Shriners Hospitals for Children - Springfield

BACKGROUND: are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases. METHODS: The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively. RESULTS: The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group. CONCLUSIONS: The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

AIM: To test a model of child, family, and service determinants of intensity of participation in leisure and recreational activities by children with cerebral palsy (CP). METHOD: Participants were 288 children with CP, age range 6 to 12 years (mean 9y 8mo, SD 2y), and their parents from seven children's hospitals. The sample comprised 166 (57.6%) males and 122 (42.4%) females, and between 40 (13.9%) and 74 (25.7%) children in each of the five levels of the Gross Motor Function Classification System. Children completed the Children's Assessment of Participation and Enjoyment by interview. Parents completed the Pediatric Outcomes Data Collection Instrument, Family Environment Scale, Coping Inventory, Measure of Processes of Care, and two questionnaires. Structural equation modeling was used to test the model. RESULTS: Fit statistics indicated a good model fit. The model explains 32% of the variance in intensity of participation. Path coefficients (p ≤ 0.05) indicate that higher gross motor function, higher enjoyment, more effective adaptive behavior, younger age, and higher family activity orientation are associated with higher intensity of participation. The path between services and participation was not significant. INTERPRETATION: Intensity of participation of children with CP is influenced by multiple child and family determinants. Children's gross motor function and behavior in life situations are important for participation; knowledge of activities the child and family enjoy has implications for opportunities for participation. Professionals are encouraged to address priorities for leisure and recreation identified by children with CP and their families.

