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Imerci A, Miller F, Howard JJ, Shrader MW. Prevalence and Treatment of Surgical Complications Following Proximal Femoral Osteotomies in Children with Cerebral Palsy: An Analysis of 1085 Hips. Indian J Orthop 2024; 58:669-679. [PMID: 38812872 PMCID: PMC11130098 DOI: 10.1007/s43465-024-01144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/24/2024] [Indexed: 05/31/2024]
Abstract
Purpose Proximal femoral osteotomy (PFO) is a reconstructive surgical option used to improve hip containment or correct internal hip rotation gait in children with cerebral palsy (CP). A few reports describe the risk of surgical complications after PFO. The purpose of this study was to determine the risk factors associated with adverse postoperative surgical outcomes in pediatric patients with CP following PFO and to report the treatment of complications. Methods Following institutional review board approval, 1085 (1003 primary and 82 secondary) PFO procedures were retrospectively reviewed in 563 children with CP with at least 1 year of follow-up after final surgery over an 18-year follow-up period. Demographic characteristics, motor type, gross motor function classification system (GMFCS) level, medical comorbidities, feeding tube status, seizure history, intervention type, and prevalence of PFO-related surgical complications and associated treatments were evaluated. Multivariate regression analysis was performed to determine risk factors for all surgical complications. Results During a 5.8-year (± 3.8 years) follow-up, at least 1 surgical complication was identified in 143 (13.1%) hips in 121 (21.5%) patients after PFO in children with CP. Of these complications, the most common was heterotopic ossification (65 [6%] of hips); most of which were asymptomatic and required no treatment. Other complications included 25 (2%) nonunions, 21 (2%) deep or superficial infections, 13 (1%) delayed unions, 12 (1%) peri-implant fractures, and 7 early implant failures (0.64). The rate of revision surgery due to these complications was 13.1% (6.8% of hips), of which 41% (30 revision surgeries) were for the treatment of nonunion. Regarding the development of delayed union or nonunion, dystonia, GMFCS level IV/V, and seizure history were identified as risk factors by multivariate analysis. Conclusions The prevalence of surgical complications after PFO was 13.1% with 6.8% of hips requiring revision surgery. Dystonia, seizure history, and nonambulatory status were the strongest predictors for the need for revision surgery after PFO. These data can be used to help counsel patients and families regarding the risks associated with PFO for children with CP.Level of proof: IV; retrospective study.
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Affiliation(s)
- Ahmet Imerci
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware Valley, Wilmington, DE USA
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
- Nemours Children’s Health, Delaware Valley, Wilmington, Delaware, USA
| | - Freeman Miller
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware Valley, Wilmington, DE USA
- Nemours Children’s Health, Delaware Valley, Wilmington, Delaware, USA
| | - Jason J. Howard
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware Valley, Wilmington, DE USA
- Nemours Children’s Health, Delaware Valley, Wilmington, Delaware, USA
| | - M. Wade Shrader
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware Valley, Wilmington, DE USA
- Nemours Children’s Health, Delaware Valley, Wilmington, Delaware, USA
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Deo NB, Agarwal A. Does Acetabulum Remodel Following Varus Derotation Osteotomy for Perthes' Disease? Rev Bras Ortop 2023; 58:e639-e645. [PMID: 37663180 PMCID: PMC10468242 DOI: 10.1055/s-0043-1772242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/05/2023] [Indexed: 09/05/2023] Open
Abstract
Objective We investigated the effect of disease stage, patient's age and final contour of femoral head on acetabulum contour following varus derotation osteotomy of proximal femur (VDRO) in unilateral Perthes's disease. Methods The study is a retrospective analysis of case records of 23 children aged ≥6 years with unilateral Perthes' disease who underwent primary VDRO procedure for containment. Acetabular index (AI) and center edge angle (CEA) were calculated bilaterally in preoperative and follow-up radiographs and compared statistically. Results There were 15 boys and 8 girls. Six hips were in Ib, 8 in IIa and 9 in IIb modified Waldenström stage while undergoing VDRO. The mean age at surgical intervention was 8.7 years. The mean follow-up duration was 3.5 years. All femoral heads were healed at final follow-up and the final Stulberg grades were I = 3, II = 8, III = 7, IV = 5. A significant acetabular dysplasia on the affected side was present preoperatively. At follow-up, the patients operated had significantly raised AI and reduced CEA. There was no significant acetabular remodeling of the affected hips at follow-up even in children operated at younger age (< 8 years) or early stages (stage Ib or IIa). The acetabulum remodeling did not correspond to the final Stulberg grade as well. Conclusion Acetabulum was found involved in early stages of Perthes' disease. Varus derotation femoral osteotomy for the diseased hip showed no significant improvement in acetabular dysplasia even when operated in early disease stages or younger age group. Residual acetabular changes were also noted even with favorable Stulberg grades.
