Surgery In Cerebral Palsy Research Articles

Multidisciplinary biomechanical evaluation of orthopedic foot surgery in cerebral palsy: A clinical case study

Multidisciplinary biomechanical evaluation of orthopedic foot surgery in cerebral palsy: A clinical case study

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.

Bony hip reconstruction for displaced hips in patients with cerebral palsy: Is postoperative immobilization indicated?

Decisions for postoperative immobilization after bony hip reconstructive surgery in cerebral palsy are controversial in current practice. The aim of this study was to check if choosing not to use any kind of postoperative immobilization is a safe practice. A retrospective cohort study was conducted in a pediatric orthopedic tertiary referral center. The study included 148 patients (228 hips) with cerebral palsy, who had bony hip surgery. Medical records were reviewed for incidence of complications, methods of pain control, and length of hospital stay. Three radiographic measures (neck-shaft angle, Reimers migration index, and acetabular index) were performed on preoperative and postoperative X-rays. X-rays were also checked for mechanical failure of implant, recurrent dislocation/subluxation, and fractures in the first 6 months postoperatively. In total, 94 (64%) were male and 54 (36%) were female. Seventy-seven (52%) were Gross Motor Function Classification System V, mean age at surgery was 8.6 years (2.5-18.4 years). Length of hospital stay was 6.25 days (SD 4.64 days). Medical complications that may have prolonged hospital stay occurred in 41 patients (27.7%). Radiological measurements showed significant improvement postoperatively (p = 0.001). Seven patients (4.7%) had another surgery in first 6 months (three for recurrent dislocation/subluxation, three for implant failure, and one for ipsilateral femur fracture). Avoiding postoperative immobilization following bony hip surgery in cerebral palsy is a safe practice and associated with reduced rate of medical and mechanical problems compared to the current literature. This approach should be utilized with optimal pain and tone management.

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.

Range of hip abduction after preventive and reconstructive surgery in cerebral palsy: a longitudinal registry study of 307 children

Background and purpose — Hip dislocation in cerebral palsy (CP) is caused by altered muscle forces on the joint during typical hip positioning in adduction–flexion–inward rotation. Preventive surgery includes adductor–psoas lengthening (APL) or varus derotation osteotomy (VDRO) of the proximal femur. We assessed the changes in the hip abduction range after these operations. Patients and methods — Data were obtained from the Swedish Surveillance Programme for CP. The range of hip abduction before and up to 18–36 months after surgery was assessed for all children who underwent APL or VDRO. Data for 1 hip per child was assessed. Ordinary linear regression was used. Results — In the 150 children who underwent APL, the mean range of abduction increased from 29° (95% confidence interval [CI] 28–32) preoperatively to 37° (CI 35–39) at 18–36 months. In the 157 children who underwent VDRO, the respective mean values were 30° (CI 29–32) and 29° (CI 28–31). The mean difference in preoperative abduction between sides was greater in children who underwent unilateral (9.4°, CI 7.8–11) than bilateral (5.5°, CI 3.4–7.6) VDRO. At 18–36 months postoperatively, the differences between sides were almost unchanged. Interpretation — The range of hip abduction increased after APL but remained unchanged after VDRO. This may explain the normal development of hip displacement after these operations. Differences in abduction between sides were not substantially affected by whether VDRO was performed uni- or bilaterally.

Quality of Surgery and Patient Selection Are Keys to Success in Hip Stabilization Surgery in Cerebral Palsy.

