Session 12: Pediatrics
Fredag den 24. oktober
09:00 – 10:30
Chairmen: Christian Wong / Ole Rahbek
Janni Jensen, Bo Mussmann, Niels Wisbech, Zaid Al-Aubaidi, Trine Torfing
Department of Radiology, Odense University Hospital; Department of Orthopedic Surgery, Odense University Hospital
Background: Leg Length Discrepancy (LLD) is often
diagnosed in young patients who undergo
repeated x-ray examinations quantifying
the length discrepancy and monitoring
In our department LLD images are
currently acquired using a low dose
bi-plane system named EOS. Prior to the
acquisition of diagnostic images a scout
image is acquired at extremely low dose
for planning purposes, i.e.
approximately 1% of the dose required
for diagnostic images. Dose reduction is
important because children and
adolescents are more sensitive to
radiation than adults and they may
undergo several LLD examinations.
Purpose / Aim of Study: The purpose of the study was to
investigate the accuracy and reliability
of LLD measurements performed on scout
images compared to diagnostic images.
Materials and Methods: A retrospective pilot study including 30
consecutive patients (age 6-15 years)
was performed. Two senior
musculoskeletal radiologists measured
the length of the femur, tibia and the
total leg length on both legs on scout
and diagnostic images. The measurements
on scout and diagnostic images were
performed in two separate sessions and
the radiologists were blinded to the
identity of the patients.
Findings / Results: No significant differences between
scouts and diagnostic images were found.
The mean femoral length difference for
the observers was 0.11 cm (p=0.09) and
0.07 cm (p=0.24) respectively, mean
tibial length difference was 0.02 cm
(p=0.77) and 0.01 cm (p=0.84). The mean
total leg length difference was 0.01 cm
(p= 0.92) and 0.03 cm (p=0.73).
ICC was >0.99 indicating excellent inter
Conclusions: The results suggest that there is no
significant difference in LLD
measurements performed on scouts and
diagnostic images. Thus, scout based LLD
measurements can be accurately and
reliably performed in EOS.
Helle Mätzke Rasmussen, Dennis Brandborg Nielsen, Niels Wisbech Pedersen, Søren Overgaard, Anders Holsgaard-Larsen
The Orthopaedic Research Unit, 1) Department of Orthopaedic Surgery and Traumatology Odense University Hospital 2) Institute of Cli
Background: Instrumented gait analysis (IGA) is used
to describe gait pattern and impairments
in children with cerebral palsy (CP). Gait
Deviation Index (GDI) is based upon
kinematic data from the IGA and is a
quantitative index that summarizes the
overall gait function into a single score.
Satisfactory concurrent and construct
validity of the GDI have been shown in
children with CP. But test-retest intra-
assessor reliability of GDI has not
previously been investigated.
Purpose / Aim of Study: The aim of this study is to investigate intra-
assessor reliability of GDI in children with
CP across two repeated sessions.
Materials and Methods: For intra-assessor reliability the
assessor teams completed the IGA on
two different days, separated by 0-9
days. A total of 18 children (mean age
8.0 years, SD 2.1) with spastic CP (10
uni- and 8 bilateral) participated. For
each IGA the GDI score of 5 trials were
obtained and the median GDI score for
each child on the left and right side were
used for further analysis. Intra-assessor
reliability was investigated with
calculation of a paired Intraclass
correlation coefficient (ICC), Standard
error of measure (SEM), and smallest
detectable change (SDC) based on 95%
Findings / Results: The reliability for GDI with ICC was found to
be 0.74-0.84 that is considered as moderate
to good. SEM was found to be 4.6-6.3 point
and finally SDC was found to be 12.7-17.4
points. No significant learning effect and/or
systematic bias were observed between
test and retest.
Conclusions: The present observed moderate to good
reliability holds promise for the use of GDI
as an outcome in clinical research
investigating difference between groups.
The SDC was found to be larger than what
can be expected for most interventions on
an individual level. Thus, GDI is not
applicable to evaluate intervention for an
Polina Martinkevich, Bjarne Møller-Madsen, Martin Gottliebsen, Line Kjeldgaard Pedersen, Ole Rahbek
Children's Orthopaedics, Aarhus University Hospital
Background: The OxAFQ was developed to assess
disability associated with foot and ankle
problems in children aged five to 16 years,
as experienced by the child and parents. It
has been throughly validated in English.
There is currently no Danish validated
foot/ankle score for children.
Purpose / Aim of Study: To validate the Danish version of the
OxAFQ in terms of agreement and reliability
(internal consistency, test-retest, child-
parent reliability), feasibility and construct
Materials and Methods: A prospective observational cohort study.
