Transiliac-Shortening Osteotomy to Treat Ischial Pressure Injury due to Fixed Pelvic Obliquity: A Case Report.

CASE: A 17-year-old adolescent boy with Gross Motor Function Classification System 5 cerebral palsy and neuromuscular scoliosis underwent posterior spinal fusion and segmental spinal instrumentation from T3 to the pelvis. He developed a right ischial pressure injury a few months postoperatively, which persisted despite nonoperative measures. He subsequently underwent an ipsilateral transiliac-shortening osteotomy 16 months after spinal surgery to treat his residual pelvic obliquity and the ischial pressure injury, which healed completely. At the 1-year follow-up visit, there were no further signs of pressure injury. CONCLUSION: This case report describes transiliac-shortening osteotomy as a viable treatment option for non-healing ischial pressure injuries secondary to fixed pelvic obliquity.

Comparing Self-Report Fatigue Assessment Tools for Adults with Cerebral Palsy in a Danish Context.

PURPOSE: Many youth and adults with Cerebral Palsy (CP) experience high levels of fatigue. This study aimed to compare three fatigue self-report questionnaires to guide clinicians. METHOD: Thirty youth and adults (age range 17-64) with CP were assessed with Danish versions of the Fatigue Impact and Severity Self-Assessment questionnaire, the Modified Mental Fatigue Scale, and the Multidimensional Fatigue Inventory. Psychometric properties were investigated. Rank order and classification models were compared across questionnaires. RESULTS: The Reduced Motivation and Physical Fatigue subscales of the Multidimensional Fatigue Inventory showed inadequate internal consistency. Participants were frequently ranked differently with the questionnaires. There were issues related to the conceptualization of physical fatigue. CONCLUSION: The choice of assessment tool should be based on assessment purpose as the questionnaires assess different aspects of fatigue severity, impact, and management. Also, test selection can have important implications on the conclusions that are made about fatigue type and severity.

Knee and ankle range of motion and spasticity from childhood into adulthood: a longitudinal cohort study of 3,223 individuals with cerebral palsy.

BACKGROUND AND PURPOSE: Reduced range of motion (ROM) and spasticity are common secondary findings in cerebral palsy (CP) affecting gait, positioning, and everyday functioning. These impairments can change over time and lead to various needs for intervention. The aim of this study was to analyze the development path of the changes in hamstring length, knee extension, ankle dorsiflexion, and spasticity in hamstrings and gastrosoleus from childhood into adulthood in individuals with CP at the Gross Motor Function Classification System (GMFCS) levels I-V. METHODS: A longitudinal cohort study was undertaken of 61,800 measurements in 3,223 individuals with CP, born 1990-2017 and followed for an average of 8.7 years (range 0-26). The age at examination varied between 0 and 30 years. The GMFCS levels I-V, goniometric measurements, and the modified Ashworth scale (MAS) were used for repeated assessments of motor function, ROM, and spasticity. RESULTS: Throughout the follow-up period, knee extension and hamstring length exhibited a consistent decline across all individuals, with more pronounced decreases evident in those classified at GMFCS levels III-V. Ankle dorsiflexion demonstrated a gradual reduction from 15° to 5° (GMFCS I-IV) or 10° (GMFCS V). Spasticity levels in the hamstrings and gastrosoleus peaked between ages 5 and 7, showing a propensity to increase with higher GMFCS levels. CONCLUSION: Passive ROM continues to decrease to 30 years of age, most pronouncedly for knee extension. Conversely, spasticity reached its peak at a younger age, with a more notable occurrence observed in the gastrosoleus compared with the hamstrings. Less than 50% of individuals had spasticity corresponding to MAS 2-4 at any age.

Foot and lower leg pain in children and adults with cerebral palsy: a population-based register study on 5,122 individuals.

