Single-event Multilevel Surgery In Children Research Articles

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.

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.

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

Does unilateral single-event multilevel surgery improve gait in children with spastic hemiplegia? A retrospective analysis of a long-term follow-up

Single event multilevel surgery (SEMLS) has become a standard intervention for children with cerebral palsy (CP). SEMLS proved to improve the gait in bilateral spastic cerebral palsy and those improvements can be maintained in the long term. However there is no evidence on the long-term outcome of unilateral SEMLS in children with unilateral spastic cerebral palsy.The gait analyses and clinical data of 14 children (9 male/5 female, mean age 12.1) with unilateral CP (6 children Gross Motor Function Classification System Scale level I and 8 children level II) were retrospectively reviewed at four time-points: preoperatively, 1year, 3–5 years and approximately 10 years after unilateral SEMLS. The Gait Profile Score (GPS) of the affected leg was used as a main and the number of fine tuning procedures as well as complications rate (Clavien-Dindo classification) as secondary outcome measures.The gait improved postoperatively and the GPS of the affected leg significantly declined by 3.73° which is well above the minimal clinical important difference of 1.6°. No deterioration of GPS occurred throughout the follow-up period. Therefore the postoperative improvement was maintained long-term. However, additional fine-tuning procedures had to be performed during the follow-up in 5 children and three complications occurred (one level II and two level III).The results indicate that children with unilateral cerebral palsy benefit from unilateral SEMLS and maintain gait improvements long-term.

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

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

Bony foot surgery performed at the same time as single-event multilevel surgery in children with cerebral palsy. Effects on pain, rehabilitation and outcome. Quantitative and qualitative analyses

Bony foot surgery performed at the same time as single-event multilevel surgery in children with cerebral palsy. Effects on pain, rehabilitation and outcome. Quantitative and qualitative analyses

The timing of single-event multilevel surgery in children with cerebral palsy walking with flexed knee gait

The timing of single-event multilevel surgery in children with cerebral palsy walking with flexed knee gait

Single‐event multilevel surgery for children with cerebral palsy: a systematic review

To conduct a systematic review of single-event multilevel surgery (SEMLS) for children with cerebral palsy, with the aim of evaluating the quality of the evidence and developing recommendations for future research. The systematic review was conducted using standard search and extraction methods in Medline, EMBASE, CINAHL, and Cochrane electronic databases. For the purposes of this review, SEMLS was defined as two or more soft-tissue or bony surgical procedures at two or more anatomical levels during one operative procedure, requiring only one hospital admission and one period of rehabilitation. Studies were included if: (1) the primary focus was to examine the effect of SEMLS in children with cerebral palsy; (2) the results focused on multiple anatomic levels and reported findings of one or more World Health Organization International Classification of Functioning, Disability and Health (ICF) domains. Studies that focused on a single intervention or level, or on the utility of a specific outcome measure were excluded. Study quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) and the Oxford Centre for Evidence-Based Medicine scale. The review also examined the reporting of surgery, adverse events, and rehabilitation. Thirty-one studies fulfilled the criteria for inclusion, over the period 1985 to October 2010. The MINORS score for these studies varied from 4 to 19, with marked variation in the quality of reporting. Study quality has improved over recent years. Valid measures of gait and function have been introduced and several of the most recent studies have addressed multiple dimensions of the ICF. A statistical synthesis of the outcome data was not conducted, although a trend towards favourable outcomes in gait was evident. Caution is advised with interpretation owing to the variable study quality. Uncontrolled studies may have resulted in an overestimation of treatment efficacy. The design and reporting of studies of SEMLS are improving with the development of multidisciplinary teamwork and frameworks such as the ICF. However, the evidence base is limited by the lack of randomized clinical trials, especially when compared with other surgical interventions such as selective dorsal rhizotomy.

