Effectiveness of an anesthetic continuous-infusion device in children with cerebral palsy undergoing orthopaedic surgery.

BACKGROUND: Effective postoperative pain management is a vital component of orthopaedic surgical care in the pediatric population. In children with cognitive impairments pain management can be difficult, making these children vulnerable to ineffectively managed postoperative pain. This prospective, randomised study evaluated the use of a local anesthetic continuous infusion device (pain pump) to manage postoperative pain in children with cerebral palsy (CP) undergoing lower extremity orthopaedic surgical procedures. METHODS: Children with a diagnosis of CP who were undergoing select orthopaedic outpatient procedures were enrolled in this study. Postoperatively, patients were randomised to receive either a pain pump in addition to oral analgesics or oral analgesics only. Patient's parents were asked to record the amount of medication administered and assess pain intensity with the use of a modified visual analogue scale for 3 days postoperatively. Parents also completed an overall pain management satisfaction questionnaire at the end of the study participation period. RESULTS: Fifty-four patients were enrolled in this study and data were analyzed on 37 patients. The mean daily pain intensity in the pain pump group was significantly lower for the day of surgery and for 2 days postoperatively, and there was an overall significant difference between the groups (P<0.0001). The amount of analgesic medication administered was significantly lower for the first 2 postoperative days, but there was not a significant difference between the 2 groups overall (P=0.29). Parent satisfaction with both pain management techniques was high and responses were similar between the 2 groups. CONCLUSIONS: Children with CP present unique postoperative pain management concerns that can be effectively addressed through the use of multimodal analgesic techniques. This study found that the pain pump is an effective pain management technique that significantly reduces pain intensity in children with CP after lower extremity orthopaedic procedures. LEVEL OF EVIDENCE: Therapeutic Level II.

Femoral head resection as a salvage procedure for the severely dysplastic hip in nonambulatory children with cerebral palsy.

BACKGROUND: Proximal femoral head resection (FHR) has been used as a treatment option in patients with cerebral palsy (CP) who suffer from pain, contractures, and impaired personal hygiene. We analyzed the overall functional outcome following this surgery and associated patient satisfaction. METHODS: This study was a retrospective case series with a follow-on questionnaire. A consecutive sample of 27 patients with CP who underwent proximal FHR between 1988 and 2004 were analyzed. Medical and radiographic records were used alongside a patient satisfaction questionnaire. Average follow-up time was 7.8 years (range, 2.3-16.5 years). RESULTS: We found an improvement in hip pain, range of motion, activities of daily living, and quality of life after surgery. Age at surgery, type of immobilization, and presence of heterotopic ossification or femoral migration did not affect the long-term surgical outcome. CONCLUSION: This study confirms the efficacy of proximal FHR for the treatment of chronic severe neuromuscular hip dysplasia in children with CP. LEVEL OF EVIDENCE: Level IV.

Rectus femoris transfer in children with cerebral palsy: evaluation of transfer site and preoperative indicators.

BACKGROUND: Rectus femoris transfer (RFT) is a treatment option for children with cerebral palsy (CP) who exhibit a stiff-knee gait pattern. The rectus femoris muscle is transferred to different sites to overcome problems such as tripping and falling. Indications for RFT often include preoperative decreased knee range of motion (KROM) during swing phase, reduced peak knee flexion in swing (PKFSW), abnormal rectus femoris firing patterns on electromyography recordings, and a positive Duncan-Ely test. This study investigated the effect of different RFT sites on kinematic outcome variables and evaluated the relationship between commonly used preoperative surgical indicators and postoperative changes in kinematics. METHODS: Thirty-eight patients with CP, who underwent RFT, with preoperative and postoperative instrumented gait analyses, were evaluated and divided by transfer site: semitendinosus, sartorius, and gracilis. Preoperative and postoperative comparisons were made for 5 knee kinematic variables: range of motion (KROM), peak flexion at loading response, peak extension at terminal stance, PKFSW, and peak extension at terminal swing. Analysis was performed in accordance to different transfer sites and overall postoperative change. RESULTS: When all limbs were analyzed together for the 5 outcome variables, it was found that patients experienced significant (P < 0.05) improvements in sagittal-plane kinematics in 3 of the outcome variables: KROM, PKFSW, and peak extension at terminal swing. Patients had a significant improvement in postoperative KROM when the preoperative KROM was less than 80% of normal. Electromyography pattern and Duncan-Ely test were not found to be useful indicators of surgical success. CONCLUSION: The authors recommend RFT in children with CP who exhibit a stiff-knee gait, regardless of transfer site. LEVEL OF EVIDENCE: Level 3.

Effectiveness of instrumented gait analysis in children with cerebral palsy--comparison of outcomes.

The aim of this study was to evaluate the impact of instrumented gait analysis on the walking performance of children with cerebral palsy at The Children's Hospital, Denver. The study population consisted of 2 groups of 10 children; an experimental group (X) and a recommendation matched control group (C). All subjects had 2 instrumented gait analyses at least 1 year apart. Group X was composed of patients who abided by the gait analysis recommendations and completed all surgical interventions. Group C included patients who chose not to follow surgical recommendations from the initial gait analysis but instead pursued alternative nonsurgical treatments. Sagittal and coronal plane kinematic outcomes for each surgical procedure were obtained from comparing sequential instrumented gait analyses, and analyzed using logistic regression. Group X was found to experience a significantly higher percentage of positive outcomes (44%) than Group C (26%). The calculated odds ratio using the Wald test indicated that patients who complied with gait analysis surgical recommendations were 3.68 times more likely to experience a positive outcome than recommendation matched patients who chose not to follow gait analysis recommendations.