Research Articles (Orthopaedic Surgery)

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Antibiogram profiles and efficacy of antibiotic regimens of bacterial isolates from chronic osteomyelitis of the appendicular skeleton: A developing-world perspective
(Health & Medical Publishing Group, 2021-06-30) Ferreira, N.; Reddy, K.; Venter, R. G.; Centner, C. M.; Laubscher, M.
ENGLISH ABSTRACT: Chronic osteomyelitis is notoriously difficult to eradicate, and high treatment failure rates have been reported in the literature.[1,2] Although no evidence-based treatment guidelines exist for the management of chronic osteomyelitis, the ideal treatment strategy can be outlined as judicious resection of all necrotic tissue, dead-space management, and neovascularisation of the debridement site followed by soft-tissue and bony reconstruction as required.[3-7] Antibiotic therapy is empirically initiated as an adjunct to surgical management, and then continued as prolonged culture-specific (targeted) therapy.[3]In the absence of non-invasive sampling methods to ascertain the microbiological profile of osteomyelitis, the choice of empirical antibiotic therapy to initiate is often aimed at the most probable infecting organism, in conjunction with current international reports.[8] As the organism and antibiotic susceptibility profiles conceivably differ between geographical regions, empirical antibiotic strategies should ideally be based on local microbiological antibiograms. There are limited data available on the local pathogen profiles and antibiograms in developing countries, including South Africa (SA).
Antifragile orthopaedic surgeons : a reflection on the training experience
(South African Orthopaedic Association, 2019) Venter, R. G.
ENGLISH ABSTRACT: I’m a newly qualified orthopaedic surgeon. It was the hardest thing I have ever done. This essay is a reflection on the things I learnt doing it. I could say that I ‘burnt out’ during my surgical training. But that expression has been used to describe such a range of symptoms, from someone merely feeling depressed, to being the cause of a colleague’s suicide, that it has lost most of its meaning. In May 2019 the World Health Organization (WHO) clarified the term, and it has its own ICD-11 code now: ‘QD85’. It’s not a disorder as such, but one of the ‘factors influencing health status or contact with health services’, specifically related to one’s work environment.
Assessment and management of shoulder pain at primary care level
(AOSIS, 2021-03) Kauta, Ntambue; De Vries, Elma; Du Plessis, Jean-Pierre; Grey, Ben; Anley, Cameron; Vrettos, Basil; Dachs, Robert; Roche, Stephen
Most patients with shoulder pain will initially visit their community health centre, private general practitioner or family physician, with various levels of experience in the assessment and management of shoulder conditions. Shoulder conditions will range from early, simple ailments that can be treated in the primary care setting, to post-traumatic injuries and complex pathologies requiring the expertise of an orthopaedic surgeon or a fellowship-trained shoulder surgeon. Correct assessment of the patient’s shoulder condition at the index consultation is a prerequisite for appropriate management. This article sets out straightforward guidelines to help general practitioners confidently identify the patient’s source of shoulder pain and initiate an appropriate management plan at primary care level. Criteria for urgent and elective referral for specialist care are also outlined.
An audit of circular external fixation usage in a tertiary hospital in South Africa
(South African Orthopaedic Association, 2018) Van der Walt, Nico; Ferreira, N.
Background: Circular external fixation is a well-known treatment modality in reconstructive orthopaedic surgery and is frequently used for deformity correction, limb lengthening, limb salvage, and complex diaphyseal and periarticular fractures. The current use of this treatment modality in the South African context remains largely unknown. This retrospective review aims to describe the indications, outcomes and complications of the use of circular external fixation in a tertiary hospital in South Africa. Materials and methods: We retrospectively reviewed the records of 480 patients treated with circular external fixation in a specialist limb reconstruction unit. We report on patient demographics, comorbidities, indications and outcomes. Results: The final cohort consisted of 346 men and 134 women with a mean age of 35.5 years (SD 14.9, range: 5–73). Comorbidities were identified in 163 (34.0%) patients. These included diabetes in 14 (2.9%) patients and smoking in 102 (21%) patients. HIV infection was diagnosed in 120 patients (25%) with a mean CD4 count of 425 cells/mm3 (SD: 223, range: 82–1056). The mean time in external fixator was 24.6% weeks (SD: 15.3, range 4–159). The treatment objective was achieved in 441 patients (92%). The overall complication rate excluding pin-site infection was 26%. Pin-site infection occurred in 88 patients (18.3%) but had no impact on the outcome of treatment. Conclusion: Circular external fixation treatment objectives can be achieved in a high percentage of patients in the context of a South African specialist reconstruction unit. This study shows favourable outcomes in deformity correction, limb lengthening, limb salvage, and complex diaphyseal and periarticular fractures. Comorbid factors, including HIV, diabetes and smoking had no effect on achieving the planned outcomes, but smoking did increase the overall time in external fixator.
