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1.
Gait Posture ; 105: 139-148, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37572544

RESUMO

BACKGROUND: Selective dorsal rhizotomy (SDR) creates a large and permanent reduction of spasticity for children with cerebral palsy (CP). Previous SDR outcomes studies have generally lacked appropriate control groups, had limited sample sizes, or reported short-term follow-up, limiting evidence for improvement in long-term gait function. RESEARCH QUESTION: Does aggressive spasticity management for individuals with CP improve long-term gait kinematics (discrete joint kinematics) compared to a control group of individuals with CP with minimal spasticity management? METHODS: This study was a secondary analysis - focused on joint-level kinematics - of a previous study evaluating the long-term outcomes of SDR. Two groups of participants were recruited based on a retrospectively completed baseline clinical gait study. One group received aggressive spasticity treatment including a selective dorsal rhizotomy (Yes-SDR group), while the other group had minimal spasticity management (No-SDR group). Both groups had orthopedic surgery treatment. Groups were matched on baseline spasticity. All participants prospectively returned for a follow-up gait study in young adulthood (greater than 21 years of age and at least 10 years after baseline). Change scores in discrete kinematic variables from baseline to follow-up were assessed using a linear model that included treatment arm (Yes-SDR, No-SDR), baseline age, and baseline kinematic value. For treatment arm, 5° and 5 Gait Deviation Index points were selected as thresholds to be considered a meaningful difference between treatment groups. RESULTS: At follow-up, there were no meaningful differences in pelvis, hip, knee, or ankle kinematic variable changes between treatment arms. Max knee flexion - swing showed a moderate treatment effect for Yes-SDR, although it did not reach the defined threshold. SIGNIFICANCE: Aggressive spasticity treatment does not result in meaningful differences in gait kinematics for persons with cerebral palsy in young adulthood compared to minimal spasticity management with both groups having orthopedic surgery.


Assuntos
Paralisia Cerebral , Rizotomia , Criança , Humanos , Adulto Jovem , Adulto , Paralisia Cerebral/complicações , Paralisia Cerebral/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Fenômenos Biomecânicos , Espasticidade Muscular/etiologia , Espasticidade Muscular/cirurgia
3.
Am J Phys Med Rehabil ; 102(10): 873-878, 2023 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-36897794

RESUMO

OBJECTIVE: Spasticity in children with cerebral palsy can be managed by a spectrum of approaches, from conservative therapy, to temporary botulinum toxin A injections, to permanent transection of sensory nerves with a selective dorsal rhizotomy. This pilot study investigated whether these three tone management approaches are associated with histological and biochemical properties of the medial gastrocnemius. DESIGN: A convenience sample of children with cerebral palsy undergoing gastrocnemius lengthening surgery was enrolled. Intraoperative biopsies were obtained from three individuals (one each: minimal tone treatment; frequent gastrocnemius botulinum toxin A injections; previous selective dorsal rhizotomy). All individuals had plantarflexor contractures, weakness, and impaired motor control before the biopsy. RESULTS: Differences between participants were observed for muscle fiber cross-sectional area, fiber type, lipid content, satellite cell density, and centrally located nuclei. The most pronounced difference was the abundance of centrally located nuclei in the botulinum toxin A participants (52%) compared with the others (3-5%). Capillary density, collagen area and content, and muscle protein content were similar across participants. CONCLUSIONS: Several muscle properties seemed to deviate from reported norms, although age- and muscle-specific references are sparse. Prospective studies are necessary to distinguish cause and effect and to refine the risks and benefits of these treatment options.


Assuntos
Toxinas Botulínicas Tipo A , Paralisia Cerebral , Fármacos Neuromusculares , Criança , Humanos , Toxinas Botulínicas Tipo A/uso terapêutico , Projetos Piloto , Fármacos Neuromusculares/uso terapêutico , Estudos Prospectivos , Paralisia Cerebral/patologia , Resultado do Tratamento , Músculo Esquelético/patologia , Espasticidade Muscular/tratamento farmacológico , Espasticidade Muscular/etiologia
4.
Clin Biomech (Bristol, Avon) ; 102: 105871, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36701840

