[Expert assessment of lower extremity prosthetics]. / Begutachtung von Prothesenversorgungen der unteren Extremität.

Although the number of major amputations is declining throughout Germany, more than 57,000 surgical procedures for amputation still take place. As a consequence of high prosthetic care costs, these often lead to disputes before the social court in which expert medical opinions are required. With knowledge of the legal norms, the remit of the expert opinion can be fulfilled. The expert begins with evaluation of the patient's file and a search of the contested parts. The investigation includes a medical history, in addition to a physical examination, in order to be able to comment on the disputed beneficial use of the therapeutic appliance and respond to questions of proof. Questionnaires may be helpful.

[Imaging diagnostics of the foot : What the orthopaedic surgeon expects from the radiologist]. / Bildgebende Diagnostik des Fußes : Was der Orthopäde vom Radiologen erwartet.

CLINICAL/METHODICAL ISSUE: Foot pain is in the case of long-term congenital, acquired or posttraumatic foot deformities a relevant clinical problem. STANDARD RADIOLOGICAL METHODS: On the basis of the clinical findings and the orthopaedic question, radiographs of the foot while standing in two planes are supplemented by radiographs of the ankle in an anterior-posterior plane. The imaging diagnostics of the foot are based on the conventional X­ray diagnostic workup and becomes even more precise and differentiated by the possibility of intersecting imaging procedures. PERFORMANCE: The diagnostic significance of imaging methods is discussed in this overview by means of clinical examples. In this context, cross-sectional imaging procedures can serve the clinician in the further decision-making process and clarify the question whether surgical treatment, for example, in the case osteoarthrosis is indicated. PRACTICAL RECOMMENDATIONS: Primarily, prior to any imaging procedure the appropriate medical history, inspection, clinical examination and the gait analysis in patients with foot pain are necessary. Interdisciplinary communication between orthopaedic/trauma surgeons and radiologists is necessary in order to provide the right imaging modality for difficult questions, to correctly interpret the resulting imaging findings, and to derive a therapeutic consequence from this. The decision whether conservative therapy or a surgical procedure is recommended will be made depending on the patients' prior therapies and the restriction of quality of life.

Structural changes in the thigh muscles following trans-femoral amputation.

INTRODUCTION: Early ambulation is the principal objective in trans-femoral amputees. Postamputation modifications complicate the rehabilitation process due to a reduced control at the interface between stump and prosthesis. The aim of this study is to determine whether magnetic resonance imaging depicts the amount of fatty degeneration of the thigh muscles after trans-femoral amputation (TFA). METHODS: A total of 12 patients following a TFA on the basis of a bone neoplasm or metastasis with an evaluable postoperative MRI were identified. Using the Goutallier classification, the fatty degeneration of the thigh muscles was analyzed in the middle (M) and at the distal end (E) of the residual limb at T1 (10.6 months) and T2 (25.6 months). RESULTS: Analysis at two different levels showed different grades of fatty degeneration of thigh muscles after TFA at T1 and T2. Comparing fatty degeneration at both levels of the stump, the quadriceps femoris revealed a significant change (p = 0.01) at T1 and M. sartorius and adductor (p = 0.02) at T2. CONCLUSIONS: MRI is an excellent diagnostic tool to evaluate fatty degeneration after TFA. The highest amount of fatty degeneration of the quadriceps muscle was monitored within the first 10 months. Early physiotherapy is important to strengthen the remaining stump muscles during rehabilitation.

Preoperative scoring and limits of prognostication: functional outcome after surgical decompression in metastatic spinal cord compression.

OBJECTIVE: To determine whether preoperative parameters correlate with the postoperative functional outcome in para- and tetraplegic patients with lung, kidney, breast and prostate cancer and metastatic spinal cord compression (MSCC). METHODS: Information on 43 patients undergoing decompressive surgery and rehabilitation for MSCC was reviewed, including primary tumor, age, pre- and postoperative ambulation status, mobility subcategory of the Spinal Cord Injury Measure (mSCIM) and the Tokuhashi score. Differences between groups were analyzed by the nonparametric χ(2) test, and correlation coefficients (Spearman's rho) were computed. RESULTS: Preoperative ambulation (p < 0.001), the American Spinal Injury Association Impairment Scale (p < 0.001) and the type of operation (p = 0.02) influenced the postoperative functional outcome. Any positive change in the mSCIM was influenced by preoperative ambulation (p < 0.001). Patients with breast carcinoma showed significantly more positive changes in the mSCIM compared with other tumors (p = 0.002). No correlation was found between the treatment categories of the Tokuhashi score and the preoperative ambulatory status (p = 0.13) or the change in ambulation status (p = 0.29). CONCLUSION: The postoperative functional outcome of MSCC patients shows a linear association between the categories of the Tokuhashi score and the change in ambulation status. We recommend surgical decompression even in a palliative situation (Tokuhashi score 0-8) with the aim of optimizing the short-term rehabilitation outcome.

