and 700 new children per annum in Australia, with approximately 34 000 children and adults currently living with CP. This figure is predicted to rise inexorably over the next 20 years. The care of children with physical disabilities, including those with CP, is usually coordinated by paediatricians, general practitioners and allied health teams including physiotherapists, with input from paediatric orthopaedic surgeons when appropriate. The emphasis in care for children with CP has moved from 'reactive' to 'proactive'. In the past, children are often referred when symptomatic, for example when a hip dislocation had occurred and became painful. The emphasis now is on coordinated, multidisciplinary care in which musculoskeletal manifestations of disability are identified by screening programmes. Systematic screening, especially when population-based and linked to a register, avoids children getting 'lost in the system'. Early and more effective interventions may be offered for the prevention of contractures, dislocation of the hip and spinal deformities. In this review, we will focus on the assessment of gait in children with physical disabilities, and monitoring for hip and spine deformity.

Effects of multilevel surgery on a flexed knee gait in adults with cerebral palsy

Aims

A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood.

Patients and Methods

At a mean of 22.9 months (standard deviation 12.9), after single event multi level surgery, 3D gait analysis was undertaken pre- and post-operatively for 37 adult patients with bilateral cerebral palsy and a fixed knee gait.

Results

There was a significant improvement of indices and clinical and kinematic parameters including extension of the hip and knee, reduction of knee flexion at initial contact, reduction of minimum and mean knee flexion in the stance phase of gait, improved range of movement of the knee and a reduction of mean flexion of the hip in the stance phase. Genu recurvatum occurred in two patients (n = 3 legs, 4%) and an increase of pelvic tilt (> 5°) was found in 12 patients (n = 23 legs, 31%).

Conclusion

Adult patients with bilateral cerebral palsy and a flexed knee gait benefit from multilevel surgery including hamstring lengthening. The risk of the occurence of genu recurvatum and increased pelvic tilt is lower than has been previously reported in children. Cite this article: Bone Joint J 2017;99-B:1256–64.

Long-term outcomes of external femoral derotation osteotomies in children with cerebral palsy

External femoral derotation osteotomy (FDO) is an orthopaedic intervention to correct increased femoral anteversion and associated excessive internal hip rotation and internal foot progression during gait in children with cerebral palsy. The resulting functional issues may include clearance problems and hip abductor lever-arm dysfunction. The purpose of this study was to evaluate long-term gait outcomes of FDO. Twenty ambulatory patients (27 sides) with cerebral palsy who underwent pre-operative (P0) and a one year post-operative (P1) gait analysis as part of the standard of care had a second post-operative analysis (P2) approximately 11 years post-surgical intervention. Mean hip rotation in stance showed statistically significant decreases in internal rotation at P1 post-surgical intervention that were maintained long-term (mean hip rotation P0: 21±9, P1: 0±9 and P2: 6±12 degrees internal). Similar results were seen with mean foot progression (P0: 9±16 degrees internal, P1: 14±13 degrees external, P2: 13±16 degrees external). However, 2/27 sides (9%) showed a recurrence of internal hip rotation of >15° at the 11year follow-up. The reasons for this recurrence could include age, surgical location and ongoing disease process all of which need to be further examined. We conclude that FDO can show long-term kinematic and functional benefits when performed in the prepubescent child with cerebral palsy in comparison to the natural progression of of hip rotation in cerebral palsy.

What's New in the Orthopaedic Treatment of Cerebral Palsy

BACKGROUND

The orthopaedic treatment of the patient with cerebral palsy (CP) is complex and must take into account the heterogeneity and natural history of the condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This update serves to summarize some of the recent publications in the field of pediatric orthopaedics that have made important contributions to our understanding and care of the patient with CP.

METHODS

We searched the PubMed database using the following terms: "cerebral palsy" AND "orthopedic." The results were then filtered to include only review papers or clinical trials published in English from 2010 to 2014. The obtained list of references was then reviewed for publications in the fields of lower extremity muscle imbalance, foot and ankle deformities, hip and acetabular dysplasia, and advances in orthopaedic-related technology.

RESULTS

Updates in the field of pediatric orthopaedics are constant and the current level of evidence for the effectiveness of specific treatment modalities in patients with CP was reviewed. The search method yielded 153 publications, of which 31 papers were identified as having contributed important new findings.

CONCLUSIONS

Our understanding of orthopaedic treatments for children with CP continues to grow and expand. The studies reviewed illustrate just some of the strides we have taken in utilizing evidence-based surgical decision making in practice. Nevertheless, there remains a paucity of randomized controlled trials and higher evidence research, which may contribute to the variability in current practices among providers. By elucidating these gaps we can more purposefully delegate our time and resources into targeted areas of research.

