Ambulatory Children Research Articles

Independently ambulatory children with spina bifida experience near-typical knee and ankle joint moments and forces during walking

BackgroundSpina bifida, a neurological defect, can result in lower-limb muscle weakness. Altered ambulation and reduced musculoskeletal loading can yield decreased bone strength in individuals with spina bifida, yet individuals who remain ambulatory can exhibit normal bone outcomes. Research questionDuring walking, how do lower-limb joint kinematics and moments and tibial forces in independently ambulatory children with spina bifida differ from those of children with typical development? MethodsWe retrospectively analyzed data from 16 independently ambulatory children with spina bifida and 16 children with typical development and confirmed that tibial bone strength was similar between the two groups. Plantar flexor muscle strength was measured by manual muscle testing, and 14 of the children with spina bifida wore activity monitors for an average of 5 days. We estimated tibial forces at the knee and ankle using motion capture data and musculoskeletal simulations. We used Statistical Parametric Mapping t-tests to compare lower-limb joint kinematic and kinetic waveforms between the groups with spina bifida and typical development. Within the group with spina bifida, we examined relationships between plantar flexor muscle strength and peak tibial forces by calculating Spearman correlations. ResultsActivity monitors from the children with spina bifida reported typical daily steps (9656 [SD 3095]). Despite slower walking speeds (p = 0.004) and altered lower-body kinematics (p < 0.001), children with spina bifida had knee and ankle joint moments and forces similar to those of children with typical development, with no detectable differences during stance. Plantar flexor muscle weakness was associated with increased compressive knee force (p = 0.002) and shear ankle force (p = 0.009). SignificanceHigh-functioning, independently ambulatory children with spina bifida exhibited near-typical tibial bone strength and near-typical step counts and tibial load magnitudes. Our results suggest that the tibial forces in this group are of sufficient magnitudes to support the development of normal tibial bone strength.

Effects of distraction-based distal fixation on pelvic parameter development in early onset scoliosis.

Prior studies have suggested that distraction-based treatment for early onset scoliosis (EOS) may impede the natural development of the sagittal spinal alignment and pelvic parameters. However, to date no study has investigated the effect of distal fixation on pelvic development. Ambulatory children with EOS undergoing index distraction-based treatment with distal fixation below T11 were retrospectively reviewed. Patients with distal fixation to the pelvis were identified and compared to children with Spine-based fixation at T12-L5. Radiographic measurements were performed for coronal and sagittal alignment in addition to pelvic parameters (pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) and compared at initial presentation, first erect radiograph, and at 2years following instrumentation. 33 ambulatory children were identified with a minimum of 2-year follow-up (25 female, average 6.59 ± 2.6years), with 33% (N = 11) instrumented to the pelvis (54.4% female, average 4.42 ± 2.2years, initial Cobb 76.1°). Children in the pelvis cohort were significantly younger at treatment initiation (P < 0.001). There was no significant difference in PI at the study time periods, however, there was a significant change in PI between presentation and 2-year follow-up with the pelvic fixation demonstrating a mean 12.3° decrease in PI vs a 3.8° increase in the spine-based cohort (P = 0.027). Distal fixation to the pelvis in ambulatory children with EOS treated with growth-friendly instrumentation was associated with a mean decrease in PI of 12.3° that developed over the 2-year treatment duration. Further research is needed to investigate the long-term implications of these findings on pelvic and spinal development.

P.18 Comparison of the performance of the upper limb module in children with Becker muscular dystrophy, Duchenne muscular dystrophy and healthy controls