Cerebral palsy patients are at risk of hip instability, to which various soft tissue and bony surgeries are performed should conservative management fail. We aim to identify factors associated with treatment failure to guide surgical management. Cerebral palsy patients treated at 2 university-affiliated tertiary pediatric orthopaedic referral centers with hip stabilization surgery performed for subluxation in 1998 to 2015 with minimum of 5 years follow-up were reviewed. Failure was defined as reoperation to the same hip because of recurrent subluxation. Age, sex, Gross Motor Function Classification System level, tone abnormality, operation type, Reimer's migration index (RMI), and acetabular index (AI) were assessed. Cut-off values were identified through Youden index on receiver operating characteristic curve. Eighty-nine hips from 55 patients with mean follow-up of 12.4 years were analyzed. Revision surgery was performed in 14 hips. Postoperative hip subluxation (P<0.001) and acetabular dysplasia (P=0.001) were predictive of failure, with postoperative RMI conferring an adjusted hazard ratio of 1.13 (95% confidence interval: 1.08-1.19, P<0.001) on multivariable survival analysis. Achieving a postoperative RMI of <27.5% predicts success with 92.9% sensitivity and 72% specificity with area under curve of 0.916 (P<0.001), while postoperative AI of <23.1 degrees predicts success with 92.3% sensitivity and 62.2% specificity with area under curve of 0.796 (P=0.001). In subgroup analysis of soft-tissue-only procedures, RMI >44% preoperative and >32% postoperative were associated with reoperation. In femur-only osteotomies, preoperative RMI >48% and postoperative RMI >28% were associated with failure. In pelvic and combined osteotomies, postoperative RMI >32% and AI >30 degrees were associated with failure. Other factors analyzed were not associated with reoperation. Patient selection and quality of surgery in terms of residual postoperative hip subluxation and acetabular dysplasia are associated with need for remedial surgery. Soft-tissue-only procedures should aim to correct RMI to <32%. Bony surgery should be considered when preoperative RMI >44%, and pelvic osteotomies if RMI >48%. Pelvic osteotomies should target postoperative RMI <32% and AI <30 degrees. Level II-prognostic study.

Aponeurotic release of semimembranosus: A technical note to increase correction gained with hamstring lengthening surgery in cerebral palsy.

The aim of this study was to determine the intraoperative corrective effect of the aponeurotic release of semimembranosus (SM) as a single procedure or an adjunct procedure to distal myotendinous release of semitendinosus (ST) and myofascial release of SM lengthening in the correction of knee flexion deformity in cerebral palsy (CP). In this prospective study, 46 knees of 23 consecutive ambulatory patients (15 boys and 8 girls; mean age=8.33 years; age range=5-12 years) with spastic diplegic CP with a gross motor function classification system level (GMFCS) II or III were included. The patients were then divided into 2 groups. In group I, there were 10 patients (4 boys, 6 girls; mean age=8.6±2), and combined release of ST in the myotendinous junction and SM in the myofascial junction, followed by aponeurotic release of SM were carried out. In group II, there were 13 patients (2 girls, 11 boys; mean age=8±2.35), and aponeurotic release of SM was done first and followed by the combined release of ST in the distal myotendinous junction and the myofascial release of SM. Intraoperative popliteal angle (PA) measurements were recorded in each group. PA was reduced from 58.1°±7.6° (range=46°-75°) to 41.2°±8.8° (range=20°-54°) in group 1 and from 59.1°±11.3° (range=40°-87°) to 42.7°±10.8° (range=24°-64°) in group 2. No significant difference was observed between the groups in terms of reduction in PA (p=0.867). In group 1, adding the aponeurotic release of SM further reduced the PA to 31.7°± 8.5° (range=14°-47°) (p=0.002). In group 2, adding the myotendinous release of ST and myofascial release of SM further reduced the PA to 32.9°±7.2° (range=16°-44°) (p=0.004). There was no significant difference between the final PA values in the 2 groups (p=0.662). There was no difference in terms of early complications. Aponeurotic release of SM is equally effective to reduce the intraoperative PA with combined myotendinous release of ST and myofascial release of SM. Combining all the 3 procedures provides a better correction without forceful manipulation or lengthening of the lateral hamstrings during the correction of knee flexion deformity in CP.

Long-term follow-up after multilevel surgery in cerebral palsy.

