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Femoral neck fractures in children are severe injuries associated with the potentially disastrous complication of femoral head osseous necrosis. Our primary goal was to identify what factors contribute to the occurrence of femoral head osteonecrosis in skeletally immature patients with femoral neck fractures. We evaluated a large consecutive series of pediatric patients with femoral neck fractures. Between 1970 and 2000, 20 patients with a mean age of 11 years (range, 4-15 years) with femoral neck fractures were identified. All traumatic epiphyseal, transcervical, and basicervical (Types I, II, and III) fractures were included. There were 14 male patients and six female patients. The mean followup was 7 years (range, 1-28 years). Timing of surgery, type of fixation, and quality of reduction were analyzed with respect to the primary outcome measure-radiographic evidence of femoral head osteonecrosis. Eighteen of 20 hip fractures healed without complication; all had good or excellent reductions. Two patients had osteonecrosis develop; both had fair or poor reductions. Five patients were treated more than 48 hours after injury, including the two patients who had osteonecrosis develop. The mean time to fixation for the remaining patients was 12 hours. There was no relationship between capsular decompression and osteonecrosis development. Quality of reduction and timing of reduction influenced the risk of osteonecrosis. [ABSTRACT FROM AUTHOR]

Background: Children with cerebral palsy (CP) or acquired brain insult (ABI) present with motor disorders affecting movement, muscle tone, and posture. While CP is commonly a consequence of perinatal brain insult (PBI), pediatric ABI can occur between birth and adolescence, with movement patterns that may not be consistent with CP., Research Question: Are gait patterns associated with CP different from those with pediatric ABI?, Materials/methods: Children with unilateral motor impairment and history of ABI at ≥18 months of age were identified from gait lab records and matched with children with CP having a history of PBI at ≤ 1 year old. Matching was by GMFM-D, age at Instrumented Gait Analysis (IGA), and sex. Kinematic and temporospatial data from the earliest IGA were analyzed. The primary outcome measurement was average knee flexion in stance, as children with CP tend to walk with a more flexed knee and individuals with a brain insult as older children, youth and adults tend to walk with a more extended knee. Secondary variables were temporospatial parameters and lower limb kinematics in stance and swing. Wilcoxon or T-Tests were used., Results: Twenty-six unilaterally affected children with CP (age: 10.8±3.3 years; f:6/m:20; GMFCS I:14, II:38), and 26 unilateral children with ABI (age:11.1±4.3 years; f:6/m:20) were included in each group. Significantly lower knee flexion angles during stance and swing, and shorter single support duration on the affected side were found in the ABI group as compared to CP (p<0.05). In children with ABI, there was a negative correlation between age of insult and severity of internal hip rotation (p<0.05)., Conclusions/significance: Children with ABI tend to walk with less stability on the affected side as reflected by the more extended knee and reduced single support compared with children with CP. The age at which the brain insult occurs has a significant effect on the hip rotational profile in children with ABI. Further studies on muscle activation patterns, kinetic data and response to treatment are warranted to gain insight on how the stage of brain and musculoskeletal system development at the time of injury affect gait patterns., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jose Salazar-Torres reports a relationship with Colliers Project Leaders that includes: consulting or advisory. Jason Howard reports a relationship with Scholar Rock Inc that includes: consulting or advisory. Wade Shrader reports a relationship with Orthopediatrics that includes: consulting or advisory. Wade Shrader reports a relationship with DePuy Orthopaedics Inc that includes: consulting or advisory. Wade Shrader reports a relationship with American Academy for Cerebral Palsy and Developmental Medicine that includes: board membership. Wade Shrader reports a relationship with GCMAS that includes: board membership. Jason Howard reports a relationship with ACCELTRDE that includes: funding grants. Editorial Board for Gait and Posture JST/NL Editorial Board for Physical and Occupational Therapy in Pediatrics JST/NL Editorial board for JAAOS MWS Editorial board for JPOSNA MWS If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Children with cerebral palsy (CP) have high rates of foot deformity. Accurate assessment of foot morphology is crucial for therapeutic planning and outcome evaluation. This study aims to evaluate the reliability of a novel photo-based Modified Foot Posture Index (MFPI) in the evaluation of foot deformity in children with CP., Methods: Thirteen orthopaedic surgeons with neuromuscular clinical focus from 12 institutions evaluated standardized standing foot photographs of 20 children with CP, scoring foot morphology using the MFPI. Raters scored the standardized photographs based on five standard parameters. Two parameters assessed the hindfoot: curvature above and below the malleoli and calcaneal inversion/eversion. Three parameters assessed the midfoot and forefoot: talonavicular congruence, medial arch height, and forefoot abduction/adduction. Summary MFPI scores range from -10 to +10, where positive numbers connote planovalgus, whereas negative numbers connote a tendency toward cavovarus. Intra- and interrater reliability were calculated using a 2-way mixed model of the intraclass correlation coefficient (ICC) set to absolute agreement., Results: Feet spanned the spectrum of potential pathology assessable by the MFPI, including no deformity, mild, moderate, and severe planovalgus or cavovarus deformities. All scored variables showed high intrarater reliability with ICCs from 0.891 to 1. ICCs for interrater reliability ranged from 0.965 to 0.984. Hindfoot total score had an ICC of 0.979, with a 95% CI, 0.968-0.988 ( P <0.001). The forefoot total score had an ICC of 0.984 (95% CI, 0.976-0.991, P <0.001). Mean total score by the MFPI was 3.67 with an ICC of 0.982 (95% CI, 0.972-0.990, P <0.001)., Conclusions: The photo-based MFPI demonstrates high intra- and interrater reliability in assessing foot deformities in children with CP. Its noninvasive nature and ease of use make it a promising tool for both clinical and research settings. MFPI should be considered as part of standard outcomes scores in studies regarding the treatment of CP-associated foot deformities., Level of Evidence: Level V., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Cerebral palsy (CP) is a pediatric onset disorder with poorly understood molecular causes and progression, making early diagnosis difficult. Circular RNAs are regulatory RNAs that show promise as biomarkers in various diseases but the role of circular RNAs in CP is beginning to be understood. This study identified the role of circNFIX in regulating the expression of myocyte-specific enhancer factor 2C (MEF2C), an important transcription factor for sarcomere development. We found that circNFIX is downregulated in the muscle cells of individuals with CP, and its localization shifts toward the nucleus as visualized using single-molecule resolution imaging. The decreased expression of circNFIX, MEF2C, and MEF2C targets persisted throughout myoblasts to myotubes differentiation, and in the skeletal muscle tissue. Bioinformatic and experimental validation confirmed that circNFIX acts as a sponge for miR373-3p, a microRNA that represses MEF2C translation. In normal muscle, circNFIX derepresses MEF2C translation by sponging miR373-3p, allowing for normal sarcomere generation. In CP, reduced circNFIX expression results in loss of miRNA sponging, leading to lower MEF2C expression and downregulation of sarcomere genes, potentially causing shortened and dysfunctional muscle fibers. Knockdown (KD) of circNFIX reduced myogenic capacity of myoblasts to fuse and form myotubes similar to