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Background: Femoral derotation osteotomy (FDO) is the standard treatment for internal rotation gait (IRG) in children with cerebral palsy (CP) although high rates of recurrence have been reported recently. Various factors associated with recurrence could be identified, but no predictor named.Research Questions: Does FDO lead to a change of internal transversal hip moments? Are preoperative internal transversal hip moments a predictor for recurrence of IRG?Methods: 41 children with spastic bilateral CP and 72 limbs that received a FDO (10.4 ± 2.7 years at surgery) were included retrospectively. Kinematic data were analyzed pre- (2 ± 3 months), postoperatively (12 ± 3 months) and at long-term follow-up (at least five years postoperatively; 84 ± 13 months), internal transversal hip moments were analyzed pre- and postoperatively.Results: The maximum peaks of the internal hip rotation moment during loading response decreased significantly (p = 0.003). The minimum during the second half of the stance phase increased significantly (p = 0.004) and the initially internal externally rotating moment changed to an internal internally rotating moment. No correlation between changes in hip rotation from postoperatively to the long-term follow-up and the preoperative internal hip rotation moment could be identified.Significance: FDO leads to changes in internal hip rotation moments. Preoperative internal hip rotation moments can't be used as predicting factor for recurrence of IRG. The data suggest, that recurrence of IRG depends less on patient specific motion patterns, but more on the time point of surgery and the therapy of all concomitant deformities during SEMLS. [ABSTRACT FROM AUTHOR]

Aim: We investigated the long-term efficacy and safety of multilevel surgery (MLS) in ambulatory children with bilateral spastic cerebral palsy (CP).Method: Two hundred and thirty-one children were evaluated at short term (1.1y, SD 0.4) and long term (9.1y, SD 3.0) follow-up using clinical examination and gait analysis. MLS was investigated by studying changes in the Gait Profile Score (GPS) referenced to the minimally important clinical difference.Results: Ambulatory children aged 10 years and 7 months (SD 2y 11mo) at MLS in Gross Motor Function Classification System levels I (19), II (144), and III (68) showed a decrease (improvement) in preoperative GPS from 16.3° (SD 4.8) to 11.3° (SD 3.2) at short-term follow-up, an improvement of 5°. At long-term follow-up, GPS was maintained at 11.4° (SD 3.1). Overall, 177 (76.6%) children maintained their improvement in GPS after 9 years.Interpretation: Multilevel surgery is a safe and effective surgical intervention, which leads to a significant improvement in gait kinematics in children with bilateral spastic CP. This study improves our understanding of MLS in the long term and will help to inform families and children when planning for MLS.What This Paper Adds: Largest study of multilevel surgery (MLS) for children with bilateral spastic cerebral palsy, with longest follow-up. MLS resulted in significant long-term improvements in gait function. Minor adverse events were common, while events requiring intervention were uncommon (4% of children). Thirty-nine per cent of children required additional surgery during follow-up. 'Single-event multilevel surgery' was changed to the more realistic term 'multilevel surgery'. [ABSTRACT FROM AUTHOR]

Increased anterior pelvic and trunk tilt is a common finding in patients with bilateral cerebral palsy especially during walking with assistive devices. As previous studies demonstrate various gait alterations when using assistive devices, the assessment of surgical interventions may be biased when the patients become independent of (or dependent on) assistive devices after therapy. Furthermore, some of these patients in fact are able to walk without devices even though in daily life they prefer to use them. Consequently, for such patients the classification into GMFCS level II or III may be ambiguous. The specific aim of this study was therefore to assess the influence of the use of forearm crutches and posterior walker during walking and to set this influence in relation to outcome effects of surgical intervention studies. 26 ambulatory patients with spastic bilateral CP (GMFCS II-III) were included who underwent 3D gait analysis. All patients used forearm crutches or posterior walkers in everyday life even though they were able to walk without assistive devices for short distances. Independent of the type of assistive devices, the patients walk on average with more anterior trunk tilt and pelvic tilt (7°±6° and 3°±2°) and with a maximum ankle dorsiflexion decreased by 2° (±3°) when walking with assistive devices, enhancing the mal-positioning present without device. Oppositely, the knees on average are more extended by 6° (±4°) when using the assistive devices. These effects have to be taken into account when assessing gait patterns or when monitoring the outcome after intervention as assistive devices may partially hide or exaggerate therapeutic effects. [ABSTRACT FROM AUTHOR]

The article offers step-by-step instructions for surgical treatment of severe cavovarus foot deformity in charcot-marie-tooth disease.

