Paediatrics
Markus Winther Frost, Ole Rahbek, Jens Trærup, A. Axel Ceccotti, Søren Kold
Dept. of Orthopedic Surgery and Interdisciplinary Orthopaedics, Aalborg University Hospital; Dept. of Orthopedic Surgery and Interdisciplinary Orthopaedics, Aalborg University Hospital; Dept. of Orthopedic Surgery, Aalborg University Hospital; Dept. of Orthopedic Surgery, Aalborg University Hospital; Dept. of Orthopedic Surgery and Interdisciplinary Orthopaedics, Aalborg University Hospital
Background: More than 16000 intramedullary Precice and Fitbone lengthening nails have been implanted worldwide. Complications are so far only heterogeneously reported in small case series, and no systematic overview of complications exists.
Purpose / Aim of Study: To perform a systematic literature review of complications with Fitbone and Precice bone lengthening nails in lower extremity bone lengthening.
Materials and Methods: In PubMed, EMBASE, Cochrane Library a systematic search, with no limits concerning study design, date or language, was performed with search string of medical subject headings: Bone Nails, Bone Lengthening and “Word” Fitbone and Precice nail. One author selected the articles. The first and last author assessed complications. Complications were severity graded (Black et al. 2015) and categorized into subgroups based on origin.
Findings / Results: The search found 952 articles, 116 were full text screened and 41 included. 983 segments were lengthened in 782 patients (age: 8-74 years). Number of patients: 208 congenital, 305 acquired limb shortening, 111 short status, 158 unidentified etiology. We identified 332 complications (34% of segments). Type I (minimal intervention): 11% of segments; Type II (substantial change in treatment plan): 15% of segments; Type IIIA (failure to achieve goal): 5% of segments; Type IIIB (new pathology or permanent sequelae): 3% of segments. Joint contracture/subluxation/luxation was the most frequent type IIIB complication. The two most frequent origins of complications were related to device (13% of segments) and bone (9% of segments).
Conclusions: The risks of complications represent average risks as data did not allow stratification of risks based on etiology of lengthening. Intramedullary lengthening nails were introduced to reduce complications in limb lengthening. The overall risk of complication is still high with one complication for every three segments lengthened. In one of every four segments, the complication has a major impact on treatment: substantial change in treatment, such as unplanned surgery (15%), failure of achieving lengthening goal (5%) or introduction of a new pathology or permanent sequelae (3%).
Dept. of Orthopedic Surgery and Interdisciplinary Orthopaedics, Aalborg University Hospital; Dept. of Orthopedic Surgery and Interdisciplinary Orthopaedics, Aalborg University Hospital; Dept. of Orthopedic Surgery, Aalborg University Hospital; Dept. of Orthopedic Surgery, Aalborg University Hospital; Dept. of Orthopedic Surgery and Interdisciplinary Orthopaedics, Aalborg University Hospital
Background: More than 16000 intramedullary Precice and Fitbone lengthening nails have been implanted worldwide. Complications are so far only heterogeneously reported in small case series, and no systematic overview of complications exists.
Purpose / Aim of Study: To perform a systematic literature review of complications with Fitbone and Precice bone lengthening nails in lower extremity bone lengthening.
Materials and Methods: In PubMed, EMBASE, Cochrane Library a systematic search, with no limits concerning study design, date or language, was performed with search string of medical subject headings: Bone Nails, Bone Lengthening and “Word” Fitbone and Precice nail. One author selected the articles. The first and last author assessed complications. Complications were severity graded (Black et al. 2015) and categorized into subgroups based on origin.
Findings / Results: The search found 952 articles, 116 were full text screened and 41 included. 983 segments were lengthened in 782 patients (age: 8-74 years). Number of patients: 208 congenital, 305 acquired limb shortening, 111 short status, 158 unidentified etiology. We identified 332 complications (34% of segments). Type I (minimal intervention): 11% of segments; Type II (substantial change in treatment plan): 15% of segments; Type IIIA (failure to achieve goal): 5% of segments; Type IIIB (new pathology or permanent sequelae): 3% of segments. Joint contracture/subluxation/luxation was the most frequent type IIIB complication. The two most frequent origins of complications were related to device (13% of segments) and bone (9% of segments).
Conclusions: The risks of complications represent average risks as data did not allow stratification of risks based on etiology of lengthening. Intramedullary lengthening nails were introduced to reduce complications in limb lengthening. The overall risk of complication is still high with one complication for every three segments lengthened. In one of every four segments, the complication has a major impact on treatment: substantial change in treatment, such as unplanned surgery (15%), failure of achieving lengthening goal (5%) or introduction of a new pathology or permanent sequelae (3%).
Martin Wyman Rathcke, Robert Herzog, Mathilde Lundgaard-Nielsen, Susan Warming, Michael Rindom Krogsgaard
Section for Sports Traumatology M51, Bispebjerg and Frederiksberg Hospital; Dept. of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Dept. of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Dept. of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Section for Sports Traumatology M51, Bispebjerg and Frederiksberg Hospital
Background: The treatment of anterior cruciate ligament (ACL) rupture in the pediatric population (children < 16 years) is debated, primarily because of a high risk of re-rupture after ACL- reconstruction (ACLR). In Denmark the treatment of pediatric ACL rupture is centralized in two centers.
Purpose / Aim of Study: To present the 1-year follow-up results in a consecutive cohort from one center in Denmark after pediatric ACLR using hamstring autografts and epiphysis sparing techniques.
Materials and Methods: Between 2012 and 2018 all children < 16 years operated with an ACLR were evaluated preoperatively and at 1-year follow-up. Evaluation included pediatric patient related outcome scores (PROMs): Pedi-IKDC and KOOS-child, in addition to laxity measurements with a rolimeter. Laxity measurements at one-year follow-up were made by an experienced physiotherapist, independent of the surgeon.
