Outcome evaluation in pediatric orthopedics

Validation of the French version of the Caregivers' Priorities and Child Health Index of Life with Disabilities questionnaire

INTRODUCTION

The Caregivers' Priorities and Child Health Index of Life with Disabilities (CPCHILD) is a questionnaire that measures the health-related quality of life (HRQL) of children with cerebral palsy (CP). Though measuring HRQL is challenging in these children, it is a valuable help for medical decision-making. There is no questionnaire to assess HRQL in French-speaking children with severe CP.

OBJECTIVE

To translate and adapt transculturally the CPCHILD questionnaire into French (CPCHILD-FV).

MATERIAL AND METHODS

The CPCHILD was translated from English into French by forward and backward translation by independents translators. The questionnaire was then tested on 32 caregivers of patients with CP classified as GMFCS IV or V, remarks of caregivers were analyzed by an expert committee and, if necessary, modifications were performed. Internal consistency of the CPCHILD-FV was assessed using a sample of 32 parents or caregivers and test-retest reliability was assessed on a random sample of 10 patients.

RESULTS

The translation and transcultural process resulted in a French version of the CPCHILD. Some items of the CPCHILD required careful discussion to ensure that items had the same meaning as in the original. Internal consistencies were over 0.70 for each domain except for health, and 0.97 for the total scores. The ICC for the test-retest reliability of the CHILD-FV total score was 0.98 (95% CI: 0.93-0.99) and ranged from 0.59 to 0.99 for the domains.

CONCLUSION

The translation and cross-cultural adaptation of the CPCHILD questionnaire provides a French version than can measure the HRQL of children with severe CP.

LEVEL OF EVIDENCE

IV; prospective study without control group.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

To evaluate the outcomes of PRP treatment in Achilles tendinopathy: An intriguing methodological problem

INTRODUCTION

Assessing the outcomes of Platelet Rich Plasma (PRP) treatment in Achilles Tendinopathy (AT) may prove difficult due to several methodological reasons. For example, given that the simple mean of VISA-A score is just the result of positive, negative or null values, this may provide incomplete information, and therefore the size of individual changes can remain unknown. On the contrary, calculating the score changes in each subject after treatment would allow a more appropriate evaluation of the clinical results. However, this method has been applied only to few small-scale studies. Therefore we performed a retrospective study aiming to determine: (1) are the percentages of positive outcomes of the present research comparable to those of previous studies performed in different settings? (2) Is there a relationship between the size of increase of the clinical score and the patient satisfaction?

HYPOTHESES

The percentages of positive outcomes of the present research are comparable to those of previous studies performed in different settings.

MATERIAL AND METHODS

This is a retrospective observational study. Eighty-four patients submitted to PRP treatment for mid-portion AT were enrolled. Pain and function were evaluated by means of VISA-A scale. Besides the mean, in each subject the pre- and post-treatment difference of VISA-A score was computed and the outcome was defined clinically no detectable, detectable and evident according to the increasing values of the score (0 to 9 points, 10 to 19, and≥20 points change, respectively). The Likert's scale for the patients satisfaction was also used.

RESULTS

The mean VISA-A increased significantly after treatment (from 50.1±9.1 at baseline to 63.7±13.8 at 3 months (p=0.00001) and 67.2±14.1 at 6 months (p=0.00001)). At 3 and 6 months the subjects belonging to the prefixed categories were 15, 45, 24 and 19, 36, 29, respectively. Moreover, large discrepancies were observed between the size of increase of the clinical score and patients satisfaction, mainly for intermediate increases of the score.

DISCUSSION

The percentages of positive outcomes found in this study are slightly lower than those reported in literature. The different patients expectations about the efficacy of the therapy can explain the discrepancies between the size of increase of the clinical score and the individual satisfaction. In comparison to the simple mean, the individual changes of VISA-A score allow a proper evaluation of the outcomes. The research shows that discrepancies can be present in the percentage of positive clinical outcomes between different studies. The size of increase of the clinical score does not always match patient satisfaction.