Burden and profile of spinal pathology at a major tertiary hospital in the Western Cape, South Africa
(South African Orthopaedic Association, 2019) Miseer, S.; Mann, T.; Davis, J. H.
Background: Spinal pathology in the Western Cape is managed at three tertiary level hospitals, including Tygerberg Hospital. The Tygerberg Hospital Orthopaedic Spinal Unit is responsible for the management of spinal pathology for the 3.4 million people in the hospital’s catchment area. However, the unit’s overall burden of disease and associated resource use is currently unclear.Aim: The first aim was to investigate the overall burden and clinical profile of spinal pathology presenting to the Tygerberg Hospital Spinal Unit over a one-year period. The second aim was to determine resource use associated with spine pathology admissions.Methods: Overall burden was investigated by performing a retrospective review of all patients admitted to the Spine Unit between 1 October 2016 and 30 September 2017. Demographic and clinical data was collected, and patients were assigned to one of five spinal pathology sub-groups. Resource use was determined by length of hospital stay, waiting times, advanced imaging and theatre usage.Results: Overall burden comprised 349 individual patients and 376 admissions, including readmissions. Trauma (51%) and infection (24%) accounted for the majority of admitted pathology with degenerative (10%), deformity (7%) and malignancy (7%) representing fewer admissions. Motor vehicle accidents were the primary mechanism of injury, accounting for 48% of spine trauma. Tuberculosis was the causative organism in 87% of spinal infections with 44% HIV co-infection. Hospital resource use was considerable with 92% of spine patients requiring advanced imaging, a median operating time of 3 h 36 min and a median hospital stay of 19 days. Infection and malignancy sub-groups had the longest waiting times for advanced imaging and theatre with a median wait of 14–16 days, accounting for approximately 62% of the typical total hospital stay.Conclusions: The Spine Unit experienced a substantial patient burden requiring significant hospital resources. Reduced in-patient waiting times and upskilling of orthopaedic services at secondary hospitals represent key areas for health system strengthening. However, multi-sectoral strategies would be required to effectively address our high burden of largely preventable spinal pathology.
Calcific myonecrosis following snakebite
(South African Orthopaedic Association, 2017) Ferreira, N.; Marais, L. C.
Calcific myonecrosis is a rare condition and is believed to be a late sequela of untreated compartment syndrome. Patients usually present with a progressively enlarging mass, years after the initial injury, that can be misdiagnosed as a soft tissue sarcoma. Calcific myonecrosis following snakebite is extremely rare. The anterior compartment of the leg is most frequently involved and appears to be especially vulnerable to developing this complication. Conservative management should be considered in asymptomatic patients but spontaneous soft tissue breakdown with sinus formation may develop and prolonged surveillance is advised. We report two similar cases of calcific myonecrosis of the anterior compartment of the lower leg that developed decades following snakebite.
Cerebral palsy care in South Africa : a paradigm shift
(South African Orthopaedic Association, 2019) Du Toit, Jacques
ENGLISH ABSTRACT: The word ‘paradigm’, derived from the Greek paradeigma, refers to a ‘framework’ or ‘a very clear and typical example of something’.¹ A paradigm shift thus signifies a change in the demand for certain competencies and/or expertise within a specific framework. This certainly applies to patients affected by cerebral palsy (CP) in a developed world context. The domain of childhood CP has entered a new paradigm which entails significant changes regarding patient profile, treatment approach, outcomes and expectations. After an initially slow uptake, the developed world has now successfully adjusted to a broader biopsychosocial approach. Most of the developing world, however, still lacks a structured framework with the ability to accommodate and address the needs of this changing cohort of patients.
Cervical spine injury outcome - A review of 101 cases treated in a tertiary referral unit
(Health & Medical Publishing Group, 2007) Frielingsdorf K.; Dunn R. N.
