Increased acute postoperative wound problems following spinal fusion in overweight patients with adolescent idiopathic scoliosis.

This study assessed the rate of adverse wound events in individuals with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and sought to determine if obesity was related to the rate of adverse wound events. A retrospective review of patients with adolescent idiopathic scoliosis that underwent posterior spinal fusion between 2001 and 2013 was performed. Preoperative, perioperative, and postoperative data, including wound adverse events, were obtained through medical record review. Using the Center for Disease Control BMI criteria, participants were grouped into overweight/obese (BMI%≥85 percentile) or healthy/underweight (BMI%<85 percentile) groups. Obesity and prolonged hospital stay were independent risk factors for increased risk of wound problems.

Relationship of Strength, Weight, Age, and Function in Ambulatory Children With Cerebral Palsy.

BACKGROUND: The natural history of ambulatory function in individuals with cerebral palsy (CP) consists of deterioration over time. This is thought to be due, in part, to the relationship between strength and weight, which is postulated to become less favorable for ambulation with age. METHODS: The study design was prospective, case series of 255 subjects, aged 8 to 19 years, with diplegic type of CP. The data analyzed for the study were cross-sectional. Linear regression was used to predict the rate of change in lower extremity muscle strength, body weight, and strength normalized to weight (STR-N) with age. The cohort was analyzed as a whole and in groups based on functional impairment as reflected by Gross Motor Function Classification System (GMFCS) level. RESULTS: Strength increased significantly over time for the entire cohort at a rate of 20.83 N/y (P=0.01). Weight increased significantly over time for the entire cohort at a rate of 3.5 kg/y (P<0.0001). Lower extremity STR-N decreased significantly over time for the entire cohort at a rate of 0.84 N/kg/y (P<0.0001). The rate of decline in STR-N (N/kg/y) was comparable among age groups of the children in the study group. There were no significant differences in the rate of decline of STR-N (N/kg/y) among GMFCS levels. There was a 90% chance of independent ambulation (GMFCS levels I and II) when STR-N was 21 N/kg (49% predicted relative to typically developing children). DISCUSSION: The results of this study support the longstanding clinically based observation that STR-N decreases with age in children with CP. This decrease occurs throughout the growing years, and across GMFCS levels I to III. Independent ambulation becomes less likely as STR-N decreases. This information can be used to support the rationale, and provide guidelines, for a range of interventions designed to promote ambulation in children with CP.

Accuracy of skinfold and bioelectrical impedance assessments of body fat percentage in ambulatory individuals with cerebral palsy.

AIM: This study assessed the accuracy of measurements of body fat percentage in ambulatory individuals with cerebral palsy (CP) from bioelectrical impedance analysis (BIA) and skinfold equations. METHOD: One hundred and twenty-eight individuals (65 males, 63 females; mean age 12y, SD 3, range 6-18y) with CP (Gross Motor Function Classification System [GMFCS] levels I (n=6), II (n=46), and III (n=19) participated. Body fat percentage was estimated from (1) BIA using standing height and estimated heights (knee height and tibial length) and (2) triceps and subscapular skinfolds using standard and CP-specific equations. All estimates of body fat percentage were compared with body fat percentage from dual-energy X-ray absorptiometry (DXA) scans. Differences between DXA, BIA, and skinfold body fat percentage were analyzed by comparing mean differences. Agreement was assessed by Bland-Altman plots and concordance correlation coefficients (CCC). RESULTS: BMI was moderately correlated with DXA (Pearson's r=0.53). BIA body fat percentage was significantly different from DXA when using estimated heights (95% confidence intervals [CIs] do not contain 0) but not standing height (95% CI -1.9 to 0.4). CCCs for all BIA comparisons indicated good to excellent agreement (0.75-0.82) with DXA. Body fat percentage from skinfold measurements and CP-specific equations was not significantly different from DXA (mean 0.8%; SD 5.3%; 95% CI -0.2 to 1.7) and demonstrated strong agreement with DXA (CCC 0.86). INTERPRETATION: Accurate measures of body fat percentage can be obtained using BIA and two skinfold measurements (CP-specific equations) in ambulatory individuals with CP. These findings should encourage assessments of body fat in clinical and research practices.