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Affiliation(s)
- Nitish Bikram Deo
- Médico Ortopedista, Hospital Universitário Tribhuvan, Maharajgunj Medical Campus, Instituto de Medicina, Maharajgunj, Kathmandu, Nepal
| | - Anil Agarwal
- Médico Ortopedista, Departamento de Ortopedia Pediátrica, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, IÍndia
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Vasconcellos AL, Tagawa AS, Rhodes JT, Silveira LJ, Skinner AA, Frumberg DB. Postoperative Immobilization After Hip Reconstruction in Cerebral Palsy: No Difference Between Hip Spica and Abduction Pillow. Front Surg 2022; 9:863287. [PMID: 36034398 PMCID: PMC9407031 DOI: 10.3389/fsurg.2022.863287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose This study aims to compare radiographic outcomes and complication rates of immobilization with an abduction pillow to spica casting for postoperative care after a hip reconstruction with varus derotational proximal femur osteotomy (VDRO) with or without pelvic osteotomy for children with cerebral palsy (CP). Methods 233 children (1–18 years old) diagnosed with CP that underwent VDRO with or without pelvic osteotomy were identified, of which 188 patients were immobilized with a spica cast and 45 were immobilized with an abduction pillow, based on surgeon preference. 123 (65%) in the Spica group and 21 (47%) in the pillow group had pelvic osteotomies. Demographic data and complication rates were collected. Radiographic parameters, including anatomic medial proximal femoral angle (aMPFA), acetabular index (AI) and migration percentage (MP), were measured for each patient at the completion of surgery, six weeks post-operatively, and one year post-operatively. Results There was not a statistically significant difference in BMI (p = 0.285), gender distribution (p = 0.984), or median follow-up time (p = 0.314) between groups. Rates of complications were consistent among groups with no differences in instances of delayed unions (p = 0.10), subluxations (p = 0.55), infection (p = 0.71), or non-unions (p = 0.10). There was no statistically significant difference in number of patients with an ideal aMPFA, AI, or MP (p = 0.44, p = 0.19, p = 1.00) at one year post-operatively. Conclusions Immobilization with an abduction pillow is a safe and effective alternative to hip spica casting following hip reconstruction.
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Affiliation(s)
- Alexander L. Vasconcellos
- Department of Orthopaedic Surgery, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Alex S. Tagawa
- Center for Movement and Gait Analysis, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, United States
| | - Jason T. Rhodes
- Center for Movement and Gait Analysis, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, United States
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Lori J. Silveira
- Department of Pediatrics, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, United States
| | - Austin A. Skinner
- Center for Movement and Gait Analysis, Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, United States
| | - David B. Frumberg
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, United States
- Correspondence: David B. Frumberg
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Badina A, du Cluzel de Remaurin X, Khouri N. Long-term outcomes of hip reconstruction surgery in children with GMFCS III diplegic cerebral palsy. Orthop Traumatol Surg Res 2022; 109:103344. [PMID: 35660081 DOI: 10.1016/j.otsr.2022.103344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The results of hip reconstruction surgery are known for non-walking (GMFCS IV and V) and walking (GMFCS I and II) patients. Few studies deal with GMFCS III patients in isolation. Their intermediate functional status can be deteriorated by asymmetrical contractures, hip dislocation, multi-level deformities of the lower limbs, leading to motor function degradation, and possibly losing their ability to walk. The aim of our study was to establish whether surgical results were maintained over time and whether the functional status changed. MATERIAL AND METHODS Fifteen patients with GMFCS III spastic diplegia, treated for hip subluxation, were reviewed. The mean age at the time of surgery was 10 years old. The mean follow-up after surgery was 11 years. Reconstructive surgery was performed on 21 hips including pelvic osteotomy in all cases, with associated femoral osteotomy in 19 cases. Clinical (pain, joint mobility, walking aids, walking distance, GMFCS level) and radiological data (Melbourne Cerebral Palsy Hip Classification, standard coxometry) were recorded preoperatively and at the last follow-up. RESULTS Preoperatively, 6 patients were losing their ability to walk due to pain and flexion-adduction contracture. At the last follow-up, no patients had pain and joint mobility was improved in all cases. For one patient, recovery to their previous functional state required a period of two years. In the long term, 14 patients were GMFCS III and only one patient was GMFCS IV due to reasons unrelated to hip surgery. The radiological parameters improved significantly. The Melbourne score was IV preoperatively for all patients. At the last follow-up, 10 hips were grade I, 6 hips were grade II and 5 hips were grade III. DISCUSSION Correction of architectural disorders of the subluxed hip by pelvic osteotomy, in most cases associated with femoral osteotomy, improves functional and radiological status for GMFCS III patients. This improvement is maintained in the long-term. Complementary surgeries correcting the other deformities of the lower limbs were necessary in more than half of the patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alina Badina
- Service de chirurgie orthopédique pédiatrique, Hôpital Necker Enfants Malades, Université Paris Descartes, 149, rue de Sèvres, 75015 Paris, France
| | - Xavier du Cluzel de Remaurin
- Service de chirurgie orthopédique pédiatrique, Hôpital Necker Enfants Malades, Université Paris Descartes, 149, rue de Sèvres, 75015 Paris, France
| | - Nejib Khouri
- Service de chirurgie orthopédique pédiatrique, Hôpital Necker Enfants Malades, Université Paris Descartes, 149, rue de Sèvres, 75015 Paris, France.