Inclusion criteria were children aged
between 5 to 16 years with parents
attending the outpatient clinic at children's
orthopedics. Patients with a significant
proximal musculoskeletal component,
cognitive impairment or inability to
understand Danish were excluded. Both
OxAFQ and Child Health Questionnaire
(CHQ) were obtained. Re-test of OxAFQ
was done after 2 days. Reliability and
agreement was assessed by the intraclass
correlation coefficient and as limits of
agreement. Construct validity assessed as
Spearman rho against CHQ.
Findings / Results: Eighty-two children, mean age 11.7 years
(range 5.5 to 16.0) and their parents
participated. We found good internal
consistency for the Physical and the School
& Play domain, but lower for the Emotional
domain. Construct validity was good for
convergent validity. Good agreement was
found within and between children and
parents. The OxAFQ was fast and easy to
complete. A tendency towards ceiling
effects was observed in the School & Play
and Emotional domains.
Conclusions: To our knowledge this is the first
independent validation of the OxAFQ. We
found it valid and feasible for use in the
outpatient clinic to assess the degree to
which children are affected by their foot and
ankle conditions. OxAFQ is now available in
a Danish validated version.
Line Kjeldgaard Pedersen, Ole Rahbek, Lone Nikolajsen, Bjarne Møller-Madsen
Department of Childrens Orthopedics, www.dpor.dk, Aarhus University Hospital; Department of Anaestesiology, Aarhus University Hospital
Background: Assessment of pain in children with
cerebral palsy (CP) is a challenge
since they might not be capable of
using a self-rating assessment tool;
hence an observational or behavioral
pain score is needed.
The r-FLACC behavioral pain scale
has only been assessed for reliability
and validity in the original language
Purpose / Aim of Study: To translate the r-FLACC pain scale
and evaluate the parameters of
reliability and validity in order to use
the r-FLACC for pain assessment in
children with (CP).
Materials and Methods: Forward and back-translations were
performed according to guidelines.
Twenty children with CP undergoing
orthopedic surgery were included. The
parents assessed the pain intensity
with the Observational Visual Analog
Scale and a 2 min standardized video
recording was made for r-FLACC
scoring. Two nurses r-FLACC scored
the recordings independently. Ten of
the recordings were reviewed again 1
Findings / Results: Reliability was supported by three
measurement properties. Internal
consistency was excellent with a
Cronbachs alpha of 0.9278 and
0.9758. A test–retest showed excellent
intra-rater reliability with a Spearman
Correlation of 0.0040 and an intra-
class correlation (ICC) of 0.97530.
Inter-rater reliability was acceptable
with a Spearman Correlation of 0.000
and an ICC of 0.74576. Validity was
supported by three measurement
properties. Construct validity was
supported by a significant increase in r-
FLACC scores following surgery
(p=0.0427). Criterion validity was
acceptable with Pearson’s Correlation
Coefficients of 0.75 and 0.59 when
comparing the r-FLACC scores and the
Conclusions: The translated version of the r-FLACC
behavioral pain scale has high
reliability and validity and may be
considered as gold standard for pain
assessment in children with CP.
Kirsten Nordbye-Nielsen, Unni Narayanan, Ole Rahbek, Bjarne Møller-Madsen
Department of Children’s Orthopedics , Aarhus University Hospital, Denmark; Divisions of Orthopaedic Surgery , The Hospital for Sick Children, & Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada; Department of Children’s Orthopedics, Aarhus University Hospital, Denmark
Background: 2/3 of children with cerebral palsy (CP)
are ambulant, and undergo interventions
to improve their gait, increase physical
function and participation in daily
activities. The GOAL questionnaire was
recently developed in Canada, to serve
as a meaningful outcome measurement
for these interventions. It identifies
children’s and parents’ expectations of
interventions, with 48 items across 6
domains, covering all ICF domains, as a
priority-based outcome instrument for
children with CP.
Purpose / Aim of Study: Danish translation and adaptation of GOAL, a
patient reported priority based outcome
measure for ambulatory children with
cerebral palsy GMFCS I, II and III.
Materials and Methods: Danish forward and backward
translation of the GOAL questionnaire
was carried out in accordance with the
international guideline set up by the
Translation and Cultural Adaptation
Group (TCA) – Principles of Good
Practice (PGP). This guideline consists of
10 items defined as the framework in the
translation process. Preparation,
Forward Translation, Reconciliation, Back
Translation, Back Translation Review,
Harmonization, Cognitive debriefing,
Review of Cognitive Debriefing and
Results and Finalization, Proofreading
and Final Report.