Cervical spinal cord injury (SCI) is a devastating event for the patient and family. It has a huge impact on society because of the intensive resources required to manage the patient in both the acute and rehabilitation phases. Given the resource-limited setting in South Africa, questions are often raised regarding whether the outcome of this group of patients justifies the expense of their care. However local data have not been available to date. Objective. To evaluate the mortality, morbidity and functional outcome of cervical SCI patients in the South African environment. Material and methods. All cervical SCI patients managed in the acute spinal cord injury unit at Groote Schuur Hospital over a 12-month period were included. Epidemiological data, management, complications, neurological status and change were assessed. Those referred for rehabilitation were followed up in terms of mortality and ambulation status. Results. There were 101 patients, with an average age of 34.7 years. Motor vehicle accidents were the commonest cause of injury, with violence contributing 21%. Fifty-nine patients required referral to a rehabilitation unit. Of these, 18 were functional walkers, and only 6 were care-dependent. By 1 year post injury all but 1 patient had been discharged from the health service. Fourteen patients died; in half of these cases injury was at C5 level and above. Conclusion. Despite cervical SCI being a devastating event, aggressive early intervention yields a better-than-expected 1-year survival rate. Associated problems, such as pressure sores, remain a major problem both for the patient and in terms of health care costs. It is difficult to predict prognosis on presentation because of spinal shock. It is recommended that all patients initially be treated aggressively, with exit strategies in place once all the information is available and a confident assessment of poor prognosis can be made.
Chevron osteotomy of the first metatarsal for hallux valgus
(Health & Medical Publishing Group, 1989) Hendrix, M. R. G.; Davis, B. L.
A retrospective study of 50 chevron osteotomies evaluated subjective and objective functional and cosmetic results, which were in keeping with other reported studies - i.e. satisfactory subjective cosmesis in 98%; excellent or good pain relief in 84%; and satisfactory objective cosmesis in 84%. The correction of the 1st intermetatarsal angle averaged 3,3°, and that of the metatarsophalangeal valgus averaged 15°. Average active range of motion of the 1st metatarsophalangeal joint was 60°. Complications were generally mild and asymptomatic, and were usually iatrogenic. The findings of this study, together with information gained from a concomitant stress analysis, led to recommendations regarding operative technique.
Circular external fixation in the management of tibial plateau fractures in patients over the age of 55 years
(South African Orthopaedic Association, 2018) Marais, L. C.; Ferreira, N.
Introduction: Tibial plateau fractures in the elderly pose significant treatment challenges because of coexisting medical problems, pre-existing degenerative joint disease and osteoporosis. While several studies have reported promising results with the use of circular external fixation, little data is available on its use in older patients. This study aims to compare the complications and union rate of circular external fixation in patients over the age of 55 years with that achieved in younger patients. Materials and methods: We retrospectively reviewed all patients treated with circular external fixation over a six-year period. Patients were divided in two groups: Group 1 consisted of patients under the age of 55 years and Group 2 of patients 55 years and older. Group 1 consisted of 63 cases (mean age 37.2 ± 9.1 years and Group 2 of 16 cases (mean age 60.2 ± 5.8 years). Apart from the patient age, there was no significant difference between the two groups in terms of demographics, mechanism of injury (p-value = 0.9) or the prevalence of polytrauma (p=1.0). Results: At a mean follow-up of 19 ± 6.2 months all but two of the fractures had united. The mean overall duration of external fixation was 20.2 ± 8.2 weeks, with a slightly longer mean time-in-frame in Group 1 (20.9 ± 1.1 weeks) in comparison to Group 2 (17.8 ± 1.4 weeks, p=0.1). Complications occurred more frequently in patients over the age of 55 years (56% vs 37%, p-value = 0.2). Loss of reduction also occurred more frequently in patients over 55 years (19%), compared to patients younger than 55 years (6%) (p=0.1). Conclusion: Circular external fixation may be a viable treatment option in patients over the age 55 years who sustain high-energy tibial plateau fractures associated with significant soft tissue compromise. No significant difference was found in terms of the union rate or the development of complications when compared to younger patients.
Circular frames of the humerus : salvage surgery case series
(South African Orthopaedic Association, 2019-11) Pretorius, H. S.; Strauss, K.; Ferreira, N.; Lamberts, R. P.
