{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T08:33:51Z","timestamp":1781512431568,"version":"3.54.1"},"reference-count":90,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T00:00:00Z","timestamp":1758067200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background: Cerebral palsy (CP) is a static, non-progressive brain pathology that affects mobility and musculoskeletal health. Objective: This review aims to describe the pediatric orthopedic management strategy at one specialty center with focus on optimal lifelong mobility function for ambulatory CP. Methods: Beginning in the 1990s, a protocol was developed to proactively monitor children with surgical or conservative interventions. After three decades, we undertook a prospective institutional review, board-approved 25\u201345-year-old adults callback study. Inclusion criteria were all children treated through childhood who could be located and were willing to return for a full evaluation. Results: Pediatric orthopedic interventions focused on regular surveillance with proactive treatment of progressive deformities. When function was impacted, we utilized multi-level orthopedic surgery guided by instrumented gait analysis. Childhood outcomes of this approach were evaluated through retrospective studies. Results show high correction rates were achieved for planovalgus foot deformity, knee flexion contracture, torsional malalignments, and stiff-knee gait. Our prospective adult callback study evaluated 136 adults with CP, gross motor function classification system levels I (21%), II (51%), III (22%), and IV (7%), with average ages of 16 \u00b1 3 years (adolescent visit) compared with 29 \u00b1 3 years (adult visit). Adults in the study had an average of 2.5 multi-level orthopedic surgery events and 10.4 surgical procedures. Compared with adults without disability, daily walking ability was lower in adults with CP. Adults with CP had limitations in physical function but no increased depression. A higher frequency of chronic pain compared with normal adults was present, but pain interference in daily life was not different. Adults demonstrated similar levels of education but higher rates of unemployment, caregiver needs, and utilization of Social Security disability insurance. Conclusions: The experience from our center suggests that consistent, proactive musculoskeletal management at regular intervals during childhood and adolescence may help maintain in gait and mobility function from adolescence to young adulthood in individuals with CP.<\/jats:p>","DOI":"10.3390\/children12091252","type":"journal-article","created":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T13:03:02Z","timestamp":1758114182000},"page":"1252","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Outcomes of Pediatric Orthopedic Management of Ambulatory Cerebral Palsy Utilizing a Closely Monitored, Lifespan-Guided Approach"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1383-4683","authenticated-orcid":false,"given":"Zhe","family":"Yuan","sequence":"first","affiliation":[{"name":"Department of Orthopedics, Nemours Children\u2019s Health, Wilmington, DE 19803, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7719-6465","authenticated-orcid":false,"given":"Nancy","family":"Lennon","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Nemours Children\u2019s Health, Wilmington, DE 19803, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chris","family":"Church","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Nemours Children\u2019s Health, Wilmington, DE 19803, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8207-2109","authenticated-orcid":false,"given":"Michael Wade","family":"Shrader","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Nemours Children\u2019s Health, Wilmington, DE 19803, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0033-5623","authenticated-orcid":false,"given":"Freeman","family":"Miller","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Nemours Children\u2019s Health, Wilmington, DE 19803, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.yapd.2019.04.002","article-title":"Cerebral Palsy: Diagnosis, Epidemiology, Genetics, and Clinical Update","volume":"66","author":"Taylor","year":"2019","journal-title":"Adv. Pediatr."