Single-event multilevel surgery (SEMLS) is frequently used to correct pathological gait patterns in children with bilateral spastic cerebral palsy (BSCP) in a single session surgery. However, in-depth long-term evaluation reports of gait outcomes are limited. Therefore, we investigated if SEMLS is able to correct lower extremity joint and pelvic angles during gait towards typically developing gait patterns (TDC) in children with BSCP, and if so, if this effect is durable over a 10-year period. In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7-18.2years at the time of SEMLS were retrospectively recruited. Three-dimensional gait data were captured preoperatively, as well as at short-, mid-, and long-term post-operatively, and used to analyze: movement analysis profile (MAP), gait profile score (GPS), and lower extremity joint and pelvic angles over the course of a gait cycle using statistical parametric mapping. In agreement with previous studies, MAP and GPS improved towards TDCs after surgery, as did knee extension during the stance phase (ɳ2 = 0.67; p < 0.001), while knee flexion in the swing phase (ɳ2 = 0.67; p < 0.001) and pelvic tilt over the complete gait cycle (ɳ2 = 0.36; p < 0.001) deteriorated; no differences were observed between follow-ups. However, further surgical interventions were required in 8 out of 13 of the participants to maintain improvements 10years post-surgery. While the overall gait pattern improved, our results showed specific aspects of the gait cycle actually deteriorated post-SEMLS and that a majority of the participants needed additional surgery, supporting previous statements for the use of multilevel surgery rather than SEMLS. The results highlight that the field should not only focus on the overall gait scores when evaluating treatment outcomes but should offer additional long-term follow-up of lower extremity function.

Rectus femoris transfer surgery in cerebral palsy: can causal inferences be made from observational data?

This commentary is on the original article by Schwartz and Ries on pages 196–203 of this issue.

Blood transfusion following major orthopaedic surgery in cerebral palsy: a retrospective analysis.

Progressive musculoskeletal pathology is ubiquitous among children with cerebral palsy (CP). Corrective surgery places them at risk of major blood loss and red blood cell (RBC) transfusion. Significant variability exists in uptake of perioperative patient blood management (PBM) strategies. This study aimed to examine factors contributing to RBC transfusion and assist in future development of care pathways. A retrospective review at a tertiary paediatric hospital was undertaken to identify patients with CP undergoing either primary spinal fusion or single event, multilevel surgery (SEMLS) between 2010 and 2015. Solely soft tissue procedures were excluded. Data collected included demographics, Gross Motor Function Classification System level, surgical details, perioperative PBM and transfusion rates. Univariable analysis was performed to assess contributing factors to RBC transfusion. A total of 36 spinal fusion and 98 SEMLS patients were included. Preoperatively, 12% were anaemic, but only 19% had a ferritin checked. Overall, 49 patients (37%) received RBC transfusions. Intraoperative usage of tranexamic acid and cell salvage was 89% and 81%, respectively, for the spine cohort, and 22% and 3% for the SEMLS cohort. Successively higher Gross Motor Function Classification System levels, sodium valproate usage, longer surgical times, spinal fusion, pelvis instrumentation and more osteotomies were associated with RBC transfusion. More than one-third of CP patients who underwent major orthopaedic surgery received RBC transfusion. As expected, the more severely affected patients undergoing longer procedures were at highest risk. Significant improvements can be made in PBM to help optimize patients for surgery and minimize the need for transfusion.

Mothers’ experiences after single-event multilevel orthopedic surgery in cerebral palsy: A descriptive qualitative study

Background &amp; Aim: Mothers with children with cerebral palsy experience various problems during the care process, especially after surgery. Since these problems of parents directly affect the care provided to the child, it is essential to evaluate the problems that families experience in this process. This study aims to explore the experiences of mothers of children with cerebral palsy and to find out how these mothers care for their children that underwent single-event multilevel orthopedic surgery due to cerebral palsy. Methods &amp; Materials: A descriptive phenomenological study was used to explore the life experiences of 24 participants who had children with CP. This study was performed in the Department of Orthopedics at a Training and Research Hospital in Turkey, between March and July 2015. The study was completed with the participation of 24 mothers who had children with cerebral palsy. A qualitative, face-to-face and in-depth interview technique were used for data collection. Colaizzi’s method and Professional Software for Qualitative and Mixed Methods Research 11 software were used for analysis. Results: The mean age was 37.29±6.86. Based on the mothers’ care experiences data, three main themes were identified, namely “Be concern about the process,” “Facing the Difficulties and Coping,” “Adaptations the changing family lifestyle.” Conclusions: The findings demonstrated that CP affects intra-family relations and functions, and contributes to various physical and mental health problems, and financial statement. We believe that the findings may help healthcare professionals to provide and plan education in the field of healthcare services in a way that helps families cope with the process successfully.