Effect of formal training in scaling, scoring and classification of the International Standards for Neurological Classification of Spinal Cord Injury.

STUDY DESIGN: Prospective, longitudinal cohort study. OBJECTIVES: To quantify the effect of formal training in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) on the classification accuracy and to identify the most difficult ISNCSCI rules. SETTINGS: European Multicenter Study on Human Spinal Cord Injury (EMSCI). METHODS: EMSCI participants rated five challenging cases of full sensory, motor and anorectal examinations before (pre-test) and after (post-test) an ISNCSCI instructional course. Classification variables included sensory and motor levels (ML), completeness, ASIA Impairment Scale (AIS) and the zones of partial preservation. RESULTS: 106 attendees were trained in 10 ISNCSCI workshops since 2006. The number of correct classifications increased significantly (P<0.00001) from 49.6% (2628 of 5300) in pre-testing to 91.5% (4849 of 5300) in post-testing. Every attendee improved, 12 (11.3%) achieved 100% correctness. Sensory levels (96.8%) and completeness (96.2%) are easiest to rate in post-testing, while ML (81.9%) and AIS (88.1%) are more difficult to determine. Most of the errors in ML determination arise from sensory levels in the high cervical region (C2-C4), where by convention the ML is presumed to be the same as the sensory level. The most difficult step in AIS classification is the determination of motor incompleteness. CONCLUSION: ISNCSCI training significantly improves the classification skills regardless of the experience in spinal cord injury medicine. These findings need to be considered for the appropriate preparation and interpretation of clinical trials in spinal cord injury.

[Treatment of hip dysplasia in young adults]. / Behandlung der Hüftgelenkdysplasie beim jungen Erwachsenen.

Developmental dysplasia of the hip (DDH) is one of the most common disorders of hips in children. The deformity can remain asymptomatic into adolescence and adulthood; however, it is considered to be a form of prearthritis and is the main cause of premature osteoarthritis of the hip. The deformity affects the acetabulum but can also be accompanied by changes in the shape of the proximal femur. If conservative treatment for mild DDH is insufficient, or in cases of moderate to severe DDH, operative treatment should be carried out, for example by corrective osteotomy of the pelvis and/or the proximal femur and hip arthroscopy may be considered adjunctively in order to resolve the prearthritis and prevent premature osteoarthritis of the hip. This manuscript elucidates the deformity, the diagnostic measures required to make the diagnosis and the treatment options available for prevention of arthritis.

The effect of polytrauma as a possible confounder in the outcome of monotraumatic vs polytraumatic paraplegic patients: a clinical cohort study.

STUDY DESIGN: Clinical cohort study. OBJECTIVE: To evaluate if the impact of the severity of the trauma as a possible confounding factor influences the neurological and functional recovery in paraplegia during the course of a 6-month follow-up period after injury. SETTING: Spinal Cord Injury Center, Heidelberg University Hospital, Germany. METHODS: A retrospective monocentric analysis, from 2002 to 2008, of the Heidelberg European Multicenter Study about spinal cord injury database was performed. We included 31 paraplegic patients (neurological level T1-T12) who were assigned either to a monotrauma (polytraumaschluessel (PTS) 1) or to a polytrauma (PTS≥2) group. The American Spinal Injury Association Impairment Scale, lower extremity motor score, pin prick, light touch and the spinal cord independence measure (SCIM) were obtained at five distinct time points after trauma. Data were analyzed using Mann-Whitney U-test (α<0.05). RESULTS: The changes in lower extremity motor score, pin prick and light touch showed no significant differences in both groups over the whole evaluation period. Polytraumatic paraplegics showed a significantly delayed increase of SCIM between 2 and 6 weeks compared with monotraumatic patients, followed by a quantitative increase in the subitems bladder management, bowel management, use of toilet and prevention of pressure sores between 3 and 6 months (P=0.031). The mean length of primary rehabilitation in the polytrauma group was 5.5 vs 3.6 months in monotrauma. CONCLUSIONS: The prognosis of polytraumatic paraplegics in terms of neurological recovery is not inferior to those with monotrauma. Multiple-injured patients need a prolonged hospital stay to reach the functional outcome of monotraumatic patients.

