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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 2 years growth remaining, and smaller (<30 degrees) 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. LEVEL OF EVIDENCE: V.

Background and Objectives: Ambulant children with cerebral palsy can demonstrate persistent "foot drop" after successful gastrocsoleus lengthening (GSL) surgery for equinus deformity. This may be due to inadequate strength and/or selective motor control of the ankle dorsiflexor muscles. A procedure has been developed to reduce foot drop-Tibialis Anterior Tendon Shortening (TATS), to be performed in conjunction with GSL. However, it is currently unclear how ankle dorsiflexor function changes after surgery and which children could benefit from TATS. This review summarises changes in ankle dorsiflexor function after GSL for equinus, as reported in the literature. Methods: A search was performed of the Medline, Embase and PubMed databases from 1980 to 5 March 2021. Keywords included "cerebral palsy", "equinus deformity", "orthopedic procedures" and "gait analysis". The search identified 1974 studies. Thirty-three cohort studies met the inclusion criteria for this review. Results: Twenty-two studies reported improvement in swing phase ankle dorsiflexion kinematics, after GSL. There was also evidence that clinical measures of ankle dorsiflexor strength improved after surgery. Four studies reported changes in selective motor control, with mixed results across the studies. Conclusions: There is good evidence that swing phase ankle dorsiflexion improves after GSL surgery. Although, there is limited evidence that this correlates with reduced foot drop or diminished need for an ankle-foot orthosis. Future research should be prospective, randomised, include a large sample size, and should focus on identifying the optimal candidates for TATS.

AIM: This study investigated the prevalence of scoliosis in a large, population-based cohort of individuals with cerebral palsy (CP) at skeletal maturity to identify associated risk factors that may inform scoliosis surveillance. METHODS: Young people with CP born between 1990 and 1992 were reviewed through routine orthopaedic review or a transition clinic. Classification of CP was recorded by movement disorder, distribution, gross and fine motor function. Clinical examination was undertaken and those with clinical evidence of scoliosis or risk factors had radiographs of the spine. Scoliosis severity was measured and categorised by Cobb angle. RESULTS: Two hundred and ninety-two individuals were evaluated (78% of the birth cohort) at a mean age of 21 years, 4 months (range 16-29 years). Scoliosis (Cobb angle >10°) was found in 41%, with strong associations to the Gross Motor Function Classification System (GMFCS), Manual Abilities Classification System (MACS) and dystonic/mixed movement disorders. Those at GMFCS V were 23.4 times (95%CI 9.9-55.6) more likely to develop scoliosis than those at GMFCS I. Severe curves (Cobb >40°, 13% of the cohort) were found almost exclusively in those functioning at GMFCS IV and V, and were 18.2 times (95%CI 6.9-48.5) more likely to occur in those with dystonia than those with spasticity. CONCLUSIONS: Scoliosis was very common in young people with CP, with prevalence and severity strongly associated with GMFCS and MACS level and dystonic movement disorder. Severe curves were almost exclusively found in non-ambulant children. Clinical screening for scoliosis should occur for all children with CP, with radiographic surveillance focusing on those functioning at GMFCS IV and V.