LEVEL OF EVIDENCE

Level 4-literature review.

Abnormality of standing posture improves in patients with bilateral spastic cerebral palsy following lower limb surgery

OBJECTIVES

The degree of abnormality of the gait pattern of children with bilateral spastic cerebral palsy (BSCP) can be reduced by lower limb orthopaedic surgery. However, little attention is paid to the effects of surgery on standing posture. Here, we investigated the abnormality of standing posture in young people with BSCP as well as the effects of surgery on standing posture.

METHODS

We have developed an index of standing posture, the Standing Posture Score (SPS), which is similar in composition to the gait profile score (GPS). We applied SPS retrospectively to 32 typically developing children and 85 children with BSCP before and after surgery to the lower limbs aimed at improving gait. We investigated the relationship between SPS and GPS before surgery and also the relationship between changes in these variables before and after surgery.

RESULTS

SPS is significantly higher in young people with BSCP. SPS reduces after surgery and this reduction is correlated with the reduction in GPS.

INTERPRETATION

Successful surgery improves the alignment of the lower limbs in BSCP in standing and may have a positive impact on the activities of daily living which depend on a stable and efficient standing posture.

Does unilateral single-event multilevel surgery improve gait in children with spastic hemiplegia? A retrospective analysis of a long-term follow-up

Single event multilevel surgery (SEMLS) has become a standard intervention for children with cerebral palsy (CP). SEMLS proved to improve the gait in bilateral spastic cerebral palsy and those improvements can be maintained in the long term. However there is no evidence on the long-term outcome of unilateral SEMLS in children with unilateral spastic cerebral palsy. The gait analyses and clinical data of 14 children (9 male/5 female, mean age 12.1) with unilateral CP (6 children Gross Motor Function Classification System Scale level I and 8 children level II) were retrospectively reviewed at four time-points: preoperatively, 1year, 3-5 years and approximately 10 years after unilateral SEMLS. The Gait Profile Score (GPS) of the affected leg was used as a main and the number of fine tuning procedures as well as complications rate (Clavien-Dindo classification) as secondary outcome measures. The gait improved postoperatively and the GPS of the affected leg significantly declined by 3.73° which is well above the minimal clinical important difference of 1.6°. No deterioration of GPS occurred throughout the follow-up period. Therefore the postoperative improvement was maintained long-term. However, additional fine-tuning procedures had to be performed during the follow-up in 5 children and three complications occurred (one level II and two level III). The results indicate that children with unilateral cerebral palsy benefit from unilateral SEMLS and maintain gait improvements long-term.

Orthopedic surgery in cerebral palsy: Instructional course lecture

Orthopedic surgery (OS) plays an important role in the management of cerebral palsy (CP). The objectives of OS are to optimize functions and prevent deformity. Newer developments in OS for CP include emphasis on hip surveillance, minimally invasive procedures, use of external fixators instead of plates and screws, better understanding of lever arm dysfunctions (that can only be corrected by bony OS), orthopedic selective spasticity-control surgery, and single-event multilevel lever arm restoration and anti spasticity surgery, which have led to significant improvements in gross motor function and ambulation, especially in spastic quadriplegia, athetosis, and dystonia. The results of OS can be dramatic and life altering for the person with CP and their caregivers if it is performed meticulously by a specialized surgical team, at the appropriate age, for the correct indications, employing sound biomechanical principles and is followed by physician-led, protocol based, intensive, multidisciplinary, institutional rehabilitation, and long term followup. However, OS can be a double-edged sword, and if performed less than optimally, and without the supporting multidisciplinary medical and rehabilitation team, expertise and infrastructure, it often leads to significant functional worsening of the person with CP, including irretrievable loss of previous ambulatory capacity. OS must be integrated into the long term management of the person with CP and should be anticipated and planned at the optimal time and not viewed as a "last resort" intervention or failure of rehabilitation. This instructional course lecture reviews the relevant contemporary principles and techniques of OS in CP.

Gait analysis in children with cerebral palsy

Cerebral palsy (CP) children present complex and heterogeneous motor disorders that cause gait deviations.

Clinical gait analysis (CGA) is needed to identify, understand and support the management of gait deviations in CP. CGA assesses a large amount of quantitative data concerning patients’ gait characteristics, such as video, kinematics, kinetics, electromyography and plantar pressure data.