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Angelis S, Vynichakis G, Trellopoulos A, Apostolopoulos A, Filippou D, Salmas M, Chandrinos M, Balfousias T, Palaiodimos L, Kyriazi N, Michelarakis J. Derotational Subtrochanteric Osteotomy and External Fixation for the Treatment of Neurogenic Hip Dislocation in Children with Cerebral Palsy: Could This Be a Viable Method of Treatment? Cureus 2020; 12:e7437. [PMID: 32351817 PMCID: PMC7186101 DOI: 10.7759/cureus.7437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The treatment of painful and chronic dislocated hip in children with severe cerebral palsy (CP) is particularly demanding and controversial. Numerous surgical techniques have been described, and their outcomes vary a lot. The purpose of the present study is to evaluate a new method, which combines varus derotational subtrochanteric osteotomy (VDSO) and external osteosynthesis: (VDSOEO). Methods Six non-ambulatory children with spastic quadriplegia and chronic dislocated painful hips were treated. The technique involved a small incision on the subtrochanteric site of the osteotomy, followed by retention with a single-sided external osteosynthesis with rotational correction capability [swiveling clamp (SC)] for the reduction of the femur head in the acetabulum, and finally by the osteotomy. Hardware was removed without a second intervention four-six months postoperatively and after the osteotomy was healed. Evaluation of the method was based on clinical, functional, and radiological criteria. Results Four patients achieved improved radiological scores. Two patients demonstrated resubluxation during the period of the osteotomy's healing process. However, no patients experienced pain, and all were able to sit post-surgery, while caregivers reported improved capacity for nursing care. Conclusions It is our strong belief that this approach can improve the quality of life in children with severe CP and painful and chronic dislocated hips. It is a viable and definitely less invasive procedure than classic pelvic or femur osteotomies.
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Affiliation(s)
- Stavros Angelis
- Surgical Anatomy, National and Kapodistrian University of Athens Medical School, Athens, GRC
- Orthopaedics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
- Orthopaedics, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, GRC
| | - Georgios Vynichakis
- Orthopaedics, General Hospital of Piraeus Tzaneio, Piraeus, GRC
- Orthopaedics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
- Surgical Anatomy, National and Kapodistrian University of Athens Medical School, Athens, GRC
| | - Angelos Trellopoulos
- Orthopaedics, Hygeia Hospital, Athens, GRC
- Orthopaedics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
| | - Alexandros Apostolopoulos
- Orthopaedics, East Surrey Hospital/Surrey and Sussex Healthcare National Health Service Trust, Redhill, GBR
| | - Dimitrios Filippou
- Surgery, National and Kapodistrian University of Athens Medical School, Athens, GRC
| | - Marios Salmas
- Orthopaedics, National and Kapodistrian University of Athens Medical School, Athens, GRC
| | - Michail Chandrinos
- Orthopaedics, General Hospital of Piraeus Tzaneio, Piraeus, GRC
- Orthopaedics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
| | | | - Leonidas Palaiodimos
- Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York, USA
| | - Niki Kyriazi
- Orthopaedics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
| | - John Michelarakis
- Orthopaedics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
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Park H, Abdel-Baki SW, Park KB, Park BK, Rhee I, Hong SP, Kim HW. Outcome of Femoral Varus Derotational Osteotomy for the Spastic Hip Displacement: Implication for the Indication of Concomitant Pelvic Osteotomy. J Clin Med 2020; 9:jcm9010256. [PMID: 31963548 PMCID: PMC7020049 DOI: 10.3390/jcm9010256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/05/2020] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
