Publications by authors named "Julieanne P Sees"

18 Publications

  • Page 1 of 1

Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children With Cerebral Palsy With Stiff Knee Gait.

J Pediatr Orthop 2021 Jul 19. Epub 2021 Jul 19.

Gait Analysis Laboratory, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.

Background: Children with cerebral palsy (CP) often present with a stiff knee gait pattern because of rectus femoris (RF) spasticity and/or contracture. Rectus femoris transfers (RFTs) and resections are surgical procedures aimed at reducing muscle stiffness, thereby improving knee flexion during the swing phase of gait. Previous research has consistently demonstrated objective benefits of rectus transfer using instrumented gait analysis (IGA). Rectus femoris resection (RFR), a relatively simpler procedure, shows similar improvement in knee range of motion during gait. The objective of this study was to compare surgical outcomes between rectus transfers and resections using 3-dimensional IGA.

Methods: Children with spastic CP who had RFTs or resections were retrospectively matched by walking speed and preoperative knee kinematics from 3-dimensional IGA (peak and timing of peak knee flexion in swing). Secondary outcomes included knee range of motion and maximum knee extension during gait.

Results: Twenty-eight children were included in both the transfer group [age 9.4±2 y; Gross Motor Function Classification System (GMFCS) I (3 children), II (15 children), III (8 children), and IV (2 children)] and the resection group [age 10.6±2.5 y; GMFCS I (1 child), II (14 children), and III (13 children)]. Both surgical groups showed statistically significant short-term postsurgical improvements in peak knee flexion during swing (P<0.001 for the transfer group and P=0.003 for the resection group) and Duncan-Ely test (P=0.004 for the transfer group and P<0.001 for the resection group). Further analysis by GMFCS level showed children at GMFCS levels III/IV had a greater tendency to crouch after RFT when compared with children at GMFCS levels I/II. This tendency was not observed in the RFR group.

Conclusions: Both transfer and resection surgeries significantly improved gait kinematics short-term outcomes in children with spastic CP who present with stiff knee gait pattern. Further studies are required to compare long-term outcomes of both surgeries.

Level Of Evidence: Level III-retrospective matched-cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000001886DOI Listing
July 2021

Single-event multilevel surgery in cerebral palsy: Value added by a co-surgeon.

Medicine (Baltimore) 2021 Jun;100(24):e26294

National Academy of Medicine Fellowship, American Osteopathic Association, Chicago, IL, USA.

Abstract: The aim of this study was to compare outcomes for single-event multilevel surgery (SEMLS) in cerebral palsy (CP) performed by 1 or 2 attending surgeons.A retrospective review of patients with CP undergoing SEMLS was performed. Patients undergoing SEMLS performed by a single senior surgeon were compared with patients undergoing SEMLS by the same senior surgeon and a consistent second attending surgeon. Due to heterogeneity of the type and quantity of SEMLS procedures included in this study, a scoring system was utilized to stratify patients to low and high surgical burden. The SEMLS events scoring less than 18 points were categorized as low burden surgery and SEMLS scoring 18 or more points were categorized as high burden surgery. Operative time, estimated blood loss, hospital length of stay, and operating room (OR) utilization costs were compared.In low burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 8 patients had SEMLS performed by 2 surgeons. In high burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 12 patients had SEMLS performed by 2 surgeons. For high burden SEMLS, operative time was decreased by a mean of 69 minutes in cases performed by 2 co-surgeons (P = 0.03). Decreased operative time was associated with an estimated savings of $2484 per SEMLS case. In low burden SEMLS, a trend toward decreased operative time was associated for cases performed by 2 co-surgeons (182 vs 221 minutes, P = 0.11). Decreased operative time was associated with an estimated savings of $1404 per low burden SEMLS case. No difference was found for estimated blood loss or hospital length of stay between groups in high and low burden SEMLS.Employing 2 attending surgeons in SEMLS decreased operative time and OR utilization cost, particularly in patients with a high surgical burden. These findings support the practice of utilizing 2 attending surgeons for SEMLS in patients with CP.Level of Evidence: Level III.
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http://dx.doi.org/10.1097/MD.0000000000026294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213317PMC
June 2021

Evaluation of Risk Factors for Cerebrospinal Leakage in Pediatric Patients With Cerebral Palsy Treated With Intrathecal Baclofen.

J Pediatr Orthop 2020 Jul;40(6):e522-e526

Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children, Wilmington, DE.

