Establishing surgical indications for hamstring lengthening and femoral derotational osteotomy in ambulatory children with cerebral palsy

PURPOSE: Surgical procedures, such as medial hamstring lengthening (MHL) and femoral derotational osteotomy (FDO), can improve the gait of children with cerebral palsy (CP); however, substantial variation exists in the factors that influence the decision to perform surgery. The purpose of this study was to use expert surgeon opinion through a Delphi technique to establish consensus for indications in ambulatory children with CP. METHODS: A 15-member panel, all established experts with at least nine years’ experience in the surgical management of children with CP, was created (mean of 20.81 years’ experience). All panel members also had expertise of the use of movement analysis for the assessment of gait disorders in children with CP. The group initially focused on two of the most commonly performed procedures, MHL and FDO, in an attempt to gain consensus (> 80%). This was obtained through a standardized, iterative Delphi process. RESULTS: For MHL, a total of 59 questions were surveyed: 41 indication questions and 18 outcome questions, for which there was consensus on ten indication questions and seven outcomes. For FDO, a total of 55 questions were surveyed: 43 indication questions and 12 outcome questions, for which there was consensus on 29 indication questions and eight outcomes. CONCLUSION: This study is the first to use an expert panel to identify best-practice indications for common surgical procedures of children with CP. The results from this study will allow for more informed evaluation of practice and form the basis for future improvement efforts to standardize surgical recommendations internationally. LEVEL OF EVIDENCE: Level IV