Clinical presentation of spondylodiscitis as a long-term complication in incomplete paraplegia: a report of three cases.

STUDY DESIGN: Case report. OBJECTIVE: Complications in spinal cord injury (SCI) are a challenging problem for the patients and often difficult to manage. Three cases of spondylodiscitis, localized at the lumbosacral junction in long-term paraplegic patients are presented. SETTING: Spinal Cord Injury Center, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany. CLINICAL PRESENTATION: In all three cases, neurological deterioration (ASIA A) was caused by a secondary compression of the spinal cord at the lumbosacral spine. Increase of spasticity and pain, atonic bladder and sphincter function accompanied by vegetative symptoms were present in all patients. Microbiological analysis of the sacral area showed coagulase negative staphylococcus in two cases, whereas in one case no microorganism was found. The diagnosis was made by MRI of the whole spine and surgical treatment was required. At follow-up (6 months), patients showed no AIS (ASIA Impairment Scale) changes. CONCLUSION: If neurological deterioration occurs, spondylodiscitis should be ruled out in paraplegic individuals. The therapeutic goal is to achieve emergent decompression of the spinal cord and to administrate adequate antibiotic therapy to avoid a neurologically complete situation.

Diagnostic criteria of traumatic central cord syndrome. Part 2: a questionnaire survey among spine specialists.

STUDY DESIGN: A questionnaire survey. OBJECTIVES: To evaluate the need for the introduction of quantitative diagnostic criteria for the traumatic central cord syndrome (TCCS). SETTING: An online questionnaire survey with participants from all over the world. METHODS: An invitation to participate in an eight-item online survey questionnaire was sent to surgeon members of AOSpine International. RESULTS: Out of 3340 invited professionals, 157 surgeons (5%) from 41 countries completed the survey. Whereas most of the respondents (75%) described greater impairment of the upper extremities than of the lower extremities in their own TCCS definitions, symptoms such as sensory deficit (39%) and bladder dysfunctions (24%) were reported less frequently. Initially, any difference in motor strength between the upper and lower extremities was considered most frequently (23%) as a 'disproportionate' difference in power. However, after presenting literature review findings, the majority of surgeons (61%) considered a proposed difference of at least 10 points of power (based on the Medical Research Council scale) in favor of the lower extremities as an acceptable cutoff criterion for a diagnosis of TCCS. Most of the participants (40%) felt that applying a single criterion to the diagnosis of TCCS is insufficient for research purposes. CONCLUSION: Various definitions of TCCS were used by physicians involved in the spinal trauma care. The authors consider a difference of at least 10 motor score points between upper and lower extremity power a clear diagnostic criterion. For clinical research purposes, this diagnostic criterion can be considered as a face valid addendum to the commonly applied TCCS definition as introduced by Schneider et al.

[Collagen hydroxyapatite (Healos) saturated with gentamicin or levofloxacin. In vitro antimicrobial effectiveness - a pilot study]. / Mit Gentamicin oder Levofloxacin gesättigter Kollagenhydroxyapatit (Healos). Antimikrobielle In-vitro-Wirksamkeit - eine Pilotstudie.

BACKGROUND: The functions of synthetic bone graft substitutes include not only structural support to provide bone healing and osseous ingrowth but also the ability to serve as a local antibiotic delivery system to prevent or treat infections of the spine. MATERIAL AND METHODS: The impregnation and antibiotic efficiency of gentamicin and levofloxacin with Healos was investigated in vitro and compared with Healos without an antibiotic additive. These antibiotic-loaded bone graft substitutes were examined without dilution and with 10-fold and 100-fold dilution for activity against spondylodiscitis-causing bacteria on different agar plates using an agar diffusion method. RESULTS: All hydroxyapatite (HA)/collagen-saturated diluted antibiotics showed elliptical inhibition zones on the corresponding agar plates. For both antibiotics, there was a linear correlation between dilution and area of the inhibition zone. CONCLUSION: The analysis showed that the antimicrobial activity of HA/collagen-saturated antibiotics corresponded to the antimicrobial dilutions. These results should be further analyzed using in vivo studies to determine the remaining antibiotic efficiency after implantation of bone graft substitutes.

Biomechanical analysis of stair ascent in persons with Chopart amputation.

