Hip Dysplasia In Cerebral Palsy Research Articles

Imaging Parameters of Hip Dysplasia in Cerebral Palsy: A Systematic Review.

Cerebral Palsy is the leading cause of childhood physical disability globally. The motor disorders of CP are often associated with musculoskeletal anomalies, of which hip displacement is the second most common abnormality after abnormalities of foot and ankle. Various radiological parameters have been described in the literature which detects and quantifies hip dysplasia, with MP being the current gold standard. This study aims to review these radiological indicators of hip dysplasia in children with cerebral palsy from the published literature. A literature search using PubMed, Embase, and Google Scholar was done on 15th June 2021 focusing on surveillance of hip dysplasia in cerebral palsy. The studies to be included were to have used anyone or more radiological parameter for detection of hip dysplasia with the use of any of the radiological methods. The initial search yielded 1184 results. After the screening of the abstracts and full texts, a final of 30 studies was included for this systematic review. The majority of the studies were graded as Level 3 evidence (16/30), followed by Level 2 studies (14/30). X-ray was the most common modality of detection of dysplasia followed by CT scan, ultrasonography, and arthrogram. The reproducibility of the various parameters shows good to excellent intraclass coefficients. Parameters other than MP can be used to screen hips in CP. This would be useful in patients in whom either the lateral acetabular edge is not discernible on a plain anteroposterior radiograph or there are issues in the positioning of the patient. Additional views and structures can be visualized which can lead to improved screening and planning. Further investigations are required to appreciate the full potential of these parameters and how they can be better utilized.

Severe Hip Dysplasia in Skeletally Mature Patients With Spastic Cerebral Palsy: The Technique and Early Outcome of Comprehensive Surgical Correction (Including the Bernese PAO).

Treatment of symptomatic hip dysplasia in skeletally mature patients with spastic cerebral palsy (CP) can be challenging. This study examines our technical experience with the Bernese periacetabular osteotomy (PAO) in combination with adjunctive procedures in the treatment of this complex hip deformity. Sixteen consecutive patients (18 hips) with symptomatic CP hip dysplasia were treated with a PAO and variable adjunctive procedures and retrospectively reviewed. Two patient (2 hips) were excluded due to insufficient follow-up. The average age at the time of surgery was 17.7 years (range: 13 to 28 y). We compared the preoperative to postoperative changes in radiographic parameters as well as early outcomes as measured by patient assessment of hip pain and function using the modified Harris Hip Score (mHHS). The average time of follow-up was 3.3 years (range: 2.0 to 6.3 y). Tönnis angles decreased from a median of 30 degrees (range: 18 to 45 degrees) preoperatively to a median of 6 degrees (range: -9 to 21 degrees) postoperatively. Lateral center-edge angles increased from a median of -8 degrees (range: -28 to 15 degrees) to a median of 32 degrees (range: 19 to 38 degrees). Anterior center-edge angles increased from a median of 2 degrees (range: -22 to 39 degrees) to a median of 35 degrees (range: 22 to 47 degrees). The extrusion index decreased from a median of 57% preoperatively (range: 35% to 73%) to a median of 21% (range: 11% to 36%) postoperatively.The median mHHS was 62 (range: 37 to 81) preoperatively and 85 (range: 65 to 100) postoperatively. Notably, the pain component of the mHHS improved from 20 (range: 0 to 44) to 42 (range: 30 to 44). Tönnis osteoarthritis grade preoperatively was either 0 (11 hips) or 1 (5 hips) and remained unchanged in 11 hips and increased by 1 grade in 5 hips. It has been our experience that the Bernese PAO in combination with appropriate adjunctive treatments has provided a very satisfactory surgical approach in the treatment of CP hip dysplasia. In the adolescent and young adult with spastic CP, utilizing the Bernese PAO technique makes it possible to obtain redirection of often a very severe acetabular dysplasia. Adjunctive soft tissue procedures and a proximal femoral osteotomy are frequently necessary to maintain postoperative stability. A notable improvement in the quality of life and function directly attributable to our surgical treatment of their pre-existing problematic hip dysplasia has been consistently noted in early follow-up for our patients. Level IV-therapeutic.

Anteverting Bernese periacetabular osteotomy in the treatment of neurogenic hip dysplasia in cerebral palsy.

All patients with hypertonic cerebral palsy undergoing Bernese periacetabular osteotomy (PAO) between 2005 and 2014 were reviewed. Clinical and radiographic parameters, including the cerebral palsy hip classification and anterior and posterior wall indices were collected to assess acetabular reorientation. Twenty (83%) of 24 procedures involved the correction of posterolateral acetabular insufficiency and were 'anteverting PAOs'. All 20 experienced improvements in radiographic indices. Eleven (58%) of 19 PAOs in ambulatory patients were performed in the setting of other multilevel orthopedic surgery. The anteverting PAO is successful in correcting the posterolateral acetabular insufficiency present in spastic hip dysplasia, and can be performed in conjunction with a single-event multilevel surgery.

Outcomes of Isolated Varus Derotational Osteotomy in Children With Cerebral Palsy Hip Dysplasia and Predictors of Resubluxation.