PURPOSE: The aim of this article was to compare longitudinal changes in hip morphology in cerebral palsy (hypertonic) and spinal muscular atrophy (hypotonic) to examine the influence of muscle tone on development of hip displacement. METHODS: Children with spinal muscular atrophy (Types I and II) and cerebral palsy (Gross Motor Function Classification System IV and V) with hip displacement (migration percentage >30%) were included. Head shaft angle, migration percentage, and acetabular index were measured at T1 (1-2.5 years), T2 (3-5 years), and T3 (6-8 years). Analysis of variance testing and linear regression were utilized. RESULTS: Sixty patients (cerebral palsy, N = 41; spinal muscular atrophy, N = 19) were included. Hip displacement occurred earlier in spinal muscular atrophy (34 months) than cerebral palsy (49 months) (p = 0.003). Head shaft angle was high and did not change between T1, T2, and T3, but significant changes in migration percentage were found (cerebral palsy: 23%, 36%, 45% (p < 0.01) and spinal muscular atrophy: 37%, 57%, 61% (p = 0.02)). Migration percentage increased by age in cerebral palsy (r = 0.41, p < 0.001), but not in spinal muscular atrophy (r = 0.18, p = 0.09). Acetabular index increased with migration percentage (cerebral palsy: r = 0.41, p < 0.001; spinal muscular atrophy: r = 0.48, p < 0.001). CONCLUSION: Persistent lateral physeal tilt by head shaft angle was found for both spinal muscular atrophy and cerebral palsy. Abnormal physeal alignment may be causally related to weakness of the hip abductor muscles rather than spasticity or muscle imbalance, resulting in coxa valga and secondary acetabular dysplasia. LEVEL OF EVIDENCE: III (case-control study).

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. LEVEL OF EVIDENCE: V.

This article presents a classification of lower limb musculoskeletal pathology (MSP) for ambulant children with cerebral palsy (CP) to identify key features from infancy to adulthood. The classification aims to improve communication, and to guide referral for interventions, which if timed appropriately, may optimise long-term musculoskeletal health and function. Consensus was achieved by discussion between staff in a Motion Analysis Laboratory (MAL). A four-stage classification system was developed: Stage 1: Hypertonia: Abnormal postures are dynamic. Stage 2: Contracture: Fixed shortening of one or more muscle-tendon units. Stage 3: Bone and joint deformity: Torsional deformities and/or joint instability (e.g., hip displacement or pes valgus), usually accompanied by contractures. Stage 4: Decompensation: Severe pathology where restoration of optimal joint and muscle-tendon function is not possible. Reliability of the classification was tested using the presentation of 16 clinical cases to a group of experienced observers, on two occasions, two weeks apart. Reliability was found to be very good to excellent, with mean Fleiss' kappa ranging from 0.72 to 0.84. Four-stages are proposed to classify lower limb MSP in children with CP. The classification was reliable in a group of clinicians who work together. We emphasise the features of decompensated MSP in the lower limb, which may not always benefit from reconstructive surgery and which can be avoided by timely intervention.

PURPOSE: The aim of this study is to report the safety and eff-cacy of soft-tissue surgery incorporating split transfer of tibi-alis anterior to peroneus brevis (SPLATT-PB) for children with hemiplegic spastic equinovarus. METHODS: This was a retrospective case series of children and adolescents with spastic hemiplegia who had a novel combination of SPLATT-TB, intramuscular tenotomy of tibialis posterior and either spasticity management or gastrocsole-us lengthening as the index surgery. The principal outcome measures were changes in pain and difficulty with shoe wear and radiological parameters obtained from weight-bearing anteroposterior and lateral radiographs of the affected foot before and after surgery. RESULTS: A total of 63 patients with symptomatic spastic equinovarus met the inclusion criteria. Mean age at surgery was 9.8 years (6 to 18) and the mean follow-up was seven years (range 3 to 10 years). Foot pain and problems with shoe wear improved after surgery. Seven radiological criteria showed a clinically and statistically significant improvement at follow-up, the majority being in the normal range. There were 11 surgical adverse events, all classified as Modified Cla-vien-Dindo Grade II. Three patients required further surgery for recurrent equinus, eight patients required further surgery for valgus deformities and four patients required bony surgery for residual varus deformities. CONCLUSION: Soft-tissue surgery for spastic equinovarus was successful in the majority of children with spastic hemiplegia, particularly between ages eight and 12 years, resulting in a plantigrade, flexible foot with minimal pain or limitations in shoe-wear. Children younger than 8 years at index surgery were more prone to overcorrection into valgus. Children older than 12 years had persistent varus deformities requiring bony surgery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