Findings / Results: During the 6-year period 113 patients < 16 years had an ACL reconstruction. 82 patients (73 %) had completed the one-year follow-up program. Three patients (2 girls and 1 boy) had been reoperated because of graft rupture. The mean age at follow up was 14.5 years (SD 1.5) (‰48 %; Š 52%). The most common reasons for injury among both genders was soccer (41.5%) and handball (22,3%). Side to side laxity difference at follow- up was 1.00 mm (SD 1.48) for boys and 1.00 mm (SD 1,13) for girls. Mean Pedi-IKDC score: 86.3 (SD 13.0). Mean KOOS-Child subscales: Pain 88.7 (SD 11.4), Symptoms 87.7 (SD 11.4), ADL 97.6 (SD 4.6), Sport/Rec. 81.1 (SD 17.1), QOL 68.4 (SD 17.1).
Conclusions: The re-rupture rate, the stability and the subjective scores at one-year follow-up were satisfactory, except for the KOOS-Child subscale Quality of Life. However, the scores from this subscale were influenced by the restrictions in the program related to return to sport.
Section for Sports Traumatology M51, Bispebjerg and Frederiksberg Hospital; Dept. of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Dept. of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Dept. of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Section for Sports Traumatology M51, Bispebjerg and Frederiksberg Hospital
Background: The treatment of anterior cruciate ligament (ACL) rupture in the pediatric population (children < 16 years) is debated, primarily because of a high risk of re-rupture after ACL- reconstruction (ACLR). In Denmark the treatment of pediatric ACL rupture is centralized in two centers.
Purpose / Aim of Study: To present the 1-year follow-up results in a consecutive cohort from one center in Denmark after pediatric ACLR using hamstring autografts and epiphysis sparing techniques.
Materials and Methods: Between 2012 and 2018 all children < 16 years operated with an ACLR were evaluated preoperatively and at 1-year follow-up. Evaluation included pediatric patient related outcome scores (PROMs): Pedi-IKDC and KOOS-child, in addition to laxity measurements with a rolimeter. Laxity measurements at one-year follow-up were made by an experienced physiotherapist, independent of the surgeon.
Findings / Results: During the 6-year period 113 patients < 16 years had an ACL reconstruction. 82 patients (73 %) had completed the one-year follow-up program. Three patients (2 girls and 1 boy) had been reoperated because of graft rupture. The mean age at follow up was 14.5 years (SD 1.5) (‰48 %; Š 52%). The most common reasons for injury among both genders was soccer (41.5%) and handball (22,3%). Side to side laxity difference at follow- up was 1.00 mm (SD 1.48) for boys and 1.00 mm (SD 1,13) for girls. Mean Pedi-IKDC score: 86.3 (SD 13.0). Mean KOOS-Child subscales: Pain 88.7 (SD 11.4), Symptoms 87.7 (SD 11.4), ADL 97.6 (SD 4.6), Sport/Rec. 81.1 (SD 17.1), QOL 68.4 (SD 17.1).
Conclusions: The re-rupture rate, the stability and the subjective scores at one-year follow-up were satisfactory, except for the KOOS-Child subscale Quality of Life. However, the scores from this subscale were influenced by the restrictions in the program related to return to sport.
Mathilde Lundgaard-Nielsen, Robert Bennike Herzog, Susan Warming, Martin Rathcke, Michael Rindom Krogsgaard, Mette K. Zebis
Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Section for Sports Traumatology, Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg Hospital; Section for Sports Traumatology, Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg Hospital; University College Copenhagen, Faculty of Health, Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy
Background: Functional performance are commonly recommended prior to the decision of return to sport (RTS) after ACL reconstruction (ACL-re) with a criteria of leg symmetry index (LSI) above 90 % of the contralateral uninjured limb
Purpose / Aim of Study: The purpose is to describe the leg symmetry index (LSI) of single leg hop test among children with an ACL-r and compare with healthy controls
Materials and Methods: ACL-re children and age-matched healthy controls recruited schools participated. They performed: Single leg hop tests (SLH, 6M-timed, TLH og COH). The highest result out of three trials on each leg were noted. The LSI were calculated as the injured or weak limb/uninjured or best limb*100 for the ACL-group and healthy group respectively except for the 6M-timed where it is opposite. All results are presented as mean±SD
Findings / Results: 376 healthy children and 88 children at 1-year follow up after ACL-re participated. Age-group 11-12 years consisted of 210 school children and 10 ACL-re, age-group 13-14 years of 125 school children and 36 ACL-re and age-group 15-16 years of 41 and 42 children respectively. The absolute values between the best/uninjured side of the healthy controls and the ACL-re at one year follow up respectively were: SLH healthy group 113.5 ± 28.3 and ACL-group 119.1 ± 24.2. 6M-timed healthy group 2.4 ± 0.5 and ACL-group 2.3 ± 0.4. TLH healthy group 370.9 ± 82.2 and ACL 82.2 and ACL-group 374.4 ± 100.5. COH healthy group 308.9 ± 84.5 and ACL-group 319.6 ± 94.1. The percentage side to side differences (LSI) between weak/best limb for the controls and injured/uninjured limb for the ACL-re at one-year follow-up were for the controls 10 % (SLH 89.3 ± 8.6, 6M-timed 110.1 ± 9.4; TLH 91.6 ± 8.1 and COH 91.6 ± 8.1) whereas it for the ACL-re were 3 % (SLH 96.6 ± 12.5; 6M-timed 96.7 ± 10.8; TLH 97.5 ± 9.4 and COH 97.9 ± 13.0)
Conclusions: No differences were seen between the best limb of the healthy controls and the uninjured limb for the ACL-re at one-year follow-up. However, the ages-matched controls showed a 10% side to side difference in performing the four SLH which were only 3 % for the ACL matched controls showed a 10% side to side difference in performing the four SLH which were only 3 % for the ACL-re children at a one-year follow-up. Based on these results the LSI criteria of > 90 % before RTS seems to be a reasonable parameter for ACL up. Based on these results the LSI criteria of > 90 % before RTS seems to be a reasonable parameter for ACL-re children
Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital; Section for Sports Traumatology, Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg Hospital; Section for Sports Traumatology, Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg Hospital; University College Copenhagen, Faculty of Health, Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy
Background: Functional performance are commonly recommended prior to the decision of return to sport (RTS) after ACL reconstruction (ACL-re) with a criteria of leg symmetry index (LSI) above 90 % of the contralateral uninjured limb
Purpose / Aim of Study: The purpose is to describe the leg symmetry index (LSI) of single leg hop test among children with an ACL-r and compare with healthy controls
Materials and Methods: ACL-re children and age-matched healthy controls recruited schools participated. They performed: Single leg hop tests (SLH, 6M-timed, TLH og COH). The highest result out of three trials on each leg were noted. The LSI were calculated as the injured or weak limb/uninjured or best limb*100 for the ACL-group and healthy group respectively except for the 6M-timed where it is opposite. All results are presented as mean±SD
Findings / Results: 376 healthy children and 88 children at 1-year follow up after ACL-re participated. Age-group 11-12 years consisted of 210 school children and 10 ACL-re, age-group 13-14 years of 125 school children and 36 ACL-re and age-group 15-16 years of 41 and 42 children respectively. The absolute values between the best/uninjured side of the healthy controls and the ACL-re at one year follow up respectively were: SLH healthy group 113.5 ± 28.3 and ACL-group 119.1 ± 24.2. 6M-timed healthy group 2.4 ± 0.5 and ACL-group 2.3 ± 0.4. TLH healthy group 370.9 ± 82.2 and ACL 82.2 and ACL-group 374.4 ± 100.5. COH healthy group 308.9 ± 84.5 and ACL-group 319.6 ± 94.1. The percentage side to side differences (LSI) between weak/best limb for the controls and injured/uninjured limb for the ACL-re at one-year follow-up were for the controls 10 % (SLH 89.3 ± 8.6, 6M-timed 110.1 ± 9.4; TLH 91.6 ± 8.1 and COH 91.6 ± 8.1) whereas it for the ACL-re were 3 % (SLH 96.6 ± 12.5; 6M-timed 96.7 ± 10.8; TLH 97.5 ± 9.4 and COH 97.9 ± 13.0)
Conclusions: No differences were seen between the best limb of the healthy controls and the uninjured limb for the ACL-re at one-year follow-up. However, the ages-matched controls showed a 10% side to side difference in performing the four SLH which were only 3 % for the ACL matched controls showed a 10% side to side difference in performing the four SLH which were only 3 % for the ACL-re children at a one-year follow-up. Based on these results the LSI criteria of > 90 % before RTS seems to be a reasonable parameter for ACL up. Based on these results the LSI criteria of > 90 % before RTS seems to be a reasonable parameter for ACL-re children
Mathilde Kofoed-Hansen, Josephine Michelsen, Merete Speedtsberg, Tina Torabi, Jesper Bencke, Christian Wong
Human Movement Analysis Laboratory, Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Human Movement Analysis Laboratory, Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Human Movement Analysis Laboratory, Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre
Background: Mollii (Inerventions, Danderyd) is a full-body garment with 58 integrated electrodes with capability of stimulating 40 muscles in the body. The body garment with 58 integrated electrodes with capability of stimulating 40 muscles in the body. The Mollii suit facilitates reciprocal inhibition of a spastic muscle by stimulation of the antagonist muscle.
Purpose / Aim of Study: The aim of this preliminary study was to investigate the effect of the Mollii suit on gait function in children with cerebral palsy as a part of a larger study of whole-body function.
Materials and Methods: 29 children with spastic cerebral palsy GMFCS 1-2 (15 boys; 13 girls; 11.3±3.2 years; 1.41 ± 0.29 m, 37.9 ± 12.7 kg) were included in this six 12.7 kg) were included in this six-month prospective study. The month prospective study. The Mollii suit was individually adapted to stimulate the antagonists of their affected muscles in both upper- and lower extremities. The children wore the suit one hour daily during activities of daily living for six months. Gait function was evaluated with a 3-D gait analysis before and after the intervention with kinematic, kinetic and temporospatial temporospatial outcome parameters related to the ankle joint. Paired samples statistics were used for every parameter obtained from the gait analysis. Effect sizes (Cohen’s d or Wilcoxon effect size r) were calculated.
Findings / Results: 17 children (10 boys; 7 girls; 10.9±3.2 years, 1.37±0.34 m, 36.5±12.1 kg) completed the intervention. Temporospatial Temporospatial parameters including cadence, stride length, gait velocity and limp index were unchanged after six months of treatment with the Mollii suit. Dorsiflexion in stance phase improved significantly from 11.4±6.5° to 15.7±4.5° (p=0.001, r=0.49). Dorsiflexion in swing phase was significantly improved from -8±10.2° to - -4.6±9.5° (p=0.012, r= 0.36).
Conclusions: Improved dorsiflexion in swing phase is a positive change which might improve gait function by decreasing the risk of stumbling. Improved dorsiflexion in stance phase could be a measure of less spasticity in the plantar flexor muscles and hence better shock absorption. This preliminary study shows moderate effect on biomechanical gait parameters, as an effect of this intervention, but further evaluation of the full data set and the reasons for the large drop out should be considered before a concluding assessment of this new intervention method may be obtained.
