Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

The February 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures.

Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit. A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed. Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%). Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition

Aims

The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V.

The August 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: DDH: What can patients expect after open reduction?; Femoral head deformity associated with hip displacement in non-ambulatory cerebral palsy; Bony hip reconstruction for displaced hips in patients with cerebral palsy: is postoperative immobilization indicated?; Opioid re-prescriptions after ACL reconstruction in adolescents are associated with subsequent opioid use disorder; Normative femoral and tibial lengths in a modern population of USA children; Retrospective analysis of associated anomalies in 636 patients with operatively treated congenital scoliosis; Radiological hip shape and patient-reported outcome measures in healed Perthes’ disease; Significantly displaced adolescent posterior sternoclavicular joint injuries.

Aims

Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app).

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

Aims. The Uppföljningsprogram för cerebral pares (CPUP) Hip Score distinguishes between children with cerebral palsy (CP) at different levels of risk for displacement of the hip. The score was constructed using data from Swedish children with CP, but has not been confirmed in any other population. The aim of this study was to determine the calibration and discriminatory accuracy of this score in children with CP in Scotland. Methods. This was a total population-based study of children registered with the Cerebral Palsy Integrated Pathway Scotland. Displacement of the hip was defined as a migration percentage (MP) of > 40%. Inclusion criteria were children in Gross Motor Function Classification System (GMFCS) levels III to V. The calibration slope was estimated and Kaplan-Meier curves produced for five strata of CPUP scores to compare the observed with the predicted risk of displacement of the hip at five years. For discriminatory accuracy, the time-dependent area under the receiver operating characteristic curve (AUC) was estimated. In order to analyze differences in the performance of the score between cohorts, score weights, and subsequently the AUC, were re-estimated using the variables of the original score: the child’s age at the first examination, GMFCS level, head shaft angle, and MP of the worst hip in a logistic regression with imputation of outcomes for those with incomplete follow-up. Results. The discriminatory accuracy of the score in the new population of 367 children was high (AUC 0.78 (95% confidence interval (CI) 0.71 to 0.86)). The calibration of the score was insufficient (slope 0.48 (95% CI 0.31 to 0.65)), and the absolute risks of displacement of the hip in this population were overestimated. The AUC increased with re-estimated weights (0.85 (95% CI 0.79 to 0.91)). Conclusion. The CPUP Hip Score had a high ability to discriminate between children at different levels of risk for displacement of the hip. The score overestimated the absolute risks of displacement in this population, which may have resulted from differences in the way children were initially registered in the two programmes. The results are promising, but the score weights may need re-estimation before its clinical application in Scotland. Cite this article: Bone Joint J 2022;104-B(5):640–644

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Abstract. Objectives. Single-event multilevel surgery (SEMLS) is the standard orthopaedic treatment for gait abnormalities in children with diplegic cerebral palsy (CP). The primary aim of this study was to report the long-term functional mobility of these patients after surgery. The secondary aim was to assess the relationship between functional mobility and quality of life (QoL). Methods. Patients were included if they met the following criteria: 1) diplegic CP; 2) Gross Motor Function Classification System (GMFCS) I to III; 3) SEMLS at age ≤ 18. A total of 61 patients, mean age at surgery 11 years eight months (SD 2y 5m), were included. A mean of eight years (SD 3y 10m) after SEMLS, patients were contacted and asked to complete the Functional Mobility Scale (FMS) questionnaire over the telephone and given a weblink to complete an online version of the CP QOL Teen. FMS was recorded for all patients and CP QOL Teen for 23 patients (38%). Results. Of patients graded GMFCS I and II preoperatively, at long-term follow-up the proportion walking independently at home, school/work and in the community was 71% (20/28), 57% (16/28) and 57% (16/28), respectively. Of patients graded GMFCS III preoperatively, at long-term follow-up 82% (27/33) and 76% (25/33) were walking either independently or with an assistive device at home and school/work, respectively, while over community distances 61% (20/33) required a wheelchair. The only significant association between QoL and functional mobility was better ‘feelings about function’ in patients with better home FMS scores (r=0.55; 95% confidence interval 0.15 to 0.79; p=0.01). Conclusion. The majority of children maintained their preoperative level of functional mobility at long-term follow-up after SEMLS. Despite the favourable functional mobility, there was little evidence to establish a link between functional status and quality of life

