Saturday, February 26, 2005
Iliopsoas surgery in pediatric CP patients may not add significant benefitsBy Kathleen Misovic
Based on the results of a multicenter, randomized clinical trial, iliopsoas lengthening in children with cerebral palsy, in the context of multilevel surgery, does not add significant benefits for functional outcomes or quality of life, said the presenters of Podium Presentation 262 yesterday.
Hip flexion contracture in the ambulatory child with cerebral palsy (CP) is common, and may be detrimental to function and well being. In this study, children with CP and significant static hip flexion contractures (greater than 15 degrees) scheduled to undergo multilevel surgery (MLS) and a standardized physiotherapy program, were randomized to either undergo or not undergo concurrent iliopsoas lengthening.
All patients underwent a standardized, physical examination prior to surgery and at 12 months postoperatively. The Gillette Functional Assessment Questionnaire (FAQ), Gross Motor Function Measure parts D and E (GMFM), Pediatric Outcomes Data Collection Instrument (PODCI), and the Pediatric Quality of Life Measure (PedsQL) were also completed at these times. Analyses were performed on an intention-to-treat basis.
The study involved 79 children with a mean age of 10.4 years (+/- 3.5 years), 44 of whom were randomized to undergo iliopsoas surgery and 35 of whom were randomized not to do so. Preoperative FAQ assessments demonstrated limited walking ability in both groups due to issues relating to balance and endurance. Postoperatively, there were significant improvements in static hip contractures in those undergoing iliopsoas surgery with concurrent improvements in walking ability (p=0.03, rank sum test). However there were no significant differences between the two groups detected using the GMFM, PODCI and PedsQL.
"The improvement in hip flexion contracture in both groups may have been a tribute to the physical therapy program," said the authors. "This was aggressive in its goal of aiming to achieve full hip extension in all children regardless of their status with regard to iliopsoas lengthening.…It is being increasingly appreciated that strengthening programs targeting specific muscle groups may improve function and well being."
This study is the first to provide evidence that iliopsoas lengthening in the setting of MLS in ambulatory children with CP improves static contracture but may not significantly alter functional outcome or QoL. "We therefore suggest that iliopsoas lengthening may prolong the operative experience and expose the child to added morbidity without evidence of significant benefit…" the authors concluded.
The co-authors included Marinis Pirpiris, PhD, MD, Mepi, BmedSc, FRACS; Norman Y. Otsuka, MD, FACS, FRCS(C); Fred J. Dorey, PhD; Gilda Robles, RN, NP, and Christine Caron, PT, all of Los Angeles; Philip E. Gates, MD, of Shreveport, La.; James J. McCarthy, MD, of Philadelphia; Chester M. Tylkowski, MD, of Lexington, Ky.; and Jacques D'Astous, MD, of Salt Lake City. The study was funded with a grant from the Clinical Outcomes and Advisory Board, Shriners Hospitals for Children.