History Fractures involving the epiphyseal plate, or physis, are common musculoskeletal injuries occurring in children with open growth plates. These fractures represent between 15% and 18% of all pediatric fractures [13, 24, 26] and present diagnostic and treatment challenges for orthopaedic surgeons. The first detailed description of injuries involving the epiphyseal plate was in 1863 by Foucher [8]. In 1898, Poland classified these fractures into four types [20]. Aitken further defined the characteristics of different types of physes with respect to structure, location, weightbearing status, and susceptibility to injury, suggesting that prognosis be considered on an individual basis [1]. In 1963, two Canadian orthopaedic surgeons, Robert B. Salter (1924-2010) and W. Robert Harris (1922-2005), created a physeal fracture classification system based on anatomy, fracture pattern, and prognosis [26]. Salter and Harris described two major types of epiphyseal plates: the pressure epiphysis and the traction epiphysis. Pressure epiphyses provide longitudinal growth, occur at the end of long bones, are intraarticular, and bear weight. In contrast, traction epiphyses provide appositional growth, occur at the origin or insertion of muscles, are extraarticular, and do not bear weight. Their classification focuses on injuries at pressure epiphyses. They recognized that physeal fractures consistently occur through the same histologic plane called the zone of provisional calcification (Fig. 1). This zone, located in the zone of hypertrophy, represents a transitional point between calcified and noncalcified extracellular matrix proteins, making it weaker than its surrounding osseous-ligamentous structures, and therefore more susceptible to injury.Fig. 1: The histology of the physis with standard hematoxylin and eosin staining is shown. The top of the slide is oriented toward the epiphysis while the bottom is oriented toward the metaphysis. The four zones of the physis and the surrounding fibrocartilaginous structures are shown. The most common region for physeal fractures to occur is through the zone of provisional calcification, which is a subzone of the zone of hypertrophy.Since the landmark paper by Salter and Harris [26], which characterized five types of physeal fractures (Fig. 2), various authors have expanded on the original work of Salter and Harris in attempts to be more comprehensive. Rang [21] added a sixth type of physeal injury which described damage to the perichondral ring that resulted from direct open injuries. Ogden [15] described nine types of injuries. This revised classification system included subclassifications of the original five Salter-Harris patterns meant to stratify the risk of growth arrest based on injury patterns. In addition, he described four new types that included injury to developing bone's other growth mechanisms (metaphyseal, diaphyseal, periosteal, zone of Ranvier, and epiphyseal perichondrium) not included in the Salter-Harris classification system. However despite multiple attempts to revise and expand on the classification of Salter and Harris, their system continues to be the most-widely used classification system of physeal injuries.Fig. 2: The five basic fracture types of the Salter-Harris classification are shown. A Type I fracture is a separation through the physis. A Type II fracture enters in the plane of the physis and exits through the metaphysis. The resulting metaphyseal fragment is called the Thurston-Holland fragment (*). A Type III fracture enters in the plane of the physis and exits through the epiphysis. A Type IV fracture crosses the physis, extending from the metaphysis to the epiphysis. A Type V fracture is a crush injury resulting in injury to the physis.Purpose An ideal fracture classification system should be reproducible, possess high inter- and intraobserver reliability, anticipate prognosis indicator, and guide clinical decision-making. Physeal injuries have the potential for growth arrest and resulting deformity; however, not all injuries to the physis pose the same risk. Therefore, a classification system that is able to identify injury patterns that carry a high risk of physeal arrest and deformity would be desirable. Salter and Harris’ [26] originally stated purpose was the accurate description of physeal injuries and prognosis relating to premature physeal closure. Description The Type I fracture (Figs. 2, 3), as originally described by Salter and Harris [26], extends directly through the growth plate, resulting in separation of the epiphysis from the metaphysis. According to Salter and Harris, the Type I fracture is more common in younger patients with a thicker physis.Fig. 3: This radiograph shows a Salter-Harris Type I fracture of the distal tibia. The fracture is in the plane of the physis (white arrows).Salter-Harris Type II (Figs. 2, 4) fractures are the most common type, accounting for 74% of physeal fractures. The fracture line enters in the plane of the physis and exits through the metaphysis. The separate metaphyseal fragment created is known as a Thurston-Holland fragment.Fig. 4: A Salter-Harris Type II fracture of the distal tibia is shown. The path of the fracture is from the lateral metaphysis to the medial physis (white arrows). The resulting metaphyseal Thurston-Holland fragment is denoted by the asterisk.Salter-Harris Type III (Figs. 2, 5) fractures also enter in the plane of the physis, but exit through the epiphysis, resulting in an intraarticular fracture. Type III fractures are much less common than Type II fractures, however, potential sequelae include posttraumatic arthritis in addition to growth arrest.Fig. 5: This radiograph shows a Salter-Harris Type III facture of the distal tibia. The fracture is intraarticular, exiting through the epiphysis (white arrows).Salter-Harris Type IV (Figs. 2, 6) fractures cross the physis, extending through the epiphysis and metaphysis. This fracture pattern disrupts the physis and articular surface and has an element of longitudinal instability. In addition to the risk of complete physeal arrest, a longitudinally malreduced Type IV fracture may result in the formation of a transphyseal bony bar with subsequent asymmetric growth or growth deformity.Fig. 6: The injury at the distal tibial sustained by a pediatric patient is a Salter-Harris Type IV fracture (white arrows) and can be seen traveling from the medial metaphysis to exit through the epiphysis. The injury at the distal fibula is a Salter-Harris Type I fracture (white line).Finally, Salter-Harris Type V (Figs. 2, 7) fractures are crush injuries at the physis as a result of compressive forces. These fractures are rare, and some authors, such as Peterson and Burkhart [18], have questioned their existence, but others, including Rathjen and Birch [22], accept them as a distinct etiology. This type of compressive damage to the physis also can occur as a stress injury and can be seen in gymnasts with repetitive loading on an extended wrist [4].Fig. 7: This radiograph shows a Salter-Harris Type V fracture or crush injury to the physis of the proximal radius. The smaller arrows show the path of the fracture while the larger arrows represent the compressive force causing the injury.To understand the pathomechanics of a physeal fracture, a basic understanding of growth plate histology is necessary. Salter and Harris [26] performed extensive histologic analysis of normal physeal anatomy, fracture patterns at the physis, and physeal healing after fracture. The physis can be subdivided into four different zones, starting from the epiphysis and extending to the metaphysis (Fig. 1). Zone 1 is the “resting zone” and is located adjacent to the epiphysis and contains resting cells or germinal matrix, largely composed of relatively metabolically inactive chondroblasts. Zone 2 is the “proliferative zone” and contains more active chondrocytes that produce extracellular matrix proteins. Zone 3 is the “hypertrophic zone” and contains chondrocytes that are larger and more organized, but have decreased production of extracellular matrix proteins. This zone often is broken into three subzones: the zone of maturation, the zone of degeneration, and the zone of provisional calcification. The zone of provisional calcification constitutes a transitional area between calcified and noncalcified extracellular matrix proteins, effectively making this zone the weakest [24]. Through histologic analysis, Salter and Harris showed that fracture propagation and physeal separation typically occur at this level. Zone 4 is the final layer—the “zone of calcification”—where cartilage is calcified and begins to be remodeled into bone. The physis is encircled at is periphery by fibrocartilaginous tissue that includes the groove of Ranvier and the ring of LaCroix (Fig. 1). The groove of Ranvier is a microscopic stricture at the diaphyseal end of the physis. It contains chondroblasts, osteoblasts, and fibroblasts that support the peripheral growth of the physis. The ring of LaCroix is a strong fibrous structure that overlies the groove of Ranvier and connects the epiphyseal periosteum to the metaphyseal periosteum, adding stability to the physis [22]. Salter and Harris [26] reported that, in the majority of physes, the blood supply to the proliferating cells arises from the epiphysis via its periosteum. Since the zone of provisional calcification is metaphyseal relative to the proliferating cells of the physis, epiphyseal blood supply theoretically remains intact with Types I and II fractures. Conversely, Types III and IV fractures exit epiphyseal, violating and potentially devascularizing the proliferating cell layer. Salter and Harris recognized that certain physes were especially prone to devascularization, namely the femoral and radial head. The epiphyses in these locations are completely covered by articular cartilage and have no periosteal blood supply. Alternately, the blood supply is metaphyseal and laterally traverses the rim of the physis, easily disrupted by the shear forces seen in a Type 1 fracture [6]. This model provides a framework to think about the types of physeal fractures, however, clinical reality is somewhat more complex. Subsequent histologic studies have shown that, depending on the forces involved, physeal injuries commonly involve multiple layers of the physis and rarely are isolated to the zone of provisional calcification [9, 14]. This is clinically evident with Type II fractures. These fractures can result in growth arrest despite theoretically leaving the proliferating cells and their blood supply intact. Jaramillo et al. [9] reported that MRI has the ability to elucidate which physeal zones are involved in an injury, allowing for better understanding of the growth plate injury. Validation Although the Salter-Harris classification is in common use, there are relatively few formal validation studies. Thawrani et al. [30] examined the intra- and interobserver reliability of classifying pediatric distal tibia fractures and found very high rates of intraobserver reliability and fairly robust rates of interobserver reliability (Kappa coefficient, 0.57-0.67). Several studies have compared the ability to classify fractures involving the growth plate on plain radiographs versus three-dimensional (3-D) imaging [11, 19, 27]. These studies do not specifically use interobserver reliability as an endpoint, instead showing that fracture displacement is consistently underappreciated on plain radiographs [11, 19], and that 3-D imaging can better elucidate fracture patterns and change the classification of the fracture [27]. A high rate of interobserver reliability of the classification is important to its clinical utility. Despite a lack of formal validation, the Salter-Harris classification has stood the test of time and is in widespread use. One may speculate that this prevalence is attributable to its inherent simplicity and being nearly universally known in the orthopaedic community. There are limitations to using a poorly validated classification system and there may be some benefit to perform additional validation studies of the Salter-Harris classification. Limitations The most significant limitation, as discussed above, is a paucity of studies formally validating the Salter-Harris classification, including interobserver reliability, intraobserver reliability, and accuracy in predicting fracture behavior. This validation is necessary to establish confidence in the classification and its implications. Lack of validation does not mean the classification is invalid, however, users should be aware of this limitation and use the classification accordingly. Future efforts to improve validation of the Salter-Harris classification could potentially resolve these concerns. Another major limitation is that the Salter-Harris classification is not an independent predictor of a fracture's prognosis. It is tempting to equate physeal arrest with prognosis when discussing fractures involving the physis, however, physeal arrest is only one component and is of variable clinical significance depending on remaining growth and the location of the deformity. Salter and Harris [26] recognized the complexity of this issue and commented that prognosis was not related to fracture classification alone, but also to the age of the patient, preservation of blood supply, presence of an open fracture, method of reduction, intraarticular displacement, quality of reduction, method and length of immobilization, and, of particular importance, the specific physis involved. Even if the outcome is limited to the presence of growth arrest alone, many authors agree that the Salter-Harris classification is not a good predictor of prognosis [2, 3, 7, 12, 23, 29]. For example, fractures involving the distal femoral physis tend to be high energy and have a rate of physeal arrest near 40% [2, 7]. Initial fracture displacement and accuracy of reduction have been found to be the most important prognostic indicators [2, 12]. Multiple studies examining physeal fractures at the distal tibia also have found that fracture displacement and mechanism of injury are the most significant prognostic indicators [10, 25, 28]. In a study of distal radius fractures, Cannata et al. [5] found that the rate of physeal arrest at the distal radius was less than 30% while the rate of physeal arrest at the distal ulna approached 80%, however, neither was significantly correlated to Salter-Harris classification and fewer than 5% of patients had residual symptoms or functional deficits. The most commonly reported predictors of physeal arrest appear to be initial fracture displacement, mechanism of injury, and accuracy of reduction. Discussion of the prognostic utility of the Salter-Harris classification highlights another significant limitation, which is lack of anatomic specificity. In their original article, Salter and Harris [26] recognized important variations in gross anatomy between different physes, however their proposed classification and discussion focused on the microanatomy of the generic physis. This prevents the classification from becoming overly complex; however, it limits the ability of the classification system to guide treatment or indicate prognosis with any specific fracture. This lack of specificity and comprehensiveness has been the impetus behind several subsequently proposed classification systems. In 1982, Ogden [15] proposed a classification scheme that expanded the Salter-Harris classification by adding four additional fracture types and multiple subtypes of each of the five original fracture types. The classification was meant to be applicable throughout the body, but rarely is used today, likely because of its complexity. In 1994, Peterson [17] proposed an expanded system based on an impressive epidemiologic study of physeal injuries. Peterson [16] added two new variants of physeal injuries (Peterson Types I and VI) (Fig. 8). A Peterson I injury is a metaphyseal fracture with extension into the physis (Fig. 9). A Peterson Type VI injury represents the loss of part of the physis. Peterson and Burkhart [18] also removed the Salter-Harris Type V fracture variant, questioning its existence; however, the omission of the Salter-Harris Type V fracture generally is not accepted. Rathjen and Birch [22] suggested maintaining the Salter-Harris classification and adding Peterson Types I and VI as additional and unique entities.Fig. 8: The Peterson classification adds two new fracture variants to the Salter-Harris classification. A Peterson Type I fracture is transmetaphyseal with extension into the physis, and a Peterson Type VI fracture has loss of part of the physis and typically is described as an open “lawnmower” type of injury.Fig. 9: This radiograph shows a Peterson Type I fracture of the distal radius. The fracture line is marked by arrows and can be seen crossing the metaphysis, and also extending into the physis.Conclusions and Uses The Salter-Harris classification continues to be relevant and serve an important purpose in orthopaedics despite substantial limitations. It is not a comprehensive system for classifying physeal injuries, guiding treatment, or determining prognosis. These limitation may be inherent to a classification that is intended to be generically applied to physeal fractures and does not attempt to account for anatomic variation between physes or unique clinical considerations of fractures in different locations. The Salter-Harris classification does provide a foundation to help clinicians understand how pediatric fractures relate to the anatomy and architecture of an open physis. Additionally, the generic nature of the classification allows it to be extremely simple and widely applied. The Salter-Harris classification has become part of the language used in orthopaedics, is nearly universally understood, and is used by orthopaedic practitioners, greatly facilitating communication. This is where the classification derives much of its utility. It may be more appropriate to think of the Salter-Harris classification as descriptive terminology with general clinical implications than a specific fracture classification that is expected to dictate treatment and prognosis. A thorough understanding of the scope of pediatric trauma and anatomy is necessary to guide treatment decisions and understand expected outcomes.