CP cells evident from the lower fusion index in CP and KD as compared to control myotubes. This is the first study reporting reduction of MEF2C in CP and single-molecule resolution imaging of circNFIX's subcellular distribution and its role in CP, suggesting circNFIX as a potential therapeutic target and biomarker for early CP diagnosis., Competing Interests: Conflicts of interest The authors declare that they have no conflicts of interest with the contents of this article., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Hip surveillance in cerebral palsy (CP) is an accepted practice with evidence-based guidelines implemented. For the skeletally immature with open triradiate cartilage (TRC), recommendations for radiographic surveillance stemmed from population-based studies. For nonambulatory CP, progression of hip displacement after skeletal maturity has been reported; less is known for ambulatory CP. We aimed to determine the prevalence and risk factors associated with progressive hip displacement after TRC closure, a proxy for skeletal maturity, for ambulatory CP., Methods: This is a retrospective cohort study of patients with ambulatory CP (Gross Motor Function Classification System I-III), with unilateral or bilateral involvement, hypertonic motor type, regular hip surveillance (≥3 radiographs after age 10 yr, 1 before TRC closure, ≥1 after age 16 yr), and 2-year follow-up post-TRC closure. The primary outcome was migration percentage (MP). Other variables included previous preventative/reconstructive surgery, topographic pattern, sex, scoliosis, epilepsy, and ventriculoperitoneal shunt. An "unsuccessful hip" was defined by MP ≥30%, MP progression ≥10%, and/or requiring reconstructive surgery after TRC closure. Statistical analyses included chi-square and multivariate Cox regression. Kaplan-Meier survivorship curves were also determined. Receiver operating characteristic analysis was used to determine the MP threshold for progression to an "unsuccessful hip" after TRC closure., Results: Seventy-six patients (39.5% female) met the inclusion criteria, mean follow-up 4.7±2.1 years after TRC closure. Sixteen (21.1%) patients had an unsuccessful hip outcome. By chi-square analysis, diplegia ( P =0.002) and epilepsy ( P =0.04) were risk factors for an unsuccessful hip. By multivariate analysis, only first MP after TRC closure ( P <0.001) was a significant risk factor for progression to an unsuccessful hip; MP ≥28% being the determined threshold (receiver operating characteristic curve analysis, area under curve: 0.845, P <0.02)., Conclusions: The risk of MP progression after skeletal maturity is relatively high (21%), similar to nonambulatory CP. Annual hip surveillance radiographs after TRC closure should continue for Gross Motor Function Classification System I-III with an MP ≥28% after TRC closure, especially for bilateral CP and epilepsy., Level of Evidence: III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to define how different force environments by neuromuscular diagnosis (hypertonic versus hypotonic) impact the growth and morphology of the proximal femoral and acetabular regions relative to typically developing children., Methods: Children with cerebral palsy and spinal muscular atrophy were compared with typically developing children aged 6 months to 11 years. Routine pelvic radiographs were evaluated using measures of hip geometry for the proximal femur and acetabulum. The data were analyzed using general linear models to estimate the developmental patterns according to age and diagnosis., Results: One hundred eighty-four children met the inclusion criteria: 58 spastic cerebral palsy Gross Motor Function Classification System I-V (263 hips), 32 spinal muscular atrophy (79 hips)), and 94 typically developing (187 hips) were included with a mean age of 4.9 ± 3.1 years. Using spinal muscular atrophy as a reference, significant differences in proximal femoral development included long thin versus short neck ( p  < 0.01) and round versus flat epiphysis ( p  = 0.001). A thin neck-wide epiphysis was found in spinal muscular atrophy versus thick neck-small epiphysis for typically developing ( p  < 0.05). The ratio of acetabular width to proximal femoral epiphysis width differed significantly for typically developing ( p  = 0.001) compared with cerebral palsy and spinal muscular atrophy. There was a negative correlation between migration percentage and acetabular width to epiphysis width in children with cerebral palsy, but no correlation in children with spinal muscular atrophy., Conclusion: Hip geometry was impacted by the force environment experienced during growth. These findings emphasize the crucial roles of gross motor function, muscle tone, and strength differences in determining hip morphology., Level of Evidence: III, retrospective case control., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Aim: To describe what is known about hip problems in individuals with developmental central hypotonia., Method: Searches were conducted in five databases to October 2023. Down syndrome was excluded from this analysis of less well-known genetic diagnoses. At least two reviewers independently screened titles, abstracts, read full-text articles, and extracted data., Results: Of 89 full-text articles, 79 met inclusion criteria. Studies included 544 individuals aged 1 month to 63 years with Kabuki, 49, XXXXY, Prader-Willi, PURA, Koolen de Vries, Emanuel, TRPM3, Wolf-Hirschhorn, and other rare syndromes. Most diagnoses may be associated with a combination of differences in hip structure or stability that are evident at birth, or develop in early infancy, with increasing hip dysplasia and subluxation over time. Joint or ligamentous laxity was most reported along with hypotonia and hypermobility as risk factors. Limited data were identified about conservative or surgical intervention and outcomes in these populations., Interpretation: Children with significant hypotonia, with or without a confirmed genetic diagnosis, are at increased risk of hip problems that may be missed with standard neonatal screening. Ultrasound is recommended between 6 weeks and 6 months, and annual orthopaedic review with regular radiographs for older children and adults with significant and persistent hypotonia., (© 2024 The Author(s). Developmental Medicine & Child Neurology published by John Wiley & Sons Ltd on behalf of Mac Keith Press.)

Background: Abnormal gait kinematics are common in youth with cerebral palsy (CP), but prior studies have not analyzed their longitudinal change throughout childhood. This study examines how age and orthopaedic surgery influence gait kinematics throughout childhood in those with ambulatory CP., Methods: In this institutional review board-approved prospective cohort study, children with spastic CP (GMFCS I-III) were recruited at age 17-40 months. Instrumented gait analysis was performed at 3-year intervals from age 4 to 21 years, collecting longitudinal kinematic data in bare feet at a self-selected speed. The change in Gait Profile Score (ΔGPS) between each pair of gait analyses (intervals) was analyzed by age distribution (<10, 10-15, ≥15 years) and by presence/absence of orthopaedic surgery., Results: The study included 31 children (GMFCS: I [13], II [14], III [4]). A baseline instrumented gait analysis was performed at age 5.8 ± 1.6 years with subsequent analysis at 2.5 ± 1.3-year intervals. Examining ΔGPS from baseline to final outcome, 87% of limbs were improved/unchanged; 298 intervals of ΔGPS were analyzed and classified as nonsurgical or surgical. Analysis revealed greater GPS improvement in intervals with surgery versus intervals without ( p = 0.0004). Surgical intervals had significantly greater GPS improvement in the <10- vs. >15-year-old groups, p = 0.0063., Conclusions: Improvement in gait kinematics in children with CP is significantly influenced by age and timing of orthopaedic surgical intervention for gait correction, and was most pronounced for children <10 years old. Although surgery was associated with improved outcomes in all age groups, these improvements were significantly less for children >10 years old. These results reinforce the importance of considering the timing of orthopaedic surgery.

