Outcome tools used for ambulatory children with cerebral palsy: responsiveness and minimum clinically important differences.

This prospective longitudinal multicenter study of ambulatory children with cerebral palsy (CP) examined changes in outcome tool score over time, tool responsiveness, and used a systematic method for defining minimum clinically important differences (MCIDs). Three hundred and eighty-one participants with CP (Gross Motor Function Classification System [GMFCS] Levels I-III; age range 4-18y, mean age 11y [SD 4y 4mo]; 265 diplegia, 116 hemiplegia; 230 males, 151 females). At baseline and follow-up at least 1 year later, Functional Assessment Questionnaire, Gross Motor Function Measure, Pediatric Quality of Life Inventory, Pediatric Outcomes Data Collection Instrument, Pediatric Functional Independence Measure, temporal-spatial gait parameters, and oxygen cost were collected. Adjusted standardized response means determined tool responsiveness for nonsurgical (n=292) and surgical (n=87) groups at GMFCS Levels I to III. Most scores reaching medium or large effect sizes were for GMFCS Level III. Nonsurgical group change scores were used to calculate MCID thresholds for ambulatory children with CP. These values were verified by examining participants who changed GMFCS levels. Tools measuring function were responsive when a change large enough to cause a change in GMFCS level occurred. MCID thresholds assess change in study populations over time, and serve as the basis for designing prospective intervention studies.

Gross Motor Function Classification System and outcome tools for assessing ambulatory cerebral palsy: a multicenter study.

The relationships between different levels of severity of ambulatory cerebral palsy, defined by the Gross Motor Function Classification System (GMFCS), and several pediatric outcome instruments were examined. Data from the Gross Motor Function Measure (GMFM), Pediatric Orthopaedic Data Collection Instrument (PODCI), temporal-spatial gait parameters, and oxygen cost were collected from six sites. The sample size for each assessment tool ranged from 226 to 1047 participants. There were significant differences among GMFCS levels I, II, and III for many of the outcome tools assessed in this study. Strong correlations were seen between GMFCS level and each of the GMFM sections D and E scores, the PODCI measures of Transfer and Mobility, and Sports and Physical Function, Gait Velocity, and Oxygen Cost. Correlations among tools demonstrated that the GMFM sections D and E scores correlated with the largest number of other tools. Logistic regression showed GMFM section E score to be a significant predictor of GMFCS level. GMFM section E score can be used to predict GMFCS level relatively accurately (76.6%). Study data indicate that the assessed outcome tools can distinguish between children with different GMFCS levels. This study establishes justification for using the GMFCS as a classification system in clinical studies.

Nonselective partial dorsal rhizotomy: a clinical experience with 1-year follow-Up.

The ability to perform a 'selective' dorsal rhizotomy has been challenged. EMG responses are inconsistent and often do not represent reflex responses. We perform nonselective partial dorsal rhizotomy (NSPDR) when reflex response is not evident. Ten children undergoing primarily NSPDR were evaluated preoperatively and postoperatively with the Modified Ashworth Scale, gait lab analyses gross motor function measure and the NSPDR was performed by nonselectively sectioning 50-75% of the dorsal roots not demonstrating a reflex response. Standard selective rhizotomy was performed in the remainder. Only 17 of 106 (16%) dorsal roots demonstrated reflex responses. The results reported in this study demonstrate a benefit to patients undergoing primarily NSPDR which is similar to that reported for patients in whom a selective procedure was intended.

Foot pressure and radiographic outcome measures of lateral column lengthening for pes planovalgus deformity.

The purpose of this study was to establish and characterize the relationship between foot pressure analysis and radiographic measurements in children that underwent a lateral column lengthening procedure for pes planovalgus (PPV). Eight children (13 feet) with PPV that had failed non-operative treatment underwent a lateral column lengthening procedure. Pre-operative and post-operative standing AP and lateral radiographs and foot pressure data were obtained. The relationships between the radiographic and foot pressure measurements were investigated. The findings from this study demonstrated strong relationships between these parameters. The relationships seen in this study indicate that the addition of foot pressure analysis provides objective documentation of the improvement in foot pressure distribution following a lateral column lengthening. Also, there is a direct, positive relationship between the key radiographic and foot pressure measurements.

Age-related kinetic changes in normal pediatrics.

Kinetic data have become an important adjunct to kinematic and electromyography data in the interpretation of gait data and in the clinical decision making for children with pathologic gait patterns. A normative database is essential for comparison with the patterns of walking in children with gait abnormalities. Gait analyses of 23 able-bodied children (ages 4-10 years) were compared with those of five able-bodied adults. The patterns and amplitudes of the normal able-bodied children's kinetics showed five significant differences from those of the adults: (a) diminished hip-abduction moment, (b) diminished plantar-flexion moment, (c) diminished A2 power generation, (d) diminished knee-extensor moment, and (e) pattern of knee-power data. The data indicated a progression toward the adult normals because differences were more significant in the youngest group (4- to 5-year-olds) than in the older groups (6- to 7- and 8- to 10-year-olds).

