1
|
Karkenny AJ, Mackey C, Sharkey MS. What Do We Really Know About the Natural History of Spastic Hip Dysplasia and Pain in Total-involvement Cerebral Palsy? A Systematic Review. J Pediatr Orthop 2024; 44:340-346. [PMID: 38323400 DOI: 10.1097/bpo.0000000000002639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Hip surveillance protocols and surgery for spastic hip dysplasia have become standard of care for children with cerebral palsy (CP) out of concern for long-term sequelae, including pain. It is unclear if available data support that spastic hip dysplasia/dislocation independently correlates with pain in total-involvement CP. A better understanding of this correlation may help guide decision-making for these medically complex patients. METHODS We undertook a systematic literature review to assess published data on the association of spastic hip dysplasia and pain in total-involvement CP using PubMed (which includes the MedLine databases) and EMBASE databases. A total of 114 English-language articles were identified. Fifteen articles met the inclusion criteria and were evaluated using the PRISMA guidelines for systematic reviews. RESULTS Of 15 articles that specifically assessed the association of spastic hip dysplasia and pain, 5 articles provided strong evidence per our criteria regarding the correlation of pain and spastic hip dysplasia. All 5 articles described the severity of CP in their studied population, radiographically defined hip displacement, included a control group, and described how pain was assessed. Nevertheless, there was no standard classification of dysplasia between studies and the ages of patients and methods of pain determination varied. Four of the articles provided level III evidence and one provided level II evidence. Of these 5 articles with the strongest available evidence, data from 2 did not support a correlation between hip dysplasia and hip pain, 2 supported a correlation, and 1 was equivocal. CONCLUSIONS Even the best available evidence on spastic hip dysplasia and pain reveals no consensus or conclusion on whether spastic hip dysplasia and dislocation in total-involvement CP is independently correlated with pain. LEVEL OF EVIDENCE Level III-Prognostic study.
Collapse
Affiliation(s)
- Alexa J Karkenny
- Department of Orthopaedic Surgery, Montefiore Einstein, Bronx, NY
| | | | | |
Collapse
|
2
|
Battisti N, Cozzaglio M, Faccioli S, Perazza S, Groppi A, Menta L, Motta M, Piovesan R, Digennaro GL, Rodocanachi M, Ronchetti AB, Sarno C, Saviola D, Valagussa G, Cersosimo A. Prevention of hip dislocation in severe cerebral palsy (GMFCS III-IV-V): an interdisciplinary and multi-professional Care Pathway for clinical best practice implementation. Eur J Phys Rehabil Med 2023; 59:714-723. [PMID: 37796120 PMCID: PMC10795071 DOI: 10.23736/s1973-9087.23.07978-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/28/2023] [Accepted: 09/07/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Hip displacement (HD) and dislocation in severe Cerebral Palsy (CP) (GMFCS III, IV, V) are important causes of worsening disability and quality of life. Prevention must be started from the first months of life through screening programs and early treatments, both conservative and surgical. Evidence from Clinical Practice Guidelines also suggests the development of Care Pathways for good clinical practice. At the beginning of 2020 an interdisciplinary, multi-professional working group, composed of 26 members (including Physiatrists, Physiotherapist, Neuro-psychomotor Therapists and Orthopedists representing the respective Italian Scientific Societies) with the involvement of the FightTheStroke Foundation families' association, was set up. AIM The aim of the multi-professional panel was the production of evidence-based recommendations for the Care Pathway "Prevention of Hip Displacement in children and adolescents with severe CP" for best clinical practice implementation in our national context. DESIGN Clinical Care Pathway (Clinical Practice Guideline). SETTING Inpatient and outpatient. POPULATION Children with severe CP (GMFCS III-IV-V). METHODS The recommendations of this Care Pathway were developed using the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) guidelines for Care Pathways development and the Grading of Recommendations Assessment Development and Evaluation (GRADE ADOLOPMENT) working group for adoption or adaption or de novo development of recommendations from high-quality guidelines. In 2020 a multidisciplinary working group (WG) developed four research questions on the prevention of HD on the following topics: screening, botulinum toxin treatment, postural management and preventive soft tissue surgery. A comprehensive review of the biomedical literature was performed on each question. Guidelines, Systematic Reviews and Primary studies were retrieved through a top-down approach. References were screened according to inclusion criteria and quality was assessed by means of specific tools. A list of recommendations was then produced divided by intervention (screening programs, postural management, botulinum toxin, preventive surgery). In a series of meetings, the panel graduated recommendations using the GRADE evidence to decision frameworks. RESULTS Fifteen recommendations were developed: seven on screening programs, four on postural management strategies, one on botulinum toxin, and three on preventive surgery. Evidence quality was variable (from very low to moderate) and only a few strong recommendations were made. CONCLUSIONS In severe CP at high risk of hip dislocation, it is strongly recommended to start early hip surveillance programs. In our national context, there is a need to implement Screening programs and dedicated Network teams. We also strongly recommend a comprehensive approach shared with the families and goal-oriented by integrating the different therapeutic interventions, both conservative and not, within Screening programs. CLINICAL REHABILITATION IMPACT Implementing a comprehensive multi-professional approach for the prevention of hip dislocation in severe CP.