Background: Spinal muscular atrophy (SMA) is caused by abnormalities of the survival motor neuron (SMN) 1 gene, leading to deficiency in SMN protein and loss of spinal cord alpha motor neurons. Newer disease-modifying agents (DMA) targeting the involved genes, including nusinersen and gene replacement therapies, have improved gross motor and respiratory function, but their impact on scoliosis development has not been established. This study aimed to determine risk factors for scoliosis development in SMA, specifically genetic severity and DMA use., Methods: In this retrospective cohort study, children with SMA and minimum 2-year follow-up were included. The primary outcome was the prevalence of clinically relevant scoliosis. Secondary outcomes included SMA type, SMN2 copy number, Hammersmith Functional Motor Scale (HFMS), ambulatory status [functional mobility scale at 50m (FMS 50 )], DMA use, and hip displacement as risk factors. Univariate/multivariate logistic regression analyses were performed to identify dependent/independent risk factors., Results: One hundred sixty-five patients (51% female) with SMA types I-III met the inclusion criteria, with total follow-up of 9.8 years. The prevalence of scoliosis was 79%; age of onset 7.9 years. The major curve angle for the entire cohort at first assessment and final follow-up was 37 degrees (SD: 27 degrees) and 62 degrees (SD: 31 degrees) ( P <0.0001), respectively. Significant risk factors for scoliosis by univariate analysis were SMA type (I/II, P =0.02), HFMS (>23, P <0.001), nonambulatory status (FMS 50 =1, P <0.0001), DMA treatment ( P =0.02), and hip displacement ( P <0.0001). Multivariate analysis revealed that HFMS >23 ( P =0.02) and DMA ( P =0.05) treatment were independent (protective) risk factors., Conclusions: The development of scoliosis in SMA is high, with risk factors associated with proxy measures of disease severity, including SMA type, nonambulatory status, hip displacement, and most notably, gross motor function (by HFMS). DMA use and HFMS >23 were associated with a decreased risk of scoliosis development. Identified risk factors can be used in the development of surveillance programs for early detection of scoliosis in SMA., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The neck-shaft angle and head-shaft angle in children with varying levels of neurological disability were evaluated to define change over different ages., Methods: Children aged 1-12 years with spastic cerebral palsy, spinal muscular atrophy types 1 and 2, or typical development were reviewed to evaluate the neck-shaft angle and head-shaft angle. Patients were divided into five groups: Gross Motor Function Classification System levels I and II, Gross Motor Function Classification System level III, Gross Motor Function Classification System levels IV and V, spinal muscular atrophy types 1 and 2, and typical development. A linear mixed model was utilized to evaluate neck-shaft angle and head-shaft angle., Results: Data from 196 children (mean age 4.8 ± 4.5 years) were included. Gross Motor Function Classification System levels I and II: 22 children, 130 hip radiographs measured, neck-shaft angle 143.7 ± 7.4, and head-shaft angle 160.0 ± 7.1. Gross Motor Function Classification System level III: 8 children, 33 hips evaluated, neck-shaft angle 153.1 ± 4.3, and head-shaft angle 163.4 ± 4.2. Gross Motor Function Classification System levels IV and V: 30 children, 137 hip radiographs measured, neck-shaft angle 156.4 ± 5.6, and head-shaft angle 167.9 ± 6.8. Spinal muscular atrophy types 1 and 2: 32 children, 83 hip radiographs measured, neck-shaft angle 161.9 ± 9.7, and head-shaft angle 173.4 ± 7.4. Typical development: 104 children, 222 hip radiographs measured, neck-shaft angle 138.6 ± 7.0, and head-shaft angle 156.4 ± 5.9. There were significant statistical differences when comparing neck-shaft angle and head-shaft angle., Conclusion: As children grow, neck-shaft angle and head-shaft angle tend to decrease in typical development and Gross Motor Function Classification System levels I and II groups. However, in low-tone (spinal muscular atrophy types 1 and 2) and high-tone groups (Gross Motor Function Classification System levels IV and V), neck-shaft angle and head-shaft angle tend to increase with age. In both low-tone and high-tone groups, coxa valga is observed. When evaluating the effect of proximal femur-guided growth, these defined normal growth patterns should be considered., Level of Evidence: Level III Retrospective comparative study., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Competing Interests: IN, MF, BD, SC, PG, MM, MWS all received travel grants from the Elsass Foundation to support travel and accommodation to attend the round three face-to-face summit. IN also received competitive grant funds from the Elsass Foundation to establish the Network infrastructure.

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

Cerebral palsy (CP) is a heterogeneous group of disorders with different clinical types and underlying genetic variants. Children with CP are at risk for fragility fractures secondary to low bone mineral density, and although bisphosphonates are prescribed for the treatment of children with bone fragility, there is limited information on long-term bone impact and safety. Children with CP usually present overtubulated bones, and the thickening of cortical bone by pamidronate treatment can potentially further narrow the medullary canal. Our purpose was to report bone alterations attributable to pamidronate therapy that impact orthopedic care in children with CP. The study consisted of 41 children with CP treated with pamidronate for low bone mineral density from 2006 to 2020. Six children presented unique bone deformities and unusual radiologic features attributed to pamidronate treatment, which affected their orthopedic care. The cases included narrowing of the medullary canal and sclerotic bone, atypical femoral fracture, and heterotopic ossification. Treatment with bisphosphonate reduced the number of fractures from 101 in the pretreatment period to seven in the post-treatment period ( P  < 0.001). In conclusion, children with CP treated with bisphosphonate have a reduction in low-energy fractures; however, some fractures still happen, and pamidronate treatment can lead to bone alterations including medullary canal narrowing with sclerotic bone and atypical femoral fractures. In very young children, failure to remodel may lead to thin, large femoral shafts with cystic medullary canals. More widespread use of bisphosphonates in children with CP may make these bone alterations more frequent. Level of evidence: Level IV: Case series with post-test outcomes., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Increasingly long and complex informed consents have yielded studies demonstrating comparatively low participant comprehension and satisfaction with traditional face-to-face approaches. In parallel, interest in electronic consents for clinical and research genomics has steadily increased, yet limited data are available for trio-based genomic discovery studies. We describe the design, development, implementation, and validation of an electronic iConsent application for trio-based genomic research deployed to support genomic studies of cerebral palsy. iConsent development incorporated stakeholder perspectives including researchers, patient advocates, institutional review board members, and genomic data-sharing considerations. The iConsent platform integrated principles derived from prior electronic consenting research and elements of multimedia learning theory. Participant comprehension was assessed in an interactive teachback format. The iConsent application achieved nine of ten proposed desiderata for effective patient-focused electronic consenting for genomic research. Overall, participants demonstrated high comprehension and retention of key human subjects' considerations. Enrollees reported high levels of satisfaction with the iConsent, and we found that participant comprehension , iConsent clarity , privacy protections , and study goal explanations were associated with overall satisfaction . Although opportunities exist to optimize iConsent, we show that such an approach is feasible, can satisfy multiple stakeholder requirements, and can realize high participant satisfaction and comprehension while increasing study reach., Competing Interests: Conflicts of Interest Paul Gross is President and CEO of the CP Research Network, which contributed to the funding of this project. Mr. Gross personally made financial contributions (donations) to CPRN to support this work, but receives no financial compensation related to either. Dr. Noritz has consulted for Abbott Nutrition, unrelated to this project. Dr. Shrader receives research funding from NIH and serves on the National Advisory Board for Medical Rehabilitative Research for NIH/NICHD.