BACKGROUND: Pain is common in individuals with cerebral palsy (CP) and the most reported pain site is the foot/lower leg. We analyzed the prevalence of pain in the foot/lower leg and the associations with age, sex, gross motor function, and clinical findings in individuals with CP. METHOD: This was a cross-sectional register-study, based on data reported to the Swedish Cerebral Palsy Follow-up Program (CPUP). All participants in CPUP, four years-of-age or older, were included. Pearson chi-square tests and logistic regression were used to analyze the prevalence and degree of pain in the foot/lower leg. RESULTS: In total, 5,122 individuals were included from the CPUP database: 58% were males and 66% were under 18 years-of-age. Overall, 1,077 (21%) reported pain in the foot/lower leg. The odds ratios (ORs) of pain were higher in females (OR 1.31, 95% confidence interval (CI) 1.13-1.53), individuals who could ambulate (Gross Motor Function Classification System Level I (OR 1.84, CI 1.32-2.57) and II (OR 2.01, CI 1.46-2.79) compared to level V), and in individuals with decreased range of motion of the ankle (dorsiflexion 1-10 degrees (OR 1.43, CI 1.13-1.83) and ≤ 0 degrees (OR 1.46, CI 1.10-1.93) compared to ≥ 20 degrees). With increasing age the OR of pain increased (OR 1.02, CI 1.01-1.03) as well as the reported pain intensity (p < 0.001). CONCLUSIONS: Pain in the foot and lower leg appears to be a significant problem in individuals with CP, particularly in those who walk. As with pain in general in this population, both pain intensity and frequency increase with age. The odds of pain in the foot and lower leg were increased in individuals with limited dorsiflexion of the ankle. Given the cross-sectional design causality cannot be inferred and it is unknown if pain causes decreased range of motion of the ankle or if decreased range of motion causes pain. Further research is needed on causal pathways and importantly on prevention.

Anterior Proximal Tibial Screw Hemiepiphysiodesis Decreases Posterior Tibial Slope in Knee Flexion Contracture: A Case Report.

CASE: A 13-year-old adolescent boy with hemiplegic cerebral palsy suffering from fixed knee flexion deformity of 10° despite extensive conservative treatment. Owing to a posterior tibial slope (PTS) of 16°, anterior hemiepiphysiodesis was applied to the proximal tibia. The 2 screws were removed after 9 months. Final follow-up at 16 months showed complete knee extension and a PTS of 4°. CONCLUSION: The presented technique is a good alternative in knee flexion deformity with an increased PTS and has surprisingly not been described in the literature. This might be worth considering for other pathologies such as pediatric anterior cruciate ligament injury with an increased PTS.

Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis.

BACKGROUND: Spasticity can significantly affect a patient's quality of life, caregiver satisfaction, and the financial burden on the healthcare system. Baclofen is one of only a few options for treating spasticity. The purpose of this study is to investigate the impact of intrathecal baclofen (ITB) therapy on severe40.23 spasticity and motor function in patients with cerebral palsy. METHODS: We conducted a systematic review in PubMed, Scopus, Ovid, and the Cochrane Library in accordance with the PRISMA guidelines. We included studies based on eligibility criteria that included desired participants (cerebral palsy patients with spasticity), interventions (intrathecal baclofen), and outcomes (the Ashworth scales and the Gross Motor Function Measure [GMFM]). The within-group Cohen's d standardized mean differences (SMD) were analyzed using the random effect model. RESULTS: We screened 768 papers and included 19 in the severity of spasticity section and 6 in the motor function section. The pre-intervention average spasticity score (SD) was 3.2 (0.78), and the post-intervention average score (SD) was 1.9 (0.72), showing a 40.25% reduction. The SMD for spasticity reduction was - 1.7000 (95% CI [-2.1546; -1.2454], p-value < 0.0001), involving 343 patients with a weighted average age of 15.78 years and a weighted average baclofen dose of 289 µg/day. The SMD for the MAS and Ashworth Scale subgroups were - 1.7845 (95% CI [-2.8704; -0.6986]) and - 1.4837 (95% CI [-1.8585; -1.1088]), respectively. We found no relationship between the participants' mean age, baclofen dose, measurement time, and the results. The pre-intervention average GMFM (SD) was 40.03 (26.01), and the post-intervention average score (SD) was 43.88 (26.18), showing a 9.62% increase. The SMD for motor function using GMFM was 0.1503 (95% CI [0.0784; 0.2223], p-value = 0.0030), involving 117 patients with a weighted average age of 13.63 and a weighted average baclofen dose of 203 µg/day. In 501 ITB implantations, 203 medical complications were reported, including six new-onset seizures (2.96% of medical complications), seven increased seizure frequency (3.45%), 33 infections (16.26%), eight meningitis (3.94%), and 16 cerebrospinal fluid leaks (7.88%). Delivery system complications, including 75 catheter and pump complications, were also reported. CONCLUSION: Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.