No previous studies have suggested a reliable criterion for determining the addition of a concomitant pelvic osteotomy by using a large patient cohort with quadriplegic cerebral palsy and a homogenous treatment entity of femoral varus derotational osteotomies (VDRO). In this retrospective study, we examined our results of hip reconstructions conducted without a concomitant pericapsular acetabuloplasty in patients with varying degrees of hip displacement. We wished to investigate potential predictors for re-subluxation or re-dislocation after the index operation, and to suggest the indications for a simultaneous pelvic osteotomy. We reviewed the results of 144 VDROs, with or without open reduction, in 72 patients, at a mean follow-up of 7.0 (2.0 to 16.0) years. Various radiographic parameters were measured, and surgical outcomes were assessed based on the final migration percentage (MP) and the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS) grades. The effects of potential predictive factors on the surgical outcome was assessed by multivariate regression analysis. A receiver operating characteristic (ROC) curve analysis was also performed to determine whether a threshold of each risk factor existed above which the rate of unsatisfactory outcomes was significantly increased. In total, 113 hips (78.5%) showed satisfactory results, classified as MCPHCS grades I, II, and III. Thirty-one hips (21.5%) showed unsatisfactory results, including six hip dislocations. Age at surgery and preoperative acetabular index had no effects on the results. Lower pre- and postoperative MP were found to be the influential predictors of successful outcomes. The inflection point of the ROC curve for unsatisfactory outcomes corresponded to the preoperative MP of 61.8% and the postoperative MP of 5.1%, respectively; these thresholds of the pre- and postoperative MP may serve as a guideline in the indication for a concomitant pelvic osteotomy. Our results also indicate that the severely subluxated or dislocated hip, as well as the hip in which the femoral head is successfully reduced by VDRO but is still contained within the dysplastic acetabulum, may benefit from concomitant pelvic osteotomy.
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Affiliation(s)
- Hoon Park
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea; (H.P.); (S.-P.H.)
| | - Sharkawy Wagih Abdel-Baki
- Department of Orthopaedic Surgery, Aswan University Hospital, Aswan University Faculty of Medicine, Aswan 81528, Egypt;
| | - Kun-Bo Park
- Division of Pediatric Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea;
| | - Byoung Kyu Park
- Department of Orthopaedic Surgery, Inje University Haeundae Paik Hospital, Busan 48108, Korea;
| | - Isaac Rhee
- Medical Course, University of Melbourne, Melbourne Medical School, Melbourne 3010, Australia;
| | - Seung-Pyo Hong
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea; (H.P.); (S.-P.H.)
| | - Hyun Woo Kim
- Division of Pediatric Orthopaedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea;
- Correspondence: ; Tel.: +82-2-2228-2180
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Agarwal KN, Chen C, Scher DM, Dodwell ER. Migration percentage and odds of recurrence/subsequent surgery after treatment for hip subluxation in pediatric cerebral palsy: a meta-analysis and systematic review. J Child Orthop 2019; 13:582-592. [PMID: 31908675 PMCID: PMC6924128 DOI: 10.1302/1863-2548.13.190064] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This meta-analysis aims to systematically assess and quantitatively pool the best clinical evidence for migration percentage (MP) and odds ratio (OR) for recurrence/reoperation following treatment for hip subluxation in children with cerebral palsy (CP), including Botulinum Toxin A (BNT-A), soft-tissue lengthening and osteotomies. METHODS Pubmed, EMBASE and Cochrane were systematically searched from between 1 January 1953 and 11 January 2017 inclusive for studies reporting resubluxation/reoperation rates, and/or MP following treatment for hip subluxation in children with CP. The primary outcome was odds of resubluxation/reoperation. The secondary outcome was change in MP. Studies were graded for quality using the Newcastle Ottawa Scale. This meta-analysis was performed and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS A total of 14 studies were included in analysis of odds of resubluxation/reoperation and 24 studies were included in analysis of MP. The OR for resubluxation/reoperation was lower for combined osteotomies compared with femoral (OR = 0.49; 95% confidence interval (CI) 0.25 to 0.98) and for femoral osteotomy compared to soft-tissue procedures (OR = 0.20; 95% CI 0.07 to 0.61). There was no difference in odds of recurrence/reoperation between pelvic and femoral osteotomies (OR = 2.27; 95% CI 0.37 to 13.88). Combined osteotomies provided the greatest improvement in MP, while BoNT-A showed no improvement in MP. CONCLUSION Resubluxation/reoperation rates are high; management with osteotomies is preferred to soft-tissue procedures alone in preventing resubluxation/reoperation. This meta-analysis is limited by the observational nature and small sample sizes of many of the included studies, with their inherent risk of bias and lack of homogeneity of patient characteristics at baseline. It is possible that with larger and higher quality studies, the results and conclusions of this analysis may be altered.