Findings / Results: The Danish translation process, done by the
ten steps, according to the TCA group
guidelines, have been carried out to Child and
Parent version of GOAL questionnaire. 12
literal and 21 conceptual changes were
made. Ex.: Gymnastics was added in item 32,
Gait appearance was translated to:
Gangmønster. Questionnaires have been
accepted for further validation and reliability
studies in a Danish context in 2014.
Conclusions: The GOAL questionnaire has the potential to
become a much needed priority–based
outcome measure for children with
ambulatory CP undergoing various gait
interventions, in Denmark.
Peter Buxbom, Stig Sonne-Holm, Christian Wong
Orthopedic Department, Hvidovre Hospital
Background: Approximately 25-28% of children with
cerebral palsy (CP) develop subluxation or
dislocation of the hip that needs surgical
intervention. When this problem is
discovered in early childhood the preferred
treatment is a combination of periacetabular
and varizating femoral osteotomy. However,
16-22 % of these children require another
similar surgery due to re-luxation during
Purpose / Aim of Study: To descriptively assess migration and
rotation around periacetabular osteotomies
in children with CP measured by
radiostereometric analysis (RSA).
Materials and Methods: A protocol of perioperative insertion of 4-8
tantalum markers on each side of the
femoral and periacetabular osteotomy was
performed and RSA radiographs were
recorded and subsequently analysed
longitudinally postoperatively (in cast) and
at time 5, 12 weeks, 6 and 12 months after
Findings / Results: The cohort consisted of 6 girls and 9 boys, 8
left and 7 right hips. The median age was
7.3 years. 12 underwent Dega, 2 Salter and
1 Chiari osteotomy. All had 3 months follow-
up period, and 9 had been followed 1 year.
The average Maximum Total Point Motion
(MTPM) is 1.57, 1.52, 1.88 and 2.17 at
respectively 5, 12 weeks, 6 and 12 months.
Conclusions: Results show initial movement across the
osteotomy in spite of being casted for 5
weeks. However, this pattern ceases from 5
weeks to 3 months, where the ΔMTPM
decrease the remaining follow-up period.
Salter and Chiari osteotomies demonstrate
largest MTPM values, though there is not
enough data to perform statistical analysis.
Anders Holsgaard-Larsen, Rasmus Skov Sørensen, Carsten Jensen, Dennis Brandborg Nielsen, Annie Gam-Pedersen, Niels Wisbech Pedersen
The Orthopaedic Research Unit , Department of Orthopaedic Surgery and Traumatology Odense University Hospital 2) Institute of Clinic
Background: Gait Deviation Index (GDI) describes
the overall gait quality and summarizes
it into a single score based upon three-
dimensional gait analysis (3DGA). In
the Region of Southern Denmark,
children with cerebral palsy (CP) are
referred to 3DGA if surgical
intervention is considered and
subsequently, as a follow-up. Thus, the
effect of treatment on gait quality in
children with CP may be quantified.
Purpose / Aim of Study: In a retrospective study we
investigated the effect of treatment on
gait quality (measured by GDI) in
children with CP.
Materials and Methods: Data from children (<16 years)
diagnosed with CP and referred to
3DGA (either as a diagnostic
instrument or for the purpose of follow-
up) was extracted from a local
database for the year 2012. The GDI
score was calculated for each child
and limb and used for further analysis.
Findings / Results: 29 children with follow-up analysis
were referred to 3DGA in 2012.
Children were diagnosed with
unilateral (n = 6) or bilateral spastic CP
(n = 23). Age and GDI score at first
3DGA were 8.2 ± 2.8 years and 69 ±
11 (mean ± sd), respectively. Time
between follow-ups was 710 ± 367
days. A weak, albeit non-significant
association between GDI and age was
observed (r = 0.25, 95CI: -0.13 to
0.56), suggesting the effect of age is
only weakly reflected in gait quality.
However, a significant negative
association (r = 0.41, 95CI: -0.93 to
-0.24) between GDI at first 3DGA and
the improvement in GDI was observed.
Proposing, that children with poor gait
quality, benefit more from intervention
than children with good.
Conclusions: Significant improvements in GDI,
especially for patients with poor gait
quality, were observed. The present
study holds promise for future clinical
interpretations, involving more
patients, and possibly providing a tool
for stratification on different treatments.
Søren Bødtker, Søren Anker Pedersen, Lene Larsen, Vibeke Rosenkvist, Svandhild Ivarsslaten, Mai Pedersen
Orthopaedics, University Hospital Hvidovre; Pediatrics, University Hospital Hvidovre; Anaestecis, University Hospital Hvidovre; physiotherapy, University Hospital Hvidovre
Background: Complex regional pain syndrome (CRPS) is
a neuropathic condition charterized by
circular allodynia and functional loss.
