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Katsma M, Liu H, Pan X, Ryan KJ, Roye DP, Chambers HG. Management and treatment of musculoskeletal problems in adults with cerebral palsy: Experience gained from two lifespan clinics. J Pediatr Rehabil Med 2024; 17:19-33. [PMID: 38552124 PMCID: PMC10977450 DOI: 10.3233/prm-240018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/07/2024] [Indexed: 04/02/2024] Open
Affiliation(s)
- Mark Katsma
- Department of Orthopedic Surgery, Balboa Naval Medical Center, San Diego, CA, USA
| | - Haiqing Liu
- Pediatric Orthopedic Department of Shantou University, Guangzhou Huaxin Orthopedic Hospital, Guangzhou, China
| | - Xiaoyu Pan
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
- Departments of Nutrition and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kyle J. Ryan
- University of California San Diego, San Diego, CA, USA
- Department of Orthopedic Surgery and Rehabilitation, Rady Children’s Hospital, San Diego, CA, USA
| | - David P. Roye
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Henry G. Chambers
- University of California San Diego, Rady Children’s Hospital, San Diego, CA, USA
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Assessment of gait quality and efficiency after undergoing a single-event multilevel surgery in children with cerebral palsy presenting an intoeing gait pattern. Childs Nerv Syst 2022; 38:1523-1530. [PMID: 35552497 DOI: 10.1007/s00381-022-05548-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The biomechanical impact of undergoing a single-event multilevel surgery (SEMLS) for children with cerebral palsy (CP) presenting an intoeing gait pattern has been widely documented. However, past studies mostly focused on gait quality rather than efficiency. Thus, there is a need to determine the impact of undergoing a SEMLS on gait quality and efficiency in children with CP presenting an intoeing gait pattern. METHODS Data from 16 children with CP presenting an intoeing gait pattern who underwent a SEMLS were retrospectively selected. Gait kinematics was quantified before (baseline) and at least 1 year after the surgery (follow-up). Gait quality was investigated with the Gait Profile Score (GPS), hip internal rotation angle and foot progression angle (FPA). Gait efficiency was analysed using clinically accessible variables, namely the normalised gait speed and medio-lateral and vertical centre of mass excursions (COMp). Dependent variables were compared between sessions with paired t-tests. RESULTS At the follow-up, children with CP exhibited a more outward FPA and GPS as well as a decreased hip internal rotation angle. No changes in normalised gait speed and vertical COMp excursion were observed, and medio-lateral COMp excursion was slightly decreased. CONCLUSION Children with CP presenting an intoeing gait pattern who underwent a SEMLS exhibited an increased gait quality, but gait efficiency was only minimally improved at the follow-up compared to baseline. Further studies are needed to identify contributors of gait efficiency in children with CP, and the best treatment modalities to optimise both their gait quality and efficiency.
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Schwartz MH, Ries AJ, Georgiadis AG. Short-term causal effects of common treatments in ambulatory children and young adults with cerebral palsy: three machine learning estimates. Sci Rep 2022; 12:7818. [PMID: 35551496 PMCID: PMC9098860 DOI: 10.1038/s41598-022-11875-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/29/2022] [Indexed: 12/11/2022] Open
Abstract
Orthopedic and neurological impairments (e.g., muscle contractures, spasticity) are often treated in children and young adults with cerebral palsy (CP). Due to challenges arising from combinatorics, research funding priorities, and medical practicalities, and despite extensive study, the evidence base is weak. Our goal was to estimate the short-term effectiveness of 13 common orthopedic and neurological treatments at four different levels of outcome in children and young adults diagnosed with CP. The outcome levels considered were body structures, specific gait kinematic deviations, overall gait kinematic deviations, and functional mobility. We used three well-establish causal inference approaches (direct matching, virtual twins, and Bayesian causal forests) and a large clinical gait analysis database to estimate the average treatment effect on the treated (ATT). We then examined the effectiveness across treatments, methods, and outcome levels. The dataset consisted of 2851 limbs from 933 individuals (some individuals underwent multiple treatment episodes). Current treatments have medium effects on body structures, but modest to minimal effects on gait and functional mobility. The median ATT of 13 common treatments in children and young adults with CP, measured as Cohen's D, bordered on medium at the body structures level (median [IQR] = 0.42 [0.05, 0.60]) and became smaller as we moved along the causal chain through specific kinematic deviations (0.21 [0.01, 0.33]), overall kinematic deviations (0.09 [0.03, 0.19]), and functional mobility (-0.01 [-0.06, 0.13]). Further work is needed to understand the source of heterogeneous treatment effects, which are large in this patient population. Replication or refutation of these findings by other centers will be valuable to establish the generalizability of these results and for benchmarking of best practices.
