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Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

ObjectiveTo determine if paediatric athletes exhibit differences in positive screenings on the Sport Mental Health Assessment Tool (SMHAT-1) compared with adults.MethodsTeam USA Olympic and Paralympic paediatric athletes ≤21 years (n=589; 58.8% female; age=19.5±1.7 years) completed the SMHAT-1 between January 2021 and September 2024. A comparative sample of Team USA adult athletes (n=493, 54.2% female; age=27.3±4.9 years) matched for sex and sport was randomly sampled, and the percentage of athletes with a positive screening on each questionnaire was calculated. χ2 analysis compared the proportion of positive screenings between paediatric and adult samples. Piecewise linear regression assessed the association between age and total questionnaire scores.ResultsThe proportion of positive screenings was lower for paediatric athletes for the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) (χ2(1)=21.2, p<0.001) and Athlete Psychological Strain Questionnaire (APSQ) (χ2(1)=4.47, p=0.034). Increasing age of paediatric athletes was associated with higher AUDIT-C (β=0.41, p<0.001) and APSQ scores (β=0.35, p<0.001); however, a negative deviation was observed in AUDIT-C (β=−0.44, p<0.001) and APSQ scores (β=−0.38, p=0.002) among adults. Further, increasing age of paediatric athletes was associated with increased General Anxiety Disorder-7 (β=0.14, p=0.045) and ASSQ (β=0.12, p=0.029) scores; however, there was no significant deviation from this age trend in adults for either score (p>0.05).ConclusionPaediatric athletes produce a similar proportion of positive screenings to adults on subcomponents of the SMHAT-1, but they show a lower proportion of positive screenings for alcohol misuse and psychological strain. The changes in SMHAT-1 subcomponent scores among paediatric athletes warrant continued exploration to determine how the interaction of psychosocial development and elite sport may impact mental health.

Background Injury and illness surveillance is essential for understanding the relative risks of sports participation to develop effective strategies to optimize athlete health, wellness, and performance. Epidemiological studies examining injuries and illnesses among Team USA youth athletes are limited, particularly among athletes competing in Winter sports. The purpose of this study was to characterize the injury and illness incidence rate among Team USA athletes participating in the 2024 Winter Youth Olympic Games (YOG). Methods Injuries and illnesses among 101 Team USA youth athletes (40.6% female; age, 17 ± 1 years) were prospectively documented. Injury and illness prevalence, and incidence rate (IR) per 1,000 athlete-days (AD), and incidence rate ratios (IRR) were calculated with accompanying 95% confidence intervals ([95% CI]). Results Nineteen (18.8%) Team USA athletes reported at least one injury during the 2024 Winter YOG (38.0 [26.1, 53.3] injuries per 1,000 AD). Injury IR was highest among athletes competing in bobsled (166.7 [54.1, 388.9] injuries per 1,000 AD), and overuse was the most common mechanism of injury (17.3 [9.7, 28.5] injuries per 1,000 AD) among all athletes. There were no differences in injury IRs between male and female athletes (IRR [95%CI], 1.6 [0.7, 3.3]), but female athletes reported all time-loss injuries. Ten (9.9%) athletes reported at least one illness (15.0 [8.0, 26.5] per 1,000 AD), with respiratory illness (6%) being the most common type (6.9 [2.5, 15.0] per 1,000 AD). Conclusion This study highlights the need for focused efforts for injury and illness prevention for youth female athletes and athletes participating in high-risk sliding sports. Additionally, consideration for implementation of respiratory illness mitigation measures and load management strategies at and leading up to future competitions for youth athletes is key.