Simultaneous subtalar arthroeresis, midfoot soft tissue release, and talo-navicular arthrodesis in children with planovalgus neurologic foot.

PURPOSE: Planovalgus foot deformity (PVFD) is common in children with neuromuscular conditions and severe deformity may require surgical correction. This study aims to assess clinical and radiological outcomes of PVFD secondary to neuromuscular disease managed by subtalar arthroeresis (SuAE), midfoot soft tissue release and talo-navicular arthrodesis (TNA). METHODS: A retrospective analysis of children with neuromuscular disease and nonreducible PVFD who underwent SuAE, midfoot soft tissue release, and TNA and with a minimum follow-up of 5 years was performed. A total of 60 patients with neuromuscular disease (108 feet) including cerebral palsy were reviewed. Mean age at surgery was 12.7 ± 4.6 years (6-17). Mean follow-up was 7 ± 2.9 years (5-10). Clinical outcomes and radiologic correction at final follow-up were compared with preoperative values. Statistical analysis was performed and significance was set at P < 0.01. RESULTS: Statistically significant radiological improvements between pre- and postoperative values were found for all angle values. At final follow-up, there was a significant improvement in VAS score (4.8 vs. 2; P < 0.01). There was also a positive trend in the improvement of walking ability. No cases of pseudoarthrosis were reported at final follow-up. Screw removal was required in 5 out of 108 feet (4.6%) and 2 feet (3.3%) had delayed medial wound healing. CONCLUSIONS: SuAE combined with TNA and midfoot soft tissue is a safe and feasible procedure that can provide good clinical and radiologic results in patients with neuromuscular disease and nonreducible PVFD; the procedure can improve foot stability, and has a limited number of complications. LEVEL OF EVIDENCE: IV.

Relationship Between Postural Asymmetry, Balance, and Pain in Children With Spastic Cerebral Palsy.

BACKGROUND: Primary symptoms of cerebral palsy (CP), such as spasm and weakness, can lead to secondary musculoskeletal problems. Exploring the interplay and impact of secondary symptoms is essential in CP management. METHODS: A total of 56 children (32 males and 24 females) aged eight to 12 years in level I to III of Gross Motor Function Classification System (GMFCS) completed The Pediatric Balance Scale and Wong-Baker Faces Scale and the Posture and Postural Ability Scale. Relationships between the three groups were examined using the Kruskal-Wallis test, Tukey test, gamma coefficient, De Somers D, phi coefficient, Cramér V, and one-way analysis of variance. RESULTS: There was a significant correlation between balance and postural asymmetry (P < 0.001), and no significant difference in balance was there between the severe and moderate asymmetry groups (P = 0.759) and between the mild asymmetry and no asymmetry groups (P = 0.374). Furthermore, there was a significant relationship between postural asymmetry and each of the variables of pain (P < 0.001) and gross motor function (P = 0.002). Although a meaningful correlation was identified between balance and gross motor function (P < 0.001), the relationship between postural asymmetry and balance in GMFCS levels was not found (P = 0.052, P = 0.052, P = 0.233). Conversely, no significant relationship was detected between pain and gross motor function (P = 0.072). SIGNIFICANCE: Postural asymmetry negatively impacts balance and correlates with pain intensity. Addressing postural problems can contribute to pain management and improved balance.

Prevalence and Risk Factors for Cerebral Palsy in Children With Congenital Heart Disease Based on Risk of Surgical Mortality.

BACKGROUND: Children with congenital heart disease (CHD) have a higher prevalence of motor impairment secondary to brain injury, resulting in cerebral palsy (CP). The purpose of this study is to determine the prevalence of CP in CHD in a single-center cohort, stratify risk based on surgical mortality using Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) categories and identify risk factors. METHODS: Retrospective cohort study of pediatric patients registered in the University of Florida (UF) Society of Thoracic Surgeons Congenital Heart Surgery database from 2006 to 2017 with a diagnosis of CHD who continued follow-up for more than two years at UF. RESULTS: A total of 701 children with CHD met inclusion criteria. Children identified to have CP were 54 (7.7%). Most common presentation was spastic hemiplegic CP with a Gross Motor Function Classification System of level 2. Analysis of surgical and intensive care factors between the two groups showed that children with CHD and CP had longer time from admission to surgery (P = 0.003), higher STAT categories 4 and 5 (P = 0.038), and higher frequency of brain injury and seizures (P < 0.001). Developmental disabilities and rehabilitation needs were significantly greater for children with CHD and CP when compared with those with CHD alone (P < 0.001). CONCLUSIONS: In our cohort, 7.7% children with CHD develop CP; this is significantly higher than the 2010 US population estimate of 0.3%. Our study suggests higher STAT categories, brain injury, and seizures are associated with developing CP in children with CHD.