Long-term Outcomes Following Multilevel Surgery in Cerebral Palsy.

This long-term consecutive, retrospective single-center cohort study evaluates long-term outcomes of single-event multilevel surgery in diplegic cerebral palsy with respect to functional status, gait, and patient satisfaction. All patients with diplegic cerebral palsy who underwent single-event multilevel surgery >10 years previously were included. Retrospective gait assessment was performed using the Edinburgh Visual Gait Score (EVGS) and Gillette Functional Assessment Questionnaire Walking Scale (FAQWS) preoperatively and at midterm postoperative follow-up (median 2.6 y) and prospectively at most recent review [median 18 y, interquartile (IQ) range: 14.4 to 20.5 y]. The Short Form-36 (SF-36) was used prospectively to evaluate outcome compared with population norms for adults from the UK. The complete assessment was possible in 26 of 39 patients who met the inclusion criteria. There was a statistically significant improvement at most recent follow-up compared with the preoperative assessment for EVGS and FAQWS [Wilcoxon Matched Pairs Signed Rank test -4.42 (P<0.0001) and 3.98 (P=0.0001), respectively]. The median Physical Health and Mental Health Component Summary scores for the SF-36 were 43.0 (IQ range: 32.8 to 46.8) and 55.3 (IQ range: 46.1 to 61.1), respectively. This study demonstrates significant long-term improvements in function, independence and patient satisfaction that continue into adulthood. This will inform discussions with patients and families considering this treatment option. Level IV-Retrospective cohort study.

Investigating the Feasibility of a Modified Quantitative Sensory Testing Approach to Profile Sensory Function and Predict Pain Outcomes Following Intrathecal Baclofen Implant Surgery in Cerebral Palsy.

Intrathecal baclofen (ITB) pumps used to manage spasticity in children with cerebral palsy (CP) also improve pain outcomes for some but not all patients. The purpose of this clinical feasibility study was to explore whether a quantitative sensory testing approach could a) be modified and used to subgroup individuals into sensory profiles and b) test whether the profiles were related to postimplant pain outcomes (i.e., pain responsive or pain persistent). A purposeful clinical sample of nine children with CP (mean age = 12.5 years, male = 56%) and complex communication needs participated. A prospective within-subject design was used to measure proxy-reported pain before and after ITB implant. Pain response status was determined by proxy-reported pain intensity change (>50% change in maximum rated intensity). A modified quantitative sensory testing (mQST) procedure was used to assess behavioral responsivity to an array of calibrated sensory (tactile/acute nociceptive) stimuli before surgery. Seven individuals with presurgical pain had mQST differentiated sensory profiles in relation to ITB pain outcomes and relative to the two individuals with no pain. Presurgically, the ITB pain responsive subgroup (N = 3, maximum rated pain intensity decreased >50% after ITB implant) showed increased behavioral reactivity to an acute nociceptive stimulus and cold stimulus, whereas the ITB pain persistent subgroup (N = 4) showed reduced behavioral reactivity to cold and repeated von Frey stimulation relative to the no pain individuals. Implications for patient selection criteria and stratification to presurgically identify individuals with CP "at risk" for persistent postprocedure pain are discussed.

Radiation Prophylaxis for Hip Salvage Surgery in Cerebral Palsy: Can We Reduce the Incidence of Heterotopic Ossification?