Single-use bioreactors continue to gain large interest in the biopharmaceutical industry. They are frequently used for mammalian cell cultivations, e.g. production of monoclonal antibodies and vaccines. This is motivated by several advantages of these bioreactors such as reduced risk of cross contaminations or short lead times. Single-use bioreactors differ in terms of shape, agitation principle, and gassing strategy. Hence, a direct process transfer or scale-up can be a challenge. Conventional stirred tank bioreactor designs are therefore still considered as the gold standard due to their well-defined and characterized properties. Based on this knowledge, a stirred single-use bioreactor family from 50 to 2000 L scale was developed with geometrical ratios similar to conventional reusable systems. To follow a quality by designapproach, the single-use bioreactor family evaluated here was characterized by using process engineering methods such as the power input per volume, the mixing time, and the kLa value. The process engineering characterization demonstrates that these systems are suitable for cultivations of mammalian cells, even for high cell density and high titer applications. Based on the data, a scale-up or process transfer is possible between this bioreactor family as well as reusable systems. Therefore, this bioreactor family represents a major progress for the single-use technology. [ABSTRACT FROM AUTHOR]

To examine gait patterns and gait quality, 7 twins with cerebral palsy were measured preoperatively and after surgical intervention. The aim was to study differences and/or similarities in gait between twins, the influence of personal characteristics and birth conditions, and to describe the development of gait over time after single event multilevel surgery. A standardized clinical exam and a three-dimensional gait analysis were performed. Gait patterns were classified according to Sutherland and Davids, and the Gillette Gait Index was calculated as a global measure of the gait impairment. Next to subject characteristics at time of first measurement, and at time of birth, birth conditions were collected. Gait patterns were determined as crouch gait in 13 legs, as stiff gait in 6 legs and as jump gait in 8 legs. One leg showed a normal gait pattern. The knee flexion–extension angle correlated most constant with the knee flexion–extension angle of the contralateral leg (range 0.91–0.99). Correlations with the legs of the sibling showed variable correlations (range 0.44–0.99); with all other legs medium to high correlations of 0.73–0.91 were found. The Gillette Gait Index was found to initially decrease after surgical intervention. Similar correlations were found between twins or between legs for the gait pattern expressed by the knee flexion–extension angle, and the Gillette Gait Index improved after surgery. It seems that gait quality in twins with cerebral palsy is characterized predominantly by the traumatic disorder: genetic dispositions and personal characteristics only play a negligible role. [Copyright &y& Elsevier]

Abstract: Adverse effects such as increased anterior pelvic tilt (APT) are reported after muscle-tendon lengthening (MTL) for the correction of flexed knee gait in cerebral palsy. The conversion of biarticular muscles (CBM) to monoarticular muscles represents an alternative treatment, but only few short-term results have been published, without comparison with MTL. The long-term outcome of 21 diplegic patients treated with CBM in a prospective study was compared with the results in MTL patients in a matched-pair analysis. Standardized clinical examination and three-dimensional gait analysis were done before surgery, 1 year thereafter, and at long-term follow-up a mean of 9.2 years postoperatively. Mean APT increased one year after surgery in both groups. This increase was higher in MTL patients and statistically significant only for this group. Knee flexion at initial contact and minimum knee flexion in stance were significantly decreased in both groups, while in swing the CBM group tended to show more of a decrease in knee flexion but at the cost of reduced peak flexion. Both groups showed deterioration of kinematic knee parameters through to long-term follow-up; the favourable effects of CBM disappeared, and the two groups displayed comparable average pelvic and knee kinematics. Considering individual patterns the prevalence of increased APT was lower in the CBM group 1 year after surgery, indicating that sparing the semitendinosus may have a positive effect on pelvic stability. However, after 9 years 30% of the patients in both groups showed increased APT indicative of persistent hamstring insufficiency. These results demonstrate that CBM, a significantly more extensive procedure, has no long-term advantage over MTL. [Copyright &y& Elsevier]

During the last decades single-use bioreactors have become widely accepted in the biopharmaceutical industry. Single-use technologies bring many advantages over conventional solutions, such as a reduced investment and operational cost as well as an optimized time-to-market. So far, this type of bioreactor is mainly used for cell culture applications. Results for microbial fermentations are rarely found, commonly due to limited oxygen transfer rates. The aim of this study was to establish a high cell density fermentation process for a recombinant Escherichia coli considering a rocking motion type and an adapted stirred 50-L single-use bioreactor. By using the design space approach an OTRmax/OURmax model was established. The feeding strategies were optimized and verified based on a model for both single-use systems to achieve high cell densities. In both single-use bioreactors a recombinant protein was successfully expressed. [ABSTRACT FROM AUTHOR]

Abstract: Satisfactory short-term results after femoral derotation osteotomy (FDO) for the treatment of internal rotation gait in cerebral palsy have been reported by various authors. However, there are only a few longer-term studies reporting results 5years after FDO and these are not in agreement. There are no reports on the clinical course beyond the pubertal growth spurt. 33 children with diplegia (n =59 legs, age: 10.5±3.6years) and internally rotated gait were examined pre- (E0), 1year (E1), 3±1 (E2) and 9±2 (E3)years after distal (27 legs) or proximal (32 legs) FDO as part of multilevel surgery, using standardized clinical exam and 3D gait-analysis at all examinations. The amount of intra-operative derotation averaged 25°. ANOVA was used for statistics (p <0.05). Mean hip internal rotation in stance at E0 of 17.3° was significantly changed to 1.0° of external rotation at E1 and was maintained at 4.2° at E3. The same clinical course was found for foot progression angle. The mid-point of passive hip rotation at E0 was 21°. This was significantly decreased to 6° at E1 and showed a small but significant increase reaching 12° at E3. The results of this study showed a good overall correction of internally rotated gait following FDO. These improvements were maintained at long-term follow-up after the pubertal growth spurt. Recurrence was observed in some cases with overall severe deterioration. In those patients persistent dynamic factors leading to recurrence should be further investigated. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

