Hip Surveillance Research Articles

G108 Impact of Sleep Systems (SS) on Posture and Quality of Life (QOL) in Children with Neurological Disabilities

AimsChildren with neurodisability and limited mobility are at an increased risk of postural deformity which impacts on their overall health and QOL. SS are used as part of an individualised...

Utility of combined hip abduction angle for hip surveillance in children with cerebral palsy

Utility of combined hip abduction angle for hip surveillance in children with cerebral palsy

Are hips stable in children with cerebral palsy?

This commentary is on the original article by Terjesen on pages 951-957 of this issue. In 2010, the mechano-biological principles of proximal femoral geometry and muscle forces were implemented on a three-dimensional finite element model of the proximal femur, in order to predict changes in morphology over time in both typically developing children and children with cerebral palsy (CP).1 The simulation relies on the assumption that cyclic octahedral shear stress promotes growth and cyclic hydrostatic compressive stress inhibits growth. This finite element model predicts an increase in femoral anteversion and coxa valga for load conditions in children with CP when compared with typically developing children. In this study, growth was simulated over a period of approximately 5 months. From three population-based studies2–4 we know that hip displacement is common in children with CP (with an overall incidence of approximately one-third); it is often present by 2–3 years of age; range of motion is a poor indicator of hips at risk; and it is directly related to gross motor function as graded by the Gross Motor Function Classification System (GMFCS). In these studies the cut-off values for the migration percentage were set at slightly different levels: 30–33% for hip subluxation and 90–100% for hip dislocation.2–4 In a new study, Terjesen has carefully evaluated and reported a population-based hip surveillance programme for children with CP in Norway.5 A large number of children (n=335) were included and the data were collected and analysed meticulously. Hip displacement occurred in 26% of all children (subluxation in 22% and dislocation in 4%) and in 63% of those at GMFCS levels IV and V. The mean migration percentage was 20.4% at the initial radiographs and 34.0% at the end of the study. The rate of increase in migration percentage increased with decreasing functional level, from 0.2% per year at GMFCS level I to 9.5% at GMFCS level V. Radiographic hip surveillance from age 1 to 2 years was recommended for non-ambulatory children with CP on a regular basis. Current management options for hip displacement in children with CP include reconstructive procedures such as varus derotation osteotomy of the proximal femur,6 preventive surgery such as adductor releases,7 or a combination of both.8 A large recently published study7 demonstrated that the success of preventive surgery for hip displacement was directly related to GMFCS level. ‘Success’ was defined as the absence of subsequent surgical procedures during the study period of 7 years and a migration percentage of less than 50%. The success rate was 32%. However, the success rate was predicted by GMFCS level, with 94% at GMFCS level II decreasing to 14% at GMFCS level V. Finally, the question remains as to when the hip is stable or unstable in patients with CP. The data from current studies support the fact that hips in children with CP on a high functional level (GMFCS levels I, II, and III) are usually stable, or easily made so – but that hips in non-ambulatory children with CP (GMFCS levels IV and V) are usually not stable! Hip surveillance is important and needs to start by the age of 2 years in non-ambulatory children. The main goal of systematic hip screening is to prevent hip dislocation. Future research, based on the understanding of the biomechanics of the proximal femur, should focus on specific management guidelines for each GMFCS level or at least for ambulatory and non-ambulatory children with CP.