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Kumar, D.S., Perez, G., and Friel, K.M. (2023). Adults with Cerebral Palsy: Navigating the Complexities of Aging. Brain Sci., 13.","DOI":"10.3390\/brainsci13091296"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1174","DOI":"10.1111\/dmcn.15526","article-title":"Prevalence and Incidence of Chronic Conditions among Adults with Cerebral Palsy: A Systematic Review and Meta-Analysis","volume":"65","author":"Ryan","year":"2023","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Miller, F., Bachrach, S., Lennon, N., and O\u2019Neil, M. (2020). Cerebral Palsy, Springer.","DOI":"10.1007\/978-3-319-50592-3"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Shrader, M.W., Church, C., Lennon, N., Shields, T., Salazar-Torres, J.J., Howard, J.J., and Miller, F. (2021). Well-Being of Ambulatory Adults with Cerebral Palsy: Education, Employment, and Physical Function of a Cohort Who Received Specialized Pediatric Care. Front. Neurol., 12.","DOI":"10.3389\/fneur.2021.732906"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"H\u00e4gglund, G., Lauge-Pedersen, H., and Wagner, P. (2007). Characteristics of Children with Hip Displacement in Cerebral Palsy. BMC Musculoskelet. Disord., 8.","DOI":"10.1186\/1471-2474-8-101"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"93","DOI":"10.3109\/21679169.2013.795241","article-title":"Falls, Fear of Falling and Falls Risk in Adults with Cerebral Palsy: A Pilot Observational Study","volume":"15","author":"Morgan","year":"2013","journal-title":"Eur. J. Physiother."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1016\/j.bone.2018.07.002","article-title":"Age Trajectories of Musculoskeletal Morbidities in Adults with Cerebral Palsy","volume":"114","author":"Whitney","year":"2018","journal-title":"Bone"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e498","DOI":"10.1097\/BPO.0000000000001461","article-title":"What\u2019s New in the Orthopaedic Treatment of Ambulatory Children with Cerebral Palsy Using Gait Analysis","volume":"40","author":"Sees","year":"2020","journal-title":"J. Pediatr. Orthop."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1016\/j.gaitpost.2020.06.020","article-title":"Orthopaedic Management of Knee Joint Impairment in Cerebral Palsy: A Systematic Review and Meta-Analysis","volume":"80","author":"Campbell","year":"2020","journal-title":"Gait Posture"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1111\/j.1469-8749.2008.03104.x","article-title":"The Gross Motor Function Classification System--Expanded and Revised","volume":"50","author":"McDowell","year":"2008","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1487","DOI":"10.1111\/dmcn.15375","article-title":"Stability of the Gross Motor Function Classification System over Time in Children with Cerebral Palsy","volume":"64","author":"Huroy","year":"2022","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"647","DOI":"10.1111\/j.1469-8749.2007.00647.x","article-title":"Change in Ambulatory Ability of Adolescents and Young Adults with Cerebral Palsy","volume":"49","author":"Day","year":"2007","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1111\/j.1469-8749.2008.03196.x","article-title":"Stability and Decline in Gross Motor Function among Children and Youth with Cerebral Palsy Aged 2 to 21 Years","volume":"51","author":"Hanna","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"381","DOI":"10.1111\/j.1469-8749.2008.03250.x","article-title":"Walking Function, Pain, and Fatigue in Adults with Cerebral Palsy: A 7-Year Follow-up Study","volume":"51","author":"Opheim","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1002\/jcsm.12287","article-title":"Determinants of Muscle Preservation in Individuals with Cerebral Palsy across the Lifespan: A Narrative Review of the Literature","volume":"9","author":"Verschuren","year":"2018","journal-title":"J. Cachexia Sarcopenia Muscle."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1111\/j.1469-8749.2009.03462.x","article-title":"Adults with Cerebral Palsy: A Workshop to Define the Challenges of Treating and Preventing Secondary Musculoskeletal and Neuromuscular Complications in This Rapidly Growing Population","volume":"51","author":"Tosi","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1097\/PHM.0b013e3182063bc9","article-title":"Survey Results of Pain Treatments in Adults with Cerebral Palsy","volume":"90","author":"Hirsh","year":"2011","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1191\/026921501670159475","article-title":"Functional Level of Young Adults with Cerebral Palsy","volume":"15","author":"Nieuwstraten","year":"2001","journal-title":"Clin. Rehabil."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Maestro-Gonzalez, A., Bilbao-Leon, M.C., Zuazua-Rico, D., Fernandez-Carreira, J.M., Baldonedo-Cernuda, R.F., and Mosteiro-Diaz, M.P. (2018). Quality of Life as Assessed by Adults with Cerebral Palsy. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0191960"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"167","DOI":"10.2340\/16501977-2517","article-title":"Exploring Social Participation in Young Adults with Cerebral Palsy","volume":"51","author":"Jacobson","year":"2019","journal-title":"J. Rehabil. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"832","DOI":"10.2106\/00004623-200504000-00020","article-title":"Soft-Tissue Releases to Treat Spastic Hip Subluxation in Children with Cerebral Palsy","volume":"87","author":"Presedo","year":"2005","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"596","DOI":"10.2522\/ptj.20070314","article-title":"Reference Curves for the Gross Motor Function Measure: Percentiles for Clinical Description and Tracking over Time among Children with Cerebral Palsy","volume":"88","author":"Hanna","year":"2008","journal-title":"Phys. Ther."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Ma, N., Gould, D., Camathias, C., Graham, K., and Rutz, E. (2023). Single-Event Multi-Level Surgery in Cerebral Palsy: A Bibliometric Analysis. Medicina, 59.","DOI":"10.3390\/medicina59111922"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1016\/j.gaitpost.2021.09.177","article-title":"Mobility and Gait in Adults with Cerebral Palsy: Evaluating Change from Adolescence","volume":"90","author":"Lennon","year":"2021","journal-title":"Gait Posture"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1097\/BPO.0000000000002057","article-title":"Residual Deformity and Outcome of Ambulatory Adults with Cerebral Palsy: A Long-Term Longitudinal Assessment","volume":"42","author":"Saisongcroh","year":"2022","journal-title":"J. Pediatr. Orthop."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/j.gaitpost.2021.08.005","article-title":"Factors Associated with Walking Activity in Adults with Cerebral Palsy","volume":"90","author":"Lennon","year":"2021","journal-title":"Gait Posture"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1179","DOI":"10.1016\/j.jclinepi.2010.04.011","article-title":"The Patient-Reported Outcomes Measurement Information System (PROMIS) Developed and Tested Its First Wave of Adult Self-Reported Health Outcome Item Banks: 2005\u20132008","volume":"63","author":"Cella","year":"2010","journal-title":"J. Clin. Epidemiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1097\/PEP.0000000000000512","article-title":"Gait Analysis Parameters and Walking Activity Pre- and Postoperatively in Children with Cerebral Palsy","volume":"30","author":"Nicholson","year":"2018","journal-title":"Pediatr. Phys. Ther."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1097\/PEP.0000000000000340","article-title":"Commentary on \u201cDeveloping a Clinical Protocol for Habitual Physical Activity Monitoring in Youth with Cerebral Palsy\u201d","volume":"29","author":"Bjornson","year":"2017","journal-title":"Pediatr. Phys. Ther."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1819","DOI":"10.1249\/MSS.0b013e3181dc2e54","article-title":"Pedometer-Measured Physical Activity and Health Behaviors in U.S. Adults","volume":"42","author":"Bassett","year":"2010","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1007\/s11832-012-0413-3","article-title":"Pes Planovalgus Deformity Surgical Correction in Ambulatory Children with Cerebral Palsy","volume":"6","author":"Kadhim","year":"2012","journal-title":"J. Child. Orthop."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1053\/j.jfas.2013.06.010","article-title":"Long-Term Outcome of Planovalgus Foot Surgical Correction in Children with Cerebral Palsy","volume":"52","author":"Kadhim","year":"2013","journal-title":"J. Foot Ankle Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1097\/BPB.0000000000001174","article-title":"The Impact of Hamstring Lengthening on Stance Knee Flexion at Skeletal Maturity in Ambulatory Cerebral Palsy","volume":"34","author":"Kanashvili","year":"2025","journal-title":"J. Pediatr. Orthop. Part B"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1016\/S0966-6362(03)00070-5","article-title":"Distal Hamstring Lengthening in Ambulatory Children with Cerebral Palsy: Primary versus Revision Procedures","volume":"19","author":"Chang","year":"2004","journal-title":"Gait Posture"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"121","DOI":"10.3944\/AOTT.2009.121","article-title":"Knee capsulotomy for fixed knee flexion contracture","volume":"43","author":"Woratanarat","year":"2009","journal-title":"Acta. Orthop. Traumatol Turc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1097\/BPB.0000000000000370","article-title":"The Effectiveness of Posterior Knee Capsulotomies and Knee Extension Osteotomies in Crouched Gait in Children with Cerebral Palsy","volume":"25","author":"Taylor","year":"2016","journal-title":"J. Pediatr. Orthop. Part B"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1303","DOI":"10.1007\/s11999-011-2215-1","article-title":"Rectus Femoris Transfer Improves Stiff Knee Gait in Children with Spastic Cerebral Palsy","volume":"470","author":"Thawrani","year":"2012","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"520","DOI":"10.1097\/BPO.0000000000001886","article-title":"Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children with Cerebral Palsy with Stiff Knee Gait","volume":"41","author":"Church","year":"2021","journal-title":"J. Pediatr. Orthop."