RESUMO

BACKGROUND: Previous study showed the triceps surae exhibits spring-like behavior about the ankle during walking in children with cerebral palsy. Thus, the work generated by the triceps surae is diminished relative to typically developing children. This study investigated whether the quadriceps offset the lack of triceps surae work production in children with cerebral palsy who walk in crouch. METHODS: Seven children with cerebral palsy (8-16 yrs) and 14 typically developing controls (8-17 yrs) walked overground at their preferred speed in a motion analysis laboratory. Shear wave tensiometers were used to track patellar and Achilles tendon loading throughout the gait cycle. Tendon force measures were coupled with muscle-tendon kinematic estimates to characterize the net work generated by the quadriceps and triceps surae about the knee and ankle, respectively. FINDINGS: Children with cerebral palsy generated significantly less triceps surae work when compared to controls (P < 0.001). The reverse was true at the knee. Children with cerebral palsy generated positive net work from the quadriceps about the knee, which exceeded the net quadriceps work generated by controls (P = 0.028). INTERPRETATION: There was a marked difference in functional behavior of the triceps surae and quadriceps in children with cerebral palsy who walk in crouch. In particular, the triceps surae of children with cerebral palsy exhibited spring-like behavior about the ankle while the quadriceps exhibited more motor-like behavior about the knee. This redistribution in work could partly be associated with the elevated energetic cost of walking in children with cerebral palsy and is relevant to consider when planning treatments to correct crouch gait.


Assuntos
Tendão do Calcâneo , Paralisia Cerebral , Humanos , Criança , Fenômenos Biomecânicos , Articulação do Joelho , Marcha , Músculo Quadríceps , Músculo Esquelético
5.
Gait Posture ; 100: 126-131, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36521256

RESUMO

BACKGROUND: Assessments of lower limb torsion are ubiquitous in clinical gait analysis practice as pathologic lower limb rotational deformity may contribute to gait abnormalities, anterior knee pain, as well as other debilitating conditions. Understandably, the overall utility of any torsional assessment is dependent on the measurement method's intrinsic accuracy, precision, and robustness to clinical interference factors. Recently, biplanar radiography (BPR) measurements of torsion have been shown to be both accurate and precise, but the robustness of BPR to potential interference factors is unknown. RESEARCH QUESTION: How robust are BPR lower limb torsional assessments to six potential interference factors: amount of torsion, skeletal maturity, radiograph quality, prior osteotomy, presence of implants, and observer training background and experience? METHODS: In this retrospective cohort study, four observers of diverse backgrounds and experience generated digital 3D reconstructions of 44 lower limbs using BPR images obtained during standard of care visits (age range 7-35 years). From each reconstruction, four lower limb torsional parameters were computed: femoral torsion, femorotibial rotation, tibial torsion, and transmalleolar axis equivalent. The mean absolute deviation (MAD) of each torsional parameter - calculated across the four observers - was used as the measure of reliability and tested against all interference factors. RESULTS: Results demonstrated that the average MAD was 2.1 degrees for femoral torsion, 3.0 degrees for transmalleolar axis equivalent, 3.8 degrees for femorotibial rotation, and 4.7 degrees for tibial torsion. None of the six potential interference factors were found to systematically influence BPR reliability across all four torsional parameters. Of the factors found to statistically influence one or more torsional parameter, none affected MAD values to a clinically meaningful extent. SIGNIFICANCE: In addition to being accurate and precise, BPR appears to be robust to several clinical factors relevant to children and young adults with or at risk for pathological lower limb torsion.


Assuntos
Fêmur , Tíbia , Criança , Adulto Jovem , Humanos , Adolescente , Adulto , Tíbia/cirurgia , Fêmur/cirurgia , Estudos Retrospectivos , Reprodutibilidade dos Testes , Imageamento Tridimensional/métodos , Extremidade Inferior , Radiografia , Anormalidade Torcional
6.
J Child Orthop ; 16(6): 442-453, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36483640

RESUMO

Purpose: In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement. Method: A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022. Results: There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates. Conclusion: The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research. Level of evidence: level V.

7.
J Child Orthop ; 16(2): 111-120, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35620124

RESUMO

Purpose: The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results: Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment. Conclusion: The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy. Level of Evidence: V.