AIM: We explored the experiences of parents of children with cerebral palsy (CP) when engaging in hip surveillance for their child and aimed to identify the barriers and facilitators they encounter. METHODS: We conducted a pragmatic qualitative study through five focus groups conducted with 23 parents and primary care givers of young people with cerebral palsy. A semi-structured topic guide was used to facilitate discussion. Recordings were transcribed verbatim and transcripts analysed using content analysis. RESULTS: Six major categories emerged: (i) hip surveillance is a shared responsibility; (ii) knowledge is empowering; (iii) hip surveillance should be proactive rather than reactive; (iv) consistency and support from health professionals is valuable; (v) good communication is crucial; and (vi) challenges associated with having an X-ray may not be appreciated. Participants made recommendations related to: service model enhancements, information provision and improving both communication and the experience of having an X-ray. CONCLUSION: Despite having a good understanding of the need and importance of hip surveillance for their child, several barriers to parent engagement exist. Findings will inform the implementation of a family-centred model for hip surveillance and may be relevant to those undertaking or planning the implementation of hip surveillance in other areas.

The identification of musculoskeletal impairments from gait analysis in children with cerebral palsy is a complex task, as is formulating (surgical) recommendations. In this paper, we present how we built a decision support system based on gait kinematics, anthropometrics, and physical examination data. The decision support system was trained to learn the association between these data and the list of impairments and recommendations formulated historically by experienced clinicians. Our aim was 2-fold, train a computational model that would be representative of data-based clinical reasoning in our center, and support new or junior clinicians by providing pre-processed impairments and recommendations with the associated supportive evidence. We present some of the challenges we faced, such as the issues of dimensionality reduction for kinematic data, missing data imputations, class imbalance and choosing an appropriate model evaluation metric. Most models, i.e., one model for each impairments and recommendations, achieved a weighted Brier score lower than 0.20, and sensitivity and specificity greater than 0.70 and 0.80, respectively. The results of the models are accessible through a web-based application which displays the probability predictions as well as the (up to) 5 best predictors.

AIM: This study aimed to explore health professionals' experiences of implementing hip surveillance for young people with cerebral palsy (CP) and to identify any barriers they encounter. METHODS: A cross-sectional web-based survey of health professionals supporting children with CP was conducted. Responses were analysed through mixed methods. Responses to items presented as ordinal scales were analysed using descriptive statistics, and open-ended responses through a qualitative approach to identify themes. RESULTS: A total of 32 paediatricians, 2 rehabilitation specialists and 50 physiotherapists completed the survey, with respondents working within both hospital- and community-based settings. Barriers most frequently reported were inconsistency in radiology practice and reporting (35%), parent engagement (32%), limited communication between clinicians (31%), lack of clarity in lines of responsibility (27%) and forgetting to undertake surveillance (26%). Four major themes were identified through qualitative analysis: (i) recognition of the importance of clinical guidelines to hip surveillance; (ii) the value of each role in the team around a child; (iii) the challenge of sharing responsibility; and (iv) the importance of communication in facilitating collaboration. CONCLUSIONS: Barriers can be encountered at each phase of the hip surveillance process, but there are also factors that act as facilitators. Locally, the results will inform the development of an enhanced state-wide approach to hip surveillance for all children with CP. The identified barriers do not appear unique to the local context, and the findings may be transferable to other settings. Awareness of the potential barriers and facilitators would be valuable to those implementing hip surveillance in other areas.

