Objective: To synthesize evidence of surgical treatment intensity, defined as a measure of the quantity of invasive procedures, received by patients in patients with cancer within a defined time period around the ‘end of life’ (EoL). Background: Concern regarding overly ‘aggressive’ care or high health care utilization at the EoL, particularly in cancer, is growing. The contribution surgery makes to the quality and cost of EoL care in cancer has not yet been quantified. Methods: This PROSPERO registered systematic review used PRIMSA guidelines to search electronic databases for observational studies detailing surgical intensity at the EoL in adult cancer patients. Intensity was compared by disease, individual characteristics, geographical region, and palliative care involvement. A risk of bias tool assessed quality and a narrative synthesis of findings was completed. Results: In total, 39 papers were identified in this search. Up to 79% of patients underwent invasive procedures in the last month of life. Heterogeneity in patient groups, inclusion criteria, and EoL time periods lead to huge variation in results, with treatment intention often not identified. Patient, geographical, and pathological factors, alongside involvement of palliative/hospice care, were all identified as contributors to treatment intensity variation. Conclusions: A significant proportion of patients with cancer undergo invasive and costly invasive procedures at the EoL. There is significant reporting heterogeneity, with variation in patient inclusion criteria and EoL timeframes, demonstrating uncertainty within the literature. Identification of the context where surgical treatment intensity at the EoL is potentially inappropriate is not currently possible.

Aims: The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. Methods: This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results: Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion: The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP. Cite this article: Bone Jt Open 2023;4(8):580–583.

AIMS:The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study.METHODS:All children registered on the Cerebral Palsy Integrated Pathway Scotland surveillance programme undergo regular pelvic radiographs. Any child who had a MP measuring over 35% since the programme's inception in 2013, in at least one hip and at one timepoint, was identified. The national radiography database was then interrogated to identify all pelvic radiographs for each of these children from birth through to the date of analysis. A minimum of a further two available radiographs following the initial measurement of MP ≥ 35% was required for inclusion.RESULTS:A total of 239 children (346 hips) were identified as suitable for analysis at a mean of 6.5 years (2.0 to 14.8) follow-up. In all, 1,485 radiographs taken both prior to and after a hip had a MP ≥ 35% were examined and the MP measured to identify any progression of displacement. Interrogation of the data identified that hips with a MP up to 46% returned to a MP below 40% without intervention, and all hips with a MP equal to or greater than 46% displaced further and the MP did not return to the normal range. Statistical analysis showed the result to be 98% specific with this degree of certainty that hips reaching a MP ≥ 46% would not spontaneously regress.CONCLUSION:These findings are clinically relevant in showing that it may be reasonable to continue to monitor hips with a MP not exceeding 46%. This threshold will also guide referral for further management of a displacing hip. Cite this article: Bone Joint J 2021;103-B(2):411-414.

PURPOSE:The purpose of this study is to report the number of children from a total population of children with cerebral palsy (CP) in Scotland who had a displaced or dislocated hip at first registration in a national surveillance programme.METHODS:Migration percentage (MP), laterality, Gross Motor Function Classification System (GMFCS) level, CP subtype, distribution of CP and age were analyzed in 1171 children. Relative risk was calculated with 95% confidence intervals. Hip displacement and dislocation were defined as a MP of 40 to 99 and > 100 respectively.RESULTS:Radiographs were available from the first assessment of 1171 children out of 1933 children registered on the system. In all, 2.5% of children had either one or both hips dislocated (29/1171) and dislocation only occurred in children of GMFCS levels IV and V. A total of 10% of children had a MP 40 to 99 in one or both hips (117/1171). An increasing GMFCS level was strongly associated with an abnormal MP. Hip dislocation was unusual in patients under the age of seven years. A MP of 40 to 99 was not seen in children with isolated dystonia. Displacement was more frequent in children with bilateral involvement and dislocation was only seen in spastic and mixed tone groups.CONCLUSION:This data gives an overview of the number of CP children who have hip displacement/dislocation in Scotland and who will possibly require surgery.LEVEL OF EVIDENCE:I.