Purpose: Proximal femoral osteotomy (PFO) is a reconstructive surgical option used to improve hip containment or correct internal hip rotation gait in children with cerebral palsy (CP). A few reports describe the risk of surgical complications after PFO. The purpose of this study was to determine the risk factors associated with adverse postoperative surgical outcomes in pediatric patients with CP following PFO and to report the treatment of complications., Methods: Following institutional review board approval, 1085 (1003 primary and 82 secondary) PFO procedures were retrospectively reviewed in 563 children with CP with at least 1 year of follow-up after final surgery over an 18-year follow-up period. Demographic characteristics, motor type, gross motor function classification system (GMFCS) level, medical comorbidities, feeding tube status, seizure history, intervention type, and prevalence of PFO-related surgical complications and associated treatments were evaluated. Multivariate regression analysis was performed to determine risk factors for all surgical complications., Results: During a 5.8-year (± 3.8 years) follow-up, at least 1 surgical complication was identified in 143 (13.1%) hips in 121 (21.5%) patients after PFO in children with CP. Of these complications, the most common was heterotopic ossification (65 [6%] of hips); most of which were asymptomatic and required no treatment. Other complications included 25 (2%) nonunions, 21 (2%) deep or superficial infections, 13 (1%) delayed unions, 12 (1%) peri-implant fractures, and 7 early implant failures (0.64). The rate of revision surgery due to these complications was 13.1% (6.8% of hips), of which 41% (30 revision surgeries) were for the treatment of nonunion. Regarding the development of delayed union or nonunion, dystonia, GMFCS level IV/V, and seizure history were identified as risk factors by multivariate analysis., Conclusions: The prevalence of surgical complications after PFO was 13.1% with 6.8% of hips requiring revision surgery. Dystonia, seizure history, and nonambulatory status were the strongest predictors for the need for revision surgery after PFO. These data can be used to help counsel patients and families regarding the risks associated with PFO for children with CP. Level of proof: IV; retrospective study., Competing Interests: Conflict of interestsDrs. Imerci, Miller, Howard, and Shrader declare that they have no conflicts of interest., (© Indian Orthopaedics Association 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

This study aimed to evaluate assessment and referral practices for the early detection and diagnosis of children at risk for or with cerebral palsy (CP) by health care and education providers in Maryland and Delaware. A secondary aim was to identify barriers for using early detection tools and identify opportunities for change to support early diagnosis and improve care. Seventy-two participants answered ≥ 50% of the survey questions. Most were occupational or physical therapists (86%) working in early intervention (61%). Eighty-eight percent indicated awareness that CP can be diagnosed by 12 months. Though 86% stated they typically suspect a diagnosis of CP between 0 and 12 months, only 19% reported that their patients received a CP diagnosis < 12 months. The Developmental Assessment of Young Children (73%) and the Peabody Developmental Motor Scales-2 (59%) were used most. Many respondents indicated never using magnetic resonance imaging (70%), the General Movements Assessment (87%), or the Hammersmith Infant Neurological Exam (69%). Participants identified clinical signs and symptoms prompting a referral for the diagnostic assessment of CP, most commonly stiffness in legs (95%), excessive head lag (93%), and persistent fisting (92%). Policy and organizational change, clinician education, and training are needed to support the implementation of CP early detection guidelines.

Purpose: Hip displacement (HD) is common in spinal muscular atrophy (SMA), but neither genetic severity nor gross motor function level have been investigated as risk factors. Although disease-modifying agents (DMA) have improved function and overall health, their effects on the prevention of HD are unknown. The purpose of this study was to determine risk factors for HD development in SMA., Methods: Retrospective cohort. Children with SMA presenting between January 2005 and August 2021, at least 1 hip radiograph, and a minimum 2-year follow-up were included. The primary outcome measure was the prevalence of HD (migration percentage ≥40%). Secondary outcomes included SMA type (I/II/III), survival motor neuron 2 copy number, Hammersmith Functional Motor Scale (HFMS, out of 66), ambulatory status (Functional Mobility Scale at 50 m), clinically relevant scoliosis (>40 degrees and/or surgery), and DMA treatment (>1-year duration, nusinersen/risdiplam/onasemnogene abeparvovec) as risk factors. Univariate and multivariate logistic regression analyses were performed., Results: Eighty-two patients (52% female) with SMA type I (n=32, 39%), II (n=36, 44%), and III (n=14, 17%) met the inclusion criteria, with a final follow-up of 4.5 (SD: 2.7) years. Age at first hip radiograph was 3.4 (SD: 2.9) years. The prevalence of HD was 75.6%, with a mean age of onset of 4.6 (SD: 2.7) years. When stratified by SMA type, the prevalence/age of onset (mean, years) was 84%/3.1 (SD: 1.7), 80%/5.8 (SD: 2.3), and 36%/9.0 (SD: 4.3), respectively. HFMS score >23 was protective against HD by receiver operating characteristic analysis ( P =0.008). Significant risk factors by univariate analysis were SMA type I ( P =0.002) and II ( P =0.002), HFMS ≤23 ( P =0.01), nonambulatory status (Functional Mobility Scale at 50 m = 1, P =0.001), clinically relevant scoliosis ( P =0.01), and DMA treatment ( P =0.01). By multivariate analysis, only SMA type II ( P =0.04) and scoliosis ( P =0.04) were independent risk factors., Conclusions: The prevalence of HD in SMA is highly linked to disease severity. Identified risk factors can be used in the development of surveillance programs for early detection of HD in SMA, allowing for timely management., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

