Multilevel Surgery In Children Research Articles

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies.

To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level III, Systematic review of level III studies.

Outpatient hospital utilization after single event multi-level surgery in children with cerebral palsy.

This study aimed to examine outpatient hospital utilization (number of specialties seen and number of visits to each specialty) in the year after single event multi-level surgery (SEMLS) in children with cerebral palsy (CP), and to determine if utilization differs across the medical center in the year after compared to the year before SEMLS. This retrospective cross-sectional study used electronic medical record data of outpatient hospital utilization in children with CP who underwent SEMLS. Thirty children with CP (Gross Motor Function Classification System Levels I-V, mean age of 9.9 years) were included. In the year after surgery, a significant difference (p = 0.001) was found for the number of specialties seen, with non-ambulatory children seeing more specialties than ambulatory children. No statistically significant difference was found between the number of outpatient visits to each specialty in the year after SEMLS. Compared to the year before SEMLS, fewer therapy visits occurred in the year after SEMLS (p < 0.001) but significantly more visits to orthopaedics (p = 0.001) and radiology (p = 0.001). Children with CP had fewer therapy visits but more orthopaedic and radiology visits the year after SEMLS. Nearly half of the children were non-ambulatory. Examination of care needs in children with CP undergoing SEMLS is justified with consideration of ambulatory status, surgical burden, and post-operative immobilization.

Assessment of gait quality and efficiency after undergoing a single-event multilevel surgery in children with cerebral palsy presenting an intoeing gait pattern.

The biomechanical impact of undergoing a single-event multilevel surgery (SEMLS) for children with cerebral palsy (CP) presenting an intoeing gait pattern has been widely documented. However, past studies mostly focused on gait quality rather than efficiency. Thus, there is a need to determine the impact of undergoing a SEMLS on gait quality and efficiency in children with CP presenting an intoeing gait pattern. Data from 16 children with CP presenting an intoeing gait pattern who underwent a SEMLS were retrospectively selected. Gait kinematics was quantified before (baseline) and at least 1year after the surgery (follow-up). Gait quality was investigated with the Gait Profile Score (GPS), hip internal rotation angle and foot progression angle (FPA). Gait efficiency was analysed using clinically accessible variables, namely the normalised gait speed and medio-lateral and vertical centre of mass excursions (COMp). Dependent variables were compared between sessions with paired t-tests. At the follow-up, children with CP exhibited a more outward FPA and GPS as well as a decreased hip internal rotation angle. No changes in normalised gait speed and vertical COMp excursion were observed, and medio-lateral COMp excursion was slightly decreased. Children with CP presenting an intoeing gait pattern who underwent a SEMLS exhibited an increased gait quality, but gait efficiency was only minimally improved at the follow-up compared to baseline. Further studies are needed to identify contributors of gait efficiency in children with CP, and the best treatment modalities to optimise both their gait quality and efficiency.

Оценка эффективности применения технологии одномоментных многоуровневых хирургических вмешательств у детей с ДЦП

Оценивалась эффективность применения методики одномоментных многоуровневых хирургических вмешательств в процессе лечения детей с детским церебральным параличом (ДЦП). В клинике было проведено ретроспективное исследование результатов лечения с 2006 по 2016 год у 270 детей (145 мальчиков и 125 девочек) в возрасте от 3 до 18 лет. Все дети были разделены на две группы: в первой группе выполняли поэтапные вмешательства (227 вмешательств на 340 сегментах) на одном сегменте; во второй применяли SEMLS (120 вмешательств на 602 сегментах). Проведен сравнительный анализ удаленных результатов лечения в группах по следующим критериям: общая продолжительность койко-дня в течение последующего года от начала лечения; общая продолжительность иммобилизации; продолжительность реабилитации до начала ходьбы. Выявлено, что у детей основной группы общая продолжительность койко-дня в среднем на 25 ± 4 дня меньше; общая продолжительность иммобилизации, при ее необходимости, в среднем на 25 ± 4 дня меньше, чем в контрольной группе; продолжительность реабилитации до начала ходьбы составляет 3,5 месяца, в отличие от контрольной группы, в которой данный период составляет 6,5 месяца.