Common gait deviations in CP can be grouped into the gait patterns of spastic hemiplegia (drop foot, equinus with different knee positions) and spastic diplegia (true equinus, jump, apparent equinus and crouch) to facilitate communication. However, gait deviations in CP tend to be a continuum of deviations rather than well delineated groups. To interpret CGA, it is necessary to link gait deviations to clinical impairments and to distinguish primary gait deviations from compensatory strategies.

CGA does not tell us how to treat a CP patient, but can provide objective identification of gait deviations and further the understanding of gait deviations. Numerous treatment options are available to manage gait deviations in CP. Generally, treatments strive to limit secondary deformations, re-establish the lever arm function and preserve muscle strength.

Additional roles of CGA are to better understand the effects of treatments on gait deviations.

Cite this article: Armand S, Decoulon G, Bonnefoy-Mazure A. Gait analysis in children with cerebral palsy. EFORT Open Rev 2016;1:448-460. DOI: 10.1302/2058-5241.1.000052.

The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy

Crouched gait is common in children with cerebral palsy (CP), and there are various treatment options. This study evaluated the effectiveness of single-event multilevel surgery including posterior knee capsulotomy or distal femoral extension osteotomy to correct knee flexion contracture in children with CP. Gait analyses were carried out to evaluate gait preoperatively and postoperatively. Significant improvements were found in physical examination and kinematic measures, which showed that children with CP and crouched gait who develop knee flexion contractures can be treated effectively using single-event multilevel surgery including a posterior knee capsulotomy or distal femoral extension osteotomy.

Biomechanical Assessment of Patellar Advancement Procedures for Patella Alta

Crouch gait deformity is common in children with cerebral palsy and often is associated with patella alta. Patellar tendon advancement typically is used to correct patella alta and restore normal knee mechanics. The purpose of this study was to determine the mechanical strength of surgical constructs used for fixation during patellar advancement procedures. This study used a cadaveric model to determine which of 3 surgical techniques is biomechanically optimal for patellar tendon advancement in treating patella alta. Twenty-four human cadaveric knees (8 per group) were prepared using 1 of 3 different common surgical techniques: tibial tubercle osteotomy, patellar tendon partial resection and repair at the distal patella, and patellar tendon imbrication. The patella was loaded from 25 to 250 N at 1 Hz for 1000 cycles. A significant difference in patella displacement under cyclical loading was found between surgical techniques. Tibial tubercle osteotomy exhibited significantly less displacement under cyclical loading than distal patella excision and repair (P<.0001) or imbrication (P=.0088). Imbrication exhibited significantly less displacement than distal patella excision and repair (P=.0006). Tibial tubercle osteotomy survived longest. Based on failure criteria of 5 mm of displacement, tibial tubercle osteotomy lasted between 250 and 500 cycles. The other 2 techniques failed by 25 cycles. This study offers quantitative evidence regarding the relative mechanical strength of each construct and may influence choice of surgical technique. [Orthopedics. 2016; 39(3):e492-e497.].

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single-event multilevel surgery

AIM

To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery.

METHOD

Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]).

RESULTS

There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001).

INTERPRETATION

Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile.

Body mass index in ambulatory children with cerebral palsy: A cohort study

AIM

Children with cerebral palsy (CP) have reduced levels of physical activity compared with children without physical disability and experience risk factors for becoming overweight or obese. In the Australian CP population, there is little information available about the weight status of children with CP. The aims of this study were to compare the distribution of body mass index (BMI) in a cohort of ambulant children with CP with the BMI distribution of Australian children and explore the relationship between BMI and gross motor function.

METHODS

A retrospective cohort study of 587 children with CP Gross Motor Function Classification System (GMFCS) levels I-III who attended a Gait Laboratory between July 1995 and January 2012 was carried out. The BMI and Z-score were calculated at each assessment. Data were grouped into the categories of underweight, healthy, overweight and obese according to age-specific and sex-specific percentiles.

RESULTS

There were 348 boys and 240 girls with a mean age 11.2 (standard deviation 3.2) years. Mean BMI Z-score was 0.11 (standard deviation 1.33). Seven percent of children were underweight, 73.6% healthy, 7.3% overweight and 12.1% obese. This was similar to the distribution of children without disability. The largest percentage of children in the healthy group were classified GMFCS I. The largest percentage of children in the obese group were classified GMFCS III.

CONCLUSIONS

In this cohort, 19.4% of ambulant children with CP were overweight or obese. This is of concern as BMI may impact on the outcomes of surgical intervention and rehabilitation. Further research is needed to determine the consequences of obesity for children with CP.

