Single-event Multilevel Surgery Research Articles

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy

BackgroundCrouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures. Patients and methodsWe reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively. ResultsOverall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery. ConclusionAlthough DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait. Level of evidenceTherapeutic level IV

Evaluation of Single Event Multilevel Surgery (SEMLS) in Cerebral Palsy Children with Lower Limb Deformities

Evaluation of Single Event Multilevel Surgery (SEMLS) in Cerebral Palsy Children with Lower Limb Deformities

"Coronal Split/Overlap Repair" Patellar Tendon Shortening in Skeletally Immature Patients.

"Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy. The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks. Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap1-3. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication4, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened2,5-7, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened8,9. The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises. Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase1,3,8. Reported complications with this technique were mainly superficial infection. Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field. 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery.

Patellar tendon shortening surgery restores the knee extensor mechanism in flexed knee gait in children with cerebral palsy

BackgroundThis study evaluated a patellar tendon shortening (PTS) surgical procedure that uses an overlapping repair combined with an additional Tycron non-absorbable suture to support the shortening in children with Cerebral Palsy (CP). This study aimed to outline this surgical technique and to evaluate its effectiveness in restoring the knee extensor mechanism. MethodsThe sagittal plane lower limb kinematics, peak knee extensor moment, gait deviation index (GDI), localised movement deviation profile (MDP), temporospatial parameters, passive knee extension ROM, quadriceps lag, and knee extensor strength were calculated pre- and postoperatively. To determine significant differences a robust linear regression model with high breakdown point and high efficiency was fitted to the data. ResultsIn this retrospective cohort study, a total of 41 patients with CP who were treated with unilateral or bilateral PTS in isolation or as part of single event multilevel surgery (SEMLS), with a mean age of 11.1 years were included. The knee extension angle improved at initial contact (p < 0.0001), and during stance phase (p < 0.0001). The peak internal knee extensor moment decreased during early (p = 0.0014) and late stance phase (p < 0.0001). The quadriceps lag decreased (p < 0.0001) and knee extensor strength increased (p < 0.0001). The GDI improved (p < 0.0001), as well as the localised MDP for sagittal angles (p < 0.0001) and moments (p = 0.0001). Walking speed (p = 1.0) remained unchanged, but the cadence decreased (p = 0.024) and step length increased (p = 0.0001). ConclusionsThe knee extension angle and moment during stance phase improved significantly. The children with CP in this study showed improvements in knee extensor strength and quadriceps lag. Thereby it can be concluded that the PTS procedure was able to restore the knee extensor mechanism effectively.

Comparison of outcomes following surgical intervention and inpatient rehabilitation stays in children with cerebral palsy.

Literature is limited on functional outcomes in children with cerebral palsy (CP) following surgical procedures and a subsequent inpatient rehabilitation unit (IRU) stay. To compare functional outcomes and length of stay (LOS) in children with CP following a surgical procedure and IRU stay based on the surgical procedure performed, pattern of involvement, etiology, and Gross Motor Function Classification System (GMFCS) level. Retrospective cohort study. Tertiary care pediatrics. Pediatric patients with CP who underwent one of three surgical procedures followed by an IRU stay. Selective dorsal rhizotomy (SDR), single-event multilevel orthopedic surgery (SEMLS), or intrathecal baclofen (ITB) pump implantation and subsequent IRU stay. IRU LOS, Functional Independence Measure for Children (WeeFIM) total score, sub-scores, and efficiency. Children undergoing SDR had a longer LOS (p ≤ .015). Children with spastic diplegia, GMFCS level II, and prematurity-based CP had higher WeeFIM efficiency scores (p ≤ .046, ≤.021, and .034 respectively). Greater changes in WeeFIM™ scores were associated with spastic diplegia, SDR, GMFCS level II, longer LOS, and higher admission scores (p ≤ .045). Although statistically and functionally significant improvements in children with CP following surgical interventions and an IRU stay were seen, those with higher WeeFIM change scores tended to have spastic diplegia, to have undergone SDR, GMFCS level II, longer LOS, and higher admission scores.

Single-Event Multi-Level Surgery in Cerebral Palsy: A Bibliometric Analysis.

