D.D.S.H.: developmental dysplasia of the spastic hip: strategies of management in cerebral palsy. A new suggestive algorithm

Optimizing Hip Replacement Procedure in Cerebral Palsy-Related Spastic Hip Dysplasia: A Case Report

Cerebral palsy (CP) often results in severe hip issues, disrupting musculoskeletal development and mobility due to problems such as dislocations and contractures, aggravated by spasticity and heightened muscular tone. While total hip arthroplasty (THA) is required in CP patients, the procedure carries high risks due to concerns about dislocation and wear. This study explores a method of intraoperative navigation to precisely execute preoperative strategies for spinopelvic alignment and optimal cup placement. We discuss a case of a 22-year-old male CP patient with bilateral hip dislocations who experienced significant discomfort, impeding mobility and affecting his performance as a Paralympic rower. He underwent bilateral hip replacement surgeries, guided by preoperative gait analysis and imaging, with navigation aiding in accurate acetabular component placement and correction of excessive femoral anteversion using a modular stem. The patient achieved excellent stability in both standing and rowing postures. Overall, computer navigation enhances complex hip repair by facilitating intraoperative data collection and precise execution of preoperative plans. This approach may extend the lifespan of prostheses, particularly by achieving precise acetabular component placement based on spinopelvic alignment principles, thereby offering significant benefits for CP patients undergoing THA.

Hips in cerebral palsy: A clinico-radiological evaluation of hip subluxation in cerebral palsy

Background

The study was done on children with cerebral palsy in the ages of 2-18 years, with focus on hip subluxation. The objectives of the study were to look at the distribution of different types of CP in the target population; the prevalence of hip subluxation and its association with types and severity of CP.

Methods

This is a cross sectional descriptive observational study, done on a hospital out-patient setting. Children with cerebral palsy of ages 2-18 years were recruited and clinically evaluated. Radiological evaluation of the pelvis was done for all subjects. Primary outcome measure was presence of hip subluxation described as Migration Percentage >30% in one or both hips. Prevalence of subluxation and its association with various subtypes of CP were assessed.

Results

203 subjects with cerebral palsy underwent the study. Spastic type of presentation constituted the majority (82.8%). Quadriplegic distribution (53.2%) and functional level of GMFCS 5 (39.4%) were most prevalent. Hip subluxation was noted in 105 of the 203 children with CP (51.7%). 3 patients had complete dislocation of the hip (1.4%). There was an increased prevalence of hip subluxation noted with increasing GMFCS E&R score as well as increasing topographical distribution, which were both statistically significant on univariate analysis (p < 0.005). On multivariate analysis, it was found that neither topographical distribution nor GMFCS E&R score were independent risk factors.

Conclusions

Hip subluxation is a significant, debilitating and common treatable complication in children with CP. Subjects with widespread topographical distribution and poor functional ambulatory status are at an increased risk of developing hip subluxation. There also exists a correlation between GMFCS scores and topographical classification and hence, neither are risk factors independent of each other. This study is a first of its kind in the Indian scenario and it hopes to be a step in the direction towards risk stratification, early diagnosis and prompt specific treatment of hip complications in children with cerebral palsy.

Developmental Dysplasia of the Hip: Prevalence and Correlation with Other Diagnoses in Physiotherapy Practice-A 5-Year Retrospective Review

(1) Background: The objective of this study was to assess the prevalence of Developmental Dysplasia of the Hip (DDH) as a primary or secondary diagnosis during physiotherapy practice. No other studies have investigated the prevalence and associations of DDH within the practice of pediatric rehabilitation. (2) Methods: This retrospective review was performed on 12,225 physiotherapy referrals to the King Abdullah Specialized Children’s Hospital (KASCH), Riyadh, Kingdom of Saudi Arabia, from May 2016 to October 2021. Only DDH referrals for conservative treatment were included in the study. The plan for brace treatment was carried out by the pediatric orthopedics clinic in KASCH. The diagnostic methods were either a pelvic radiograph or ultrasound, depending on the participant’s age. DDH is considered one of the most common secondary complications for children with other medical diagnoses. (3) Results: The most common indication for referral was neurological diagnosis (44%), followed by orthopedic (28%), genetic (19%), cardiac (5%), ophthalmologic (3%), dermatologic (1%) and rheumatologic (0.5%) diagnoses. (4) Conclusion: The prevalence of DDH among all referrals in this study was 6%. In physiotherapy practice, neurologic, genetic, and orthopedic primary or secondary diagnoses were the most prevalent when DDH referrals were investigated. A relatively high prevalence of DDH in the pediatric rehabilitation clinic at KASCH in Riyadh was reported in this study.