Is dynamic motor control clinically important for identifying gait deviations in individuals with cerebral palsy?

INTRODUCTION: Individuals with cerebral palsy (CP) often present with altered motor control. This can be assessed selectively during sitting/lying with the Selective Control Assessment of the Lower Extremity (SCALE), or dynamically with the dynamic motor control index during walking (walk-DMC). Both approaches suggest that altered selective motor control relate to larger gait deviations. RESEARCH QUESTION: Does the walk-DMC provide valuable information in addition to the SCALE for estimating gait deviations in individuals with CP. METHODS: Retrospective, treadmill-based gait analysis data of 157 children with spastic CP (mean 11.4±3.5 years) and Gross Motor Function Classification System levels I (n=45), II (n=88) or III (n=24) were extracted. Gait kinematic deviations were evaluated using the Gait Profile Score (GPS). The SCALE, walk-DMC and GPS were extracted for the more clinically involved leg (unilateral-analysis), and for both legs together (bilateral-analysis). RESULTS: GPS moderately correlated with both SCALE and walk-DMC scores, unilaterally and bilaterally (r≥0.4; p<0.001). Multivariate linear regression analyses were conducted, taking into account potential confounding factors. In the unilateral analysis, 54% of the GPS variance was explained (p<0.001), with both walk-DMC and SCALE significantly contributing to the GPS variance (p=0.006 and p=0.008, respectively). In the bilateral analysis, 61% of the GPS variance was explained (p<0.001), with both walk-DMC and SCALE significantly contributing to the GPS variance (p=0.006 and p<0.001, respectively). Dimensionless walking speed and use of assistive devices were the only confounding factors included in each analysis. SIGNIFICANCE: Both SCALE and walk-DMC significantly contribute to GPS variance, suggesting that they likely measure different components of motor control, and both may be useful in understanding the underlying relationship between motor control and deviations in gait kinematics.

Machine learning applied to gait analysis data in cerebral palsy and stroke: A systematic review.

BACKGROUND: Among neurological pathologies, cerebral palsy and stroke are the main contributors to walking disorders. Machine learning methods have been proposed in the recent literature to analyze gait data from these patients. However, machine learning methods still fail to translate effectively into clinical applications. This systematic review addressed the gaps hindering the use of machine learning data analysis in the clinical assessment of cerebral palsy and stroke patients. RESEARCH QUESTION: What are the main challenges in transferring proposed machine learning methods to clinical applications? METHODS: PubMed, Web of Science, Scopus, and IEEE databases were searched for relevant publications on machine learning methods applied to gait analysis data from stroke and cerebral palsy patients until February the 23rd, 2023. Information related to the suitability, feasibility, and reliability of the proposed methods for their effective translation to clinical use was extracted, and quality was assessed based on a set of predefined questions. RESULTS: From 4120 resulting references, 63 met the inclusion criteria. Thirty-one studies used supervised, and 32 used unsupervised machine learning methods. Artificial neural networks and k-means clustering were the most used methods in each category. The lack of rationale for features and algorithm selection, the use of unrepresentative datasets, and the lack of clinical interpretability of the clustering outputs were the main factors hindering the clinical reliability and applicability of these methods. SIGNIFICANCE: The literature offers numerous machine learning methods for clustering gait data from cerebral palsy and stroke patients. However, the clinical significance of the proposed methods is still lacking, limiting their translation to real-world applications. The design of future studies must take into account clinical question, dataset significance, feature and model selection, and interpretability of the results, given their criticality for clinical translation.

Development and validation of a predictive model for poor prognosis of communication disorders in children with cerebral palsy after cervical perivascular sympathectomy.