Spastic Paralysis of the Elbow and Forearm

As the physiologic recovery period concludes, the patient is evaluated for surgical procedures that may rebalance muscle function and correct deformity. Upper extremity function is the product of complex and highly sophisticated mechanisms working in unison, and a careful, systematic preoperative evaluation is critical. A good function of the hand cannot be achieved without adequate position of the shoulder, elbow, forearm, and wrist. The goals of surgery must be practical and clearly understood by the patient and the family.

Multilevel surgery in adults with cerebral palsy

Aims

Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate.

Methods

This study analysed the short-term outcome (mean 1.7 years, standard deviation 0.9) of 97 ambulatory adults with BSCP who performed three-dimensional gait analysis before and after SEMLS at one institution.

Results

Two objective gait variables were calculated pre- and post-operatively; the Gillette Gait Index (GGI) and the Gait Profile Score (GPS). The results were analysed in three groups according to their childhood surgical history (group 1 = no surgery, group 2 = surgery other than SEMLS, group 3 = SEMLS). Improvements in gait were shown by a significant decrease of GPS (p = 0.001). Similar results were obtained for both legs (GGI right side and left side p = 0.01). Furthermore, significant improvements were found in all subgroups although this was less marked in group 3, where patients had undergone previous SEMLS.

Discussion

SEMLS is an effective and safe procedure to improve gait in adults with cerebral palsy. However, a longer rehabilitation period is to be expected than found in children. SEMLS is still effective in adult patients who have undergone previous SEMLS in childhood. Take home message: Single-event multilevel surgery is a safe and effective procedure to improve gait disorders in adults with bilateral spastic cerebral palsy. Cite this article: Bone Joint J 2016;98-B:282–8.

Predictors of outcome after single-event multilevel surgery in children with cerebral palsy

Aims

Single event multilevel surgery (SEMLS) has been shown to improve gait in children with cerebral palsy (CP). However, there is limited evidence regarding long-term outcomes and factors influencing them.

Methods

In total 39 children (17 females and 22 males; mean age at SEMLS ten years four months, standard deviation 37 months) with bilateral CP (20 Gross Motor Function Classification System (GMFCS) level II and 19 GMFCS level III) treated with SEMLS were included. Children were evaluated using gait analysis and the Gait Deviation Index (GDI) before SEMLS and one, two to three, five and at least ten years after SEMLS. A linear mixed model was used to estimate the effect of age at the surgery, GMFCS and follow-up period on GDI.

Results

There was a mean improvement of 12.1 (-15.3 to 45.1) GDI points one year after SEMLS (p <  0.001) and 10.3 (-23.1 to 44.2) GDI points ten years after SEMLS compared with before SEMLS (p < 0.001). GMFCS level III children aged ten to 12 years had the most improvement. The GMFCS III group had more surgical procedures at the index SEMLS (p < 0.001) and during the follow-up period (p = 0.039). After correcting for other factors, age at surgery was the only factor predictive of long-term results. Our model was able to explain 45% of the variance of the change in GDI at the different time points. Take home message: Children with GMFCS III level aged ten to 12 are the benchmark responders to SEMLS in the long-term. Cite this article: Bone Joint J 2016;98-B:278–81.

Evaluation and management of crouch gait

PURPOSE OF REVIEW

Crouch gait is defined as excessive ankle dorsiflexion, knee and hip flexion during the stance phase. This gait disorder is common among patients with cerebral palsy. The present article brings an up-to-date literature review on the pathoanatomy, natural history, and treatment of this frequent gait abnormality.

RECENT FINDINGS

Hamstrings are often not shortened in patients with crouch. Patella alta must be addressed if surgery is performed. Surgical correction of joint contractures and lever arm dysfunction can be effectively achieved through a single-event multilevel surgery.

SUMMARY

Crouch gait is a common gait deviation, often seen among ambulatory diplegic and quadriplegic patients, once they reach the pubertal spurt, when weak muscles can no longer support a toe walking pattern because of rapidly increased weight. This form of gait is highly ineffective and might compromise walking ability over time. The anterior knee is overloaded; pain, extensor mechanism failure, and arthritis might develop. Its progressive nature often requires surgical intervention. The cause of crouch gait is multifactorial, and surgery should be tailored to meet the individual's specific anatomic and physiologic abnormalities.

Cerebral palsy

Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.

Long-term outcomes after multilevel surgery including rectus femoris, hamstring and gastrocnemius procedures in children with cerebral palsy

BACKGROUND/AIMS

Multilevel surgical intervention is a common approach for the correction of gait abnormalities in children with cerebral palsy (CP). The short-term outcomes for the combination of rectus femoris transfer, hamstring lengthening and gastrocnemius lengthening have been well documented using three-dimensional motion analysis. However, the impact of time, growth, and puberty on these short-term outcomes of this combination of procedures is not well understood. The purpose of this study was to evaluate the long-term outcomes of these procedures on gait in patients with CP.

