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

PURPOSE: 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. METHODS: 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 1 year 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. RESULTS: 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. CONCLUSION: 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.

Efficacy of expansion pharyngoplasty and hypoglossal nerve stimulation in treating sleep apnea.

OBJECTIVE: We investigated whether a palatal conversion procedure combined with a second-stage hypoglossal nerve stimulator (HGNS) insertion can be beneficial for those patients who have a complete concentric velopharyngeal collapse and may initially not meet the criteria for use of HGNS. METHODS: A retrospective chart review included all patients who underwent a planned multi-level sleep surgery including expansion sphincter pharyngoplasty (ESP) followed by HGNS. All patients had a complete concentric collapse (CCC) of the velopharynx (VP) on pre-intervention drug-induced sleep endoscopy (DISE) and were initially not a candidate for HGNS. These patients then underwent ESP followed by a DISE to confirm elimination of the CCC of the VP. They then went on to HGNS implantation several months later followed by a sleep study. RESULTS: A total of 20 patients were identified and included in the retrospective chart analysis. All patients who underwent ESP successfully converted their VP from CCC to an anterior-posterior collapse pattern and thus met inclusion criteria for HGNS. After the HGNS was implanted, patients showed a significant reduction of the mean AHI from 53.9 before ESP to 8.2 after ESP and HGNS and a decrease in the Epworth Sleep Score (ESS) from a mean of 13.3 to 5.7. CONCLUSION: ESP can be effective in eliminating the CCC of the VP thus making patients become HGNS candidates. In selected OSA patients, who have multilevel upper airway obstruction with complete concentric VP collapse, the combination of ESP and HGNS insertion should be considered as a planned 2-staged approach.

Long-term stability of results following surgery for obstructive sleep apnea (OSA).

PURPOSE: Although upper airway surgery in selected patients with obstructive sleep apnea (OSA) has been shown to be beneficial, its long-term effects have been questioned. The main objective was to evaluate whether results following surgery remain stable over time, both in objective and subjective terms. As a secondary aim, such stability was also measured in relation with the type of surgery performed. METHODS: This work constitutes a retrospective study of OSA adult patients subjected to the following surgical procedures: different types of pharyngoplasties, tongue-base surgery, partial epiglottectomy or hyoid suspension. Those who exclusively underwent tonsillectomy or nasal surgery were excluded. Before surgery, a sleep study, and an assessment of the patients' sleepiness and quality of life were performed, which were repeated at 8, 34, and 48 months after surgery. A total of 153 patients was included. RESULTS: Following surgery, the apnea-hypopnea index decreased from 34.84/h to 14.54/h and did not vary more than one point in subsequent controls (p = 0.01). The oxygen desaturation index changed from 31.02/h to 14.0/h and remained stable in the second (15.34/h) and third (11.43/h) controls (p = 0.01). Parameters measuring sleepiness and well-being demonstrated the maintenance of long-term benefits. New pharyngoplasties were observed to be more stable than classic pharyngoplasties in the long term (p = 0.04). Single-level surgeries were found to be more stable than multilevel surgeries, although a statistically significant difference was not observed (p = 0.07). CONCLUSION: The benefits obtained remained stable in the long term. In our sample, modern pharyngoplasty techniques showed superiority over the classic ones regarding long-term stability.

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

INTRODUCTION: 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. MATERIALS AND METHODS: In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7-18.2 years 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. RESULTS: 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 10 years post-surgery. CONCLUSIONS: 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.

Combined Selective Dorsal Rhizotomy and Single-Event Multilevel Surgery in a Child with Spastic Diplegic Cerebral Palsy: A Case Report.