Background: Insertion of an intrathecal baclofen (ITB) pump can provide significant benefits in patients with cerebral palsy (CP). However, there are little data describing the risk of complications. Specifically, there is a lack of data describing the incidence of cerebrospinal fluid (CSF) leakage and risk factors following ITB placement. The purpose of our study was to describe risk factors for developing CSF leak in pediatric patients with CP treated with ITB and to report the treatment and outcome of CSF leaks.

Methods: Following institutional review board approval, 720 ITB procedures in 341 children with CP were identified retrospectively over a 15-year study period. Patients' demographic characteristics, medical comorbidities, muscle tone patterns, feeding tube status, seizure history, inpatient events, ITB-related CSF leak and headache complaints and their management, and other complications were evaluated.

Results: Eighty-five (24.9%) patients experienced 90 CSF leak episodes over a follow-up time of 6.3±3.9 years. There were 72 episodes of headache as a result of CSF leakage in 61 (71.7%) of these 85 patients. There was a positive correlation between the risk of CSF leak and preoperative comorbidities such as epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. The risk of CSF leak after primary ITB administration was 5.8% (20/341), and the risk after secondary ITB procedures due to complications was 24.2% (32/132). There was no significant relationship between CSF leak and primary ITB (P=0.21), but the risk of CSF leak was positively correlated to the secondary ITB due to complications (P<0.05).

Conclusions: CSF leak was fairly common (25% incidence), and it correlated with epilepsy/seizure history, feeding tube, mixed type CP, and dystonic type CP. Recurrent ITB procedures were a risk factor for CSF leak. Half of these patients had self-limited symptoms that improved with conservative medical treatment, and the epidural blood patch was successful in resistant cases. Successful treatment of CSF leakage complications allows patients to continue ITB.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001472DOI Listing
July 2020

What's New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis.

J Pediatr Orthop 2020 Jul;40(6):e498-e503

Department of Orthopaedics.

Background: Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment.

Methods: A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review.

Results: The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis.

Conclusions: Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance.

Level Of Evidence: Level IV-literature review.
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http://dx.doi.org/10.1097/BPO.0000000000001461DOI Listing
July 2020

The effectiveness of epidural blood patch in patients with cerebral palsy treated with intrathecal baclofen implantation.

Paediatr Anaesth 2020 02 14;30(2):153-160. Epub 2020 Jan 14.

Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.

Background: Cerebrospinal fluid leak and postdural puncture spinal headache following intrathecal baclofen therapy are known complications. Although primary treatments are conservative, epidural blood patch is an alternative in patients with persistent and severe symptoms.

Aim: The purpose of this article is to review the effectiveness of epidural blood patch for the treatment of spinal headache and cerebrospinal fluid leak associated with intrathecal baclofen treatment in children with cerebral palsy.

Methods: Our database was reviewed for epidural blood patch in 341 pediatric patients with cerebral palsy who underwent primary intrathecal baclofen treatment from 2004 to 2018 at one institution. The number of patches, time frame of treatment, and effectiveness of the epidural blood patch were collected. All patients treated with epidural blood patch were evaluated for primary and secondary intrathecal baclofen-related procedures, and subsequent treatment of intrathecal baclofen associated with cerebrospinal fluid leak and spinal headache.

Results: Twenty-nine epidural blood patch procedures were performed on 26 patients who had received intrathecal baclofen procedures. Of these 26 patients, four had a secondary epidural blood patch. The incidence of spinal headache/cerebrospinal fluid leak was 31% (107/341), and 81/107 (76%) patients with spinal headache/cerebrospinal fluid leak responded to conservative treatments. Success rate for initial epidural blood patch was 79.3% (23/29). The second epidural blood patch was performed in four patients after failure of initial epidural blood patch. Second epidural blood patch success rate was 75% (3/4).

Conclusion: Spinal headache and cerebrospinal fluid leak are known complications after intrathecal baclofen treatment in children with cerebral palsy. When conservative treatments are unsuccessful, epidural blood patch can be used with confidence for these patients. In patients with ongoing symptoms, it is possible to obtain success by repeating the epidural blood patch to continue intrathecal baclofen treatment and avoid aggressive surgery.
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http://dx.doi.org/10.1111/pan.13791DOI Listing
February 2020

What's New in Pediatric Hip?