The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait

Information on the timing and long-term outcome of single-event multilevel surgery in children with bilateral spastic cerebral palsy (CP) walking with flexed knee gait is limited. Based on our clinical experience, we hypothesized that older children with bilateral spastic CP would benefit more from single-event multilevel surgery than younger children. Moreover, any improvement in older children could be maintained with fewer additional surgery events. We performed a retrospective analysis of the long-term outcomes of single-event multilevel surgery. Thirty-two children (17 males, 15 females) who had received single-event multilevel surgery between 1995 and 2000 with a mean age at the time of surgery of 10 years 6 months (range 5y 8mo-15y 6mo; SD 3y 1mo) and in Gross Motor Function Classification System level II (n=12) or III (n=20) were included in the study. The inclusion criteria required that all children were ambulatory with spastic bilateral CP, had a flexed knee gait, had a full set of data for single-event multilevel surgery preoperatively and at 1 year and 10 years postoperatively, had not had previous surgery on their lower limbs, had not had any treatment with botulinum toxin A before gait assessment, and had not received intrathecal baclofen medication. The follow-up time lasted for over 10 years until the participants reached adulthood (mean age at the last follow-up 21 years 4 months, SD 3y 4mo). Data were collected on six separate occasions: preoperatively, at 1 year, at 2 to 3 years, at 5 years, at 7 to 8 years, and at 10 or more years postoperatively. The primary outcome was the Gait Deviation Index, and the secondary outcomes were the number and type of initial and additional surgeries. A linear mixed model and Spearman's rank correlation coefficient were used to prove the hypothesis. The older the child was at the time of the surgery, the better the long-term result ((Age,Time) =0.15; p=0.03). We did not find any correlation between age at the time of surgery and the number of bony or soft-tissue procedures performed initially as well as during the 10 years of follow-up. Children with CP who require single-event multilevel surgery at an older age fare better in the long term than those who are younger at the time of surgery. The pubertal growth spurt is discussed as a contributing factor to gait deterioration.

Single-Event Multilevel Surgery in Children with Spastic Diplegia

Single-event multilevel surgery is considered the standard of care to improve gait and functioning of children with spastic diplegic cerebral palsy. However, the evidence base is limited. This pilot study is the first randomized controlled trial of single-event multilevel surgery, to our knowledge. Nineteen children (twelve boys and seven girls with a mean age of nine years and eight months) with spastic diplegia were enrolled. Eleven children were randomized to the surgical group and eight, to the control group. The control group underwent a program of progressive resistance strength training. The randomized phase of the trial concluded at twelve months. The control group then exited the study and progressed to surgery, whereas the surgical group continued to be followed in a prospective cohort study. The primary outcome measures were the Gait Profile Score (GPS) and the Gillette Gait Index (GGI). Secondary outcome measures were gross motor function (Gross Motor Function Measure-66 [GMFM-66]), functional mobility (Functional Mobility Scale [FMS]), time spent in the upright position, and health-related quality of life (Child Health Questionnaire [CHQ]). A total of eighty-five surgical procedures were performed, with a mean of eight procedures per child (standard deviation, four). The surgical group had a 34% improvement in the GPS and a 57% improvement in the GGI at twelve months. The control group had a small nonsignificant deterioration in both indices. The between-group differences for the change in the GPS (-5.5; 95% confidence interval, -7.6 to -3.4) and the GGI (-218; 95% confidence interval, -299 to -136) were highly significant. The differences between the groups with regard to the secondary outcome measures were not significant at twelve months. At twenty-four months after surgery, there was a 4.9% increase in the GMFM-66 score and improvements in the FMS score, time spent in the upright position, and the physical functioning domain of the CHQ in the surgical group. This study provides Level-II evidence that single-event multilevel surgery improves the gait of children with spastic diplegic cerebral palsy twelve months after surgery. Improvements in other domains, including gross motor function and quality of life, were not observed until twenty-four months after surgery.