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Affiliation(s)
- Michael H Schwartz
- Gillette Children's Specialty Healthcare, St. Paul, USA. .,Department of Orthopedic Surgery, University of Minnesota, Minneapolis, USA. .,Center for Gait and Motion Analysis, 205 University Ave. SE, St. Paul, MN, 55101, USA.
| | - Andrew J Ries
- Gillette Children's Specialty Healthcare, St. Paul, USA
| | - Andrew G Georgiadis
- Gillette Children's Specialty Healthcare, St. Paul, USA.,Department of Orthopedic Surgery, University of Minnesota, Minneapolis, USA
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Boyer ER, Duffy EA, Walt K, Muñoz Hamen A, Healy MT, Schwartz MH, Novacheck TF. Long-term functional outcomes after an external femoral derotation osteotomy in individuals with cerebral palsy. Gait Posture 2021; 87:184-191. [PMID: 33945965 DOI: 10.1016/j.gaitpost.2021.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/13/2021] [Accepted: 04/16/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is unknown how a femoral derotation osteotomy (FDO) during childhood affects functional outcomes in adulthood among individuals with bilateral cerebral palsy (CP). RESEARCH QUESTIONS How do long-term functional outcomes after an FDO compare to matched individuals who did not have an FDO? How do outcomes change over time? METHODS We queried the gait laboratory database for individuals who underwent an external FDO in childhood and were currently ≥25 years old. Participants returned for a long-term analysis (gait, physical examination, functional tests, imaging, questionnaires). The matched non-FDO group included only individuals in Gross Motor Function Classification System levels I-II, yielding three groups (non-FDO I-II, FDO I-II, FDO III-IV). RESULTS Sixty-one adults (11 non-FDO, 34 FDO I-II, 16 FDO III-IV) returned 13-25 years after baseline (non-FDO) or surgery (FDO). The non-FDO and FDO I-II groups were matched at baseline on most variables, except the FDO group had weaker hip abductors. At long-term, groups were similar on gait variables (median long-term hip rotation [primary outcome], non-FDO: -4°, FDO I-II: -4°, FDO III-IV: -5°), hip abduction test, fear of falling, and most pain measures despite anteversion being 29° greater in the non-FDO group. The FDO I-II group reported more falls than the non-FDO group. All groups improved on hip rotation, foot progression, and hip abductor strength. Speed and step length decreased/tended to decrease for all three groups. Hip abduction moment and gait deviation index did not change. Improvements in the FDO groups were maintained from short- to long-term. SIGNIFICANCE These results challenge the notion that an FDO is necessary to correct mean stance hip rotation for higher functioning individuals since nearly identical results were achieved by adulthood in the non-FDO I-II group. However, an FDO provides improvement earlier and maintenance from short- to long-term. This should factor into the shared decision-making process.
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Affiliation(s)
- Elizabeth R Boyer
- Gillette Children's Specialty Healthcare, 200 University Avenue East, Saint Paul, MN, 55101, United States; University of Minnesota, Orthopedic Surgery, 2450 Riverside Ave, Minneapolis, MN, 55454, United States.
| | - Elizabeth A Duffy
- Gillette Children's Specialty Healthcare, 200 University Avenue East, Saint Paul, MN, 55101, United States.
| | - Kathryn Walt
- Gillette Children's Specialty Healthcare, 200 University Avenue East, Saint Paul, MN, 55101, United States.
| | - Antonio Muñoz Hamen
- Instituto Teletón Antofagasta, Oficina Carmela 249, Sector la Chimba, Antofagasta, Chile.
| | - Michael T Healy
- Gillette Children's Specialty Healthcare, 200 University Avenue East, Saint Paul, MN, 55101, United States; University of Minnesota, Orthopedic Surgery, 2450 Riverside Ave, Minneapolis, MN, 55454, United States.