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1097\/BPO.0000000000000701","article-title":"Persistence and Recurrence Following Femoral Derotational Osteotomy in Ambulatory Children with Cerebral Palsy","volume":"37","author":"Church","year":"2017","journal-title":"J. Pediatr. Orthop."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1097\/BPO.0000000000000672","article-title":"Long-Term Outcome of External Tibial Derotation Osteotomies in Children with Cerebral Palsy","volume":"37","author":"Er","year":"2017","journal-title":"J. Pediatr. Orthop."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1097\/BPO.0000000000000671","article-title":"Long-Term Outcome of Internal Tibial Derotation Osteotomies in Children with Cerebral Palsy","volume":"37","author":"Er","year":"2017","journal-title":"J. Pediatr. Orthop."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"834","DOI":"10.1097\/BPO.0000000000000563","article-title":"Hip Reconstruction in Children with Unilateral Cerebral Palsy and Hip Dysplasia","volume":"36","author":"Abousamra","year":"2016","journal-title":"J. Pediatr. Orthop."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1007\/s11832-011-0352-4","article-title":"Recurrence after Surgery for Equinus Foot Deformity in Children with Cerebral Palsy: Assessment of Predisposing Factors for Recurrence in a Long-Term Follow-up Study","volume":"5","author":"Joo","year":"2011","journal-title":"J. Child. Orthop."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"792","DOI":"10.1097\/01241398-200211000-00020","article-title":"Long-Term Follow-up of Surgery for Equinovarus Foot Deformity in Children with Cerebral Palsy","volume":"22","author":"Chang","year":"2002","journal-title":"J. Pediatr. Orthop."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"2865","DOI":"10.1007\/s11136-013-0397-6","article-title":"An Examination of the PROMIS(\u00ae) Pediatric Instruments to Assess Mobility in Children with Cerebral Palsy","volume":"22","author":"Kratz","year":"2013","journal-title":"Qual. Life Res."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"536","DOI":"10.1016\/j.gaitpost.2012.09.011","article-title":"Long Term Outcome of Single Event Multilevel Surgery in Spastic Diplegia with Flexed Knee Gait","volume":"37","author":"Sung","year":"2013","journal-title":"Gait Posture"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1177\/18632521241233165","article-title":"Long-Term Outcomes of Reconstructive Treatment for Painful Dislocations in Patients with Cerebral Palsy","volume":"18","author":"Koch","year":"2024","journal-title":"J. Child. Orthop."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"101717","DOI":"10.1016\/j.jcot.2021.101717","article-title":"What Are the Long-Term Outcomes of Lateral Column Lengthening for Pes Planovalgus in Cerebral Palsy?","volume":"24","author":"Kruger","year":"2022","journal-title":"J. Clin. Orthop. Trauma"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e377","DOI":"10.1097\/BPO.0000000000002081","article-title":"Long-Term Outcomes of Talonavicular Arthrodesis for the Treatment of Planovalgus Foot in Children with Cerebral Palsy","volume":"42","author":"Maroto","year":"2022","journal-title":"J. Pediatr. Orthop."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"e510","DOI":"10.1097\/BPO.0000000000001437","article-title":"Improved Clinical and Functional Outcomes in Crouch Gait Following Minimally Invasive Hamstring Lengthening and Serial Casting in Children with Cerebral Palsy","volume":"40","author":"Long","year":"2020","journal-title":"J. Pediatr. Orthop."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Geisb\u00fcsch, A., Klotz, M.C.M., Putz, C., Renkawitz, T., and Horsch, A. (2022). Mid-Term Results of Distal Femoral Extension and Shortening Osteotomy in Treating Flexed Knee Gait in Children with Cerebral Palsy. Children, 9.","DOI":"10.3390\/children9101427"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1097\/01241398-198807000-00008","article-title":"Treatment of Spastic Equinus by Aponeurosis Lengthening","volume":"8","author":"Olney","year":"1988","journal-title":"J. Pediatr. Orthop."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1302\/0301-620X.83B3.0830364","article-title":"Isolated Calf Lengthening in Cerebral Palsy. Outcome Analysis of Risk Factors","volume":"83","author":"Borton","year":"2001","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"e65","DOI":"10.1097\/BPO.0000000000001972","article-title":"Outcome of Gastrocnemius Soleus Facial Lengthening in Ambulatory Patients with Cerebral Palsy","volume":"42","author":"Stotts","year":"2022","journal-title":"J. Pediatr. Orthop."