The effect of osteotomy on bowing and height in children with X-linked hypophosphatemia.

The clinical records of 40 patients with X-linked hypophosphatemia who were treated and followed for at least 36 months were examined retrospectively. The patients were divided into those treated with medication only (group A) and those treated with medication and surgery (group B). At follow-up, significant improvement in bowing angles was noted for group B patients compared with those treated medically. There was, however, no improvement in the height of children in group A, and there was a significant decrease in height among the children treated surgically (group B). Neither height nor bowing angles of femurs or tibias at presentation predicted the need for future osteotomies. However, children who eventually needed surgery were found to be obese at presentation significantly more frequently than children who did not require osteotomy.

Brucella osteomyelitis of a closed femur fracture.

A 19-year-old man incurred a closed femoral fracture complicated by hematogenous dissemination of Brucella osteomyelitis. Repeated limited incision and drainage were ineffective in eradicating infection. Wide debridement, delayed wound closure, and vigorous antimicrobial therapy with streptomycin and tetracycline, along with cephalosporin for secondary staphylococcal infection, were necessary measures before the infection was eradicated. A constant awareness of brucella musculoskeletal infection is advisable when caring for patients frequently exposed to all kinds of livestock, including domesticated and wild animals.

Electromagnetic stimulation of canine bone grafts.

We evaluated the use of pulsed electromagnetic-field stimulation to affect the rate of healing or incorporation of segmental autogenous cortical bone grafts in the dog in vivo. This non-invasive method of electrical stimulation has been implicated in increasing bone osteogenesis or augmentation of the repair process in the canine fibular osteotomy. We utilized two-month and six-month stimulation protocols. At six months, all of the animals were evaluated biomechanically using rapid-loading torsional testing. Histological evaluation using tetracycline labeling was used to evaluate cumulative new-bone formation and porosity, while graft-host time to union was evaluated roentgenographically every two weeks. Recent reports have implied that particular pulse configurations might be effective in improving graft revascularization and incorporation. The results of our investigation indicated that there was no significant effect on the biomechanical strength, histological presentation, or time to union with either two months or six months of pulsed electromagnetic-field stimulation using the particular waveform described.

Proximal femoral osteotomy in cerebral palsy.

The purpose of this study was to examine the results of the proximal femoral osteotomy for the management of hip deformity in 32 children, aged 4 to 15 years. Twenty-two bilateral and ten unilateral procedures were performed. The indications for surgery were subluxation in 16, dislocation in two, and intoeing and femoral anteversion in 14. The average follow-up was two years and 11 months. CE angle of Wiberg, acetabular index and neck shaft angle were evaluated. The average time to regain preoperative ambulatory status was six months with intensive physical therapy. In osteotomies performed for subluxation, dislocation did not occur; roentgenographic indices showed variability in the degree of subluxation. Osteotomy performed in children older than 8 years of age produced no evidence of acetabular remodeling. THere was no recurrence with osteotomies for dislocation. In those patients with internal rotation gait, improvement resulted. Complications were few and minor. Hip dislocation in children with progressive subluxation, in spite of previous soft-tissue releases, is preventable by proximal femoral osteotomy. The inability of the roentgenographic indices to quantitate the increased stability indicates the procedure's major effect is to realign muscle forces about the hip. Treatment of the intoeing gait produced improvement of rotational deformity.

Hormonal effects on the morphology of bone defect healing.

Standard defects were produced in the radii of hypophysectomized immature rats. All animals were injected with Methimazole, and grouped according to hormone supplementation, growth hormone (GH), thyroxine (T4), the combination, or no hormones. Lack of GH and T4 caused a retardation of defect healing and callus formation but not a total cessation. The presence of GH in the hypophysectomized animal caused a larger callus due to greatly increased chondrogenesis throughout the 6 week study. Thyroxine in the hypophysectomized animal increased bone metabolism and caused more cartilage and bone formation than seen in the hormone deficient group, but not as great as that seen in the GH injected animals or the T4 and GH injected animals. Growth hormone allowed greater chondrogenesis; T4 enhanced maturation to bone. The combination allowed the development of a callus similar in stage and proportion of tissue to that observed in the pituitary intact animals. The influences of GH and T4 on the healing of a bone defect in the immature rat correspond to influences of GH and T4 on growing epiphyseal plate.