Heterotopic ossification (HO) is a well-recognized complication of proximal femoral resection (PFR) surgery in children with cerebral palsy (CP). Although single-dose radiation prophylaxis (SDRP) has been shown to be effective at lowering the rates of HO following adult total hip arthroplasty; there has been limited study examining the efficacy of SDRP for HO prevention in children with CP undergoing PFR. The purpose of this study was to assess the efficacy of SDRP in children with CP undergoing PFR. This retrospective case control series identified all patients from one tertiary children's hospital undergoing PFHR. Patients were dichotomized into (1) SDRP and (2) non-SDRP groups. In SDRP, radiation was delivered preoperatively at a dose of 7.5 Gy utilizing a 6 MV photon beam. The incidence of HO in the SDRP cohort was compared to historic data using binomial testing. The size of HO lesions was compared using Wilcoxon signed-rank test. McCarthy, Brooker, and Anatomic Classifications of HO were compared using repeated measures logistic regression. Twenty-three patients (mean age, 15.5) and 35 hips (17 SDRP, 18 Non-SDRP) were included in the analysis. There were 17 females and 6 males in the cohort with the majority classified as GMFCS V, 21/23 (91%). HO was seen in 6 of the SDRP cohort (6/17, 35%) and 15 of the non-SDRP cohort (15/18, 83%) (P=0.015). The average size of HO at maturity was 282.7 mm in the SDRP cohort compared with 1221.5 mm in the Non-SDRP cohort (P=0.026). Radiation treatment was associated with a 938.9 mm decrease in HO size at maturity (P= 0.026). Multivariate repeated measures logistic regression analysis found that non-SDRP hips had 13 times higher odds of developing HO (P=0.015). There were no significant differences in infection rates between the 2 cohorts and there were no radiation-associated complications. Short-term follow up demonstrates that SDRP is a safe and efficacious intervention in decreasing the incidence and size of HO in children with CP undergoing PFR. Level III-Case control cohort study.

Fascicular motor neurotomy associated to single event multilevel surgery in cerebral palsy. A long-term review with gait analysis

The aim of this study is assessment of functional benefits after multilevel surgery associated with selective partial neurotomies, focusing on rectus femoris (RF), semitendinosus and semimembranosus muscles (medial hamstring MH) and the function of hip and knee joints. This is a series of patients who had multilevel surgery associated with selective neurotomy on RF, MH between 2009 and 2016. Clinical data were knee range of motion and Modified Ashworth Scale for RF and MH, energy expenditure index and gross motor function measure. Gait analysis data were speed, cadence, step length, time of stance phase, articular range of motion and articular moment on hip and knee flexion. Gait deviation index (GDI) and gait profile score (GPS) were calculated. All data were collected before surgery, and at last gait analysis follow-up available for each patient. Thirty-four patients were included. The average time assessment after surgery was 33.35 months ± 13.8. There is significant improvement of GDI and GPS, respectively from 74.2 ± 11.6 to 79.7 ± 8.2 ( P = 0.010) and from 11.54 ± 4.1 to 9.5 ± 2.5 ( P = 0.005). Knee flexion decreased at body weight acceptance phase: 30.8 ± 9.9° to 24.7 ± 6.6° ( P = 0.006). Maximum joint moments were closer toward normality at knee on 55% of gait cycle: 0.2118 ± 0.25 Nm/kg to 0.1119 ± 0.14 Nm/kg ( P = 0.003), at hip on 10% of gait cycle: 0.1261 ± 0.39 Nm/kg to 0.4419 ± 0.32 Nm/kg ( P = 0.004) and for knee flexion at 95% of gait cycle: 0.1340 ± 0.45 Nm/kg to 0.1883 ±0.068 Nm/kg ( P = 0.005). GMFM (E item) increased from 75.39 ± 30.3% to 78.84 ± 27.8% ( P = 0.009). There is clinical and functional benefits. GDI and GPS were improved after procedure combining single event multilevel surgery with neurotomy. Moreover, kinematics of gait cycle is improved particularly at the beginning of gait cycle.

Fascicular motor neurotomy associated to single event multilevel surgery in cerebral palsy. A long-term review with gait analysis