LEVEL OF PROOF

IV retrospective study without control group.

Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review

AIM

To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework.

METHOD

This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework.

RESULTS

Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%).

INTERPRETATION

The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.

Clinical gait analysis and physical examination don't correlate with physical activity of children with cerebral palsy. Cross-sectional study

Gait analysis and physical clinical measures are usually performed in children with cerebral palsy to help the surgeons make therapeutic decision. However, the level of physical activity in daily life is not systematically assessed. The aim of this cross sectional study was to examine the correlations between: three-dimensional gait analysis kinematic and spatiotemporal parameters, clinical measures and physical activity. Participants were 30 children with cerebral palsy (10–18 y), with GMFCS I–III. Daily physical activity was measured with an Actigraph GT3X accelerometer in free living environment during seven consecutive days. The percent of time spent in sedentary, in moderate to vigorous physical activity and the number of steps per day were computed from the accelerometer data. Kinematics parameters did not correlate with physical activity. Moderate correlations were found between spatio-temporal parameters and physical activity, for instance timing of toe-off (r = −0.40, p = 0.03). Few physical examination parameters were correlated with physical activity, such as the hip flexors selective motor control (r = 0.69 with moderate to vigorous activity and r = 0.70 with steps per day, p < 0.05). The physical activity profile cannot be sufficiently determined by a combination of clinical measures.

Which Metrics Are Being Used to Evaluate Children and Adolescents After ACL Reconstruction? A Systematic Review

PURPOSE

To identify a comprehensive list of outcome measures previously used in the literature to evaluate clinical outcomes after reconstruction of the anterior cruciate ligament (ACL) in patients 18 years of age or younger.

METHODS

A literature search was performed by querying MEDLINE, Embase and Cochrane computerized databases for relevant articles that reported clinical outcomes in pediatric patients undergoing ACL reconstruction. Studies that were nonclinical, that reported on patients older than 19 years, that were not available in English, or that included fewer than 10 patients were excluded. Outcome measures of all eligible studies were recorded.

RESULTS

We identified 77 studies published between 1986 and 2018 in 20 peer-reviewed journals. The mean age of the patients was 13.9 years. The ACL rerupture rate was reported in 60% of studies; 32 studies (42%) reported a rate of return to preinjury activity or sports. The use of adult-validated patient-reported outcome measures were reported in 63 (82%) articles. The Lysholm (64%), International Knee Documentation Committee (IKDC) (56%) and Tegner (37%) scores were the most commonly reported. Two patient-reported outcome measures designed for pediatric patients (the Pedi-IKDC and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) were employed in 5 (6%) recent studies.

CONCLUSIONS

There is variability across studies in the metrics used to assess clinical outcomes following ACL reconstruction in children and adolescents. Validated pediatric-specific instruments were used infrequently.

CLINICAL RELEVANCE

A large body of existing pediatric ACL-reconstruction literature relies on a variable set of outcome measures that have not been developed or validated for children and adolescents. More recently, contemporary studies have begun to employ pediatric- and adolescent-specific validated measures, yet their use remains uncommon.

Research priorities in children requiring elective surgery for conditions affecting the lower limbs: a James Lind Alliance Priority Setting Partnership

OBJECTIVE

To identify and prioritise research questions concerning the elective surgical management of children with conditions affecting the lower limb by engaging patients, carers and healthcare professionals.

DESIGN

A modified nominal group technique.

SETTING

UK.

PARTICIPANTS

388 individuals (29 patients, 155 parents/carers, 204 healthcare professionals) were recruited through hospital clinics, patient charities and professional organisations and participated in the initial prioritisation survey; 234 individuals took part in the interim prioritisation survey. 33 individuals (3 patients, 9 parents/carers, 11 healthcare professionals, 7 individuals representing the project's steering group and 3 James Lind Alliance (JLA) facilitators) attended the final face-to-face workshop to rank the top 10 research priorities.