This study reports the long-term outcomes of hamstring lengthening to treat flexed knee gait in children with ambulatory cerebral palsy (CP) after skeletal maturity. This retrospective longitudinal observational study used instrumented gait analysis (GA) <8 and >15 years old in children with bilateral CP. The primary variable was knee flexion in stance phase. Eighty children (160 limbs) were included; 49% were male, 51% female. Mean age at first GA was 6.0 (SD: 1.2) years and 19.6 (SD: 4.5) years at final GA. Mean follow-up was 13.7 (SD: 4.7) years. Children were classified as Gross Motor Function Classification System I-8, II-46 and III-26. Average Gross Motor Function Measure Dimension D was 72% (SD: 20%). Hamstring lengthenings occurred once in 82, twice in 54 and three times in 10 limbs. From initial to final GA, average knee flexion in stance was unchanged, 27.8° (SD: 14.8°) to final 27.0° (SD: 11.2°; P = 0.54). Knee flexion at foot contact was 39.6° (SD: 13.0°), improving to final GA of 30.7° (SD: 10.6°; P < 0.001). Initial gait deviation index was 65.8 (SD: 31.9), improving to final 78.9 (SD: 28.2; P < 0.001). Older age, males and concomitant plantar flexor lengthening predicted change toward more flexed knee gait. Hamstring lengthening did not lead to back-kneeing gait at maturity while maintaining childhood stance phase knee flexion. A subgroup still developed significant flexed knee gait posture and may have benefited from more aggressive treatment options. This outcome may also be impacted by diverse functional levels, etiologies and treatments of flexed knee gait., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Foot deformities are prevalent in children with cerebral palsy, but there is limited research on the progression of foot posture during growth. Our study aimed to evaluate the change in dynamic foot posture in children with cerebral palsy., Methods: Children with cerebral palsy, aged 17-40 months, were recruited to participate in this Institutional Review Board-approved prospective longitudinal study by having serial foot posture evaluations. The coronal plane index and foot segmental impulses were measured with dynamic pedobarography. Data were compared between children stratified by Gross Motor Function Classification System level and typically developing children using serial Welch's t -tests across time with Holm correction for multiple comparisons., Results: In total, 33 children (54 limbs) were included in the analysis (21 bilateral and 12 unilateral; Gross Motor Function Classification System: I-13, II-14, III-4, IV-2. Children completed 16.9 (± 4.4) evaluations (initial age 2.9 (± 0.7) and final age 18.6 (± 1.7) years)). Early valgus foot posture normalizes in children at Gross Motor Function Classification System levels I/II and persists in children at levels III/IV who do not have foot surgery. For most young children, foot posture development is variable., Conclusion: Foot posture in young children with cerebral palsy begins in valgus and tends to normalize in youth who walk without an assistive device. Conservative management of foot deformity is recommended in early childhood., Level of Evidence: Level II, prognostic study., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Foot deformities in methyl-CpG binding protein 2 (MECP2) disorders are thought to be common, but reports are scant. The purpose of this study was to report the prevalence and type of foot deformities and surgical management for MECP2 disorders. In this retrospective, comparative study, all children presenting between June 2005 and July 2020, with a genetically confirmed MECP2-related disorder, were included. The primary outcome measure was the prevalence of surgery for foot deformities. Secondary outcomes included type and frequency of foot surgeries, age at surgery, ambulatory status, genetic severity, presence of scoliosis/hip displacement, seizures, and associated comorbidities. Chi-square testing was utilized for the analysis of risk factors. Fifty-six patients (Rett syndrome: N  = 52, MECP2 duplication syndrome: N  = 4; 93% female) met the inclusion criteria. The mean age at first presentation to orthopedics was 7.3 (SD, 3.9) years, with a final follow-up of 4.5 (SD, 4.9) years. Seven (13%) patients developed foot deformities, most commonly equinus or equinovarus (five patients, 71%), requiring surgical management. The remaining two patients had calcaneovalgus. The most common surgical procedure was Achilles tendon lengthening, followed by triple arthrodesis, at a mean age of 15.9 (range: 11.4-20.1)  years. Hip displacement ( P  = 0.04), need for hip surgery ( P  = 0.001) and clinically relevant scoliosis ( P  = 0.04) were significant risk factors for the development of symptomatic foot deformities. Although not as prevalent as scoliosis or hip displacement, foot deformities are still relatively common in MECP2 disorders, often necessitating surgical intervention to improve brace tolerance. Level of evidence: Level III - a retrospective comparative study., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Happiness, comfort, and motor function contribute to satisfaction with life for individuals with cerebral palsy (CP). Evidence-based medical care can improve motor function and physical health of youth with CP. Less is known about medical care and its relationship to health-related quality of life (HRQOL) in adolescents and young adults with CP. This study aimed to describe HRQOL among adolescents with CP to examine differences between adolescent (self) and parent (proxy) reports of HRQOL and to explore associations of pain, age, and gross motor function with HRQOL., Methods: This is a retrospective study including adolescents with CP classified as Gross Motor Function Classification System levels I to V, ages 11 to 20 years, reading ≥ a fourth-grade level, and who completed the self-reported Pediatric Outcomes Data Collection Instrument (PODCI). Parents completed the PODCI concurrently or within 12 months and scores were compared. In addition, self-reported scores were compared between age bands, across Gross Motor Function Classification System levels, with typically developing youth (TDY), and between youth with/without pain., Results: PODCI scores from 102 adolescents [59 males; 15.0 (SD: 2.6) years old] were examined. Scores from 50 adolescents and parents were matched. Mean self-reported scores were significantly higher than mean parent-reported scores in 4 domains: upper extremity and physical function ( P =0.018), sports and physical function ( P =0.005), happiness ( P =0.023), and global functioning ( P =0.018). All domains, except Happiness, were significantly < TDY ( P <0.01). The presence of pain was associated with lower scores in all domains ( P <0.05)., Conclusion: Examining HRQOL with the PODCI revealed significant limitations in physical function and higher pain in adolescents with CP compared with TDY. Self- and parent-reported PODCI results should be considered separately. Adolescents report higher HRQOL compared with parent proxy. Recognizing and validating the perspectives of youth and their parents presents an opportunity for providers to discuss different points of view with families. Such engagement can help promote self-efficacy in youth with CP as they transition to the responsibility of guiding their own care in adulthood., Level of Evidence: III, Retrospective comparative study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: To determine the dose-response relationship of collagenase Clostridium histolyticum (CCH) on collagen content and the change in muscle fiber bundle stiffness after ex vivo treatment of adductor longus biopsies with CCH in children with cerebral palsy (CP)., Method: Biopsy samples of adductor longus from children with CP (classified in Gross Motor Function Classification System levels IV and V) were treated with 0 U/mL, 200 U/mL, 350 U/mL, or 500 U/mL CCH; percentage collagen reduction was measured to determine the dose-response. Peak and steady-state stresses were determined at 1%, 2.5%, 5%, and 7.5% strain increments; Young's modulus was calculated., Results: Eleven patients were enrolled (nine males, two females, mean age at surgery 6 years 5 months; range: 2-16 years). A linear CCH dose-response relationship was determined. Peak and steady-state stress generation increased linearly at 5.9/2.3mN/mm 2 , 12.4/5.3mN/mm 2 , 22.2/9.7mN/mm 2 , and 33.3/15.5mN/mm 2 at each percentage strain increment respectively. After CCH treatment, peak and steady-state stress generation decreased to 3.2/1.2mN/mm 2 , 6.5/2.9mN/mm 2 , 12.2/5.7mN/mm 2 , and 15.4/7.7mN/mm 2 respectively (p < 0.004). Young's modulus decreased from 205 kPa to 100 kPa after CCH (p = 0.003)., Interpretation: This preclinical ex vivo study provides proof of concept for the use of collagenase to decrease muscle stiffness in individuals with CP., (© 2023 Mac Keith Press.)