8.
Gait Posture ; 96: 29-34, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35567894

RESUMO

BACKGROUND: The sagittal plane alignment of ankle-foot orthoses (AFO) and AFO footwear combinations (AFO-FC) has been shown to influence gait outcomes. As such, clinicians often target a particular alignment during the fabricating and fitting of an AFO to maximize outcomes. RESEARCH QUESTION: How does the alignment of an AFO change during the fabrication and fitting process with respect to the intended, benchmark sagittal plane alignment identified by the consulting orthotist? STUDY DESIGN: Prospective METHODS: The assessment of AFO alignment was performed using a convenience sample of 125 custom molded AFOs from 68 individuals fabricated at our center (57 bilateral AFOs, 11 unilateral AFOs). The alignment of each AFO was measured at 5 distinct steps during the fabrication and fitting process using a recently validated method to measure AFO neutral angle using differential inclinometers. RESULTS: Prior to fabrication, the intended, benchmark alignment set by the consulting orthotist was 90 degrees for 92% of AFOs, was between 1 and 7 degrees of dorsiflexion for 7% of AFOs and was 5 degrees of plantarflexion for 1% of AFOs. Repeated measures ANOVA showed that AFO alignment changed between all fabrication and fitting steps. Overall, paired t-tests confirmed that AFO alignment was consistently 2-5 degrees more dorsiflexed than the benchmark alignment. Prior to fitting shoes, 55% of fabricated AFOs measured more than 2 degrees from the benchmark alignment. After fitting shoes, nearly 87% of AFO-FCs were more than 2 degrees from the benchmark alignment. SIGNIFICANCE: The finding of systematic dorsiflexion bias and changes in AFO alignment throughout the fabrication and fitting process indicates the need to improve AFO fabrication precision. The neutral angle measurement methodology - using differential inclinometers - provides a means to improve this precision by enabling orthotists to precisely quantify and make appropriate adjustments to AFO alignment throughout the entire fabrication and fitting process.


Assuntos
Órtoses do Pé , Tornozelo , Articulação do Tornozelo , Fenômenos Biomecânicos , Marcha , Humanos , Amplitude de Movimento Articular
9.
Paediatr Neonatal Pain ; 4(1): 44-52, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-35546914

RESUMO

While children with cerebral palsy (CP) may undergo 8-22 orthopedic surgeries in their lifetime, little is known about the associated pain. We aimed to assess the pain presence before and one year after lower extremity orthopedic surgery, predictors of pain presence at follow-up, and the association between pain and orthopedic outcomes related to surgery. This retrospective study included 86 children with CP (M age = 10.0 years, SD = 3.2; range = 4.1-17.3 years, Gross Motor Functional Classification System (GMFCS) level I-III) who underwent orthopedic surgery and had completed questionnaires at gait analyses before (M = 2.7 months; range = 0.0-5.7) and after surgery (M = 11.8 months; range = 9.0-14.9). Pain presence, location, and Pediatric Outcomes Data Collection Instrument (PODCI) scores were documented before and after surgery at gait analyses. Pain prevalence was 60% at baseline and 56% at follow-up. Significant predictors of pain presence at follow-up included (1) pain presence at baseline (range of odds ratios [OR] across any/all locations = 3.22 to 15.54), (2) older age (range of OR for any pain, back, knee, and foot pain = 1.24-1.26), (3) female sex (decreased OR for males for ankle pain = 0.12), (4) having hip surgery (decreased OR for foot pain = 0.20), and (5) lower GMFCS level (OR for foot pain = 0.41). Changes in PODCI Sports and Physical Function scores were associated with changes in hip and knee pain (P < .03); PODCI scores worsened for patients who had pain at both time points and improved for patients who had pain at baseline but not follow-up. Pain was present for over half of the participants before and after orthopedic surgery. Pain presence at follow-up was predicted by pain presence at baseline. Pain and functional outcomes were correlated at follow-up. Prospective studies examining perioperative pain experience and factors predicting pain outcomes are warranted.

10.
J Child Orthop ; 16(1): 55-64, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35615393

RESUMO

Purpose: There is marked variation in indications and techniques for hamstring surgery in children with cerebral palsy. There is particular uncertainty regarding the indications for hamstring transfer compared to traditional hamstring lengthening. The purpose of this study was for an international panel of experts to use the Delphi method to establish consensus indications for hamstring surgery in ambulatory children with cerebral palsy. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with statements regarding hamstring surgery, including surgical indications and techniques, post-operative care, and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither of these thresholds was reached. Results: The panel reached consensus or general agreement for 38 (84%) of 45 statements regarding hamstring surgery. The panel noted the importance of assessing pelvic tilt during gait when considering hamstring surgery, and also that lateral hamstring lengthening is rarely needed, particularly at the index surgery. They noted that repeat hamstring lengthening often has poor outcomes. The panel was divided regarding hamstring transfer surgery, with only half performing such surgery. Conclusion: The results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy. Level of evidence: level V.

11.
J Child Orthop ; 16(1): 65-74, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35615394

RESUMO

Purpose: The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. Methods: The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest 2 ratings. Results: For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and smaller (<30 degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture. Conclusion: Anterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery. Level of evidence: V.