Human Movement Analysis Laboratory, Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Human Movement Analysis Laboratory, Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Human Movement Analysis Laboratory, Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre; Dept. of Orthopaedic Surgery , Copenhagen University Hospital, Amager-Hvidovre
Background: Mollii (Inerventions, Danderyd) is a full-body garment with 58 integrated electrodes with capability of stimulating 40 muscles in the body. The body garment with 58 integrated electrodes with capability of stimulating 40 muscles in the body. The Mollii suit facilitates reciprocal inhibition of a spastic muscle by stimulation of the antagonist muscle.
Purpose / Aim of Study: The aim of this preliminary study was to investigate the effect of the Mollii suit on gait function in children with cerebral palsy as a part of a larger study of whole-body function.
Materials and Methods: 29 children with spastic cerebral palsy GMFCS 1-2 (15 boys; 13 girls; 11.3±3.2 years; 1.41 ± 0.29 m, 37.9 ± 12.7 kg) were included in this six 12.7 kg) were included in this six-month prospective study. The month prospective study. The Mollii suit was individually adapted to stimulate the antagonists of their affected muscles in both upper- and lower extremities. The children wore the suit one hour daily during activities of daily living for six months. Gait function was evaluated with a 3-D gait analysis before and after the intervention with kinematic, kinetic and temporospatial temporospatial outcome parameters related to the ankle joint. Paired samples statistics were used for every parameter obtained from the gait analysis. Effect sizes (Cohen’s d or Wilcoxon effect size r) were calculated.
Findings / Results: 17 children (10 boys; 7 girls; 10.9±3.2 years, 1.37±0.34 m, 36.5±12.1 kg) completed the intervention. Temporospatial Temporospatial parameters including cadence, stride length, gait velocity and limp index were unchanged after six months of treatment with the Mollii suit. Dorsiflexion in stance phase improved significantly from 11.4±6.5° to 15.7±4.5° (p=0.001, r=0.49). Dorsiflexion in swing phase was significantly improved from -8±10.2° to - -4.6±9.5° (p=0.012, r= 0.36).
Conclusions: Improved dorsiflexion in swing phase is a positive change which might improve gait function by decreasing the risk of stumbling. Improved dorsiflexion in stance phase could be a measure of less spasticity in the plantar flexor muscles and hence better shock absorption. This preliminary study shows moderate effect on biomechanical gait parameters, as an effect of this intervention, but further evaluation of the full data set and the reasons for the large drop out should be considered before a concluding assessment of this new intervention method may be obtained.
Johanne Jørgensen, Mads Werner, Josephine Michelsen, Christian Wong
Department of Orthopedic Surgery, Hvidovre Hospital; Multidisciplinary Pain Center, Rigshospitalet; Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital
Background: Chronic pain in children and adolescents with cerebral palsy (CP) is a partly overlooked and undertreated clinical problem, while being a major determinant for quality of life.
Purpose / Aim of Study: To better understand the underlying pain mechanisms, we investigated the somatosensory profiles of children and adolescents with and without CP, and chronic pain with quantitative sensory testing (QST).
Materials and Methods: This prospective cross-sectional, explorative study investigated 51 subjects; 25 with CP (9 with chronic pain [CP-P], 16 without [CP-NP]), and 26 without CP (14 with chronic pain [non-CP-P], 12 without [controls]). All subjects were recruited from the outpatient orthopedic clinic. The subjects had their reaction time tested prior to the QST. The QST included assessments of warmth (WDT), cool (CDT), mechanical (MDT) and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; and tests of wind-up (WUR), dynamic mechanical allodynia (DMA) and conditioned pain modulation (CPM).
Findings / Results: There were no statistical differences in QST results between subjects with CP-P and CP-NP. Reaction times were longer in subjects with CP compared to subjects without CP (P=0.010). Subjects with CP demonstrated hypoesthesia in WDT (P=0.031) and CDT (P=0.029), with a trend for mechanical hypoesthesia in MDT (P=0.052), and no difference in HPT compared to controls. When rating pain during HPT-assessment, more subjects with CP rated the pain intensity as high (13/25 vs. 2/12, P=0.008), and in WUR, fewer subjects with CP registered increasing pain over time (6/25 vs. 7/12, P=0.041), compared to controls. Subjects in the non-CP-P group demonstrated hypoesthesia in WDT (P=0.008) and HPT (P=0.021), and more subjects rated the pain intensity as high (9/14 vs. 2/12, P=0.014), compared to controls. Regarding the rest of the QST variables, no significant differences were shown.
Conclusions: The somatosensory profiles of subjects with CP demonstrated similarities regardless of the pain phenotype; thermal and mechanical hypoesthesia and decreasing pain in responses to WUR. Further sensory studies are warranted examining the pathophysiological mechanism of pain in children and adolescents with CP.
Department of Orthopedic Surgery, Hvidovre Hospital; Multidisciplinary Pain Center, Rigshospitalet; Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital
Background: Chronic pain in children and adolescents with cerebral palsy (CP) is a partly overlooked and undertreated clinical problem, while being a major determinant for quality of life.
Purpose / Aim of Study: To better understand the underlying pain mechanisms, we investigated the somatosensory profiles of children and adolescents with and without CP, and chronic pain with quantitative sensory testing (QST).
Materials and Methods: This prospective cross-sectional, explorative study investigated 51 subjects; 25 with CP (9 with chronic pain [CP-P], 16 without [CP-NP]), and 26 without CP (14 with chronic pain [non-CP-P], 12 without [controls]). All subjects were recruited from the outpatient orthopedic clinic. The subjects had their reaction time tested prior to the QST. The QST included assessments of warmth (WDT), cool (CDT), mechanical (MDT) and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; and tests of wind-up (WUR), dynamic mechanical allodynia (DMA) and conditioned pain modulation (CPM).