BACKGROUND: Compared to walking on level ground, ascending stairs requires a large range of motion not only of the hip and knee joint, but also of the ankle joint. The prosthesis often worn by persons with partial foot amputation largely prevents the ankle motion needed during stair ascent. OBJECTIVES: Aim of this study was to assess subjects with a Chopart amputation utilizing a clamshell device during stair ascent to identify potential biomechanical deficits. STUDY DESIGN: Cross-sectional study with reference group. METHODS: Six subjects with unilateral Chopart amputation and 17 unimpaired subjects underwent three-dimensional motion analysis while ascending stairs in a step-over-step manner. RESULTS: During weight acceptance, the involved side showed increased external hip-flexing and reduced knee-flexing moments and the sound side a higher ankle power than in the control group. The sound side showed higher external knee-flexing, dorsi-flexing, and hip-adducting moments than the controls during weight acceptance. CONCLUSION: The mechanism observed on the involved side differs from that in controls, but is comparable to the mechanisms used by subjects with transtibial amputation reported in the literature. However, compensatory movements on the sound side take place at the ankle and knee joint, differing from subjects with more proximal amputations. CLINICAL RELEVANCE: This study underpins the importance of adequate foot leverage and ankle function in cases of partial foot amputation, particularly in transfer situations such as stair ascent. If ankle range of motion is adequate, prosthetic/orthotic devices combining shank leverage with a hinged spring mechanism at the ankle may be promising.

Health-related quality of life in elderly cancer patients, elderly non-cancer patients and an elderly general population.

Health-related quality of life (QoL) is a major topic within the care for cancer patients (CP). Compared with the general population (GP), QoL of CP is worse in most dimensions; however, only few data comparing QoL of CP with that of other patients have been provided so far. We determined QoL with the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire in hospitalized patients aged 60 years and older: 195 CP and 130 patients treated for other medical disorders (MP). In addition, data were compared with an age- and gender-stratified German GP. Explorative statistical analyses were performed. The CP aged >or=70 years compared with those aged 60-69 years had decreased QoL in two scales, physical and cognitive functioning, MP in four scales, physical and role functioning, fatigue and dyspnoea respectively. Compared with the GP, both CP and MP had worse QoL in almost all scales. The CP and MP differed in two of 15 scales only, with CP having lower scores in emotional functioning and more loss of appetite. In conclusion, reduced QoL in elderly CP compared with GP cannot solely be attributed to the diagnosis of cancer, but also to a medical disorder requiring inpatient hospital care.

Progressive spastic paraplegia: the combination of Scheuermann's disease, a short-segmented kyphosis and dysplastic thoracic spinous processes.

STUDY DESIGN: Case report. OBJECTIVE: To describe a rare case of paraplegia in a patient with Scheuermann's disease and dysplastic thoracic spinous processes. SETTING: Spinal Cord Injury Center, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany. CLINICAL PRESENTATION: The authors report on a 15-year-old boy with progressive incomplete spastic paraplegia presenting segmental dysplastic thoracic spinous processes and Scheuermann's disease. The magnetic resonance imaging showed a kyphotic angulation at T 5/6 and signs of myelopathy. Hypoplastic thoracic processes and hypoplastic paraspinal muscles in the upper thoracic spine were observed intraoperatively. In this case, dorsoventral stabilization from T 4-7 was performed and the neurological outcome improved at follow-up (6 months). CONCLUSION: Paraplegia can be accelerated in patients with Scheuermann's disease, severe kyphotic angulation and dysplastic posterior elements. After operative treatment, neurological recovery and a normal walking pattern were shown.

Prosthetic restoration of the forefoot lever after Chopart amputation and its consequences onto the limb during gait.

BACKGROUND: In subjects with Chopart amputation the foot lever is clearly diminished. Usually high or low profile prostheses are routinely utilized to re-establish the lost forefoot lever. RESEARCH QUESTION: The aim of this study was to investigate to what extent the proposed prostheses were able to replace the forefoot lever in chopart-amputees. METHODS: An instrumented 3D gait analysis, including plantar and socket pressure measurements, was performed in thirteen subjects with Chopart amputation using a clamshell and/or a Bellmann prosthesis including an ankle foot orthosis during level ground walking. RESULTS: The largest range of motion (p < 0.05) in the ankle joint was seen for the Bellmann prosthesis (32 ±â€¯3°) followed by the Bellmann prosthesis with ankle-foot orthosis (22 ±â€¯6°) whereas in the clamshell prosthesis (10 ±â€¯4°) almost no ankle motion was seen. Conversely, the highest ankle joint moment (p < 0.05) was seen for the clamshell prosthesis (1.04 ±â€¯0.24Nm/kg) followed by the Bellmann prosthesis with ankle-foot orthosis (0.66 ±â€¯0.14Nm/kg) and, finally, the Bellmann (0.37 ±â€¯0.11Nm/kg) alone offering the lowest joint moment. CONCLUSION: High-profile prostheses with ventral shell are more suitable to reacquire the lost forefoot lever after Chopart amputation. However, the issue of restricted range of motion in the ankle joint with the clamshell prosthesis needs to be addressed.