The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX-A) alone, casting alone, and the combination of BTX-A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty-nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo-controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX-A only (B), placebo injection plus casting (C), or BTX-A plus casting (B+C). The dosage for the BTX-A injections was 4U/kg per extremity. Assessments were performed at baseline, 3, 6, 7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1-year study indicate that BTX-A alone provided no improvement in the parameters measured in this study, while casting and BTX-A/casting were effective in the short- and long-term management of dynamic equinus in children with spastic CP.

The relationships between different levels of severity of ambulatory cerebral palsy, defined by the Gross Motor Function Classification System (GMFCS), and several pediatric outcome instruments were examined. Data from the Gross Motor Function Measure (GMFM), Pediatric Orthopaedic Data Collection Instrument (PODCI), temporal‐spatial gait parameters, and oxygen cost were collected from six sites. The sample size for each assessment tool ranged from 226 to 1047 participants. There were significant differences among GMFCS levels I, II, and III for many of the outcome tools assessed in this study. Strong correlations were seen between GMFCS level and each of the GMFM sections D and E scores, the PODCI measures of Transfer and Mobility, and Sports and Physical Function, Gait Velocity, and Oxygen Cost. Correlations among tools demonstrated that the GMFM sections D and E scores correlated with the largest number of other tools. Logistic regression showed GMFM section E score to be a significant predictor of GMFCS level. GMFM section E score can be used to predict GMFCS level relatively accurately (76.6%). Study data indicate that the assessed outcome tools can distinguish between children with different GMFCS levels. This study establishes justification for using the GMFCS as a classification system in clinical studies.