Findings / Results: There were no statistical differences in QST results between subjects with CP-P and CP-NP. Reaction times were longer in subjects with CP compared to subjects without CP (P=0.010). Subjects with CP demonstrated hypoesthesia in WDT (P=0.031) and CDT (P=0.029), with a trend for mechanical hypoesthesia in MDT (P=0.052), and no difference in HPT compared to controls. When rating pain during HPT-assessment, more subjects with CP rated the pain intensity as high (13/25 vs. 2/12, P=0.008), and in WUR, fewer subjects with CP registered increasing pain over time (6/25 vs. 7/12, P=0.041), compared to controls. Subjects in the non-CP-P group demonstrated hypoesthesia in WDT (P=0.008) and HPT (P=0.021), and more subjects rated the pain intensity as high (9/14 vs. 2/12, P=0.014), compared to controls. Regarding the rest of the QST variables, no significant differences were shown.
Conclusions: The somatosensory profiles of subjects with CP demonstrated similarities regardless of the pain phenotype; thermal and mechanical hypoesthesia and decreasing pain in responses to WUR. Further sensory studies are warranted examining the pathophysiological mechanism of pain in children and adolescents with CP.
Søren Bødtker, Billy B Kristensen, Lene D L Svendsen, Louise Klingberg, Ellen Koefoed, Mai Petersen
Orthopedics, Copenhagen University Hospital Hvidovre; Ambulatory Surgery, Copenhagen University Hospital Hvidovre; Pediatrics, Copenhagen University Hospital Hvidovre; Orthopedics, Copenhagen University Hospital Hvidovre; Physiotherapy, Copenhagen University Hospital Hvidovre; Physiotherapy, Copenhagen University Hospital Hvidovre
Background: Complex regional pain syndrome (CRPS) is a neuropathic condition characterized by circular allodynia and functional loss of an extremity. Treatment with continuous peripheral nerve blockade in children has so far only been reported in case studies.
Purpose / Aim of Study: This study reports our results and complications combining continuous peripheral nerve blockade for pain relieve and physio-occupational therapy in children with CRPS.
Materials and Methods: Inclusion criteria were children meeting Budapest criteria for CRPS, having sensory disturbances and allodynia, thereby losing the ability to self-support on their limb. Under general anesthesia and with ultrasound and electric stimulation guidance, a catheter was placed close to either the sciatic nerve, the saphenous nerve or the Brachial plexus. All children received continuous infusion of ropivacaine 0.2%, 5-7 mL/h combined with immediate physiotherapy and/or occupational therapy with a supplement of self-training every two hours throughout the day. The therapy focused on improving coordination, strength and sensory motor skills.
Findings / Results: 28 children were consecutively included (25 girls and 3 boys). 23 children had foot pain, 4 had pain in the hand and 1 had combined foot and hand pain. On admission the average age was 12 years (8-16); the average duration of pain was 12 months (2-64) with a median VAS score of 9 (7-10). Initiation of pain was either no trauma (9), minor trauma/distortions (17) or fracture (2). After an average observation period of 68 months (5.6 year) the median VAS score was 0 (0-7). In 2 children the treatment plan had no effect. In one child a relapse occurred 3 weeks after removal of the catheter, but renewed nerve catheter treatment was successful. One catheter had to be replaced due to accidental discontinuation. Finally, one child had a superficial infection. No neurological complications were observed during the period.
Conclusions: Treatment with continuous peripheral nerve block and training seems safe, effective and feasible for children with CRPS, resulting in pain-free or almost pain-free patients.
Orthopedics, Copenhagen University Hospital Hvidovre; Ambulatory Surgery, Copenhagen University Hospital Hvidovre; Pediatrics, Copenhagen University Hospital Hvidovre; Orthopedics, Copenhagen University Hospital Hvidovre; Physiotherapy, Copenhagen University Hospital Hvidovre; Physiotherapy, Copenhagen University Hospital Hvidovre
Background: Complex regional pain syndrome (CRPS) is a neuropathic condition characterized by circular allodynia and functional loss of an extremity. Treatment with continuous peripheral nerve blockade in children has so far only been reported in case studies.
Purpose / Aim of Study: This study reports our results and complications combining continuous peripheral nerve blockade for pain relieve and physio-occupational therapy in children with CRPS.
Materials and Methods: Inclusion criteria were children meeting Budapest criteria for CRPS, having sensory disturbances and allodynia, thereby losing the ability to self-support on their limb. Under general anesthesia and with ultrasound and electric stimulation guidance, a catheter was placed close to either the sciatic nerve, the saphenous nerve or the Brachial plexus. All children received continuous infusion of ropivacaine 0.2%, 5-7 mL/h combined with immediate physiotherapy and/or occupational therapy with a supplement of self-training every two hours throughout the day. The therapy focused on improving coordination, strength and sensory motor skills.
Findings / Results: 28 children were consecutively included (25 girls and 3 boys). 23 children had foot pain, 4 had pain in the hand and 1 had combined foot and hand pain. On admission the average age was 12 years (8-16); the average duration of pain was 12 months (2-64) with a median VAS score of 9 (7-10). Initiation of pain was either no trauma (9), minor trauma/distortions (17) or fracture (2). After an average observation period of 68 months (5.6 year) the median VAS score was 0 (0-7). In 2 children the treatment plan had no effect. In one child a relapse occurred 3 weeks after removal of the catheter, but renewed nerve catheter treatment was successful. One catheter had to be replaced due to accidental discontinuation. Finally, one child had a superficial infection. No neurological complications were observed during the period.
Conclusions: Treatment with continuous peripheral nerve block and training seems safe, effective and feasible for children with CRPS, resulting in pain-free or almost pain-free patients.
Christina Bach Sandholm, Malene Tousgaard Foget Østergaard, Inger Mechlenburg, Kirsten Nordbye-Nielsen
Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: The prevalence of hip contractures in children with Cerebral Palsy (CP) in Denmark is unknown. Moreover, it is unclear if hip contracture leads to pain in the lower extremities.