Cervical perivascular sympathectomy (CPVS) can improve communication disorders in children with cerebral palsy (CP); however, there are no research reports on the factors affecting surgical efficacy. This study aimed to establish a nomogram for poor prognosis after CPVS. We collected data from 313 CP patients who underwent CPVS at the Neurosurgery Cerebral Palsy Center of the Second Affiliated Hospital of Xinjiang Medical University from January 2019 to January 2023. Among them, 70% (n = 216) formed the training cohort and 30% (n = 97) the validation cohort. The general data and laboratory examination data of both groups were analyzed. In training cohort, 82 (37.96%) showed improved postoperative communication function. Logistic analysis identified motor function, serum alkaline phosphatase, serum albumin, and prothrombin activity as the prognostic factors. Using these four factors, a prediction model was constructed with an area under the curve (AUC) of 0.807 (95% confidence interval [CI], 0.743-0.870), indicating its ability to predict adverse outcomes after CPVS. The validation cohort results showed an AUC of 0.76 (95% CI, 0.650-0.869). The consistency curve and Hosmer-Lemeshow test (χ2 = 10.988 and p = 0.202, respectively) demonstrated good consistency between the model-predicted incidence and the actual incidence of poor prognosis. Motor function, serum alkaline phosphatase, serum albumin, and prothrombin activity are independent risk factors associated with the prognosis of communication disorders after CPVS. The combined prediction model has a good clinical prediction effect and has promising potential to be used for early prediction of prognosis of CPVS.

Estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa: a systematic review with meta-analysis.

Malnutrition is more prevalent among children with cerebral palsy and a major factor for child morbidity and mortality in children with different co-morbidity, especially in Sub-Saharan Africa: The main aim of this systematic review and meta-analysis was to estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa. We searched PubMed, Web of Science, Google Scholar, Research Gate, and institutional repositories for papers that reported the proportion of malnutrition among children with cerebral palsy that were published between December 2010 and September 2023. Data were retrieved using the standardized JBI data extraction checklist through Microsoft Excel, and then exported to STATA 17 for further analysis. DerSimonian and Laird's estimator was used to calculate the pooled effect size in the random-effects model. Statistics such as the Cochran Q test and I2 test were employed to measure heterogeneity. Egger's test and the funnel plot were used to look for publication bias. This systematic review and meta-analysis used 16 studies from Sub-Saharan Africa to estimate the proportion of malnutrition among 2,120 children with cerebral palsy. The pooled proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa by using random-effects model analysis was found to be 59.7% (95% CI; 49.8-69.6). The proportion of malnutrition was also estimated by sample sizes categorized as ≤ 120 and > 120, and the proportion of malnutrition was found to be 54.0 (95% CI: 44.7-63.3) and 64.5 (95% CI: 50.5-78.5). Moreover, the proportion of malnutrition was estimated by accounting for the difference in the year of publication. In this regard, the study classified before ≤ 2017 and > 2017, and the proportion of malnutrition was found to be 53.7 (95% CI: 38.0-69.3) and 62.5 (95% CI: 49.7-75.3) in Sub-Saharan Africa respectively. Malnutrition among children with cerebral in Sub-Saharan Africa was found to be very high. Hence, enhancing and developing strategic guidelines for malnutrition screening, prevention, and nutritional support are crucial among children with cerebral palsy. Furthermore, systematic review, randomized control trials, and qualitative studies are recommended to understand the burden more among children with cerebral palsy in the continent.

Association Between Two Methods of Spinal and Pelvic Analysis Among Children With Cerebral Palsy.

OBJECTIVES: Children with cerebral palsy have weak muscles, which may impair postural adjustments. These postural adjustments are required for gait and dynamic balance during the daily living activities. The aim of this study was to investigate the association between Cobb's angle and Formetric 4D surface topography system in evaluating spinal and pelvic deformity in children with cerebral palsy. METHODS: One hundred children with spastic diplegia (6 to 8 years old) diagnosed as cerebral palsy participated in this study and selected from the Outpatient Clinic of Faculty of Physical Therapy. Digital x- ray and formetric analysis were used to measure spinal deformities and pelvic deviation in children with cerebral palsy. RESULTS: There were positive correlations between Cobb's angle and formetric parameters, including trunk imbalance, lateral deviation, and pelvic tilt. Also, Formetric parameters were significant predictors of Cobb's angle, including trunk imbalance (for a one-degree increase, Cobb's angle increases by 0.227, lateral deviation (for a one-degree increase, Cobb's angle increases by 0.665), and pelvic tilt (for a one-degree increase, Cobb's angle increases by 0.252). CONCLUSION: Formetric 4D surface topography system was effective in evaluating spinal and pelvic deformity in children with cerebral palsy when compared with Digital x-ray.