AIM: The prevalence of severely symptomatic deformities of the first metatarsophalangeal (MTP) joint in adolescents with cerebral palsy (CP) requiring arthrodesis is unknown. Recent literature regarding these deformities is limited. We studied the presentation of severe, symptomatic deformities of the first ray in a large population of children and adolescents with CP and their association with gross motor function, CP subtype, and other musculoskeletal deformities. METHOD: We identified 41 patients with CP and a symptomatic deformity of the first MTP joint, managed by arthrodesis, from a large population based database over a 21-year period. Information recorded included demographics, CP subtype, Gross Motor Function Classification System (GMFCS), clinical presentation, and radiological features. RESULTS: Adolescents with spastic diplegia, at GMFCS levels II and III, were the most common group to develop symptomatic hallux valgus. In contrast, non-ambulant adolescents, at GMFCS levels IV and V, with dystonia or mixed tone, more commonly had dorsal bunions. INTERPRETATION: The type of first MTP joint deformity in patients with CP may be predicted by the type and distribution of movement disorder, and by GMFCS level. Specific patterns of associated musculoskeletal deformities may contribute to the development of these disorders and may provide a guide to surgical management. WHAT THIS PAPER ADDS: The prevalence of severe bunions requiring fusion surgery was 2%. The two types of bunion were hallux valgus and dorsal bunion. The type of bunion can be identified on both clinical and radiological grounds. The cerebral palsy subtype is predictive of the type of bunion.

AIM: We investigated the validity of the Gait Outcomes Assessment List (GOAL), as an assessment of gait function in children with cerebral palsy (CP). METHOD: We studied a prospective cohort of 105 children with CP (Gross Motor Function Classification System [GMFCS] levels I-III; 65 males, 40 females; mean [SD] age 11y 11mo [3y 5mo], range 6-20y), who attended gait assessment over a 10-month period. Parents completed the GOAL, Functional Mobility Scale (FMS), and Functional Assessment Questionnaire (FAQ) during their child's gait evaluation. Ninety children completed instrumented gait analysis (IGA). Total GOAL and domain scores, Gait Profile Score (GPS), and Gait Variable Scores were calculated. RESULTS: The total GOAL discriminated between GMFCS levels (mean [SD] GMFCS level I, 72.5 [12.7]; GMFCS level II, 61.4 [13.0]; GMFCS level III, 38.8 [10.6]; [F2,97 =42.4, p<0.001]). Moderate correlations were found between total GOAL and FMS (5m and 50m r=0.59; 500m r=0.66) and FAQ walking (r=0.77) and activities list (r=0.75, p<0.01). There was a moderate negative correlation between total GOAL and GPS (r=-0.59) and gait appearance domain and GPS (r=-0.52, p<0.01). INTERPRETATION: The GOAL is a valid assessment of gait function in ambulant children with CP. It has the potential to improve understanding of the child's and parents' priorities and thus, in conjunction with IGA, provide a more balanced assessment across the domains of the World Health Organization's International Classification of Functioning, Disability and Health. WHAT THIS PAPER ADDS: The Gait Outcomes Assessment List (GOAL) can discriminate between Gross Motor Function Classification System levels. The GOAL correlates with standard functional assessments and gait analysis. Used with gait analysis, the GOAL provides comprehensive assessment across all International Classification of Functioning, Disability and Health domains.

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'.

Purpose Botulinum toxin-A (or Botox) is widely used for the management of equinus gait in children with cerebral palsy but few recent studies have included instrumented gait analysis. Methods This was a prospective cohort study. Gait analysis was performed four weeks before and four weeks after Botulinum toxin-A injection for spastic equinus to detect the maximum effects on gait kinematics. Outcome measures included the Gait Profile Score (GPS), the Gait Variable Score (GVS) for the ankle, maximal ankle dorsiflexion and maximal knee extension at midstance. Results In all, 37 children participated (20 boys); mean age five years seven months (4 years 1 month to 8 years 2 months); 19 with unilateral and 18 bilateral involvement. At a mean four weeks post-injection, the GPS and ankle GVS were unchanged. However maximum ankle dorsiflexion increased for the whole group; median 7.7° (confidence interval (CI) 4° to 10.6°) to 11.5° (CI 7.7° to 12.9°), p = 0.02. Maximum midstance knee extension was unchanged for the whole group, but median knee flexion increased in children with bilateral involvement; 10.9° (CI 7.4° to 20.8°) to 16.5° (CI 8.4° to 19.7°), p = 0.58. Conclusion Injections of the gastrocsoleus for spastic equinus did not result in objective improvements in overall gait. Improvements in ankle dorsiflexion for children with bilateral involvement may be offset by deterioration at the knee.