INTERVENTIONS

Surveys were distributed using various media resources such as newsletters, internet messaging boards and the 'Paediatric Lower Limb Surgery Priority Setting Partnership (PSP) website. Printed copies of the questionnaire were also made available to families in outpatient clinics.

OUTCOME MEASURES

Survey results, top 10 and top 26 priority rankings RESULTS: The process took 18 months to complete (July 2017-January 2019); 388 people generated 1023 questions; a total of 801 research questions were classified as true uncertainties. Following the JLA methodology, 75 uncertainties were developed from the initial 801 questions. Twenty six of those were selected through a second survey and were taken to the final face-to-face workshop where the top 10 research priorities were selected. The top10 priorities included questions on cerebral palsy, common hip conditions (ie, Perthes' disease and developmental dysplasia of the hip) as well as rehabilitation techniques and methods to improve shared decision-making between clinicians and patients/families.

CONCLUSIONS

This is the first JLA PSP in children's orthopaedic surgery, a particularly under-researched and underfunded area. We have identified important research topics which will guide researchers and funders and direct their efforts in future research.

Age-Appropriate Pediatric Sports Patient-Reported Outcome Measures and Their Psychometric Properties: A Systematic Review

BACKGROUND

Phenomena including early sport specialization and year-round training and competition have contributed to an increase in pediatric sports injuries. There has been a concomitant increase in clinical studies focusing on physically active children and adolescents. These studies include investigations of patient-reported outcome measures (PROMs). While the use of PROMs in pediatric orthopaedics has been increasing, PROMs are often inappropriately applied to study populations for whom they are not specifically validated.

PURPOSE

The purpose of this study was to establish a comprehensive list of pediatric- and adolescent-validated PROMs and catalog their psychometric properties as a resource for clinicians and researchers.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of articles in PubMed, Embase, and the Cochrane library was performed to identify articles developing and validating PROMs appropriate for use in pediatric sports medicine research. The inclusion criteria were as follows: age <18 years, the use of surveys and questionnaires, and the presence of sports-related injuries. The psychometric properties of included PROMs were entered into an electronic database.

RESULTS

Our search strategy identified 14,708 unique articles, among which 139 studies (0.9%) were included in the final data analysis. Forty-seven distinct PROMs were identified, as well as 160 cross-cultural adaptations. While all identified PROMs were validated in physically active young participants, only 12 (26%) were specifically created initially for active children. Thirty (64%) PROMs were health-related quality-of-life measures; 13 (28%) were psychosocial measures; and 4 (9%) were activity scales. No studies validated PROMs for use with wrist/hand injuries, and only 1 PROM each was valid for hip, back/spinal, and foot/ankle injuries in pediatric sports.

CONCLUSION

This systematic review yielded 47 unique PROMs reliable and valid for use in pediatric and adolescent sports medicine. This list will unify clinicians and researchers in using these age-appropriate measures while identifying areas that are still in need of appropriate PROMs for young athletes.

Utilization of a Wide Array of Nonvalidated Outcome Scales in Pediatric Orthopaedic Publications: Can't We All Measure the Same Thing?

PURPOSE

Clinical changes are best evaluated with standardized, validated outcomes, including both patient-reported outcome measures and surgeon-reported outcome measures (PROMs and SROMs). The purpose of this study was to describe the spectrum of outcome measures used in pediatric orthopaedic publications over the past 10 years and to determine the proportion that are in fact age-appropriate, validated, and appropriately applied in terms of condition and population.

METHODS

The Journal of Bone and Joint Surgery, The Bone and Joint Journal, Journal of Pediatric Orthopaedics A and B, and Journal of Children's Orthopaedics were systematically searched for studies including children aged 18 and below, over a 10-year period from January 2005 to December 2014. Economic evaluations, letters, editorials, review articles, and clinical guidelines were excluded. SROMs and PROMs used were extracted, as were details on subject age and condition for which they were used. Each outcome scale was assessed for validity, and the proportion of scales used appropriately was calculated. Cochrane-Armitage test of trend was used to determine changes in PROM and SROM utilization over the study period.

