Long-term follow-up after multilevel surgery in cerebral palsy

Abstract

Introduction

Single-event multilevel surgery (SEMLS) is frequently used to correct pathological gait patterns in children with bilateral spastic cerebral palsy (BSCP) in a single session surgery. However, in-depth long-term evaluation reports of gait outcomes are limited. Therefore, we investigated if SEMLS is able to correct lower extremity joint and pelvic angles during gait towards typically developing gait patterns (TDC) in children with BSCP, and if so, if this effect is durable over a 10-year period.

Materials and methods

In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7–18.2 years at the time of SEMLS were retrospectively recruited. Three-dimensional gait data were captured preoperatively, as well as at short-, mid-, and long-term post-operatively, and used to analyze: movement analysis profile (MAP), gait profile score (GPS), and lower extremity joint and pelvic angles over the course of a gait cycle using statistical parametric mapping.

Results

In agreement with previous studies, MAP and GPS improved towards TDCs after surgery, as did knee extension during the stance phase (ɳ2 = 0.67; p < 0.001), while knee flexion in the swing phase (ɳ2 = 0.67; p < 0.001) and pelvic tilt over the complete gait cycle (ɳ2 = 0.36; p < 0.001) deteriorated; no differences were observed between follow-ups. However, further surgical interventions were required in 8 out of 13 of the participants to maintain improvements 10 years post-surgery.

Conclusions

While the overall gait pattern improved, our results showed specific aspects of the gait cycle actually deteriorated post-SEMLS and that a majority of the participants needed additional surgery, supporting previous statements for the use of multilevel surgery rather than SEMLS. The results highlight that the field should not only focus on the overall gait scores when evaluating treatment outcomes but should offer additional long-term follow-up of lower extremity function.

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References

  1. 1.

    Ancillao A, Van Der Krogt MM, Buizer AI et al (2017) Analysis of gait patterns pre- and post-single event multilevel surgery in children with cerebral palsy by means of offset-wise movement analysis profile and linear fit method. Hum Mov Sci 55:145–155

    Article  Google Scholar 

  2. 2.

    Baker R, Mcginley JL, Schwartz M et al (2012) The minimal clinically important difference for the Gait Profile Score. Gait Posture 35:612–615

    Article  Google Scholar 

  3. 3.

    Baker R, Mcginley JL, Schwartz MH et al (2009) The gait profile score and movement analysis profile. Gait Posture 30:265–269

    Article  Google Scholar 

  4. 4.

    Barre A, Armand S (2014) Biomechanical ToolKit: open-source framework to visualize and process biomechanical data. Comput Meth Prog Bio 114:80–87

    Article  Google Scholar 

  5. 5.

    Bell KJ, Õunpuu S, Deluca PA et al (2002) Natural progression of gait in children with cerebral palsy. J Pediatr Orthop 22:677–682

    PubMed  Google Scholar 

  6. 6.

    Bohm H, Hosl M, Doderlein L (2017) Predictors for anterior pelvic tilt following surgical correction of flexed knee gait including patellar tendon shortening in children with cerebral palsy. Gait Posture 54:8–14

    Article  Google Scholar 

  7. 7.

    Dreher T, Thomason P, Svehlik M et al (2018) Long-term development of gait after multilevel surgery in children with cerebral palsy: a multicentre cohort study. Dev Med Child Neurol 60:88–93

    Article  Google Scholar 

  8. 8.

    Dreher T, Vegvari D, Wolf SL et al (2013) Long-term effects after conversion of biarticular to monoarticular muscles compared with musculotendinous lengthening in children with spastic diplegia. Gait Posture 37:430–435

    Article  Google Scholar 

  9. 9.

    Hof AL (1996) Scaling gait data to body size. Gait Posture 4:222–223

    Article  Google Scholar 

  10. 10.

    Kadaba MP, Ramakrishnan HK, Wootten ME (1990) Measurement of lower extremity kinematics during level walking. J Orthop Res 8:383–392

    CAS  Article  Google Scholar 

  11. 11.

    Klausler M, Speth BM, Brunner R et al (2017) Long-term follow-up after tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy. Gait Posture 58:457–462

    Article  Google Scholar 

  12. 12.

    Kuchen DB, Eichelberger P, Baur H et al (2020) Long-term follow-up after patellar tendon shortening for flexed knee gait in bilateral spastic cerebral palsy. Gait Posture 81:85–90

    Article  Google Scholar 

  13. 13.

    Lamberts RP, Burger M, Du Toit J et al (2016) A systematic review of the effects of single-event multilevel surgery on gait parameters in children with spastic cerebral palsy. PLoS ONE 11:e0164686

    Article  Google Scholar 

  14. 14.

    Levine TR, Hullett CR (2006) Eta squared, partial eta squared, and misreporting of effect size in communication research. Hum Commun Res 28:612–625

    Article  Google Scholar 

  15. 15.

    Mcginley JL, Dobson F, Ganeshalingam R et al (2012) Single-event multilevel surgery for children with cerebral palsy: a systematic review. Dev Med Child Neurol 54:117–128

    Article  Google Scholar 

  16. 16.

    Moreau N, Tinsley S, Li L (2005) Progression of knee joint kinematics in children with cerebral palsy with and without rectus femoris transfers: a long-term follow up. Gait Posture 22:132–137

    Article  Google Scholar 

  17. 17.