AIM: Economic appraisal can help guide policy-making for purchasing decisions, and treatment and management algorithms for health interventions. We conducted a systematic review of economic studies in cerebral palsy (CP) to inform future research. METHOD: Economic studies published since 1970 were identified from seven databases. Two reviewers independently screened abstracts and extracted data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Any discrepancies were resolved by discussion. RESULTS: Of 980 identified references, 115 were included for full-text assessment. Thirteen articles met standard criteria for a full economic evaluation, two as partial economic evaluations, and 18 as cost studies. Six were full economic evaluations alongside clinical studies or randomized controlled trials, whereas seven involved modelling simulations. The economic case for administration of magnesium sulfate for imminent preterm birth is compelling, achieving both health gain and cost savings. Current literature suggests intrathecal baclofen therapy and botulinum toxin injection are cost-effective, but stronger evidence for long-term effects is needed. Lifestyle and web-based interventions are inexpensive, but broader measurement of outcomes is required. INTERPRETATION: Prevention of CP would avoid significant economic burden. Some treatments and interventions have been shown to be cost-effective, although stronger evidence of clinical effectiveness is needed. What this paper adds Cost-effectiveness evidence shows prevention is the most significant strategy. Some treatments are cost-effective, but stronger evidence for long-term effectiveness is required. Comparison of treatment costs is challenging owing to variations in methodologies and varying clinical indications.

The clinical care of children with physical disabilities is a major priority for paediatricians and paediatric orthopaedic surgeons. Cerebral palsy (CP) is the prototypical condition and remains the most common cause of physical disability in developed countries. The incidence is approximately 2 per 1000 live births, translating to between 600 and 700 new children per annum in Australia, with approximately 34 000 children and adults currently living with CP. This figure is predicted to rise inexorably over the next 20 years. The care of children with physical disabilities, including those with CP, is usually coordinated by paediatricians, general practitioners and allied health teams including physiotherapists, with input from paediatric orthopaedic surgeons when appropriate. The emphasis in care for children with CP has moved from 'reactive' to 'proactive'. In the past, children are often referred when symptomatic, for example when a hip dislocation had occurred and became painful. The emphasis now is on coordinated, multidisciplinary care in which musculoskeletal manifestations of disability are identified by screening programmes. Systematic screening, especially when population-based and linked to a register, avoids children getting 'lost in the system'. Early and more effective interventions may be offered for the prevention of contractures, dislocation of the hip and spinal deformities. In this review, we will focus on the assessment of gait in children with physical disabilities, and monitoring for hip and spine deformity.

AIM: Children with cerebral palsy (CP) have reduced levels of physical activity compared with children without physical disability and experience risk factors for becoming overweight or obese. In the Australian CP population, there is little information available about the weight status of children with CP. The aims of this study were to compare the distribution of body mass index (BMI) in a cohort of ambulant children with CP with the BMI distribution of Australian children and explore the relationship between BMI and gross motor function. METHODS: A retrospective cohort study of 587 children with CP Gross Motor Function Classification System (GMFCS) levels I-III who attended a Gait Laboratory between July 1995 and January 2012 was carried out. The BMI and Z-score were calculated at each assessment. Data were grouped into the categories of underweight, healthy, overweight and obese according to age-specific and sex-specific percentiles. RESULTS: There were 348 boys and 240 girls with a mean age 11.2 (standard deviation 3.2) years. Mean BMI Z-score was 0.11 (standard deviation 1.33). Seven percent of children were underweight, 73.6% healthy, 7.3% overweight and 12.1% obese. This was similar to the distribution of children without disability. The largest percentage of children in the healthy group were classified GMFCS I. The largest percentage of children in the obese group were classified GMFCS III. CONCLUSIONS: In this cohort, 19.4% of ambulant children with CP were overweight or obese. This is of concern as BMI may impact on the outcomes of surgical intervention and rehabilitation. Further research is needed to determine the consequences of obesity for children with CP.