A prospective cohort study of the effects of lower extremity orthopaedic surgery on outcome measures in ambulatory children with cerebral palsy.

BACKGROUND: Lower-extremity musculotendinous surgery is standard treatment for ambulatory children with deformities such as joint contractures and bony torsions resulting from cerebral palsy (CP). However, evidence of efficacy is limited to retrospective, uncontrolled studies with small sample sizes focusing on gait variables and clinical examination measures. The aim of this study was to prospectively examine whether lower-extremity musculotendinous surgery in ambulatory children with CP improves impairments and function measured by gait and clinical outcome tools beyond changes found in a concurrent matched control group. METHODS: Seventy-five children with spastic CP (Gross Motor Function Classification System levels I to III, age 4 to 18 y) that underwent surgery to improve gait were individually matched on the basis of sex, Gross Motor Function Classification System level, and CP subtype to a nonsurgical cohort, minimizing differences in age and Gross Motor Function Measure Dimension E. At baseline and at least 12 months after baseline or surgery, participants completed gait analysis and Gross Motor Function Measure, and parents completed outcome questionnaires. Mean changes at follow-up were compared using analysis of covariance adjusted for baseline differences. RESULTS: Surgery ranged from single-level soft tissue release to multilevel bony and/or soft tissue procedures. At follow-up, after correcting for baseline differences, Gillette Gait Index, Pediatric Outcomes Data Collection Instrument Expectations, and Pediatric Quality of Life Inventory (PedsQL) Physical Functioning improved significantly for the surgical group compared with the nonsurgical group, which showed minimal change. CONCLUSIONS: On the basis of a matched concurrent data set, there was significant improvement in function after 1 year for a surgical group compared with a nonsurgical group as measured by the Gillette Gait Index, with few significant changes noted in outcome measures. Changes over 1 year are minimal in the nonsurgical group, supporting the possibility of ethically performing a randomized controlled trial using nonsurgical controls. LEVEL OF EVIDENCE: Therapeutic level 2. Prospective comparative study.

Clinical applications of outcome tools in ambulatory children with cerebral palsy.

This article provides an overview of outcome tools commonly used to assess ambulatory children with cerebral palsy, research findings from a recent large multi-center study, and ways to integrate the research findings into clinical practice. The information presented in this article and in the referenced articles provides information on: outcome tools' discriminatory ability and responsiveness; readily available comparison data on 7 commonly used outcome tools that can be used at the point of care; prediction equations for the Parent report Pediatric Outcomes Data Collection Instrument (PODCI) by age and Gross Motor Function Classification System (GMFCS) level; and minimum clinically important difference thresholds by GMFCS level. This information can help clinicians select the best outcome tools to discriminate among severity levels and avoid ceiling effects. The scores provided allow direct comparisons between a specific patient and a matched cohort, assisting clinicians in the creation of comprehensive and individualized evaluation and management plans. Use of appropriate outcome tools to assess children with cerebral palsy can lead to best practices and reduced costs in the clinical setting.

Outcomes of gastrocnemius-soleus complex lengthening for isolated equinus contracture in children with cerebral palsy.