Abstract: The evidence in support of distal rectus femoris transfer (DRFT) as part of single-event multilevel surgery (SEMLS) is limited due to inconsistent outcome reports and a lack of randomized studies. The purpose of this prospective randomized trial was to establish whether the results of SEMLS without DRFT are similar to those of a conventional approach that includes DRFT in the SEMLS. In all, 32 children with spastic diplegia (GMFCS I–III) and an indication for DRFT were recruited and randomized into a DRFT (15 children) and a NON-DRFT group (17 children) using a minimization method. During SEMLS, bilateral DRFT was performed only in the DRFT group. Three-dimensional gait analysis and clinical examination were performed before and 1year after surgery. In both groups a significant increase in range of motion during swing and knee flexion velocity were found, which was significantly higher in the DRFT group. While peak knee flexion in swing (pKFSw) was preserved in the DRFT group and significantly decreased in the NON-DRFT group, pKFSw timing was significantly earlier in both groups. The clinical relevance of the higher overall benefits in the DRFT group is limited, considering that 33% of patients in this group did not benefit from the procedure. Furthermore, 53% of the NON-DRFT patients did not undergo what proved to be an unnecessary DRFT. Subgroup analysis showed benefits for patients with decreased pKFSw, while those with severe flexed-knee gait (normal or increased pKFSw) did not profit from DRFT. This may explain the inconsistent overall results, and DRFT is therefore not recommended as a “prophylactic” procedure in patients with severe flexed-knee gait. [Copyright &y& Elsevier]

Background: Equinus of the foot at the ankle is one of the most common deformities in patients with spastic diplegic cerebral palsy, leading to gait disturbances and secondary deformities. During single-event multilevel surgery, equinus is commonly corrected by calf muscle lengthening, such as gastrocnemius-soleus intramuscular aponeurotic recession. Various studies have described satisfactory short-term results after gastrocnemius-soleus intramuscular aponeurotic recession. However, there is no evidence for maintenance of equinus correction because of the small and heterogeneous case series and short follow-up time previously reported. Methods: The present study provides long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery for the treatment of equinus in forty-four patients with spastic diplegia who were able to walk (forty-eight legs had lengthening of the gastrocnemius and thirty-four legs had lengthening of the gastrocnemius and soleus). Standardized three-dimensional gait analysis and clinical examination were done preoperatively and at one year, a mean (and standard deviation) of 3 ± 1 years, and a mean of 9 ± 2 years after surgery. Results: Significant improvements in kinematic and kinetic ankle parameters on gait analysis as well as passive dorsiflexion in clinical examination were found one year after surgery. While there was a significant loss of passive dorsiflexion at the time of long-term follow-up, the improvements in gait analysis parameters were maintained. The endurance of gait improvements was accompanied by a persistent increase of dorsiflexor muscle strength without relevant loss of plantar flexor strength. Although it was not significant, there was a tendency for deterioration of gait analysis parameters over the nine years. The analysis of individual patterns showed recurrence of equinus at the ankle in 24% of the legs. Early-onset calcaneal gait was found one year after surgery in seven legs (9%), but without secondary crouch gait, and there was recovery at the time of the long-term follow-up. Late-onset calcaneal gait was seen at the time of long-term follow-up in eight legs (10%), of which four had an accompanying crouch gait. Conclusions: Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to sat-isfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession. [ABSTRACT FROM AUTHOR]

Background: Hamstring lengthening commonly is performed for the treatment of flexed knee gait in patients with spastic diplegic cerebral palsy. Satisfactory short-term results after hamstring lengthening have been demonstrated in various studies. However, evidence for the effectiveness of hamstring lengthening to correct flexed knee gait is scant because of small and inhomogeneous case series, different surgical techniques, and short follow-up. Methods: The long-term results for thirty-nine patients with spastic diplegia and flexed knee gait who were managed with intramuscular hamstring lengthening as a part of multilevel surgery are presented. Standardized three-dimensional gait analyses and clinical examinations were performed for all patients preoperatively and at one, three, and six to twelve years postoperatively. Results: Significant improvements in kinematic parameters and the popliteal angle were noted at short-term follow-up (p < 0.01), supporting the results of previous studies. Long-term results showed significant deterioration of minimum knee flexion in stance and the popliteal angle (p < 0.01), whereas the improvements in the Gross Motor Function Classification System and Gillette Gait Index were maintained. This recurrence of flexed knee gait is partial and measurable. Increased pelvic tilt was found in 49% of the limbs postoperatively, which may represent one factor leading to recurrence of flexed knee gait. Genu recurvatum was seen in eighteen patients (twenty-seven limbs; 35%) one year postoperatively, especially in the patients with a jump knee gait pattern preoperatively. At long-term follow-up, genu recurvatum resolved in many limbs, but 12% of the limbs showed residual genu recurvatum, indicating that overcorrection represents a problem following hamstring lengthening. Conclusions: The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning. [ABSTRACT FROM AUTHOR]

The article presents a study which discusses design space definition for stirred single-use bioreactor family. Topics discussed include increase in popularity of single-use bioreactors in the biopharmaceutical industry and their use in mammalian cell cultivations. Topics discussed include aeration in the study performed by a combi sparger, modern CHO process was considered with a peak cell density in the study and use of single-use bioreactor in the cultivation of mammalian and insect cells.