Purpose: Use of spinal cord monitoring in children with cerebral palsy (CP) and neuromuscular scoliosis is challenging. The previous reports suggest low success rates in the setting of CP, and it is unclear if transcranial electric motor evoked potentials (TcMEP) monitoring is contraindicated in patients with an active seizure disorder. The purpose of this study was to determine (1) are patients with CP able to be appropriately monitored with TcMEP? and (2) does TcMEP cause an increase in seizure activity?, Methods: This was an institutional review board-approved retrospective cohort study observing 304 patients from 2011 to 2020. Inclusion criteria included all patients with CP undergoing posterior spinal fusion during this time. Intraoperative data were examined for the ability to obtain monitoring and any intraoperative events. Patients were followed for 3 months postoperatively to determine any increase in seizure activity that could have been attributed to the TcMEP monitoring., Results: Of the 304 patients who were observed, 21% (20.8%) were unable to be monitored due to lacking baseline signals from the extremities. Seventy-seven percent (77.5%) were successfully monitored with TcMEP. For these patients, no increased seizure activity was documented either intra- or postoperatively., Conclusion: A high percentage of children (77.5%) with CP were able to be successfully monitored with TcMEP during posterior spinal fusion. Furthermore, the concerns about increased seizure activity after TcMEP were not supported by the data from this cohort. Technical details of successful neuromonitoring in these patients are important and included increased stimulation voltage requirements and latency times., Level of Evidence: III retrospective comparative study., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

The COVID-19 pandemic has caused unprecedented challenges in the care of children with cerebral palsy (CP) and other neuromuscular complex chronic conditions (NCCCs). The purpose of this study is to explore the direct impact of the COVID-19 pandemic on healthcare delivery. From May to August 2020, medical professionals caring for CP and NCCC patients across multiple countries and disciplines completed a self-administered cross-sectional survey comparing practices before and during the COVID-19 pandemic. Of the 79 healthcare workers from eight countries who participated-predominantly pediatric orthopedic surgeons (32%), pediatricians (30%), and pediatric physiatrists (23%)-most of them felt that caring for NCCC patients during the pandemic presented unique difficulties, and they reported a significant decrease in the in-person NCCC clinic volume ( p < 0.001), multidisciplinary appointments ( p < 0.001), surgical cases ( p = 0.008), and botulinum toxin/phenol injections. Most providers affirmed that institutional guidelines for perioperative emergent/urgent and elective procedures, workplace settings, and technology were modified to accommodate the ongoing public health crisis. The usage of telemedicine significantly increased for NCCC patient visits ( p < 0.001). During the COVID-19 pandemic, many children with NCCCs lost access to routine, multidisciplinary care. Telemedicine became an integral part of communication and management. In the setting of the COVID-19 pandemic and with the threat of future healthcare disruptions, these data lay the foundation for trending the evolution of healthcare delivery and accelerating best practice guidelines for children with CP and NCCCs.

Femoral fractures in children withcerebral palsy (CP) represent a frequent medical problem, and treatment represents a challenge. The purpose of this study was to review the closed displaced femoral fractures in our population of nonambulatory children with CP to compare the results of nonoperative and operative treatment modalities to improve the care of these children. From 2006 to 2020, children with nonambulatory CP were selected with inclusion criteria of displaced femoral fracture and were divided into nonoperative and operative groups. Forty-four children met the inclusion criteria. The nonoperative group included 23 children and the operative group included 21 children. Mechanism of injury was unknown in 48% of the fractures. Fourteen (25%) fractures occurred after a femoral plate fixation during a reconstructive hip surgery, and 38 (86%) children had osteopenia. Our results reveal a high prevalence of osteopenia, low-energy trauma, malunion in nonoperative treatment, and peri-implant fractures. Suspicion of child abuse should be considered when the fracture has an unclear mechanism of the injury. Removal of proximal femoral implants may be considered to prevent peri-implant fractures. Femoral fractures should preferably be treated nonoperatively. Operative treatment should be considered for diaphyseal fractures in children capable of standing transfers, larger children, children with more severe spasticity or movement disorder or those who have suffered a high-energy fracture. Due to the high prevalence of proximal fractures in the presence of hardware, operative treatment is usually required for these fractures. In contrast, distal fractures are adequately managed nonoperatively., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: To report survival probability of a large cohort of children with cerebral palsy (CP) after spinal fusion., Method: All children with CP who had spinal fusion between 1988 and 2018 at the reporting facility were reviewed for survival. Death records of the institutional CP database, institutional electronic medical records, publicly available obituaries, and the National Death Index through the US Centers for Disease Control were searched. Survival probabilities with different surgical eras, comorbidities, ages, and curve severities were compared using Kaplan-Meier curves., Results: A total of 787 children (402 females, 385 males) had spinal fusion at a mean age of 14 years 1 month (standard deviation 3 years 2 months). The 30-year estimated survival was approximately 30%. Survival decreased for children who had spinal fusion at younger ages, longer postoperative hospital stays, longer postoperative intensive care unit stays, gastrostomy tubes, and pulmonary comorbidities., Interpretation: Children with CP who required spinal fusions had reduced long-term survival compared with an age-matched typically developing cohort; however, a substantial number survived 20 to 30 years after the surgery. This study had no comparison group of children with CP scoliosis; therefore, we do not know whether correction of scoliosis affected their survival., (© 2023 Mac Keith Press.)

Aim: To evaluate the effects of intrathecal baclofen pump (ITBP) therapy on hip dysplasia in young patients with cerebral palsy (CP)., Method: This was a retrospective cohort series of prospectively collected data. Inclusion criteria were all patients with CP in Gross Motor Function Classification System (GMFCS) levels IV or V who underwent ITBP placement under 8 years old with at least 5 years of follow-up. Thirty-four patients were matched to a control group of 71 patients based on GMFCS level, motor type, medical comorbidities, worst hip migration percentage at ITBP placement, age, and Modified Ashworth scale scores. Patients were followed for at least 5 years or until they had hip reconstructive surgery. The primary outcome was the development of hip displacement as measured by the migration percentage at the latest follow-up or the preoperative migration percentage before hip reconstruction., Results: The migration percentage at last follow-up was not statistically different between groups (ITBP: 36.2%, non-ITBP: 44.4%, p = 0.14). The rates of future preventative, reconstructive, and recurrent hip surgery were not different between groups., Interpretation: The use of ITBP as an early treatment of spasticity did not alter the natural history of progressive hip displacement in non-ambulatory patients with CP and hip displacement is likely multifactorial, not solely due to spasticity., (© 2023 Mac Keith Press.)