Purpose / Aim of Study: To identify the prevalence of hip contractures and their association with gross motor function among Danish children with CP. In addition to investigate the association between hip contracture and pain in the lower extremities.
Materials and Methods: This cross-sectional study included 688 children with a pediatrician-verified diagnosis of CP in Denmark born in 2001- 2019 and registered in the National Danish Clinical Quality Database for Cerebral Palsy (CPOP). The dataset included children aged 5 to 12 years across all Gross Motor Function Classification System (GMFCS) levels. GMFCS level was and range of motion reported by physiotherapists, and by using goniometer, contractures were defined according to the ”traffic-light algoritm” used in CPOP in the nordic countries. Data was collected in the period 2018-2019. The associations were estimated as odds ratios (OR) with 95% confidence intervals by logistic regressions, adjusted for age, GMFCS and the experience of pain in the lower extremities.
Findings / Results: The population included 59% boys and 41% girls with a mean age of 8 years. The prevalence of hip contracture was 22%, across all five GMFCS levels. There was a significant inverse association at GMFCS level IV (OR=1.99, 95% CI: 1.10;3.62) and V (OR=5.49, 95% CI: 3.33;9.07) and the odds for hip contracture. Furthermore, the presence of hip contracture increased the experience of pain in the lower extremities (OR=1.43, 95% CI: 0.95;2.15).
Conclusions: The present study indicates that, a higher GMFCS-level increases the prevalence of hip contracture and that the occurrence of hip contractures is associated with the experience of pain in the lower extremities of children with CP.
Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: The prevalence of hip contractures in children with Cerebral Palsy (CP) in Denmark is unknown. Moreover, it is unclear if hip contracture leads to pain in the lower extremities.
Purpose / Aim of Study: To identify the prevalence of hip contractures and their association with gross motor function among Danish children with CP. In addition to investigate the association between hip contracture and pain in the lower extremities.
Materials and Methods: This cross-sectional study included 688 children with a pediatrician-verified diagnosis of CP in Denmark born in 2001- 2019 and registered in the National Danish Clinical Quality Database for Cerebral Palsy (CPOP). The dataset included children aged 5 to 12 years across all Gross Motor Function Classification System (GMFCS) levels. GMFCS level was and range of motion reported by physiotherapists, and by using goniometer, contractures were defined according to the ”traffic-light algoritm” used in CPOP in the nordic countries. Data was collected in the period 2018-2019. The associations were estimated as odds ratios (OR) with 95% confidence intervals by logistic regressions, adjusted for age, GMFCS and the experience of pain in the lower extremities.
Findings / Results: The population included 59% boys and 41% girls with a mean age of 8 years. The prevalence of hip contracture was 22%, across all five GMFCS levels. There was a significant inverse association at GMFCS level IV (OR=1.99, 95% CI: 1.10;3.62) and V (OR=5.49, 95% CI: 3.33;9.07) and the odds for hip contracture. Furthermore, the presence of hip contracture increased the experience of pain in the lower extremities (OR=1.43, 95% CI: 0.95;2.15).
Conclusions: The present study indicates that, a higher GMFCS-level increases the prevalence of hip contracture and that the occurrence of hip contractures is associated with the experience of pain in the lower extremities of children with CP.
Hans-Christen Husum, Michel Bach Hellfritzsch, Martin Gottliebsen, Mads Henriksen, Ole Rahbek
Interdisciplinary Orthopaedics, Aalborg University Hospital; Department of Radiology, Aarhus University Hospital; Department of Orthopaedics, Aarhus University Hospital; Department of Radiology, Aarhus University Hospital; Interdisciplinary Orthopaedics, Aalborg University Hospital
Background: MRI is increasingly used in the assessment of residual acetabular dysplasia (RAD) as cartilaginous structures are investigated for their role in hip stability. Osseous migration index (OMI) is a commonly used parameter in the assessment of RAD in conventional radiology. We propose the cartilaginous migration index (CMI) as a new and improved measurement for hip stability.
Purpose / Aim of Study: Primary aim was to establish the reliability of OMI and CMI in a retrospective cohort of patients examined for RAD. Secondary aim was to compare findings of OMI and CMI and agreement of MRI with XR.
Materials and Methods: We retrospectively identified sixteen patients (2 male, mean age 5 years(±1.57)), examined for RAD during a period of 2½ years, at the Department of orthopedics, Aarhus University Hospital, Aarhus, Denmark. MRI scans were all performed without sedation. Four raters performed blinded repeated measurements of OMI, CMI, pelvic rotation index and pelvic tilt index in MRI and XR. Bland Altman plots and intraclass correlation coefficients (ICC) were calculated for agreement and reliability.
Findings / Results: Intrarater reliability for OMI(XR), OMI(MRI) and CMI all had ICC values above 0.97 with 95% CI in the range of 0.91-0.99. Mean differences and ranges were: OMI(MRI)-OMI(XR) 0.083 (0,0.38), OMI(MRI)-CMI 0.08 (0-0.23), OMI(XR)-CMI 0.062 (0, 0.27). Bland Altman plots for OMI(XR) and OMI(MR) produced a mean difference of 0.07 LOA (-0.12-0.25) with higher disagreements at low average MI values. Mean OMI(XR) was lower than mean OMI(MRI) 0.17 versus 0.24 (P<0.001) Differences in OMI(MR) and OMI(XR) showed no correlation to pelvic rotation index or pelvic tilt index but a positive correlation to the interval between XR and MRI exams.
Conclusions: We propose CMI as a new radiographic measurement, and conclude that it has good reliability and correlates positively to OMI(XR) and OMI(MRI). Measurement of MI in XR and MRI had good to excellent reliability. Our results show that pelvic radiographs underestimated OMI when compared to pelvic MRI.