Collapse
Affiliation(s)
- Nicoletta Battisti
- Pediatric Physical Medicine and Rehabilitation Unit, IRCCS Institute of Neurological Sciences, Bologna, Italy -
| | - Massimo Cozzaglio
- Pediatric Physical Medicine and Rehabilitation Unit, IRCCS Ca' Granda Ospedale Maggiore Polyclinic Hospital, Milan, Italy
| | - Silvia Faccioli
- Children Rehabilitation Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Postgraduate Program in Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Perazza
- Children Rehabilitation Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Lorena Menta
- Pediatric Rehabilitation Area, AUSL Parma, Parma, Italy
| | - Matteo Motta
- Child and Adolescent Neurology and Psychiatry Unit, ASST Lecco, Lecco, Italy
| | | | - Giovanni L Digennaro
- Pediatric Orthopedics and Traumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | | | - Claudia Sarno
- UFSMIA Service of Rehabilitation, Azienda Usl Toscana Centro, Florence, Italy
| | - Donatella Saviola
- Cardinal Ferrari Santo Stefano Rehabilitation Center, KOS Care, Fontanellato, Parma, Italy
| | - Giulio Valagussa
- Villa Santa Maria Foundation, Tavernerio, Como, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Antonella Cersosimo
- Pediatric Physical Medicine and Rehabilitation Unit, IRCCS Institute of Neurological Sciences, Bologna, Italy
| |
Collapse
|
3
|
Hsu CM, Sheu H, Lee WC, Kao HK, Yang WE, Chang CH. Soft Tissue Releases With Simultaneous Guided Growth Decrease Risk of Spastic Hip Displacement Recurrence. J Pediatr Orthop 2023; 43:e707-e712. [PMID: 37493018 DOI: 10.1097/bpo.0000000000002472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Soft tissue release (STR) is an established treatment for spastic hip displacement, but recurrence of hip displacement is not uncommon. This study aims to (1) evaluate the recurrence of hip displacement after STR, (2) define associated factors of recurrence, and (3) elucidate the effects of guided growth on hip displacement recurrence. METHODS The study subjects included 66 individuals with spastic cerebral palsy treated by STR with or without guided growth for hip displacement. The treatment goal was the maintenance of migration percentage (MP) to <40%. Recurrence was defined by a rebound of the MP by 5% or more after the first postoperative year. Children with recurrence were compared with those without recurrence using the Mann-Whitney U test and the χ 2 test. The risk factors for recurrence were evaluated using multiple logistic regression analysis. RESULTS Nineteen individuals (29%) had a recurrence of hip displacement after the first postoperative year. They sustained a 2-fold increase in the rate of treatment failure ( P < 0.001) and reoperation ( P = 0.04). Age, sex, motor function, and preoperative radiographic parameters were comparable between individuals with and without recurrence. The use of guided growth was associated with less risk of recurrence than without (5% and 39%, respectively, odds ratio = 0.01 to 0.45, respectively) despite the similar risk of failure (35% and 48%, respectively, odds ratio = 0.15 to 4.82). CONCLUSIONS Recurrence of the MP >5% after the first postoperative year is an important early indicator for failure to control MP to <40% and reoperation. Guided growth not only decreases coxa valga but also reduces the risk of recurrent hip displacement after STR. LEVEL OF EVIDENCE Level III; case-control study.
