Journal of Pediatric Rehabilitation Medicine

Introduction: The purpose of this study was to evaluate the long term results of 19 painful dislocated hips in patients with spastic cerebral palsy (CP) who were treated with hip arthrodesis and internal fixation.

Patients and Methods: The study included 19 patients with spastic CP with a mean age of 17 years and five months (min 10+11 and max 30+8) at the time of surgery. There were 11 tetraplegics, 5 diplegics, 2 diplegics with athetosis, and one hemiplegic. Functionally, 4 patients were community ambulators, 2 were household, and 13 were non-ambulators. Six patients had previous hip procedures prior to arthrodesis. The main surgical indications were pain and too much joint destruction to reconstruct the hip. The mean follow-up period was 11 years and one month.

Results: All patients showed bone union and pain relief, and postural improvement was seen in almost all patients. Four patients needed revision, with implant change and bone graft for delayed union. In two cases, the hip arthrodesis ended up being converted into a Castle procedure due to difficulties in positioning and/or increasing spinal deformity.

Conclusion: Hip arthrodesis is a reasonable option in treating painful spastic subluxated and dislocated hips in CP, primarily in unilateral cases and in patients with ambulatory ability.

Progressive hip displacement is the second most common deformity in children with cerebral palsy (CP) [1]. 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 [2,3]. 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' ('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.

Objective: The aim of this study was to investigate the relationship between hip displacement (HD) in individuals with severe cerebral palsy with function and quality of life (QOL). The second aim was to identify differences in these outcomes when comparing surgical and non-surgical management for HD.

Design: Cross-sectional study of 26 participants born between 1988 and 1998 who had hip displacement on their most recent hip radiograph.

Method: Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD©) questionnaire. Hip migration percentage and a validated hip classification were used.

Results: Significant positive correlation coefficients (CC) were found for mobility and comfort (CC=0.620, ρ = 0.001) as well as for QOL and comfort (CC=0.683, ρ < 0.001). Orthopedic hip surgery was associated with better scores for mobility (median [95% CI]); surgery vs. none; (36.1 [27.7, 44.4]) vs (25.6 [22.2, 29.8]) and personal care, (32.1 [27.1, 43.2]) vs (25.9 [22.7, 30.8]). Severity of HD had no significant association with comfort or QOL.

Conclusion: Mobility and personal care scores were significantly better in children who had undergone reconstructive hip surgery. However, QOL and pain scores were not associated with the severity of hip displacement or undertaking reconstructive hip surgery.

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 movement pain was identified in 13 (32.5%) of 40 children and young adults with cerebral palsy who were in residential care. All of the participants were non-ambulatory (Level IV and V of the GMFCS), and their ages ranged from 8 to 26 years (median 16.5 years). Ten of the 13 participants had unilateral hip dislocation and three had bilateral dislocations. Degenerative hip changes were identified on radiographs of the painful dislocated hips. The occurrence of pain during a daily episode of washing, dressing, and transfer was recorded using non-verbal indicators. Washing of the lower body elicited significantly more pain responses than dressing (p=0.008) and transfer (p< 0.001). None of the participants had daily pain during all of the care activities. Pain was present in 1/3 of the patients and was intermittent in nature, indicating that conservative management can be considered for persons with cerebral palsy at Levels IV and V of the GMFCS who have established hip dislocations and this type of pain. This management could include medication, attention to seating and positioning, and careful handling during daily care activities.

For ambulatory children with cerebral palsy, the assessment of walking energy efficiency is utilized to determine functional changes following surgical, pharmacologic, or orthotic interventions. While the assessment of energy efficiency is considered a useful outcome tool, minimal information exists about the changes in energy efficiency over one year in children with cerebral palsy at different gross motor function classification system (GMFCS) levels and whether the patterns of change are similar to their able-bodied peers. The purpose of this study was to determine whether energy efficiency variables change similarly over one year in children with cerebral palsy by GMFCS level and whether they differ from their age-matched peers. Forty-five able-bodied children and 34 children with cerebral palsy, GMFCS levels I-III participated in the study. Energy efficiency variables were measured at baseline and at 12 months using a Cosmed K4b $^{2}$ . All subjects walked at their self-selected velocity for testing around a 33m track. Baseline velocity and net non-dimensional cost (NNcost) differed by GMFCS level and between the able-bodied peers and all GMFCS levels. Children in GMFCS level III had the highest cost and the slowest velocity. When controlling for age and baseline values, significant differences in the magnitude of change were seen in velocity between children in GMFCS level III and children in GMFCS level I and II and their able-bodied peers. In comparison to their able-bodied peers, all GMFCS levels had an increase in NNcost over one year when controlling for age and baseline NNcost, with the difference in magnitude increasing by GMFCS level. Consistent with the literature, children with cerebral palsy had an increase in NNcost over one year in comparison to their able-bodied peers, which increased with GMFCS level. This finding demonstrates that when evaluating the change in walking energy efficiency with maturation and therapeutic intervention, comparisons should be made by GMFCS level.