Treatment with peripheral nerve blockade
in children and adults has yet only been
reported as case studies.
Purpose / Aim of Study: This study reports our results and
complications on treatment combining
continous pain relieve combined with
physio-occupational therapy in children
Materials and Methods: Inclusion criterias were circular
sensory disturbances and allodynia, thus
loosing ability to self-support on their
limb. A catheter was implanted close to
either N. ischiaticus, N. saphenous or
brachial plexus. Implantation was done
in GA and guided by EMG and ultrasound.
All patients received a specific and
continous pain relieve by Naropin,
combined with immidiate physiotherapy
and/or occupational therapy with a
supplement of 2 hours of walking. The
theraphy focused on improving
coordination, strength, and sensory
Findings / Results: 16 children were consecutively included
(13 girls:3 boys) with foot pain (13),
hand pain (2) and combined foot/hand
pain (1). At admission the average age
was 11 years (9-14); average duration of
pain were 9 months (2-33) with a VAS
score of 9 (7-10). Initiation of pain
was either no (7) or minor trauma (7
distorsions, 1 fracture and 1 surgical
induced). After an average observation
period of 12 months (6-37) the VAS score
was 0 (0-4). No relapses, neurological
complications or infection occurred
during the observation period.
Conclusions: Treatment with pain catheter and
training seems safe and effective for
children with CRPS, resulting in
pain-free or almost pain-free patients.
Line Kjeldgaard Pedersen, Polina Martinkevich, Ole Rahbek, Lone Nikolajsen, Bjarne Møller-Madsen
Department of Childrens Orthopedics, www.dpor.dk, Aarhus University Hospital; Department of Anaestesiology, Aarhus University Hospital
Background: The threshold for pain can be
measured quantitatively by pressure
algometry. To our knowledge pain
thresholds in children undergoing
orthopedic surgery have never been
Purpose / Aim of Study: To assess pressure pain thresholds
(PPT) and level of pain in children
before and after orthopedic surgery.
Materials and Methods: 24 children aged 6-16 years were
included. PPT and Numerical Rating
Scale (NRS) were obtained at 3-6
weeks before surgery, on the day of
surgery, the first day and 6-12 weeks
after surgery. A Somedic® pressure
algometer was used on the thenar of
the dominant hand and the lateral part
of the lower leg. PPT is defined as the
minimum pressure applied that induces
Findings / Results: A decrease in PPT between 3-6 weeks
before surgery and the first
postoperative day of 20,16 kPa
(p=0,20) and 47,6 kPa (p=0,04) was
measured by pressure algometry on
both the hand and the leg,
respectively. An increase in PPT
between the first postoperative day
and follow-up at 6-12 weeks of 35,7
kPa (p<0,01) and 119,3 kPa (p<0,01)
was observed. NRS showed significant
changes between these periods
(p=0,04; p<0,01; p<0,01). No
significant correlations between PPT
for both hand and leg measurements
and NRS were found. Age and sex of
the child influenced pain perception.
Conclusions: Children undergoing orthopedic
surgery demonstrate significant
changes in PPT. The pressure pain
threshold decreases in the period
between 3-6 weeks preoperatively and
increases to a usual level at 6-12
weeks postoperatively, though no
correlation between the PPT and NRS
could be documented. It is unknown
how PPT is influenced by surgery.
Modulation of pain threshold could
improve future pain management and
reduce consumptions of opioids.
Mette Tavlo, Lise Karlsmark, Klaus Hindsø
Børneortopædkirurgisk Sektion, HovedOrtoCentret, Rigshospitalet; Klinik for Ergo- og Fysioterapi, Rigshospitalet
Background: From 2005 – 2007 two treatments for
clubfoot (CF) were offered at Rigshospitalet:
the Ponseti and the Copenhagen method
(Cph.), which is a surgical procedure. During
this period parents chose the treatment.
Purpose / Aim of Study: This study aimed to compare mechanical and
patient related outcome measures (PROMS)
between the treatments.
Materials and Methods: A consecutive series of 28 patients met
the inclusion criteria. 23 patients with 33
CF participated. The mechanical outcome
measures were pedobarographicly
collected as heel/foot peak pressure,
contact-area-quotient, centre of
pressure deviation and heel-foot angle.
Mechanical parameters were chosen as
they represented CF deformities: cavus,
hindfoot and forefoot adduction. PROMS
regarding appearance and function were
scored by the child and parents using a
visual analog scale (0 – 100).