Background: Elite pediatric athletes face unique physiological and developmental challenges that influence their risk of injury and illness. Specifically, pediatric Paralympic athletes encounter additional barriers due to underlying impairments and, in some cases, the use of assistive devices. While epidemiological comparisons of non-pediatric Olympic and Paralympic athletes exist, there is limited understanding of potential differences in incidence between pediatric Olympic and Paralympic athletes. Hypothesis: To compare injury and illness incidence between pediatric Olympic and Paralympic Team USA athletes during the Paris 2024 Olympic and Paralympic Games. Methods: Team USA healthcare providers documented all injuries and illnesses that occurred among Team USA athletes (Overall n=862; Olympic n=635; Paralympic n=227) during the Paris Games within the USOPC Injury and Illness Surveillance System (IIS). The USOPC IIS records details of injuries and illnesses according to the 2020 IOC Consensus Statement for sport epidemiology. Athlete exposure was measured using the number of days an athlete was in Paris and summed to calculate athlete-days (AD). Pediatric athletes were defined as any athlete aged 21 or younger. Incidence rate (IR) with 95% confidence intervals [95%CI] per 1,000 ADs were calculated for both injuries and illnesses. Incidence rate ratios (IRR) were calculated to compare IR between pediatric Olympic and Paralympic athletes. Results: 144 pediatric athletes (mean age, 19.7±1.5y, range 15-21y) competed for Team USA during the Paris Games, representing 16.7% of all Team USA athletes. Pediatric athletes sustained 32 injuries (12.7%) and 20 illnesses (12.6%). Injury IR in Team USA pediatric athletes was 12.8 [95%CI: 8.7, 18.0] per 1,000 AD. The injury IR in Olympic pediatric athletes was 12.5 [95% CI: 8.0, 18.6] per 1,000 AD, compared to 13.7 [95% CI: 5.9, 27.0] per 1,000 AD in Paralympic athletes. Illness IR in Team USA pediatric athletes was 8.0 [95%CI: 4.9, 12.3] per 1,000 AD. Illness IR in pediatric Olympic athletes was 6.8 [95%CI: 3.6, 11.6] per 1,000 AD and in Paralympic athletes was 12.0 [95%CI: 4.8, 24.7]. Paralympic pediatric athletes demonstrated a higher, though non-significant, illness IR relative to their Olympic peers (IRR [95%CI]: 1.7 [0.6-4.8]). Conclusion: Although not statistically significant, illness IR was higher in Paralympic athletes, which is consistent with findings in non-pediatric elite athlete populations. This difference may reflect a true disparity that our study was underpowered to detect. As pediatric participation in elite sport increases, continued surveillance and targeted prevention strategies are needed to address the distinct health profiles of pediatric Paralympic athletes.

Abstract Purpose Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. Methods A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. Results Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). Conclusions The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. Level of Evidence V

ObjectiveTo describe the incidence of injuries and illnesses among paediatric Team USA athletes competing in the Tokyo 2020 Olympic and Paralympic Games, and the 2022 Beijing Olympic and Paralympic Games.MethodsAn electronic medical record system documented all injuries and illnesses that occurred while competing in the four Games periods. Incidence (IR) with 95% CI per 1000 athlete days were calculated for both injuries and illnesses. Incidence rate ratios (IRR) were calculated to compare injury and illness rates based on age (paediatric vs non-paediatric) sex, Games period and sport type.ResultsTwo hundred paediatric athletes (age range, 15–21 years) competed across the four Games periods, representing 16.1% of all Team USA athletes. The overall injury IR (95% CI) was 13.4 (9.8 to 18.1), and the overall illness IR was 5.5 (3.3 to 8.7). There were no differences in incidence between paediatric and non-paediatric athletes for either injury (IRR (95% CI): 0.9 (0.6 to 1.2)) or illness (IRR (95% CI): 0.9 (0.5 to 1.5)). Female paediatric athletes were more likely to sustain an injury compared with male paediatric athletes (IRR (95% CI): 2.4 (1.1 to 5.3)). The most common mechanism of injury was gradual onset (IR, 4.3 (2.3 to 7.2)), and injuries most commonly occurred during practices (IR, 7.0 (4.5 to 10.5)).ConclusionPaediatric athletes account for a substantial proportion of Team USA athletes. It is essential that paediatric sports medicine experts are included in the medical team given that paediatric Team USA athletes are just as likely as their adult teammates to sustain an injury or illness.

