Risk factors for pancreatitis after posterior spinal fusion in children with cerebral palsy.

This study reports on the prevalence and risk factors of acute pancreatitis after posterior spinal fusion for cerebral palsy scoliosis. Pancreatitis diagnosis was based on elevated amylase or lipase above three times the upper normal limit. Perioperative data were compared between patients with and without pancreatitis. We included 300 patients; 55% developed acute pancreatitis. Gastrostomy dependence was more common in the pancreatitis group (P=0.048). Perioperative data were similar between groups. Patients with pancreatitis had longer duration of hospitalization (19 vs. 13 days, P<0.001). Acute pancreatitis is common after cerebral palsy scoliosis surgery. Gastrostomy dependence increases its risk. Although no mortality was reported, hospital stay was longer.

Hallux valgus deformity correction without fusion in children with cerebral palsy.

This study aimed to evaluate the outcomes of nonarthrodesis surgical treatment of hallux valgus (HV) deformity in children with cerebral palsy using radiographic and gait analysis parameters. There were 25 patients who had hallux valgus correction in 39 feet. The mean age at surgery was 15±2.8 years and the mean follow-up duration was 14.6 months. The first metatarsal osteotomy was performed in nine feet, bunionectomy in 25 feet, and Aiken osteotomy in 32 feet. None had metatarsophalangeal joint fusion. We observed a significant correlation between HV correction and other foot and ankle gait parameters. Our study showed correction of HV deformity at short-term follow-up without fusion of the metatarsophalangeal joint. LEVEL OF EVIDENCE: Level IV Therapeutic Studies.

Correction of Pelvic Obliquity After Spinopelvic Fixation in Children With Cerebral Palsy: A Comparison Study With Minimum Two-Year Follow-up.

STUDY DESIGN: Single institution cohort data were collected prospectively and reviewed retrospectively. OBJECTIVES: This study aims to compare outcomes among three different instrumentation types: unit rod, iliac screws, and sacral alar iliac (SAI) screws in terms of pelvic obliquity correction in children with cerebral palsy (CP). SUMMARY OF BACKGROUND DATA: The optimal choice for spinopelvic fixation in CP scoliosis with pelvic obliquity is controversial. METHODS: Patients with minimum 2 years' follow-up were divided into three groups according to instrumentation type and matched based on preoperative pelvic obliquity and coronal major curve magnitude. Radiographic measurements included horizontal pelvic obliquity angle (PO), spinopelvic angle (SPA), coronal and sagittal Cobb angles, and T1 pelvic angle. Procedures were performed in one pediatric institution between 2004 and 2012. All measurements were performed by a single independent reviewer who was not involved in the procedures. RESULTS: Seventy-seven patients (42 unit rod, 14 iliac screw, and 21 SAI screw) were included. Gender and age distribution was similar across all groups (56% males, 44% females, mean age 13.5 years). Mean follow-up was 3.6 years. Comparing pre- and postoperative measurements, there was a significant decrease (p < .05) in PO, SPA, and coronal major cob angle in all groups. No significant loss of correction occurred during follow-up. Postoperatively, TPA improved in all groups. Nonsymptomatic loosening was noted in 59% of unit rods, 57% of iliac screws, and 52% of SAI screws. One prominent iliac screw needed removal. One nonsymptomatic rod fracture, one infected pseudarthrosis, and one rod malposition occurred in unit rod group. CONCLUSIONS: This study suggests that for correction of pelvic obliquity in cerebral palsy scoliosis, iliac and SAI screws were similar to the unit rod in comparative effectiveness and implant safety profile. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Hip Reconstruction in Children With Unilateral Cerebral Palsy and Hip Dysplasia.

BACKGROUND: Highly functioning children with unilateral cerebral palsy (CP) who have hip involvement (type IV hemiplegia) may present with hip dysplasia during their adolescence. The aim of this report is to assess the outcomes of combined femoral and acetabular reconstruction in this population. METHODS: This study is a retrospective review of all patients with unilateral CP, Gross Motor Function Classification System types I and II, who had hip reconstruction for unilateral dysplasia between 1989 and 2013. Clinical variables (pain and hip passive range of motion) were reviewed. Hip morphology was assessed radiographically according to Melbourne Cerebral Palsy Hip Classification System. Three-dimensional gait analyses were also reviewed to evaluate the effect of surgery on these patients' gaits. RESULTS: Twelve patients were included with a mean age at surgery of 14 years (range, 7 to 19 y) and follow-up mean of 4 years (range, 1 to 8 y). Nine hips were improved according to Melbourne Cerebral Palsy Hip Classification System. Migration percentage decreased significantly (P<0.001) from 45% (30% to 86%) to 15% (0% to 28%). Neck shaft angle decreased (P<0.001) from 144 degrees (range, 129 to 156 degrees) to 125 degrees (range, 114 to 139 degrees). Tonnis angle and Sharp angle also decreased significantly. All patients were pain free at the last visit. Overall level of gait function as measured by Gait Deviation Index and Gait Profile Score [78 (61 to 89) and 12 (8 to 16), respectively] for all patients was maintained without significant changes. CONCLUSIONS: In hemiplegic type IV CP, with high functional level (Gross Motor Function Classification System I and II), hip dysplasia is a rare occurrence during adolescent years. Combined hip reconstruction improves hip morphology, relieves pain, and maintains a high level of function. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Gait Pattern and Lower Extremity Alignment in Children With Diastrophic Dysplasia.

