Migration percentage and odds of recurrence/subsequent surgery after treatment for hip subluxation in pediatric cerebral palsy: A meta-analysis and systematic review

Agarwal, Kavita; Chen, C; Scher, David M.; Dodwell, Emily

doi:10.1302/1863-2548.13.190064

Cited by 21 publications

(33 citation statements)

References 65 publications

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“…However, adductor surgery alone was associated with similar survivorship as having no prior surgery, highlighting the importance of osseous procedures in the treatment of hip displacement in CP. Similarly, in their systematic review, Agarwal et al 29 used pooled odds ratios to compare proximal femoral osteotomy with hip adductor surgery alone, finding an 80% decrease in recurrence risk for osseous procedures.…”

Section: Discussionmentioning

confidence: 99%

Hip Displacement After Triradiate Cartilage Closure in Nonambulatory Cerebral Palsy

Asma¹,

Ulusaloğlu²,

Shrader³

et al. 2022

Journal of Bone and Joint Surgery

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Background:Recommendations with regard to the need for continued hip surveillance after skeletal maturity are based on expert opinion rather than evidence. This study aimed to determine the prevalence of and risk factors associated with progressive hip displacement in cerebral palsy (CP) after triradiate cartilage (TRC) closure.Methods:Patients who had spastic nonambulatory CP (Gross Motor Function Classification System IV to V) and hypertonic (spastic or mixed-type) motor type and follow-up of at least 2 years after TRC closure were included. The primary outcome variable was the hip migration percentage (MP). The secondary outcome variables included patient age at the time of TRC closure, prior preventative or reconstructive surgery, a prior intrathecal baclofen pump, history of scoliosis, history of epilepsy, a prior gastrostomy tube, a previous tracheostomy, and gender. An unsuccessful hip outcome was defined as a hip with an MP of ≥40% and/or requiring a reconstructive surgical procedure after TRC closure.Results:In this study, 163 patients met the inclusion criteria, with a mean follow-up of 4.8 years (95% confidence interval [CI], 4.4 to 5.1 years) after TRC closure at a mean patient age of 14.0 years (95% CI, 13.7 to 14.3 years). Of these hips, 22.1% (36 of 163) had an unsuccessful hip outcome. In multivariate analysis, the first MP at TRC closure (hazard ratio [HR] per degree, 1.04; p < 0.001) and pelvic obliquity (HR per degree, 1.06; p = 0.003) were independent risk factors for an unsuccessful hip outcome, but gender was not found to be significant (HR for male gender, 1.7 [95% CI, 0.8 to 3.58; p = 0.16]; female gender was the reference). However, the mean survival time for progression to an unsuccessful hip outcome was longer for female patients at 9.2 years [95% CI, 8.1 to 10.2 years]) compared with 6.2 years (95% CI, 5.6 to 6.9 years) for male patients (p = 0.02). There was also a significant improvement in survivorship for prior reconstructive surgical procedures (p = 0.002). The survivorship in patients who underwent reconstructive surgery performed at a patient age of ≥6 years was significantly higher compared with those who underwent surgery performed at <6 years of age (p < 0.05). A first MP at TRC closure of ≥35% was associated with an unsuccessful hip outcome, as determined by receiver operating characteristic (ROC) curve analysis (p < 0.001; area under the ROC curve of 0.891, sensitivity of 81%, and specificity of 94%).Conclusions:The risk factors for the progression of hip displacement after TRC closure in patients with CP included a higher MP and increased pelvic obliquity; there was decreased survivorship for male patients and patients with no prior reconstructive surgery. Patients with these risk factors and/or an MP of ≥35% at TRC closure should have continued radiographic surveillance to detect late hip displacement.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Section: Discussionmentioning

confidence: 99%

Hip Displacement After Triradiate Cartilage Closure in Nonambulatory Cerebral Palsy

Asma¹,

Ulusaloğlu²,

Shrader³

et al. 2022

Journal of Bone and Joint Surgery

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“…Despite that the study was underpowered, our overall reported failure rates are important to consider as previous studies report failure rates after hip reconstruction between 8% and 74%. [10][11][12][13][14] The definition of failure in this study is conservative as we utilized a threshold MP of ≥ 30% to define resubluxation, whereas many studies use a MP > 50%. Using the expanded criteria to define failure, 8 hips in our cohort met failure criteria, leading to an adjusted failure rate of 4.1% for the total cohort.…”

Section: Discussionmentioning

confidence: 99%

Can Over-containment Prevent Recurrence in Children With Cerebral Palsy and Hip Dysplasia Undergoing Hip Reconstruction?