INTRODUCTION: High energy fractures like gunshot-related injuries or high velocity road traffic accidents are often complex to treat and have been associated with a higher non-union rate, especially when there is extensive bone loss. Fractures with severe comminution may not heal due to bone loss and an inability to achieve adequate fracture stability. Treatment of fractures that are not amenable to plating or nailing may lead to non-unions, septic or aseptic, that need repeat surgeries. Stabilisation with external fixation is a reliable option to maintain stability and provide a suitable environment for union. MATERIALS AND METHODS: This retrospective study used medical records of all patients with complex mid-shaft humerus fractures, as well as their complications, that were treated with hexapod circular external fixation between January 2009 and September 2015. All the patients in this case series presented with severe humerus fractures or complications thereof which were not amenable to conventional therapy. RESULTS: Union was achieved in ten out of the 12 cases (83.3%). Union was achieved without bone graft or any other interventions at the fracture site except implant removal where indicated. The median time in external fixation was 196 days (interquartile range: 112-228). The most common complication encountered in this series was pin-site infection. Fixation points were noted to be infected in 33% of cases at some time during the treatment period. CONCLUSION: This study suggests that humeral non-unions and complex humerus fractures that are not amenable to conventional fixation methods, such as intramedullary nails and plates, can successfully achieve union when treated with a hexapod circular external fixator. Level of evidence: Level 4
Closed traction reduction of cervical spine facet dislocations : compelled by law
(Health & Medical Publishing Group, 2019) Potgieter, M.; Badenhorst, D. H.; Mohideen, M.; Davis, J. H.
Background. Following a 2015 ruling, the South African (SA) Constitutional Court obligates closed reduction of cervical facet dislocations sustained through low-energy injury mechanisms, within 4 hours of injury. Closed traction reduction of cervical facet dislocations requires specific equipment and expertise, which have limited availability in SA. Objectives. To review the time delays, delaying factors and success rate of closed reductions of cervical facet dislocations in a tertiary-level orthopaedic department and training facility, and to consider the feasibility of such a reduction within 4 hours after injury. Methods. The clinical records and imaging screens of patients presenting with cervical facet dislocations to an academic training hospital between November 2008 and March 2016 were retrospectively reviewed, with specific attention to demographic information, mechanism of injury, time delays from injury to treatment and factors resulting in delay, as well as the success rate in closed cervical reduction. Results. Ninety-one patients with cervical dislocation presented during the study period, of whom 69 were included for further review. The mean age at presentation was 37.6 (range 18 - 65) years. Successful reduction was achieved in 71% (n=49) of cases, with a median delay time from injury to reduction of 26 (interquartile range (IQR) 19.50 - 31.75) hours. Only 1 patient of 69 patients received successful reduction within 6 hours after injury. Neurological improvement was noticed in 5 of 53 patients with neurological deficit – after successful reduction. Two patients improved with two American Spinal Injury Association (ASIA) grades (from A to C), and 2 improved with one ASIA grade (from A to B and D to E). Conclusions. Successful reduction of a cervical facet dislocation within 4 hours presents a challenge to healthcare infrastructure globally. The relative scarcity of this type of injury (91 cases during 8 years in a tertiary referral hospital) prevents district-level clinicians from readily acquiring a level of experience to confidently perform closed reduction of these injuries, unless very specific training and support are provided towards this end.
Common mistakes when writing the conclusion of a research manuscript
(South African Orthopaedic Association, 2018) Ferreira, Nando
ENGLISH ABSTRACT: The last couple of years have seen a tremendous change in mindset towards research in South Africa. This was in part due to new Health Professions Council of South Africa (HPCSA) requirements to register as a specialist, resulting in an increased output of research from predominantly academic training centres. This renewed focus on conducting research was, however, not always reciprocated by support with the analysis and reporting of research findings.
A computer tomography-based anthropomorphic study of forearm osteology : implications for prosthetic design
(Medpharm Publications, 2021-08-31) Pretorius, Henry S.; Ferreira, Nando; Burger, Marilize C.