Becker muscular dystrophy (BMD) is an X-linked recessive disorder, a type of dystrophinopathy. BMD is a milder form of Duchenne Muscular Dystrophy (DMD). Both diseases are characterised by progressing muscle weakness. Upper limb function is not routinely assessed in ambulant children in these conditions; however, it can be of great importance. It is hoped that advances in gene therapy will result in boys with DMD having significant improvements and therefore having a presentation trajectory more like boys with BMD. It is therefore of great importance both clinically and in research trials to have validated outcome measures to be able to successfully monitor improvements and plateaus in this cohort. The Performance of Upper Limb Module (PUL 2.0) is a validated outcome measure for DMD predominantly used to assess change in upper limb function in non-ambulant boys over time. PUL 2.0 data was collected for 63 children in total. Twenty-one of these children with BMD were compared to 21 age-matched children with DMD and 21 healthy controls. A correlation analysis will be used to explore the differences, taking weight of the boys into account. Functional scores (using the Hammersmith functional motor score) for the boys with BMD will be explored and compared to the PUL scores as well as differences in the height of the boys. The initial analysis demonstrates a ceiling effect for the PUL in BMD, with 18/21 achieving full marks, with them more closely aligning with healthy controls than boys with DMD. In future clinical trials for boys with DMD including outcome measures without a ceiling effect will allow all improvements to be captured. It is important to establish if boys with BMD have functional difficulties that the PUL is not capturing. This study is a part of a larger team approach to understanding more about outcome measures in BMD.

From the original SARS-CoV-2 strain to the Omicron variant: Predictors of COVID-19 in ambulatory symptomatic children

ObjectivesTo determine the predictors of a positive SARS-CoV-2 test in a pediatric ambulatory setting. Patients and methodsWe performed a cross-sectional prospective study (November 2020-February 2022) of 93 ambulatory settings in France. We included symptomatic children < 15 years old tested for SARS-CoV-2. For each period corresponding to the spread of the original strain and its variants (period 1: original strain; period 2: Alpha, period 3: Delta; period 4: Omicron), we used a multivariate analysis to estimate adjusted odds ratios (aORs) associated with COVID-19 among age, signs, symptoms or contact, and 95 % confidence intervals (95CIs). ResultsOf 5,336 children, 13.9 % (95CI 13.0–14.8) had a positive test. During the first three periods, the positivity rate ranged from 5.6 % (95CI 4.6–6.7) to 12.6 % (95CI 10.8–14.6). The main factors associated with a positive test were contact with an infected adult at home or outside the home (aOR 11.5 [95CI 4.9–26.9] to 38.9 [95CI 19.3–78.7]) or an infected household child (aOR 15.0 [95CI 4.8–47.1] to 28.4 [95CI 8.7–92.6]). By contrast, during period 4, aORs for these predictors were substantially lower (2.3 [95CI 1.1–4.5] to 5.5 [95CI 3.2–7.7]), but the positivity rate was 45.7 % (95CI 42.3–49.2). ConclusionsIn pediatric ambulatory settings, before the Omicron period, the main predictor of a positive test was contact with an infected person. During the Omicron period, the odds of these predictors were substantially lower while the positivity rate was higher. An accurate diagnostic strategy should only rely on testing and not on age, signs, symptoms or contact.

Measuring advanced motor skills in children with cerebral palsy: development of normative data and percentile curves for the Challenge-20 assessment.

The Challenge-20 is an assessment of advanced motor skills of children with cerebral palsy. The purpose of this study was to develop age-related norms and percentile curves for the Challenge-20 with typically developing children ( n = 150, 7 through 11 years), and compare Challenge-20 scores of independently ambulatory children with CP, Gross Motor Function Classification System level I ( n = 135) and II ( n = 56) to these age norms. Younger TD children (7 years) scored lowest, and older children (11 years) scored highest on the Challenge-20 , showing similar developmental trajectories. Challenge-20 scores of 15% of children in GMFCS level I were situated above the lower 2.5th percentile curve of the typically developing children's Challenge-20 growth curve, that is, overlapping into the typically developing child zone. The Challenge-20 is sensitive to the progression of advanced gross motor skills in typically developing children. Children with cerebral palsy, GMFCS I follow similar, albeit lower, Challenge score trajectory to that of typically developing children, and in some cases come close to lower level abilities of typically developing children. The reference values with typically developing children extend the Challenge-20 's utility when assessing advanced gross motor skill of independently ambulatory children with cerebral palsy for physiotherapy intervention and physical activity planning and open the door to re-thinking more about advanced gross motor interventions for children with cerebral palsy in GMFCS levels I and II given their potential to progress along the developmental trajectory.