Collapse
Affiliation(s)
- Cheng-Min Hsu
- Department of Orthopaedic Surgery, Pediatric Section and Sports Medicine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | | | | | | | | |
Collapse
|
4
|
Sketchler B, Yngve DA. Intrailiac Osteotomy With Superior Lateral Outcropping Bone: A Previously Undescribed Procedure for Hip Subluxation in Cerebral Palsy. Cureus 2023; 15:e42065. [PMID: 37602084 PMCID: PMC10433783 DOI: 10.7759/cureus.42065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Surgical treatment of hip subluxation in cerebral palsy typically involves proximal femoral osteotomy with or without concurrent supra-acetabular pelvic osteotomy. The literature lacks data on isolated pelvic osteotomy for this condition. We present superior lateral outcropping bone as a novel procedure for augmenting pelvic osteotomies for additional femoral coverage. METHODS In this retrospective case series, all patients were included for whom a single surgeon at a single institution performed pelvic osteotomy with adjunctive superior lateral outcropping bone for the treatment of hip subluxation in cerebral palsy over a 12-year period. Patients with less than two years of X-ray follow-up were excluded, as were patients with frank dislocation preoperatively. Regarding each case, multiple variables were collected, including X-ray measurements of migration percentage and acetabular index preoperatively, immediately postoperatively, and at last available X-ray. Paired t tests were performed to confirm a significant difference between preoperative and postoperative measurements. Surgical failure was defined as either any subsequent hip or pelvic procedure other than myotendinous lengthening or alcohol nerve blocks, or final migration percentage of greater than 50%. RESULTS Thirty-three hips (23 patients, 13 males) were included. Mean age at surgery was seven years. Mean time to follow-up was 49 months. Migration percentage of the hips improved from an average 44% preoperatively to 25% at first postoperative measurement and 22% at final follow-up (p < 0.001). Acetabular index improved from an average 27 degrees preoperatively to 15 degrees at first postoperative measurement and 17 degrees at final follow-up (p < 0.001). No hips met failure criteria of repeat surgery other than myotendinous lengthening or nerve blocks, but two presented with a migration percentage of greater than 50% at final follow-up, giving us a failure rate of 6%. CONCLUSIONS We present a novel procedure that appears to provide safe and successful outcomes for hip subluxation in cerebral palsy. Our clinical results compare favorably to those in the literature for isolated proximal femoral osteotomy for similar patient populations, yet there is no need for implanted hardware.
Collapse
Affiliation(s)
- Benjamin Sketchler
- Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, USA
| | - David A Yngve
- Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, USA
| |
Collapse
|
5
|
Guided Growth Improves Coxa Valga and Hip Subluxation in Children With Hereditary Multiple Exostoses. J Pediatr Orthop 2023; 43:e67-e73. [PMID: 36509457 DOI: 10.1097/bpo.0000000000002296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND In children with severe hereditary multiple exostoses (HME), coxa valga, and hip subluxation are common deformities. The literatures related to surgical management and prevention of hip joint subluxation in HME are scarce. In this study, we aimed to investigate the efficacy of guided growth procedure to correct coxa valga and hip subluxation in HME patients. METHODS We retrospectively retrieved 12 patients who received guided growth procedures for coxa valga and hip subluxation in HME patients with proximal femur exostoses with a minimum follow-up time of 2 years between 2012 and 2019. Radiographic parameters include head-shaft angle, Hilgenreiner-epiphyseal angle, acetabular index, Reimer migration percentage, center-edged angle, articulo-trochanteric distance, and femoral neck length for comparison between preoperative and latest follow-up results. It was conducted statistically by paired t test and Wilcoxon signed rank test. RESULTS In this study, the mean difference between preoperative and latest follow-up was significant in head-shaft angle (12±5 degrees; CI, 10-14; P<0.001), Hilgenreiner-epiphyseal angle (12±5 degrees; CI, 10-15; P<0.001), and MP (7%±8%; CI, 3-11; P=0.001). There was a low revision rate (4 of 21, 19%) and no complication in our study. Compared with previous studies on guided growth in children with cerebral palsy and developmental dysplasia of the hip, our study showed good comparable outcomes. CONCLUSION The results indicated that guided growth improves the hip radiographic parameters of children with HME and may prevent coxa valga and hip subluxations. It is a safe procedure and provides predictable results. LEVEL OF EVIDENCE Level IV; therapeutic, case series.