The added value of orthotic management in the context of multi-level surgery in children with cerebral palsy.

BACKGROUND: Treatment of cerebral palsy includes an interdisciplinary concept and in more severe cases the well-established multi-level surgery (MLS). Different kinds of orthoses are typically part of postoperative treatment but there is a lack of knowledge about their additional benefit. RESEARCH QUESTION: Do ankle foot orthoses lead to an additional, measurable improvement of gait after MLS? METHODS: 20 children with bilateral spastic cerebral palsy (9 retrospective, 11 in a postoperative clinical routine) were included. All had a preoperative gait analysis before MLS. Postoperatively, they were fitted with different ankle foot orthoses (AFO), depending on their individual needs. Dynamic ankle foot orthoses (DAFO), combined DAFO with additional dynamic, elastic shank adaptation (DESA) and ground reaction force AFOs (GRAFO) were used. Patients underwent a second gait analysis 1.5 (± 0.6) years postoperatively barefoot and with orthoses. Data analysis included testing for normal distribution (Shapiro-Wilk-Test) and further nonparametric statistical testing on basis of a Wilcoxon Single-Rank Test. RESULTS: The operation produced changes in the hip, knee and ankle joint, and the pelvis. Spatiotemporal parameters showed significant changes due to additional use of the orthoses. Further, additional kinematic changes occurred at the hip, knee and ankle joint as well as the foot. The Gillette Gait Index (GGI) improved significantly by supplementary orthoses, but not by surgery alone. The Gait Profile Score (GPS) and Gait Deviation Index (GDI) rather showed changes due to the surgery. SIGNIFICANCE: MLS significantly improves GPS and GDI more than a year after surgery, which can be interpreted as an improvement in gait pattern. In contrast, the GGI is improved by additional postoperative orthotic treatment, which implies that walking ability itself has improved, rather than the gait pattern. Orthoses show a positive additional effect on surgical results at different anatomical levels. Spatiotemporal parameters are positively influenced solely by additional orthotic support.

Wearing Time of Ankle-Foot Orthoses with Modular Shank Supply in Cerebral Palsy: A Descriptive Analysis in a Clinically Prospective Approach.

OBJECTIVE: To date there is only limited knowledge about the wearing time of orthoses. Ankle-foot orthoses (AFOs) have not been studied with this research question. Additional influences of the orthotic design as well as weekdays and the weekend are also unknown. DESIGN: Monocentric, clinically prospective intervention study. PATIENTS: Inclusion of 10 patients with bilateral spastic cerebral palsy. METHODS: Equipment of all subjects with a dynamic ankle-foot orthosis (DAFO) and modular shank supply (MSS, dynamic elastic shank adaptation or ground reaction AFO). Integration of temperature sensors for recording the wearing time for a period of 3 months. RESULTS: The actual wearing time was below the recommendations on actually worn days as well as the average of the entire study period. In addition, the actual usage in terms of days and hours was well below the recommendations. The wearing time showed differences between weekdays and weekend. Differences between DAFO and MSS were not detectable. CONCLUSION: The actual usage behavior of ankle-foot orthoses differs from the recommendations of the prescriber. This applies to both DAFOs and modular use with shank supplies. Environmental factors may have a significant impact on wearing times on weekdays and the weekend.

Single ingestion of di-(2-propylheptyl) phthalate (DPHP) by male volunteers: DPHP in blood and its metabolites in blood and urine.