The Impact of "Fear of Falling" on Physical Performance, Balance, and Ambulation in Duchenne Muscular Dystrophy.

The aim of this study was to investigate falls and the fear of falling (FOF) in children with Duchenne muscular dystrophy (DMD) and to determine the relationships between the FOF and physical performance, balance, and ambulation. Thirty-eight ambulatory children with DMD were included in the study. The functional level, falling history, FOF, physical performance, balance, and ambulation were assessed by using Brooke Lower Extremity Functional Classification, History of Falls Questionnaire, Pediatric Fear of Falling Questionnaire (Ped-FOF), timed performance tests, Timed "Up and Go" (TUG) test, and North Star Ambulatory Assessment (NSAA), respectively. Of the 38 children (mean age: 9.00 ± 2.03 years) 97.4% had a history of serious fall last year and 62.2% were injured due to this fall. The Ped-FOF score was 13.79 ± 7.20. Weak to moderate relations were determined between Ped-FOF and functional level (r = 0.33), frequency of falls (r = 0.41), duration of climbing 4-steps (r = 0.38), TUG (r = 0.36), and NSAA (r = -0.32) (p < 0.05). Ambulatory children with better performance scores had lower levels of FOF despite their history of serious falls and injuries. FOF tends to increase as the symptoms of the disease progresses. Investigating the history of falls and FOF from the earliest period will guide to take precautions and make necessary interventions on time in treatment programs.

Pilates-based exercises for gait and balance in ambulant children with cerebral palsy: feasibility and clinical outcomes of a randomised controlled trial

Purpose To determine if Pilates-based exercise classes could be feasible and effective in changing gait kinematics and balance in ambulant children with Cerebral Palsy (CP). Materials and Methods A single-blind multi-centre randomised controlled trial compared a four-week, twice-weekly Pilates-based exercise class to a usual exercise control, for ambulant children with CP. Clinical outcome measures were three-dimensional trunk and lower limb kinematics during walking on level ground, uneven ground and crossing an obstacle; and clinical balance measures. Feasibility outcomes were adherence and enjoyment. Results Forty-six children (29 male, mean age 10 years 8 months (range 7–17 years), 23 per group) participated. After the four-week intervention, there were no significant between-group differences in trunk or lower limb gait kinematics. Differences were detected in Berg Balance Scale (1.38 points, 95% CI 0.58–2.18) and Functional Walking Test (1.40 points, 95% CI 0.58–2.22), but they were less than the minimum clinically important difference and therefore clinically insignificant. Median class attendance was 5/8 classes. Conclusion Pilates-based exercises did not change lower limb or trunk kinematics during walking in children with CP and had a clinically insignificant impact on balance. Lower than anticipated adherence prompts consideration of more flexible delivery of future interventions. Implications for Rehabilitation Ambulant children with CP can experience impairment of trunk control, negatively impacting balance and gait. In this study, Pilates-based exercise classes did not change kinematics of the trunk or lower limbs during walking and led to negligible improvement in functional balance. Children did not manage to do their Home Exercise Programme, indicating that Pilates-based exercise should be delivered within supervised practice. Children missed on average one in three classes due to unforeseen circumstances, so this should be anticipated when planning group classes.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis.

BACKGROUNDThe effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient’s ability to mobilize after the fusion is not well understood. AIMTo see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability.METHODSA retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room.RESULTSThe ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967).CONCLUSIONSpinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.

Promoting 24-hour movement guideline adherence in ambulatory children with cerebral palsy.

Promoting 24-hour movement guideline adherence in ambulatory children with cerebral palsy.

A core outcome set for lower limb orthopaedic surgery for children with cerebral palsy: An international multi-stakeholder consensus study.