METHODS

Twenty-two patients underwent rectus femoris transfers, medial hamstring lengthenings and gastrocnemius lengthenings in combination with a selection of other soft tissue and/or bony procedures of the lower limb. All patients had a pre-operative motion analysis and post-operative analysis one and 11 years following surgery.

RESULTS

Significant changes in both clinical and gait variables from pre to 1 year post surgery confirmed the short-term gait benefits of this combination of surgical procedures. Long-term follow-up data indicated that the passive range of motion gains noted 1 year after surgery were lost at the knee and ankle. However, the improvements in ankle dorsiflexion and knee extension at initial contact were maintained over 11 years. As well, peak ankle dorsiflexion in stance was maintained and peak ankle plantar flexor moments and powers did not show declines long-term. Peak knee flexion showed a decline over the long-term, however, the timing of peak knee flexion in swing was maintained.

CONCLUSION

When compared to declines in gait kinematics in persons with CP without surgery, these results demonstrate the possible long-term benefits of surgical intervention.

Long-term ambulatory change after lower extremity orthopaedic surgery in children with cerebral palsy: a retrospective review

BACKGROUND

Long-term studies of lower extremity orthopaedic surgery in children with cerebral palsy (CP) tend to focus on gait kinematics and kinetics, with little to no emphasis on gross motor ambulatory function. The current study was undertaken to examine the long-term impact of surgery on ambulatory function in patients with CP enrolled in a government-funded, outpatient therapy program.

METHODS

Retrospective medical record review was conducted of 127 children with CP, Gross Motor Function Classification System (GMFCS) levels I to IV, followed up to 14 years after lower extremity orthopaedic surgery. Data were extracted from medical/operative records and routine physical therapy evaluations performed over the course of follow-up. Functional Mobility Scale (FMS) scores were assigned based on gross motor function information contained in each 6- to 12-month physical therapy evaluation. Data were compared statistically among GMFCS levels.

RESULTS

Average length of follow up was 11.8±4 years. Subjects underwent 0.61±0.43 surgical procedures per person-year in 0.16±0.09 operative sessions per person-year with no differences between GMFCS levels. Subjects at GMFCS level I improved significantly in community (P=0.02) but not household ambulation, reflecting the ceiling effect of the FMS. Subjects at GMFCS levels II to IV showed statistically significant improvements at all distances. Subjects at level III gained more in household than long-distance ambulation (P=0.002). Subjects functioning at GMFCS level II improved by 1 FMS level for household and school distances, and 2 FMS levels for community distances (P<0.02). Subjects at level IV exhibited small ambulatory gains at all distances (P<0.04).

CONCLUSIONS

Significant long-term improvement in functional ambulation is seen after surgery for children at all GMFCS levels. Children with more independence tend to make gains in long-distance ambulation, whereas those who use assistive devices tend to improve more in short-distance ambulation. This information may be useful to clinicians when counseling patients and their families regarding potential for ambulatory improvement after lower extremity orthopaedic surgery.

LEVEL OF EVIDENCE

Level IV: case series.

Gait improvement surgery in ambulatory children with diplegic cerebral palsy

BACKGROUND AND PURPOSE

Instrumented 3-D gait analyses (GA) in children with cerebral palsy (CP) have shown improved gait function 1 year postoperatively. Using GA, we assessed the outcome after 5 years and evaluated parental satisfaction with the surgery and the need for additional surgery.

PATIENTS AND METHODS

34 ambulatory children with spastic diplegia had preoperative GA. Based on this GA, the children underwent 195 orthopedic procedures on their lower limbs at a mean age of 11.6 (6-19) years. On average, 5.7 (1-11) procedures per child were performed. Outcome measures were evaluation of gait quality using the gait profile score (GPS) and selected kinematic parameters, functional level using the functional mobility scale (FMS), and the degree of parental satisfaction.

RESULTS

The mean GPS improved from 20.7° (95% CI: 19-23) preoperatively to 15.4° (95% CI: 14-17) 5 years postoperatively. There was no significant change in GPS between 1 and 5 years. The individual kinematic parameters at the ankle, knee, and hip improved statistically significantly, as did gait function (FMS). The mean parental satisfaction, on a scale from 0 to 10, was 7.7 (2-10) points. There was a need for additional surgical procedures in 14 children; this was more frequent in those who had the index operation at an early age.