This retrospective study was to investigate radiographic and clinical outcomes in treatment of hip instability in children and young adults undergoing periacetabular osteotomy (PAO) with or without femoral osteotomy. 19 patients (21 hips) with CP were treated with PAO with or without femoral osteotomy The mean age was 16.2 years old (7 to 28 years). Five patients (5 hips) received PAO, Six patients (7 hips) PAO with femoral derotation osteotomy, Eight patients (9 hips) PAO with varus derotational osteotomy (VDRO). Anteroposterior pelvic radiographs and CT were taken to assess the migration percentage (MP), lateral center-edge angle (LCEA), Sharp angle, femoral neck anteversion, neck-shaft angle. Gross Motor Function Classification System (GMFCS) was assessed pre- and post-surgery. Complications were recorded. The mean follow-up time was 41.2 months (range, 24 to 86 months). All hips but one were pain free at final visit. The GMFCS improved by one level in 10 of 19 patients. MP improved from a mean of 76.6% to 18.6% at the final follow-up(p<0.001). The mean pre-operative LCEA and Sharp angle were −33.5 ? and 35 ? respectively, improved to 21.5 ? and 11.8 ? at the final follow-up (p < 0.001). There were six patients (7 hips) had re-subluxation at latest follow-up. Nervus cutaneus femoris lateralis was impaired in four patients after surgery. There was no re-dislocation, AVN, or infections in this group. Satisfactory clinical and radiologic results can be obtained by PAO with or without femoral osteotomy minor complications

To assess long and short term kinematic gait outcomes after rectus femoris transfers (RFT) in ambulatory children with cerebral palsy (CP). A retrospective review was conducted of ambulatory children with spastic diplegic CP, who had RFT plus motion analysis preoperatively and 1 year post-operatively. Those with 5 and 10 year post-operative motion analysis were also included. The primary variables were: peak knee flexion range of motion in swing (PKFSW), timing of peak knee flexion in swing as a percent of the gait cycle (PKF%GC), and knee range of motion from peak to terminal swing (KROM). Responders and non-responders were identified. Descriptive, kinematic and kinetic variables were evaluated as predictors of response. 119 ambulatory children (237 limbs) with spastic diplegic CP who had RFT were included. Mean age at surgery was 10.2 years (range 5.5 to 17.5). Sixty-seven participants were classified at GMFCS Level II and 52 at GMFCS Level III. All participants (237 limbs) had a preoperative and 1 year postoperative motion analysis. Motion analysis at 5 and 10 years post-operatively included 82 limbs and 28 limbs, respectively. Ninety-three (39%) limbs improved in both PKFSW and PKF%GC. PKFSW improved in 59% of limbs. Responders started 1.2 SD below the mean PKFSW preoperatively, and improved by an average of 1.9 SD to reach a normal range at 1 year post-operatively (p < 0.05). Improvement was maintained at 5 and 10 years postoperatively. Those at GMFCS level II were more likely [OR 1.71, CI 1.02, 2.89] to have improved PKFSW at 1 year postoperatively than those at GMFCS level III. PKF%GC improved in 70% of limbs. Responders had delayed PKF%GC, starting 10 SD above the mean (later in the gait cycle) preoperatively. Their timing improved towards normal values: 5 SD, 5.9 SD, 3.5 SD from the mean, (earlier in the gait cycle) at 1, 5 and 10 years postoperatively, respectively (p<0.05). KROM improved in only 24% of limbs. For all variables, there was a significant difference in mean preoperative values between responders and non-responders (p<0.05). RFT improves short and long-term kinematic gait outcomes. The majority of children responded to RFT with improvements in PKFSW or PKF%GC at 1, 5, and 10 years post RFT. GMFCS level is a predictor of improved PKFSW, with children at GMFCS Level II having an increased likelihood of improvement at 1 year post surgery. Children who have worse preoperative values of PKFSW, PKF%GC, and KROM have a greater potential for benefit from RFT. Characteristics associated with responders who maintain long term positive outcomes need to be identified

Treatment for hip displacement in children and youth with cerebral palsy (CP) is dependent upon when the problem is detected. Hip surveillance aims to identify hip displacement early through systematic screening and, together with timely orthopaedic intervention, can eliminate the need for salvage hip procedures. Here we report the impact on surgical practice of 1) hip surveillance program advocacy and knowledge translation efforts and 2) initial population-based program implementation. A retrospective review was completed of all children with CP undergoing surgery for hip displacement at a provincial tertiary pediatric hospital in the years 2004 to 2018. Date and type of surgery, age at surgery, Gross Motor Function Classification System (GMFCS) level, and pre-operative migration percentages (MP) were collected. Surgeries were categorized as soft-tissue release, reconstructive, and salvage procedures. Results were collected for three time periods: historical (September 2004- June 2010), hip surveillance advocacy and knowledge translation (July 2010- August 2015), and post provincial hip surveillance program implementation (September 2015 – December 2018). A total of 261 surgeries on 321 hips were reviewed. The rate of salvage procedures dropped from 29% (24) of surgeries performed in the historical period to 12% (14) during the period that included targeted hip surveillance knowledge translation and development of provincial guidelines. Since implementation of the surveillance program, salvage procedures have accounted for 7% (4) of interventions performed; all of these were in patients new to the province or existing patients. During the three study periods, reconstructive surgeries accounted for 64%, 81%, and 80% of the interventions performed. The mean initial MP at time of reconstructive surgery has decreased from 66% (SD 20%) in the historical time period to 57% (SD 25%) and 57% (SD 22%) in the subsequent time periods. There were a greater number of children at GMFCS levels III and IV in the two more recent time periods suggesting surveillance may assist in identifying children at these levels of impairment. The rate of soft-tissue surgeries was low during all time periods with the number trending higher since program implementation (7%, 7%, 10%). Knowledge translation and use of standardized surveillance guidelines can have a significant impact on the prevalence of salvage hip surgeries. Centers should utilize existing surveillance guidelines and educate key stakeholders about the importance of hip surveillance in the absence of a formal hip surveillance program

Aims

The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study.