INTRODUCTION: Children with spastic diplegic cerebral palsy (CP) often have functional and gait impairments related to spasticity and loss of range of motion (ROM). Selective dorsal rhizotomy (SDR) and single-event multilevel surgery (SEMLS) are surgical interventions that are used to manage spasticity and functional gait impairments, respectively. This is the first known case report of a child with spastic diplegic CP who underwent combined SDR and SEMLS. CASE REPORT: Our patient is a 7-year-old girl with spastic diplegic CP, functioning at the Gross Motor Function Classification System (GMFCS) level II, who presented with spasticity and contractures in bilateral lower extremities leading to functional gait impairments, despite conservative management. Combined SDR/SEMLS was offered with the goal of simultaneously managing spasticity and contractures while reducing the need for multiple procedures. Postoperatively, the patient's functional mobility, ROM, spasticity, and strength were assessed at various follow-up intervals. The patient had increased lower extremity weakness and functional decline postoperatively. Persistent genu recurvatum and knee instability required prolonged rehabilitation services, and she demonstrated functional gains with these interventions. At follow-ups, spasticity was resolved and ROM improved. By the 12-month follow-up, the Gross Motor Function Measure-66 was improved to 68.9 (55th percentile) from the preoperative level of 62.1 (35th percentile). By the 30-month follow-up, she was able to participate in novel recreational activities. DISCUSSION/CONCLUSION: Multidisciplinary teams may consider combined SDR/SEMLS for management of spasticity, gait impairment, and contracture in carefully selected patients with spastic CP.

Effects of soft tissue surgery on transverse kinematics in patients with cerebral palsy.

BACKGROUND: Gait disturbances, including flexed knee gait, stiff knee gait, and tip-toeing gait, are common in patients with cerebral palsy (CP). There has been no reports regarding kinematic changes in the transverse plane after soft tissue surgeries, such as distal hamstring lengthening (DHL), rectus femoris transfer (RFT), and tendo-Achilles lengthening (TAL). This study aimed to evaluate changes in the transverse plane after soft tissue surgery in patients with CP by assessing the effects of the DHL, RFT, and TAL. METHODS: The study enrolled 156 consecutive patients (mean age, 8.4 years; range, 4.4 to 20.9), representing 213 operated limbs, who underwent soft tissue surgery including DHL with semitendinosus transfer, RFT, and TAL. All patients were assessed by preoperative and 1-year postoperative three-dimensional gait analysis. Changes in transverse plane kinematics after soft tissue surgery and affecting factors were analyzed. RESULTS: Sagittal kinematics including knee flexion at initial contact, ankle dorsiflexion at initial contact, and mean ankle dorsiflexion in the stance phase were significantly improved after single event multilevel surgery (all p < 0.001). Transverse kinematics, including mean tibial rotation and foot progression angle, were significantly improved to a more external angle after soft tissue surgeries (- 2.9°, p = 0.004 and - 9.5°, p < 0.001). The mean hip rotation was significantly improved to a more external angle by RFT (- 4.7°, p = 0.010) and the foot progression angle was significantly improved to a more external angle by TAL (- 3.9°, p = 0.028). CONCLUSIONS: This study found that the transverse kinematics were improved to a more external angle after soft tissue surgery in patients with CP. Therefore, clinicians should consider that soft tissue surgery can affect the transverse plane kinematics in patients with CP. To confirm our findings, further research regarding the natural history of femoral and tibial torsion in children with CP is needed.

Long-term results of multilevel surgery in adults with cerebral palsy.

BACKGROUND: Deterioration of gait in adolescent and adult patients with cerebral palsy can be associated with multiple factors. Multilevel surgery (MLS) is one option in adults with cerebral palsy to improve gait function with encouraging short-term results. It is a question whether these improvements are maintained over time. METHODS: In a retrospective consecutive cohort study, adults with bilateral spastic cerebral palsy (BSCP) treated with MLS between 1995 and 2011 were scanned for potential inclusion. Patients needed to fulfill the following inclusion criteria: age at MLS > 17, standardized three-dimensional gait analysis (3D-GA) including clinical examination at pre-operative (E0), a short-term follow-up (E1) and at least seven years (E2) after the index MLS. Twenty adults (10 women, 10 men) with a Gross Motor Function Classification Level (GMFCS) I-III and a mean age at MLS of 24.8 years were included in this study. The average long-term follow-up was 10.9 years. The Gait Profile Score (GPS) was used as primary outcome measure. RESULTS: The GPS improved significantly from 13.8° before surgery to 11.2° at short-term (p = 0.007) and to 11.3° at long-term follow-up (p = 0.002). Mean GPS showed a slight deterioration between E1 and E2 due to a minority of six patients (30%) who showed a significant loss of correction. CONCLUSION: Surgical treatment in adults with BSCP was feasible and effective in the long-term. Significant improvement of gait and function was maintained in the majority of patients, while some patients were prone to develop crouch gait, hip flexion contractures, or pain.

Comparison of robotic and coblation tongue base resection for obstructive sleep apnoea.

