The Use of minimally invasive technique in multi surgery for children with cerebral palsy: preliminary results

The Use of minimally invasive technique in multi surgery for children with cerebral palsy: preliminary results
1 Oxford Gait laboratory, Nuffield orthopaedic Center Oxford;
2Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Center, Oxford;
3Division of Applied Biomedical Research, King’s college, London, UK

Background/objectives: Muscle weakness is a recognized problem in children with cerebral palsy (CP). We have previously show that 1 year after single-stage multi-level surgery(SSMLS),muscle and motor function do not return to pre –operative levels, despite significant gait improvements. We have therefore combined minimally invasive ‘strength preserving’ surgical techniques that allow earlier mobilization, with strength training. This includes performing decoration osteotomies using closed corticotomy and intramedullary stable elastic nail fixation (ISEN) and replacing open muscle lengthening with percutaneous lengthening where possible. The study compared the outcomes of strength preserving surgery (SPS) with conventional SSMLS.
Design: Comparative prospective cohort study.
Participants and Setting: Ten children with diplegic CP (mean age 10 years 6months) underwent SPS (n=18 operated limbs) combined with 10 children (mean age 11 years 4 months after surgery. They were matched for ambulatory level (GMFCS level II-III) and compared with 10 children (mean age 11 years 4 months) who underwent conventional SSMLS (n=20 operated limbs) and a strengthening all operations in an Orthpaedic Hospital setting.
Materials/Methods: Clinical examination, gait kinematics (vicon MX) and Gillette gait index, isometric muscle strength (MIE digital dynamometry) and motor function (GMFM88) were assessed pre –operatively and 12 months after surgery. Routine radiographs were taken after 6 and 12 weeks. Differences between the two groups at 12 months after surgery were evaluated by analysis of co-variance (p=<0.05).
Results: The SPS group had significantly reduced operative time (p=0.013) and blood loss (p=0.004) and significantly improved time to mobilization (p=0.00002), compared with the SSMLS group. There were no complications intra-operatively or during hospitalization in either group. In the SSMLS group there was one failure of fixation requiring revision otherwise all osteotomies in both groups healed within 12 weeks. There was significant improvement in the Gillette Gait Index in both the SSMLS group (p=0.023) and the group(0.0001), with no between group difference in gait kinematics. There was improved muscle strength in the SPS group compared to the SSMLS group, which reach significant between group difference function.
Conclusions/significance: Performing multi-level surgery can safely and effectively be achieved with minimally invasive techniques, with the additional benefits of improved muscle strength, faster mobilization and reduced operative time and blood loss.

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