J Pediatr Orthop 2018 Jul;38(6):e300-e304

Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Developmental dysplasia of the hip (DDH), which encompasses a wide spectrum of disease from mild dysplasia to frank dislocation, is one of the most common developmental deformities of the lower extremities and one of the leading causes of future osteoarthritis and hip arthroplasty. Legg-Calvé-Perthes disease (LCPD) results from a vascular insult to the growing femoral epiphysis, which in turn can create permanent morphologic changes to the hip joint. Slipped capital femoral epiphysis (SCFE) occurs when the proximal femoral physis fails allowing the epiphysis to displace in relation to the metaphysis. Infections about the hip also create significant morbidity in the pediatric hip.

Methods: We searched the PubMed database for all studies related to DDH, LCPD, SCFE, and pediatric hip infections that were published between July 1, 2014 and August 31, 2017. The search was limited to English articles and yielded 839 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line.

Results: A total of 40 papers were selected for review based upon new and significant findings. Select historical manuscripts are also included to provide sufficient background information.

Conclusions: DDH, LCPD, SCFE, and infections about the hip continue to be important topics in pediatric orthopaedics and areas of vital research. This manuscript reviews the most important recent literature on the diagnosis and treatment of these pediatric hip conditions.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1097/BPO.0000000000001166DOI Listing
July 2018

Infections of Intrathecal Baclofen Delivery Systems and Ventriculoperitoneal Shunting Systems: Clinical Series Discussion.

Pediatr Neurosurg 2018 2;53(1):1-6. Epub 2017 Sep 2.

Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.

Background/aims: The physiological interaction between the intrathecal baclofen (ITB) delivery system and the ventriculoperitoneal (VP) shunting system in a patient who had both systems implanted has not been reported previously. The aim of our report is to evaluate the effect that one system's infection might have on the other.

Methods: Records of children who were followed at our institution between 2004 and 2015 for management of their ITB systems were reviewed. In this group, children who had VP shunts were identified, and those who had any of their ITB or VP systems infected were included.

Results: Out of 313 children managed with ITB therapy at our institution, 31 (24%) children had VP shunts. Two patients had infection in both systems, and 3 patients had infection in 1 system.

Conclusion: This report suggests that if aspiration from both systems showed positive cultures, the treatment would be removal of both systems. If the primarily not infected system does not show positive cultures, it does not need to be removed. Close follow-up is recommended, and any sign of infection or malfunction of the primarily not infected device should be approached with a high level of suspicion.
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http://dx.doi.org/10.1159/000475468DOI Listing
July 2018

Hallux valgus deformity correction without fusion in children with cerebral palsy.

J Pediatr Orthop B 2017 Mar;26(2):164-171

Department of Orthopaedics, Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.

This study aimed to evaluate the outcomes of nonarthrodesis surgical treatment of hallux valgus (HV) deformity in children with cerebral palsy using radiographic and gait analysis parameters. There were 25 patients who had hallux valgus correction in 39 feet. The mean age at surgery was 15±2.8 years and the mean follow-up duration was 14.6 months. The first metatarsal osteotomy was performed in nine feet, bunionectomy in 25 feet, and Aiken osteotomy in 32 feet. None had metatarsophalangeal joint fusion. We observed a significant correlation between HV correction and other foot and ankle gait parameters. Our study showed correction of HV deformity at short-term follow-up without fusion of the metatarsophalangeal joint.

Level Of Evidence: Level IV Therapeutic Studies.
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http://dx.doi.org/10.1097/BPB.0000000000000419DOI Listing
March 2017

What's New in the Management of Foot Deformities in Children With Cerebral Palsy.

J Pediatr Orthop 2018 Jan;38(1):e20-e24

Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.

Background: Foot deformities have been frequently reported in cerebral palsy (CP), and numerous diagnostic modalities and treatment options have recently been developed to achieve a better level of management for children with CP.

Methods: A thorough search of the English literature, published between January 2013 and March 2016, was performed. A summary of the new findings that had not previously described was reported. The review included recent advances regarding clinical and gait evaluation, orthotic management, botulinum toxin A treatment, and surgical correction.

Results: The review summarized new findings reported in 46 articles and abstracts that were published between January 2013 and March 2016. Older articles were included and cited when an original description was mentioned, or when a change or development of some findings was discussed.

Conclusions: Foot deformity forms an essential part of evaluating children with CP. Dramatic advances have been achieved in gait assessment, conservative management, and surgical correction. Promising results have been reported with the goal to reach a higher level of orthopaedic care and optimize the functional potentials for children with CP.

Level Of Evidence: Level IV-literature review.
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http://dx.doi.org/10.1097/BPO.0000000000000901DOI Listing
January 2018

Scoliosis in Down's syndrome.

J Pediatr Orthop B 2017 Jul;26(4):383-387

Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.