AIM: To examine the kinematic gait deviations at the trunk and pelvis of children with hereditary spastic paraplegia (HSP). METHOD: This exploratory observational study quantified gait kinematics for the trunk and pelvis from 11 children with HSP (7 males, 4 females) using the Gait Profile Score and Gait Variable Scores (GVS), and compared the kinematics to data from children with typical development using a Mann-Whitney U test. RESULTS: Children with HSP (median age 11y 4mo, interquartile range 4y) demonstrated large deviations in the GVS for the trunk and pelvis in the sagittal and coronal planes when compared to the gait patterns of children with typical development (p=0.010-0.020). Specific deviations included increased range of movement for the trunk in the coronal plane and increased excursion of the trunk and pelvis in the sagittal plane. In the transverse plane, children with HSP demonstrated later peaks in posterior pelvic rotation. INTERPRETATION: The kinematic gait deviations identified in this study raise questions about the contribution of muscle weakness in HSP. Further research is warranted to determine contributing factors for gait dysfunction in HSP, especially the relative influence of spasticity and weakness.

AIM: We studied 'hip health' in a population-based cohort of adolescents and young adults with cerebral palsy to investigate associations between hip morphology, pain, and gross motor function. METHOD: Ninety-eight young adults (65 males, 33 females) from the birth cohort were identified as having developed hip displacement (migration percentage >30) and were reviewed at a mean age of 18 years 10 months (range 15-24y). Hip morphology was classified using the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS). Severity and frequency of pain were recorded using Likert scales. Gross motor function was classified by the Gross Motor Function Classification System (GMFCS). RESULTS: Hip pain was reported in 72% of participants. Associations were found between pain scores and both hip morphology and GMFCS. Median pain severity score for MCPHCS grades 1 to 4 was 2 (interquartile range [IQR] 1.0-3.0) compared to 7 (IQR 6.0-8.0) for grades 5 and 6 (severe subluxation or dislocation). Hip surveillance and access to surgery were associated with improved hip morphology and less pain. INTERPRETATION: Poor hip morphology at skeletal maturity was associated with high levels of pain. Limited hip surveillance and access to surgery, rather than GMFCS, was associated with poor hip morphology. The majority of young adults who had access to hip surveillance, and preventive and reconstructive surgery, had satisfactory hip morphology at skeletal maturity and less pain.

Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.

BACKGROUND: Proximal femoral osteotomy is the most common major reconstructive surgery in the region of the hip joint in children and adolescents. Given that it may be required across a wide range of ages and indications, appropriate instrumentation is necessary to ensure a technically satisfactory result. Recent developments in fixation include cannulation of the blade plate and locking screw technology. METHODS: We conducted a prospective audit of our first 25 patients who had a unilateral or bilateral proximal femoral osteotomy using a recently available system which combines cannulation and locking plate technology. The principal outcome measures were the radiographic position of the osteotomy at the time of union and surgical adverse events. RESULTS: Forty-five proximal femoral osteotomies were performed in 25 patients, mean age 8 years (range 3-17 years), for a variety of indications, the most common of which was hip subluxation in children with cerebral palsy. All osteotomies were soundly united by 6 weeks in children and by 3 months in adolescents, in the position achieved intra-operatively. There were no revision procedures and the technical goals of surgery were achieved in all patients. There was one adverse event, a low-grade peri-prosthetic infection, diagnosed at the time of implant removal. CONCLUSIONS: In this prospective audit of our first 25 patients, the new system performed well across a wide range of ages, body weights and surgical indications. Further comparative studies will be required to determine whether it offers additional advantages over more traditional systems.