Background: The aim of this study was to accurately establish the variability in the anatomy of the radius and ulna in the context of the design of an intramedullary nail for both bones. Methods: Forearm computed tomography scans were used to measure the specific internal and external anatomy of the radius and ulna in adult patients. Patients with fractures or dislocations involving either the radius and/or ulna were excluded. Results: A total of 97 scans, comprising 84% male and 16% female patients, were included. The mean radius length was 238.43±18.38 mm (95% CI 234.60–241.74 mm). The mean curvature was an arc with a radius of 561.43±93.49 mm (95% CI 543.09–580.78 mm). The smallest measurement of the canal width was 5.17 mm (95% CI 4.87–5.47 mm). The ulna showed a mean length of 259.90±19.88 mm (95% CI 255.89–263.91 mm). The smallest measurement of the canal width was 4.80±1.30 mm (95% CI 4.53–5.87 mm). The mean proximal shaft angle was 11.39±3.30° (95% CI 10.76–12.82°). Conclusion: This computed tomography scan-based anthropomorphic study has identified novel anatomical features and associations of human forearm bones. This information will be used in the design and manufacture of anatomic intramedullary devices to better manage radius and ulna fractures or pathology.
The confinement of athletes by COVID-19 : effects on training, wellbeing and the challenges when returning to competition
(Spanish Association of Sport Science, 2020) Lamberts, Robert; Gomez-Ezeiza, Josu
The current COVID-19 pandemic has resulted in a global health emergency of unprecedented magnitude. Most governments around the world have enforced isolation strategies in an effort to curb the spread of the virus and, in so doing, they have hopefully afforded hospitals much needed time to prepare for the high patient influx (Sarto et al., 2020). These confinement strategies have also had a profound impact on the majority of athletes, restricting their movement and limiting, or prohibiting, their access to training facilities. Suddenly, athletes are no longer able to follow their normal training schedules and major sport events have been cancelled or postponed.
Congenital pseudarthrosis of the tibia : treatment with free vascularised fibular grafts
(Health & Medical Publishing Group, 1993) Smith, C. S. F.; Zeeman, V. R. B. J.; Wade, W. J.
Congenital pseudarthrosis is uncommon. We report on a series of 4 patients treated by means of free vascularised fibular grafts. Complications encountered were graft fracture, delayed union and angulation deformities. Modifications in the surgical technique improved later results. We recommend wide excision of pathological bone, bridging of the defect by free vascularised fibular grafts and rigid fixation.
Costotransversectomy in thoracic spinal tuberculosis
(Champagne Media, 2016) Botha, A. H.; Davis, J. H.
BACKGROUND: The escalating global pandemic of tuberculosis infections results in 8 million new cases diagnosed each year. The thoracic and thoracolumbar spine is the most prevalent area involved in musculoskeletal tuberculosis. Deformity with associated neurological compromise, requiring extended in-patient treatment and rehabilitation, is common. Multidrug-resistant tuberculosis is prevalent and tissue samples are needed to obtain bacterial culture and sensitivity. Decompression of the spinal canal, directly or indirectly, should accelerate neurological recovery METHODS: A retrospective study was performed at Tygerberg Hospital to evaluate the efficacy of costotransversectomy in spinal thoracic tuberculosis with regard to neurological recovery and deformity. Neurological status was compared at 6 months post-operatively with the pre-surgical status. The end deformity was compared with Rajasakeran's equation RESULTS: Thirty patients met the inclusion criteria, with an average age of 37 years. Fifteen patients were HIV positive, and ten of them on highly active antiretroviral therapy (HAART). The average CD4 count was 235. The mean neurological status of the group was classified as Frankel C, but this improved to Frankel D at 6 months post-surgery. Initial sagittal deformity was 18.7°, which increased to 26° one year post-operatively. This was not significantly different from the 25.6° kyphosis predicted by the Rajasekaran formula. A 67% positive culture yield for TB was obtained which compared favourably to percutaneous transpedicular needle biopsies performed at the same institute which had a yield of 56% CONCLUSIONS: Costotransversectomy is a simple procedure resulting in indirect decompression of the spinal cord, improving the microbiological diagnosis of spinal tuberculosis, and possibly leading to earlier neurological recovery, without the risk of creating further instability and greater deformity
COVID-19 pandemic… what about the obesity and inactivity "pandemics"?
(Medpharm Publications, 2020) Kirby, J. H.; Duffett, R. G.