},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Horsch, A., Klotz, M.C.M., Platzer, H., Seide, S.E., and Ghandour, M. (2022). Recurrence of Equinus Foot in Cerebral Palsy Following Its Correction-A Meta-Analysis. Children, 9.","DOI":"10.3390\/children9030339"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1097\/BPB.0000000000000501","article-title":"The Effect of Plantar Flexor Lengthening on Foot Pressure in Ambulatory Children with Cerebral Palsy","volume":"27","author":"Abousamra","year":"2018","journal-title":"J. Pediatr. Orthop. Part B"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1111\/j.1469-8749.1985.tb14134.x","article-title":"Triple Arthrodesis for Children with Spastic Cerebral Palsy","volume":"27","author":"Ireland","year":"1985","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1097\/01241398-199311000-00004","article-title":"Long-Term Follow-up of Triple Arthrodesis in Patients with Cerebral Palsy","volume":"13","author":"Tenuta","year":"1993","journal-title":"J. Pediatr. Orthop."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1391","DOI":"10.2106\/00004623-199910000-00004","article-title":"Triple Arthrodesis: Twenty-Five and Forty-Four-Year Average Follow-up of the Same Patients","volume":"81","author":"Saltzman","year":"1999","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1097\/BPO.0000000000000361","article-title":"Long-Term Outcomes of Triple Arthrodesis in Cerebral Palsy Patients","volume":"35","author":"Trehan","year":"2015","journal-title":"J. Pediatr. Orthop."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1097\/01241398-199801000-00016","article-title":"Kinematic and Kinetic Analysis of Distal Derotational Osteotomy of the Leg in Children with Cerebral Palsy","volume":"18","author":"Stefko","year":"1998","journal-title":"J. Pediatr. Orthop."},{"key":"ref_63","first-page":"84","article-title":"Results of Tibial Rotational Osteotomy without Concomitant Fibular Osteotomy in Children with Cerebral Palsy","volume":"25","author":"Ryan","year":"2005","journal-title":"J. Pediatr. Orthop."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"1327","DOI":"10.1007\/s11999-011-2219-x","article-title":"Coronal Plane Knee Moments Improve after Correcting External Tibial Torsion in Patients with Cerebral Palsy","volume":"470","author":"Aiona","year":"2012","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1097\/BPO.0000000000000173","article-title":"Surgical Management of Persistent Intoeing Gait Due to Increased Internal Tibial Torsion in Children","volume":"34","author":"Davids","year":"2014","journal-title":"J. Pediatr. Orthop."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"743","DOI":"10.1097\/BPO.0000000000000525","article-title":"Correction of Tibial Torsion in Children with Cerebral Palsy by Isolated Distal Tibia Rotation Osteotomy: A Short-Term, In Vivo Anatomic Study","volume":"36","author":"Andrisevic","year":"2016","journal-title":"J. Pediatr. Orthop."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1016\/j.gaitpost.2016.08.004","article-title":"The Rotational Profile: A Study of Lower Limb Axial Torsion, Hip Rotation, and the Foot Progression Angle in Healthy Adults","volume":"49","author":"Hudson","year":"2016","journal-title":"Gait Posture"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/j.jcm.2019.01.005","article-title":"Does the Type of Toeing Affect Balance in Children with Diplegic Cerebral Palsy? An Observational Cross-Sectional Study","volume":"18","author":"Khatib","year":"2019","journal-title":"J. Chiropr. Med."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/j.gaitpost.2019.12.002","article-title":"Causes of Out-Toeing Gait in Children with Cerebral Palsy","volume":"76","author":"Cao","year":"2020","journal-title":"Gait Posture"},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.gaitpost.2010.03.002","article-title":"Walking Abilities of Young Adults with Cerebral Palsy: Changes after Multilevel Surgery and Adolescence","volume":"32","author":"Gannotti","year":"2010","journal-title":"Gait Posture"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.gaitpost.2017.12.017","article-title":"Fatigue, Quality of Life and Walking Ability in Adults with Cerebral Palsy","volume":"61","author":"Lundh","year":"2018","journal-title":"Gait Posture"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1186\/s12955-014-0132-1","article-title":"Health-Related Quality of Life of Ambulant Adults with Cerebral Palsy and Its Association with Falls and Mobility Decline: A Preliminary Cross Sectional Study","volume":"12","author":"Morgan","year":"2014","journal-title":"Health Qual. Life Outcomes."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"2196","DOI":"10.1016\/j.apmr.2017.03.013","article-title":"Long-Term Deterioration of Perceived Health and Functioning in Adults with Cerebral Palsy","volume":"98","author":"Benner","year":"2017","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"101593","DOI":"10.1016\/j.dhjo.2024.101593","article-title":"Adults with Cerebral Palsy and Functional Decline: A Cross-Sectional Analysis of Patient-Reported Outcomes from a Novel North American Registry","volume":"17","author":"Gannotti","year":"2024","journal-title":"Disabil. Health. J."