This laboratory study evaluates head shaft angle (HSA) reliability using ranges of simulated femoral orientation often seen in children with cerebral palsy. A dry femur was mounted in a jig that enabled the bone to be positioned in a range of internal and external rotation (-40° to + 40°) and flexion (0°-60°), alone or in combination. A metal wire was placed as a surrogate physis to give two HSA angles of 140° and 160°. Radiographs were taken of the femur in differing combinations of rotation, flexion and the two HSA angles. The HSA was measured by four independent observers on two separate occasions. Intraclass correlation coefficients (ICCs) were used to assess interobserver and intraobserver reliability. The HSA was accurately measured within ± 5° when the femur was positioned between 20° internal rotation and 40° external rotation. Flexion up to 60° did not affect the accuracy of the measurement. The interobserver reliability for the HSA was excellent with an ICC of 0.9970 [95% confidence interval (CI): 0.9995-0.9983] for the first measurement and 0.9988 for the second (95% CI: 0.9979-0.9993, all P < 0.01). The intraobserver reliability was also excellent with an ICC of not less than 0.990 for all four observers (95% CI: 0.9806-0.9986, all P < 0.01). There was excellent interobserver and intraobserver reliability when measuring the HSA in an experimental model provided femoral rotation lay within 20° internal and 40° external rotation and less than 60° of flexion.

AimIn previous small series, some authors have suggested a difference between re-fractures through immature callus and remodelled bone. We aimed to determine whether different fracture patterns occur in early and late re-fractures of paediatric forearm bones.MethodsNotes and radiographs of 77 forearm re-fractures from children aged 2–14 years were retrieved from our institution's radiographic database. Children treated surgically at initial presentation and re-fractures beyond one year were excluded. A control group of 100 forearm fractures without complication was used for comparison. Statistical analysis used chi-square and unpaired t-tests and statistically significant results were based on a two-tailed p-value <0.05ResultsBoys (76%), left laterality (78%), radius (69%), initial greenstick (66%) and diaphyseal fractures (62%) were most common. 60% of re-fractures were complete, 27% greenstick and 13% buckle. Median time to re-fracture was 93 days. Compared with buckle/greenstick configurations, complet...

BACKGROUND AND AIMS:Cerebral palsy is the commonest long-term physical disability in children with a prevalence of between 1.77 and 2.11/1000 live births. In 2013, the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme was introduced in all 14 Health Boards in Scotland and provides a standardised musculoskeletal examination of the spine and lower limbs. The purpose of this study was to report the prevalence, subtypes, motor classification and motor ability of children with cerebral palsy in Scotland.METHODS AND RESULTS:The family/carer's postal address, the child's neurological classification, motor subtypes, Gross Motor Functional Classification (GMFCS) Level and Functional Mobility Scale of 1972 children at first registration in CPIPS 2013-2018 were analysed. Their mean age at first assessment was 7.6 years. There was an overall prevalence of cerebral palsy in Scotland of 2.02/1000. GMFCS levels and Functional Mobility Scale data and prevalence were reported by Health Board and were comparable to that reported elsewhere.CONCLUSION:For the first time, data are available on the motor abilities of the total population of children with cerebral palsy in Scotland. This information will be highly relevant to resource management of current and future motor needs of these children.

An increased Head Shaft Angle (HSA) has been reported as a risk factor for hip displacement in children with cerebral palsy (CP) but opinions differ in the literature. The purpose of this study was to re-evaluate the relationship between HSA and hip displacement in a different population of children with CP.

Purpose This study re-examined the influence of the head shaft angle (HSA) on hip dislocation in a large cohort of children with cerebral palsy (CP). Method The radiographs of GMFCS Level III – V children from a surveillance programme database were analysed and migration percentage (MP) and HSA measured. The first radiograph of each patient was taken to remove the effect of the surveillance programme. The most displaced hip in each child, by MP, was used for analysis and the corresponding HSA measured. Hip displacement was defined as MP u003e40% and logistic regression was used to adjust for HSA, GMFCS, age and sex. Results 640 children were eligible (271 female (42.3%), 369 male (57.7%), mean age 8.2 years, GMFCS III: 160 (25%), GMFCS IV: 184 (28.75%), GMFCS V: 296 (46.25%). 118 children (18.44%) had a MP u003e40% and mean HSA was 160° (range 111 – 180°). Statistical analysis showed that an increasing HSA was associated with hip displacement (odds ratio of 1.02 for a 1° change). A 10° difference in HSA between two patients of the same age, sex and GMFCS gave odds of 1.26 of the patient with the higher HSA having hip displacement. Age and sex had no influence in this model, while a high GMFCS-level was a strong risk factor. Conclusion Chougule et al found no correlation between HSA and hip migration in children with CP using linear regression analysis. However, the relationship between these variables is not linear. The present study independently confirms an earlier study that HSA is a risk factor for hip displacement in GMFCS III-V children.