    Nieuwenhuys A, Papageorgiou E, Desloovere K et al (2017) Statistical parametric mapping to identify differences between consensus-based joint patterns during gait in children with cerebral palsy. PLoS ONE 12:e0169834

    Article  Google Scholar 

  18. 18.

    Nieuwenhuys A, Papageorgiou E, Pataky T et al (2016) Literature review and comparison of two statistical methods to evaluate the effect of botulinum toxin treatment on gait in children with cerebral palsy. PLoS ONE 11:e0152697

    Article  Google Scholar 

  19. 19.

    Norlin R, Tkaczuk H (1985) One-session surgery for correction of lower extremity deformities in children with cerebral palsy. J Pediatr Orthop 5:208–211

    CAS  Article  Google Scholar 

  20. 20.

    Ounpuu S, Gorton G, Bagley A et al (2015) Variation in kinematic and spatiotemporal gait parameters by Gross Motor Function Classification System level in children and adolescents with cerebral palsy. Dev Med Child Neurol 57:955–962

    Article  Google Scholar 

  21. 21.

    Ounpuu S, Solomito M, Bell K et al (2015) Long-term outcomes after multilevel surgery including rectus femoris, hamstring and gastrocnemius procedures in children with cerebral palsy. Gait Posture 42:365–372

    Article  Google Scholar 

  22. 22.

    Park MS, Chung CY, Lee SH et al (2009) Effects of distal hamstring lengthening on sagittal motion in patients with diplegia: hamstring length and its clinical use. Gait Posture 30:487–491

    Article  Google Scholar 

  23. 23.

    Pataky TC (2010) Generalized n-dimensional biomechanical field analysis using statistical parametric mapping. J Biomech 43:1976–1982

    Article  Google Scholar 

  24. 24.

    Pataky TC, Robinson MA, Vanrenterghem J (2013) Vector field statistical analysis of kinematic and force trajectories. J Biomech 46:2394–2401

    Article  Google Scholar 

  25. 25.

    Rutz E, Baker R, Tirosh O et al (2013) Are results after single-event multilevel surgery in cerebral palsy durable? Clin Orthop Relat Res 471:1028–1038

    Article  Google Scholar 

  26. 26.

    Rutz E, Gaston MS, Tirosh O et al (2012) Hip flexion deformity improves without psoas-lengthening after surgical correction of fixed knee flexion deformity in spastic diplegia. Hip Int 22:379–386

    Article  Google Scholar 

  27. 27.

    Simon-Martinez C, Jaspers E, Mailleux L et al (2017) Negative influence of motor impairments on upper limb movement patterns in children with unilateral cerebral palsy. A statistical parametric mapping study. Front Hum Neurosci 11:482

    Article  Google Scholar 

  28. 28.

    Sung KH, Chung CY, Lee KM et al (2013) Long term outcome of single event multilevel surgery in spastic diplegia with flexed knee gait. Gait Posture 37:536–541

    Article  Google Scholar 

  29. 29.

    Svehlik M, Steinwender G, Kraus T et al (2011) The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait. Dev Med Child Neurol 53:730–735

    Article  Google Scholar 

  30. 30.

    Terjesen T, Lofterod B, Skaaret I (2015) Gait improvement surgery in ambulatory children with diplegic cerebral palsy. Acta Orthop 86:511–517

    Article  Google Scholar 

  31. 31.

    Thomason P, Baker R, Dodd K et al (2011) Single-event multilevel surgery in children with spastic diplegia: a pilot randomized controlled trial. J Bone Jt Surg Am 93:451–460

    Article  Google Scholar 

  32. 32.

    Thomason P, Selber P, Graham HK (2013) Single event multilevel surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study. Gait Posture 37:23–28

    Article  Google Scholar 

  33. 33.

    Vogel-Tgetgel ND, Klausler M, Brunner R et al (2020) Short-term outcome of double-shelled braces in neuromuscular scoliosis. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03600-6

    Article  PubMed  Google Scholar 

  34. 34.

    Tomaszewski R, Rutz E, Mayr J et al (2020) Surgical treatment of benign lesions and pathologic fractures of the proximal femur in children. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03687-x

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors thank the Ralf-Loddenkemper Stiftung for their financial support to this project and they thank the members of the gait analysis lab at the University Children’s Hospital Basel for their assistance in data collection and their continuous support.

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Authors

Contributions

ER, RB, MF, NH and RV contributed to the study conception and design. Material preparation, data collection and analysis were performed by MF, NH and RV. The first draft of the manuscript was written by NH and RV, all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Rosa Visscher.

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The authors declare that they have no conflict of interest.

Ethical approval

This study, approved by the local ethical committee (EKNZ 304/08, PB_2018-00168), was conducted according to the current version of the World Medical Association Declaration of Helsinki.

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All participants and/or their parents gave written informed consent for the study.

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Visscher, R., Hasler, N., Freslier, M. et al. Long-term follow-up after multilevel surgery in cerebral palsy. Arch Orthop Trauma Surg (2021). https://doi.org/10.1007/s00402-021-03797-0

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Keywords

  • Cerebral palsy
  • Multilevel surgery
  • Statistical parametric mapping
  • Long-term outcomes
  • Clinical gait analysis
  • Longitudinal care