The natural history of hip development in cerebral palsy

The purpose of this study was to evaluate a population-based radiographic hip surveillance programme for children with cerebral palsy (CP) and to assess the natural history of hip displacement. The study comprised 335 children (188 males, 147 females), born during 2002 to 2006 in the 10 south-eastern counties in Norway. Their mean age at the first radiograph was 3 years (range 6mo-7y 11mo) and the mean age at the most recent follow-up was 5 years 5 months. Distribution according to CP type was spastic hemiplegia in 38%, diplegia in 27%, quadriplegia in 21%, dyskinesia in 10%, and ataxia in 3%; Gross Motor Function Classification System (GMFCS) levels I to V were, 44%, 14%, 8%, 11%, and 23% respectively. Migration percentage (MP), acetabular index, and pelvic obliquity were measured on the radiographs. Hip displacement (MP>33%) occurred in 26% of all children (subluxation in 22% and dislocation in 4%) and in 63% of those in GMFCS levels IV or V. Dislocation occurred in 14 children at a mean age of 4 years 5 months (range 1y 10mo-9y 7mo). The mean migration percentage was 20.4% at the initial radiographs and 34.0% at the last follow-up. Mean progression in migration percentage increased markedly with decreasing functional level, from 0.2% per year at GMFCS level I to 9.5% at level V. There is a pronounced trend towards hip displacement in nonambulant children. Close surveillance from age 1 to 2 years is needed to find the appropriate time for preventive surgery. Since 12% of the nonambulant children developed dislocation, our routines for hip surveillance need improvement.

The role for hip surveillance in children with cerebral palsy

Spastic hip displacement is the second most common deformity seen in children with cerebral palsy (CP), and the long-term effects can be debilitating. Progressive hip displacement leading to dislocation can result in severe pain as well as impaired function and quality of life. Recent population-based studies have demonstrated that a child's Gross Motor Functional Classification System (GMFCS) level is most predictive for identifying hips "at-risk" for progressive lateral displacement. As a result, in many developed countries, hip surveillance has now been adopted as an integral piece of the comprehensive care puzzle for the management of children with spastic hip displacement. This paper reviews the spectrum of treatments available for progressive hip displacement, examines the current literature on the success of hip surveillance, and illustrates an example of a current hip surveillance program stratified by the GMFCS level.

Prevalence of hip dislocation among children with cerebral palsy in regions with and without a surveillance programme: a cross sectional study in Sweden and Norway

BackgroundHip dislocation is a serious complication among children with cerebral palsy (CP). The aim of this study was to compare the prevalence of hip dislocation among children with CP in an area providing regular care with an area providing hip surveillance services.MethodsThis is a cross-sectional study in seven Norwegian counties providing regular care and one Swedish healthcare region where a hip surveillance programme was introduced in 1994. Data were provided by the Norwegian Cerebral Palsy Register and the CP Register in Southern Sweden. Children born 1996 - 2003 with moderate to severe CP, defined as Gross Motor Classification System (GMFCS) levels III - V, were included. In all, 119 Norwegian and 136 Swedish children fulfilled the criteria. In Norway, data on hip operations and radiographs of the hips were collected from medical records, while these data are collected routinely in the Swedish register. The hip migration percentage was measured on the recent radiographs. Hip dislocation was defined as a migration percent of 100%.ResultsThe proportion of children at GMFCS levels III - V was 34% in the Norwegian and 38% in the Swedish population. In the Norwegian population, hip dislocation was diagnosed in 18 children (15.1%; CI: 9.8 - 22.6) compared with only one child (0.7%; 95% CI: 0.01 - 4.0) in Southern Sweden (p = < 0.001). Hip surgery was performed in 53 (44.5%) of the Norwegian children and in 43 (32%) of the Swedish children (p = 0.03). The total number of hip operations was 65 in Norway and 63 in Sweden. Norwegian children were first operated at a mean age of 7.6 years (SD: 2.9) compared with 5.7 years (SD: 2.3) in Sweden (p = 0.001).ConclusionsThe surveillance programme reduced the number of hip dislocations and the proportion of children undergoing hip surgery was lower. However, with the surveillance programme the first operation was performed at a younger age. Our results strongly support the effectiveness of a specifically designed follow-up programme for the prevention of hip dislocation in children with CP.