The aim of this study is assessment of functional benefits after multilevel surgery associated with selective partial neurotomies, focusing on rectus femoris (RF), semitendinosus and semimembranosus muscles (medial hamstring MH) and the function of hip and knee joints. This is a series of patients who had multilevel surgery associated with selective neurotomy on RF, MH between 2009 and 2016. Clinical data were knee range of motion and Modified Ashworth Scale for RF and MH, energy expenditure index and Gross Motor Function Measure. Gait analysis data were speed, cadence, step length, time of stance phase, articular range of motion and articular moment on hip and knee flexion. Gait deviation index (GDI) and gait profile score (GPS) were calculated. All data were collected before surgery, and at last gait analysis follow-up available for each patient. Thirty-four patients were included. The average time assessment after surgery was 33.35 months ± 13.8. There is significant improvement of GDI and GPS, respectively from 74.2 ± 11.6 to 79.7 ± 8.2 ( P = 0.010) and from 11.54 ± 4.1 to 9.5 ± 2.5 ( P = 0.005). Knee flexion decreased at body weight acceptance phase: 30.8 ± 9.9° to 24.7 ± 6.6° ( P = 0.006). Maximum joint moments were closer toward normality at knee on 55% of gait cycle: 0.2118 ± 0.25 Nm/kg to 0.1119 ± 0.14 Nm/kg ( P = 0.003), at hip on 10% of gait cycle: 0.1261 ± 0.39 Nm/kg to 0.4419 ± 0.32 Nm/kg ( P = 0.004) and for knee flexion at 95% of gait cycle: 0.1340 ± 0.45 Nm/kg to 0.1883 ± 0.068 Nm/kg ( P = 0.005). GMFM (E item) increased from 75.39 ± 30.3% to 78.84 ± 27.8% ( P = 0.009). There is clinical and functional benefits. GDI and GPS were improved after procedure combining single event multilevel surgery with neurotomy. Moreover, kinematics of gait cycle is improved particularly at the beginning of gait cycle.

Assessing the Risk-Benefit Ratio of Scoliosis Surgery in Cerebral Palsy: Surgery Is Worth It.

The true benefits of scoliosis surgery in cerebral palsy (CP) remain uncertain. Our aims were to determine the benefits of spinal fusion according to health-related quality of life (HRQoL) improvement at long-term follow-up and to explore the effect of surgery-related complications on clinical outcomes. The cases of consecutive patients who had Gross Motor Function Classification System (GMFCS) level-IV or V cerebral palsy with 5-year follow-up from a prospective, longitudinal, multicenter database were analyzed. Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire and 4 Likert-type anchor questions preoperatively and at 1, 2, and 5 years of follow-up. Data on complications were collected prospectively. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations using repeated-measures analysis of variance (ANOVA). Spearman correlation coefficient was used to explore the association between changes in the CPCHILD at 1, 2, and 5-year follow-up and the reported complications within the follow-up period. Similarly, a comparative analysis between the percentage distribution of the answers to the 4 anchor questions and the reported complications was also performed. Sixty-nine patients with a mean age (and standard deviation) of 13.4 ± 2.6 years at enrollment were analyzed. The major Cobb angle was a mean of 81.9° ± 26.7° preoperatively and improved to a mean of 28.7° ± 14.4° at 2 years and 30.7° ± 15.3° at 5 years postoperatively. Significant improvements in CPCHILD personal care, positioning, and comfort domains were noted at all time points. The mean increase in the total score was 7.19 (p < 0.001) at 1 year, and the score gain was maintained at 2 and 5 years postoperatively. The overall complication rate was 46.4% at 1 year, 1.4% between 1 and 2 years, and 4.3% at 2 to 5 years postoperatively, with surgical intervention required in 6 patients within 1 year and in 2 additional patients within 5 years following scoliosis surgery. There was no correlation between complications and CPCHILD scores postoperatively at all time points, with the only exception of a weak correlation (ρ = -0.450, p = 0.002) with CPCHILD comfort score at 1 year after surgery. Scoliosis surgery in patients with CP leads to a significant improvement in HRQoL, which is maintained 5 years following surgery. The substantial complication rate does not correlate with HRQoL changes postoperatively, suggesting that the benefits of surgery outweigh the risks in this fragile population. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

DMCN 2017 highlights: advances in cerebral palsy, encephalitis, paediatric stroke, and more