Interdisciplinary Orthopaedics, Aalborg University Hospital; Department of Radiology, Aarhus University Hospital; Department of Orthopaedics, Aarhus University Hospital; Department of Radiology, Aarhus University Hospital; Interdisciplinary Orthopaedics, Aalborg University Hospital
Background: MRI is increasingly used in the assessment of residual acetabular dysplasia (RAD) as cartilaginous structures are investigated for their role in hip stability. Osseous migration index (OMI) is a commonly used parameter in the assessment of RAD in conventional radiology. We propose the cartilaginous migration index (CMI) as a new and improved measurement for hip stability.
Purpose / Aim of Study: Primary aim was to establish the reliability of OMI and CMI in a retrospective cohort of patients examined for RAD. Secondary aim was to compare findings of OMI and CMI and agreement of MRI with XR.
Materials and Methods: We retrospectively identified sixteen patients (2 male, mean age 5 years(±1.57)), examined for RAD during a period of 2½ years, at the Department of orthopedics, Aarhus University Hospital, Aarhus, Denmark. MRI scans were all performed without sedation. Four raters performed blinded repeated measurements of OMI, CMI, pelvic rotation index and pelvic tilt index in MRI and XR. Bland Altman plots and intraclass correlation coefficients (ICC) were calculated for agreement and reliability.
Findings / Results: Intrarater reliability for OMI(XR), OMI(MRI) and CMI all had ICC values above 0.97 with 95% CI in the range of 0.91-0.99. Mean differences and ranges were: OMI(MRI)-OMI(XR) 0.083 (0,0.38), OMI(MRI)-CMI 0.08 (0-0.23), OMI(XR)-CMI 0.062 (0, 0.27). Bland Altman plots for OMI(XR) and OMI(MR) produced a mean difference of 0.07 LOA (-0.12-0.25) with higher disagreements at low average MI values. Mean OMI(XR) was lower than mean OMI(MRI) 0.17 versus 0.24 (P<0.001) Differences in OMI(MR) and OMI(XR) showed no correlation to pelvic rotation index or pelvic tilt index but a positive correlation to the interval between XR and MRI exams.
Conclusions: We propose CMI as a new radiographic measurement, and conclude that it has good reliability and correlates positively to OMI(XR) and OMI(MRI). Measurement of MI in XR and MRI had good to excellent reliability. Our results show that pelvic radiographs underestimated OMI when compared to pelvic MRI.
Josephine Sanddahl-Mikkelsen, Christian Wong
Dept of Orthopedics, Hvidovre hospital; Dept of Orthopedics, Hvidovre hospital
Background: The Mollii suit is a low intensity and low frequency electric stimulation treatment of spasticity. Spasticity is a common characteristic in children with cerebral palsy (CP). This treatment has the advantage to be used by even immobile handicapped children, since patient participation in principle would only require donning of the suit, which would be performed by a parent or therapist.
Purpose / Aim of Study: The objective of this clinical study was to examine the effect on spasticity and function of multifocal transcutaneous electrical stimulation (TENS) incorporated in a 2-piece suit, the Mollii suit on children with CP, GFMCS 3-5.
Materials and Methods: This study was a prospective cohort study. Participants were recruited from three schools for disabled children in our region. Thirty-one participants with predominantly spastic disease, GFMCS 3-5 were included; 17 completed the study. Participants wore the suit for 1 hour every second day in a trial period of 24 weeks. We measured spasticity using the modified Ashworth (MAS) and Tardieu scales (MTS) before initiation and after 4, 12, and 24 weeks, and passive range of motion (pROM) using a goniometer. The participant's personal therapists defined and evaluated two motor related SMART goals by the goal attainment scale (GAS). GMFM-66 and posture and postural ability scale (PPAS) evaluation were performed for overall function and stability.
Findings / Results: The overall spasticity level and from the proximal arm and leg were significant reduced according to MAS. There was an additive effect on spasticity reduction over time and related to specific stimulated muscles. No clinically meaningful reduction was seen in pROM and MTS as well as in overall and dimensions of GMFM-66. SMART goals improved significantly and clinical meaningful for motor function as standing/walking and hand and arm use. We saw non-significant improvements in the sitting and prone position according to the PPAS.
Conclusions: In conclusion, this clinical study demonstrated that the use of Mollii suit in a 24-week intervention in children with CP, GFMCS 3-5 has significant reduction in spasticity and significant improvements in motor functions as mobility of walking and standing and motor skills of hand and arm.
Dept of Orthopedics, Hvidovre hospital; Dept of Orthopedics, Hvidovre hospital
Background: The Mollii suit is a low intensity and low frequency electric stimulation treatment of spasticity. Spasticity is a common characteristic in children with cerebral palsy (CP). This treatment has the advantage to be used by even immobile handicapped children, since patient participation in principle would only require donning of the suit, which would be performed by a parent or therapist.
Purpose / Aim of Study: The objective of this clinical study was to examine the effect on spasticity and function of multifocal transcutaneous electrical stimulation (TENS) incorporated in a 2-piece suit, the Mollii suit on children with CP, GFMCS 3-5.
Materials and Methods: This study was a prospective cohort study. Participants were recruited from three schools for disabled children in our region. Thirty-one participants with predominantly spastic disease, GFMCS 3-5 were included; 17 completed the study. Participants wore the suit for 1 hour every second day in a trial period of 24 weeks. We measured spasticity using the modified Ashworth (MAS) and Tardieu scales (MTS) before initiation and after 4, 12, and 24 weeks, and passive range of motion (pROM) using a goniometer. The participant's personal therapists defined and evaluated two motor related SMART goals by the goal attainment scale (GAS). GMFM-66 and posture and postural ability scale (PPAS) evaluation were performed for overall function and stability.