Aims

Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP.

Aims

To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

Botulinum toxin A (BoNT-A) is a substance that requires repeated application due to its effectiveness being lost 12–16 weeks post application. Performing these intra-muscular injections under anesthesia reduces pain and distress during applications, ensuring effective and successful functional results. This study evaluates motor development of patients undergoing 3 or more repeated BoNT-A application in a tertiary pediatric hospital and the safety as well as effect of 3 different types of anesthesia. 75 children with cerebral palsy who underwent BoNT-A application at least three times consecutively with 6-month intervals and a total of 320 procedures admitted between January 2008 and January 2018 were retrospectively examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. To observe the improvement in motor development, those with 2-1-0 level decreases in GMFCS classes were grouped and compared in terms of birth time, birth weight, cerebral palsy type and first BoNT-A application age. The 3 types of anesthesia methods (sedation analgesia, larengeal mask anesthesia (LMA) and inhalation mask anesthesia) applied during the procedures were compared in terms of sedation, procedure, recovery and total operation room time. The mean age of the children for all procedures was 45.51 ± 22.40 months. As a result of procedures, significant motor development was observed in 60 (80%) patients (p <0,000∗). No significant difference was observed when the children with cerebral palsy whose GMFCS declined in the form of level 2, 1 and unchanged were compared in terms of first application age, birth weight and gestational age. It was found that 106 (33.1%) were applied sevoflurane with anesthesia mask, 103 (32.1%) were administered sevoflurane with laryngeal mask, and 111 (34.6%) were sedation-analgesia. Only 10 out of 320 procedures were seen to develop side effects (8 vomiting, 2 bronchospasm). In the patients who underwent sedation analgesia during the first 3 BoNT-A procedures, the duration of recovery and total operating room time was seen to be significantly shorter than the others, while there was no difference between the anesthesia methods in the 4th and subsequent procedures. Regardless of the type of anesthesia, the recovery and total operating room times of those having undergone 6 or more procedures were longer than those with less than 6 procedures (p <0.009, p <0.016, respectively). As conclusion, repeated BoNT-A applications in children with CP provides progress in motor steps, it can be applied safely and effectively under anesthesia. Sedation analgesia application provides easier recovery compared to general anesthesia with LMA and mask only in the first three applications. However, recovery time increases with 4 and more repeated applications as the number of applications increases

Children with cerebral palsy (CP) have an increased risk of progressive hip displacement. While the cause of hip displacement remains unclear, spasticity and muscle imbalance around the hip are felt to be a major factor. There is strong evidence demonstrating that a selective dorsal rhizotomy (SDR) reduces spasticity. However, the impact of this decreased spasticity on hip displacement is unknown. Past studies, which are small and lack long-term follow-up, do not provide a clear indication of the effect of SDR on hip displacement. The purpose of this study was to determine the influence of SDR on hip displacement in children with CP a minimum of five years post-SDR. A retrospective chart review was completed. Participants were selected from a consecutive series of children who had an SDR before January 1, 2013 at one tertiary care facility to ensure a minimum five year follow-up. Pre-operative and minimum five year post-SDR AP pelvis radiographs were required for inclusion. Hip displacement was evaluated using change in MP between radiographs completed pre-SDR and minimum five years post-SDR, or until orthopaedic hip surgery. In total, 77 participants (45 males, 32 females) at GMFCS levels of I (1), II (11), III (22), IV (35) and V (8) were included in the review. Mean age at time of SDR was 5 years (2.8– 11.6yrs). Pre-SDR mean MP of the 154 hips was 29% (0–100%). Post-SDR, 67 (43.5%) hips in 35 children had soft tissue, reconstructive, or salvage hip procedures at an average of 4.9 years (0.5–13.8yrs) post-SDR and an average MP of 46% (11–100%). In addition, seven hips (5%) had a MP ≥ 40% (40–100%) at most recent radiographic review that averaged 11 years (5.6–18.6yrs). Overall, the total number of subjects with hip displacement measuring MP >40% or who had a surgical hip intervention, by GMFCS level, was: 0 (0%) at level I, 0 (0%) at level II, 20 (45%) at level III, 22 (59%) at level IV, and 5 (81%) at level V. The incidence of hip displacement in children with CP post-SDR did not substantially differ from the overall incidence reported in the literature when evaluated by GMFCS level. This study is the largest long-term follow-up study investigating the effect of hip displacement post-SDR. Results suggest that SDR does not impact hip displacement in CP, however, further prospective study will be required to strengthen the evidence in this regard