Single event, multilevel surgery in cerebral palsy: A clinical framework

EVALUATION OF TEE COSMED K4 LN A CLINICAL GAIT ANALYSIS LABORATORY. INTRODUCnON Stepb F&me, Ros Boyd, Jill Rodda, Donna& G&&e,, Elise Cullis, Gary Nattmss and Kerr #,&am HUGH WILLIAMSON GAIT ANALYSIS LABORATORY AND THE DEPARTMENT OF ORTHOPAEDIC SURGERY, ROYAL CHILDP.EN’S HOSPITAL, MELBOURNE INTRODUmION In clinical Gait Analysis large amoonts of data 8re generated from 3 dimensional kiiematic/kinetic studies and Electromyography The relative importance of this data and it8 relation to the the physiologicrd penalty of pathological g8it in a0 individual child may be di@icult to d&ermine and is subject to interpretation, The energy cm.t of walking may be the single bear global index of the severity of motor disorder and therefore its rn~o,~~t as-es critical importewe We have previously demonsvated the prscticality of direct measurement of oxygen con8omption in children witi mom, disorder8 and the value of this data m the understanding the nature and asses8ment of severity using the Cosmed K2 device We report our initial experience with the Cosmed K4 and the development of a clinical protocol incorporating 8 low level “stress” exercise test. MATERIAL AND METHODS The Cosmed K4 is a ii@ weight telemebic system designed tn measm’e VOZ, VCO2, Rsniratoru Freouencv. Tidal Volume Heart Rate and Lactate Threshold From this data many other parameter8 may be cakxlated or derived The principal difference8 between the K2 and K4 are meaurement of CO2 production, 8 new Oxygen analyse, and a new low resistance turbine. A teat track was developed in the Hugh Williamson Gait Analysrs laboratory in order to standardise as much as possible the condition during resting. Simultaneous recordings of Cosmed K4 datl and lap speed were made according to a strict test protocol Recordings were made in four normal volunteer on five consecutive weekdays to z&es8 test/retest relibility in care!i~lly controlled conditions which could hope to be reprodocuJ in clinical Gait Analysis Energy studies were also performed m 30 childreo attending the laboratory for 31) Kinematic and Kinetic analysis RESULTS Mean VO2 in normal volunteers ~8s 0 2 mlr’Kglm with 8 coefficient of variation of between 5% and g%, a considerable ~mpmvement compared to the perfmmance of the K2 The Coefficient of varmtion ~88 even lower for Energy Expenditure 8.8 calculated in cal/mn 0.9 and 8 sudden and marked rise in respirator freouencv. Detection of this effect was only possible by direct measurement of VC02 DISCUSSION The introduction of the Cosmed K4 was 8 logical progression from our cowem regarding the validity of energy measoremeot~ based on heart rate and distance-time parameters (PCI)

alone and concerns about the validity of the assumption RER=I m the KZ. The K4 18 a practical system in clinical gait analysis with a number of advantage8 over the K2, including improved reliabihty, the ability to measure CO2 production simultaneously with 02 consumption and therefore the abihty to detect when children with mom, disorders are exercising above their anaerobic threshold REFERENCES Daffy CM, Hill AE. Cosgrove A!‘, Cony IS, Graham HK Energy consumption in chiidren with spin.8 btfida and cerebral palsy 8 comparitive stody Dev Med sod Chtld Neurol 1996, 38,238-243 The Influence of Lep Length lneaunlitv on Gait and Enerw Consamotion Normal Children *C.M. DufTy, A.E. Hill, ‘H K. Graham The Royal Belfast Hospital for Sxk Children and ‘Musgrave Park Hospital. Belfast

in

Introduction There is much confusion regarding what constitutes a clinically significant leg length mequality Resarch to date has concentrated on static findings in terms of forces passmg through unequal hmbs (Scott) and relative degrees of pelvic tilt on long and short sides during 8tance phase only iCummings) There has been no attempt to examme the effect on the whole gait cycle of leg length mequality or to determme whether such an abnormahty has any influence on energy tort of walking Melhods We studled the mfluence of artificially tmposcd leg length inequahty on nine normal children. The children were 5 boys and 4 gwls aged 6 to 12 year8 (mean 8.7 ysrs, The study took the form orgalt analysis (Vicon. Oxford Metrics) and energy consumption studies (Cosmcd K2) while walking m random sequence barefoot. and wearing shppers on the rlgbt foot of I, 2 and 4 cm helgbt. Each child underwent gait analysis and energy conumptiou studies with each height of slipper Adequate t&me to re8t between tat8 wa? allowed.