With South Africa and the rest of the globe in lockdown for COVID-19, every citizen is finally grasping the meaning and extent of the word “pandemic”. Yet, there are other “silent pandemics” that receive insufficient media attention, viz. the obesity “pandemic”1 and the inactivity “pandemic”, which were first described in 2012.2 The prevalence of obesity is rising even amongst the youth3 and even without the added factor of being confined indoors, global physical inactivity is rising.4 However, has the economic impact of inactivity been considered? Global obesity and physical inactivity’s contribution towards chronic diseases and premature death is estimated to have a cost of up to $145 billion annually, as estimated in 2013.5 Furthermore, a quarter of the world’s adults (1.4 billion) are susceptible to physical inactivity-related diseases.4 Kohl et al. reported that up to 10% of global non-communicable diseases (NCDs) deaths result from physical inactivity, whereas the percentage increases to 30% for specific disease categories such as heart disease.2 Millions of global deaths from NCDs could have been circumvented if people were passably physically active.2
Current concepts in the management of open tibia fractures
(South African Orthopaedic Association, 2019-11) Manjra, M. A.; Basson, T.; Du Preez, G.; Du Toit, J.; Ferreira, N.
ENGLISH ABSTRACT: Open tibia fractures are associated with an increased risk of infection, delayed union, non-union and wound complications. Management is aimed at mitigating the risk of infection while optimising the biological and biomechanical environment to encourage soft tissue and bone healing. With ongoing clinical trials and research, our knowledge around best clinical practice continues to evolve. Multiple consensus documents and protocols have been formulated, yet some controversy exists around the ideal management for high risk grade III injuries. Early antibiotic therapy has become a cornerstone in the management of these injuries. However, some controversy remains around the type and duration of antibiotic therapy. Emergent debridement and lavage is a critical factor in treatment success. Intramedullary nailing is a viable fixation option for most open tibia fractures while circular external fixation has gained prominence in the management of high energy grade III injuries, especially in the presence of bone and soft tissue loss. The timing of the various treatment interventions continues to provoke debate and controversy. Considering the available literature, the local context needs to be considered. Inadequate access to theatre, shortage of staff, resources and expertise are frequently encountered. We aim to elucidate current literature with regard to the management of open tibia fractures guided in part by various consensus documents and protocols. Level of evidence: Level 5
Daily activities, participation, satisfaction, and functional mobility of adults with cerebral palsy more than 25 years after selective dorsal rhizotomy: a long-term follow-up during adulthood
(Taylor and Francis, 2019-12) Veerbeek, Berendina E.; Lamberts, Robert P.; Fieggen, A. Graham; Verkoeijen, Peter P. J. L.; Langerak, Nelleke G.
Purpose: To determine changes in level of accomplishment and satisfaction in daily activities and social participation, and functional mobility in adults with cerebral palsy (CP) more than 25 years after selective dorsal rhizotomy (SDR). Materials and methods: This long-term observational nine-year follow-up study included 26 adults (median age 35 years) with CP and spastic diplegia, and 26 matched typically developing adults. Assessment tools used were the Life-Habits questionnaire and the Functional Mobility Scale. Results: Most of the adults with CP were independent and satisfied with accomplishing life habits and no changes were determined, except for a small change in the Housing accomplishment level. Compared to typically developing adults, the CP cohort was more dependent in accomplishing Mobility and Recreation. However, the level of satisfaction was similar for most life habits except for Mobility. Functional mobility did not change, but correlated with Life-Habits results. Conclusions: Adults with CP showed high and stable levels of accomplishment and satisfaction in daily activities and social participation more than 25 years after SDR. This is in contrast with the literature, where functional decline was shown for individuals with CP as they age. The relation with functional mobility highlights the importance to focus the rehabilitation on maintaining walking ability in order to enable high level of daily activities and social participation in adults with CP. Implications for rehabilitation: Selective dorsal rhizotomy (SDR) is a valuable treatment option for a selective group of children with cerebral palsy (CP) in order to reduce spasticity. The long-term outcomes of SDR on level of accomplishment and satisfaction in daily activities and social participation as well functional mobility in adults with CP are not clear. More than 25 years after SDR adults with CP experienced stable and lasting high levels of functioning regarding daily activities and social participation and were satisfied with the way they accomplished life habits. Functional mobility was correlated to level of accomplishment and satisfaction in daily activities and social participation, which highlights the importance to focus rehabilitation programs on maintaining functional mobility in order to enable daily activities and social participation in adults with CP.

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