This study reports the recent experience in the management of scoliosis in Down's syndrome. Curve patterns, progression in brace, and surgical outcomes were recorded. Cardiac surgery history was compared between children with and without scoliosis. Out of 581 children with Down's syndrome, 62 children had scoliosis. The mean age of the children was 13.8 years. The mean magnitude was 31°. Bracing was successful in five of seven patients. Ten children had posterior spinal fusion with follow-up of 2.6 years (1-7.3). One deep wound infection was recorded with no revision. No difference was found in cardiac surgery history between children with and without scoliosis.

Level Of Evidence: Type IV - prognostic and therapeutic study.
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http://dx.doi.org/10.1097/BPB.0000000000000378DOI Listing
July 2017

Risk factors for pancreatitis after posterior spinal fusion in children with cerebral palsy.

J Pediatr Orthop B 2018 Mar;27(2):163-167

Department of Orthopedics, Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.

This study reports on the prevalence and risk factors of acute pancreatitis after posterior spinal fusion for cerebral palsy scoliosis. Pancreatitis diagnosis was based on elevated amylase or lipase above three times the upper normal limit. Perioperative data were compared between patients with and without pancreatitis. We included 300 patients; 55% developed acute pancreatitis. Gastrostomy dependence was more common in the pancreatitis group (P=0.048). Perioperative data were similar between groups. Patients with pancreatitis had longer duration of hospitalization (19 vs. 13 days, P<0.001). Acute pancreatitis is common after cerebral palsy scoliosis surgery. Gastrostomy dependence increases its risk. Although no mortality was reported, hospital stay was longer.
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http://dx.doi.org/10.1097/BPB.0000000000000376DOI Listing
March 2018

Reliability and validity of Edinburgh visual gait score as an evaluation tool for children with cerebral palsy.

Gait Posture 2016 09 15;49:14-18. Epub 2016 Jun 15.

Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington DE 19803, USA. Electronic address:

Assessment of gait abnormalities in cerebral palsy (CP) is challenging, and access to instrumented gait analysis is not always feasible. Therefore, many observational gait analysis scales have been devised. This study aimed to evaluate the interobserver reliability, intraobserver reliability, and validity of Edinburgh visual gait score (EVGS). Video of 30 children with spastic CP were reviewed by 7 raters (10 children each in GMFCS levels I, II, and III, age 6-12 years). Three observers had high level of experience in gait analysis (10+ years), two had medium level (2-5 years) and two had no previous experience (orthopedic fellows). Interobserver reliability was evaluated using percentage of complete agreement and kappa values. Criterion validity was evaluated by comparing EVGS scores with 3DGA data taken from the same video visit. Interobserver agreement was 60-90% and Kappa values were 0.18-0.85 for the 17 items in EVGS. Reliability was higher for distal segments (foot/ankle/knee 63-90%; trunk/pelvis/hip 60-76%), with greater experience (high 66-91%, medium 62-90%, no-experience 41-87%), with more EVGS practice (1st 10 videos 52-88%, last 10 videos 64-97%) and when used with higher functioning children (GMFCS I 65-96%, II 58-90%, III 35-65%). Intraobserver agreement was 64-92%. Agreement between EVGS and 3DGA was 52-73%. We believe that having EVGS as part of the standardized gait evaluation is helpful in optimizing the visual scoring. EVGS can be a supportive tool that adds quantitative data instead of only qualitative assessment to a video only gait evaluation.
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http://dx.doi.org/10.1016/j.gaitpost.2016.06.017DOI Listing
September 2016

Knee Deformities in Children With Down Syndrome: A Focus on Knee Malalignment.

J Pediatr Orthop 2018 May/Jun;38(5):266-273

Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.

Background: Patellofemoral instability (PFI) has been the most reported knee abnormality in people with Down syndrome. Other reported knee abnormalities have been associated with PFI and different management approaches have been described with variable outcomes. The aim of this study was to describe the anatomic variations of the knee in children with Down syndrome. A comparison between knees with and without PFI was performed and our experience in treating knee abnormalities in Down syndrome was also reported.

Methods: Records of all children with Down syndrome were reviewed. Two groups were identified (knees with and without PFI). Radiographic measurements included the mechanical and anatomic lateral distal femoral angles, medial proximal tibial angle, angle of depression of medial tibial plateau, lateral tibial translation, and distal femoral physis-joint angle. On the lateral view, Insall-Salvati and Blackburne-Peel ratios were measured. The sulcus angle was measured on the tangential view. Measurements were compared between the 2 groups (with and without PFI).Knees with PFI were divided into 3 subgroups based on their treatment (group A: surgical valgus correction, group B: surgical soft tissue procedures for PFI, and group C: conservative treatment). Preoperative radiographs were used for the surgical group and last available radiographs were used for the conservative group. Clinical and radiographic data were compared between the groups. For groups A and B, clinical and radiographic data were also compared between preoperative and last visits.