12.
J Orthop Res ; 40(12): 2763-2770, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-35212418

RESUMO

The purpose of this study was to quantitatively assess Achilles tendon mechanical behavior during gait in children with cerebral palsy (CP). We used a newly designed noninvasive sensor to measure Achilles tendon force in 11 children with CP (4F, 8-16 years old) and 15 typically developing children (controls) (9F, 8-17 years old) during overground walking. Mechanical work loop plots (force-displacement plots) were generated by combining muscle-tendon kinetics, kinematics, and EMG activity to evaluate the Achilles tendon work generated about the ankle. Work loop patterns in children with CP were substantially different than those seen in controls. Notably, children with CP showed significantly diminished work production at their preferred speed compared to controls at their preferred speed and slower speeds. Despite testing a heterogeneous population of children with CP, we observed a homogenous spring-like muscle-tendon behavior in these participants. This is in contrast with control participants who used their plantar flexors like a motor during gait. Statement of Clinical Significance: These data demonstrate the potential for using skin-mounted sensors to objectively evaluate muscle contributions to work production in pathological gait.


Assuntos
Tendão do Calcâneo , Paralisia Cerebral , Criança , Humanos , Adolescente , Paralisia Cerebral/complicações , Ultrassonografia , Marcha/fisiologia , Músculo Esquelético/fisiologia , Tendão do Calcâneo/fisiologia , Fenômenos Biomecânicos
13.
Dev Med Child Neurol ; 64(5): 561-568, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-34755903

RESUMO

AIM: To understand the long-term effects of comprehensive spasticity treatment, including selective dorsal rhizotomy (SDR), on individuals with spastic cerebral palsy. METHOD: This was a pre-registered, multicenter, retrospectively matched cohort study. Children were matched on age range and spasticity at baseline. Children at one center underwent spasticity treatment including SDR (Yes-SDR, n=35) and antispastic injections. Children at two other centers had no SDR (No-SDR, n=40 total) and limited antispastic injections. All underwent subsequent orthopedic treatment. Participants returned for comprehensive long-term assessment (age ≥21y, follow-up ≥10y). Assessment included spasticity, contracture, bony alignment, strength, gait, walking energy, function, pain, stiffness, participation, and quality of life. RESULTS: Spasticity was effectively reduced at long-term assessment in the Yes-SDR group and was unchanged in the No-SDR group. There were no meaningful differences between the groups in any measure except the Gait Deviation Index (Yes-SDR + 11 vs No-SDR + 5) and walking speed (Yes-SDR unchanged, No-SDR declined 25%). The Yes-SDR group underwent more subsequent orthopedic surgery (11.9 vs 9.7 per individual) and antispastic injections to the lower limbs (14.4 vs <3, by design). INTERPRETATION: Untreated spasticity does not cause meaningful impairments in young adulthood at the level of pathophysiology, function, or quality of life.


Assuntos
Paralisia Cerebral , Adulto , Paralisia Cerebral/complicações , Paralisia Cerebral/cirurgia , Criança , Estudos de Coortes , Humanos , Espasticidade Muscular/tratamento farmacológico , Espasticidade Muscular/etiologia , Espasticidade Muscular/cirurgia , Qualidade de Vida , Estudos Retrospectivos , Rizotomia/efeitos adversos , Resultado do Tratamento , Adulto Jovem
15.
Gait Posture ; 90: 86-91, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34418869

RESUMO

BACKGROUND: Changes in gait due to an ankle foot orthosis (AFO) have been shown to be impacted by the sagittal plane alignment of the AFO, but there is variability in practice and lack of consensus as to how this alignment should be measured. The neutral angle is a measure of AFO alignment that has the potential to be used by various specialties that prescribe, provide, and analyze AFOs. Currently, a lack of validated measurement methods prevents the neutral angle from being used in various clinical settings. Two experimental neutral angle measurement methods are proposed to address this shortcoming: a portable low-cost method for use during AFO fabrication and fitting, and a laboratory-based method for use during dynamic three-dimensional gait analysis (3DGA). RESEARCH QUESTION: What is the concurrent validity of the two experimental neutral angle measurement methods against the gold standard? METHODS: The gold standard neutral angle measurement (NAGOLD) was prospectively collected during a static 3DGA trial for 19 pediatric AFOs from 10 individuals. While NAGOLD was being collected, the neutral angle was simultaneously measured using digital differential inclinometers (NAINCL). Within the same 3DGA session, the neutral angle was also measured during the swing phase of gait (NASWING). The NAINCL and NASWING measurements were compared to NAGOLD using repeated measures ANOVA, ICC, and bootstrapped errors-in-variables regressions. RESULTS: Repeated measures ANOVA indicated no differences between measurement methods (p = 0.43) and ICC analysis indicated good absolute agreement (ICC(A-1) = 0.85). Mean absolute deviations between the NAINCL and NASWING with NAGOLD measurements were 2.4 ° and 1.9 °, with standard deviations of 2.9 ° and 2.7 °, respectively. Maximum observed differences were less than 7 °. The NAINCL and NASWING methods explained 74 % and 81 % of the variance in NAGOLD, respectively. SIGNIFICANCE: The concurrent validity of two new neutral angle measurement methods provides alternative means to assess AFO alignment in the clinic.