OBJECTIVES: To compare the efficacy and safety of transoral robotic surgery (TORS) with endoscope-guided coblation tongue base resection. DESIGN: Retrospective case-control study. SETTING: University-based tertiary care medical center. PARTICIPANTS: Patients with obstructive sleep apnoea (OSA) who underwent endoscope-guided tongue base coblation resection or transoral robotic surgery (TORS) in combination with lateral pharyngoplasty at a single institution in South Korea between April 2013 and December 2016 were investigated. Forty-five patients who had moderate-to-severe OSA with tongue base collapse and a minimum follow-up period of 6 months with postoperative polysomnography (PSG) were enrolled in this study. MAIN OUTCOME MEASURES: All patients underwent pre- and postoperative (at least 4 months after surgery) overnight PSG. Available information on results of the PSG, Epworth sleepiness scale and complications of the TORS and coblation groups were compared. RESULTS: Postoperative PSG studies showed improved sleep quality for most patients. The mean postoperative apnoea-hypopnea index (AHI) was reduced significantly from 45.0 to 17.0 events/h (P < .0001) in the TORS group and from 45.6 to 16.2 events/h (P < .0001) in the coblation group. The mean rates of improvement (AHI reduction > 50%) were 75.0% in TORS patients and 62.1% in coblation patients and the difference was not significant. Less frequent postoperative morbidity, including bleeding, taste dysfunction and foreign body sensation, was recorded in TORS patients. CONCLUSIONS: Both the coblation and TORS groups showed similar surgical outcomes, TORS achieved PSG results non-inferior to and complication rates comparable to coblation.

Various combinations of velopharyngeal and hypopharyngeal surgical procedures for treatment of obstructive sleep apnea: Single-stage, multilevel surgery.

OBJECTIVE: The aim of this study was to investigate the safety and outcomes of velopharyngeal surgeries combined with hypopharyngeal surgeries as single-stage interventions for treatment of obstructive sleep apnea (OSA). METHODS: Retrospective analysis of operated patients. The velopharyngeal surgical interventions were uvulopalatal flap, anterior palatoplasty, expansion sphincter pharyngoplasty, transpalatal advancement pharyngoplasty, Cahali lateral pharyngoplasty, Z-palatoplasty, and modified uvulopalatopharyngoplasty. The hypopharyngeal surgical interventions were tongue base suspension, mucosal sparing partial glossectomy, genioglossus advancement, mandibulohyoid suspension, thyrohyoid suspension, and epiglottoplasty. RESULTS: Forty-one patients were enrolled after inclusion and exclusion criteria. The evaluation of symptoms and polysomnographic findings were performed preoperatively and at a minimum of 3months postoperatively. The mean age was 42.17±9.50years and the mean follow-up time was 6.8±6.0months. After single-stage multilevel surgery, the mean apnea hypopnea index (AHI) improved from 29.13±15.87events/h to 14.28±16.14events/h (p<0.001). According to the classical definition of success criteria (>50% reduction in AHI and postoperative AHI<20events/h), the surgical success rate was 56%, with cure of OSA (AHI<5events/h) in 41% of study population. The combined surgeries also improved Epworth scores, snoring scores, and respiratory parameters significantly (in all p<0.05). The major complications were bleeding requiring re-admission in surgery room and severe tongue base edema which regressed by steroid administration. The minor complications were pain, difficulty in swallowing, velopharyngeal insufficiency, regurgitation, minor bleeding, and occlusion disorder. The mean postoperative period to beginning of normal feeding was 1.81±1.01days. The percentage of pain, the number of patients with major bleeding, and the need for patient-controlled analgesia were higher in patients undergoing tissue resection/ablative hypopharyngeal procedures. The mean postoperative period to beginning of normal feeding was shorter in patients undergoing suture/repositioning hypopharyngeal procedures. CONCLUSION: According to outcomes of this study, OSA patients with multilevel obstructions can benefit from combined surgeries for velopharyngeal and hypopharyngeal regions at the same operation stage, without experiencing persistent complaints. It is promising that, despite multiple levels of obstruction was operated at single-stage, airway safety was preserved in all patients.

Predictors of success in combination of tongue base resection and lateral pharyngoplasty for obstructive sleep apnea.