RESULTS

A total of 4614 articles were identified, of which 2251 met inclusion and exclusion criteria. In total, 259 (11.5%) of studies used a PROM, whereas 326 (14.5%) used a SROM. A total of 230 different outcome scales were identified; 115 were patient reported and 115 were surgeon reported. However, only 18.7% of SROMs and 38.3% of PROMs were applied to an age and disease-appropriate demographic. Overall, there was a significant increase in the overall utilization of PROMs during the study period (P=0.004), but no corresponding increase in pediatric-validated PROMs (P=0.164). SROM utilization did not significantly change over the study period (P=0.337).

CONCLUSIONS

Within the field of pediatric orthopaedics, an expansive variety of outcome scales are used, many of which have not been validated in children. Improved uniformity in reporting of outcomes and use of disease and age-validated outcomes scales is essential to improve multicenter research collaboration and data quality to generate appropriate evidence-based conclusions and treatment strategies in pediatric orthopaedics.

LEVEL OF EVIDENCE

Level IV-systematic review.

Use of Patient-reported Outcome Measures in Pediatric Orthopaedic Literature

BACKGROUND

Patient-reported outcomes are increasingly used as primary measures of success and impact of health care services. There is no current consensus on the efficacy of functional health status (FHS) or health-related quality of life (HRQoL) evaluation in pediatric orthopaedic surgery. The purpose of this study was to quantify and characterize the use of such patient-reported outcomes in the pediatric orthopaedic literature over the last several years.

METHODS

A cross-sectional review of 6 orthopaedic journals-Journal of Bone and Joint Surgery, Bone and Joint Journal, Spine, Journal of Pediatric Orthopaedics A, Journal of Pediatric Orthopaedics B, and Journal of Children's Orthopaedics, was conducted by 2 independent reviewers. Articles were analyzed for patient-reported outcome usage over the time periods of 2000 to 2001, 2007 to 2008, and 2012 to 2013.

RESULTS

A total of 189 articles (2.7%) were identified that used patient-reported outcomes in pediatric populations. A total of 71 (37.5%) of these articles used FHS tools, 95 (50.3%) used HRQoL tools and 23 (12.2%) used a combination of both. The use of FHS and HRQoL tools has increased over time, with 8 FHS and 2 HRQoL publications in the year 2000 expanding to 19 and 28, respectively, in 2013. Journal of Bone and Joint Surgery American Volume published both the highest total number of articles containing patient-reported outcome measures (57/189) and the highest number of articles specifically using FHS measures (28/71). Spine published the highest number of articles using HRQoL measures (43/95). The most frequently used FHS and HRQoL tools were the Lysholm knee score and the Scoliosis Research Society tools, respectively. Only 33/73 identified patient-based outcome instruments had been validated in a pediatric population.

CONCLUSIONS

Patient-reported outcome measures are underutilized in the pediatric orthopaedic literature. Instruments are frequently used that are neither designed nor validated for a pediatric population. Consequently, further work is necessary to develop, validate, and implement pediatric-specific FHS and HRQoL tools to fully understand the impact of a clinical intervention on all aspects of patient quality of life.

Contribution of clinical gait analysis to single-event multi-level surgery in children with cerebral palsy

Clinical gait analysis (CGA) has been proven useful in understanding the gait disturbances seen in children and adolescents with cerebral palsy. Another major benefit provided by CGA is a clinical and scientific evaluation of how orthopaedic surgical procedures modify gait. The information provided by instrumented CGA complements the clinical data, and the two must be interpreted jointly. Although there is some variability in the surgical details of therapeutic strategies, CGA undoubtedly influences the planning of surgery. Although CGA improves surgical outcomes, these remain challenging to predict. CGA seems cost-effective. Internal hip rotation gait is used as an example to illustrate those benefits.