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Affiliation(s)
- K. N. Agarwal
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - C. Chen
- Columbia University Medical Center, New York, USA
| | | | - E. R. Dodwell
- Hospital for Special Surgery, New York, USA,Correspondence should be sent to Dr. E. Dodwell, Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, USA. E-mail:
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Abstract
BACKGROUND Derotational osteotomy of the proximal femur has proved to be effective in the treatment of residual acetabular dysplasia. However, the reason why this osteotomy is effective remains debatable. The purpose of this study is to investigate if an alteration of femoral head orientation affects acetabular growth. METHODS A proximal femoral osteotomy was performed in 21 lambs aged 3 months: 5 varus osteotomies (110 degrees), 4 valgus osteotomies (150 degrees), and 12 derotation osteotomies. Results were compared with a control group (5 animals). Osteotomy was fixed with a screw-plate device. Version was controlled intraoperatively with K-wires. Animals were killed 3 months after surgical procedure. A morphometric study of both proximal femur and acetabulum was performed, including deepness, volume and diameters of the acetabulum, neck-shaft angle and femoral version. RESULTS The average neck-shaft angle for the normal, anteversion, and retroversion groups was 129 degrees, whereas it was 110 degrees for the varus group and 149 degrees for the valgus group. The average femoral version for the normal, valgus, and varus groups was 21 degrees of anteversion, whereas it was 38 degrees of anteversion for the so-called anteversion group and 17 degrees of retroversion for the retroversion group. Nor the neck-shaft angle, nor the femoral version correlated with the acetabular anteroposterior diameter (P=0.698, 0.6, respectively), the acetabular inferosuperior diameter (P=0.083, 0.451, respectively) or the acetabular deepness (P=0.14, 0.371, respectively). The neck-shaft angle correlated significantly with acetabular volume (P=0.023), so that the lower the neck-shaft angle, the higher the acetabular volume (r=-0.453). The femoral version did not correlated with acetabular volume (P=0.381). CONCLUSIONS Decreasing the neck-shaft angle provokes an increase in acetabular volume, whereas changes in femoral version do not affect the acetabular growth. Extra-articular osteotomies that alter femoral orientation affect intra-articular gross morphology. LEVEL OF EVIDENCE Level II-therapeutic study.
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Shore BJ, Graham HK. Management of Moderate to Severe Hip Displacement in Nonambulatory Children with Cerebral Palsy. JBJS Rev 2019; 5:e4. [PMID: 29256976 DOI: 10.2106/jbjs.rvw.17.00027] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - H Kerr Graham
- Orthopaedic Department, The Royal Children's Hospital, Parkville, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
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The spastic hip in children and adolescents. Orthop Traumatol Surg Res 2019; 105:S133-S141. [PMID: 30056240 DOI: 10.1016/j.otsr.2018.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/15/2018] [Accepted: 03/20/2018] [Indexed: 02/02/2023]
Abstract
The hip is the joint most exposed to orthopaedic complications in cerebral palsy (CP), which is the main cause of spasticity in paediatric patients. The initial immaturity of the hip allows the forces applied by the spastic and retracted muscles to displace the femoral head, eventually causing it to dislocate. The risk of hip dislocation increases with the severity and extent of CP, exceeding 70% in the most severe cases. Hip dislocation causes pain in up to 30% of cases, carries a risk of orthopaedic and cutaneous complications and hinders patient installation and nursing care. These adverse outcomes warrant routine screening, which has been proven effective in lessening the frequency and severity of hip displacement. Preventive techniques including physical therapy, orthoses and treatments to alleviate spasticity are strongly recommended in every case. The beneficial effects of treating spasticity, if needed via neurosurgical procedures, have been convincingly established. Orthopaedic surgery is required when prevention fails. Soft-tissue release is designed to correct the asymmetry in the forces applied by the muscles. Femoral osteotomy creates the possibility for spontaneous correction of secondary acetabular dysplasia. Progress has been made in standardising the use of multilevel surgery involving the soft tissues, femur and pelvis, which is often effective in correcting the morphological abnormalities and stabilising the joint. When hip pain or alterations are severe, hip resection or total hip arthroplasty are highly effective in alleviating the pain and improving patient comfort. The spastic hip is a complex condition in which currently available screening protocols and treatment strategies have been proven effective in benefitting patient outcomes.