BACKGROUND: Cerebral palsy is a permanent disorder of posture and movement caused by disturbances in the developing brain. It affects approximately 1 in every 500 children in developed countries and is the most common form of childhood physical disability. People with cerebral palsy may also have problems with speech, vision and hearing, intellectual difficulties and epilepsy. Health and therapy services are frequently required throughout life, and this care should be effective and evidence informed; however, accessing and adopting new research findings into day-to-day clinical practice is often delayed. METHODS/DESIGN: This 3-year study employs a before and after design to evaluate if a multi-strategy intervention can improve research implementation among allied health professionals (AHPs) who work with children and young people with cerebral palsy and to establish if children's health outcomes can be improved by routine clinical assessment. The intervention comprises (1) knowledge brokering with AHPs, (2) access to an online research evidence library, (3) provision of negotiated evidence-based training and education, and (4) routine use of evidence-based measures with children and young people aged 3-18 years with cerebral palsy. The study is being implemented in four organisations, with a fifth organisation acting as a comparison site, across four Australian states. Effectiveness will be assessed using questionnaires completed by AHPs at baseline, 6, 12 and 24 months, and by monitoring the extent of use of evidence-based measures. Children's health outcomes will be evaluated by longitudinal analyses. DISCUSSION: Government, policy makers and service providers all seek evidence-based information to support decision-making about how to distribute scarce resources, and families are seeking information to support intervention choices. This study will provide knowledge about what constitutes an efficient, evidence-informed service and which allied health interventions

PURPOSE: The majority of children with orthopaedic conditions in childhood survive to adult life, and there is a need for many of them to transition to adult services. This includes children with disorders such as club foot or developmental dislocation of the hip as well as those with complex syndromic conditions, bone dysplasias or neuromuscular disorders such as cerebral palsy and myelomeningocele. In many tertiary paediatric centres, transition has become a formal process in which clinicians document and communicate the status of patients who have been under their care to ensure a smooth transfer to adult services. The purpose of this report is to support the need for clear communication when children with cerebral palsy transition to adult services and to suggest that this transition represents a significant opportunity for audit and clinical research. METHODS: Some of the factors to be considered in developing a minimum data sheet for the transfer or transition of children with cerebral palsy to adult services are described. CONCLUSION: Using the model of adolescents with cerebral palsy transitioning to adult services, orthopaedic surgeons can be encouraged to develop similar methodology and documentation for many other conditions for the purposes of communication, facilitation of transition, audit and clinical research.

INTRODUCTION: Diaphyseal forearm fractures are common in children and adolescents. Intramedullary fixation with flexible nails has a high success rate. Complications related to the insertion of the radial nail include injury to the superficial branch of the radial nerve and rupture of the extensor pollicis longus (EPL) tendon. MATERIALS AND METHODS: We report a series of nine patients who sustained an EPL injury related to the insertion of an elastic intramedullary nail into the radius. RESULTS: All nine patients underwent operative management, consisting of either EPL release, EPL direct repair, or tendon transfer (using extensor indicis proprius). In all cases, the nail entry site was directly related to the location of EPL. In many of the cases the EPL dysfunction occurred early on but it's recognition was often delayed. CONCLUSION: Based on our findings, we recommend the use of a radial entry point. For surgeons who prefer the dorsal entry point, we recommend that they use an incision which allows visualisation of the extensor tendons and that any post-operative EPL dysfunction is addressed promptly.