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1016\/j.gaitpost.2012.06.032","article-title":"Walking Deterioration and Gait Analysis in Adults with Spastic Bilateral Cerebral Palsy","volume":"37","author":"Opheim","year":"2013","journal-title":"Gait Posture"},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1302\/1863-2548.12.170127","article-title":"Patient-Reported Mobility Function and Engagement in Young Adults with Cerebral Palsy: A Cross-Sectional Sample","volume":"12","author":"Lennon","year":"2018","journal-title":"J. Child. Orthop."},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"744.e9","DOI":"10.1016\/j.amjmed.2016.11.044","article-title":"Multimorbidity in Middle-Aged Adults with Cerebral Palsy","volume":"130","author":"Cremer","year":"2017","journal-title":"Am. J. Med."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1111\/j.1469-8749.2009.03429.x","article-title":"Health, Mortality, and Wellness Issues in Adults with Cerebral Palsy","volume":"51","author":"Turk","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1111\/j.1469-8749.2009.03423.x","article-title":"Pain in Adults with Cerebral Palsy: Impact and Solutions","volume":"51","author":"Vogtle","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1111\/j.1469-8749.2008.03169.x","article-title":"Subjective Well-Being and Satisfaction with Life in Adults with Spastic Cerebral Palsy: A Pilot Study of a Randomized Sample","volume":"51","author":"Blank","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"1271","DOI":"10.1111\/dmcn.14003","article-title":"From Childhood to Adulthood: Health Care Use in Individuals with Cerebral Palsy","volume":"60","author":"Roquet","year":"2018","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_82","doi-asserted-by":"crossref","unstructured":"Jonsson, U., Eek, M.N., Sunnerhagen, K.S., and Himmelmann, K. (2021). Health Conditions in Adults with Cerebral Palsy: The Association with CP Subtype and Severity of Impairments. Front. Neurol., 12.","DOI":"10.3389\/fneur.2021.732939"},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"2431","DOI":"10.1080\/09638288.2019.1701718","article-title":"Adults with Cerebral Palsy Rank Factors Associated with Quality of Life and Perceived Impact of Childhood Surgery on Adult Outcomes","volume":"43","author":"Gannotti","year":"2021","journal-title":"Disabil. Rehabil."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"241","DOI":"10.5535\/arm.2019.43.3.241","article-title":"Emerging Issues in Cerebral Palsy Associated with Aging: A Physiatrist Perspective","volume":"43","author":"Yi","year":"2019","journal-title":"Ann. Rehabil. Med."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1111\/j.1469-8749.2009.03431.x","article-title":"Cerebral Palsy Lifetime Care\u2014Four Musculoskeletal Conditions","volume":"51","author":"Murphy","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"248","DOI":"10.2522\/ptj.20060157","article-title":"Ambulatory Physical Activity Performance in Youth with Cerebral Palsy and Youth Who Are Developing Typically","volume":"87","author":"Bjornson","year":"2007","journal-title":"Phys. Ther."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1038\/nature23018","article-title":"Large-Scale Physical Activity Data Reveal Worldwide Activity Inequality","volume":"547","author":"Althoff","year":"2017","journal-title":"Nature"},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.amepre.2005.03.011","article-title":"Total and Leisure-Time Walking among U.S. Adults Should Every Step Count?","volume":"29","author":"Bates","year":"2005","journal-title":"Am. J. Prev. Med."},{"key":"ref_89","first-page":"1","article-title":"Evaluating the Efficacy of Action Observation Training in Improving Upper Limb Functionality in Children with Cerebral Palsy: A Scope Review","volume":"8","author":"Donati","year":"2024","journal-title":"OBM Neurobiol."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1055\/a-2239-1936","article-title":"Mapping the Current Research on Mindfulness Interventions for Individuals with Cerebral Palsy: A Scoping Review","volume":"55","author":"Tedeschi","year":"2024","journal-title":"Neuropediatrics"}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/12\/9\/1252\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:47:12Z","timestamp":1760035632000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/12\/9\/1252"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,17]]},"references-count":90,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,9]]}},"alternative-id":["children12091252"],"URL":"https:\/\/doi.org\/10.3390\/children12091252","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,17]]}}}