Background and Objectives: Single-Event Multi-Level Surgery (SEMLS) is a complex surgical programme in which soft tissue contractures and bony torsional deformities at the ankle, knee and hip, in both lower limbs are surgically corrected during a single operative session, requiring one hospital admission and one period of rehabilitation. The aim of SEMLS is to improve gait and function in ambulant children with cerebral palsy. Utilisation of the SEMLS concept can reduce the number of surgical events, hospital inpatient stays and reduce rehabilitation requirements to a single intensive episode. Three-dimensional gait analysis is a pre-requisite to plan intervention at multiple anatomic levels to correct fixed deformities and to improve gait and function. Materials and Methods: This study was a bibliometric analysis of SEMLS in cerebral palsy using the Clarivate Web of Science Core Collection database from 1900 to 29 May 2023. Results: A total of 84 studies met the inclusion criteria. The most highly cited article was "Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery" by Rodda et al. (2006) with 141 citations. The most productive institutions by number of articles were the Royal Children's Hospital Melbourne (Australia), Murdoch Children's Research Institute (Australia) and University of Melbourne (Australia). The most productive author by number of citations was HK Graham (Australia). Conclusions: The literature base for SEMLS consists largely of retrospective cohort studies. The aforementioned three institutes in Melbourne, Australia, which frequently collaborate together, have contributed the greatest number of studies in this field.

Knee joint contact forces to assess the effect of single event multi level surgery over time in crouch gait

Knee joint contact forces to assess the effect of single event multi level surgery over time in crouch gait

Patients and Parents' Satisfaction and Self-Reported Evaluation After Single-Event Multilevel Surgery in Cerebral Palsy.

The aim of this study was to analyze the results of single-event multilevel surgery (SEMLS) in cerebral palsy (CP) based on objective gait outcomes and self-reported evaluations. In total, 258 patients with spastic diplegic CP, GMFCS I-III, who underwent SEMLS and with preoperative and postoperative gait analyses, were included in the SEMLS group (SG). The same database was used to compose the control group (CG) formed of 88 subjects who had performed at least 2 gait analyses and did not undergo surgical intervention between tests. Demographic data, Gait Deviation Index (GDI), and a self-reported questionnaire were analyzed, and results were compared between groups. The GDI decreased from 59.6 to 57.9 in the CG and increased from 51.3 to 58.4 in the SG ( P <0.001). There was no change in patients' walking ability in the CG. The number of patients who walk community distances increased after SEMLS in the group that had a GDI improvement >5 points (from 12.3% to 24.7%, P =0.008) and in patients GMFCS I and II (from 9.2% to 20.4%, P =0.028). According to patient and parental responses on satisfaction, the most significant improvements were reported in self-esteem, mobility, body image, and independence. In total, 51.1% of the patients were extremely satisfied or satisfied, while 3.9% were unsatisfied or extremely unsatisfied with the treatment results. Of the parents surveyed, 60.1% were extremely satisfied or satisfied, whereas just 5.0% were unsatisfied or extremely unsatisfied. In the studied group, an improvement in outdoor walking for community distances after SEMLS, as reported in questionnaires, was observed only when GDI increase was >5 points and in GMFCS I and II. Level III.

Can We Extend the Indications for Multilevel Surgery to Non-Ambulatory Children with Neuromuscular Diseases? A Safety and Efficacy Study

A retrospective study that aims to analyze the safety and efficacy of single-event multilevel surgery (SEMLS) involving bifocal femoral osteotomy (BFO) performed in nine non-ambulatory children with neuromuscular diseases (NMD), with a median age of 12.86 years, to resolve both hip subluxation and ipsilateral knee flexion contracture that impaired standing, and to evaluate patient and caregiver satisfaction. Results: Median surgical time was 4 h 15 min (2 h 35 min–5 h 50 min). Hip flexion deformity improved by a median of 30° (15–35), while median improvement in knee flexion deformity was 30° (20–50). Only two patients could use a standing frame prior to surgery, although with increasing difficulty, while all children could use it following SEMLS. Mean follow-up was 27.47 months (24.33–46.9). Significant blood loss requiring transfusion was the only complication recorded (8/9). All caregivers reported slight, moderate, or significant improvement in all domains of the questionnaire, and all would undergo the procedure again and recommend it to others, as nearly all (8/9) were very satisfied. Conclusion: The findings of this study suggest that SEMLS including BFOs in non-ambulatory children with NMD can correct hip, knee, and foot deformities and simultaneously realign lower limbs to restore functional standing and wheelchair transfer. The functional results, safety, and degree of satisfaction achieved justify offering this strategy to families.

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.

Factors Associated With Short-Term Recovery Following Single-Event Multilevel Surgery for Children With Cerebral Palsy

To examine the role of multiple factors, including therapy dose, on recovery of mobility function during post-single-event multilevel surgery (SEMLS) rehabilitation in youth with cerebral palsy. Several factors expected to influence postoperative change in Gross Motor Function Measure (GMFM) were examined: age, Gross Motor Function Classification System (GMFCS) level, cognition, number of osteotomies, surgical complications, medical comorbidities, number of therapy sessions, and preoperative measures of gait, balance, and gross motor function. Sixty-nine youth with cerebral palsy, GMFSC levels I-IV, who had undergone SEMLS and rehabilitation had on average 2.6 osteotomies and 89 postoperative therapy sessions. Fewer osteotomies, higher therapy dose, higher preoperative GMFM, and lower GMFM at postoperative admission were significant in determining GMFM change. The most relevant factors on post-SEMLS recovery were therapy dose, surgical burden, and level of gross motor function immediately before and after surgery.