Collapse
|
6
|
Faccioli S, Sassi S, Ferrari A, Corradini E, Toni F, Kaleci S, Lombardi F, Benedetti MG. Hip subluxation in Italian cerebral palsy children and its determinants: a retrospective cohort study. Int J Rehabil Res 2022; 45:319-328. [PMID: 36059222 PMCID: PMC9631781 DOI: 10.1097/mrr.0000000000000545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/21/2022] [Indexed: 12/01/2022]
Abstract
The study's aim was two-fold: to describe the trend of hip subluxation in the largest sample of Italian nonambulatory cerebral palsy (CP) children ever published; to investigate its determinants. This single-centre retrospective cohort study included patients with spastic or dyskinetic CP, Gross Motor Function Classification System (GMFCS) level IV or V, age 0-18 years, having been referred to our unit before March 2020. The hip subluxation was measured by means of the migration percentage (MP). Other data were gathered such as sex, CP subtype, GMFCS level, presence of drug-resistant epilepsy, age, use of walkers with weight relief or standing devices, previous botulinum injection or hip surgery, oral or intrathecal baclofen and hip pain. Multiple linear stepwise regression was performed and descriptive statistics are provided. Spastic CP had MP maximum increase in early ages, with GMFCS level V values persistently higher than level IV. The dyskinetic subtype showed a slower increase of the MP, with GMFCS level IV presenting similar or higher values, compared to level V. Age, CP severity and spastic subtype are the main determinants. The stepwise multiple regression analysis demonstrated that weight relief walking and standing assistive devices, combined with botulinum contributed to reduce the MP progression. Dyskinetic CP showed overall lower MP values and a more variable behaviour relative to age and GMFCS level, compared to the spastic subtype. Standing and walking assistive devices, with partial or total weight relief, combined with individually targeted botulinum injections, should be considered in the management of bilateral nonambulatory CP patients, to prevent hip subluxation or its recurrence after surgery.
Collapse
Affiliation(s)
- Silvia Faccioli
- Children Rehabilitation Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia
- PhD Program in Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena
| | - Silvia Sassi
- Children Rehabilitation Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia
| | - Adriano Ferrari
- Children Rehabilitation Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia
| | - Elena Corradini
- Children Rehabilitation Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia
| | - Francesca Toni
- Physical Medicine and Rehabilitation Unit, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia
| | - Shaniko Kaleci
- Surgical Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena
| | - Francesco Lombardi
- Neurorehabilitation Unit of S. Sebastiano Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia
| | - Maria Grazia Benedetti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| |
Collapse
|
7
|
Sheu H, Lee WC, Kao HK, Yang WE, Chang CH. The effectiveness of adding guided growth to soft tissue release in treating spastic hip displacement. J Orthop Sci 2022; 27:1082-1088. [PMID: 34362633 DOI: 10.1016/j.jos.2021.06.019] [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: 03/15/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Guided growth at the proximal femur using one transphyseal screw corrects coxa valga and improves hip displacement in cerebral palsy. This study aimed to validate the effects of adding guided growth (GG) to soft tissue release (STR), in terms of decreasing the migration percentage (MP), compared to those with soft tissue alone. METHODS This retrospective study comprised patients with cerebral palsy who underwent soft tissue release alone (Group STR) or soft tissue release plus guided growth (Group GG) for hip displacement (mean age, 8.1 years; mean follow-up, 4.9 years). Difference in the MP and rate of controlling MP <40% at 2 years postoperatively and rate of revision surgeries at 5 years postoperatively were compared between the groups. RESULTS The two groups were comparable in age, side, and gross motor function level, but Group GG (n = 24) had more severe hip displacement preoperatively than did Group STR (n = 64). Group GG had a significantly greater 2-year decrease in the MP (-14.8% vs. -11.8%, p < 0.05) than did Group STR. Among patients with a pre-operative MP >50%, the rate of MP <40% was greater in Group GG (73%) than in Group STR (41%). Revision surgeries, mainly repeated guided growth and soft tissue release, were comparable between the groups. CONCLUSIONS This is the first comparative study to support adding guided growth to soft tissue release, as it results in greater improvements in hip displacement than that with soft tissue release alone. Non-ambulatory patients or severe hip displacement with MP 50%-70% could benefit from this less aggressive surgery by controlling the MP under 40% without femoral osteotomy.