Findings / Results: The overall spasticity level and from the proximal arm and leg were significant reduced according to MAS. There was an additive effect on spasticity reduction over time and related to specific stimulated muscles. No clinically meaningful reduction was seen in pROM and MTS as well as in overall and dimensions of GMFM-66. SMART goals improved significantly and clinical meaningful for motor function as standing/walking and hand and arm use. We saw non-significant improvements in the sitting and prone position according to the PPAS.
Conclusions: In conclusion, this clinical study demonstrated that the use of Mollii suit in a 24-week intervention in children with CP, GFMCS 3-5 has significant reduction in spasticity and significant improvements in motor functions as mobility of walking and standing and motor skills of hand and arm.
André Nis Klenø, Martin Bækgaard Stisen, Claes Høgh Cubel, Inger Mechlenburg, Kirsten Nordbye-Nielsen
Department of Orthopaedic Surgery and Department of Childrens Ortopaedics, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery and Department of Childrens Ortopaedics, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery and Department of Childrens Ortopaedics, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery, Department of Childrens Ortopaedics and Department of Clinical Medicine, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery, Department of Childrens Ortopaedics and CPNorth: Living life with cerebral palsy in the Nordic countries, Aarhus University Hospital, Denmark
Background: Cerebral palsy (CP) is a neurological disease occurring in children at early gestation to the age of 2 years. In Denmark, children with CP are registered in the Danish National Cerebral Palsy Database (CPOP) and offered a program that includes treatment and follow-up. To our knowledge, only one study has investigated the prevalence of knee contracture and its association with gross motor function, age and spasticity, yet it remains to be investigated in a Danish population.
Purpose / Aim of Study: To examine the prevalence of knee contracture in children with CP, and secondly to examine the association with gross motor function, age and spasticity.
Materials and Methods: The study is a cross-sectional study, including 1163 children with CP (679 boys and 479 girls) aged 1-15 years, registered in the CPOP database, with measurements performed between 2017-2019. Knee contracture was defined as a deficit greater than or equal to 5 degrees knee extension, measured with a goniometer at passive range of motion test by physiotherapists. To examine the association between knee contracture and gross motor function, age and spasticity, logistic regression analysis were performed and odds ratios (OR) with 95% confidence intervals (95% CI) were calculated. Gross motor function was assessed with Gross Motor Function Classification System Expanded and Revised (GMFCS E&R) and spasticity was measured with Modified Ashworth Scale.
Findings / Results: 509 out of 1163 children with CP had knee contracture resulting in a prevalence of 44%. In the adjusted analysis, knee contractures were significantly more frequent in GMFCS E&R level IV (OR: 1.9, 95% CI: 1.21; 2.97) and V (OR: 3.62, 95% CI: 2.36; 5.55) compared to level I. Age groups 4-6 years (OR: 1.73, 95% CI: 1.19; 2.52), 7-9 years (OR: 1.85, 95% CI: 1.29; 2.66) and 10-12 years (OR: 2.12, 95% CI: 1.39; 3.24) years were associated with a higher prevalence of knee contractures compared to age group 1-3 years.
Conclusions: There is a high prevalence of knee contractures in children with CP in Denmark and knee contractures are significantly associated with low levels of gross motor function and with older age. The study did not find knee contractures to be associated with spasticity.
Department of Orthopaedic Surgery and Department of Childrens Ortopaedics, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery and Department of Childrens Ortopaedics, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery and Department of Childrens Ortopaedics, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery, Department of Childrens Ortopaedics and Department of Clinical Medicine, Aarhus University Hospital, Denmark; Department of Orthopaedic Surgery, Department of Childrens Ortopaedics and CPNorth: Living life with cerebral palsy in the Nordic countries, Aarhus University Hospital, Denmark
Background: Cerebral palsy (CP) is a neurological disease occurring in children at early gestation to the age of 2 years. In Denmark, children with CP are registered in the Danish National Cerebral Palsy Database (CPOP) and offered a program that includes treatment and follow-up. To our knowledge, only one study has investigated the prevalence of knee contracture and its association with gross motor function, age and spasticity, yet it remains to be investigated in a Danish population.
Purpose / Aim of Study: To examine the prevalence of knee contracture in children with CP, and secondly to examine the association with gross motor function, age and spasticity.
Materials and Methods: The study is a cross-sectional study, including 1163 children with CP (679 boys and 479 girls) aged 1-15 years, registered in the CPOP database, with measurements performed between 2017-2019. Knee contracture was defined as a deficit greater than or equal to 5 degrees knee extension, measured with a goniometer at passive range of motion test by physiotherapists. To examine the association between knee contracture and gross motor function, age and spasticity, logistic regression analysis were performed and odds ratios (OR) with 95% confidence intervals (95% CI) were calculated. Gross motor function was assessed with Gross Motor Function Classification System Expanded and Revised (GMFCS E&R) and spasticity was measured with Modified Ashworth Scale.
Findings / Results: 509 out of 1163 children with CP had knee contracture resulting in a prevalence of 44%. In the adjusted analysis, knee contractures were significantly more frequent in GMFCS E&R level IV (OR: 1.9, 95% CI: 1.21; 2.97) and V (OR: 3.62, 95% CI: 2.36; 5.55) compared to level I. Age groups 4-6 years (OR: 1.73, 95% CI: 1.19; 2.52), 7-9 years (OR: 1.85, 95% CI: 1.29; 2.66) and 10-12 years (OR: 2.12, 95% CI: 1.39; 3.24) years were associated with a higher prevalence of knee contractures compared to age group 1-3 years.
Conclusions: There is a high prevalence of knee contractures in children with CP in Denmark and knee contractures are significantly associated with low levels of gross motor function and with older age. The study did not find knee contractures to be associated with spasticity.