To develop a core set of outcome domains to be measured in clinical studies on lower limb orthopaedic surgery for ambulant children with cerebral palsy (CP) that represents the priorities of an international multi-stakeholder group (children, parent/carers, and health professionals). Potential outcome domains were identified through literature review and qualitative interviews with key stakeholders. These were scored in an international two-round Delphi survey, using a 9-point Likert scale. A final consensus meeting with key stakeholders agreed on the most important outcome domains and refined the core outcome set (COS). One hundred and sixty-one health professionals and 36 individuals with CP and their parents/carers rated 21 of 41 outcomes as important in the Delphi survey. The final consensus group agreed 19 outcomes within eight domains to be included in the final COS: pain and fatigue, lower limb structure, motor function, mobility (daily life activities), gait-related outcomes, physical activity, independence, and quality of life. A COS for lower limb orthopaedic surgery for children with CP was developed. Incorporating this in the design of future clinical studies will provide a more holistic assessment of the impact of treatment while allowing meaningful comparisons and future synthesis of results from primary studies. Eight core outcome domains were identified as important to measure in future clinical research. Key stakeholders perceived pain, balance and fall, and independence as very important outcomes. Six contextual factors were identified as essential in surgical decision-making.

Factors determining change in treatment for ambulatory children with pulmonary arterial hypertension: Implications for monitoring.

While care models adapt to the COVID‐19 pandemic with virtual and hybrid visits, clinical factors associated with treatment changes among ambulatory pediatric pulmonary arterial hypertension (PAH) patients are not well characterized. To understand which data critically altered treatment recommendations, we conducted a retrospective review among ambulatory children with Group 1 PAH to determine optimal visit and diagnostic strategies. Changes in management included: unplanned new treatments, dose modifications of vasodilators or diuretics, unscheduled hospitalizations, or changes to activity recommendations, catheterization schedule, or other testing. Factors prompting management changes were classified as symptoms, exam findings, or diagnostic tests. Across 398 ambulatory visits by 48 patients, 38 patients (79%) at 88 visits (22%) required change in management, most commonly in targeted PH medication. Changes were driven by symptoms alone (15%), diagnostic testing alone (47%), exam only (2%), symptoms and exam (2%), combination of testing and symptoms or testing and exam (25%), and other reasons (9%). Patients with World Health Organization functional Class IV (odds ratio [OR] 9.04 vs. Class I, p = 0.014) or Class III (OR 2.08 vs. Class I, p = 0.050) were more likely to undergo change in management. However, among Class I patients, 18% of visits generated changes in management because of test findings. While multiple factors affect management in ambulatory pediatric PH, neither symptoms nor exam was sufficient for identifying patients warranting clinical change in management. Testing accounted for most changes. Thus, in‐person or hybrid surveillance including history, exam, and diagnostic testing remains essential for optimal management of pediatric PAH.

Comparison of Integrated Task Oriented Bodyweight Supported Overground Training with Body-Weight Supported Treadmill Training to Improve Functional Mobility in Children with Spastic Diplegic Cerebral Palsy - A Single Blinded Randomized Control Trial

Functional gait training in cerebral palsy can involve over ground gait training or treadmill-based gait training which incorporates partial body weight support (PBWS) system. Insufficient clinical evidence prevails to recommend the superiority over the other intervention. ICF model has created a paradigm shift in understanding motor learning mechanisms, with the use of repetitive, task-specific movements beneficial to restructuring motor pathways. The primary aim of the study was to compare the effect of integrated task oriented Body Weight Supported overground Training (BWSOGT) against the Body Weight Supported Treadmill Training (BWSTT) and the conventional gait training protocols to improve the functional mobility in Cerebral Palsy. Methods: A Single-blinded, randomised control design. Sixty-children with GMFCS Level of III, IV were recruited in the study with an age ranges between 4 to 14 years (mean age = 9). Participants were randomly assigned into three groups using simple randomisation method with 20 subjects in each group for 8 weeks. The training programme consists of Group A with 40% of body weight supported walker with overhead pulley system which allows multiple degrees of freedom. Body weight- supported treadmill training (Group B) in a closed environment and conventional gait protocol using standard walkers (Group C). Outcome measures: Gross Motor Function Measure dimension-88 (GMFM-88) score. Gait kinematics (Stride length, Step length, Cadence) and 10 meter walk test. Tukey’s Post Hoc for group and time interactions, Krushkal Wallis test for overall significance and Mann Whitney’s U test to compare the significance between the groups. BWSOGT group showed significance over the BWSTT and Control group in GMFM score with p = 0.000 p = 0.002, respectively. Step length of gait parameter remained unchanged in all the three groups. Integrated task oriented BWSOGT might be an effective intervention to improve functional ambulation in children with spastic cerebral palsy due to the usage of a context specific environment and the training protocol.