Kinematic studies showed sxmficantlv mcreasine. eouinus of the left foot as the height of the slipper on the r&bt foot &as ratsed &6.05), while the right foot showed significantly increasing calcane1~8. Knee flexion patterns on the left were not altered by increasing leg length mequality. but knee flexion in stance mcreased on the right, mean knee flexion barefoot on the right was 6 degrees and with the 4cm raise 15 degrees (p=O.OOOI). Similarly. hip flexion patterns on the left were not altered but maximum hip flexlon at initml contact and terminal swing were increased significantly even by the Icm shoe mix (p=O.OOOl) from 42 degrees to 54 degrees Maximum hip extension at mid stance was decreased from 3 degrees barefoot, to -3 degrees wth the 4 cm ral8e @=O.OS). Pelvic tdt was 8180 significantly greater (p
Changes in pelvic obbquity mirrored those of hip abduction as the right side of the pelvis became pragresswely hrgher with respect ot the left side a8 the height of the shppe, was mcreased. thir became signilicam when the hetght reached 4 cm tpd Therapy 69 (8): 663 - 669

Session Three SMGLE EVENT, FRAMEWORK.

MULTILEVEL

Jill Rodda, Ros Boyd, Donnachs

SURGERY

IN CEREBRAL

PALSY:

A CLINICAL

Gallagher, Elise Cullis, Gary Nattr.888 and Kerr Graham

HUGH W~LI~SON GAIT ANALYSIS LABORATORY AND THE DEPUTES ORTHOPAEDIC SURGERY, ROYAL CHILDREN’S HOSPITAL, ELBOW

OF

INTRODUCTION A programme of “Single Event, Multilevel Surgery” (SEMLS) for children with Cerebral Palsy was introduced at the Royal Children’s Hospital, Melbourne following the opening of the Hugh Williamson Gait Analysis Laboratory in 1995 Because tixs wa8 8 new and complex service it WBS deaded to form&se the programme as 8 “Clinical Fmmework” Each depatment involved in the moltidiscipIin~ mangemoot of children with Cerebral Palsy comb&d to design of a detailed flow chart, representing the interelated steps in m~~g~rn~nt. The aims were to smxmline patient management, mcrase ~mmoni~tion, improve qualtty, contain costs by minimising inpatient 8tay, and to collect data as the basis for prospective research into all aspects ofthe service MATERL4L AND METBODS The Clinical Framework WBS developed jointly by representatwes fmm The Gait Analysis Laboratory, Development8l Paediatrics. Anaenthesia, Orthopaed~c Surgery, Nursing Staff (In patient, Out patient and Operatmg The&e), Ph~io~erapy, Orihotics, Radiology, Educational Resource Centre and the Hospital Divisionat Support Unit The draft clinical fmmework was mxmediately invodwed and further developed in use by a review programme Four main outcomelquality control me8.wrps are used I) Technical and clinical outcomes are determmed by comparison of 3D Gait Lab dam at baseline and at one year post surgery 2) Functional Health Status is determmed objectively by energy stodles & subjectively by the Chdd Health Questionnaire 3) Saosfanion of patients/care18 is assessed by HSU questionnatre 4) Cost - bet&t analysis. RESULTS The first 21 patients have completed Phase I and 2 of the programme and will complete Phase 3 late, this year The Clinic81 Framework h8s been accepted within the hospital environment wth demonstrated benefits in pattent management, quality assurance, audit and prospective research. Of the first 21 patients, 19 were male and 2 were female; age range was 6 to 18 years with a mean of 13 years In paflent stay was 3 to IO days with a mean of 7 days The mean number of surgtcai procedures was 5 (4 soft tissue. 1 bony) with a range of 3 to 14. There were no unplanned readmisstons There WBS one major complication (a traction injury to the common peroneal nerve) and two minor complic8tions (superficial wound infection, cast sore). DISCUSSION The approaches to surgical management of the child with CP have been polarised and caricatured as “the birthday syndrome” (single level, repeat surgery) versus multiple

76 operatmns Surgery“

pelformed Although

parts of this type approach Integrated with and We

Cerebral

at one tune, there is much if

Palsy

surgnxl believe

thkre is a a lack of thus ~mpor~nt

Furthermore

nt is incumbent

programmes that these

REFERENCES I) Gage JR,

1991

to demonstrate alms are addressed

Gait

Analysts

121 Mac Kath press, Oxford, 2) Nene AV, Evans GA and Diplegia

Outcome

1993.75-B

488-494

3) Rang Pediatric

M, Sdver Orthopaedics

A Comprehensive

which we have described vubbshed mformation

programme. management

and &

Functional

on the

their quality, to varying

in Cerebral New Patrick

Palsy

and de la Garza, J Cerebral 2nd edmon Phdadelphla

Ev~lluUon

of Treatment

proponents

cost degrees

Climes

York JH Simultaneous Assessment

as “Smgle Event, Mululevel as to the conduct and outcome

of practical mformatlon and complex event

of expensive

m Developmental

technolog)