BACKGROUND: The aim of this study was to describe the dynamic lower extremity alignment in children with diastrophic dysplasia (DD) by 3-dimensional gait analyses. Our main hypothesis was that gait kinematics and kinetics are different than the age-normalized population and patellar dislocation can alter the gait in patients with DD. METHODS: A retrospective review of clinical data and radiographs was conducted for patients with DD who had gait analysis before lower extremity skeletal surgery excluding foot procedures. Lower extremity range of motion was measured. The Pediatric Outcomes Data Collection Instrument (PODCI) was administered to parents to evaluate their children's functional status. Gait laboratory data were collected to compare the hip and knee kinematics in cases with and without patellar dislocation. Anteroposterior standing radiographs were taken for all patients to assess the correlation between measurements (clinical, radiologic, and gait) for coronal knee alignment. RESULTS: Thirty lower extremities of 15 children (7 females and 8 males) were evaluated. The mean age was 7.4±3 years, the mean height was 97.7±15 cm (z=-5.1), and the mean weight was 20.6±6.2 kg (z=-0.8). The DD PODCI subscores were statistically significantly lower (P<0.05) than the average stature for developing children, except for the happiness score. Gait analysis, compared between all DD and an age-normalized average stature group, showed decreased forward velocity, step length, and stride length with an increased average forward tilt of the trunk and pelvis, hip flexion, hip adduction, and internal rotation (P<0.001). Delta hip and knee motion were also decreased (P<0.001). The patella was dislocated in 19 (63.3%) and central in 11 (36.6%) knees. Comparison of the minimum knee and hip flexion at the stance phase demonstrated increased crouch gait in the patellar dislocation group (P<0.001). Knee alignment measurements between clinical examination and gait analysis showed moderate correlation (r, 0.476; P=0.008). CONCLUSIONS: Children with DD demonstrated lower PODCI subscores except for happiness. Gait analysis showed limited lower extremity function of the children with DD in our study group. Patella dislocation group had increased crouch gait. LEVELS OF EVIDENCE: Level III-diagnostic study.

Infection as a Complication of Intrathecal Baclofen Treatment in Children With Cerebral Palsy.

BACKGROUND: Children with cerebral palsy (CP) and spasticity are often managed with intrathecal baclofen treatment (ITB). Complications of ITB include infection at the pump or catheter site and late complications as well as revisions of the pump and catheter because of events such as battery expiration or implant malfunction. The goal of this study is to report the short-term and long-term incidence, risk factors, and treatment outcomes of ITB infections in children. METHODS: This was a retrospective review of 294 children with CP. The number of ITB surgeries per patient, risk of infection for primary and secondary ITB-related procedures, microorganisms responsible, and associated factors, such as concurrent orthopaedic interventions, medical comorbidities, and subsequent management of ITB-related infections, were evaluated. RESULTS: Infection occurred in 28/294 patients (9.5%) with a 4.9% rate per procedure. There were 14 acute (within 90 d of surgery) and 14 late infections. The infection risk per ITB procedure was 2.4%. Risk of late infection over 5-year mean follow-up was 0.95% per year. Pump removal with acute contralateral implantation was the most successful treatment of infections. Gross Motor Function Classification System level V and G-tube were the main risk factors for infection. A total of 133 concurrent orthopaedic procedures were performed during 277 ITB procedures with no increased risk of infection. CONCLUSIONS: ITB in children with CP has a relatively low and manageable risk of infection. It is important to always consider infection as a complication with ITB because with prompt treatment the positive impact of ITB is still possible. It is safe to perform concurrent orthopaedic procedures with ITB procedures. LEVELS OF EVIDENCE: Level III-therapeutic study.

Factors predicting postoperative complications following spinal fusions in children with cerebral palsy scoliosis.

PURPOSE: The purpose of this study was to review the postoperative complications after posterior spinal fusion (PSF) in cerebral palsy (CP) scoliosis and identify the predictive preoperative risk factors. METHODS: All PSFs consecutively performed for CP scoliosis between 2004 and 2013 were reviewed. Preoperative risk score (ORS) and postoperative complications score (POCS) were used as measures of all recorded preoperative risk factors and postoperative complications, respectively. RESULTS: The review included 303 children with a mean age of 14.6 ± 3.0 years. Mean hospitalization was 16 days. Dependence on G-tube feeding was associated with higher POCS (P = 0.027). Postoperative fever, seizures, and septicemia were associated with higher ORS (P < 0.01). Specifically, postoperative pancreatitis and deep wound infections were more common in children with G-tube. CONCLUSION: This study suggests that G-tube dependence is a predictive risk factor of complications after PSF in CP scoliosis. Children with G-tube need special perioperative care. No other specific preoperative risk factor predicted postoperative complications.