INTERPRETATION

The main finding was that orthopedic surgery based on preoperative GA gave marked improvements in gait function and quality, which were stable over a 5-year period. Nevertheless, additional orthopedic procedures were necessary in almost half of the children and further follow-up with GA for more than 1 year postoperatively is recommended in children with risk factors for such surgery.

Patellar tendon shortening for flexed knee gait in spastic diplegia

We evaluated the outcome of three different approaches to the management of flexed knee gait patients with spastic diplegia. The three surgical procedures were patellar tendon shortening (PTS), PTS combined with rotational osteotomies of the femur and/or tibia, and PTS combined with supracondylar extension osteotomy (SEO) of the distal femur. The primary outcome measure was gait kinematics. The knee gait variable score (GVS) and the gait profile score (GPS) were derived from gait kinematics. 24 patients (16 male and 8 female), mean age 16.1 years (SD 5.8 years), who had surgery between 2002 and 2008, were followed for a mean of 22 months. Knee extension during gait improved by a mean of 20° throughout the gait cycle, with an improvement in the knee GVS of 14° (p<0.001). The overall gait pattern improved with a mean decrease in GPS of 4.6°. Correction of patella alta was demonstrated by an improvement in the Koshino index from 1.34 pre-operatively to 1.10 post-operatively (p<0.001). Knee and gait kinematics, physical examination measures and Koshino Index improved in all three surgical groups, suggesting that a tailored approach to the correction of flexed knee gait in spastic diplegia is both feasible and appropriate.

LEVEL OF EVIDENCE

Level III.

Does single-event multilevel surgery enhance physical functioning in the real-life environment in children and adolescents with cerebral palsy (CP)?: patient perceptions five years after surgery

Orthopedic procedures are a method of treating gait deviations and musculoskeletal pathology that develop with age in cerebral palsy (CP). Recently single-event multilevel surgery (SEMLS) has become common practice. Although there is evidence that SEMLS could improve gait, it is unclear whether it will enhance overall physical functioning and coping strategies in the real-life environment. It is unclear how improved walking capacity affects actual functioning and enables greater independence. The aim of this study was to examine the perceptions of adolescents concerning the results of surgery on personal physical functioning in the environment five or more years after SEMLS. In this study, qualitative data were gathered by open interviews and analyzed using phenomenographic approach, which aims to study variation in human understanding and perceptions of the phenomenon in question. Gait Profile Score (GPS) was used to describe the objective change. The results indicate that SEMLS had a clear positive effect on the participants' physical functioning capacity, particularly experienced as better walking ability. GPS improved by 3.5° five years postoperatively. Surgery could enhance physical activity and the motivation to maintain mobility in the future. The perceptions of the effect of surgery on physical functioning in the real-life environment varied from a challenge-avoiding, support-seeking agency to a highly active, independent agency in daily life. Our rehabilitation practice after multilevel surgery should be more focused on enhancing active agency in collaboration with adolescents with CP and their families.

Foot deformities in children with cerebral palsy

PURPOSE OF REVIEW

The present article describes common foot deformities in children with cerebral palsy and discusses treatment options for each of those deformities.

RECENT FINDINGS

Bracing is a useful treatment to correct foot deformities during gait. Surgical correction of foot deformities is typically performed as a part of multilevel single-event gait improvement surgery that has increasingly become the standard of care for ambulatory children with cerebral palsy. Foot realignment may improve knee function during stance, probably because of change of lever arm.

SUMMARY

Foot deformities are common among children with cerebral palsy. The three most common among them are equinus, planovalgus and equinovarus/equinocavovarus. Treatment consists of orthotics, physical therapy, spasticity reduction treatment and surgical correction. Guidelines for treatment are individualized and multifactorial. Important considerations include the child's level of function, the severity and flexibility of the deformity, the presence or absence of pain and skin irritation, and the changes in alignment observed over time.

2014 section on pediatrics knowledge translation lecture: clinicians and researchers on the same path toward facilitating family goals for mobility and participation

BACKGROUND

The knowledge translation (KT) lecture at the Combined Sections Meeting 2014 was a personal perspective from a researcher who had been a therapist and a longtime clinician, now a PhD candidate.

OBJECTIVE

To better integrate research and clinical care, KT is a seamless rather than separate process.

KEY POINTS

Knowledge translation can be enhanced by improved receptivity to evidence, and increasing use of research designs that encourage and even require clinician involvement, from single-subject designs to large-scale pragmatic trials. Clinical practice databases and hiring therapists to provide intervention in research efforts also serve to integrate research and clinical care. Limitations of applying mean group research results to an individual patient were also discussed and suggest an important unanswered topic for future research.