Utility of combined hip abduction angle for hip surveillance in children with cerebral palsy

Background:Spontaneous hip lateralization complicates the management of non-ambulatory children with cerebral palsy (CP). It can be diagnosed early using radiographs, but it involves standardization of positioning and exposure to radiation. Hence, the aim of this study was to assess the utility of Combined hip abduction angle (CHAA) in the clinical setting to identify those children with CP who were at greater risk to develop spontaneous progressive hip lateralization.Materials and Methods:One hundred and three children (206 hips) with CP formed our study population. There were 48 boys and 55 girls aged 2–11 years (mean 5.03 years). 61 children were Gross Motor Function Classification System (GMFCS) level 5, while 42 were GMFCS level 4. Clinical measurements of CHAA were statistically correlated with radiographic measurements of Reimer's migration percentage (MP) for bivariate associations using χ2 and t tests.Results:CHAA is evaluated against MP which is considered as a reliable measure of hip subluxation. Thus, for CHAA, sensitivity was 74.07% and specificity was 67.35%. False-positive rate was 32.65% and false-negative rate was 25.93%.Conclusions:Our study shows that correlation exists between CHAA and MP, which has been proved to be useful for hip screening in CP children at risk of hip dislocation. CHAA is an easy, rapid, cost-effective clinical test which can be performed by paraclinical health practitioners (physiotherapists) and orthopedic surgeons.

2D versus 3D imaging of hip displacement in children with cerebral palsy

2D versus 3D imaging of hip displacement in children with cerebral palsy

The application of the German hip surveillance protocol in children with bilateral spastic cerebral palsy – a single centre cohort study

Introduction: a progressive subluxation (Migration percentage of Reimers, MI) is a typical musculoskeletal complication in children with cerebral palsy. To determine the risk of progressive subluxation a German hip surveillance protocol using a „hip signal light“ was established (www.cp-netz.de). Aim of this study was to correlate the MI percentage with potential risk factors such as age and severity of groß motor functioning (GMFCS) in children with bilateral spastic CP (BSCP) by using the criteria of this new surveillance tool.

The development of Australian Standards of Care for Hip Surveillance in Children with Cerebral Palsy: How did we reach consensus?

Progressive hip displacement is the second most common deformity in children with cerebral palsy (CP). For many decades, the methods of monitoring hip health and development in children with CP varied widely between facilities. Recently, systematic population based studies have identified some of the factors and characteristics of children with CP who would most benefit from hip surveillance. Health services providing hip surveillance within Australia identified a need for clinical guidelines to assist in provision of comprehensive and best practice health care for children with CP across all patient demographics. Guidelines providing clear, evidence based information on specific timing for commencement, frequency, and discharge have not previously been published. This article analyses the supportive evidence for comprehensive hip surveillance, discusses the development of draft guidelines in Australia, and describes the process for achieving national consensus resulting in the Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care. These standards of care are being followed in clinical facilities across Australia and are endorsed by the Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM).

The consensus statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care

The 'Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care' ('Standards of Care') provides a clear and concise guideline for inclusion of hip surveillance into current services. The 'Standards of Care' have been developed by a multidisciplinary working group for the education and information of all health professionals working with children with CP and their families. The 'Standards of Care' were developed through extensive review of the literature and garnering of expert opinion from professionals working in the area within Australia and New Zealand. A formalized external consensus process was conducted from 2007 to 2008 and the 'Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care' became the basis for best practice around Australia in 2008. It has been endorsed by The Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM). Prospective longitudinal study will evaluate both effectiveness and cost/benefit outcomes of this recommended hip surveillance standard of care.

Five-year outcome of state-wide hip surveillance of children and adolescents with cerebral palsy

This study reports the five-year outcomes of a prospective population-based study of clinical hip surveillance for children with cerebral palsy (CP) according to evidence-based standards of care. Systematic hip surveillance commenced in Queensland, Australia as a state-wide program in 2005. Queensland represents a dispersed population across a large geographical area, creating unique challenges in terms of service delivery. Over five years, 1,115 children with CP were recruited, representing 73% of the expected population based on 1.9 to 2.1 per 1,000 live births. Standardized clinical and radiological assessments have been provided, with a median follow-up of 1.2 years (range 1 month -5(+8) yrs). Of the 1,115 children, 423 (38%) have been discharged and 692 (62%) remain on surveillance with 314 (28%) identified as having hip displacement with Migration Percentage (MP) equal to or greater than 30% (≥ 30). The incidence of marked hip displacement (MP ≥ 30) was directly related to gross motor function, classified according to the gross motor function classification system (GMFCS), with distribution of GMFCS I=10, (3%), II=40 (13%), III=53 (43%), IV=96 (59%), and V=115 (64%). This state-wide surveillance program has been successful in correctly identifying children with hip displacement (MP ≥ 30), fast tracking children for orthopedic review and discharging those at minimal risk. No child has progressed to dislocation while on surveillance without orthopedic review.