Assuntos
Órtoses do Pé , Tornozelo , Articulação do Tornozelo , Fenômenos Biomecânicos , Criança , Marcha , Humanos
16.
J Child Orthop ; 15(3): 270-278, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-34211604

RESUMO

PURPOSE: The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method. METHODS: The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. RESULTS: Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade. CONCLUSION: This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP. LEVEL OF EVIDENCE: V.

17.
Gait Posture ; 87: 184-191, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33945965

RESUMO

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.


Assuntos
Paralisia Cerebral , Fêmur , Transtornos Neurológicos da Marcha , Acidentes por Quedas , Adulto , Paralisia Cerebral/complicações , Medo , Fêmur/cirurgia , Marcha , Transtornos Neurológicos da Marcha/etiologia , Humanos , Osteotomia , Estudos Retrospectivos , Resultado do Tratamento
18.
Dev Med Child Neurol ; 63(3): 336-342, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33103255

RESUMO

AIM: To compare short-term outcomes between conus medullaris (conus) and cauda equina (cauda) selective dorsal rhizotomy (SDR) techniques in children with spastic cerebral palsy. METHOD: This was a retrospective review of SDR at a single center from 2013 to 2017. Gait and functional outcome measures were assessed at no more than 18 months pre-SDR (baseline) and 8 to 36 months post-SDR (follow-up). Transient complications during inpatient stay were quantified. RESULTS: In total, 21 and 59 children underwent conus and cauda SDR respectively. Ashworth Scale scores were nearly normalized at follow-up. Most physical examination and functional measures exhibited similar baseline to follow-up responses for both groups. From baseline to follow-up, sagittal plane knee kinematics for both groups significantly improved (p<0.01) by 11° at initial contact, 9° to 10° in stance phase, and 4° in swing phase. Sagittal plane ankle kinematics improved more for the cauda group than the conus group in both stance phase (10° vs 2°, p<0.01) and swing phase (13° vs 3°, p<0.01). Post-surgical complications were similar between groups. INTERPRETATION: Conus and cauda SDR techniques resulted in similar short-term outcomes except in ankle kinematics at follow-up. The cauda group exhibited a large improvement towards dorsiflexion, while there was residual equinus in the conus group despite Ashworth Scale scores normalizing equally in both groups. WHAT THIS PAPER ADDS: Conus and cauda selective dorsal rhizotomy (SDR) resulted in mostly similar short-term gait and functional outcomes. Conus SDR resulted in residual equinus dynamically, despite normalized spasticity measures. Post-surgical complications were mostly similar between SDR techniques.


Assuntos
Cauda Equina/cirurgia , Paralisia Cerebral/cirurgia , Rizotomia/métodos , Medula Espinal/cirurgia , Fenômenos Biomecânicos/fisiologia , Paralisia Cerebral/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Resultado do Tratamento
19.
J Child Orthop ; 14(5): 405-414, 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-33204348

RESUMO

PURPOSE: Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. METHODS: A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. RESULTS: Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). CONCLUSIONS: The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. LEVEL OF EVIDENCE: V.

20.
J Pediatr Orthop ; 40(6): e498-e503, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32501922

RESUMO

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.


Assuntos
Paralisia Cerebral/fisiopatologia , Análise da Marcha/tendências , Transtornos Neurológicos da Marcha/reabilitação , Adolescente , Instituições de Assistência Ambulatorial , Criança , Feminino , Marcha/fisiologia , Humanos , Joelho/fisiopatologia , Extremidade Inferior/fisiopatologia , Masculino , Procedimentos Ortopédicos , Ortopedia , Avaliação de Resultados em Cuidados de Saúde , Modalidades de Fisioterapia
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