Results: Of the 581 children with Down syndrome, 5% (31 children: 22 females, 9 males) had PFI in 56 knees. Mean age at diagnosis was 11.5±3.5 years. Of the remaining 550 children, 75 children had radiographs for 130 knees. Knees with PFI had significantly more valgus and a larger distal femoral physis-joint angle. Depression of the medial tibial plateau and lateral tibial translation were noted in knees with PFI. Insall-Salvati ratio was higher and the sulcus angle was larger in the PFI group.Of the 56 knees with PFI; 10 knees were in group A, 11 knees in group B, 33 knees in group C, and the remaining 2 knees had combined procedures. Preoperative mechanical and anatomic lateral distal femoral angles were smaller in group A than in group B or C. Grades of PFI improved in group B after surgery. This improvement was not noted in group A.

Conclusions: In children with Down syndrome, different variations of the knee anatomy can be found. Although PFI might be the most evident knee abnormality, other underlying deformities are common. Treatment of the PFI should be planned through a comprehensive anatomic approach that addresses all aspects of knee deformity.

Level Of Evidence: Level IV-prognostic and therapeutic study.
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http://dx.doi.org/10.1097/BPO.0000000000000814DOI Listing
August 2018

Evaluation of intrathecal baclofen delivery system malfunction by computed tomography scan.

Dev Med Child Neurol 2016 Apr 11;58(4):409-15. Epub 2015 Sep 11.

Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.

Aim: To describe the computed tomography (CT) findings encountered when catheter patency is questionable. The role of CT in directing treatment is evaluated.

Method: Records of children with intrathecal baclofen pump management were reviewed. Only patients with CT evaluation who had revision pump/catheter surgery were included.

Results: From 295 patients, 27 had CT contrast study; in three of them, baclofen could not be aspirated and the procedure was stopped, eight had normal scan and did not need surgery and 16 patients were reported. Four patients had normal CT (free contrast formed a perfect crescent shape), and had surgery because the pump battery was close to expiration. Five patients had inadequate fluid pooling (fluid was seen without a crescent shape). Five patients had fluid leak (fluid was seen around the pump or in the lumbar canal below catheter entrance level or outside the canal in the lumbar region). Two patients had catheter occlusion (fluid loculation around the catheter tip with no free flow).

Interpretation: CT contrast study is safe and effective for locating defects in intrathecal baclofen delivery system. When catheter patency is questionable, CT plays an important role in directing the next step of management.
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http://dx.doi.org/10.1111/dmcn.12893DOI Listing
April 2016

Infection as a Complication of Intrathecal Baclofen Treatment in Children With Cerebral Palsy.

J Pediatr Orthop 2016 Apr-May;36(3):305-9

Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.

Background: Children with cerebral palsy (CP) and spasticity are often managed with intrathecal baclofen treatment (ITB). Complications of ITB include infection at the pump or catheter site and late complications as well as revisions of the pump and catheter because of events such as battery expiration or implant malfunction. The goal of this study is to report the short-term and long-term incidence, risk factors, and treatment outcomes of ITB infections in children.

Methods: This was a retrospective review of 294 children with CP. The number of ITB surgeries per patient, risk of infection for primary and secondary ITB-related procedures, microorganisms responsible, and associated factors, such as concurrent orthopaedic interventions, medical comorbidities, and subsequent management of ITB-related infections, were evaluated.

Results: Infection occurred in 28/294 patients (9.5%) with a 4.9% rate per procedure. There were 14 acute (within 90 d of surgery) and 14 late infections. The infection risk per ITB procedure was 2.4%. Risk of late infection over 5-year mean follow-up was 0.95% per year. Pump removal with acute contralateral implantation was the most successful treatment of infections. Gross Motor Function Classification System level V and G-tube were the main risk factors for infection. A total of 133 concurrent orthopaedic procedures were performed during 277 ITB procedures with no increased risk of infection.

Conclusions: ITB in children with CP has a relatively low and manageable risk of infection. It is important to always consider infection as a complication with ITB because with prompt treatment the positive impact of ITB is still possible. It is safe to perform concurrent orthopaedic procedures with ITB procedures.