Commentary on “Factors Associated With Short-Term Recovery Following Single-Event Multilevel Surgery for Children With Cerebral Palsy”

Commentary on “Factors Associated With Short-Term Recovery Following Single-Event Multilevel Surgery for Children With Cerebral Palsy”

Influence of initial nutritional status on rehabilitation potential and motor abilities of children with cerebral palsy after orthopedic single-event multilevel surgery

Introduction. Protein-energy malnutrition in patients with cerebral palsy is an urgent problem. Given the high frequency of cerebral palsy orthopedic complications requiring surgical treatment, it is necessary to determine the impact of the initial nutritional status on the effectiveness of treatment. Purpose of the study: to analyze the impact of the initial nutritional status on the rehabilitation potential and motor abilities of children with cerebral palsy after orthopedic single-event multilevel surgeries. Materials and methods. The inclusion criteria were the age less than 18 years at the time of examination, spastic form of cerebral palsy, and a single-event multilevel surgical intervention due to orthopedic complications of cerebral palsy in medical history. Results. Lower indices of motor abilities after single-event multilevel surgeries were registered in patients with protein-energy malnutrition according to the FMS (5,50, and 500 meters) and the Gillette scale (p = 0.020, p = 0.026, p = 0.048, p = 0.008, respectively). Conclusion. The initial normal nutritional status before surgery has a positive effect on the rehabilitation potential and motor abilities of children with cerebral palsy after orthopedic single-event multilevel surgeries. Further research on this issue is needed.

Surgical Management of Severe Equinus Deformity in Ambulatory Children With Cerebral Palsy.

Tendo Achilles lengthening (TAL) for the management of equinus contractures in ambulatory children with cerebral palsy (CP) is generally not recommended due to concerns of over-lengthening, resulting in weakness and plantar flexor insufficiency. However, in some cases, surgical correction of severe equinus deformities can only be achieved by TAL. The goal of this study is to assess the outcomes following TAL in these cases. A retrospective cohort study of children with CP with severe equinus contractures (ankle dorsiflexion with the knee extended of -20 degrees or worse) who underwent TAL as part of a single event multilevel surgery, with preoperative and postoperative gait analysis studies. Continuous data were analyzed by paired t test, and categorical data by McNemar Test. There were 60 subjects: 42 unilateral, 18 bilateral CP; 41 GMFCS II, 17 GMFCS I; mean age at surgery was 10.6 years, mean follow-up was 1.3 years. Ankle dorsiflexion with the knee extended improved from -28 to 5 degrees (P<0.001). The ankle Gait Variable Score improved from 34.4 to 8.6 (P<0.001). The ankle moment in terminal stance improved from 0.43 to 0.97Nm/kg (P<0.001). Significant improvements (P<0.001) were seen in radiographic measures of foot alignment following surgery. There were few significant differences in the outcome parameters between subjects with unilateral versus bilateral CP (eg, only the bilateral group showed improved but persistent increased knee flexion in mid-stance). The outcomes following TAL for the management of severe equinus deformity in ambulatory children with CP were favorable 1 year after surgery, with significant improvements in all domains measured. This study does not advocate for the widespread use of TAL to correct equinus deformity in children with CP. However, it does show that good short-term outcomes following TAL are possible in properly selected subjects with severe contractures when the dosing of the surgery is optimal (correction of contracture to between 0 and 5 degrees of dorsiflexion with the knee extended) and the procedure is performed in the setting of single event multilevel surgery with subsequent proper orthotic management and rehabilitation.

Long-term outcome of hamstring lengthening versus transfer and the role of biceps femoris lengthening in patients with spastic diplegia and dynamic knee flexion in gait.

Orthopedic treatment of flexed-knee gait consists of hamstring lengthening along with surgery at other levels. Transfer of the semitendinosus (hamstring transfer) was introduced to avoid increase of anterior pelvic tilt as well as reduce risk of recurrence. We retrospectively assessed children with spastic cerebral palsy and flexed-knee gait pre-operatively, 1 year post-operatively, and at a minimum of 7 years post-operatively. The 39 patients were a mean 9.4 ± 3.4 years at the time of surgery, 20 subjects underwent hamstring transfer, and 19 subjects had hamstring lengthening with mean follow-up 9.1 years. Passive range of motion improved initially, but regressed at long term. Dynamic minimum knee flexion in stance decreased in both groups at the first post-operative study, and was maintained at final follow-up in 64-67% of patients. There was a small increase in anterior pelvic tilt at the 1-year follow-up which subsequently decreased to less than pre-operative in the hamstring lengthening group but remained mildly increased (5°) in the hamstring transfer group at final follow-up. Success in correcting stance knee flexion of the entire group was 69% of the Gross Motor Function Classification System grades I and II and 60% of the Gross Motor Function Classification System grade III subjects. Gait profile Score and sagittal knee Gait Variable Score both showed clinically important improvement after surgery and was mostly maintained long term for both groups. Lateral hamstring lengthening was beneficial in more severe patients, with minimal risk of adverse effects. Hamstring surgery as part of single event multi-level surgery (SEMLS) is effective in correcting flexed-knee gait in 60%-70% of patients with minimal effect on anterior pelvic tilt. There was no added advantage to hamstring transfer. Biceps Femoris lengthening may be beneficial and without significant additional risk. level III.

