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PurposeIn 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.MethodA 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.ResultsThere 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.ConclusionThe 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 evidencelevel V.

PurposeThe 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.MethodsThe 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.ResultsConsensus 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.ConclusionThe 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 evidenceV.

PurposeThere 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.MethodsThe 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.ResultsThe 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.ConclusionThe results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy.Level of evidencelevel V.

PurposeThe 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.MethodsThe 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.ResultsFor 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 2 years growth remaining, and smaller (

PurposeThe 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.MethodsThe 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.ResultsConsensus 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.ConclusionThis study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP.Level of evidenceV.

PurposeEquinus 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.MethodsA 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.ResultsConsensus 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).ConclusionsThe results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research.Level of evidenceV.

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

This study summarizes the current knowledge of the etiology of hip dysplasia in children with neuromuscular disease and the implications for management. This article is based on a review of development of the hip joint from embryology through childhood growth. This knowledge is then applied to selective case reviews to show how the understanding of these developmental principles can be used to plan specific treatments. The development of the hip joint is controlled by genetic shape determination, but the final adult shape is heavily dependent on the mechanical environment experienced by the hip joint during growth and development. Children with neuromuscular conditions show a high incidence of coxa valga, hip dysplasia, and subluxation. The etiology of hip pathology is influenced by factors including functional status, muscular tone, motor control, child's age, and muscle strength. These factors in combination influence the development of high neck–shaft angle and acetabular dysplasia in many children. The hip joint reaction force (HJRF) direction and magnitude determine the location of the femoral head in the acetabulum, the acetabular development, and the shape of the femoral neck. The full range of motion is required to develop a round femoral head. Persistent abnormal direction and/or magnitude of HJRF related to the muscular tone can lead to a deformed femoral head and a dysplastic acetabulum. Predominating thigh position is the primary cause defining the direction of the HJRF, leading to subluxation in nonambulatory children. The magnitude and direction of the HJRF determine the acetabular shape. The age of the child when these pathomechanics occur acts as a factor increasing the risk of hip subluxation. Understanding the risk factors leading to hip pathology can help to define principles for the management of neurologic hip impairment. The type of neurologic impairment as defined by functional severity assessed by Gross Motor Function Classification System and muscle tone can help to predict the risk of hip joint deformity. A good understanding of the biomechanical mechanisms can be valuable for treatment planning. [ABSTRACT FROM AUTHOR]

This article introduces a novel concept where advanced technologies have been leveraged to produce a modular walking orthosis (MOWA) within a completely digital process chain. All processes of this new supply chain are described step-by-step. The prescription and treatment of lower leg orthoses for individuals with paralysis or muscle weakness, particularly cerebral palsy (CP), are complex. A single case study indicates successful treatment with this new orthosis (MOWA). From the authors' perspective, this innovative fitting concept is promising and will contribute to creating more efficient care within a multidisciplinary team. [ABSTRACT FROM AUTHOR]

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