The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX‐A) alone, casting alone, and the combination of BTX‐A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty‐nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo‐controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX‐A only (B), placebo injection plus casting (C), or BTX‐A plus casting (B+C). The dosage for the BTX‐A injections was 4U/kg per extremity. Assessments were performed at baseline, 3,6,7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1‐year study indicate that BTX‐A alone provided no improvement in the parameters measured in this study, while casting and BTX‐A/casting were effective in the short‐ and long‐term management of dynamic equinus in children with spastic CP.

BACKGROUND: Congenital longitudinal deficiency of the fibula is the most common lower extremity congenital deficiency, with a broad spectrum of severity and subsequent reconstructive treatment. Published classification schemes do not accurately predict reconstructive treatment currently in practice. METHODS: We reviewed all medical records of patients with a dominant deformity of congenital fibular deficiency who were managed at our institution between 1971 and 2005. We assessed the impact of limb-length inequality, foot deformity, bilateral extremity involvement, and extent of fibular preservation on the treatment of the limb deficiency. RESULTS: One hundred and four patients (including twenty-two with bilateral congenital fibular deficiency) with 126 affected extremities had adequate radiographs to be included in the study. Femoral shortening was noted in seventy (85.4%) of eighty-two patients with unilateral limb involvement. Limb-length discrepancy prior to any treatment remained proportional in forty-seven (82.5%) of fifty-seven patients during an average duration of follow-up of ten years and ten months (range, two years to fifteen years and six months). Limb salvage with foot preservation was deemed feasible in thirty-eight (97.4%) of thirty-nine five-rayed feet, thirty (81.1%) of thirty-seven four-rayed feet, twenty (48.8%) of forty-one three-rayed feet, and one of nine feet having fewer than three rays. Twenty-two (41.5%) of fifty-three limbs with an absent or vestigial fibula were not treated with amputation. Of the twenty-two patients with bilateral fibular deficiency, twelve (54.5%) had preservation of both feet, three (13.6%) had unilateral amputation, and seven (31.8%) had bilateral amputation. CONCLUSIONS: We propose a simplified classification for congenital fibular deficiency based on the clinical status of the foot and the magnitude of limb shortening as a percentage of the contralateral limb on radiographs. This classification may be effectively applied in infancy to allow the physician and family to anticipate the extent of deformity at maturity and to estimate the amount of treatment required to reconstruct this limb deformity. This system more accurately predicted the management of patients with fibular deficiency who were managed at our institution over the past three decades .

Eighteen children with leg length discrepancies underwent femoral lengthenings using the Ilizarov method. Eight had concomitant tibial lengthening. Nine femoral and no tibial fractures occurred. Eight fractures occurred after lengthenings > 5 cm. Three occurred while in the frame. These healed without complication after frame extension. Six fractures occurred after frame removal. Treatment with spica casting left four patients with minimal angulation and one patient shortened. Five of nine patients lengthened for congenital discrepancies fractured. Only two patients lengthened for posttraumatic discrepancies fractured. We now preferentially lengthen the tibia because of the lower fracture rate. For substantial lengthening, we recommend concomitant tibial and femoral lengthening.