Gait stability in ambulant children with cerebral palsy during dual tasks.

The aim of this cross-sectional study was to measure the effect of dual tasks on gait stability in ambulant children with cerebral palsy (CP) compared to typically developing (TD) children. The children of the CP (n = 20) and TD groups (n = 20) walked first without a dual task, then while counting forward and finally while alternatively naming fruits and animals (DTf/a). They then completed the same cognitive exercises while sitting comfortably. We calculated the distance between the foot placement estimator (FPE) and the real foot placement in the anterior direction (DFPEAP) and in the mediolateral direction (DFPEML) as a measure of gait stability, in a gait laboratory using an optoelectronic system. Cognitive scores were computed. Comparisons within and between groups were analysed with linear mixed models. The dual task had a significant effect on the CP group in DFPEAP and DFPEML. The CP group was more affected than the TD group during dual task in the DFPEML. Children in both groups showed significant changes in gait stability during dual tasks. The impact of dual task on gait stability is possibly due to the sharing of attention between gait and the cognitive task. All children favoured a 'posture second' strategy during the dual task of alternatively naming animals and fruits. Children with CP increased their mediolateral stability during dual task.

Physical Activity Energy Expenditure Predicts Quality of Life in Ambulatory School-Age Children with Cerebral Palsy.

Background: Participation in physical activities is positively associated with better quality of life in children with cerebral palsy (CP). The objective of this study was to elucidate the relationship between the intensity of habitual physical activity (HPA) measured with an accelerometer and health-related quality of life (HRQOL) in school-age children with CP. Method: A secondary analysis of the cross-sectional data of 46 ambulatory children with CP was conducted. The participants wore an accelerometer for seven days to measure HPA: activity counts (counts/min) and physical activity energy expenditure (PAEE, kcal/kg/day), as well as %moderate-to-vigorous intensity physical activity (%MVPA), %light intensity physical activity (%LPA), and %sedentary physical activity (%SPA) were measured. Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and Child Health Questionnaire Parent Form 50 Questions (CHQ-PF50) were used to measure HRQOL. A Pearson analysis and a hierarchical regression analysis were performed. Results: PAEE significantly predicted the results of the PedsQL(child) physical domain (β = 0.579, p = 0.030), PedsQL(child) emotional domain (β = 0.570, p = 0.037), PedsQL(child) social domain (β = 0.527, p = 0.043), and PedsQL(child) total (β = 0.626, p = 0.017). However, other HPA parameters could not predict any other HRQOL. Conclusions: PAEE could be used as a biomarker in studies on HRQOL and HPA in ambulatory school-age children with CP.

Vitamin D status in children with Cerebral palsy

Background: Cerebral palsy(CP) is presently defined as a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. Low vitamin D levels in children with CP are also associated with decreased muscle strength, balance, muscle pain, paresthesias, and poor muscular coordination. Materials &amp; Method: It is the Prospective observational cross-sectional study. The patients in the study group were of both sexes and aged 6 months to 12 years. All children apart from general tests underwent investigations for serum calcium total {By an automated analyzer}, serum phosphorus {By an automated analyzer}, serum alkaline phosphatase (SAP) levels {By an automated analyzer} and 25 OH vitamin D level {By CLIA (chemi luminescence immunoassay) method}. Results: Total 141 Children who satisfied inclusion and exclusion. Male children were 96 (68%) whereas female were 45(32%).The distribution by the CP type was Quadriplegia 44.0%, Diplegia 34.8%, Hemiplegia 7.1%, Monoplegia 1.4%, Hypotonic 2.1%, Dyskinetic 0.7%, Mixed 0.7%, Evolving CP 9.2%. Ambulatory CP children were 60 (42.5%) and non ambulatory were 81 (57.5%).