Tibial rotation outcomes following hamstring lengthening as part of single event multilevel surgery in children with cerebral palsy

BackgroundHamstring lengthening remains the most common surgical procedure in the treatment of crouch gait for children with cerebral palsy (CP). While sagittal plane knee kinematics have been shown to improve post-surgery, the effects on transverse plane kinematics have not been reported. Given the differing actions of the medial and lateral hamstring muscles there is potential for change in tibial rotation post hamstring lengthening. Research questionWhat is the effect of medial only versus combined medial and lateral hamstring lengthening on tibial rotation during gait in children with CP? MethodsA retrospective analysis of children with a diagnosis of CP who underwent a hamstring lengthening procedure. These children were divided into 2 groups: G1 (n = 18) had isolated medial hamstring lengthening while G2 (n = 30) had combined medial and lateral hamstring lengthening. A matched non-surgical control group (n = 15) was also included. Kinematic data were analysed pre and post-operatively. Pre-operative to post-operative outcomes for G1 and G2, a comparison at baseline for both groups and the difference in outcomes between the groups were analysed. Baseline to follow-up outcomes for the control group were also analysed. ResultsExternal tibial rotation increased significantly within groups (G1: −10°, p < 0.01; G2: −11°, p < 0.001, control: −7.7, p < 0.01), with no significant difference in the change between the intervention groups. Foot progression angles became more external in both intervention groups (G1: −15°, p < 0.001; G2: −15°, p < 0.0001) and did not change in the control group. SignificanceResults demonstrated similar increases in external tibial rotation, regardless of whether an isolated medial or combined medial and lateral surgery was performed. The control group demonstrated a similar change in external tibial rotation suggesting that hamstring lengthening surgery does not contribute to increased external tibial rotation in children with CP compared to what would be expected due to natural progression.

Multilevel Surgery for Children With Cerebral Palsy: A Meta-analysis.

Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP). To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP. Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched. Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected. Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events. Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: -0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: -0.01 to 0.25) but did improve gait (SMD: -0.80; 95% CI: -0.95 to -0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies. Data were largely from cohort studies. Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.

The added value of orthotic management in the context of multi-level surgery in children with cerebral palsy

BackgroundTreatment of cerebral palsy includes an interdisciplinary concept and in more severe cases the well-established multi-level surgery (MLS). Different kinds of orthoses are typically part of postoperative treatment but there is a lack of knowledge about their additional benefit. Research questionDo ankle foot orthoses lead to an additional, measurable improvement of gait after MLS? Methods20 children with bilateral spastic cerebral palsy (9 retrospective, 11 in a postoperative clinical routine) were included. All had a preoperative gait analysis before MLS. Postoperatively, they were fitted with different ankle foot orthoses (AFO), depending on their individual needs. Dynamic ankle foot orthoses (DAFO), combined DAFO with additional dynamic, elastic shank adaptation (DESA) and ground reaction force AFOs (GRAFO) were used. Patients underwent a second gait analysis 1.5 (± 0.6) years postoperatively barefoot and with orthoses. Data analysis included testing for normal distribution (Shapiro-Wilk-Test) and further nonparametric statistical testing on basis of a Wilcoxon Single-Rank Test. ResultsThe operation produced changes in the hip, knee and ankle joint, and the pelvis. Spatiotemporal parameters showed significant changes due to additional use of the orthoses. Further, additional kinematic changes occurred at the hip, knee and ankle joint as well as the foot. The Gillette Gait Index (GGI) improved significantly by supplementary orthoses, but not by surgery alone. The Gait Profile Score (GPS) and Gait Deviation Index (GDI) rather showed changes due to the surgery. SignificanceMLS significantly improves GPS and GDI more than a year after surgery, which can be interpreted as an improvement in gait pattern. In contrast, the GGI is improved by additional postoperative orthotic treatment, which implies that walking ability itself has improved, rather than the gait pattern. Orthoses show a positive additional effect on surgical results at different anatomical levels. Spatiotemporal parameters are positively influenced solely by additional orthotic support.

Predictors affecting outcome after single-event multilevel surgery in children with cerebral palsy: a systematic review.

To review the potential predictors of outcome after single-event multilevel surgery (SEMLS) in children with cerebral palsy (CP). A literature search using the following criteria was performed in six electronic databases: (1) children with cerebral palsy; (2) analysed potential predictors of outcome after SEMLS; (3) minimum 12months follow-up. The potential predictors were predefined: sex; topographical distribution; socio-economic status; Gross Motor Function Classification System (GMFCS) level; preoperative kinematic summary statistic; age at surgery. Study quality was appraised with the methodological index for non-randomized studies (MINORS) and the Oxford Centre for Evidence-Based Medicine scale. Of the seven studies identified, the MINORS scores ranged from 9 to 11 and all were graded 2b on the Oxford Centre for Evidence-Based Medicine scale. There was little or no evidence to support sex, topographical distribution, or socio-economic status as predictive factors after SEMLS. Preoperative Gait Profile Score (GPS) was the best measure of expected improvement in gait kinematics. Parent-reported satisfaction and GPS were best after SEMLS in children graded GMFCS II. The best long-term results were seen in those aged between 10years and 12years of age. The candidate who might expect to realize the most improvement from SEMLS is aged between 10years and 12years, is in GMFCS level II, and has a poor preoperative GPS. Children aged 10 to 12years, in Gross Motor Function Classification System level II, with a poor preoperative Gait Profile Score might expect to realize the most improvement after single-event multilevel surgery.