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

Aim To determine dimensionality and item-level properties of the Gillette Functional Assessment Questionnaire (FAQ) 22-item skill set using factor and Rasch analyses. Method A retrospective review of parent-reported FAQ 22-item skill set data was conducted of 485 individuals (273 males, 212 females; mean age 9y 10mo, SD 3y 10mo), including 289 with cerebral palsy and 196 with a variety of other neuromusculoskeletal conditions with orthopedic impairments. Factor analyses to validate unidimensionality of the skill set and Rasch analyses to determine relative item difficulty, item and test level information, and content coverage of the item set were performed. Differential item functioning analysis of sub-groups based on sex, diagnosis grouping, and age was conducted. Precision of score estimates for the item set was analyzed. Results The FAQ 22-item skill set demonstrates unidimensional structure and good item fit statistics. No floor or ceiling effects were noted. Differential item functioning (DIF) based on age was noted for seven items, four items showed diagnosis group-related DIF, and one item sex-related DIF. Precision was adequate in the mid-range range of abilities. Interpretation Based on this analysis, the FAQ 22-item skill set is a hierarchical set of interval scaled items suitable for measuring locomotor skill ability in children.

AIM This prospective multicenter study assessed performance and changes over time, with and without surgical intervention, in the modified Timed Up and Go (mTUG) and One-Minute Walk tests (1MWT) in children with bilateral cerebral palsy (CP). Minimum clinically important differences (MCIDs) were established for these tools. METHOD Two hundred and nineteen participants with bilateral spastic CP (Gross Motor Function Classification System [GMFCS] levels I–III) were evaluated at baseline and 12 months follow-up. The non-surgical group (n=168; 54 females, 114 males; mean age 12y 11mo, [SD 2y 7mo], range 8y 1mo–19y) had no surgical interventions during the study. The surgical group (n=51; 19 females, 32 males; mean age 12y 10mo [SD 2y 8mo] range 8y 2mo–17y 5mo) underwent soft-tissue and/or bony procedures within 12 months from baseline. The mTUG and 1MWT were collected and MCIDs were established from the change scores of the non-surgical group. RESULTS Dependent walkers (GMFCS level III) required more time to complete the mTUG (p≤0.01) than independent walkers (GMFCS levels I and II). For the 1MWT, distance walked decreased with increasing impairment (p≤0.01). 1MWT and mTUG change scores were not significantly different at any GMFCS level for either the surgical or non-surgical groups (p≤0.01). INTERPRETATION Children with varying levels of function (GMFCS level) perform differently on the 1MWT and mTUG. The data and MCID values can assist clinicians in interpreting changes over time and in assessing interventions.

STUDY DESIGN: Longitudinal case studies before and after posterior spinal instrumentation and fusion (PSIF) in idiopathic scoliosis (IS). OBJECTIVES: To quantitate the changes in body segment alignment following PSIF using standard radiographic techniques and an optoelectronic measurement system. SUMMARY OF BACKGROUND DATA: Evaluation of surgical correction following PSIF is traditionally performed radiographically. Radiographic film cannot reliably document transverse and coronal plane pelvic, torso, and shoulder orientation resulting from the global effect of vertebral malalignment. METHODS: Thirty-three subjects with IS were evaluated radiographically and with an optoelectronic measurement system before and 13 months after PSIF. All subjects had a primary right thoracic curve pattern. Thirteen subjects without scoliosis were evaluated as controls. Symmetry measures and transverse and frontal plane orientation relationships were measured and compared preop, postop, and with controls. RESULTS: The major curve decreased from 60 degrees to 24 degrees after surgery. The magnitude of C7 decompensation from the sacrum decreased following PSIF. Control subjects demonstrated neutral coronal and transverse plane alignment. Preoperatively, patients had an elevated and protracted right shoulder. Postoperative data showed correction in both the coronal and transverse planes. Ten out of 33 subjects were within 5 degrees of neutral shoulder protraction before surgery. Twenty-six out of 33 were within 5 degrees of neutral following surgery. CONCLUSIONS: Optoelectronic measurement of body segment alignment may be a useful noninvasive technique in the evaluation of scoliotic deformity. This is a new method of evaluating the global effect of vertebral malalignment on body segment alignment and can be used to quantify changes following PSIF.