Background: The Shriners Hospital Upper Extremity Evaluation (SHUEE) is a video-based measure designed to assess upper extremity function in people with cerebral palsy (CP). The SHUEE completes both dynamic positional analysis (DPA; position during functional activities) and spontaneous functional analysis (spontaneous use of the involved limb). Although the SHUEE has been suggested as a measure for planning upper limb interventions and evaluating outcomes, limited evidence of its ability to detect change exists. Thus, this study aimed to describe responsiveness of the SHUEE to detect change after orthopaedic surgery., Methods: In this Institutional Review Board-approved retrospective cohort study, we identified children with CP who were administered SHUEE on≥2 encounters. We formed pairs of initial and follow-up visits between temporally adjacent visits. Pairs were assigned to a surgery or non-surgery group based on intervening upper limb orthopaedic surgery. We compared differences in baseline SHUEE scores between groups and differences in temporally adjacent SHUEE scores within groups using Welch unequal variances t tests and paired t tests, respectively., Results: Nineteen people (7 female) with hemiplegic CP had≥2 SHUEE assessments; Manual Ability Classification System levels I (3), II (8), III (7), IV (1); Gross Motor Function Classification System levels I (10), II (7), IV (2); mean age at baseline 11.9 (5.1 to 19.1) years; and follow-up at 13.4 (5.5 to 19.7) years. Six people had≥2 visits leading to 14 surgical pairs and 10 non-surgical pairs. At baseline, DPA of the wrist and forearm were significantly lower in the surgical group ( P <0.05). At follow-up, no significant difference between the groups existed in DPA measures ( P >0.05). After surgical intervention, there was a significant change in overall and wrist DPA ( P <0.05)., Conclusions: The DPA measures demonstrated responsiveness to expected positional changes in the arm after orthopaedic surgery in people with CP. The SHUEE was useful in identifying abnormal segmental alignment pre-surgically and documenting changes in alignment postoperatively. As orthopaedic surgery does not address limb neglect or bimanual ability, spontaneous functional analysis scores were as expected-unchanged., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.M. has received research support in royalties and as a consultant for Nuvasive, has received consulting fees from Synthes, and has received royalties from Wolters-Kluwer-Health-Lippincott Williams & Wilkins, all outside of the scope of the submitted work. He has also been an unpaid consultant for OrthoPediatrics and is a board member of the Pediatric Orthopedic Society of North America. M.W.S. is a member of the Editorial Board of the Journal of the Pediatric Orthopedic Society of North America, is a member of the National Advisory Board (NIH) on Medical Rehabilitation Research, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), all outside the scope of the submitted work. K.G. has received research support from NHMRC-CRE CP-Achieve and is on the Surgeon’s Advisory Board of OrthoPaediatrics Corp. H.C. has received personal fees from OrthoPaediatrics Corp. and Allergan Corp., outside the scope of the submitted work. J.R.D. is a consultant and board member of OrthoPaediatrics Corp., outside the scope of the submitted work. J.R. has received personal fees from OrthoPaediatrics Corp., outside the scope of the submitted work and research support Smith Nephew Corp and is on Editorial Board of Gait and Posture. R.M.K. owns stock in Zimmer/Biomet, Medtronic, Pfizer, and Johnson and Johnson, is on the Editorial Board of the Journal of Pediatric Orthopedics and his son works for Intrinsic Therapeutics, outside the scope of the submitted work.

Caregivers of children with cerebral palsy (CP) experience stress surrounding orthopaedic surgery related to their child's pain and recovery needs. Social determinants of health can affect the severity of this stress and hinder health care delivery. A preoperative biopsychosocial assessment (BPSA) can identify risk factors and assist in alleviating psychosocial risk. This study examined the relationship between the completion of a BPSA, hospital length of stay (LOS), and 30-day readmission rates for children with CP who underwent hip reconstruction (HR) or posterior spinal fusion (PSF). Outcomes were compared with a matched group who did not have a preoperative BPSA. The BPSA involved meeting with a social worker to discuss support systems, financial needs, transportation, equipment, housing, and other services. A total of 92 children (28 HR pairs, 18 PSF pairs) were identified. Wilcoxon analysis was statistically significant ( p = 0.000228) for shorter LOS in children who underwent PSF with preoperative BPSA (median = 7.0 days) vs. without (median = 12.5 days). Multivariate analysis showed that a BPSA, a lower Gross Motor Function Classification System level, and fewer comorbidities were associated with a shorter LOS after both PSF and HR ( p < 0.05). Identifying and addressing the psychosocial needs of patients and caregivers prior to surgery can lead to more timely discharge postoperatively.

Objective: This study aimed to determine the risk factors for reconstructive hip surgery after intrathecal baclofen pump application in children with cerebral palsy., Methods: Inclusion criteria were children with hypertonic (spastic or mixed spastic/dystonic motor type) cerebral palsy, intrathecal baclofen implantation <8 years of age, no reconstructive osteotomies prior to or concomitant with intrathecal baclofen implantation and at least a 5-year follow-up. Exclusion criteria included reconstructive osteotomies prior to or concurrent with intrathecal baclofen implantation, lack of at least 1 hip surveillance radiograph before intrathecal baclofen, lack of a 5-year follow-up, or having selective dorsal rhizotomy. In addition, patients with bony surgery plus last follow-up migration percentage ≥50% were labeled as required reconstruction hips., Results: We identified 34 patients (68 hips). The mean follow-up was 9.2 ± 2.8 years. The mean age for intrathecal baclofen application was 6.4 ± 1.2 years. Seven patients were Gross Motor Function Classification System IV, and 27 were V. Eighteen patients (52.9%) with 31 hips (45.6%) were requiring reconstruction at the final follow-up. In multivariate analysis, male sex (odds ratio 12.8, P=.012), pre-intrathecal baclofen migration percentage (odds ratio 1.1, P=0.003), age at intrathecal baclofen implantation (odds ratio 0.24, P=.002), and delta migration percentage (odds ratio 1.1, P=.002) were significant risk factors for requiring reconstruction. Patients with intrathecal baclofen <6.2 years of age had a significantly higher rate of requiring reconstruction. A pre-intrathecal baclofen migration percentage >31% had a greater risk of progression to requiring reconstruction (P=.001). Delta migration percentage higher than 15% was significantly associated with progression to requiring reconstruction (P=.043)., Conclusion: The risk of requiring reconstruction osteotomies after intrathecal baclofen was significantly increased in males, those younger (±migration percentage >31%) at the time of intrathecal baclofen implantation and those with an increased rate of migration percentage progression after intrathecal baclofen implantation., Level of Evidence: Level IV, Prognostic Study.