Botulinum neurotoxin type A responders among children with spastic cerebral palsy: Pattern-specific effects.

AIM: To identify short-term effects of botulinum neurotoxin type A (BoNT) injections on gait and clinical impairments, in children with spastic cerebral palsy (CP), based on baseline gait pattern-specific subgroups. METHOD: Short-term effects of BoNT injections in the medial hamstrings and gastrocnemius were defined in a retrospective convenience sample of 117 children with CP (median age: 6 years 4 months; GMFCS I/II/III: 70/31/16; unilateral/bilateral: 56/61) who had received gait analyses before and 2 months post-BoNT. First, baseline gait patterns were classified. Statistical and meaningful changes were calculated between pre- and post-BoNT lower limb sagittal plane kinematic waveforms, the gait profile score, and non-dimensional spatiotemporal parameters for the entire sample and for pattern-specific subgroups. These gait waveforms per CP subgroup at pre- and post-BoNT were also compared to typically developing gait and composite scores for spasticity, weakness, and selectivity were compared between the two conditions. RESULTS: Kinematic improvements post-BoNT were identified at the ankle and knee for the entire sample, and for subgroups with apparent equinus and jump gait. Limbs with baseline patterns of dropfoot and to a lesser extent true equinus showed clear improvements only at the ankle. In apparent equinus, jump gait, and dropfoot, spasticity improved post-BoNT, without leading to increased weakness or diminished selectivity. Compared to typical gait, knee and hip motion improved in the crouch gait subgroup post-BoNT. CONCLUSION: This comprehensive analysis highlighted the importance of investigating BoNT effects on gait and clinical impairments according to baseline gait patterns. These findings may help identify good treatment responders.

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy.

BACKGROUND: Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures. PATIENTS AND METHODS: We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively. RESULTS: Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery. CONCLUSION: Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait. LEVEL OF EVIDENCE: Therapeutic level IV.

Quality of life and clinical outcomes in severely involved cerebral palsy patients and spastic hips undergoing Castle surgery: a cross-sectional study.

PURPOSE: As progressive hip dislocation causes pain in children with spastic cerebral palsy (CP) and spasticity needs surgical correction, we aimed to describe clinical and radiographic outcomes in CP patients with painful hip deformity treated with the Castle salvage procedure. METHODS: We included all patients operated in the same hospital between 1989 and 2017 with painful spastic hips and femoral head deformity making joint reconstruction unfeasible. We collected clinical and functional data from medical records and evaluated radiographies to classify cases for femoral head shape and migration, type of deformity, spinal deformity, and heterotopic ossification. We investigated quality of life one year after surgery. RESULTS: We analyzed 41 patients (70 hips) with complete medical records. All had severe function compromise GMFCS V (Gross Motor Function Classification System) and heterotopic ossifications, all but one had scoliosis, and most had undergone other surgeries before Castle procedure. Patients were followed up for 77.1 months (mean) after surgery. The mean initial migration index was 73%. Seven patients had complications, being three patients minor (two femur and one tibial fracture) and four majors (patients requiring surgical revision). Quality of life was considered improved by most of the carers (35 children; 85.3%) as level 4/5 according to CPCHILD instrument. No child was able to stand or walk, but moving in and out of bed, of vehicles, and to a chair, remaining seated, or visiting public places was "very easy." CONCLUSION: We considered most patients (37 patients-90%, 66 hips-94%) as having satisfactory outcomes because they had no or minor complications, absence of pain, free mobility of the lower limbs and were able to sit in a wheelchair.

Genetic and Congenital Anomalies in Infants With Hypoxic-Ischemic Encephalopathy.