Background: Due to the limited knee range of motion, achieving adequate foot clearance while walking on level ground constitutes a major problem for patients with cerebral palsy and stiff knee gait. Stair negotiation as an activity of daily life requires a considerably higher knee range of motion than level ground walking, but little is known yet as to whether such patients are able to walk stairs.Research Question: The aim of this study was to investigate how patients with a limited knee range of motion negotiate stairs. Do they increase their peak knee flexion and use the same pattern as in walking on level ground? How do the muscles act during stair negotiation?Methods: In this explorative study, 17 adults with bilateral, spastic cerebral palsy and stiff knee gait and 25 healthy subjects were examined. 3D motion analysis, including electromyography, was performed while walking on level ground, upstairs, and downstairs. A linear mixed model was used for between- and within-group comparisons.Results: Walking upstairs and downstairs, patients increased their peak knee flexion by around 30° compared to level walking. Thus, increased knee flexion may be seen as the main mechanism for maintaining foot clearance on stairs. An increased pelvic obliquity (elevation) and hip flexion were also found and involved subjects showed a slight increase in rectus femoris activity when walking on stairs compared to level walking within the phases of high knee flexion.Significance: This study showed that patients with cerebral palsy and stiff knee gait are able to flex their knees more than would be required for level walking. Hence, the patients are able to adapt their rectus activity to stair walking to some extent. Therefore, further investigations might help to open up new therapeutic options to facilitate level walking and stair negotiation in patients with stiff knee gait. [ABSTRACT FROM AUTHOR]

Background: The evidence for distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in children with spastic diplegic cerebral palsy is limited because of inconsistent outcomes reported in various studies and the lack of long-term evaluations. Methods: This study investigated the long-term results (mean, nine years) for fifty-three ambulatory patients with spastic diplegic cerebral palsy and stiff-knee gait treated with standardized distal rectus femoris transfer as a part of multilevel surgery. Standardized three-dimensional gait analysis and clinical examination were carried out before surgery and at one year and nine years after surgery. Patients with decreased peak knee flexion in swing phase who had distal rectus femoris transfer to correct the decreased peak knee flexion in swing phase (C-DRFT) were evaluated separately from those with normal or increased peak knee flexion In swing phase who had distal rectus femoris transfer done as a prophylactic procedure (P-DRFT). Results: A significantly Increased peak knee flexion in swing phase was found in the C-DRFT group one year after surgery, while a significant loss (15°) in peak knee flexion in swing phase was noted in the P-DRFT group. A slight but not significant increase in peak knee flexion in swing phase in both groups was noted at the time of the long-term follow-up. A significant improvement in timing of peak knee flexion in swing phase was only found for the C-DRFT group, and was maintained after nine years. Knee motion and knee flexion velocity were significantly increased in both groups and were maintained at long-term follow-up In the C-DRFT group, while the P-DRFT showed a deterioration of knee motion. Conclusions: Distal rectus femoris transfer is an effective procedure to treat stiff-knee gait featuring decreased peak knee flexion in swing phase and leads to a long-lasting increase of peak knee flexion in swing phase nine years after surgery. Patients with more involvement showed a greater potential to benefit from distal rectus femoris transfer. How-ever, 18% of the patients showed a permanently poor response and 15% developed recurrence. In patients with severe knee flexion who underwent a prophylactic distal rectus femoris transfer, a significant loss in peak knee flexion in swing phase was noted and thus a prophylactic distal rectus femoris transfer may not be Indicated in these patients. [ABSTRACT FROM AUTHOR]

Planovalgus foot is a common pediatric deformity which may be associated with pain. To evaluate flexibility of the foot, the heel raise test is used. During this test the arch and hindfoot are assessed. Several studies have described planovalgus foot based on 3D gait and standing analysis. However, no studies have evaluated foot flexibility during heel raise using an objective 3D analysis. Therefore, the purpose of this study is to evaluate the flexibility of planovalgus feet during the heel raise test using an objective 3D assessment and to determine whether any hypotheses can be generated about potential differences between painful and painless flexible planovalgus feet and reference feet. Here, 3D foot analysis was conducted in 33 children (7 reference feet, 16 painless, and 10 painful flexible planovalgus feet) during the heel raise test. To identify the characteristics of planovalgus foot, the concept of 3D projection angles was used as introduced in the Heidelberg Foot Measurement Method (HFMM), with a modified marker set. All feet showed dynamic movements of the medial arch and hindfoot from valgus to varus position during heel raise. Reference feet had the smallest range of motion, perhaps due to joint stability and absence of foot deformity. Painful and painless flexible planovalgus feet demonstrated similar movements. No significant differences were found between the painful and painless groups. However, the kinematics of the pain group seemed to differ more from those of the reference group than did kinematics of the painless group. This assessment is a new, practical, and objective method to measure the flexibility of small children's feet. [ABSTRACT FROM AUTHOR]