The appropriate intervention for hip subluxation or dislocation in children affected by cerebral palsy (CP) remains controversial. The purpose of this retrospective study was to report radiographic and clinical outcomes following isolated femoral varus derotational osteotomy (VDRO) in children with CP hip dysplasia. Risk factors for resubluxation and avascular necrosis (AVN) were also examined. A cohort of 100 patients (199 hips) with CP treated with isolated VDRO between 2003 and 2009 was reviewed. All but 1 patient received bilateral surgery. Patients were followed for an average of 5.4 years (range, 1.03 to 10.20 y). Anteroposterior pelvic radiographs were used to assess migration percentage (MP), Shenton's line, and presence of AVN. Resubluxation was defined as a postoperative break in Shenton's line. Radiographic outcomes and risk analysis was performed in the 91 subjects (179 hips) with radiographic follow-up >1 year. Significant improvement was observed in MP, and all hips had a reconstituted Shenton's line following surgery. Over the course of follow-up, 16% of hips were noted to have a repeat break in Shenton's line. Univariate risk analysis showed preoperative MP, Gross Motor Function Classification System (GMFCS) level, and age at surgery were risk factors for a recurrent line break. Preoperative MP and GMFCS level were found to be predictors of resubluxation in multivariate analysis. AVN was detected in 10 hips (5.7%). GMFCS level V patients were more at risk for resubluxation, but less at risk for AVN when compared with ambulatory (GMFCS I/II/II) patients and GMFCS level IV patients. Performing a VDRO without additional procedures provided a stable and concentrically reduced hip joint in this population of children with CP. Attention should be paid to initial ambulatory status during the postoperative period. Concomitant procedures such as pelvic osteotomy should be considered for patients of GMFCS level IV and V, as these patients were more at risk for recurrent subluxation. Level III-retrospective comparative study.

Acetabular Remodeling After a Varus Derotational Osteotomy in Children With Cerebral Palsy.

The optimal surgical intervention for hip dysplasia in cerebral palsy (CP) is controversial. The purpose of this study was to determine (1) whether an isolated varus derotation osteotomy (VDRO) for the treatment of CP hip dysplasia allows for acetabular remodeling as measured by acetabular depth ratio (ADR), (2) the predictive factors for acetabular remodeling after an isolated VDRO for the treatment of CP hip dysplasia, and (3) to establish the normal ADR in typical children for comparison. Eighty-seven CP patients (174 hips) treated with an isolated VDRO between 2003 and 2009 were retrospectively reviewed. The average age at surgery was 4.6 years (range, 2.4 to 10.6 y) and the average follow-up period was 5.1 years (range, 1.1 to 9.9 y). Acetabular remodeling was assessed on radiographs by the ADR. Changes in preoperative and postoperative ADR were analyzed using linear mixed-effects models. Patients were divided into 2 different groups for the postoperative ADR analysis: Gross Motor Function Classification System (GMFCS) levels I, II, and III compared with GMFCS levels IV and V. The progression of ADR versus age was determined in a set of 917 normal children (1834 hips) for comparison. There was a statistically significant increase (improvement) in ADR postsurgically for the collective CP set (P<0.001) and for both GMFCS categories (I/II/III, IV/V: P<0.001). GMFCS level, sex, and intraoperative neck shaft angle (NSA) were determined to be significant predictors for postoperative ADR improvement. GMFCS level was the most significant predictor for an increase in ADR after surgery (P<0.001). Less improvement in ADR was observed in patients of GMFCS levels IV and V compared with patients of GMFCS levels I, II, and III (P<0.001). A lower intraoperative NSA resulted in greater postoperative increase in ADR (P<0.05). Overall, isolated VDRO allowed for acetabular remodeling in CP hip dysplasia. Acetabular remodeling was increased in patients of GMFCS levels I, II, and III compared with patients of GMFCS levels IV and V. Increased varization at the time of VDRO improved acetabular remodeling. This study recommends considering GMFCS level and intraoperative NSA during surgical planning for CP hip dysplasia.

Pathologic Hip Morphology in Cerebral Palsy and Down Syndrome

The pathogenesis and clinical course of hip dysplasia in cerebral palsy and Down syndrome is different than idiopathic developmental dysplasia of the hip. Unlike idiopathic developmental hip dysplasia, hip development in cerebral palsy and Down syndrome is typically normal in utero and instability develops after birth secondary to musculoskeletal disorders associated with the disease condition. For this reason, treatment protocols in Down syndrome and cerebral palsy hip dysplasia differ greatly from protocols designed to treat idiopathic hip dysplasia. The purpose of this review is to describe the pathologic hip morphology that results from cerebral palsy and Down syndrome.

Progress in neuromuscular disorders

The value of gait analysis as a tool for evaluation is affirmed by the number of articles that report its use in gait evaluation. Physical examination measures alone have limited value. Numerous gait analysis parameters have been identified and reported as valid. Joint angular velocity distinguishes normal from spastic gait. Gait analysis can distinguish between idiopathic toe-walkers and children with cerebral palsy. Gait analysis can evaluate the effects of orthotics, lower extremity surgery, and postoperative therapy on gait. Botulinum toxin, intrathecal baclofen, and rhizotomy are all reported as being effective in spasticity management. The role of each still requires further definition. Cerebral palsy hip dysplasia can be effectively managed with aggressive surgical intervention. Pain relief in long-standing cerebral palsy hip dislocations can be achieved with either prosthetic replacement or proximal femoral resection. Pelvic obliquity may occur in Duchenne muscular dystrophy after fusion of lumbar curves to L5. Functional outcome measures show significant benefit of spinal fusion in patients with Duchenne muscular dystrophy. Circular frame limb lengthening is well tolerated in spina bifida without increased risk. Patients with lower-level myelomeningocele have a delayed onset of walking. Elbow surgery in arthrogryposis effectively improves function and restores range of motion.