The base of the tongue has been recognized as a significant site of obstruction in patients with obstructive sleep apnea (OSA). Our aim was to determine the independent predictors of surgical success in tongue base resection combined with lateral pharyngoplasty for OSA. Thirty-one OSA patients who underwent endoscopie-guided coblator or transoral robotic tongue base resection in combination with lateral pharyngoplasty for the treatment of retroglossal obstruction between March 2012 and December 2015 were enrolled in this study. Retroglossal obstruction was identified by preoperative nasopharyngoscopy with drug-induced sleep endoscopy and/or Müller's maneuver in supine position. Patients were divided into success and failure groups according to surgical outcome (postoperative apnea-hypopnea index (AHI) less than 20 and reduction more than 50% in baseline AHI). Physical profile, polysomnography, cephalometry parameters, and drug-induced sleep endoscopy and/or Müller's maneuver findings were compared between the two groups. Tonsil grade (p = 0.002), lateral oropharyngeal wall collapse on Müller's maneuver (p = 0.002), and AHI during rapid eye movement (REM AHI) (p = 0.038) were significantly higher in the success group than in the failure group. Tongue base collapse was more evident in the failure group than in the success group when patients open their mouth. (p = 0.037) Bigger tonsil size and higher REM AHI are favorable predictive factors, even in multilevel surgery such as tongue base resection, whereas tongue base collapse during mouth opening may be an unfavorable predictive factor.

The influence of multilevel upper airway surgery on CPAP tolerance in non-responders to obstructive sleep apnea surgery.

The aim of this study was to evaluate the influence of multilevel upper airway surgery on subsequent continuous positive airway pressure (CPAP) use and tolerance in patients with moderate to severe obstructive sleep apnea (OSA). The study cohort enrolled 67 consecutive patients, who underwent septoplasty plus modified uvulopharyngopalatoplasty (mUPPP) with or without modified tongue base suspension (mTBS) due to CPAP intolerance, and who had residual OSA requiring CPAP therapy [non-responders to surgery, apnea-hypopnea index (AHI) >15 events/h] that had been confirmed by control polysomnography at the sixth month postoperatively. A questionnaire including questions on postoperative CPAP use, problems faced during CPAP use after the surgery, change in OSA symptoms, and satisfaction with the surgery was designed, and filled through interviews. Seventeen (25.4 %) patients had septoplasty plus mUPPP and 50 (74.6 %) had septoplasty plus mUPPP combined with mTBS. Postoperatively, mean AHI (45.00 ± 19.76 vs. 36.60 ± 18.34), Epworth sleepiness scale (ESS) score (18.00 ± 4.45 vs. 13.00 ± 4.72), oxygen desaturation index (ODI) (48.98 ± 16.73 vs. 37.81 ± 17.03), and optimal CPAP level (11.80 ± 1.40 vs. 8.96 ± 1.20) were decreased (p < 0.001 for all parameters). Fifty-nine percent of patients reported that they fairly satisfied with the surgery and 49.2 % reported that their symptoms were completely resolved. While none of the cases could tolerate CPAP before surgery, almost half (47.8 %) of the cases used CPAP without problems postoperatively. Postoperative CPAP users had significantly higher postoperative AHI (p = 0.001), supine AHI (p = 0.009), ESS (p = 0.019), and ODI (p = 0.014), and significantly lower postoperative minimum O2 saturation (p = 0.001) compared with non-users. Multilevel upper airway surgery with less invasive techniques may improve CPAP tolerance in well-selected patients.

Hip-joint congruity after Dega osteotomy in patients with cerebral palsy: long-term results.

INTRODUCTION: Neurogenic hip dislocation is quite common in children with cerebral palsy (CP). The purpose of this study was to evaluate the long-term outcome of single-event multilevel surgery (SEMLS) in combination with hip reconstruction by using a periacetabular osteotomy as described by Dega concerning post-operative remodeling and plasticity of the femoral head post-operatively. METHODS: A total of 72 patients with CP as the primary disease and in whom a complex surgical hip reconstruction was performed during SEMLS between 1998 and 2004 were included in the study. There were 45 men and 27 women, with a median age of 7.6 (4.7-16.3) years at the time SEMLS was performed. The mean follow-up time was 7.7 years (4.9-11.8). X-rays were taken before and after surgery, and Rippstein 1 and 2 were used for follow-up. As the most reliable value for decentration, migration percentage (MP) as described by Reimers was used. To measure hip-joint cover at follow-up, the centre-edge angle was used. The hip was divided into four different categories according to sphericity and congruity. Using this approach, we could evaluate joint remodeling. RESULTS: Pre-operatively, the mean MP measured by X-ray was 68 %. Directly after surgery, this value decreased on average by 12 % and at the long-term follow-up was 16.0 % on average. A high rate of incongruence was observed on X-rays taken directly after surgery: 66 hip joints were classified as incongruent. The number of aspherical and incongruent joints decreased to 54 at the follow-up examination. CONCLUSION: Data of our study with high plasticity of the hip joint suggest that even if the femoral head is deformed and a persistent incongruency after surgery is expected, hip reconstruction can be recommended.

