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

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

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

Aim. To assess the risk of hip dislocations in children with cerebral palsy (CP) attending special schools, and the effects of preventative soft tissue surgery (psoas and adductor tenotomy). Method. 110 children were reviewed from 1985-2000. Severity of CP was graded according to the Gross Motor Function Classification System (GMFCS). Hemiplegics - grade 1, Diplegics grades 2 & 3, Quadriplegics grades 4 & 5. Patients were grouped into age groups 5, 10 and 15 years and the number of hip dislocations in each group were noted. Numbers of patients who had preventative soft tissue surgery was also noted. Indication for surgery, >35% femoral head uncovering. Results. Percentage of dislocations increased with CP severity. At 15 years, no dislocations in GMFCS 2, 6% GMFCS 3, 19% GMFCS 4 and 40% in GMFCS 5. The number of patients with at least 1 hip dislocation increased with age at all age groups. GMFCS 4 (age 5 yrs 9%, age 10 yrs 20% and 15 yrs 30%). GMFCS 5 (age5 yrs 22%, age 10 yrs 48% and age 15 yrs 50%). By 15 years, 54 hips in GMFCS 2 & 3 (diplegics), preventative soft tissue surgery had not reduced chances of hip dislocation; only 1 dislocated (2%). In GMFCS 4 & 5 (quadriplegics), dislocations reduced from 40% in those without surgery to 26% in those who had preventive soft tissue surgery. This was particularly so in GMFCS 5 where there was a reduction from 83% dislocation without surgery to 33% with soft tissue preventive surgery. Conclusions. Preventive soft tissue surgery was effective in reducing the rate of hip dislocation in quadriplegic CP especially GMFCS 5

Proximal femoral deformity is common in children with cerebral palsy (CP), contributing to hip instability and ambulation difficulties. This population-based cohort study investigates the prevalence and significance of these deformities in relation to Gross Motor Function Classification System (GMFCS) level. Children with a confirmed diagnosis of CP born within a three-year period were identified from a statewide register. Motor type, topographical distribution and GMFCS level were obtained from clinical notes. Neck Shaft Angle (NSA) and Migration Percentage (MP) were measured from an anteroposterior pelvis x-ray with the hips internally rotated. Measurement of FNA was by the Trochanteric Palpation Test (TPAT) or during fluoroscopic screening of the hip with a guide wire in the centre of the femoral neck. Linear regression analysis was performed for FNA, NSA and MP according to GMFCS level. 292 children were eligible. FNA was increased in all GMFCS levels. The lowest measurements were at GMFCS levels I and II p<0.001. GMFCS levels III, IV, and V were uniformly high p<0.001. Neck shaft angle increased sequentially from GMFCS levels I to V (p<0.001). This study confirms a very high prevalence of increased FNA in children with CP in all GMFCS levels. In contrast, NSA and MP progressed step-wise with GMFCS level. We propose that increased FNA in children with CP represents failure to remodel normal fetal alignment because of delay in ambulation and muscle imbalance across the hip joint. In contrast, coxa valga is an acquired deformity and is largely related to lack of weight bearing and functional ambulation. The high prevalence of both deformities at GMFCS levels IV and V explain the high rate of displacement in these hips and the need for proximal femoral realignment surgery in the prevention and management of hip displacement

Purpose. The incidence of hip displacement in children with cerebral palsy is approximately 30% in large population based studies. The purpose of this study was to report the long-term effect of hip surgery on the incidence of hip displacement using a newly validated Cerebral Palsy (CP) hip classification. Method. Retrospectively, a sub-group of 100 children who underwent surgery for hip displacement were identified from a large-population based cohort of children born with CP between January 1990 and December 1992. These children were followed to skeletal maturity and closure of their tri-radiate cartilage. All patients returned at maturity for clinical and radiographic examination, while caregivers completed the disease specific quality of life assessments. Patients were grouped according to motor disorder, topographical distribution and GMFCS. Radiographs were independently graded according to CP hip classification scheme to ensure reliability. Surgical Failures were defined as CP Grade > IV. Results. Ninety-seven children and 194 hips were available for final review. According to GMFCS, greater than half the children were GMFCS IV and V (67/94, 67%), 12 were II and 18 were III. Fifteen hips were dislocated or had salvage surgery for dislocation (15/194, 7.7%) at time of skeletal maturity. The majority of hips were graded Grade II and III (149/194, 76.8%). A total of 39 (39/194, 20%) hips were classified as surgical failure with 95% (37/39) hips occurring in GMFCS IV and V children. Conclusion. Using the CP hip classification scheme, the natural history and outcome of 100 children with CP at skeletal maturity have been described. Despite hip surveillance and surgical intervention GMFCS IV and V children are at the greatest risk for surgical failure at skeletal maturity. In this study, the majority of failures were associated with either no hip surveillance and/or index surgery at a non-specialist centre. In contrast, hip surveillance and index surgery at a specialist tertiary centre was associated with a very high probability of a successful outcome. This is the first population based cohort study of children with cerebral palsy followed from index surgery to skeletal maturity for hip displacement. Surgical success rates for the treatment of hip displacement in children with cerebral palsy have not previously been reported. This information will aid surgeons in the treatment of hip displacement in children with cerebral palsy