BACKGROUND: The goal of the gastrocnemius-soleus complex (GSC) lengthenings in children with cerebral palsy (CP) is to achieve a plantigrade foot and normalize kinematics during gait. The study purpose was to evaluate the results of GSC lengthening for isolated equinus contracture in individuals with CP. It was hypothesized that GSC lengthenings would normalize passive ankle range of motion, kinematic, kinetic, and temporal spatial parameters. METHODS: Gait data from 15 able-bodied participants from the laboratory normal database and passive range of motion, kinematic, kinetic, and temporal spatial gait parameters, and oxygen cost were collected and analyzed for 27 individuals with CP (36 limbs) with isolated equinus contracture who received GSC lengthenings. Data were compared between preoperative and postoperative assessments. RESULTS: Mean age at baseline was 11.4 years (+/-3.2 y). Mean time between surgery and postoperative gait analysis was 1.3 years (+/-0.3 y). Passive range of motion measurements were obtained. Kinematic and kinetic data for the hip, knee and ankle, and temporal spatial parameters were obtained from a representative gait trial preoperatively and postoperatively. Paired t tests (P<0.05) determined whether preoperative data differed from postoperative data or from able-bodied data. The passive range of motion at the ankle was improved and normalized postoperatively. Ankle kinematics normalized without compensatory changes occurring at the knee or hip kinematics. Ankle moments and powers become more normal but did not completely normalize. Kinematics and kinetics of the hip and knee were not adversely affected. No changes in the temporal spatial data or oxygen cost occurred postoperatively. CONCLUSIONS: These data support the finding that with appropriate patient selection isolated GSC lengthening does not result in overcorrection. LEVEL OF EVIDENCE: Retrospective comparative study; level 3.

Analysis of the pediatric outcomes data collection instrument in ambulatory children with cerebral palsy using confirmatory factor analysis and item response theory methods.

BACKGROUND: Traditional use of the Pediatric Outcomes Data Collection Instrument (PODCI) assumes that all items have the same structure, are measuring the intended constructs, and assess the right levels of function to show change after orthopaedic or neurological intervention. Item response theory (IRT) methods can statistically account for inherent differences in PODCI item characteristics and thus reveal attributes of the measure important to effectiveness research. Our study uses IRT methods to determine whether PODCI items fit the projected dimensional structure of the PODCI, assess function on each dimension at the right level for a population of ambulatory children with cerebral palsy (CP), and reveal changes after intervention in this population. METHODS: Proxy-reported PODCI questionnaires for 570 ambulatory children with CP were randomly divided into 2 groups for model creation and model testing using exploratory and then confirmatory factor analysis. The resulting model was compared with the projected dimensional structure, tested for fit of individual items, and examined for gaps and ceiling effects. Response changes at 1 year were compared between those with (n = 91) and without (n = 284) surgical intervention using paired t tests. RESULTS: Factor analysis reduced the projected dimensions from 5 to 4 for this population, resulting in dimensions for mobility, upper extremity function (UEF), comfort and general health, and self-worth. All but 3 items fit their respective dimensions; ceiling effects were noted in 3 dimensions. Responses showed changes in the comfort and general health, mobility, and UEF dimensions in those who had surgery; in those children who did not have surgery, only the UEF responses changed. CONCLUSIONS: The PODCI can show change after intervention when data are analyzed using IRT methods. Ceiling effects in 3 dimensions may limit the amount of change the PODCI can show in a population of ambulatory children with CP. LEVEL OF EVIDENCE: Level II. This was a retrospective investigation of a diagnostic tool, the PODCI, using a randomized cross-sectional design for model development, and a case-control design to assess sensitivity to change.

Comparison of three heel cord surgeries in children with cerebral palsy.

This nonrandomized prospective descriptive study compared outcomes of three isolated heel cord surgeries in children with spastic diplegia cerebral palsy (CP): (1) heel cord advancement (HCA), (2) heel cord lengthening according to Vulpius (HCL-V), and (3) heel cord lengthening according to White (HCL-W). Thirty-two children were tested prior to and approximately 1 year after undergoing one of the three surgeries. Objective measures were collected for ankle passive and active range of motion, gross motor function measure (GMFM), and gait. All surgeries indicated significant improvements in end range passive and active ankle dorsiflexion, GMFM, and dorsiflexion during gait. Gait speed was significantly improved for the HCA group, but appeared to be the result of maturity. Gait speed for the HCL-V and HCL-W groups was unchanged. The study was the first to directly compare three heel-cord-lengthening surgeries.