Collapse
Affiliation(s)
- Huan Sheu
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Wei C Lee
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan K Kao
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Wen E Yang
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chia H Chang
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
8
|
Zakrzewski AM, Carl JR, McCarthy JJ. Proximal Femoral Screw Hemiepiphysiodesis in Children With Cerebral Palsy Improves the Radiographic Measures of Hip Subluxation. J Pediatr Orthop 2022; 42:e583-e589. [PMID: 35452015 DOI: 10.1097/bpo.0000000000002152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Allyson M Zakrzewski
- Department of Orthopaedics, Cincinnati Children's Hospital Medical Center, Cincinnati OH
| | | | - James J McCarthy
- Department of Orthopaedics, Cincinnati Children's Hospital Medical Center, Cincinnati OH
| |
Collapse
|
9
|
Ellipsoidal Process of the Femoral Head in Legg-Calvé-Perthes Disease: Effect of Prophylactic Hemiepiphysiodesis. Indian J Orthop 2022; 56:1431-1438. [PMID: 35928651 PMCID: PMC9283556 DOI: 10.1007/s43465-022-00662-z] [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: 03/20/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Legg-Calvé-Perthes disease (LCPD) often causes the residual deformity, typically appearing as an ellipsoidal shape. In some cases, this ovalization is related to the asymmetric growth of the femoral head physis, which presents a growth-inhibiting necrotic area in the anterosuperior quadrant. The objective of the present study is to evaluate the effectiveness of selective hemiepiphysiodesis of the healthy physis in the posteroinferior quadrant as a means of disrupting femoral head ovalization in cases of LCPD with the previous onset of ovalization. METHODS We performed a prospective study of 39 LCPD hips operated on consecutively by selective hemiepiphysiodesis of the posteroinferior portion of the head during the reossification phase.Surgical indication was based on a progressive increase in the ellipsoidal index (EI), the presence of a double epiphyseal nucleus of reossification, physeal narrowing, and physeal angulation. Hemiepiphysiodesis was performed at the mean patient age of 8.8 years (SD 1.5) and a mean of 4.7 years (SD 1.4) following disease onset. RESULTS Preoperative EI was 1.80 (SD 0.2), which was reduced to 1.72 (SD 0.2) postoperatively (P > 0.05). Physeal angulation increased from 50° preoperatively (SD 9.3) to 54.29° (SD 9.7) at the end of growth (P > 0.05). The final result according to the Stulberg classification revealed 20 class-II cases, 16 class III, and 3 class IV, and SDS was 25.97 (SD 9.95), range: 9.36-51.67. CONCLUSION As revealed by the EI, the ellipsoidal process may be stopped by selective hemiepiphysiodesis in the posteroinferior quadrant of the femoral head. LEVEL OF EVIDENCE II.
Collapse
|
10
|
Lebe M, van Stralen RA, Buddhdev P. Guided Growth of the Proximal Femur for the Management of the 'Hip at Risk' in Children with Cerebral Palsy-A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:609. [PMID: 35626786 PMCID: PMC9140189 DOI: 10.3390/children9050609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Guided growth is frequently used to modify lower-limb alignment in children, and recently temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF) has been used for the management of hips at risk of subluxation in cerebral palsy (CP) patients. The aim of our study was to evaluate the efficacy of TMH-PF in the management of neuromuscular hip dysplasia in children with cerebral palsy. METHODS A systematic search of the literature was performed by using PubMed, EMBASE, CINAHL, MEDLINE, Scopus and Cochrane databases. Pre- and postoperative radiographic changes of the migration percentage (MP), head-shaft angle (HSA) and acetabular index (AI) were included in a meta-analysis. Secondary outcomes were treatment complication rates, technical considerations and the limitations of this novel technique. RESULTS Four studies (93 patients; 178 hips) met the eligibility criteria for inclusion in the meta-analysis. All three radiographic measurements showed significant changes at a minimum of 2 years of follow-up. Mean changes for MP were 8.48% (95% CI 3.81-13.14), HSA 12.28° (95% CI 11.17-13.39) and AI 3.41° (95% CI 0.72-6.10), with I2 of 75.74%, 0% and 87.68%, respectively. The serious complication rate was overall low; however, physeal 'growing off' of the screw was reported in up to 43% of hips treated. CONCLUSION TMH-PF is an effective and predictable method to treat CP patients with 'hips at risk', and the overall complication rate is low; however, further work is required to identify the best candidates and surgical timing, as well as choice of technique and implant.
Collapse
Affiliation(s)
- Moritz Lebe
- Broomfield & Addenbrookes Hospitals, Chelmsford CM1 7ET, UK; (M.L.); (P.B.)
| | | | - Pranai Buddhdev
- Broomfield & Addenbrookes Hospitals, Chelmsford CM1 7ET, UK; (M.L.); (P.B.)
