Purpose: The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon’s opinion through a modified Delphi technique. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%–79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results: Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment. Conclusion: The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy. Level of Evidence: V
Population based studies have found that approximately 33% of children with cerebral palsy are at risk for progressive lateral hip displacement/subluxation during childhood. There is growing evidence supporting the practice of hip surveillance for children with cerebral palsy and many developed countries have established national and state surveillance programs. However, across POSNA there is a lack of consensus regarding a radiographic hip screening protocol for children with cerebral palsy. Therefore, the purpose of this quality initiative was to develop a POSNA-wide radiographic hip screening schedule using a Modified Delphi technique. A group of 24 pediatric orthopedic surgeons participated in the Modified Delphi technique to achieve consensus regarding a hip radiographic screening protocol. The development of a POSNA - wide radiographic hip screening protocol has the potential to standardize screening practices across our society, decrease practice variation and ultimately improve the quality of health care delivery for children with cerebral palsy and other neuromuscular conditions.
Analysis of a child’s gait is an important aspect of a pediatric orthopedic evaluation. Children with cerebral palsy often have significant gait impairments that negatively impact their ambulation, activity in society, and their quality of life. Instrumented gait analysis, with motion capture, can provide significant data to help the surgeon better understand specific pathophysiology and to plan surgical correction. Modern instrumented gait analysis is comprised of many components, including kinematics, kinetics, electromyography, pedobarography, and metabolic assessment. Newer technology allows for wearable measurement devices in the community to provide information about environmental activity, such as step counts, that augment information traditionally measured in gait laboratories. The synthesis of data from these components allow for the team to accurately assess individual components of pathological gait and systematically plan surgical procedures to address the significant impairments. Literature suggests that the use of instrumented gait analysis can be effective in the treatment and care of children with cerebral palsy. Following surgical recommendations from gait analysis can lead to changes in surgical plans derived from physical exam alone, overall less surgical procedures, and possibly improved outcomes.
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