The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus.Prospectively collected data was analysed in 26 patients with hemiplegic (n = 13) and diplegic (n = 13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (+/- 5.6 months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15 degrees, p = 0.032), maximum ankle dorsiflexion during swing phase (11.68 degrees, p < 0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p = 0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p = 0.024).The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP. (C) 2016 Elsevier B.V. All rights reserved.

Objective: To determine the relationship between the Edinburgh Visual Gait Score (EVGS) and the Gait Profile Score (GPS).Method: Three dimensional gait data and EVGS scores from 151 diplegic children (Gross Motor Function Classification System (GMFCS) levels I-III) were used for analysis.Results: The EVGS correlated strongly with GPS (r = 0.816). There was a significant difference in both gait scores between each level of the GMFCS.Conclusions: The strong correlation of GPS with EVGS implies that any advantages of using GPS can also be applied to centres without 3-dimensional gait analysis facilities if the EVGS is used. (C) 2015 Elsevier B.V. All rights reserved.

Background: Migration percentage (MP) is an accepted method of assessing lateral displacement of the femoral head in children with cerebral palsy (CP). Difficulty in positioning of patients for pelvic radiography remains a concern for the reliability of the MP. Methods: This 2-part quantitative study examined 100 anteroposterior pelvic radiographs for children with CP. Fifty were from a region that had a positioning protocol for hip surveillance of children with CP and 50 images were from a region without. Images were assessed for acceptability of position in relation to hip abduction/adduction and/or pelvic rotation. Ten images deemed Acceptable or Borderline from the region with no protocol were then randomly selected. MP was measured on 2 separate occasions by 5 children's orthopaedic surgeons and statistically analyzed for intrarater and interrater reliability. Results: There was no statistically significant difference in the acceptability of images between the 2 regions with 60% to 66% of the images meeting the criteria outright. When allowances were made for slight variation of abduction/adduction within 5 degrees, 74% to 80% of the images were acceptable. Reliability was variable with limits of agreement between 4.96% and 15.15%. Observers more familiar with the software measuring package had higher reliability within and between occasions. Variability within and between observers decreased as MP increased. Conclusions: Poor positioning did not appear to be the main reason for the variation in reliability of MP. Repeat measurements were reliable although standardized technique, training, and familiarity with software measuring programmes did influence outcomes. Level of Evidence: This is a Level I diagnostic study divided into 2 parts. The first half is a retrospective study of pelvic radiographs of children with CP as part of their annual/biannual orthopaedic assessment. The second half is an interrater and intrarater reliability study of MP measurement.

Transition from paediatric to adult health-care services has been characterized as being poorly planned and coordinated, resulting in a reduction in services and may be distressing for families. This study aimed to establish what provisions are currently available in Scotland for transition of young people with cerebral palsy and what some clinicians believe future provisions should involve. Semi-structured interviews were conducted with 13 community paediatricians (or equivalents in health boards without community paediatricians) from 12 different Scottish health boards. Interviews were audio recorded, transcribed and analysed thematically using framework analysis. Both current transition provision and the areas that the clinicians felt needed improvement varied greatly between health boards. Key areas in need of improvement were coordination and communication within health services and also between health services and educational, social services and adult health services to which young people were transitioning. Transition remains problematic and variable. For transition to be improved, further research is needed to explore the effect this variation is having on young people and their families.

A goal attainment scale (GAS) was used to evaluate outcomes of surgical and non-surgical interventions to improve gait in 45 children with diplegic cerebral palsy. Personal goals were recorded during pre-intervention gait analysis in two groups. Twenty children underwent orthopaedic surgery (Group 1) and 25 children received a non-operative intervention (Group 2). Children and/or their carers were contacted post-intervention by telephone to complete a GAS questionnaire, rating the achievement of goals on a 5-point scale. The goals were similar in both groups. The composite GAS was transformed into a standardised measure (T-score) for each patient. Both groups on average achieved their goals (mean T-score for Group 2 was 56.3, versus 47.1 for Group 1). The difference between these two means was significant (p=0.010). Additionally, 16 children had undergone a follow-up gait analysis during the study period, but the relationship between their Gait Profile Score and GAS was not statistically significant. Both surgical and non-surgical interventions enabled children to achieve their goals, although Group 1 reported higher achievements. The GAS reflects patient's/parent's/carer's aspirations and may be as relevant as post-intervention kinematic or kinetic outcomes.