Perioperative complications of orthopedic surgery for lower extremity in patients with cerebral palsy.

Because complications are more common in patients with cerebral palsy (CP), surgeons and anesthesiologists must be aware of perioperative morbidity and be prepared to recognize and treat perioperative complications. This study aimed to determine the incidence of and risk factors for perioperative complications of orthopedic surgery on the lower extremities in patients with CP. We reviewed the medical records of consecutive CP patients undergoing orthopedic surgery. Medical history, anesthesia emergence time, intraoperative body temperature, heart rate, blood pressure, immediate postoperative complications, Gross Motor Function Classification System (GMFCS) level, Cormack-Lehane classification, and American Society of Anesthesiologists physical status classification were analyzed. A total of 868 patients was included. Mean age at first surgery was 11.8 (7.6) yr. The incidences of intraoperative hypothermia, absolute hypotension, and absolute bradycardia were 26.2%, 4.4%, and 20.0%, respectively. Twenty (2.3%) patients had major complications, and 35 (4.0%) patients had minor complications postoperatively. The incidences of intraoperative hypothermia, absolute hypotension, and major postoperative complications were significantly higher in patients at GMFCS levels IV and V compared with patients at GMFCS levels I to III (P<0.001). History of pneumonia was associated with intraoperative absolute hypotension and major postoperative complications (P<0.001). These results revealed that GMFCS level, patient age, hip reconstructive surgery, and history of pneumonia are associated with adverse effects on intraoperative body temperature, the cardiovascular system, and immediate postoperative complications.

[Modern view on the effectiveness of surgical methods for treating obstructive sleep apnea syndrome]. / Sovremennyi vzglyad na effektivnost' khirurgicheskikh metodov lecheniya sindroma obstruktivnogo apnoe sna.

Obstructive sleep apnea (OSA) syndrome is not only a widespread pathology, but also has far-reaching social consequences due to patients' poor quality of nighttime sleep and high daytime sleepiness. To date, a large number of methods, both conservative and surgical, have been developed for the treatment of OSA. Surgeries performed for OSA are aimed at correcting the structures of the nose, pharynx, larynx, as well as the hyoid and jaw bones and the muscles attached to them. Despite the seventy-five-year history of the use of surgical treatment methods, there is still no complete clarity regarding the advisability of certain types of operations. The article presents data from meta-analyses published over the last ten years and devoted to various types of surgical procedures aimed at combating OSA in adult and pediatric populations. Rhinosurgical approaches, uvulopalatopharyngoplasty, surgical advancement of the lower jaw in adults and expansion of the upper jaw in children, interventions on the hyoid bone and mental tubercle, removal of the palatine and pharyngeal tonsils, operations for laryngomalacia and bariatric surgery are considered. Data on the effectiveness of the most common operations: tonsillectomy in adults (85%), multilevel pharyngoplasty (60%); and about a wide range of data on the effectiveness of uvulopalatoplasty (25 to 94%) are presented. Effective surgical options and criteria for a positive prognosis of such treatment, the possibility of complete cure of OSA, that is, reducing the apnea/hypopnea index (AHI) below 5 events per hour in adults, are discussed. In conclusion, the need to continue research using Sher's criteria for the effectiveness of surgical operations is emphasized: a reduction in AHI by 50% or more or below 20 events per hour. Research that includes long-term postoperative follow-up is especially important.

Blood Loss and Related Laboratory Changes after Single-Event Multilevel Surgery and Hip Reconstructive Surgery in Patients with Cerebral Palsy.