Levels Of Evidence: Level III-therapeutic study.
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http://dx.doi.org/10.1097/BPO.0000000000000443DOI Listing
November 2016

Pamidronate Treatment to Prevent Reoccurring Fractures in Children With Cerebral Palsy.

J Pediatr Orthop 2016 Mar;36(2):193-7

Departments of *Orthopaedics †Biomedical Research ‡Medical Imaging §Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.

Background: Some children with cerebral palsy (CP) have frequent fractures due to low bone mineral density and receive treatment with pamidronate, an intravenous bisphosphonate. Our review evaluates the outcome of pamidronate treatment in these children.

Methods: A retrospective chart review was performed, and 32 patients (14 girls and 18 boys) with CP Gross Motor Function Classification System level III (2 patients), IV (3 patients), and V (27 patients) treated with 5 courses of pamidronate for low mineral density were identified. Patients with a minimum of 2 years of follow-up were included in the study. Data collection was a review of the demographics and pretreatment, peritreatment, and posttreatment fracture history.

Results: The mean age at treatment was 11.6 years (range, 2.9 to 19.6 y). There were 102 fractures (mean duration 2.5 y) pretreatment and 28 fractures posttreatment. With an average follow-up of 6.4 years, posttreatment rate of fracture decreased to 0.10 fractures per year from the pretreatment rate of 2.4 fractures per year (P<0.001). The femur was the most common bone fractured both pretreatment (54%) and posttreatment (61%); the major site was the distal third of the femur. There were 11 fractures during the course of pamidronate treatment at a rate of 0.33 fractures per year. Only 11 patients (34%) sustained fracture posttreatment. No correlation with fracture pattern or occurrence was found with patient age, number of pretreatment fractures, or sex. Most fractures were caused by low-energy injuries, and most were managed nonoperatively.

Conclusions: In patients with CP and disuse osteoporosis, the most common fracture sustained involved the distal femur via low-velocity injury, and most fractures were treated nonoperatively. Although the fracture pattern and the treatment remained unchanged, reoccurring fractures in these children can be effectively treated medically to interrupt the fracturing tendency.
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http://dx.doi.org/10.1097/BPO.0000000000000421DOI Listing
March 2016

Overview of foot deformity management in children with cerebral palsy.

J Child Orthop 2013 Nov 14;7(5):373-7. Epub 2013 Sep 14.

AI DuPont Hospital for Children, Box 269, Wilmington, DE 19899 USA.

Foot deformities in children with cerebral palsy are common. The natural history of the deformities of the feet is very variable and very unpredictable in young children less then 5 years old. Treatment for the young children should be primarily with orthotics and manual therapy. Equinus is the most common deformity, with orthotics augmented with botulinum toxin being the primary management in young children. When fixed deformity develops lengthening only the muscle which is contracted is preferred. Varus deformity of the feet is often associated with equinus, and can almost always be managed with orthotics until 8 or 10 years of age. Planovalgus is the most common deformity in children with bilateral lower extremity spasticity. The primary management is orthotics until the child no longer tolerates the orthotic; then surgical management needs to consider all the deformities and all should be corrected. This requires correcting the subtalor subluxation with calcaneal lengthening or fusion, medial midfoot correction with osteotomy or fusion.
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http://dx.doi.org/10.1007/s11832-013-0509-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3838514PMC
November 2013

Delayed Abdominal Compartment Syndrome as a Complication of Spinal Surgery: Literature Review and Case Report.

Spine Deform 2013 Nov 21;1(6):464-467. Epub 2013 Nov 21.

Department of Orthopaedic Surgery, Jefferson Medical College, 1015 Walnut Street, Curtis Building, Sure 810, Philadelphia, PA 19107, USA.

Posterior spinal fusion surgery for neuromuscular scoliosis is associated with favorable outcomes and high caregiver satisfaction scores. However, these patients represent a medically fragile patient population prone to complications. One of the more unpredictable complications is abdominal compartment syndrome (ACS), the etiology of which is not fully understood. This case report represents the first case report of delayed ACS to develop 3 days after spinal fusion in a patient with no history of previous abdominal surgeries undergoing correction for neuromuscular scoliosis. This case outlines the clinical course, risk factors for ACS, and indications for urgent surgical decompression of the abdomen. Given the high mortality, it is important for orthopedic surgeons to understand prevention, presentation, and timely management associated with ACS.
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http://dx.doi.org/10.1016/j.jspd.2013.07.011DOI Listing
November 2013
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