Guided Growth of the Proximal Femur for the Management of Hip Dysplasia in Children With Cerebral Palsy

BACKGROUND

Progressive hip displacement is one of the most common and debilitating deformities seen in children with cerebral palsy (CP). The aim of this study was to evaluate the results of temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF) using a transphyseal screw to control hip migration during growth in children with CP.

METHODS

This was a retrospective study of children with CP and hip dysplasia, age 4 to 11 years and GMFCS levels III-V. There were 28 patients with 56 hips that underwent TMH-PF surgery between 2007 and 2010. Clinical and radiologic evaluation was performed preoperatively, at 6, 12, and 60 months following the index surgery. Acetabular index (AI), neck-shaft angle (NSA) and migration percentage (MP) were measured. All complications were recorded.

RESULTS

All radiographic measurements were significantly improved at the final follow-up. Positive correlations were found between NSA, MP, and AI. Multiple regression analysis revealed that MP, time from surgery, and age were influenced by the decrease of the NSA. The femoral physis grew off the screw in 9 hips within 36 months. The screw head broke during attempted screw exchange in 1 hip. The remain cases (4 hips) were treated by placing a second screw parallel to the existing one. Finally, progressive subluxation occurred in 3 hips when the physis grew off the screw and were treated by skeletal reconstruction.

CONCLUSIONS

TMH-PF was effective in controlling progressive subluxation of the hip in the majority of cases, obviating the need for major reconstructive surgery in these children with CP.

LEVEL OF EVIDENCE

Level IV.

Guided Growth of the Proximal Femur for Hip Displacement in Children With Cerebral Palsy

BACKGROUND

Guided growth by 1 eccentric transphyseal screw has been used to correct lower limb deformities. Pilot animal studies showed encouraging results in producing varus deformity in the proximal femur. The purpose of this study was to report the preliminary results of guided growth surgery to treat spastic hip displacement.

METHODS

This case series study included consecutive patients who received soft-tissue release and guided growth at the proximal femur from January 2004 to May 2012 with minimal 2-year follow-up. Surgical indications were children with spastic cerebral palsy aged 4 to 10 years, a gross motor function classification system level IV or V, and hip displacement on 1 or both sides. Study outcomes were Reimer's migration percentage (MP) and the head-shaft angle (HSA).

RESULTS

Nine children with 13 spastic displaced hips received surgery at the age of 6.2 years and were followed up for a mean of 45.6 months. The mean MP improved significantly from 52.2% preoperatively to 45.8% at 3 months, 40.3% at 1 year, and 37.1% at 2 years after operation. HSA was unchanged in the first 3 months, and deceased from 173.3 to 166.4 degrees at 1 year (P<0.01) and to 162.7 degrees at 2 years postoperatively. The screw was usually backed out from the femoral epiphysis in the second postoperative year, and no radiologic bony bar or other surgical complications occurred.

CONCLUSIONS

The immediate postoperative improvement of MP was the result of soft-tissue release. From postoperative 3 months to 2 years, the HSA was reduced by 10.6 degrees and the MP further improved by 8.7%. Less surgical dissection, faster recovery of motion, and less comorbidity than varus osteotomy make guided growth surgery a treatment option for coxa valga in spastic hip displacement in nonambulant cerebral palsy children.

LEVEL OF EVIDENCE

Level IV-therapeutic, case series.

The Effects of a Home-Based Connective Tissue Targeting Therapy on Hip Development in Children With Cerebral Palsy: Six Case Reports

Hip subluxation in children with Cerebral Palsy (CP) has an incidence of 10-30 %, and children with severe CP having the highest incidence. The condition deteriorates if left untreated. Surgery is the most common method used in managing hip subluxation because standard conservative therapies do not improve it. Surgery may have to be repeated and comes at a biological cost to the child. A new home-based CAM, Advanced Biomechanical Rehabilitation (ABR), has shown encouraging results leading to improved spinal stability and stability in sitting in children with severe CP. This case report examines hip development over time in six children with severe CP in the ABR Program. Changes in their clinical picture and pelvic X-Rays are reported. ABR appeared to help stabilize and improve hip subluxation, resulting in these children not requiring further surgical intervention. These findings warrant further investigation of ABR as a noninvasive therapy for hip subluxation.

[The hip joint in neuromuscular disorders]

Physiologic motor and biomechanical parameters are prerequisites for normal hip development and hip function. Disorders of muscle activity and lack of weight bearing due to neuromuscular diseases may cause clinical symptoms such as an unstable hip or reduced range of motion. Disability and handicap because of pain, hip dislocation, osteoarthritis, gait disorders, or problems in seating and positioning are dependent on the severity of the disease, the time of occurrence, and the means of prevention and treatment. Preservation of pain-free and stable hip joints should be gained by balancing muscular forces and by preventing progressive dislocation. Most important is the exact indication of therapeutic options such as movement and standing therapy as well as drugs and surgery.