CONCLUSION

We all need to assume responsibility for the researcher-clinician partnership, making our jobs more joyful and fulfilling, and hopefully the biggest beneficiaries will be our current and future patients.

Mechanical work and energy consumption in children with cerebral palsy after single-event multilevel surgery

Multilevel surgery is commonly performed to improve walking in children with cerebral palsy (CP). Classical gait analysis (kinetics, kinematics) demonstrated positive outcomes after this intervention, however it doesn't give global indication about gait's features. The assessment of energy cost and mechanical work of locomotion can provide an overall description of walking functionality. Therefore, we propose to describe the effects of multilevel surgery in children with CP, considering energetics, mechanical work, kinetic and kinematic of walking. We measured external, internal, total work, energy cost, recovery, efficiency, kinetic and kinematic of walking in 10 children with CP (4 girls, 6 boys; 13 years ± 2) before and 1 year after multilevel surgery. Kinetic and kinematic results are partially comparable to previous findings, energy cost of walking is significantly reduced (p < 0.05); external, internal, total work, recovery, efficiency are not significantly different (p = 0.129; p = 0.147; p = 0.795; p = 0.119; p = 0.21). The improvement of the walking's energy consumption is not accompanied by a corresponding improvement of mechanical work. Therefore it is conceivable that the improvement of walking economy depend on a reduced effort of the muscle to maintain the posture, rather then to an improvement of the mechanism of energy recovery typical of human locomotion.

[Bilateral spastic cerebral palsy with ambulatory ability (diplegia): pathophysiology, state of the art of conservative and surgical treatment and rehabilitation]

BACKGROUND

Infantile cerebral palsy is one of the most common diseases resulting in chronic disability and is mostly concomitant with impairment in the ability to walk.

DISEASE PATTERN

Muscle contractions typically develop during the growth phase with subsequent joint contracture and instability as well as bone deformities to various extents. From a biomechanical viewpoint the gait impairment is due to a lever arm dysfunction.

THERAPEUTIC STRATEGIES

The therapy concept is multimodal and involves conservative as well as operative measures. The objectives are to lower the muscle tonus, to avoid muscle and joint contractures and bone deformities and to correct already fixed malformations in order to achieve the best possible function for the patient. Complicated multilevel operations are often necessary to achieve this aim.

CONCLUSION

Extensive knowledge on the biomechanics of gait and the pathobiomechanics of spastic bilateral cerebral palsy are necessary to carry out surgery. Using instrumental gait analyses the biomechanical relationships can be analyzed better and complicated operations can be planned with greater precision.

The cerebral palsy transition clinic: administrative chore, clinical responsibility, or opportunity for audit and clinical research?

PURPOSE

The majority of children with orthopaedic conditions in childhood survive to adult life, and there is a need for many of them to transition to adult services. This includes children with disorders such as club foot or developmental dislocation of the hip as well as those with complex syndromic conditions, bone dysplasias or neuromuscular disorders such as cerebral palsy and myelomeningocele. In many tertiary paediatric centres, transition has become a formal process in which clinicians document and communicate the status of patients who have been under their care to ensure a smooth transfer to adult services. The purpose of this report is to support the need for clear communication when children with cerebral palsy transition to adult services and to suggest that this transition represents a significant opportunity for audit and clinical research.

METHODS

Some of the factors to be considered in developing a minimum data sheet for the transfer or transition of children with cerebral palsy to adult services are described.

CONCLUSION

Using the model of adolescents with cerebral palsy transitioning to adult services, orthopaedic surgeons can be encouraged to develop similar methodology and documentation for many other conditions for the purposes of communication, facilitation of transition, audit and clinical research.

Effects of gastrocnemius fascia lengthening on gait pattern in children with cerebral palsy using the gait profile score

The aim of the present study was to investigate the efficacy of the GPS regarding the quantification of changes in gait following the gastrocnemius fascia lengthening in children with CP. Nineteen children with CP were selected and evaluated in the preoperative period (PRE session) and approximately one year postoperatively (POST session; mean 13.1 ± 5.1 months) using 3D gait analysis and computing the GPS and GVSs. As the GPS represents the difference between the patient's data and the average from the reference dataset, the higher the value of GPS is, more compromised gait of the subject. A statistically significant improvement in mean GPS was found in the POST session (PRE: 13.38 ± 5°; POST: 10.26 ± 2.41°; p<0.05), with an improvement close to 23%. Moreover, the GVSs demonstrated statistically significant improvements in ankle dorsi-plantarflexion (PRE: 22.20 ± 16.36°; POST: 11.50 ± 6.57°; p<0.05) and pelvic rotation (PRE: 9.53 ± 3.87°; POST: 6.47 ± 2.98°; p<0.05). A strong correlation (r=0.75; p<0.05) was found between the preoperative GPS and the percentage of GPS improvement. The results demonstrated that the gastrocnemius fascia lengthening produced a global gait pattern improvement, as showed by the GPS value, which decreased after surgery. Besides this, the GVS permitted to better evidence the joints more compromised by the pathology and their improvement due to the surgery, in this case not only the GVS of the ankle joint but also of the pelvis were characterized by higher GVS values.