Retrospective Evaluation of Changes in Gait Patterns in Children and Adolescents With Cerebral Palsy After Multilevel Surgery.

The purpose of this study was to retrospectively investigate changes in gait patterns after single-event multilevel surgery in children and adolescents with bilateral cerebral palsy. Three-dimensional instrumented pre- and postoperative gait data of 12 patients were compared to data of 12 healthy control subjects using principal component analysis to reduce the dimensionality of kinematic and kinetic gait data and detect gait differences. The differences between pre- and postoperative data and between postoperative data and data of control subjects were calculated using a linear mixed model. The results revealed 14 significant effects for pre- and postoperative waveforms and 11 significant effects for postoperative and control waveforms. Patients after single-event multilevel surgery walked with smaller internal foot progression angle throughout the gait cycle, lower knee flexion at initial swing, and earlier knee extension during terminal swing. Retained gait deviations included excessive pelvic tilt and internally rotated and flexed hips over the entire gait cycle. Contrary to our hypothesis, postoperative waveforms in the sagittal plane differed more from control waveforms than from preoperative waveforms. These results emphasize the importance of carefully planning further conservative therapy 2 years after single-event multilevel surgery.

Evolution of self-care and functional mobility after single-event multilevel surgery in children and adolescents with spastic diplegic cerebral palsy.

To explore the evolution of self-care and functional mobility after multilevel surgery in children and adolescents with spastic diplegic cerebral palsy and to identify factors affecting these outcomes. Thirty-four participants (22 males, 12 females) were evaluated before surgery, and at 2 months, 6 months, 1 year, 18 months, and 2 years after surgery. Self-care was assessed with the Pediatric Evaluation of Disability Inventory Dutch edition. The Mobility Questionnaire47 (MobQues47) and Functional Mobility Scale (FMS) were used to measure functional mobility. All outcomes revealed a significant decrease 2 months after single-event multilevel surgery (SEMLS) (p-value between <0.001 and 0.02) followed by a significant increase at 6 months (p<0.001 and p=0.045). Between 6 months and 1 year, a significant increase was also revealed for Mobques47 (p<0.001), FMS (p≤0.008), and the Pediatric Evaluation of Disability Inventory Functional Skills Scale (PEDI-FSS) (p=0.001). Improvement continued until 18 months for the PEDI-FSS. Initial score, initial muscle strength, Gross Motor Function Classification System level, age, and number of surgical interventions significantly influenced time trends for self-care and/or functional mobility. Most preoperative scores are regained at 6 months after SEMLS. Further improvement is seen until 18 months. Participants with a higher functional level before surgery will temporarily lose more than participants with lower initial functional ability, but they also fast regain their function. Self-care and functional mobility decrease significantly in the first months after single-event multilevel surgery (SEMLS). Six months after SEMLS most preoperative scores are regained. Impact of SEMLS is more pronounced for functional mobility than for self-care. Muscle strength and functionality at baseline are important influencing factors on the evolution after SEMLS.

Short-term outcomes of single event multilevel surgery for children with diplegia in a South African setting

Background: Although single event multilevel surgery (SEMLS) is well supported in the literature for walking children with cerebral palsy (CP) there is little evidence to show the outcomes in developing countries with limited resources. Further there is no literature reporting on the use of SEMLS in walking children with HIV encephalopathy (HIVE). The primary aim of this study was to investigate whether SEMLS can have good short-term outcomes in a South African setting, and the secondary aim was to compare the outcomes of SEMLS in children with diplegia secondary to CP and HIVE. Methods: A prospective cohort study of ten children with spastic diplegia was enrolled (six with CP, four with HIVE) and followed up for 12 months. All children underwent SEMLS and received peri-operative therapy at a local clinic, hospital or a special-needs school. The primary outcome measures were the Edinburgh Visual Gait Score (EVGS), Gross Motor Function Measure-66 (GMFM-66) and the Functional Mobility Scale (FMS) measured pre-operatively (T1), at six months (T2) and at one year (T3). Results: There was an overall mean improvement of 6.4 in the EVGS and 3.2% in the GMFM-66 at the one-year follow-up assessment. The FMS revealed an initial deterioration in function at six months, with return to pre-operative function at the one-year assessment. Improvements in the GMFM-66 were found to be clinically significant. When comparing children with CP to those with HIVE the improvements were similar. Conclusion: The results of this study indicate that the early outcomes of SEMLS in a South African setting, with scarce resources, are similar to those seen in developed countries. It may also be possible to use the same SEMLS treatment principles seen in the management of children with CP for children with static HIVE. Further follow-up is however needed in both of these areas. Level of evidence: Level 4

Long-term development of gait after multilevel surgery in children with cerebral palsy: a multicentre cohort study.

