Arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in adolescents with cerebral palsy: A retrospective comparison study of three surgical techniques.

Purpose: We compared the outcomes of arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in 31 adolescents with cerebral palsy, using three different methods of fixation: K-wires, non-locking plates, and locking plates. Methods: Clinical outcomes included time to weight-bearing, fusion rates and surgical complications. Radiographic assessment included comparing pre- and post-operative hallux valgus angles, intermetatarsal angles, interphalangeal angles, and lateral metatarsophalangeal angles. Patient-reported outcomes included pre- and post-operative visual analogue scales addressing bunion pain and concerns, difficulties with wearing shoes and braces, and difficulties with foot hygiene. Results: Of the 31 adolescents (16 male), 10 patients had K-wire fixation, 11 had a non-locking dorsal plate, and 10 had fixation with a dorsal locking plate. Mean age at surgery was 16 years (12-18 years) and mean follow-up was 4 years (2.7-6.5 years). Patients with K-wire fixation had delayed weight-bearing and had more complications than those managed by dorsal plating. There were significant improvements in radiographic parameters (except interphalangeal angle) and in patient-reported outcomes, in all groups (p < 0.001). However, radiographic and clinical outcomes were better in the dorsal plating groups compared to the K-wire group. Conclusion: Arthrodesis of the first metatarsophalangeal joint gave good correction of deformity with improvements in symptoms and radiographic parameters in adolescents with cerebral palsy. We recommend dorsal plating that allowed early weight-bearing and had fewer complications with better clinical and radiographic outcomes, than K-wire fixation. Level of evidence: IV: Retrospective case series.

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.

Hip Surgery in Cerebral Palsy: A Bibliometric Analysis.

Hip dislocation in cerebral palsy can lead to pain, pressure sores and difficulty with perineal hygiene. Hip surveillance programs have been implemented to identify patients who might benefit from early intervention and preventive strategies. Surgical techniques used to treat hip dislocation include soft tissue procedures, guided growth, osteotomies and salvage procedures. A search was conducted using Clarivate Web of Science Core Collection on 18 October 2022, to identify all studies of bony or soft tissue surgery for hip pathology in children with cerebral palsy. Fifty-nine original studies and reviews with at least 20 citations were included in this bibliometric analysis. We found that there has been an increase in studies over the decades, with the most studies being published in the Journal of Pediatric Orthopaedics. The United States of America was the most productive country, with Boston Children's Hospital and Harvard University publishing the most articles. The Methodological Index for Non-randomized Studies (MINORS) scoring system was used to analyse the methodological quality of included cohort studies, with the median score being 11 out of 18; many studies had no prospective calculation of study size and lacked control groups. Overall, the literature on this topic appears to be preferentially published in the Journal of Pediatric Orthopaedics, and influential papers by Hagglund 2005 and 2014 continue to be highly cited.

Hip Surveillance and Management of Hip Displacement in Children with Cerebral Palsy: Clinical and Ethical Dilemmas.

Hip displacement is the second most common musculoskeletal deformity in children with cerebral palsy. Hip surveillance programs have been implemented in many countries to detect hip displacement early when it is usually asymptomatic. The aim of hip surveillance is to monitor hip development to offer management options to slow or reverse hip displacement, and to provide the best opportunity for good hip health at skeletal maturity. The long-term goal is to avoid the sequelae of late hip dislocation which may include pain, fixed deformity, loss of function and impaired quality of life. The focus of this review is on areas of disagreement, areas where evidence is lacking, ethical dilemmas and areas for future research. There is already broad agreement on how to conduct hip surveillance, using a combination of standardised physical examination measures and radiographic examination of the hips. The frequency is dictated by the risk of hip displacement according to the child's ambulatory status. Management of both early and late hip displacement is more controversial and the evidence base in key areas is relatively weak. In this review, we summarise the recent literature on hip surveillance and highlight the management dilemmas and controversies. Better understanding of the causes of hip displacement may lead to interventions which target the pathophysiology of hip displacement and the pathological anatomy of the hip in children with cerebral palsy. We have identified the need for more effective and integrated management from early childhood to skeletal maturity. Areas for future research are highlighted and a range of ethical and management dilemmas are discussed.

Foot drop after gastrocsoleus lengthening for equinus deformity in children with cerebral palsy.

BACKGROUND: Gastrocsoleus lengthening (GSL) is the most common surgical procedure to treat equinus deformity in ambulant children with cerebral palsy (CP). Foot drop, where the ankle remains in plantarflexion during swing phase, can persist in some children post-operatively. There is currently limited understanding of which children will demonstrate persistent foot drop after GSL. RESEARCH QUESTION: Which children develop persistent foot drop after GSL surgery for equinus? METHODS: We conducted a retrospective cohort study on ambulant children with CP who had GSL surgery for fixed equinus deformity. The aims of the study were: to determine the frequency of persistent foot drop post-operatively and to compare outcome parameters from physical examination and three-dimensional gait analysis for children with hemiplegia or diplegia. RESULTS: One hundred and ten children functioning at GMFCS Levels I/II/III of 28/75/7 met the inclusion criteria for this study. There were 71 boys and mean age was 9.1 years at time of GSL surgery. The overall frequency of persistent foot drop was 25%, with a higher frequency of persistent foot drop in children with hemiplegia (42%) than children with diplegia (19%). There were significant improvements in dorsiflexor strength and in selective motor control in children with diplegia but not in children with hemiplegia. Mean (SD) pre-operative mid-swing ankle dorsiflexion for children with hemiplegia was - 14.0° (9.9°) and improved post-operatively to - 1.6° (5.5°). For children with diplegia, the pre-operative mid-swing ankle dorsiflexion was - 12.1° (12.9°) and improved post-operatively to + 4.2° (6.9°). SIGNIFICANCE: Foot drop is present following GSL surgery for fixed equinus deformity in a significant number of children with hemiplegia and to a lesser extent in children with diplegia, which may reflect a difference in the central nervous system lesion between these groups. New management approaches are required for this important and unsolved problem.

Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review.

Purpose: In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement. Method: A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022. Results: There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates. Conclusion: The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research. Level of evidence: level V.

Assessment of foot alignment and function for ambulatory children with cerebral palsy: Results of a modified Delphi technique consensus study.

Purpose: The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results: Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment. Conclusion: The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy. Level of Evidence: V.

Finding consensus for hamstring surgery in ambulatory children with cerebral palsy using the Delphi method.

Purpose: There is marked variation in indications and techniques for hamstring surgery in children with cerebral palsy. There is particular uncertainty regarding the indications for hamstring transfer compared to traditional hamstring lengthening. The purpose of this study was for an international panel of experts to use the Delphi method to establish consensus indications for hamstring surgery in ambulatory children with cerebral palsy. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with statements regarding hamstring surgery, including surgical indications and techniques, post-operative care, and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither of these thresholds was reached. Results: The panel reached consensus or general agreement for 38 (84%) of 45 statements regarding hamstring surgery. The panel noted the importance of assessing pelvic tilt during gait when considering hamstring surgery, and also that lateral hamstring lengthening is rarely needed, particularly at the index surgery. They noted that repeat hamstring lengthening often has poor outcomes. The panel was divided regarding hamstring transfer surgery, with only half performing such surgery. Conclusion: The results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy. Level of evidence: level V.

Understanding skeletal muscle in cerebral palsy: a path to personalized medicine?

Until recently, there has been little interest in understanding the intrinsic features associated with the pathomorphology of skeletal muscle in cerebral palsy (CP). Coupled with emerging evidence that challenges the role of spasticity as a determinant of gross motor function and in the development of fixed muscle contractures, it has become increasingly important to further elucidate the underlying mechanisms responsible for muscle alterations in CP. This knowledge can help clinicians to understand and apply treatment modalities that take these aspects into account. Thus, the inherent heterogeneity of the CP phenotype allows for the potential of personalized medicine through the understanding of muscle pathomorphology on an individual basis and tailoring treatment approaches accordingly. This review aims to summarize recent developments in the understanding of CP muscle and their relationship to musculoskeletal manifestations, in addition to proposing a treatment paradigm that incorporates this new knowledge.

Three-Dimensional Gait Analysis in Children Undergoing Gastrocsoleus Lengthening for Equinus Secondary to Cerebral Palsy.

Background and Objectives: Equinus is the most common deformity in children with cerebral palsy, and surgical lengthening of the gastrocsoleus muscle-tendon unit is the most commonly performed operation for children with cerebral palsy. Treatment outcomes of orthopaedic surgery can be measured objectively with three-dimensional gait analysis. This study examined the quality of evidence for gastrocsoleus lengthening surgery based on objective measures. Materials and Methods: A search was performed with Medline, Embase and PubMed from 1990 to 25 August 2020 using the keywords "cerebral palsy", "equinus", "surgery" and "gait analysis". Only studies of gastrocsoleus lengthening surgery using three-dimensional gait analysis were included, yielding 34 studies. Results: Fourteen studies reported swing phase kinematics and all studies reported a significant improvement. Rates of recurrent equinus and calcaneus were reported in 21 studies and varied widely based on follow-up period and surgical technique. Conclusions: Poor study quality and marked variability in study samples and interventions made comparison difficult. Future studies should consider prospective design, controls or comparison groups and more detailed breakdowns of outcomes by cerebral palsy subtype, sagittal gait pattern, and equinus type in order to allow more rigorous treatment recommendations to be made.

Indications for gastrocsoleus lengthening in ambulatory children with cerebral palsy: a Delphi consensus study.

PURPOSE: Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. METHODS: A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. RESULTS: Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). CONCLUSIONS: The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. LEVEL OF EVIDENCE: V.

Establishing surgical indications for hamstring lengthening and femoral derotational osteotomy in ambulatory children with cerebral palsy.

PURPOSE: Surgical procedures, such as medial hamstring lengthening (MHL) and femoral derotational osteotomy (FDO), can improve the gait of children with cerebral palsy (CP); however, substantial variation exists in the factors that influence the decision to perform surgery. The purpose of this study was to use expert surgeon opinion through a Delphi technique to establish consensus for indications in ambulatory children with CP. METHODS: A 15-member panel, all established experts with at least nine years' experience in the surgical management of children with CP, was created (mean of 20.81 years' experience). All panel members also had expertise of the use of movement analysis for the assessment of gait disorders in children with CP. The group initially focused on two of the most commonly performed procedures, MHL and FDO, in an attempt to gain consensus (> 80%). This was obtained through a standardized, iterative Delphi process. RESULTS: For MHL, a total of 59 questions were surveyed: 41 indication questions and 18 outcome questions, for which there was consensus on ten indication questions and seven outcomes. For FDO, a total of 55 questions were surveyed: 43 indication questions and 12 outcome questions, for which there was consensus on 29 indication questions and eight outcomes. CONCLUSION: This study is the first to use an expert panel to identify best-practice indications for common surgical procedures of children with CP. The results from this study will allow for more informed evaluation of practice and form the basis for future improvement efforts to standardize surgical recommendations internationally. LEVEL OF EVIDENCE: Level IV.

Botulinum Toxin in the Management of Children with Cerebral Palsy.

During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.