| |
Collapse
|
11
|
Sleth C, Bauzou F, De Cristo C, Alkar F, Joly-Monrigal P, Jeandel C, Cottalorda J, Louahem M’Sabah D, Delpont M. Is there a persistent capital femoral epiphysis growth after screw fixation for slipped capital femoral epiphysis? J Hip Preserv Surg 2022; 9:90-94. [PMID: 35854809 PMCID: PMC9291370 DOI: 10.1093/jhps/hnac019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/03/2022] [Accepted: 03/10/2022] [Indexed: 01/25/2023] Open
Abstract
Femoral neck screwing during child development is controversial. The objective of this study was to evaluate the residual growth of the capital femoral physis after screw fixation. This retrospective study included children aged younger than 12 years treated for slipped capital femoral epiphysis (SCFE) with a single percutaneous partially threaded cannulated screw. The children were followed up for at least 1 year. Some patients also underwent prophylactic contralateral screwing. Preoperative, immediate postoperative and final follow-up X-rays were evaluated to determine the degree of slippage, pin–joint ratio (PJR), neck–pin ratio (NPR), number of threads crossing the physis, neck–shaft angle (NSA), screw–physis angle and screw position in the physis. We included 17 patients (29 hips: 18 SCFE and 11 prophylactic) with a mean age of 10.1 years (range: 7.1–11.9 years) at the time of surgery. Significant evolution of radiological growth parameters of the proximal femoral physis was noted during a mean follow-up of 2.4 years (range: 1–4.3 years). The mean PJR significantly decreased from 7.3 to 6.0, the mean NPR significantly decreased from 106 to 96 and the mean number of threads beyond the physis decreased from 3.3 to 1.8. The mean NSA decreased by 6.5°, from 139° to 132.5°. Persistent capital femoral epiphysis growth occurs after screw fixation. The NSA significantly decreases over time but remains within the physiological limits. Level of evidence: IV (case series)
Collapse
Affiliation(s)
- Camille Sleth
- Pediatric Surgery, Lapeyronie Hospital, University of Montpellier, France
| | - François Bauzou
- Pediatric Surgery, Lapeyronie Hospital, University of Montpellier, France
| | - Claudia De Cristo
- Pediatric Surgery, Lapeyronie Hospital, University of Montpellier, France
| | - Fanny Alkar
- Pediatric Surgery, Lapeyronie Hospital, University of Montpellier, France
| | | | - Clément Jeandel
- Pediatric Surgery, Lapeyronie Hospital, University of Montpellier, France
| | - Jérôme Cottalorda
- Pediatric Surgery, Lapeyronie Hospital, University of Montpellier, France
| | | | - Marion Delpont
- Pediatric Surgery, Lapeyronie Hospital, University of Montpellier, France
| |
Collapse
|
12
|
The Effects of Preterm Birth on Musculoskeletal Health-Related Disorders. J Clin Med 2021; 10:jcm10215082. [PMID: 34768599 PMCID: PMC8584797 DOI: 10.3390/jcm10215082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 12/21/2022] Open
Abstract
Preterm birth is associated with various diseases and conditions which demand multidisciplinary medical care. Approximately 10% of all neonates are born prematurely with an increasing survival rate in almost all Western countries. This ongoing, yet desirable trend is creating new challenges for sufficient medical treatment regimens, which should be upheld throughout the patients’ lives. Orthopedic surgeons are focused on musculoskeletal disorders and the improvement of patients’ ability to cope with the challenges of everyday life. The most common conditions associated with preterm birth are cerebral palsy and a dysregulation of the calcium/phosphorus metabolism, which may lead to fractures. These diseases may vary greatly in their organic manifestation and clinical presentation. This demands multidisciplinary cooperation and parental support. Clinical management is aimed on the early enhancement of a patient’s physical, as well as neurological condition, and to prevent the development of secondary musculoskeletal disorders. In this article, we give an overview of the current literature on the most common musculoskeletal disorders associated with preterm birth and critically discuss state of the art diagnostic standards and treatment algorithms.
Collapse
|
13
|
Masquijo JJ, Artigas C, de Pablos J. Growth modulation with tension-band plates for the correction of paediatric lower limb angular deformity: current concepts and indications for a rational use. EFORT Open Rev 2021; 6:658-668. [PMID: 34532073 PMCID: PMC8419796 DOI: 10.1302/2058-5241.6.200098] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Growth modulation (GM) with tension-band plates (TBPs) by tethering part of the growth plate is an established technique for the correction of angular deformities in children, and it has increasingly supplanted more invasive osteotomies.Growth modulation with TBPs is a safe and effective method to correct a variety of deformities in skeletally immature patients with idiopathic and pathological physes. The most common indication is a persistent deformity in the coronal plane of the knee exceeding 10°, with anterior and/or lateral joint pain, patellofemoral instability, gait disturbance, or cosmetic concerns. GM has also shown good results in patients with fixed flexion deformity of the knee and ankle valgus.This paper reviews the history of the procedure, current indications, and recent advances underlying physeal manipulation with TBPs. Cite this article: EFORT Open Rev 2021;6:658-668. DOI: 10.1302/2058-5241.6.200098.