Since the days of Hippocrates, scripts have included descriptions of infants who were unable to move their arms. However, it was not until the mid-1700s that an obstetric cause for the paralysis was considered. In 1872, the term obstetrical brachial plexus palsy was coined when a correlation was made between excessive traction on the brachial plexus during delivery and the clinical finding of arm paralysis. Surgical intervention became the norm in the beginning of the 19th century and continued until 1930. Poor outcomes and spontaneous resolution of obstetrical brachial plexus palsy prompted a 40-year span of conservative treatment. By the late 1960s, advances in technology and microsurgical techniques revived interest in surgical intervention in the management of obstetrical brachial plexus palsy. This article focuses on obstetrically caused brachial plexus injury, including risk factors, clinical presentation, and treatment options and outcomes. An understanding of current medical practices and their outcomes also provides a basis on which to develop sound support strategies to help parents who face this dilemma.

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

A method of recording a residual limb indentation stiffness map was developed for possible use as an aid in calculating prosthetic socket rectifications. The method was tested to determine the level of repeatability attainable. A hand-held, pencil-like device was used, with an air-driven piston that indented the tissue 10 times per second. The indentor tip contained an electromagnetic digitizer element that sensed position and orientation 120 times per second. The examiner moved the device around the limb; sampling was variable in density, and typically concentrated on critical areas. An interactive visual display of sampled data quality was used to guide sampling. The indentation maps typically contained approximately 4,000 locations, in a cylindrical coordinate system, with sampling locations spaced every 3.2 mm vertically, and every 0.087 radians tangentially. The behavior of the system was characterized using six test subjects on whom recorded indentations ranged from 1.5 to 21 mm. The largest range of indentations (i.e., worst disagreement) recorded at a single location was 5.4 mm. The average standard deviation on repeated measurement ranged from 7 to 15%, and averaged 0.67 mm in absolute terms. Many of the structurally significant anatomical features of the limbs were visible, including the patella and patellar tendon, fibular head, shin, biceps femoris tendon, semitendinosus, and popliteal area.

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.

An intraoperative autologous transfusion program was used in conjunction with preoperative phlebotomy in 25 children undergoing elective spinal surgery. Operative red blood cells, 10,000 ml, with an average hematocrit of 55%, as well as 7,300 ml of preoperative phlebotomy blood were returned to the patients. No complications were noted. The complete blood count on discharge was satisfactory, and the clotting parameters were unchanged. The results of this study show that intraoperative autologous transfusion with preoperative phlebotomy is safe, easy to perform, and cost-effective in children undergoing elective spinal surgery. The risks of homologous blood transfusions were eliminated.

BACKGROUND: Contemporary clinical assessments of activity are needed across the age span for children with cerebral palsy (CP). Computerized adaptive testing (CAT) has the potential to efficiently administer items for children across wide age spans and functional levels. OBJECTIVE: The objective of this study was to examine the psychometric properties of a new item bank and simulated computerized adaptive test to assess activity level abilities in children with CP. DESIGN: This was a cross-sectional item calibration study. METHODS: The convenience sample consisted of 308 children and youth with CP, aged 2 to 20 years (X=10.7, SD=4.0), recruited from 4 pediatric hospitals. We collected parent-report data on an initial set of 45 activity items. Using an Item Response Theory (IRT) approach, we compared estimated scores from the activity item bank with concurrent instruments, examined discriminate validity, and developed computer simulations of a CAT algorithm with multiple stop rules to evaluate scale coverage, score agreement with CAT algorithms, and discriminant and concurrent validity. RESULTS: Confirmatory factor analysis supported scale unidimensionality, local item dependence, and invariance. Scores from the computer simulations of the prototype CATs with varying stop rules were consistent with scores from the full item bank (r=.93-.98). The activity summary scores discriminated across levels of upper-extremity and gross motor severity and were correlated with the Pediatric OUTCOMES: Data Collection Instrument (PODCI) physical function and sports subscale (r=.86), the Functional Independence Measure for Children (Wee-FIM) (r=.79), and the Pediatric Quality of Life Inventory-Cerebral Palsy version (r=.74). LIMITATIONS: The sample size was small for such IRT item banks and CAT development studies. Another limitation was oversampling of children with CP at higher functioning levels. CONCLUSIONS: The new activity item bank appears to have promise for use in a CAT application for the assessment of activity abilities in children with CP across a wide age range and different levels of motor severity.

We surveyed the incidence of recognized latex sensitivity in myelodysplasia patients in 16 Shriners Hospitals. The percentage of involved patients ranged from 0 to 22% (mean 5%). Twenty-two children had a significant anaphylactic reaction. We provide recommendations for preoperative prophylaxis and sources of listings of latex and latex-free hospital products and home products.

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