Findings / Results: Relapse rate did not differ between
treatment groups (Ponseti 33%, Cph. 36%).
Appearance- (VAS-mean Ponseti 5.2, Cph.
12.8, p = 0.01) and functional-limitation
(VAS-mean Ponseti 5.5, Cph. 12.6, p = 0.01)
differed significantly in favour of Ponseti.
Children with bilateral CF were found to be
significant more satisfied (VAS-mean unilat.
21.6, bilat. 13.5, p = 0.02) with their feet
compared to children with unilateral CF. No
pedobarographic parameters differed
between treatment groups.
Conclusions: Ponseti treatment of idiopatic clubfoot seems
to yield better PROMS than surgical
correction. The treatments resulted in equal
mechanical properties when measured
during gait in a pedobarographical analysis.
Rasmus Hviid Larsen, Danny Stefan Ekström, Jens Martin Lauritsen, Christian Færgemann
Department of Orthopedics and Traumatology, Odense University Hospital
Background: Prevention of mortality and severe injury
following trauma requires unbiased
epidemiological surveillance. The
epidemiology of children or adolescents
admitted to a Danish trauma centre is
largely unknown in particular in relation
to home- and leisure risk areas.
Purpose / Aim of Study: To describe the epidemiology and
severity of potential severely injured
children and adolescents admitted to
Odense University Hospital (OUH).
Materials and Methods: A descriptive study including all children
and adolescents aged 0-17 admitted to
the level 1 trauma centre at OUH 2002-
2011. Data was extracted from the
multiple trauma register and medical
Findings / Results: 950 children and adolescents were
included. The median age was 13 (0-17)
years. Boys accounted for 60.6 % of
the cases. Accidents accounted for
97.2 %, violence 1.4 %, and self-inflicted
injuries 0.4 %. More than ¾ of the
injuries occurred either in traffic or at
home. The occurrence was greatest in
the summer (34.0 %), during weekends
(48.9 %), and in the hours between
12.00 and 20.00 (59.2 %). 58.5 % of the
injuries were due to traffic. Of these
39.7 % were passengers in motor
vehicles, 27.5 % drivers/passengers of
a scooter/MC, 21.8 % bicyclists and 10.3
% pedestrians. The median ISS and
MAIS was 4 (1-75) and 2 (1-6),
respectively. Head/face injuries
accounted for 36.5 % and extremities
for 30.9 % of all injuries. 153 (16.1 %
suffered from severe injuries (ISS>15).
Altogether, 49 (5.2 %) died due to their
injuries. The mortality among severely
injured was 31.4 %.
Conclusions: Based on a local trauma register it was
possible to describe the epidemiology
and severity of potential severely injured
children and adolescents admitted to a
level trauma centre.
Ahmed Abdul-Hussein Abood, Ole Rahbek, Bjarne Møller-Madsen
Dept. of Children's Orthopaedics, Aarhus University Hospital
Background: Most common types of coalitions are
Calcaneonavicular (CN) and Median Bar
(MB). These are classified as a bony
coalition and a partial fibrous or
cartilaginous type. The condition may cause
pain and decreased mobility in the subtalar
Purpose / Aim of Study: A retrospective study of the outcome after
resection of tarsal coalitions in children.
Materials and Methods: Using the Danish medical database,
patients with the diagnosis Tarsal
Coalition (DQ668A) from 2006 till 2014
treated at Aarhus University Hospital
was searched. In addition, 13 operation
codes were used to search for patients,
with a Tarsal Coalition but who were
registered with a different diagnosis.
Patients, receiving surgical treatment
between the age of 5 and 16 in the year
2006 till 2014 were included in the study.
The primary outcome was defined as the
number of re-operations performed or
planned after initial resection of tarsal
bone. Furthermore, the patients were
post-operative subjectively classified as
better and worse or unchanged, in
comparison to prior to the operation.
Findings / Results: 24 feet in 18 children were included in study
with a mean follow-up of 11 months.
Patients were divided into two groups of
coalitions, CN in 15 feet, and MB in 9 feet.
Three CN feet underwent additional surgery
(resection of relapsed bridge n= 3,
Arthrodesis n=0) compared to 2 feet in the
MB group (resection of relapsed bridge n=
0, Arthrodesis n=2). In the CN group, 11
feet were described as better and 4 as
worse or unchanged. In the MB group, 6
feet were described as better and 3 as
worse or unchanged.
Conclusions: Overall 80 % of the feet improved after
surgery, which is in accordance with
previous literature. Adiditional surgery was
needed in 20 % of the cases. Before
surgery, patients should be informed of the
relatively high risk of additional surgery.