Collapse
Affiliation(s)
- J Javier Masquijo
- Department of Pediatric Orthopaedics, Sanatorio Allende, Córdoba, Argentina
| | - Cristian Artigas
- Hospital Roberto del Rio, Santiago, Chile
- Clínica Alemana, Santiago, Chile
| | - Julio de Pablos
- Advanced Bone Reconstruction Surgery, Hospital San Juan de Dios y Complejo Hospitalario de Navarra, Pamplona, Spain
| |
Collapse
|
14
|
|
15
|
Abstract
AIMS Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth. METHODS We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer's migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw. RESULTS A total of 37 hips in Group 1 and 24 hips in Group 2 were compared. Group 1 showed a more substantial decrease in the HSA (p = 0.003) and the MP (p = 0.032). Both groups had significant and similar improvements in the AI (p = 0.809) and the FAVA (p = 0.304). Group 1 presented a higher incidence of the physis growing-off the screw (p = 0.038). Results of the regression analysis indicated that the eccentricity of screw position correlated with HSA correction and increases the risk of the physis growing-off the screw. CONCLUSION Guided growth is effective in improving coxa valga and excessive femoral anteversion in CP children. For younger children, despite compromised efficacy of varus correction, we recommend a more centered screw position, at least across the middle quarter of the medial physis, to avoid early revision. Cite this article: Bone Joint J 2020;102-B(9):1242-1247.
Collapse
Affiliation(s)
- Po-Jen Hsu
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuan-Wen Wu
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Che Lee
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Chieh Lin
- Department of Orthopaedic Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ken N Kuo
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Ting-Ming Wang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Department of Orthopaedic Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
16
|
Internal fixation of intracapsular femoral neck fractures in elderly patients: mortality and reoperation rate. Aging Clin Exp Res 2020; 32:1173-1178. [PMID: 31175608 DOI: 10.1007/s40520-019-01237-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/31/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND A significant increase in the prevalence of intracapsular femoral neck fractures in the elderly population was reported but the best treatment is still debated. AIM To evaluate the mortality rate and the reoperation rate of stable neck fractures treated with cannulated screw fixation in elderly patients. METHODS This was a retrospective study of patients older than 60 years with a Garden I or II femoral neck fractures treated with cannulated screw fixation without capsulotomy. A total of 244 patients (246 hips) who underwent surgery between 2008 and 2018 were included. The average age at the time of surgery was 80 years (range 60-99 years). The mean ASA score was 2.64 (range 1-4). Mortality rate, complications, reoperation rate, the time elapsed between surgeries were recorded. RESULTS The mortality rate was 50.0%. There were 16 mortalities (6.6%) in the first-month follow-up. We observed higher mortality rates in ASA 4 (80.8%). In 22 patients (8.9%), complications after surgery were observed, and in 11 patients (4.5%) underwent conversion surgery to hemiarthroplasty at a mean of 14.6 months (range 2-48 months) after the femoral screw fixation. Two patients were treated with hardware removal and Gamma Nail for a peri-implant subtrochanteric femur fracture. INTERPRETATION Cannulated screw fixation should be considered a valid option in intraarticular femoral Garden I-II fractures in elderly patients. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
|
17
|
Abstract
BACKGROUND Spastic hip subluxation or dislocation that is associated with an excessive coxa valga deformity is a common pathologic condition in children with cerebral palsy (CP) that is often treated with large bone reconstructive procedures. Guided growth techniques (such as stapling, plate, or transphyseal screw) have been widely used to alter the growth axis in patients with a lower-limb deformity but only a few reports have described their use in patients with coxa valga deformities. QUESTIONS/PURPOSES (1) Does guided growth surgery using a transphyseal screw combined with adductor tenotomy prevent progressive coxa valga deformity and lateral hip subluxation in children with CP? (2) What factors influence the correction of coxa valga deformity and the success of hip stabilization? (3) What complications were associated with this operation and how often did children treated with it undergo reoperation? METHODS From 2012 to 2016, at our institution, three authors (H-CH, KNK, K-WW) retrospectively studied data on children with CP who underwent guided growth of the hip for progressive bilateral hip subluxation associated with coxa valga deformities. A single percutaneous screw was inserted across the inferomedial portion of proximal femoral physis in an AP view and centered along femoral neck in lateral view under fluoroscopy guidance. During the period, we treated 25 consecutive children with CP who had progressive hip subluxation with coxa valga deformities. The indications