Hip surveillance for children with cerebral palsy: Are the Australian standards the gold standard?

Although surveillance for hip displacement in children with cerebral palsy (CP) was routine practice in Australia since 1997, these surveillance programs varied widely between states. This prompted efforts to convene a national working group to standardize a hip surveillance program for this population, culminating with the publication of the “Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care” [1]. These recommendations, comprehensively detailed in this edition of the journal, have been formally adopted since 2008. They aim to reduce the morbidity associated with hip displacement in CP by facilitating early detection and timely referral, which will presumably lead to early and more efficient or cost-effective management of hip displacement. (Child health) surveillance is the systematic and ongoing collection, analysis, and interpretation of indices of growth and development, which includes gathering data from screening tests (in this case clinical and radiologic tests) in order to identify, investigate, and, where appropriate, correct deviations from predetermined norms [2]. Hip surveillance, in essence, serves as a screening program aimed at identifying children who could potentially benefit from early intervention: in this case, a form of tertiary prevention to impede the

Late diagnosis of developmental dysplasia of the hip

A neonatal clinical screening program for developmental dysplasia of the hip (DDH) operates in South Australia to diagnose DDH as early as possible. However, some cases of DDH are diagnosed late (>3 months of age). The aims of this study were to identify the specific risk factors for late diagnosis by comparing early diagnosed DDH, late diagnosed DDH, and normal controls in the South Australian population. There were 1945 children with DDH born between 1988 and 2003, of which 67 cases were late diagnosis (3.4%). Maternal characteristics, pregnancy, and delivery details were analyzed, and compared with controls (early diagnosed DDH and the general population). There was a trimodal pattern of age at presentation with a gradual increase in the incidence of late diagnosed DDH over the time period in this study. Birthweight (<2500 g), birth in a rural setting, and early hospital discharge following delivery (<4 days) were significant risk factors for late diagnosed DDH. Breech presentation and delivery by caesarean section were protective for late diagnosed DDH. Risk factors for late diagnosed DDH relate to factors that influence the screening program. A rigorous population-based hip surveillance program is important for early diagnosis of DDH.

Hip surveillance for children with cerebral palsy: Are the Australian standards the gold standard?

Hip surveillance for children with cerebral palsy: Are the Australian standards the gold standard?

Hip surveillance in Tasmanian children with cerebral palsy

Children with cerebral palsy (CP) are at risk of hip subluxation. Over time, subluxation can lead to dislocation, deformity and pain. Hip surveillance in the form of an X-ray and clinical examination of this 'at risk group' can identify early subluxation. Early subluxation can be treated, preventing hip dislocation in many cases. Hip surveillance in CP commenced in Tasmania in 1992. To audit the hip surveillance data to date, perform a literature review to understand the emerging evidence for prevention and management of hip subluxation in CP and update hip surveillance guidelines. New guidelines were written and distributed, and an audit of the previous 12 years performed by review of medical files and X-rays. Two hundred and eighteen children had been involved in the hip surveillance programme. Fifteen cases of dislocation were recorded in this time. The incidence of subluxation and surgery, as well as the gross motor function classification system (GMFCS) level, was recorded. Data from Tasmania showed a similar incidence of hip subluxation according to GMFCS level, and frequency of different surgical interventions as other recent audits. Some children with minor subluxation improved without orthopaedic intervention once weight bearing occurred, which had not before been appreciated. Migration percentage alone is not adequate to fully describe the outcome of hip subluxation. More appropriate measures of outcome in terms of quality of life for children with CP need to be developed.