Background: Bilateral internal rotation gait is a common gait abnormality in children with bilateral cerebral palsy, but still not fully understood.Research Question: The aim of this clinical study was to analyze the effects of artificially induced bilateral internal rotation gait on kinematics and kinetics. Our hypothesis was, that the internal rotation gait defined as increased dynamic internal hip rotation itself causes significant alterations in gait kinematics and kinetics.Methods: 30 typically developing children with a mean age of 12 (SD 3) years (range 8 - 16) performed three-dimensional gait analysis in two different conditions: with unaffected gait and with artificially induced bilateral internal rotation gait with two rotation bandages worn in order to internally rotate the hips. Kinematic and kinetic changes between these two conditions were calculated and compared using a mixed linear model with "gait condition" as fixed effect and both "limb" and "patient" as random effects.Results: The rotation bandages induced a significant increase in internal hip rotation and foot progression angle towards internal without affecting pelvic rotation. The peak hip internal rotator moment during loading response and the peak hip external rotator moment during the first half of stance phase increased significantly and the peak hip internal rotator moment during the second half of stance phase decreased significantly. Anterior pelvic tilt, hip flexion, knee flexion and ankle dorsiflexion increased significantly. The first peak of the frontal hip moment decreased, and the second increased significantly. The second peak of the frontal knee moment decreased significantly, while the first didn't change significantly.Significance: The data suggest, that the bilaterally increased dynamic internal hip rotation itself has a relevant impact on frontal hip moments. The increased anterior pelvic tilt, hip and knee flexion may be either induced by the pull of the rotation bandage or a secondary gait deviation. [ABSTRACT FROM AUTHOR]

Femoral derotation osteotomy (FDO) is a well‐established procedure for the correction of internal rotation gait in children with cerebral palsy. Various studies have demonstrated good results for FDO both in short‐term and long‐term evaluation with some describing recurrence and over‐ or under‐corrections. The present study evaluates the use of an objective intraoperative derotation measurement through electromagnetic tracking. We report the static and dynamic results of 11 cases with internal rotation gait (8 male, 3 female, mean age 22.2 years), that underwent FDO with intraoperative electromagnetic tracking and conventional goniometric measurement of the correction. The dynamic and static changes were assessed through three‐dimensional gait analysis after a mean of 12 months after surgery and rotational imaging preoperative and after a mean of eleven days postoperatively. Mean hip rotation in stance significantly decreased from 20.9° (SD 5.9) to 5.8° (SD 4.7°) after FDO. The mean amount of derotation quantified by electromagnetic tracking was 23.2° (16.5°–28.8°) and 25.1° (20.0°–33.0°) for goniometric measurement. Both measurement modalities showed small differences to rotational imaging (electromagnetic bone tracking [EMT]: 0.72°; goniometer: 1.19°) but a large deviation when compared to three‐dimensional gait analysis (EMT: 8.5°, goniometer: 9.1°). In comparison to the static changes and EMT measurement, the dynamic changes measured during 3‐D‐gait analysis reflected only 66% of the actual derotation performed during surgery. Although electromagnetic tracking allows a precise intraoperative assessment of the derotation during FDO, the amount of intraoperative correction is not reflected in the improvements in three‐dimensional gait analysis. [ABSTRACT FROM AUTHOR]

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 [ABSTRACT FROM AUTHOR]

Background: Total shoulder arthroplasty (TSA) can improve function in osteoarthritic shoulders, but the ability to perform activities of daily living (ADLs) can still remain impaired. Routinely, shoulder surgeons measure range of motion (ROM) using a goniometer. Objective data are limited, however, concerning functional three-dimensional changes in ROM in ADLs after TSA in patients with degenerative glenohumeral osteoarthritis. Methods: This study included ten consecutive patients, who received TSA for primary glenohumeral osteoarthritis. The patients were examined the day before, 6 months, and 3 years after shoulder replacement as well. We compared them with a control group (n = 10) without any shoulder pathology and measured shoulder movement by 3D motion analysis using a novel 3 D model. The measurement included static maximum values, the ability to perform and the ROM of the ADLs “combing the hair”, “washing the opposite armpit”, “tying an apron”, and “taking a book from a shelf”. Results: Six months after surgery, almost all TSA patients were able to perform the four ADLs (3 out of 40 tasks could not be performed by the 10 patients); 3 years postoperatively all patients were able to carry out all ADLs (40 out of 40 tasks possible). In performing the ADLs, comparison of the pre- with the 6-month and 3-year postoperative status of the TSA group showed that the subjects did not fully use the available maximum flexion/extension ROM in performing the four ADLs. The ROM used for flexion/extension did not change significantly (preoperatively 135°-0° -34° vs. 3 years postoperatively 131° -0° -53°). For abduction/adduction, ROM improved significantly from 33°-0° -27° preoperatively to 76° -0° -35° postoperatively. Compared to the controls (118°) the TSA group used less ROM for abduction to perform the four ADLs 3 years postoperatively. Conclusion: TSA improves the ability to perform ADL and the individual ROM in ADLs in patients with degenerative glenohumeral osteoarthritis over the course of 3 years. However, TSA patients do not use their maximum available abduction ROM in performing ADLs. This is not related to limitations in active ROM, but rather may be caused by pathologic motion patterns, impaired proprioception or both. [ABSTRACT FROM AUTHOR]