We investigated the long-term efficacy and safety of multilevel surgery (MLS) in ambulatory children with bilateral spastic cerebral palsy (CP). Two hundred and thirty-one children were evaluated at short term (1.1y, SD 0.4) and long term (9.1y, SD 3.0) follow-up using clinical examination and gait analysis. MLS was investigated by studying changes in the Gait Profile Score (GPS) referenced to the minimally important clinical difference. Ambulatory children aged 10 years and 7 months (SD 2y 11mo) at MLS in Gross Motor Function Classification System levels I (19), II (144), and III (68) showed a decrease (improvement) in preoperative GPS from 16.3° (SD 4.8) to 11.3° (SD 3.2) at short-term follow-up, an improvement of 5°. At long-term follow-up, GPS was maintained at 11.4° (SD 3.1). Overall, 177 (76.6%) children maintained their improvement in GPS after 9 years. Multilevel surgery is a safe and effective surgical intervention, which leads to a significant improvement in gait kinematics in children with bilateral spastic CP. This study improves our understanding of MLS in the long term and will help to inform families and children when planning for MLS. Largest study of multilevel surgery (MLS) for children with bilateral spastic cerebral palsy, with longest follow-up. MLS resulted in significant long-term improvements in gait function. Minor adverse events were common, while events requiring intervention were uncommon (4% of children). Thirty-nine per cent of children required additional surgery during follow-up. 'Single-event multilevel surgery' was changed to the more realistic term 'multilevel surgery'.

Analysis of gait patterns pre- and post- Single Event Multilevel Surgery in children with Cerebral Palsy by means of Offset-Wise Movement Analysis Profile and Linear Fit Method

Gait analysis is used for the assessment of walking ability of children with cerebral palsy (CP), to inform clinical decision making and to quantify changes after treatment. To simplify gait analysis interpretation and to quantify deviations from normality, some quantitative synthetic descriptors were developed over the years, such as the Movement Analysis Profile (MAP) and the Linear Fit Method (LFM), but their interpretation is not always straightforward.The aims of this work were to: (i) study gait changes, by means of synthetic descriptors, in children with CP that underwent Single Event Multilevel Surgery; (ii) compare the MAP and the LFM on these patients; (iii) design a new index that may overcome the limitations of the previous methods, i.e. the lack of information about the direction of deviation or its source.Gait analysis exams of 10 children with CP, pre- and post-surgery, were collected and MAP and LFM were computed. A new index was designed asa modified version of the MAP by separating out changes in offset (named OC-MAP).MAP documented an improvement in the gait pattern after surgery. The highest effect was observed for the knee flexion/extension angle. However, a worsening was observed as an increase in anterior pelvic tilt. An important source of gait deviation was recognized in the offset between observed tracks and reference. OC-MAP allowed the assessment of the offset component versus the shape component of deviation.LFM provided results similar to OC-MAP offset analysis but could not be considered reliable due to intrinsic limitations. As offset in gait features played an important role in gait deviation, OC-MAP synthetic analysis was proposed as a novel approach to a meaningful parameterisation of global deviations in gait patterns of subjects with CP and gait changes after treatment.

Distal femoral extension and shortening osteotomy as a part of multilevel surgery in children with cerebral palsy.

There are several reports describing an increase in anterior pelvic tilt after hamstring lengthening in children with cerebral palsy (CP). Distal femoral extension and shortening osteotomy (DFESO) is an alternative treatment for correction of flexed knee gait, but investigations analyzing outcome and influence on adjacent joint are few in the literature. The purpose of this study was to analyze the influence of DFESO on knee and pelvis in children with CP. Furthermore, it was of interest if an additional patellar tendon advancement (PA) influences outcome. In this retrospective study, 31 limbs of 22 children (GMFCS I-III; mean age: 12.1±3.1 years), who received DFESO were included and kinematic parameters (knee, pelvis) measured by 3-D-gait analysis were compared before and at least 1 year after surgery (mean follow-up period: 15.6 months). After surgery, during stance phase minimum knee flexion improved significantly by 20.5° (P<0.001) and mean anterior pelvic tilt increased by 4.0 degrees (P=0.045). In 16 limbs, the postoperative increase in maximum anterior pelvic tilt was more than 5°. Limbs who received an additional PA showed the biggest increase in anterior pelvic tilt. DFESO is an effective method for correction of flexed knee gait in children with CP. Furthermore, the results of this study indicate that DFESO may lead to an increase in anterior pelvic tilt, which may lead to a recurrence of flexed knee gait. In this context, PA seemed to aggravate the effect on the pelvis.