Di-(2-propylheptyl) phthalate (DPHP) is used as a plasticizer for polyvinyl chloride products. A tolerable daily intake of DPHP of 0.2 mg/kg body weight has been derived from rat data. Because toxicokinetic data of DPHP in humans were not available, it was the aim of the present work to monitor DPHP and selected metabolites in blood and urine of 6 male volunteers over time following ingestion of a single DPHP dose (0.7 mg/kg body weight). Concentration-time courses in blood were obtained up to 24 h for DPHP, mono-(2-propylheptyl) phthalate (MPHP), mono-(2-propyl-6-hydroxyheptyl) phthalate (OH-MPHP), and mono-(2-propyl-6-oxoheptyl) phthalate (oxo-MPHP); amounts excreted in urine were determined up to 46 h for MPHP, OH-MPHP, oxo-MPHP, and mono-(2-propyl-6-carboxyhexyl) phthalate (cx-MPHP). All curves were characterized by an invasion and an elimination phase the kinetic parameters of which were determined together with the areas under the concentration-time curves in blood (AUCs). AUCs were: DPHP > MPHP > oxo-MPHP > OH-MPHP. The amounts excreted in urine were: oxo-MPHP > OH-MPHP> > cx-MPHP > MPHP. The AUCs of MPHP, oxo-MPHP, or OH-MPHP could be estimated well from the cumulative amounts of urinary OH-MPHP or oxo-MPHP excreted within 22 h after DPHP intake. Not considering possible differences in species-sensitivity towards unconjugated DPHP metabolites, it was concluded from a comparison of their AUCs in DPHP-exposed humans with corresponding earlier data in rats that there is no increased risk of adverse effects associated with the internal exposure of unconjugated DPHP metabolites in humans as compared to rats when receiving the same dose of DPHP per kg body weight.

Effects of multilevel surgery on a flexed knee gait in adults with cerebral palsy.

AIMS: A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood. PATIENTS AND METHODS: At a mean of 22.9 months (standard deviation 12.9), after single event multi level surgery, 3D gait analysis was undertaken pre- and post-operatively for 37 adult patients with bilateral cerebral palsy and a fixed knee gait. RESULTS: There was a significant improvement of indices and clinical and kinematic parameters including extension of the hip and knee, reduction of knee flexion at initial contact, reduction of minimum and mean knee flexion in the stance phase of gait, improved range of movement of the knee and a reduction of mean flexion of the hip in the stance phase. Genu recurvatum occurred in two patients (n = 3 legs, 4%) and an increase of pelvic tilt (> 5°) was found in 12 patients (n = 23 legs, 31%). CONCLUSION: Adult patients with bilateral cerebral palsy and a flexed knee gait benefit from multilevel surgery including hamstring lengthening. The risk of the occurence of genu recurvatum and increased pelvic tilt is lower than has been previously reported in children. Cite this article: Bone Joint J 2017;99-B:1256-64.

Di-(2-propylheptyl) phthalate (DPHP) and its metabolites in blood of rats upon single oral administration of DPHP.

Di-(2-propylheptyl) phthalate (DPHP) does not act as a reproductive toxicant or endocrine disruptor in contrast to other phthalates. Considering adverse effects of phthalates to be linked to their metabolism, it was the aim of the present study to investigate in the rat the blood burden of DPHP and its metabolites as a basis for understanding the toxicological behavior of DPHP. Rats were administered single oral doses of DPHP of 0.7 and 100mg/kg body weight. Concentration-time courses of DPHP and metabolites were monitored in blood. The areas under the concentration-time curves in blood (AUCs), normalized for the dose of DPHP, showed the following order: DPHP

Multilevel surgery in adults with cerebral palsy.

AIMS: Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate. METHODS: This study analysed the short-term outcome (mean 1.7 years, standard deviation 0.9) of 97 ambulatory adults with BSCP who performed three-dimensional gait analysis before and after SEMLS at one institution. RESULTS: Two objective gait variables were calculated pre- and post-operatively; the Gillette Gait Index (GGI) and the Gait Profile Score (GPS). The results were analysed in three groups according to their childhood surgical history (group 1 = no surgery, group 2 = surgery other than SEMLS, group 3 = SEMLS). Improvements in gait were shown by a significant decrease of GPS (p = 0.001). Similar results were obtained for both legs (GGI right side and left side p = 0.01). Furthermore, significant improvements were found in all subgroups although this was less marked in group 3, where patients had undergone previous SEMLS. DISCUSSION: SEMLS is an effective and safe procedure to improve gait in adults with cerebral palsy. However, a longer rehabilitation period is to be expected than found in children. SEMLS is still effective in adult patients who have undergone previous SEMLS in childhood. TAKE HOME MESSAGE: Single-event multilevel surgery is a safe and effective procedure to improve gait disorders in adults with bilateral spastic cerebral palsy.