In adolescent idiopathic scoliosis (AIS) there has been a shift towards increasing the number of implants and pedicle screws, which has not been proven to improve cosmetic correction. To evaluate if increasing cost of instrumentation correlates with cosmetic correction using clinical photographs. 58 Lenke 1A and B cases from a multicenter AIS database with at least 3 months follow-up of clinical photographs were used for analysis. Cosmetic parameters on PA and forward bending photographs included angular measurements of trunk shift, shoulder balance, rib hump, and ratio measurements of waist line asymmetry. Pre-op and follow-up X-rays were measured for coronal and sagittal deformity parameters. Cost density was calculated by dividing the total cost of instrumentation by the number of vertebrae being fused. Linear regression and spearman’s correlation were used to correlate cost density to X-ray and photo outcomes. Three independent observers verified radiographic and cosmetic parameters for inter/interobserver variability analysis. Average pre-op Cobb angle and instrumented correction were 54° (SD 12.5) and 59% (SD 25) respectively. The average number of vertebrae fused was 10 (SD 1.9). The total cost of spinal instrumentation ranged from $6,769 to $21,274 (Mean $12,662, SD $3,858). There was a weak positive and statistically significant correlation between Cobb angle correction and cost density ( r  = 0.33, p  = 0.01), and no correlation between Cobb angle correction of the uninstrumented lumbar spine and cost density ( r  = 0.15, p  = 0.26). There was no significant correlation between all sagittal X-ray measurements or any of the photo parameters and cost density. There was good to excellent inter/intraobserver variability of all photographic parameters based on the intraclass correlation coefficient (ICC 0.74–0.98). Our method used to measure cosmesis had good to excellent inter/intraobserver variability, and may be an effective tool to objectively assess cosmesis from photographs. Since increasing cost density only improves mildly the Cobb angle correction of the main thoracic curve and not the correction of the uninstrumented spine or any of the cosmetic parameters, one should consider the cost of increasing implant density in Lenke 1A and B curves. In the area of rationalization of health care expenses, this study demonstrates that increasing the number of implants does not improve any relevant cosmetic or radiographic outcomes.

Abstract Purpose The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method. Methods The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. Results Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade. Conclusion This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP. Level of evidence V

Spasticity is characterized by velocity-dependent increase in tonic stretch reflexes and tendon jerks. Many people affected by spasticity receive late treatment, or no treatment, which greatly reduces the potential to regain full motor control and restore function. There is much to consider before determining treatment for people with spasticity. Treatment of pediatric patients increases the complexity, because of the substantial difference between adult and pediatric spasticity. Proper patient evaluation, utilization of scales and measures, and obtaining patient and caregiver history is vital in determining optimal spasticity treatment. Further, taking into consideration the limitations and desires of individuals serve as a guide to best management. We have grouped contributing factors into the IDAHO Criteria to elucidate a multidisciplinary approach, which considers a person's complete field of experience. This model is applied to goal setting, and recognizes the importance of a spasticity management team, comprising the treatment subject, his/her family, the environment, and a supportive, well-informed medical staff. The criteria take into account the complexity associated with diagnosing and treating spasticity, with the ultimate goal of improved function.

Background In contrast with treatment recommendations for adolescent idiopathic scoliosis, there are no clear algorithms for treating patients with early-onset scoliosis. There has been rapid expansion of treatment options for children with early-onset scoliosis, including casting, growth rods, the vertical expandable prosthetic titanium rib, and anterior vertebral stapling. Questions/purposes Given the range of treatment options, we assessed variability in decision making regarding treatment of patients with early-onset scoliosis. Methods We presented 12 clinical and radiographic vignettes about patients with early-onset scoliosis to 13 experienced spine surgeons who are members of the Chest Wall and Spine Deformity Study Group. The reviewers were asked to choose type of treatment, type of construct, construct location, and whether a thoracotomy should be performed. Results All 13 surgeons agreed regarding the need for surgery in eight of the 12 cases. When the reviewers chose surgery, 76% (40%–100%) selected the vertical expandable prosthetic titanium rib; of those selecting that approach, 61% (0%–100%) coincided on using it bilaterally. Agreement was 20% (0%–60%) for growing rods and 4% (0%–25%) for fusions. Among all cases, agreement regarding whether instrumentation should extend to the pelvis was 71% (50%–100%). In all but two cases, at least 85% of surgeons recommended against a thoracotomy. Conclusions Although most surgeons agreed about the indication for surgery, we found wide variability in choice of construct type, number of constructs, and level of instrumentation.