Early mobilisation by locomotion therapy following minimally invasive multi-level surgery for children and young adults with cerebral palsy

Early mobilisation by locomotion therapy following minimally invasive multi-level surgery for children and young adults with cerebral palsy

Temporal trends in inpatient pediatric sleep apnea surgery: 1993-2010.

We sought to characterize changes in the patterns of inpatient surgical sleep care over time and ascertain if these changes were consistent with previously reported trends in adult surgical sleep care. Repeated cross-sectional study. Discharge data from the U.S. Nationwide Inpatient Sample for 125,691 nasal, palatal, or hypopharyngeal procedures in children for sleep-disordered breathing or obstructive sleep apnea (OSA) from 1993 to 2010 were analyzed using cross-tabulations and multivariate regression modeling. Inpatient surgical sleep procedures increased from 45,671 performed in 1993 to 2000 (study period 1) to 80,020 in 2001 to 2010 (study period 2). Overall, patients were commonly male (61.3%), privately insured (46.8%), 2 to 6 years old (39.4%), and white (36.4%). Obesity was reported in 4.6% and 6.7% of children during study periods 1 and 2, respectively (P < .0001). Tonsillectomy (with and without adenoidectomy) was the most commonly performed procedure in both study periods. With the exception of uvulopalatopharyngoplasty and tracheostomy, all sleep procedures increased over time; however, multilevel surgery did not significantly increase (P = .28). Children who underwent sleep surgery during study period 2 were more likely to receive a supraglottoplasty (P = .0125) and to undergo procedures at high-volume hospitals (P = .0311), and less likely to undergo a tracheostomy (P < .0001). These data reflect changing trends in the surgical management of pediatric OSA, with significant increases in nasal and hypopharyngeal procedures, particularly lingual tonsillectomy and supraglottoplasty. Unlike the trend in adults, multilevel surgery in children with sleep disordered breathing or OSA has not yet been integrated into routine clinical practice. 2C Laryngoscope, 127:1235-1241, 2017.

Single event multilevel surgery in children with bilateral spastic cerebral palsy: a multicentre, long‐term, follow‐up study

Single event multilevel surgery in children with bilateral spastic cerebral palsy: a multicentre, long‐term, follow‐up study

Five year multicenter follow-up study after single-event multilevel surgery in children and adolescents with Cerebral Palsy in Norway – A study protocol

Five year multicenter follow-up study after single-event multilevel surgery in children and adolescents with Cerebral Palsy in Norway – A study protocol

Predictors of outcome after single-event multilevel surgery in children with cerebral palsy: a retrospective ten-year follow-up study.

Single event multilevel surgery (SEMLS) has been shown to improve gait in children with cerebral palsy (CP). However, there is limited evidence regarding long-term outcomes and factors influencing them. In total 39 children (17 females and 22 males; mean age at SEMLS ten years four months, standard deviation 37 months) with bilateral CP (20 Gross Motor Function Classification System (GMFCS) level II and 19 GMFCS level III) treated with SEMLS were included. Children were evaluated using gait analysis and the Gait Deviation Index (GDI) before SEMLS and one, two to three, five and at least ten years after SEMLS. A linear mixed model was used to estimate the effect of age at the surgery, GMFCS and follow-up period on GDI. There was a mean improvement of 12.1 (-15.3 to 45.1) GDI points one year after SEMLS (p < 0.001) and 10.3 (-23.1 to 44.2) GDI points ten years after SEMLS compared with before SEMLS (p < 0.001). GMFCS level III children aged ten to 12 years had the most improvement. The GMFCS III group had more surgical procedures at the index SEMLS (p < 0.001) and during the follow-up period (p = 0.039). After correcting for other factors, age at surgery was the only factor predictive of long-term results. Our model was able to explain 45% of the variance of the change in GDI at the different time points. Children with GMFCS III level aged ten to 12 are the benchmark responders to SEMLS in the long-term.

Effects of Therapeutic Exercise on Muscle Function following Single-Event Multilevel Surgery in Children with Spastic Lower Limb Monoplegic Cerebral Palsy

Effects of Therapeutic Exercise on Muscle Function following Single-Event Multilevel Surgery in Children with Spastic Lower Limb Monoplegic Cerebral Palsy