for surgery were migration percentage > 30% and head-shaft angle > 155° with at least 2 years growth remaining. Of those, 13 patients underwent guided growth alone, and 48% (12) underwent a combination of guided growth and adductor tenotomy. Of the 25 patients treated with this approach, 96% (24) were available for follow-up with complete data at a minimum of 2 years follow-up (mean 50 months; range 25 to 72). All children (17 boys and seven girls; 48 hips) underwent surgery at a mean age of 8 years (range 5 to 12). With regard to the gross motor function classification system, three patients were Level 1, four patients were Level II, seven patients were Level III, seven were Level IV, and three were Level V. Radiographic parameters including the head-shaft angle, Hilgenreiner's epiphyseal angle, acetabular index, and Reimer's migration percentage were assessed before surgery and at the latest follow-up examination by one author (H-CH). Complications and reoperations were assessed by chart review. During the period in question, we generally offered secondary reconstructive surgery to patients who underwent a guided growth procedure once their subluxation progressed. RESULTS With the data available, the coxa valga and lateral hip subluxation improved in terms of the reduction of head-shaft angle by a mean of 13° ± 7° (95% CI 11 to 15; p < 0.001) and the reduction of the migration percentage by 10% ± 11% (95% CI 7 to 13; p < 0.001). After controlling for potentially confounding variables like gender, gross motor function classification system, Hilgenreiner's epiphyseal angle and acetabular index, we found that longer follow-up duration (r = 0.234; p < 0.001) and a smaller preoperative migration percentage (r = -0.258; p = 0.004) were associated with larger changes in the head-shaft angle. In terms of complications, we found that the proximal femoral physis grew off the screw tip in 44% (21 of 48 hips) at a mean of 28 months. Among these, 31% of hips (15 of 48) in 33% of patients (eight of 24) underwent replacement with a longer screw. Among the 17% of hips (eight of 48) in 21% of patients (five of 24) who had progressive lateral subluxation and underwent secondary reconstructive surgery, we found that their preoperative acetabular index was higher (mean 29° versus 21°; p < 0.001), as was their head-shaft angle (mean 166° versus 162°; p = 0.045), and migration percentage (mean 54% versus 36 %; p < 0.001). CONCLUSIONS Although guided growth with single transphyseal screw did not create as large a degree of varus as proximal femoral osteotomy, it did stabilize the hip in children with cerebral palsy with migration percentage less than 50% in our series. It is a simple procedure that can be of benefit to children with cerebral palsy with unstable hip. Reoperation in patients where the physis has grown off the screw tip can be a problem; fortunately, it is a rather minor procedure to replace with a longer screw. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
18
|
Intra-Articular Cytokine Levels in Adolescent Patients after Anterior Cruciate Ligament Tear. Mediators Inflamm 2018; 2018:4210593. [PMID: 30245587 PMCID: PMC6136581 DOI: 10.1155/2018/4210593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 06/22/2018] [Accepted: 07/18/2018] [Indexed: 02/01/2023] Open
Abstract
The treatment of anterior cruciate ligament (ACL) injuries in children and adolescents is challenging. Preclinical and clinical studies investigated ACL repairing techniques in skeletally immature subjects. However, intra-articular bioenvironment following ACL tear has not yet been defined in skeletally immature patients. The aim of this study was to measure cytokine concentrations in the synovial fluid in adolescent population. Synovial levels of IL-1β, IL-1ra, IL-6, IL-8, IL-10, and TNF-α were measured in 17 adolescent patients (15 boys) with ACL tears who underwent ACL reconstruction including acute (5), subacute (7), and chronic (5) phases. Femoral growth plates were classified as “open” in three patients, “closing” in eight, and “closed” in six. Eleven patients presented an ACL tear associated with a meniscal tear. The mean Tegner and Lysholm scores (mean ± SD) of all patients were 8 ± 1 and 50.76 ± 26, respectively. IL-8, TNF-α, and IL-1β levels were significantly greater in patients with “open” physes. IL-1ra and IL-1β levels were significantly higher in patients with ACL tear associated with a meniscal tear. Poor Lysholm scores were associated with elevated IL-6 and IL-10 levels. IL-10 levels positively correlated with IL-6 and IL-8 levels, whereas TNF-α concentration negatively correlated with IL-6 levels. Skeletally immature patients with meniscal tears and open growth plates have a characteristic cytokine profile with particularly elevated levels of proinflammatory cytokines including IL-8, TNF-α, and IL-1β. This picture suggests that the ACL tear could promote an intra-articular catabolic response in adolescent patients greater than that generally reported for adult subjects. The study lacks the comparison with synovial samples from healthy skeletally immature knees due to ethical reasons. Overall, these data contribute to a better knowledge of adolescent intra-articular bioenvironment following ACL injuries.
Collapse
|