BACKGROUND: Slipped capital femoral epiphysis is known to produce characteristic deformities in the proximal femur, which affect hip motion and may cause a limp. This paper assessed the 3D gait kinematics in adolescents after single screw fixation of moderate to severe, stable, unilateral slipped capital femoral epiphysis. Our goals were to characterize the 3D kinematic patterns and to investigate the correlation between the severity of radiological deformity and severity of gait disturbance. METHODS: This was a retrospective study of patients seen at our institution between 2000 and 2009. Antero-posterior and frog lateral X-rays were reviewed to measure: Southwick's lateral slip angle, the alpha angle of Notzli and Klein's line offset. Quantitative 3D gait data was collected using a state of the art motion capture system. Kinematic waveforms were compared using a functional data analysis version of the t-test. FINDINGS: There were 30 patients with an average age at pinning of 13y (10-17y). Mean gait profile scores were significantly abnormal for slipped side (10.8°) versus sound side (6.8°), slipped side versus normal (5.6°) and sound side versus normal. There was little statistically significant correlation between severity of radiographic deformity and degree of gait disturbance. INTERPRETATION: Major kinematic pattern deviations could be associated with (a) morphology of the proximal femur and potential femoral acetabular impingement problems and (b) leg length discrepancy. Gait analysis was able to quantify the kinematic deviations due to the anatomical deformities.

BACKGROUND: Lengthening of soft-tissue contractures is frequently required in children with a wide variety of congenital and acquired deformities. However, little is known about the biomechanics of surgical procedures which are commonly used in contracture surgery, or if variations in technique may have a bearing on surgical outcomes. We investigated the hypothesis that the site of intramuscular tenotomy (IMT) within the muscle-tendon-unit (MTU) of the tibialis posterior (TP) would affect the lengthening characteristics. METHODS: We performed a randomized trial on paired cadaver tibialis posterior muscle-tendon-units (TP-MTUs). By random allocation, one of each pair of formalin-preserved TP-MTUs received a high IMT, and the other a low IMT. These were individually tensile-tested with an Instron(®) machine under controlled conditions. A graph of load (Newtons) versus displacement (millimetres) was generated for each pair of tests. The differences in lengthening and load at failure for each pair of TP-MTUs were noted and compared using paired t tests. RESULTS: We found 48% greater lengthening for low IMT compared to high IMT for a given load (P = 0.004, two tailed t test). Load at failure was also significantly lower for the low IMT. These findings confirm our hypothesis that the site of the tenotomy affects the amount of lengthening achieved. This may contribute to the reported variability in clinical outcome. CONCLUSIONS: Understanding the relationship between tenotomy site and lengthening may allow surgeons to vary the site of the tenotomy in order to achieve pre-determined surgical goals. It may be possible to control the surgical "dose" by altering the position of the intramuscular tenotomy within the muscle-tendon-unit.

BACKGROUND: Cerebral palsy (CP) may cause severe spasticity, requiring neurosurgical procedures. The most common neurosurgical procedures are continuous infusion of intrathecal baclofen and selective dorsal rhizotomy. Both are invasive and complex procedures. We hypothesized that a percutaneous radiofrequency lesion of the dorsal root ganglion (RF-DRG) could be a simple and safe alternative treatment. We undertook a pilot study to test this hypothesis. METHODS: We performed an RF-DRG procedure in 17 consecutive CP patients with severe hip flexor/adductor spasms accompanied by pain or care-giving difficulties. Six children were systematically evaluated at baseline, and 1 month and 6 months after treatment by means of the Modified Ashworth Scale (MAS), Gross Motor Function Measure (GMFM) and a self-made caregiver's questionnaire. Eleven subsequent children were evaluated using a Visual Analogue Scale (VAS) for spasticity, pain and ease of care. RESULTS: A total of 19 RF-DRG treatments were performed in 17 patients. We found a small improvement in muscle tone measured by MAS, but no effect on the GMFM scale. Despite this, the caregivers of these six treated children unanimously stated that the quality of life of their children had indeed improved after the RF-DRG. In the subsequent 11 children we found improvements in all VAS scores, in a range comparable to the conventional treatment options. CONCLUSION: RF-DRG is a promising new treatment option for severe spasticity in CP patients, and its definitive effectiveness remains to be defined in a randomised controlled trial.