Objective: The aim of the investigation was to assess the contribution of pain to functional, social, and health-related quality-of-life outcomes in adults with cerebral palsy. Design: This monocentric, prospective study included long-term data for ambulant adults with cerebral palsy and at levels I-III in the Gross Motor Function Classification System who had received orthopedic multilevel surgery in adulthood and in whom preoperative and postoperative three-dimensional gait analysis was conducted, including the Gait Profile Score. A questionnaire including the Visual Analog Scale, Oswestry Disability Index, and European Quality of Life 5 Dimensions 3 Level was analyzed. Results : Twenty-four adults at a mean age of 38.0 yrs were included. Sixteen patients (66.7%) indicated that they experienced pain and 10 patients (41.7%) had pain for more than 6 mos. Overall, 13 patients (54%) experienced both pain and anxiety. There was no correlation of the Gait Profile Score with pain, Gross Motor Function Classification System, and Oswestry Disability Index. The Oswestry Disability Index showed a positive correlation with the Gross Motor Function Classification System (r = 0.39, P = 0.05) and pain (r = 0.57, P = 0.004). Conclusions: Pain and anxiety represent relevant comorbidities in adults with cerebral palsy. The occurrence of pain correlates with the Oswestry Disability Index and is higher than in children with cerebral palsy. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. Methods: The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%–79% falling into the highest or lowest 2 ratings. Results: For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2years growth remaining, and smaller (<30degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture. Conclusion: Anterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: This prospective study evaluated the development of proprioception over the course of 3 years after shoulder arthroplasty. Methods: Twenty-one patients were enrolled who underwent total shoulder arthroplasty ( n = 10) or hemiarthroplasty (HEMI) ( n = 11) for shoulder osteoarthritis. All patients were examined 1 day before the operation, 6 months and 3 years after surgery in a motion analysis study with an active angle-reproduction (AAR) test. Results: Overall proprioception measured by the AAR deteriorated significantly 3 years after surgery [from 6.6° (SD 3.1) to 10.3° (SD 5.7); p = 0.017] and was significantly worse than in the control group [10.3° (SD 5.7) vs. 7.8° (SD 2.3); p = 0.030). In the HEMI subgroup, 3 years after shoulder replacement, there is a significant deterioration of proprioception at 30° of external rotation [from 3.1° (SD 3.5) to 12.8° (SD 10.7); p = 0.031]. On average, in the TSA subgroup proprioception deteriorated from 7.1° (SD 3.1) to 8.6° (SD 1.4) and in the HEMI subgroup from 6.1° (SD 2.1) to 12.4° (SD 8.3). The comparison of postoperative impairment of proprioception between the TSA and HEMI subgroup showed significantly worse proprioception for the HEMI subgroup at 30° of external rotation [9.8° (SD 10.1) vs. 1.6° (SD 6.3) in the TSA group; p = 0.046]. Conclusion: In conclusion, proprioception that was measured by an AAR test remained unchanged or deteriorated 3 years after shoulder arthroplasty. The postoperative deterioration of proprioception was more distinctive in HEMI than in TSA group. [ABSTRACT FROM AUTHOR]

Background: Single-use rocking-motion-type bag bioreactors provide advantages compared to standard stirred tank bioreactors by decreased contamination risks, reduction of cleaning and sterilization time, lower investment costs, and simple and cheaper validation. Currently, they are widely used for cell cultures although their use for small and medium scale production of recombinant proteins with microbial hosts might be very attractive. However, the utilization of rocking- or wave-induced motion-type bioreactors for fast growing aerobic microbes is limited because of their lower oxygen mass transfer rate. A conventional approach to reduce the oxygen demand of a culture is the fed-batch technology. New developments, such as the BIOSTAT® CultiBag RM system pave the way for applying advanced fedbatch control strategies also in rocking-motion-type bioreactors. Alternatively, internal substrate delivery systems such as EnBase® Flo provide an opportunity for adopting simple to use fed-batch-type strategies to shaken cultures. Here, we investigate the possibilities which both strategies offer in view of high cell density cultivation of E. coli and recombinant protein production. Results: Cultivation of E. coli in the BIOSTAT® CultiBag RM system in a conventional batch mode without control yielded an optical density (OD600) of 3 to 4 which is comparable to shake flasks. The culture runs into oxygen limitation. In a glucose limited fed-batch culture with an exponential feed and oxygen pulsing, the culture grew fully aerobically to an OD600 of 60 (20 g L-1 cell dry weight). By the use of an internal controlled glucose delivery system, EnBase®Flo, OD600 of 30 (10 g L-1 cell dry weight) is obtained without the demand of computer controlled external nutrient supply. EnBase®Flo also worked well in the CultiBag RM system with a recombinant E. coli RB791 strain expressing a heterologous alcohol dehydrogenase (ADH) to very high levels, indicating that the enzyme based feed supply strategy functions well for recombinant protein production also in a rocking-motion-type bioreactor. Conclusions: Rocking-motion-type bioreactors may provide an interesting alternative to standard cultivation in bioreactors for cultivation of bacteria and recombinant protein production. The BIOSTAT® Cultibag RM system with the single-use sensors and advanced control system paves the way for the fed-batch technology also to rocking-motiontype bioreactors. It is possible to reach cell densities which are far above shake flasks and typical for stirred tank reactors with the improved oxygen transfer rate. For more simple applications the EnBase® Flo method offers an easy and robust solution for rocking-motion-systems which do not have such advanced control possibilities. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method. Methods: The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results: Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade. Conclusion: This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP. [ABSTRACT FROM AUTHOR]