Short-term causal effects of common treatments in ambulatory children and young adults with cerebral palsy: three machine learning estimates

Orthopedic and neurological impairments (e.g., muscle contractures, spasticity) are often treated in children and young adults with cerebral palsy (CP). Due to challenges arising from combinatorics, research funding priorities, and medical practicalities, and despite extensive study, the evidence base is weak. Our goal was to estimate the short-term effectiveness of 13 common orthopedic and neurological treatments at four different levels of outcome in children and young adults diagnosed with CP. The outcome levels considered were body structures, specific gait kinematic deviations, overall gait kinematic deviations, and functional mobility. We used three well-establish causal inference approaches (direct matching, virtual twins, and Bayesian causal forests) and a large clinical gait analysis database to estimate the average treatment effect on the treated (ATT). We then examined the effectiveness across treatments, methods, and outcome levels. The dataset consisted of 2851 limbs from 933 individuals (some individuals underwent multiple treatment episodes). Current treatments have medium effects on body structures, but modest to minimal effects on gait and functional mobility. The median ATT of 13 common treatments in children and young adults with CP, measured as Cohen’s D, bordered on medium at the body structures level (median [IQR] = 0.42 [0.05, 0.60]) and became smaller as we moved along the causal chain through specific kinematic deviations (0.21 [0.01, 0.33]), overall kinematic deviations (0.09 [0.03, 0.19]), and functional mobility (-0.01 [-0.06, 0.13]). Further work is needed to understand the source of heterogeneous treatment effects, which are large in this patient population. Replication or refutation of these findings by other centers will be valuable to establish the generalizability of these results and for benchmarking of best practices.

Cost savings for single event multilevel surgery in comparison to sequential surgery in ambulatory children with cerebral palsy

BackgroundThe purpose of this study was to determine the differences in billable provider charges between single event multilevel surgery (SEMLS) based on comprehensive gait analysis and a staged surgical approach (SSA) without comprehensive gait analysis for the orthopedic treatment of ambulatory children with cerebral palsy (CP). MethodsThe charges associated with nine common orthopedic surgical combinations (both unilateral and bilateral, soft tissue or soft tissue plus bony) for children with CP were determined and compared between SEMLS and SSA. The charges included surgical, anesthesia, operating room, recovery room, hospital stay, physical therapy, and, for SEMLS only, comprehensive computerized gait analysis. ResultsTotal charges to complete each combination was higher for SSA than for SEMLS. The differential ranged from $10,247 to $75,069 with the percentage difference ranging from 20% to 47%. The mean difference was $43,606 (p = 0.0002). The dollar difference (r = 0.98, p < 0.0001) and percentage difference (r = 0.79, p = 0.01) were both related to the total charge of the SEMLS surgery. SignificanceFinancial costs are lower for SEMLS vs. SSA for the treatment of multilevel gait issues in children with CP. The cost of gait analysis is much smaller than the cost differential between SEMLS and SSA. Although some patients who have SEMLS may need additional orthopedic surgery with associated costs, this is also possible for SSA. Therefore, due to the many benefits of SEMLS, which also include more informed treatment decision-making as well as reduced time away from school and work (for caregivers), SEMLS guided by gait analysis is recommended over SSA for the treatment of gait disorders in children with CP.

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers

BackgroundThe prevalence of inflicted femur fractures in young children varies (1.5–35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma.ObjectiveThis study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures.Materials and methodsThis retrospective study included children (0–6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel.ResultsThe study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0–5 months (29%, positive likelihood ratio [LR +] 8.35), 6–12 months (18%, LR + 5.98) and 18–23 months (14%, LR + 3.74). Indicators of neglect were age 6–11 months (18%, LR + 4.41) and age 18–23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups.ConclusionIt is unlikely that an isolated femur fracture in ambulatory children age > 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.