Purpose. The authors have used the Edinburgh Visual Gait Score (VGS) in the management of diplegic cerebral palsy patients treated with Botulinum toxoid injections into their hamstrings muscles. Video-filmed gait episodes were recorded before and after Botox injections over a treatment period of 6 years from 2007 to 2012. Method. The video-recordings of 32 patients were available for VGS analysis. Ages ranged from 5 to 22 years, with 17 patients under the age of 12 years, and 15 over 12 years. Gross Motor Function Classification System (GMFSC) levels were accorded to: 8 patients level 1, 10 patients level 2, and 14 patients level 3; 15 were boys and 17 girls. The indication for hamstring injections were a GMFCS level of 1 to 3, age five years or older, no previous hamstring surgery, and a patient keen to have the Botox treatment. Video-recordings were taken with a Sony and a Canon Digital camera in a back-front-back view and a lateral left-right view; walking distance ap was 10 metres, lateral camera distance 5 metres. All injections of Botox were done by the senior author without anaesthetic or sedation. All assessments were done by the junior authors; they did not know the patients, the status before or after injections or repeat injections, or the dates of injections and filming of the episodes. Results. After the Botox injections into the hamstrings bilaterally, no patient changed GMFCS level status, nobody deteriorated; all could be classified in the GMFCS. Conclusion. The Edinburgh VGS is a reliable analysis method for classifying GMF levels in diplegic walking cerebral palsy patients. Video-recordings are permanent and can repeatedly be re-assessed in future; different visual parameters may be chosen for assessment. ONE DISCLOSURE

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

Intramuscular injections of botulinum neuro toxin A (BoNT-A) have been a cornerstone in the treatment of spasticity for the last two decades. In India, the treatment is now offered to children with spastic cerebral palsy (CP). However, despite its use, the evidence for its functional effects is limited and inconclusive. The objective of this study is to determine whether BoNT-A makes walking easier in children with CP. We hypothesize that injections with BoNT-A will not reduce energy cost during walking, improve walking capacity, reduce pain or improve self-perceived performance and satisfaction. Between the period of 2012 and 2014, 35 children with spastic CP less than 10 years of age were included. The patients were classified according to their gross motor function classification system (GMFCS) and their pre-and post-injection gait analysis were performed. Spasticity assessed by Modified Ashworth Score [MAS]. Trained parents were utilised for the post injection physiotherapy as these children will be more complaint to them. GMFCS and MAS scoring done every three months till one year follow up. Therapeutically, effect was found in 90% of the patients, an average duration of the medical effect was 6–12 months. The improvement in GMFC functional score in serial measurements was seen in these patients though some deterioration in spasticity scores at one year. Despite mild recurrence in spasticity, majority maintained independent (42%) or assisted ambulation (48%) at one year. No major side effects occurred. Botox may prove a useful adjuvant in conservative management of the spasticity of cerebral palsy. Apart from being very cost effective in these financially deprived populations, successful management with these injections may allow delay of surgical intervention until the child is older and at less risk of possible complications, including the need for repeated surgical procedures