BACKGROUND: Infants with hypoxic ischemic encephalopathy (HIE) may have underlying conditions predisposing them to hypoxic-ischemic injury during labor and delivery. It is unclear how genetic and congenital anomalies impact outcomes of HIE. METHODS: Infants with HIE enrolled in a phase III trial underwent genetic testing when clinically indicated. Infants with known genetic or congenital anomalies were excluded. The primary outcome, i.e., death or neurodevelopmental impairment (NDI), was determined at age two years by a standardized neurological examination, Bayley Scales of Infant Development, Third Edition (BSID-III), and the Gross Motor Function Classification Scales. Secondary outcomes included cerebral palsy and BSID-III motor, cognitive, and language scores at age two years. RESULTS: Of 500 infants with HIE, 24 (5%, 95% confidence interval 3% to 7%) were diagnosed with a genetic (n = 15) or congenital (n = 14) anomaly. Infants with and without genetic or congenital anomalies had similar rates of severe encephalopathy and findings on brain magnetic resonance imaging. However, infants with genetic or congenital anomalies were more likely to have death or NDI (75% vs 50%, P = 0.02). Among survivors, those with a genetic or congenital anomaly were more likely to be diagnosed with cerebral palsy (32% vs 13%, P = 0.02), and had lower BSID-III scores in all three domains than HIE survivors without such anomalies. CONCLUSIONS: Among infants with HIE, 5% were diagnosed with a genetic or congenital anomaly. Despite similar clinical markers of HIE severity, infants with HIE and a genetic or congenital anomaly had worse neurodevelopmental outcomes than infants with HIE alone.

Does Size Really Matter? Incidence of Periprosthetic Fractures After Femoral Osteotomy in Patients With Cerebral Palsy.

OBJECTIVE: Of children, 30% to 35% with cerebral palsy (CP) develop hip subluxation or dislocation and often require reconstructive hip surgery, including varus derotation osteotomy (VDRO). A recent literature review identified postoperative fractures as the most common complication (9.4%) of VDROs. This study aimed to assess risk factors for periprosthetic fracture after VDRO in children with CP. METHODS: A total of 347 patients (644 hips, 526 bilateral hips) with CP and hip subluxation or dislocation (129 females; mean age at index VDRO: 8.6 y, SD 3.4, range: 1.5 to 17.7; 2 Gross Motor Function Classification System (GMFCS) I, 35 GMFCS II, 39 GMFCS III, 119 GMFCS IV, 133 GMFCS V, 21 unavailable) were included in this retrospective, single-group intervention (VDRO) study at a tertiary referral center. Imaging and clinical documentation for patients age 18 years or younger at index surgery, treated with VDRO were reviewed to determine demographic data, GMFCS level, surgeon, type of hardware implanted, use of anticonvulsants and steroids, type of postoperative immobilization, presence of periprosthetic fractures, fracture location and mechanism, and time from surgery to fracture. Potential determinants of periprosthetic fractures were assessed using mixed effects logistic regression. RESULTS: Of 644 hips, 14 (2.2%, 95% CI: 1.3%, 3.6%) sustained a periprosthetic fracture, at a median of 2.1 years postoperatively (interquartile range: 4.6 y, range: 1.2 mo to 7.8 y). Patients with a fracture had a median age at index surgery of 7.3 years (interquartile range: 4.3, range: 2.8 to 17.8; 1 GMFCS II, 6 GMFCS IV, 7 GMFCS V). Periprosthetic fractures were not significantly related to age at index surgery ( P = 0.18), sex ( P = 0.30), body mass index percentile ( P = 0.87), surgery side ( P = 0.16), anticonvulsant use ( P = 0.35), type of postoperative immobilization ( P = 0.40), GMFCS level ( P = 0.31), or blade plate size ( P = 0.17). Only surgeon volume significantly related to periprosthetic fracture (odds ratio = 5.03, 95% CI: 1.53, 16.56, P = 0.008), with the highest-volume surgeon also using smaller blade plates ( P < 0.01). CONCLUSIONS: Periprosthetic fractures after VDRO surgery in children with CP are uncommon, and routine hardware removal appears unnecessary. The data suggest that the common dogma of putting in the largest blade plate possible to maximize fixation may increase the risk of periprosthetic fracture. Due to the overall low fracture rate, especially when contextualized relative to the risk of hardware removal, a reactive approach to hardware removal appears warranted. LEVEL OF EVIDENCE: Level III-retrospective study (targeting varus derotational osteotomies in children with cerebral palsy).