Introduction: Conservative therapy for bilateral spastic cerebral palsy (BSCP) regularly includes a modular orthosis setup with dynamic ankle-foot orthosis (DAFO) and modular shank supply (MSS). Additional effects by this modular supply have not been studied so far. The goal was thus an exploratory investigation of what effects can be expected by supplementing a DAFO with an additional MSS. Materials and Methods: Ten children with BSCP were fitted with DAFO and MSS. Dynamic elastic shank adaptations (DESAs) and ground reaction force AFOs (GRAFOs) were used, depending on the participants' individual needs. Participants underwent a gait analysis after supply and 3 months later. Data analysis included a descriptive analysis and further statistical testing using a Friedman test and post hoc Wilcoxon rank test. Results: The Gillette Gait Index (GGI) improved significantly with MSS compared with barefoot and DAFO, the Gait Deviation Index (GDI) only comparing DAFO to MSS. However, no further changes had occurred at follow-up, and for the Gait Profile Score (GPS), not at all. Step length, velocity, cadence, stance duration, and step width changed significantly after supply. Kinematic changes developed at ankle, knee, hip, and trunk. However, only minor changes had occurred at follow-up. Conclusions: DAFOs and MSS show positive effects, as observed in spatiotemporal parameters, gait indices, and kinematic data. Most kinematic effects occur at the ankle and knee joint. MSS produces additional effects, with a particular emphasis on the extending effect on the knee in terminal stance. Only minor beneficial effects on kinematic parameters of knee and trunk during swing phase occur after a familiarization phase. The changes in the spatiotemporal parameters imply a slight deterioration. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to investigate whether short-arm fiberglass cast (SAC) immobilization provides fracture stabilization comparable to that of long-arm cast (LAC) treatment of displaced distal forearm fractures after closed reduction in paediatric patients. Methods: A prospective, randomized, controlled trial of children aged four to 16 years (mean 9.9 years) was designed with a sample of 120 children, whose size was set a priori, with 60 treated with SAC and 60 with LAC. The primary outcome was fracture stability and rate of loss of reduction. The secondary outcome analysis evaluated duration of analgesic therapy, restriction in activities of daily life, and the duration until patients regained normal range of motion in the elbow. Results: No statistically significant differences were found between the two groups in loss of reduction or duration of analgesic therapy. In contrast, the duration until normal range of motion in the elbow was regained was significantly longer in the LAC group (median 4.5 days, P < 0.001). Restriction in activities of daily life did not differ significantly between the two groups except for the item "help needed with showering in the first days after trauma" (SAC 60%, LAC 87%, P = 0.001). Conclusion: Fracture immobilization with short-arm fiberglass cast in reduced distal forearm fractures is not inferior to long-arm casts in children four years and older, excluding completely displaced fractures. Furthermore, short-arm casting reduces the need for assistance during showering. Trial registration: NCT03297047, September 29, 2017 [ABSTRACT FROM AUTHOR]

Background: Postural balance can be considered a conjoined parameter of gross motor performance. It is acquired in early childhood and honed until adolescence, but may also be influenced by various conditions. A simplified clinical assessment of balance and posture could be helpful in monitoring motor development or therapy particularly in pediatric patients. While analogue scales are considered unprecise and lab-based force-plate posturography lacks accessibility, we propose a novel kinematic balance assessment based on markerless 3D sensor technology.Research Question: Can balance and posture be assessed by tracking kinematic data using a single 3D motion tracking camera and are the results representative of normal motor development in a healthy pediatric cohort?Methods: A proprietary algorithm was developed and tested that uses skeletal data from the Microsoft Kinect™ V2 3D motion capture camera to calculate and track the center of mass in real time during a set of balance tasks. The algorithm tracks the distance of the COM traveled over time to calculate a balance score (COM speed). For this study, 432 school children aged 4-18 years performed 5 balance tasks and the resulting balance scores were analyzed and correlated with demographic data.Results: Preliminary experiments demonstrated that the system was able to reliably detect differences in COM speed during different balance tasks. The method showed moderate correlation with age and sex. Athletic activity positively correlated with balance skill in the age group < 8 years, but not in older children. Body mass appeared not to be correlated with balance ability.Significance: This study demonstrates that markerless 3D motion analysis can be used for the clinical assessment of coordination and balance and could potentially be used to monitor gross motor performance at the point-of-care. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Despite of many attempts to determine or correct hip and knee joint parameters via non-invasive techniques such as regression or functional methods, in conventional gait models the position of the ankle joint center still is assumed at the center point between malleoli.Research Question: The aim of this study was to estimate the ankle joint parameters using a functional approach.Methods: To this aim, we used data of 23 typically developed adults performing two different calibration motions. Subsequently, we applied functional approaches to determine the functional joint center and axis.Results: The results show significant differences for ankle joint parameters in all directions for both calibration motions applied with respect to the malleoli line. Most prominently, we find a shift of the ankle joint center of 7 % of the foot length anteriorly to the malleoli mid-point when applying functional calibration.Conclusion: These significant alterations of the ankle joint center and axis indicate the importance of accurate determination of ankle joint parameters and consequently their influence on the clinical outcome. [ABSTRACT FROM AUTHOR]