Effect of an augmented reality active video game for gait training in children with cerebral palsy following single-event multilevel surgery: protocol for a randomised controlled trial

IntroductionIn paediatric rehabilitation, fun and motivation are also critical keys to successful therapy. A variety of interventions have shown positive effects, high level of interest, compliance and engagement with active...

Effect of single-event multilevel surgery on functional mobility of children with cerebral palsy

Introduction. Movement disorders are one of the most common complaints of patients with cerebral palsy. The attending physician needs to evaluate the motor activity of patients after treatment. The Functional Mobility Scale (FMS) is a clinically feasible tool to quantify changes after SEMLS in children with cerebral palsy.Purpose of the study. To evaluate the effect of simultaneous multilevel operations in combination with early rehabilitation treatment on the functional mobility of children with cerebral palsy in comparison with standard surgery.Materials and methods. The criterion for inclusion in the study was age at the time of examination less than 18 years, spastic cerebral palsy, surgical treatment due to orthopedic complications of cerebral palsy in two groups: after SEMLS and standard surgery. All subjects were assessed motor activity on the FMS scale.Results. The analysis performed showed no statistically significant changes in the assessment of functional mobility at a distance of 5 meters after surgical treatment in both study groups (p = 0.143; p = 0.083). A statistically significant improvement in functional mobility according to the FMS scale was found in children after simultaneous multilevel operations at distances of 50 and 500 meters (p = 0.025; p &lt; 0.001). No statistically significant changes were noted after standard operating procedures were carried out at distances of 50 and 500 meters (p = 0,063; p = 0,058).Conclusion. In children with cerebral palsy after simultaneous multilevel operations in combination with a complex of rehabilitation measures, the level of functional mobility improves. The use of the functional mobility scale allows the attending physician to objectify the dynamics of the motor function of patients with cerebral palsy after surgical treatment.

Causal Effects of Motor Control on Gait Kinematics After Orthopedic Surgery in Cerebral Palsy: A Machine-Learning Approach.

BackgroundAltered motor control is common in cerebral palsy (CP). Understanding how altered motor control affects movement and treatment outcomes is important but challenging due to complex interactions with other neuromuscular impairments. While regression can be used to examine associations between impairments and movement, causal modeling provides a mathematical framework to specify assumed causal relationships, identify covariates that may introduce bias, and test model plausibility. The goal of this research was to quantify the causal effects of altered motor control and other impairments on gait, before and after single-event multi-level orthopedic surgery (SEMLS).MethodsWe evaluated the impact of SEMLS on change in Gait Deviation Index (ΔGDI) between gait analyses. We constructed our causal model with a Directed Acyclic Graph that included the assumed causal relationships between SEMLS, ΔGDI, baseline GDI (GDIpre), baseline neurologic and orthopedic impairments (Imppre), age, and surgical history. We identified the adjustment set to evaluate the causal effect of SEMLS on ΔGDI and the impact of Imppre on ΔGDI and GDIpre. We used Bayesian Additive Regression Trees (BART) and accumulated local effects to assess relative effects.ResultsWe prospectively recruited a cohort of children with bilateral CP undergoing SEMLS (N = 55, 35 males, age: 10.5 ± 3.1 years) and identified a control cohort with bilateral CP who did not undergo SEMLS (N = 55, 30 males, age: 10.0 ± 3.4 years). There was a small positive causal effect of SEMLS on ΔGDI (1.70 GDI points). Altered motor control (i.e., dynamic and static motor control) and strength had strong effects on GDIpre, but minimal effects on ΔGDI. Spasticity and orthopedic impairments had minimal effects on GDIpre or ΔGDI.ConclusionAltered motor control did have a strong effect on GDIpre, indicating that these impairments do have a causal effect on a child’s gait pattern, but minimal effect on expected changes in GDI after SEMLS. Heterogeneity in outcomes suggests there are other factors contributing to changes in gait. Identifying these factors and employing causal methods to examine the complex relationships between impairments and movement will be required to advance our understanding and care of children with CP.

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.

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.