Background: Maintaining femoral head shape (FHS) and acetabular sphericity are important goals in preventing long-term osteoarthritis in hips in children with cerebral palsy (CP). As acetabular morphology has been widely studied, our objective was to determine FHS in CP after triradiate cartilage (TRC) closure, a proxy for skeletal maturity, and the risk factors associated with residual deformity and osteoarthritis., Methods: In this retrospective cohort study, patients with CP [Gross Motor Function Classification System (GMFCS) IV to V], minimum 4 yearly hip radiographs after age 10 years, and at least 1 radiograph after age 16 years, were included. Primary outcome was FHS (Rutz), stratified as "less severe" (Rutz A to B) and "more severe" (Rutz C to D). Secondary outcomes included migration percentage (MP), age at TRC closure, previous reconstructive (femoral with/without pelvic osteotomies) surgery, previous intrathecal baclofen, Tönnis osteoarthritis grade, and GMFCS level. Statistical analyses included χ 2 analysis and multiple logistic regression., Results: One hundred sixty-three patients (326 hips) met the inclusion criteria, with TRC closure at age 14.0 (SD: 1.8) years. At final follow-up of 4.4 (SD: 2.4) years after TRC closure, 17% (55 hips), had a "more severe" FHS. From TRC closure to final follow-up, the frequencies of "less severe" hips decreased (-10%, P <0.001), while "more severe" increased (+115%, P <0.001). In multiple regression analysis, MP at TRC closure was the only significant risk factor associated with a "more severe" FHS at final follow-up ( P =0.03). Receiver operating characteristic curve analysis determined MP≥30.5% to be associated with a "more severe" FHS at final follow-up ( P <0.009). The FHS was not affected by reconstructive surgery, sex, GMFCS level, or intrathecal baclofen use. "Less severe" hips had lower Tönnis grades (0 to 1) compared with "more severe" hips (Tönnis grades 2 to 3) at final follow-up ( P <0.001)., Conclusions: FHS at skeletal maturity was not influenced by prior reconstructive surgery but was negatively affected when MP≥30.5% at the time of TRC closure. The extent of residual femoral head deformity correlated with the severity of osteoarthritis at final follow-up., Level of Evidence: Level III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Children with cerebral palsy (CP) frequently develop both neuromuscular hip dysplasia and scoliosis, and occasionally, the timing of the worsening of both of these pathologies is concurrent. The question as to whether the hip or spine should be addressed first in CP remains controversial, with the majority of evidence being "expert opinion." The purpose of this project was to determine the impact of posterior spinal fusion (PSF) on the change in hip displacement for children with CP without previous reconstructive hip surgery., Methods: This was an Institutional Review Board-approved study that observed 67 patients from 2004 to 2018. Inclusion criteria included children with CP, 18 years of age and younger, Gross Motor Function Classification System IV and V, undergoing PSF at a single tertiary care children's hospital with a minimum 2-year follow-up. The primary outcome was the change in hip displacement as quantified by the migration percentage (MP). The hip with the highest MP (worst hip) at the spine preoperative analysis were included for analysis. Triradiate cartilage (TRC) status and pelvic obliquity correction were analyzed with multivariate analysis., Results: Sixty-seven patients were included for analysis, with a mean age of 12.5±2.3 years. The mean major curve angle of the major curve was 77±23 degrees and the mean preoperative pelvic obliquity was 21±12 degrees. There was no statistically significant change in MP after PSF from a mean preoperative value of 41±27%, to a mean postoperative value of 41±29% at the last follow-up, (P=0.76) The mean follow-up time was 4.1±2.7 years. TRC status (P=0.52) and the severity of pelvic obliquity (P=0.10) did not statistically impact the change in MP after PSF., Conclusion: PSF did not influence-either negatively or positively-the progression of hip displacement in children with CP, regardless of pelvic obliquity correction or TRC status. The lack of deterioration in hip displacement post-PSF, however, may suggest a protective effect of spine surgery., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Recommendations with regard to the need for continued hip surveillance after skeletal maturity are based on expert opinion rather than evidence. This study aimed to determine the prevalence of and risk factors associated with progressive hip displacement in cerebral palsy (CP) after triradiate cartilage (TRC) closure., Methods: Patients who had spastic nonambulatory CP (Gross Motor Function Classification System IV to V) and hypertonic (spastic or mixed-type) motor type and follow-up of at least 2 years after TRC closure were included. The primary outcome variable was the hip migration percentage (MP). The secondary outcome variables included patient age at the time of TRC closure, prior preventative or reconstructive surgery, a prior intrathecal baclofen pump, history of scoliosis, history of epilepsy, a prior gastrostomy tube, a previous tracheostomy, and gender. An unsuccessful hip outcome was defined as a hip with an MP of ≥40% and/or requiring a reconstructive surgical procedure after TRC closure., Results: In this study, 163 patients met the inclusion criteria, with a mean follow-up of 4.8 years (95% confidence interval [CI], 4.4 to 5.1 years) after TRC closure at a mean patient age of 14.0 years (95% CI, 13.7 to 14.3 years). Of these hips, 22.1% (36 of 163) had an unsuccessful hip outcome. In multivariate analysis, the first MP at TRC closure (hazard ratio [HR] per degree, 1.04; p < 0.001) and pelvic obliquity (HR per degree, 1.06; p = 0.003) were independent risk factors for an unsuccessful hip outcome, but gender was not found to be significant (HR for male gender, 1.7 [95% CI, 0.8 to 3.58; p = 0.16]; female gender was the reference). However, the mean survival time for progression to an unsuccessful hip outcome was longer for female patients at 9.2 years [95% CI, 8.1 to 10.2 years]) compared with 6.2 years (95% CI, 5.6 to 6.9 years) for male patients (p = 0.02). There was also a significant improvement in survivorship for prior reconstructive surgical procedures (p = 0.002). The survivorship in patients who underwent reconstructive surgery performed at a patient age of ≥6 years was significantly higher compared with those who underwent surgery performed at <6 years of age (p < 0.05). A first MP at TRC closure of ≥35% was associated with an unsuccessful hip outcome, as determined by receiver operating characteristic (ROC) curve analysis (p < 0.001; area under the ROC curve of 0.891, sensitivity of 81%, and specificity of 94%)., Conclusions: The risk factors for the progression of hip displacement after TRC closure in patients with CP included a higher MP and increased pelvic obliquity; there was decreased survivorship for male patients and patients with no prior reconstructive surgery. Patients with these risk factors and/or an MP of ≥35% at TRC closure should have continued radiographic surveillance to detect late hip displacement., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H329 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)