Cerebral palsy

The syndrome of cerebral palsy encompasses a large group of childhood movement and posture disorders. Severity, patterns of motor involvement, and associated impairments such as those of communication, intellectual ability, and epilepsy vary widely. Overall prevalence has remained stable in the past 40 years at 2-3·5 cases per 1000 livebirths, despite changes in antenatal and perinatal care. The few studies available from developing countries suggest prevalence of comparable magnitude. Cerebral palsy is a lifelong disorder; approaches to intervention, whether at an individual or environmental level, should recognise that quality of life and social participation throughout life are what individuals with cerebral palsy seek, not improved physical function for its own sake. In the past few years, the cerebral palsy community has learned that the evidence of benefit for the numerous drugs, surgery, and therapies used over previous decades is weak. Improved understanding of the role of multiple gestation in pathogenesis, of gene environment interaction, and how to influence brain plasticity could yield significant advances in treatment of the disorder. Reduction in the prevalence of post-neonatal cerebral palsy, especially in developing countries, should be possible through improved nutrition, infection control, and accident prevention.

Gait patterns in twins with cerebral palsy: similarities and development over time after multilevel surgery

To examine gait patterns and gait quality, 7 twins with cerebral palsy were measured preoperatively and after surgical intervention. The aim was to study differences and/or similarities in gait between twins, the influence of personal characteristics and birth conditions, and to describe the development of gait over time after single event multilevel surgery. A standardized clinical exam and a three-dimensional gait analysis were performed. Gait patterns were classified according to Sutherland and Davids, and the Gillette Gait Index was calculated as a global measure of the gait impairment. Next to subject characteristics at time of first measurement, and at time of birth, birth conditions were collected. Gait patterns were determined as crouch gait in 13 legs, as stiff gait in 6 legs and as jump gait in 8 legs. One leg showed a normal gait pattern. The knee flexion-extension angle correlated most constant with the knee flexion-extension angle of the contralateral leg (range 0.91-0.99). Correlations with the legs of the sibling showed variable correlations (range 0.44-0.99); with all other legs medium to high correlations of 0.73-0.91 were found. The Gillette Gait Index was found to initially decrease after surgical intervention. Similar correlations were found between twins or between legs for the gait pattern expressed by the knee flexion-extension angle, and the Gillette Gait Index improved after surgery. It seems that gait quality in twins with cerebral palsy is characterized predominantly by the traumatic disorder: genetic dispositions and personal characteristics only play a negligible role.

Are results after single-event multilevel surgery in cerebral palsy durable?

BACKGROUND

Gait and function may deteriorate with time in patients with spastic diplegia. Single-event multilevel surgery often is performed to either improve gait or prevent deterioration. However it is unclear whether the presumed gait improvements are durable.

QUESTIONS/PURPOSES

We therefore determined whether (1) single-event multilevel surgery improves gait in patients with spastic diplegia and (2) whether the improved function is durable.

METHODS

We retrospectively reviewed the data of 14 patients with spastic diplegia. At the time of surgery, one patient had gross motor Level I function, 10 patients had Level II function, and three patients had Level III function. There were four females and 10 males with a mean age of 13 years (range, 7-18 years). The mean number of orthopaedic procedures per single-event multilevel surgery session was 7.4 ± 2.8 (median, 6.5; range, 4-15). We used instrumented gait analysis to determine joint ROM, movement analysis profiles, and the gait profile score. The minimum followup was 1 year (mean, 2 years; range, 1-3 years).

RESULTS

At last followup, movement analysis profiles for knee flexion, for ankle dorsiflexion, and for foot progression improved as did the gait profile score. Additional surgery after the index procedure was performed in nine of the 14 patients because of relapse of the original or new gait problems. Major surgical adverse events occurred in one of the 14 patients.

CONCLUSIONS

Severe gait dysfunction in patients with spastic diplegia can be improved short-term in one operative session by single-event multilevel surgery, but to preserve the early improvements many patients require additional surgery. It is unknown whether the improvements will last for decades.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.