1. Mission Impossible: CP standardization of Orthopaedic Surgical Indications
Jim McCarthy; Rutz, Erich; Wade Shrader; Erich Rutz; Tom Novacheck; Kerr Graham; Davids, Jon R.; Kay, Robert; Tim Theologis; Unni Narayanan; Anja Van Campenhout; Laura Brower; Paul Gross
CPRN Houston Investigators Meeting May 31-June 1, 2018

2. Objective and mission:
Practical steps towards understanding and defining current orthopaedic
surgical practice variation for the treatment of children with CP.
CPRN Houston Investigators Meeting May 31-June 1, 2018

3. -Define common procedures to outline indications
INITIAL STEPS
Discuss: Time and frequency of conference calls: monthly maybe web based
-Ground rules, barriers and concerns for participation, publication, funding
-Define common procedures to outline indications
(VDRO, PSF, RFT, DFEO, HMS, GAST, PSOAS, Tibal DRO, SPLATT, Foot osteotomies, etc)
-Define categories of assessment (ie History, physical exam, GMFCS, Imaging, MAL data)
-Discuss how we will vet/group results
Use expert consensus for procedures we have consensus on
Delphi of those we can try to gain consensus
CP registry and other data for those that we agree to disagree on
CPRN Houston Investigators Meeting May 31-June 1, 2018

4. Created and tested framework for indications
1 Identified 10 great institutions interested in being involved with this project
Created and tested framework for indications
2 defined the 30+ procedures that are commonly performed
3 created a summary document (included for 2 common procedures)
CPRN Houston Investigators Meeting May 31-June 1, 2018

5. Framework for support
The clinical problem we are addressing (or preventing), and the benefit that this will translate into for the patient (intended outcome)
Features of the clinical history/symptoms that will point to the clinical problem above, including GMFCS and age.
The physical examination finding/s that support the decision
Observed gait deviation
Static (on table) exam
The Imaging findings (where applicable) to support the decision
The video &/or 3-D gait analysis findings (where applicable) that support (or suggest avoiding) the procedure.
The intra-operative examination under anesthesia that that support (or suggest avoiding) the procedure.
Other important considerations
Recommended technique/s of the procedure and variation
CPRN Houston Investigators Meeting May 31-June 1, 2018

6. Summary
Femoral derotational Osteotomy
Medial Hamstring lengthening
Clinic problem/benefit
Gait dysfunction-Internal rotation (7)
Anterior knee pain (2)
Fatigue
Lever arm deformity/disease
(Hip displacement)
Lack of knee extension in standing (2)
Lack of knee extension walking (5 ); jump or crouch gait
Anterior knee pain (3)
Post knee pain (1)
Goals (inc Step length, endurance, stand taller)
Clinical history
(includes GMFCS)
GMFCS I-III (4)
Tripping (5)
Cosmetic concerns (GOAL questionnaire)
IV-V ADLs-sever IR 
I-V hip displacement (assumes varus)
GMFC I-III (3 )
Worsening crouch (5) KF in early/midstance, late swing
Decreased ambulation/fatigue (5)
Increase need for external support
Physical exam
(includes obs gait)
Ryders test (3); FNA > (2); > 40 or > 30 with IR > 15 (1)
IR > ER (6); IR > 60, ER < 25;ER > 2x IR(2)
IR combined with ETT
No foot/other issues that would cause IR
Hip abductor weakness
Obs gait exam
IR (knees inward) (5)
Pop angle increased (7); > 60 (3); > 40 (1);
HMST shift < 20 deg improvement
knee ext deficit test: mimics gait in exam
Hamstring spasticity
knee ROM (2) > 25 deg
Sig FFD contraindication (3);FFD < 10 (2)
KFC indication
Flexed knee gait (2)
Short step length
Imaging (radiographic/other)
CT rotational profile (rarely)(4);FNA > 30
EOS FNA > 30 
AP pelvis to assess hip coverage
None (4)
Lateral knee xray (3);if > 10 (1)
Bone age if guided growth (2)
Formal Gait analysis data (Kinematics and Kinetics, EMB, plantar pressures, modeling)
Kinematics 
Internal mean hip rotation (7);in ST phase (1); > 10 degrees IR (1 ); IR > 2x ER (1;,>2SD(1); > 15 (1)
Ext pelvic rotation hemi (3)
Internal FPA (4);unless ETT (1)
Kinetics
Inc knee varus moment (2)
EMG
Pedo
Other
Inc GVS, GPS (if hip contributes from MAP)
Kinematics
Inc knee flexion in stance (6); > 20 (1)
Inc knee flexion at IC (5); > 30 (1)
Inc knee flexion in TerSw (2)
Post pelvic tilt
Inc internal extension moment midstance (3)
Hamstring prolonged activity midstance (2)
modeling of length short and slow (5);with PA> 60 (1)
Increased energy expenditure
Inc sag knee GVS, Inc GPS from knee (MAP)
Intra-operative exam under anesthesia
Preoperatively
IR > ER (4); IR > 60;ER < 25 (1); IR 2x > ER (2)
Inc anteversion on fluoroscopy
FNA > 30-35 
Postoperatively
ER 2x IR (3)
Goal to Equalize IR and ER
Goal FNA 5-10 (2)
Do not de-rotate beyond anteversion (create retroversion) (2)
Preoperatively 
PA (4) increased;> 40 (1)
FFD < 10
Knee extension deficit
Pop angle improved to 30 (2); improved by 30 (2); assess after proximal VDROs (1)
Knee ROM

7. Next steps
Create a better computerize format to collate and share data
Expand to additional list of procedures
Identify procedures for which in person Delphi would be appropriate (at AACPDM)
Begin to establish areas in need of further study (registries)