During the past year, we have refined the editorial processes of Developmental Medicine & Child Neurology, in part by optimizing statistical reviews and by setting up a group of systematic review advisors in collaboration with the American Academy of Cerebral Palsy and Developmental Medicine. Indeed, we have strengthened links with all the societies for which DMCN is the official journal (see our front cover for details) and were happy in 2017 to welcome the Australasian Academy of Cerebral Palsy and Developmental Medicine into the fold. We have also enhanced journal content in various ways. Abstracts of all our articles are now provided in Spanish and Portuguese translations, courtesy of the Latin-American Academy of Child Development and Disabilities (ALDID). Our YouTube video channel hosts a growing collection of author and editor podcasts with contributions from eminent experts including Aaron Ciechanower, Nobel prizewinner in Chemistry. Interactivity with the journal's readership has been strengthened through social media and Letters to the Editor are now posted on our website to foster debate and discussion. This year has been marked by clarification of the practical implications of physical activity, participation (which was the topic of a Virtual Issue), the validation of various outcome measures, delineation of the neurophysiological and neuroimaging signature of several neurodevelopmental conditions, refinements in genotype–phenotype associations (‘comorbid’ attention-deficit–hyperactivity disorder and autistic features were critically documented in a number of conditions), and more evidence for efficacy and safety for specific modalities of immunotherapy or tone-modulating agents. Alongside excellent original articles and critical commentaries, we have had systematic reviews on a wide range of important topics from immunoglobulins in neurological disorders, to taping procedures and outcome of scoliosis surgery in cerebral palsy. We have also had state-of-the-art reviews on such promising approaches to disability as stem cell treatment and videogame-based therapy. My Editor's Choice for the first issue of the year was a study demonstrating that following a paediatric stroke protocol improves timeliness of accurate diagnosis and appropriate treatment.1 Other papers in the 2017 volume have presented and discussed new sets of paediatric stroke guidelines and documented various outcome aspects. Assessment and classification of hand function has been another guiding thread throughout the year. One work I particularly liked for its topic, methodology, and useful result – another Editor's Choice – developed a patient-reported outcome measure assessing upper limb function related to real-life activities of individuals with Duchenne muscular dystrophy.2 This measure should usefully document the individual's self-reported evolution and evaluate the efficacy of interventions. The value of several functional classification systems has been established for children in addition to the groups addressed in the original validations, including a Mini-Manual Ability Classification System for hand function in children with cerebral palsy under 4 years and the Communication Function Classification System for communication in preschool children with speech and language disorders. Stability of the Gross Motor Function Classification System over time has been confirmed3 and the validity of the concept of cerebral palsy has also been reaffirmed. An important contribution to the debate on paediatric traumatic brain injury was provided by Minns et al.'s study of the relationship between raised intracranial pressure and retinal haemorrhage,4 and the ensuing discussion. The review on anti-N-methyl-d-aspartate receptor encephalitis following herpes simplex encephalitis5 clarifies the biphasic course of the condition with a parainfectious immune-mediated disorder amenable to immunomodulatory treatment. Looking at the novel findings and advances in the fields of paediatric neurology and neurodisability that made up the fabric of DMCN in 2017, we can foresee further important developments in 2018 and beyond.

Radiation prophylaxis for hip salvage surgery in cerebral palsy – can we reduce the incidence of heterotopic ossification?

Radiation prophylaxis for hip salvage surgery in cerebral palsy – can we reduce the incidence of heterotopic ossification?

Orthopedic surgery in cerebral palsy: Instructional course lecture.

Orthopedic surgery (OS) plays an important role in the management of cerebral palsy (CP). The objectives of OS are to optimize functions and prevent deformity. Newer developments in OS for CP include emphasis on hip surveillance, minimally invasive procedures, use of external fixators instead of plates and screws, better understanding of lever arm dysfunctions (that can only be corrected by bony OS), orthopedic selective spasticity-control surgery, and single-event multilevel lever arm restoration and anti spasticity surgery, which have led to significant improvements in gross motor function and ambulation, especially in spastic quadriplegia, athetosis, and dystonia. The results of OS can be dramatic and life altering for the person with CP and their caregivers if it is performed meticulously by a specialized surgical team, at the appropriate age, for the correct indications, employing sound biomechanical principles and is followed by physician-led, protocol based, intensive, multidisciplinary, institutional rehabilitation, and long term followup. However, OS can be a double-edged sword, and if performed less than optimally, and without the supporting multidisciplinary medical and rehabilitation team, expertise and infrastructure, it often leads to significant functional worsening of the person with CP, including irretrievable loss of previous ambulatory capacity. OS must be integrated into the long term management of the person with CP and should be anticipated and planned at the optimal time and not viewed as a “last resort” intervention or failure of rehabilitation. This instructional course lecture reviews the relevant contemporary principles and techniques of OS in CP.