Zakrzewski¹,

Bryant

McCarthy³

2022

Journal of Pediatric Orthopaedics

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Introduction: Hip reconstruction is often necessary in children with cerebral palsy (CP) but is associated with high failure rates. Over-containment deeply seats the hip within the acetabulum at the time surgical reconstruction. The goal of this study is to evaluate the effect of over-containment on radiographic outcomes and failure rates in children with CP undergoing hip reconstruction. Methods: This study is a retrospective chart review of children with CP that underwent hip reconstruction between 2010 and 2019 with at least 2 years of radiographic follow-up. Migration percentage (MP), acetabular index (AI), and neck shaft angle (NSA) were recorded preoperatively, postoperatively and throughout follow-up. Failures were defined as a MP at latest follow-up ≥30% or need for revision hip reconstruction. Hips were divided into groups based on postoperative MP—group 1 (over-containment group) had a MP≤0% and group 2 had an MP>0%. Radiographic parameters and failure rates were compared across Gross Motor Functional Classification Score (GMFCS) level, age at the time of surgery, and degree of preoperative subluxation. Results: A cohort of 108 patients (197 hips) with an average age of 7.3±3.2 years met inclusion criteria with an average follow-up of 49.6 months (range: 24 to 118 mo). There were 147 hips in group 1 and 50 hips in group 2. At latest follow-up, group 1 demonstrated lower MP, AI, and NSA in comparison to group 2. The overall failure rate in our cohort was 8.1% (16 hips). Failure rates trended lowest in hips that were over-contained (6.1% v. 14.0%) although not statistically significant. Over-containment resulted in significantly lower failure rates in GMFCS IV/V hips, children under age 6 at the time of surgery and those with a higher degree of preoperative hip displacement (MP>50%). Conclusions: Over-containment at the time of hip reconstruction can positively affect radiographic outcomes and failure rates in children with CP. Over-containment should be considered in hips at high risk of failure, especially non ambulatory children with significant hip subluxation at an early age. Level of Evidence: Level III—retrospective comparative study.

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“…Given that high rates of recurrent subluxation are seen after hip reconstruction, consideration should be had to include PFSH at the time of hardware removal to maintain the correction obtained with the previous hip reconstruction. [19][20][21][22][23] Just like the guided growth techniques used for deformities around the knee, children that undergo PFSH require close follow-up. In our cohort, the proximal femoral physis frequently grew off the screw between 1 and 2 years postoperatively.…”

Section: Discussionmentioning

confidence: 99%

Proximal Femoral Screw Hemiepiphysiodesis in Children With Cerebral Palsy Improves the Radiographic Measures of Hip Subluxation

Zakrzewski

McCarthy

2022

Journal of Pediatric Orthopaedics

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Background: Proximal femoral screw hemiepiphysiodesis (PFSH) is a promising technique for treatment of hip subluxation in children with cerebral palsy (CP). The aim of this study is to report radiographic outcomes of PFSH and to evaluate its role in changing the natural history of hip displacement in children with CP. Methods: This is a single center retrospective chart review of children with CP that underwent PFSH with at least 2 years of radiographic follow-up. Demographic information, surgical details, complications, additional surgical procedures, and need for screw exchange were recorded. Radiographs were assessed for migration percentage (MP), neck shaft angle (NSA), head shaft angle (HSA), and articular trochanter distance preoperatively as well as at 6 months, 1 year, 2 year, and latest follow-up postoperatively. Hips were divided into group 1 (no previous hip surgery) and group 2 (PFSH performed after hip reconstruction). Hips with 2 years of preoperative radiographic data were included in the natural history cohort. Results: Twenty-three patients (44 hips) met inclusion criteria with an average age of 7.3±1.7 years and a mean follow-up of 33.5 months. Group 1 and group 2 had 32 and 12 hips, respectively. Group 1 had significant improvement in all parameters (ΔMP=5%, ΔNSA=13 degrees, ΔHSA=15 degrees) group 2 showed improvements in NSA and HSA (ΔNSA=4 degrees ΔHSA=8 degrees) with only HSA reaching significance and MP remaining unchanged. All radiographic measurements worsened in the 2 years before surgery (N=25, natural history group) and improved after PFSH. Screw exchange occurred in 12 hips (27.2%) at an average of 33 months (range 27 to 42 mo) with 2 hips also undergoing pelvic osteotomy at that time. Three hips had a MP >50% at follow-up with 2 hips in group 1 undergoing hip reconstruction. No complications were noted. Conclusion: PFSH effectively alters proximal femoral growth and can improve hip subluxation in children with CP. Screws often need to be exchanged and hips should be carefully monitored. Level of Evidence: Level III—retrospective comparative study.

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Migration percentage and odds of recurrence/subsequent surgery after treatment for hip subluxation in pediatric cerebral palsy: A meta-analysis and systematic review

Cited by 21 publications

References 65 publications

Hip Displacement After Triradiate Cartilage Closure in Nonambulatory Cerebral Palsy

Hip Displacement After Triradiate Cartilage Closure in Nonambulatory Cerebral Palsy

Can Over-containment Prevent Recurrence in Children With Cerebral Palsy and Hip Dysplasia Undergoing Hip Reconstruction?

Proximal Femoral Screw Hemiepiphysiodesis in Children With Cerebral Palsy Improves the Radiographic Measures of Hip Subluxation

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