Session 12: Pediatrics

Fredag den 24. oktober
09:00 – 10:30
Lokale: Helsinki/Oslo
Chairmen: Christian Wong / Ole Rahbek

120. Micro dose acquisition in Leg length Discrepancy using the EOS imaging system
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 progression. 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 rater reliability.
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.

121. Reliability of Instrumented gait analysis in children with spastic cerebral palsy
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% confidence intervals.
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 individual child.

122. Reliability and validation of the Oxford Ankle Foot Questionnaire (OxAFQ) in 82 Danish patients aged 5 to 16 years
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 validity.
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.

123. The revised FLACC behavioural pain scale: Translation, reliability and validation for pain assessment in children with cerebral palsy
Line Kjeldgaard Pedersen, Ole Rahbek, Lone Nikolajsen, Bjarne Møller-Madsen
Department of Childrens Orthopedics,, 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 version.
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 year later.
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 VAS-OBS scores.
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.

124. Danish Translation and adaptation of Gait Outcomes Assessment List, GOAL©Questionnaire, a patient reported priority based outcome measure
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.

125. Skeletal Healing after Periacetabular Osteotomy Measured by RSA - Preliminary Results
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 adolescence.
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 surgery.
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.

126. Measuring the effect of treatment on gait quality in children with cerebral palsy – a retrospective study
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.

127. Complex regional pain syndrome (CRPS) in children - treatment with peripheral nerve catheter
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 with CRPS.
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 motor skills
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.

128. Are pain thresholds in children influenced by orthopedic surgery? - A prospective study
Line Kjeldgaard Pedersen, Polina Martinkevich, Ole Rahbek, Lone Nikolajsen, Bjarne Møller-Madsen
Department of Childrens Orthopedics,, 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 investigated.
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 pain.
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.

129. Treatment of clubfoot: Comparing surgical correction and the Ponseti Method – A comparative study
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.

130. Children and adolescents admitted to the level 1 trauma centre at Odense University Hospital 2002-2011.
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 records.
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.

131. Outcome after resection of tarsal coalition in children
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 joints.
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.