Age related progression of clinical measures and gait in ambulant children and youth with bilateral cerebral palsy without a history of surgical intervention

BackgroundAge related progression needs to be considered when assessing current status and treatment outcomes in cerebral palsy (CP). Research questionWhat is the association between age, gait kinematics and clinical measures in children with bilateral CP? MethodA retrospective database review was conducted. Subjects with bilateral CP with baseline and follow-up 3D gait analyses, but no history of intervening surgery were identified. Clinical and summary kinematic measures were examined for age related change using repeat measures correlation. Interactions with GMFCS classification and whether surgery was recommended were examined using robust linear regression. Timeseries kinematic data for baseline and most recent follow-up analyses were analysed using statistical parametric mapping. Results180 subjects were included. 75% of participants were classified as GMFCS I or II at baseline. Mean time to follow-up was 4.89 (2.8) years (range 1–15.9 years) with a mean age of 6.4 (2.4) at baseline and 11.3 (3.4) at final follow-up. 15.5% of subjects demonstrated an improvement in GMFCS classification while GDI remained stable. Age related progression was noted across many clinical measures with moderate correlations (r ≥ 0.5) noted for reduced popliteal angle, long lever hip abduction and internal hip rotation range. In gait, there was reduced hip extension in late stance (p < 0.001), increased knee flexion in mid-stance (p < 0.001), reduced peak knee flexion in swing (p < 0.001) and increased ankle dorsiflexion in stance (p < 0.001). In the coronal plane, there was reduced hip abduction in swing (p < 0.001). In the transverse plane, increased external rotation of the knee (p < 0.001) and reduced external ankle rotation were noted in early stance and through swing (p < 0.001). There were no changes in foot progression or hip rotation. SignificanceIndividuals with CP show age related progression of clinical and kinematic variables. Treatment can only be deemed successful if outcomes exceed or match these age-related changes.

Can Over-containment Prevent Recurrence in Children With Cerebral Palsy and Hip Dysplasia Undergoing Hip Reconstruction?

Hip reconstruction is often necessary in children with cerebral palsy (CP) but is associated with high failure rates. Over-containment deeply seats the hip within the acetabulum at the time surgical reconstruction. The goal of this study is to evaluate the effect of over-containment on radiographic outcomes and failure rates in children with CP undergoing hip reconstruction. This study is a retrospective chart review of children with CP that underwent hip reconstruction between 2010 and 2019 with at least 2 years of radiographic follow-up. Migration percentage (MP), acetabular index (AI), and neck shaft angle (NSA) were recorded preoperatively, postoperatively and throughout follow-up. Failures were defined as a MP at latest follow-up ≥30% or need for revision hip reconstruction. Hips were divided into groups based on postoperative MP-group 1 (over-containment group) had a MP≤0% and group 2 had an MP>0%. Radiographic parameters and failure rates were compared across Gross Motor Functional Classification Score (GMFCS) level, age at the time of surgery, and degree of preoperative subluxation. A cohort of 108 patients (197 hips) with an average age of 7.3±3.2 years met inclusion criteria with an average follow-up of 49.6 months (range: 24 to 118 mo). There were 147 hips in group 1 and 50 hips in group 2. At latest follow-up, group 1 demonstrated lower MP, AI, and NSA in comparison to group 2. The overall failure rate in our cohort was 8.1% (16 hips). Failure rates trended lowest in hips that were over-contained (6.1% v. 14.0%) although not statistically significant. Over-containment resulted in significantly lower failure rates in GMFCS IV/V hips, children under age 6 at the time of surgery and those with a higher degree of preoperative hip displacement (MP>50%). Over-containment at the time of hip reconstruction can positively affect radiographic outcomes and failure rates in children with CP. Over-containment should be considered in hips at high risk of failure, especially non ambulatory children with significant hip subluxation at an early age. Level III-retrospective comparative study.