Commentary on an article by Pamela Thomason, BPhty, MPT, et al.: “Single-Event Multilevel Surgery in Children with Spastic Diplegia. A Pilot Randomized Controlled Trial”

The management of cerebral palsy has evolved substantially over the last seventy years. Motion analysis laboratories have played a pivotal role in this evolution by providing a means with which to study the interrelationship of limb segments for the purpose of devising treatment plans and evaluating results after treatment1-3. Advances in tone management including selective dorsal rhizotomy and medications such as baclofen and botulinum toxin4,5, and the advent of functionally based physical therapies replacing traditional neurodevelopmental approaches6 were other important contributions. The World Health Organization (WHO) framework, the International Classification of Functioning, Disability and Health (ICF), and the concurrent validation of outcome instruments for classifying and assessing children with chronic motor disabilities such as cerebral palsy were indispensable to the design of clinically relevant and more objective outcome studies7. The widespread adoption of single-event multilevel surgery as the mainstay orthopaedic surgical approach for gait abnormalities in patients with cerebral palsy was also a part of this evolution. However, single-event multilevel surgery is only one component of the multifaceted management approach for patients with cerebral palsy. Nevertheless, Thomason et al. are to be congratulated for providing the first published randomized controlled trial to evaluate the outcome of single-event multilevel surgery with use of outcome measures that assess several domains within the ICF framework, including impairments of body structure and functional capabilities. The study confirms what other prospective cohort studies of the lower extremity have shown—i.e., that single-event multilevel surgery results in short-term (twelve-month) improvement in gait alignment while its impact on functional capacity is negligible or …

Level of Improvement Determined by PODCI is Related to Parental Satisfaction After Single-event Multilevel Surgery in Children With Cerebral Palsy

This study was performed to determine changes in Pediatric Outcomes Data Collection Instrument (PODCI) scores after single-event multilevel surgery (SEMS), and to evaluate the relationship between the improvements of PODCI scores and parental satisfaction after SEMS. Demographic data, preoperative and postoperative PODCI, functional assessment questionnaire (FAQ) walking scales, and self-reported parental satisfaction with SEMS were obtained from 61 parents of ambulatory patients with cerebral palsy [40 male, 21 female, mean age 10 y 2 mo (SD 3 y 8 mo), mean follow-up 2 y 2 mo]. Postoperative improvements in each subscale of PODCI and FAQ were analyzed, and multiple regression analysis was performed to identify the factors that contributed significantly to postoperative parental satisfaction. Rasch analysis was performed for the PODCI subscale that was clinically relevant. FAQ, transfers/basic mobility, sports/physical activity, and global function subscales of PODCI significantly improved after SEMS. Age, gross motor function classification system level, and the amount of improvement in sports/physical activity subscale were found to affect parental satisfaction to SEMS significantly. However, the subscale showed insufficient item responses, and ceiling and floor effects. Although changes in sports/physical activity subscale were relatively small, they were found to affect parental satisfaction with SEMS significantly. These indicate that clinicians and researchers should pay attention to sports and physical activities in patients with cerebral palsy. Diagnostic level I.

The Functional Mobility Scale: ability to detect change following single event multilevel surgery

The aim of this study was to examine the ability of the Functional Mobility Scale (FMS) to detect change in children with cerebral palsy (CP) undergoing single event multilevel surgery (SEMLS). A retrospective study was conducted of gait laboratory records and video assessments for a consecutive sample of children with CP aged 4 to 18 years who were managed by multilevel surgery. FMS ratings and Gross Motor Function Classification System (GMFCS) levels were recorded preoperatively and at regular postoperative time points. The sample comprised 66 children (32 females, 34 males) with spastic diplegia, GMFCS Levels I (n=18), II (n=24), and III (n=24). The mean age at surgery was 10 years (SD 2y 6mo, range 6-16y). For each FMS distance (5, 50, and 500m) odds ratios showed significant deterioration in mobility at 3 and 6 months postoperatively. Mobility then improved to baseline levels by 12 months and improved further by 24 months postoperatively. GMFCS level remained stable throughout most of the postoperative period for children classified as GMFCS Level III preoperatively but not for children classified as Levels I or II. The FMS was found to be a clinically feasible tool for quantifying change after SEMLS in children with CP.