Paediatrics (RCH) - Theses
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ItemProximal femoral osteotomy in children and adolescents with cerebral palsy( 2018)Background Cerebral Palsy (CP) is the most common cause of physical disability affecting children in developed countries. Approximately one third of children with CP may develop hip displacement. Non-ambulant children at Gross Motor Function Classification System (GMFCS) levels IV and V are at highest risk. Without early detection through surveillance programs, hip displacement can progress to hip dislocation, which is frequently painful and negatively impacts health-related quality of life (HRQoL). Injections of Botulinum Neurotoxin A (BoNT-A) have no role, and soft tissue surgery has a limited role in preventing hip displacement in non-ambulant children with CP. Bony hip reconstruction surgery such as a proximal femoral osteotomy (PFO) is effective in stabilising the hip and HRQoL. PFOs include Femoral Derotation Osteotomies (FDO) which aim to improve the gait of an ambulant child (GMFCS I-III), and Varus Derotation Osteotomies (VDRO) which aim to contain the hips in non-ambulant children (GMFCS IV-V). However, PFOs can carry high risks, especially in children with medical co-morbidities such as respiratory disease, nutritional deficiencies, hypertonia and osteopenia. Aim This thesis involved a series of three studies, which aimed to expand our knowledge of the trainee learning curve, outcomes and adverse events relating to PFO in children and adolescents with CP. Method and Results A new implant combining locking and cannulated technology (Locking Cannulated Blade Plate, LCBP) was recently developed for use in PFO. A pilot study was performed on the first 25 patients who had surgery with the LCBP, at the Royal Children’s Hospital (RCH), Melbourne. This study established safety for use in children as young as three, with weights as low as eleven kilograms. A further prospective, parallel cohort study of 90 consecutive children with CP was conducted to compare the LCBP against with existing non-cannulated, non-locking implant (Angled Blade Plate, ABP). Technical and radiological outcomes of surgery were similar between implants. However, the surgical technique was reported by trainees to be easier when using the LCBP, with less technical errors. Approximately 60 percent of the children experienced minor adverse events including: constipation, inadequate pain control, and respiratory compromise. However, a CP specific tool was not available to classify the severity of events. Study three was performed to clarify the Modified Clavien-Dindo (MCD) system for lower limb surgery in children with CP and test its’ reliability for classifying adverse events. Very good reliability was demonstrated amongst members within a multidisciplinary team. Conclusion Novel findings from these studies may help improve the safety and efficacy of the management of hip displacement in children with CP. Further research should address the long-term outcomes of PFO in children with CP, evaluate the validity of the MCD for children in CP and determine if the MCD can be embedded in the electronic medical records (EMR) as a routine tool for audit and clinical research.
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ItemInvestigating and interpreting the use, costs, accessibility and organisation of healthcare services among children with cerebral palsy( 2016)Background and Rationale: Cerebral palsy is an umbrella term for a group of non-progressive disorders of movement and posture. Compared to their typically-developing peers, children with cerebral palsy are at an increased risk of multiple comorbidities and frequent acute illnesses that affect almost all of the organ systems, and as a consequence, have significantly greater medical care needs. There is growing interest internationally in investigating the patterns of medical service use among children with complex conditions such as cerebral palsy. It is hoped that a greater understanding of their healthcare needs could assist with decision making around health service delivery for this group. Aims: The aims of this thesis were to describe the patterns of medical service use among children with cerebral palsy, identify factors associated with the frequency and type of medical services used by this group, and compare their hospital admission and emergency department presentation characteristics with those of the general population. A secondary aim was to explore with parents the financial implications of having a child with additional medical care needs. Methods: Population cohorts of children with cerebral palsy and data linkage techniques, as well as survey methods, were used. The Victorian Cerebral Palsy Register was linked to the emergency department and inpatient databases of the Australian state of Victoria’s two paediatric hospitals to examine service use at these centres, and to the Victorian Admitted Episodes Dataset and Victorian Emergency Minimum Dataset to investigate statewide admissions and emergency department presentations respectively among population cerebral palsy cohorts. A purposefully-designed survey gathered information from parents on other medical services used, and on how they cope financially in light of their child’s medical care needs. Results: Of 2,183 children with cerebral palsy, 814 had at least one emergency department presentation and 1,443 had at least one admission at one of Victoria’s two paediatric hospitals over a five-year period, accounting for an average of 1,400 admissions and 700 emergency department presentations at the two hospitals each year. A higher than expected proportion of paediatric emergency department presentations were triaged as high urgency (71%) and resulted in a hospital admission (44%). Children with severe and/or complex cerebral palsy had more frequent admissions and emergency department presentations to the two hospitals, as well as higher re-admission rates. A similar pattern was observed when admissions and emergency department presentations at all hospitals in the state were investigated, those children with more severe and/or complex cerebral palsy having more hospital episodes each year. Compared to the general population of children, those with cerebral palsy had longer lengths of stay (median of 3 vs 2 nights; p<0.001), and more procedures (median of 2 vs 1 procedures; p<0.001) per multi-day admission, and more emergency department presentations that were preceded by an ambulance arrival (27% vs 8%; p<0.001), triaged as being of high urgency (66% vs 34%; p<0.001) and resulted in a hospital admission (38% vs 13%; p<0.001). Ultimately, they accrued higher hospital charges per episode. The types of paediatric specialists most often seen in outpatient settings were general or developmental paediatricians, orthopaedic surgeons, rehabilitation specialists, and neurologists. Most children received medical services from a number of different providers, in multiple different settings, and this continued into adolescence and early adulthood. Overall, the number and complexity of hospital episodes, the number of professionals involved in their medical management, and the proportion of families reporting financial difficulties all rose with increasing cerebral palsy severity and complexity. Conclusions and Significance: Through a series of data linkage studies and a purposefully-designed parent survey, this thesis provides new knowledge about medical service use among children with cerebral palsy. It provides, for the first time, objective population-level data on which future decisions around health service delivery for this patient group can be based, as well as highlighting some future research priorities.
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ItemScoliosis in children with cerebral palsy: a population based study( 2015)Introduction Scoliosis is the most common spinal deformity in children with cerebral palsy. Previous published studies have been based on institutionalised patients and not on a total population of individuals with cerebral palsy. Methods This study was based on both prospective and retrospective cross-section analysis of 292 children identified from the Victorian Cerebral Palsy Register. These children were spread across GMFCS levels I–V. The children were assessed during their transition clinic appointment prior to exit from the Royal Children’s Hospital. The research looked at three main sections: clinical review for scoliosis, radiographic assessment of scoliosis, and CHQ and CPCHILD questionnaires survey. Cobb angles were measured by two experienced observers. Results If a Cobb angle of more than 10° was used, then 40% of patients were classified with scoliosis. By changing the definition of scoliosis in cerebral palsy to a Cobb angle greater than 40°, the prevalence of “clinically important scoliosis” was 12.7%. The majority of the severe curves occurred in children at GMFCS levels IV and V. As the GMFCS level increased, the mean Cobb angle increased. The mean score for the questionnaires decreased as the GMFCS level increased. Conclusion The CP scoliosis and the scores for the questionnaire were closely related to the GMFCS levels. The prevalence of CP scoliosis is overestimated in other studies. Our study shows the prevalence of CP scoliosis is 12.7% using a Cobb angle of more than 40°. Non-ambulant children are at high risk of developing scoliosis and formal spine surveillance should be considered.