| | - Michael H Schwartz
- Gillette Children's Specialty Healthcare, 200 University Avenue East, Saint Paul, MN, 55101, United States; University of Minnesota, Orthopedic Surgery, 2450 Riverside Ave, Minneapolis, MN, 55454, United States.
| | - Tom F Novacheck
- Gillette Children's Specialty Healthcare, 200 University Avenue East, Saint Paul, MN, 55101, United States; University of Minnesota, Orthopedic Surgery, 2450 Riverside Ave, Minneapolis, MN, 55454, United States.
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Desailly E, Badina A, Khouri N. Kinematics after unilateral femoral derotation osteotomy in children with diplegic cerebral palsy. Orthop Traumatol Surg Res 2020; 106:1325-1331. [PMID: 32360555 DOI: 10.1016/j.otsr.2019.11.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/14/2019] [Accepted: 11/27/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Femoral derotation osteotomy (FDO) is a treatment option in children and adolescents with cerebral palsy who have transverse plane deviations in their lower limbs. When the transverse kinematic deviations are asymmetric, the osteotomy indication can be unilateral. HYPOTHESIS Unilateral FDO has a kinematic effect on ipsilateral transverse plane deviations along with those of the pelvis and contralateral side. MATERIALS AND METHODS Among the 170 diplegic children that our team has operated on, 34 underwent unilateral FDO. Their mean age was 12.5±2.7 years; 12 were GMFCS level I and 22 were level II. The kinematic changes 18 months after surgery were evaluated with a paired Student's t test and correlations were determined with the Spearman test (p<0.05). The mean preoperative femoral anteversion was 45°±8°. In terms of kinematics, on the operated side, the children had a mean internal hip rotation of 26°±7°, external pelvis rotation of -8°±6° and inward foot progression angle of 8°±12°. RESULTS The anteversion was corrected surgically by -28°±5°. Postoperatively, the ipsilateral hip rotation (10°±10°), pelvis rotation (-2°±5°) and foot rotation (6°±12°) were significantly improved. No correlations were identified between the resulting kinematic parameters and surgical correction. The five feet that had inward rotation (13°±9°) were improved to (-5°±7°). DISCUSSION Unilateral FDO of the hip in patients with asymmetry not only reduces the internal rotation of the operated hip, it also normalizes the rotation of the pelvis and both feet. However, these improvements are not directly related to the amount of surgical correction. LEVEL OF EVIDENCE IV: case series.
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Affiliation(s)
- Eric Desailly
- Chirurgie orthopédique pédiatrique, hôpital universitaire Necker-Enfants maladies, 149, rue de Sèvres, 75743 Paris, France
| | - Alina Badina
- Chirurgie orthopédique pédiatrique, hôpital universitaire Necker-Enfants maladies, 149, rue de Sèvres, 75743 Paris, France
| | - Néjib Khouri
- Chirurgie orthopédique pédiatrique, hôpital universitaire Necker-Enfants maladies, 149, rue de Sèvres, 75743 Paris, France.
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Almoajil H, Wilson N, Theologis T, Hopewell S, Toye F, Dawes H. Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review. Dev Med Child Neurol 2020; 62:1138-1146. [PMID: 32567044 DOI: 10.1111/dmcn.14599] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/07/2020] [Indexed: 11/30/2022]
Abstract
AIM To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework. METHOD This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework. RESULTS Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%). INTERPRETATION The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.