Hip displacement is the second most common deformity in children with cerebral palsy (CP). A displaced, and particularly a dislocated hip, can have significantly adverse effects on an individual. Surgical intervention to correct progressive hip displacement or dislocation is recommended for children with CP. Success of surgical intervention is often described using radiological outcomes. There is evidence that surgical treatment for displaced or dislocated hips decreases pain and hip stiffness and improves radiological outcomes. However, there is no information in the literature regarding the impact of surgical treatment on the health related quality of life (HRQOL) in these children. The aim of our study was to examine the impact of surgical treatment of hip displacement or dislocation on HRQOL in children with CP. This prospective longitudinal cohort study involved children attending a tertiary care hospital orthopaedic department. Children with CP between the ages of 4 and 18 years, with hip displacement/dislocation, defined as a Reimer's migration percentage (MP) of >40% on a pre-operative x-ray, and undergoing surgical reconstruction were eligible for inclusion. Quality of life was measured pre-operatively and post-operatively using the CPCHILD Questionnaire. Twelve patients (one child was GMFCS level III, 4 were level IV, and 7 were level V), aged 4.0 to 17.3 years, were assessed pre-operatively and then again at least six months post-operatively. All underwent unilateral (5) or bilateral (7) reconstructive hip surgery. The migration percentage of hips undergoing reconstruction was reduced by an average of 52% (9–100%). The average change in CPCHILD score showed an increase of 6.4 points [95% CI: −1.4–14.2]. In this pilot study, no significant change was noted in HRQOL following reconstructive hip surgery, despite a marked reduction in Reimer's MP. However, only 4 of 12 parents reported that their child had daily pain pre-operatively. A larger sample size will be required to draw more accurate conclusions from these findings. There is an evident need for a multicentre study examining this issue in a larger patient population in order to determine the long-term impact of different hip interventions on quality of life in children with CP

Background and Aims:. In 2009 a combined clinic was formed by the orthopaedic Surgeons and Developmental Paediatricians in our hospital. The aim was to help improve the assessment and management of patients with Cerebral Palsy. Included in the assessment team, are the paediatric orthopaedic surgeons, the developmental paediatricians, physiotherapists and occupational therapists. Our aim was to audit the patients presenting to this clinic over a 15 month period to look at the demographic data, clinical severity and decisions taken for these patients. Methods:. We looked at patients seen in the clinic from January 2013 to March 2014. We recorded the age, gender and primary caregiver. We also recorded the reason for referral. Clinically we wanted to know the type and distribution of the CP, GMFCS score, attainment of milestones and type of schooling. We recorded underlying aetiologies and HIV status of the patients. Finally the access the patients had to physiotherapy and Occupational therapy. Results:. We saw 41 patients in total with 18 males and 23 females. The ages ranged from 5 months to 9 years (mean 4.9 years). 36 of 41 (88%) had spastic CP, 2 (5%) dystonic, 1 (2%) mixed and 2 (5%) were not recorded. Diplegic and hemiplegic predominated with 15 (37%) and 14 (34%) respectively, there were 6 (15%) quadriplegics, 1 double hemiplegic and 5 were not recorded. 13 (31%) of patients had birth asphyxia as an aetiology, 13 (31%) had brain anomalies, 9 (22%) were premature babies, the remaining 16% comprised HIV, post natal sepsis and injury. 38 (93%) were cared for by at least one parent and the remaining 3 (7%) were cared for by a grandparent. 39 (95%) had access to physiotherapy and 30 (73%) had access to occupational therapy. 21 (51%) had no access to appropriate schooling. 9 (22%) were known to be HIV positive. The recommended orthopaedic interventions were continued physiotherapy for 17 (41%) and botox in 22(54%). Discussion:. The combined clinic has highlighted the diverse nature of cerebral palsy and the challenges facing our patients. It is an invaluable tool in the goal directed management of complex cases

Purpose of Study. In children with spastic diplegia, surgery for equinus has a high incidence of both over and under correction. We wished to determine if conservative (mainly Zone 1) surgery for equinus gait, in the context of multilevel surgery, could result in the avoidance of calcaneus and crouch gait as well as an acceptable rate of recurrent equinus, at medium term follow-up. Description of Methods. This was a retrospective, consecutive cohort study of children with spastic diplegia, between 1996 and 2006. All children had distal gastrocnemius recession or differential gastrocsoleus lengthening, on one or both sides, as part of Single Event Multilevel Surgery. The primary outcome measures were the Gait Variable Scores (GVS) and Gait Profile Score (GPS) at two time points after surgery. Summary of Results. Forty children with spastic diplegia, GMFCS Level II and III were eligible for inclusion in this study. There were 25 boys and 15 girls, mean age 10 years at surgery. The mean age at final follow-up was 17 years and the mean postoperative follow-up period was seven years. The mean ankle GVS improved from 18.5° before surgery to 8.7° at short term follow-up (P<0.005) and 7.8° at medium term follow-up. Equinus gait was successfully corrected in the majority of children with a low rate of over-correction (2.5%) but a high rate of recurrent equinus (35.0%), as determined by sagittal ankle kinematics. Conclusion. Surgery for equinus gait, in children with spastic diplegia, was successful in the majority of children, at a mean follow-up of seven years, when combined with multilevel surgery, orthoses and rehabilitation. No patients developed crouch gait and the rate of revision surgery for recurrent equinus was 12.5%. NO DISCLOSURES

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.

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.