Aim: To evaluate short-term (1y postoperatively; E1) and long-term (at least 4y postoperatively; E2) changes in hamstring muscle-tendon length (MTL) and lengthening velocity after hamstring lengthening in children with bilateral cerebral palsy (CP).Method: Three-dimensional gait analysis was performed in 19 children (16 males, 3 females; 36 limbs; mean age at surgery 9y [SD 3y]; range 6-10y) with flexed knee gait, preoperative ankle dorsiflexion lower than 20 degrees, and CP before bilateral hamstring lengthening (E0), at E1 and E2. Hamstring MTL (normalized by leg length) and velocity were assessed via OpenSim software.Results: MTL increased from E0 to E1 (p=0.004) and decreased from E1 to E2 (p<0.020). Hamstring lengthening velocity did not change. In the subgroup with short, not slow hamstrings, the increase in MTL was maintained at E2.Interpretation: Hamstring lengthening is an efficient procedure to lengthen short and/or slow hamstrings short-term. The desired outcome with maintenance of the postoperative changes in hamstring MTL is only achieved for preoperatively short, not slow hamstrings.What This Paper Adds: Surgical hamstring lengthening can be confirmed via musculoskeletal modelling in OpenSim software. Surgical hamstring lengthening in cerebral palsy does not change hamstring lengthening velocity. Short, not slow hamstrings present a long-lasting muscle-tendon length (MTL) increase after hamstring lengthening. Changes in MTL after hamstring lengthening cannot be maintained for slow hamstrings. MTL does not change after hamstring lengthening for neither short nor slow hamstrings. [ABSTRACT FROM AUTHOR]

Purpose: Purpose of the present cohort study was the determination of lower body function and rotation in patients with symptomatic component mal-rotation after total knee arthroplasty using instrumented 3D gait analysis.Methods: A consecutive series of 12 patients (61.3 years ± 11.4 years) were included suffering under remaining pain or limited range of motion at least six months after total knee arthroplasty. A CT-scan according to the protocol of Berger et al. and instrumented 3D gait analysis were carried out including clinical examination, videotaping, and kinematic analysis using a Plug-in Gait model. Outcome variables were temporospatial parameters as well as kinematics in sagittal and transversal plane. Data for reference group were collected retrospectively and matched by age and gender.Results: Temporospatial parameters of the study group showed decreased velocity, cadence, and step length as well as increased step time. Single limb support was reduced for the affected limb. In sagittal plane, maximum knee flexion during swing phase was reduced for the replaced knee joint. In transverse plane, there was hardly any difference between affected and non-affected limb. Compared to the reference group, both limbs show significant increased internal ankle rotation and external hip rotation. There were significant strong linear correlations between ankle rotation and hip rotation as well as ankle rotation and radiological tibial mal-rotation.Conclusions: Patients with symptomatic component mal-rotation after total knee arthroplasty showed typically functional deficits. The affected and non-affected limb showed significant increased internal ankle rotation and external hip rotation, while only the affected, replaced knee showed reduced internal knee rotation. Identification of rotational abnormalities of hip and ankle joints seems to be mandatory in TKA to identify the patient group with external hip rotation, internal ankle rotation, and an elevated risk for symptomatic rotational TKA component mal-alignment. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the influence of supracondylar femoral derotation osteotomy (FDO) on hip abduction muscle force and frontal hip moments in children with bilateral cerebral palsy.Method: For this retrospective cohort study 79 children (36 females, 43 males; mean age at surgery 11y [SD 3y]; range 4-17y) with bilateral cerebral palsy and preoperatively and 1-year postoperatively documented frontal hip moments who received supracondylar FDO in 134 limbs were included. The control group consisted of eight children (two females, six males; mean age 11y [SD 4y]; range 5-17y) who received single-event multi-level surgery without FDO.Results: Hip joint impulse (p<0.001) and the first peak of frontal hip moments (p=0.003) increased, whereas the second peak decreased (p<0.001) from preoperatively to postoperatively. Hip abductor strength improved (p=0.001) from preoperatively to postoperatively.Interpretation: Despite the compensatory mechanism, frontal hip moments are decreased preoperatively. Supracondylar FDO results in increased frontal hip moments. Changes in anteversion directly influence hip kinetics, although no direct change of the proximal bony geometry is performed.What This Paper Adds: Internal rotation gait cannot fully restore the frontal hip moment. Supracondylar femoral derotation osteotomy (FDO) influences frontal hip kinetics in children with bilateral cerebral palsy. Supracondylar FDO changes the curve progression of frontal hip moments. Supracondylar FDO restores the hip abductor moment arm. Supracondylar FDO leads to an increase in hip abductor muscle force. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]