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Braatz F, Dreher T, Wolf SI, Niklasch M. Preoperative hip rotation moments do not predict long-term development after femoral derotation osteotomy in children with cerebral palsy. Gait Posture 2018; 61:215-219. [PMID: 29413787 DOI: 10.1016/j.gaitpost.2018.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/30/2017] [Accepted: 01/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Femoral derotation osteotomy (FDO) is the standard treatment for internal rotation gait (IRG) in children with cerebral palsy (CP) although high rates of recurrence have been reported recently. Various factors associated with recurrence could be identified, but no predictor named. RESEARCH QUESTIONS Does FDO lead to a change of internal transversal hip moments? Are preoperative internal transversal hip moments a predictor for recurrence of IRG? METHODS 41 children with spastic bilateral CP and 72 limbs that received a FDO (10.4 ± 2.7 years at surgery) were included retrospectively. Kinematic data were analyzed pre- (2 ± 3 months), postoperatively (12 ± 3 months) and at long-term follow-up (at least five years postoperatively; 84 ± 13 months), internal transversal hip moments were analyzed pre- and postoperatively. RESULTS The maximum peaks of the internal hip rotation moment during loading response decreased significantly (p = 0.003). The minimum during the second half of the stance phase increased significantly (p = 0.004) and the initially internal externally rotating moment changed to an internal internally rotating moment. No correlation between changes in hip rotation from postoperatively to the long-term follow-up and the preoperative internal hip rotation moment could be identified. SIGNIFICANCE FDO leads to changes in internal hip rotation moments. Preoperative internal hip rotation moments can't be used as predicting factor for recurrence of IRG. The data suggest, that recurrence of IRG depends less on patient specific motion patterns, but more on the time point of surgery and the therapy of all concomitant deformities during SEMLS.
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Affiliation(s)
- Frank Braatz
- University Medical Center Göttingen, Department of Trauma Surgery and Orthopaedics and Plastic Surgery, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Thomas Dreher
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Sebastian I Wolf
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Mirjam Niklasch
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
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Niklasch M, Klotz MC, Wolf SI, Dreher T. Long-term development of overcorrection after femoral derotation osteotomy in children with cerebral palsy. Gait Posture 2018; 61:183-187. [PMID: 29353743 DOI: 10.1016/j.gaitpost.2018.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/22/2017] [Accepted: 01/14/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recent studies showed rates of recurrence of internal rotation gait (IRG) after femoral derotation osteotomy (FDO) up to 40%. Some surgeons even advice overcorrection during FDO to avoid a later recurrence. RESEARCH QUESTION Evaluation of the long-term development of limbs with initial overcorrection after FDO. METHODS 29 limbs of 20 children (9.9 ± 3.2 years at surgery) with IRG, cerebral palsy (CP) and more than 5° external hip rotation postoperatively were included retrospectively. A gait analysis and clinical examination were performed preoperatively (less than one year, E0), postoperatively (9-23 months, E1) and at the long-term follow-up (at least five years postoperatively, E2). Differences between those children that remained overcorrected at E2 and those with a hip rotation within normal range at E2 were evaluated. RESULTS At E2 41% of these limbs remained overcorrected, 52% showed a hip rotation within normal range and 7% showed recurrence of IRG. A comparison of those limbs that remained overcorrected and those ending within normal range revealed neither a difference in age at surgery nor in static and dynamic torsional parameters at E0 and E1 except for pelvic rotation. A significantly larger pelvic internal rotation at E1 for those with remaining overcorrection could be identified. SIGNIFICANCE A general overcorrection during FDO in children with CP to avoid recurrence of IRG cannot be recommended, as 41% remain overcorrected. Preoperative predictors for long-term development couldn't be identified. If pelvic mal-rotation is corrected, hip rotation may change into normal range over the time in combination with the development of a flexed knee gait.
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Affiliation(s)
- Mirjam Niklasch
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany.
| | - Matthias C Klotz
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany.
| | - Sebastian I Wolf
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany.
| | - Thomas Dreher
- University Hospital Heidelberg, Clinic for Orthopaedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany.
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