Characteristics of children with hip displacement in cerebral palsy

BackgroundHip dislocation in children with cerebral palsy (CP) is a common and severe problem. The dislocation can be avoided, by screening and preventive treatment of children with hips at risk. The aim of this study was to analyse the characteristics of children with CP who develop hip displacement, in order to optimise a hip surveillance programme.MethodsIn a total population of children with CP a standardised clinical and radiological follow-up of the hips was carried out as a part of a hip prevention programme. The present study is based on 212 children followed until 9–16 years of age.ResultsOf the 212 children, 38 (18%) developed displacement with Migration Percentage (MP) >40% and further 19 (9%) MP between 33 and 39%. Mean age at first registration of hip displacement was 4 years, but some hips showed MP > 40% already at two years of age. The passive range of hip motion at the time of first registration of hip displacement did not differ significantly from the findings in hips without displacement.The risk of hip displacement varied according to CP-subtype, from 0% in children with pure ataxia to 79% in children with spastic tetraplegia. The risk of displacement (MP > 40%) was directly related to the level of gross motor function, classified according to the gross motor function classification system, GMFCS, from 0% in children in GMFCS level I to 64% in GMFCS level V.ConclusionHip displacement in CP often occurs already at 2–3 years of age. Range of motion is a poor indicator of hips at risk. Thus early identification and early radiographic examination of children at risk is of great importance. The risk of hip displacement varies according to both CP-subtype and GMFCS. It is sometimes not possible to determine subtype before 4 years of age, and at present several definitions and classification systems are used. GMFCS is valid and reliable from 2 years of age, and it is internationally accepted.We recommend a hip surveillance programme for children with CP with radiographic examinations based on the child's age and GMFCS level.

A systematic review of the evidence for hip surveillance in children with cerebral palsy

We reviewed the evidence for hip surveillance in children with cerebral palsy from the published literature. Publications were identified using the Cochrane controlled trials register, the MEDLINE, EMBASE and CINAHL databases and by hand searching key journals and their references. Studies were included if they reported the frequency, associated risk factors or surveillance measures undertaken to identify subluxation or dislocation of the hip in children with cerebral palsy. Assessment of the quality of the methodology was undertaken independently by two researchers. Four studies described the natural history, incidence and risk factors for dislocation of the hip. Two reported their surveillance results. Approximately 60% of children who were not walking by five years of age were likely to develop subluxation of the hip, with the greatest risk in those with severe neurological involvement. The introduction of surveillance programmes allowed earlier identification of subluxation and reduced the need for surgery on dislocated hips. Surveillance can identify children most at risk of subluxation using radiological methods which are widely available.

Neonatal hip surveillance and the early management of developmental dysplasia of the hip

Developmental dysplasia of the hip encompasses a range of conditions including acetabular dysplasia and frank dislocation of the hip in infancy, irreducible dislocation at walking age, and early osteoarthritis in adolescence. The earlier the condition is diagnosed and treated the better the prognosis for the hip. Clinical methods of detection in infancy have a low sensitivity which improves with the experience of the examiner, and although ultrasound is the best method for imaging the neonatal hip it does not tell us who to treat and poses logistical problems in organization. Universal screening with ultrasound is probably the best way to detect the condition but is very expensive. Although targeted ultrasound screening programmes for infants with hip instability or risk factors have been criticized, they are more practical for most centres and should be accompanied by clinical screening in the community up to walking age.

Hip surveillance in children with cerebral palsy

We studied prospectively the impact of a hip surveillance clinic on the management of spastic hip disease in children with cerebral palsy in a tertiary referral centre. Using a combination of primary clinical and secondary radiological screening we were able to detect spastic hip disease at an early stage in most children and to offer early surgical intervention. The principal effect on surgical practice was that more preventive surgery was carried out at a younger age and at a more appropriate stage of the disease. The need for reconstructive surgery has decreased and that for salvage surgery has been eliminated. Displacement of the hip in children with cerebral palsy meets specific criteria for a screening programme. We recommend that hip surveillance should become part of the routine management of children with cerebral palsy. The hips should be examined radiologically at 18 months of age in all children with bilateral cerebral palsy and at six- to 12-monthly intervals thereafter. A co-ordinated approach by orthopaedic surgeons and physiotherapists may be the key to successful implementation of this screening programme.