BACKGROUD: Single-event multilevel surgery (SEMLS) and hip reconstructive surgery (HRS) often cause intraoperative bleeding, consequently increasing the probability of transfusion and postoperative laboratory changes. Therefore, it is important to assess risk factors to predict the amount of blood loss. This study aimed to evaluate blood loss, its influencing factors, and the related laboratory changes during SEMLS and HRS in patients with cerebral palsy (CP). METHODS: We retrospectively examined consecutive CP patients who underwent SEMLS and HRS. Surrogate markers of blood loss, including preoperative and postoperative hemoglobin (Hb), hematocrit, and changes in Hb concentration, were assessed. Albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatine levels were also analyzed for related laboratory changes. Risk factors were analyzed using multiple regression and logistic regression models. RESULTS: The overall cohort comprised 1,188 patients. Of them, 1,007 and 181 underwent SEMLS and HRS, respectively. Furthermore, 72 of 181 patients underwent a concomitant Dega osteotomy. The regression model showed that low preoperative Hb concentration (p < 0.001), high albumin level (p = 0.007), low body mass index (BMI) (p = 0.002), and bilateral HRS (p < 0.001) were significant risk factors of postoperative anemia. Valproate medication was associated with Hb drop, and the risk factors for Hb level < 8 g/dL on postoperative day 2 were bilateral HRS and Dega osteotomy in the HRS subgroup. In total, 21.6% had elevated AST levels on postoperative day 2, and bilateral HRS (p < 0.001), Gross Motor Function Classification System (GMFCS) level V (p = 0.041), Dega osteotomy (p < 0.001), and high preoperative AST level (p < 0.001) increased the risk of AST elevation. CONCLUSIONS: We have summarized the estimated blood loss and related laboratory changes after SEMLS and HRS in patients with CP and identified the risk factors. Clinical guidelines should be accordingly developed to include assessment of these risk factors and their impact in the outcomes of CP patients undergoing SEMLS and HRS.

Evaluation of Multilevel Surgeries in Children With Spastic Cerebral Palsy Based on Surface Electromyography.

The root mean square (RMS) of the surface electromyography (sEMG) signal can respond to neuromuscular function, which displays a positive correlation with muscle force and muscle tension under positive and passive conditions, respectively. The purpose of this study was to investigate the changes in muscle force and tension after multilevel surgical treatments, functional selective posterior rhizotomy (FSPR) and tibial anterior muscle transfer surgery, and evaluate their clinical effect in children with spastic cerebral palsy (SCP) during walking. Children with diplegia (n = 13) and hemiplegia (n = 3) with ages from 4 to 18 years participated in this study. They were requested to walk barefoot at a self-selected speed on a 15-m-long lane. The patient's joints' range of motion (ROM) and sEMG signal of six major muscles were assessed before and after the multilevel surgeries. The gait cycle was divided into seven phases, and muscle activation state can be divided into positive and passive conditions during gait cycle. For each phase, the RMS of the sEMG signal amplitude was calculated and also normalized by a linear envelope (10-ms running RMS window). The muscle tension of the gastrocnemius decreased significantly during the loading response, initial swing, and terminal swing (p < 0.05), which helped the knee joint to get the maximum extension when the heel is on the ground and made the heel land smoothly. The muscle force of the gastrocnemius increased significantly (p < 0.05) during the mid-stance, terminal stance, and pre-swing, which could generate the driving force for the human body to move forward. The muscle tension of the biceps femoris and semitendinosus decreased significantly (p < 0.05) during the terminal stance, pre-swing, and initial swing. The decreased muscle tension could relieve the burden of the knee flexion when the knee joint was passively flexed. At the terminal swing, the muscle force of the tibial anterior increased significantly (p < 0.05), which could improve the ankle dorsiflexion ability and prevent foot drop and push forward. Thus, the neuromuscular function of cerebral palsy during walking can be evaluated by the muscle activation state and the RMS of the sEMG signal, which showed that multilevel surgical treatments are feasible and effective to treat SCP.

One-Stage Multilevel Surgery for Treatment of Obstructive Sleep Apnea Syndrome.