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Affiliation(s)
- Hajar Almoajil
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Department of Physical Therapy, College of Applied Medical Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nichola Wilson
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Tim Theologis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Paediatric Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Hopewell
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Francine Toye
- Physiotherapy Research Unite, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Dawes
- Centre for Movement, Occupational and Rehabilitation Sciences, Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK.,Oxford Health NHS Foundation Trust, Oxford, UK
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Mu X, Deng B, Zeng J, Zhang H, Zhao Y, Sun Q, Xu J, Wang L, Xu L. Orthopedic treatment of the lower limbs in spastic paralysis. BRAIN SCIENCE ADVANCES 2020. [DOI: 10.26599/bsa.2020.9050001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Spastic paralysis of the limb mainly results from the central lesion, in which spastic cerebral palsy is the common cause. Due to durative muscle spasm in spastic cerebral palsy, it is often accompanied by the formation of secondary musculoskeletal deformities, resulting in limb motor disability. Based on its pathogenesis, surgical treatment is currently applied: selective posterior rhizotomy (SPR) or orthopedic surgery. The primary purpose of early orthopedic surgery was simply to correct limb deformities, which usually led to the recurrence of deformity as a result of the presence of spasticity. With the application of SPR, high muscle tone was successfully relieved, but limb deformity was still present postoperatively. Therefore, this study aimed to elaborate on the management of orthopedic surgery, common deformities of the lower limb, and orthopedic operative methods; discuss the relationship between SPR and orthopedic procedure for limb deformity; and focus on the indications, timing of intervention, and postoperative outcome of different surgical methods.
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Affiliation(s)
- Xiaohong Mu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Bowen Deng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Jie Zeng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Houjun Zhang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Yi Zhao
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Jie Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Le Wang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Lin Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
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What's New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis. J Pediatr Orthop 2020; 40:e498-e503. [PMID: 32501922 DOI: 10.1097/bpo.0000000000001461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment. METHODS A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review. RESULTS The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis. CONCLUSIONS Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance. LEVEL OF EVIDENCE Level IV-literature review.
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Edmonds EW, Fuller CB, Jeffords ME, Farnsworth CL, Lindgren AM, Pennock AT, Upasani VV. Femoral derotational osteotomy level does not effect resulting torsion. J Exp Orthop 2020; 7:9. [PMID: 32130560 PMCID: PMC7056778 DOI: 10.1186/s40634-020-00227-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/25/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The purpose of this study was to assess the effect on femoral torsion by rotational osteotomies at three different levels as measured in 3D using both the mechanical and the anatomic axes. METHODS Ten cadaveric lower extremities underwent femoral osteotomies perpendicular to the anatomic axis (AA) at three levels: subtrochanteric, mid-diaphyseal and supracondylar. Parallel pins were placed, one in each femur segment. Computed tomography (CT) was acquired in post-osteotomies neutral position, then post-external rotation of the femur at each osteotomy level. Femurs were returned to neutral rotation between imaging exams. Using 3D CT reconstructions, custom software calculated femoral torsion (angle between the femoral neck axis and the posterior condylar axis in the transverse plane) and pin angle between segments, reoriented to both the mechanical axis (MA) and the AA. Pin angle and torsion change were compared for the three osteotomy locations (regression analysis and ANOVA performed). RESULTS Two specimens were omitted (inadequate imaging); the remaining eight donors were 55-90 years old (mean: 64 ± 15 years), CT confirmed no bony defects. All three levels of osteotomy demonstrated significant correlations between the amount of rotation at the osteotomy (pin angle change) and the resulting change in femoral torsion (R square range 0.658-0.847). No significant differences were found between osteotomy level in torsion (MA:p = 0.285, AA:p = 0.156) or in pin angle (MA:p = 0.756, AA:p = 0.753). CONCLUSIONS Performing a corrective rotational osteotomy orthogonal to the AA achieves the desired effect on MA regardless of location. This suggests that a surgeon's osteotomy level choice may be based on other risks/benefits of the various techniques.
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Affiliation(s)
- Eric W Edmonds
- Department of Orthopaedic Surgery, University of California, San Diego, USA.,Division of Orthopedics, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Corey B Fuller
- Division of Orthopedics, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Megan E Jeffords
- Division of Orthopedics, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Christine L Farnsworth
- Division of Orthopedics, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Amelia M Lindgren
- Department of Orthopaedic Surgery, University of California, San Diego, USA
| | - Andrew T Pennock
- Department of Orthopaedic Surgery, University of California, San Diego, USA.,Division of Orthopedics, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA
| | - Vidyadhar V Upasani
- Department of Orthopaedic Surgery, University of California, San Diego, USA. .,Division of Orthopedics, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.
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de Morais Filho MC. The effects of soft tissue procedures for internal hip rotation in cerebral palsy. Dev Med Child Neurol 2018; 60:971-972. [PMID: 29904906 DOI: 10.1111/dmcn.13933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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