Medncne

Operations m 18 patients

Palsy in Lovell etc. JB L~ppincott

Out&mmd

nf

as to how to m the life of a child

effectiveness and value to socxty by our Clinical Framework

Multiple

of Walking

S9

for

Spastic

J Bone

WW, Wmter 1986

io Ambulatory

No

Joint RB

Surg

eds

Cerebral

PpiSy

Selber. M.Dy L lamed R. Gage, MD 2OOEast Unwenify Avenue. St Paul. MN 55101 USA) Objwtlvc: To evaluate the reaulis of su ical treatment of children wilh ambula,twy cerebral palsy by using a compreheneive % ncbonal outcome model. Parameters mcludcd: 1) technical nsul~s 2) functional outcome, 3) parent satisfaction. and 4) cost. Desiga: A retmspectivr study of patients with spastic cetiral Isy who un,derwnt surgical treatment lo improve ambulation. None of the children r ad had prev~us surgical intervention RIientr: Pifly-four pattents with spastic cerebral phy (I7 children wtb,h~miplegi?: 22 with di orbipkgia and 15 with qwdriplegia). ThwIy seven had oribopaed~c mtervenl~cm only and 17 had both selective dorsal rbiwtomy and atb+edic surgery. Mean age at hulment wan 7.5 years All had lbeir entire coume of treatment at Gillette Children’s Hospital. M&rink grid Methods: The method of asse~wnent WBS different for each ana of outcc~me meawed. Technical outcome was assessed by computcri~d gait analysis prior 10 and followin surgical intervention. A normalcy index W on 22 variables (kinematic and &.mct~c) was used to analyze resulca. Functional outcome was,meas~rcd by oxygen consumption ps and post inlervention and I functional ability quesuonnure. Satisfaction was assessed by a retmspec(ive parent questionnaire. Cost of trcatmcnt was determined from hospital and physican b’eabnent ncnds. Mus~~mrnk and MaIn Re~ulcs: 1) Technical Outawe: The normalcy index showed improvement in 50 of 54 patients. 2) Fuel hrrasmcnt: Of the children who had only mlhopaedic surgery, lhen WBJ an overall nduclion in energy expenditure of 35%. oftbose who had a combination of rbiwtomy and reduction in energy expendihwewas 23%. Thirty of 54 children had follow-up questionnaire mforr@on. SVength. endumncc. and ability to keep up with peers were rated 8s improved m 70. 67, and 63% respective1 3) Farm1 Ltisfactlon: Qwtiomnire ntum rate was seventyone w’cent. All of x e famdies whose children had rhiiotomy (9 of I7 responded)Wre satisfied and said that they would undergo lhe procedure aggm. Eighty percent of the families whose children had wihopxdics (28 of 37 responded) said they would undergo tie procedures again. Tbc greatest hardship for families of patients with rhirovmy was the lcngtb of UK. stay in the hospital. The greatest hardships for families of tn115 who undemn1 ottbopaedic pmcedutw were post-opentive pm and scarring. 8r cod of Treatment: The avenge number of admissions for pat1ent.3 who bad the combination of rhiwtomy and atha medics was 3.2 with an ave e combined length of stay of 40.5 days. T&cat in I ! 95 dollars was $94,125.00. ‘xe average number of admissions for patienls who had onhopaedic treatment only wgs 1.7 with an averaged combined length of stay of 7.7 days and P total cost of S39.OC0.00. Conclusloor: Based on technical outcome more thyl90% of patients were Improved. However, fun&ond assessment indicated impmvemerd in only at-ad 67%. Ncvenheless, 84% of families were suff&ntly satisfied with the o$omc lhat they would have the procedunx done again. The cost of the proc&res m ti ‘I dollars is very high and long term bencfi~s are difficult to assess. particularly since t Kere ?I’C no other in-d+ studies of this type in tk )itemtuR. If the results stand up ovcr,~me and, as a consqwnce of the interventions. these children are able 10 be more functional adults. lhen the long km bendit will certainly be worth Ihc cost since these children have a long lifetime ahead of them. Crouch

gait

in spastic

diplegir

after

heel cord

B. Berghof, E. B. Zvick, L. Mderlein Dept. of Orthnpdic Surgery. Univmity of Heiddbcr&

lengthening

Gcmnny

Does Kectus Femuris <~ontrarturr .AiTert Stance-Phase Hin Fun&m? .I R Linskell. SF Fairpriesr, The Dundee Gait Lab, Dundee, Scotland