We report the results of one-stage multilevel upper airway surgery for patients who could not tolerate continuous positive airway pressure (CPAP). Patients treated with multilevel surgery at a University Hospital in 2015-2019 were identified from a prospectively maintained database. The inclusion criteria were aged 18-70 years, body mass index (BMI) < 35 kg/m2, apnea-hypopnea index (AHI) > 20, and lingual tonsil hypertrophy grade 3 or 4. Drug-induced sleep endoscopy was performed before surgery in all patients. Multilevel surgery was performed in one stage and included expansion sphincter pharyngoplasty (ESP), coblation tongue base reduction (CTBR), and partial epiglottectomy (PE) as required. The outcome measures were postoperative AHI, time percentage oxygen saturation < 90%, and Epworth Sleepiness Scale (ESS) score. A total of 24 patients were included: median age 49.1 years, average BMI 27.26 kg/m2, and 90% men. Ten patients received ESP plus CTBR plus PE, eight received ESP plus CTBR, and six received ESP plus PE. The mean preoperative AHI was 33.01 at baseline and improved to 17.7 ± 13 after surgery (p < 0.05). The ESS score decreased from 11 ± 5.11 to 7.9 ± 4.94 (p < 0.05). The surgical success rate according to Sher's criteria was 82.3%. The median follow-up was 23.3 months (range 12-36). These findings suggest that multilevel surgery is a safe and successful treatment of OSAHS.

Postoperative amyloidosis of tongue base: Extremely rare complication after multilevel sleep surgery.

Amyloidosis is to be considered in the differential diagnosis of postoperative edema of tongue base after its ablation. It might be triggered by surgical trauma. After establishment of diagnosis, cause of secondary amyloidosis should be excluded.

Factors related to better outcomes after single-event multilevel surgery (SEMLS) in patients with cerebral palsy.

BACKGROUND: Good outcomes have been described after single-event multilevel surgery (SEMLS) in cerebral palsy (CP); however, there is limited evidence regarding factors influencing them. RESEARCH QUESTION: What were the factors related to kinematic outcomes after SEMLS in the present study? METHODS: Two hundred and fifty-eight patients with spastic diplegic CP, GMFCS I-III, who underwent SEMLS and had done pre and post-operative gait analyses were included in the SEMLS Group (SEMLS-G). A second search was performed in the same database looking for patients to compose the Control Group (CG), and 88 subjects, with at least two gait analyses and with no surgical intervention between tests, were identified. Demographic data, GDI and GPS (Gait Profile Score) were analyzed in both groups, and the results compared. A second evaluation was performed in the SEMLS-G in order to identify the influence of age, gender, follow-up time, pre-operative GDI, GMFCS and gait velocity on results. RESULTS: The GDI (51.3-58.4) and GPS (2.5°) improvement occurred only in SEMLS-G (p < 0.001). On sagittal plane, there was an improvement at the knee and ankle levels in SEMLS-G, whereas the pelvic alignment improved in the CG. In SEMLS-G, patients with improvement on GDI > 10 points had lower pre-operative GDI (46.15) than other groups (p < 0.001). In addition, patients with reduction on GDI after intervention had lower pre-operative gait velocity than subjects with improvement >10 points (p = 0. 01). The increase on GDI after SEMLS was greater in patients GMFCS I and II than GMFCS III (p = 0.003). There was a negative effect of GMFCS III on GDI improvement after intervention (p = 0.014). SIGNIFICANCE: Lower pre-operative GDI, higher baseline gait velocity and GMFCS levels I and II were related to better outcomes after SEMLS in the present study. On the other hand, patients GMFCS III were more susceptible to deteriorate after SEMLS.

Maxillomandibular advancement versus multilevel surgery for treatment of obstructive sleep apnea: A systematic review and meta-analysis.

Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea (OSA), which target different levels of airway obstruction. The objective of this review was to comparatively evaluate the clinical efficacy and safety of MMA and MLS in the treatment of OSA. MEDLINE and Embase databases were searched for studies on MMA and/or MLS in OSA patients. Twenty MMA studies and 39 MLS studies were identified. OSA patients who underwent MMA showed significant improvements in AHI, LSAT, ODI, and ESS by -46.2/h, 13.5%, -30.3/h, and -8.5, respectively. The pooled rates of surgical success and cure for MMA were 85.0% and 46.3%, respectively. Patients who underwent MLS showed significant improvements in AHI, LSAT, ODI, and ESS by -24.7/h, 8.7%, -19.1/h, and -5.8, respectively. The pooled surgical success and cure rates for MLS were 65.1% and 28.1%, respectively. The rates of major complication of MMA and MLS were 3.2% and 1.1%, respectively, and the rate of minor complication of MMA was higher than that of MLS. We conclude that both MMA and MLS are effective treatment options for OSA. Compared to MLS, MMA may be more effective in improving OSA. However, the complication rate of MMA is higher.