Radiation Prophylaxis for Hip Salvage Surgery in Cerebral Palsy: Can We Reduce the Incidence of Heterotopic Ossification?

Bilateral hip heterotopic ossification with sciatic nerve compression on a paediatric patient–An individualized surgical approach: A case report

BACKGROUND

Neurogenic heterotopic ossification is an acquired serious complication described in patients with central nervous system disorders and defined by bone formation in non-osseous tissue.

CASE SUMMARY

We present an unusual case of a 13-yr-old boy presenting with hip pain and severe gait impairment 5 mo after the diagnosis of hemiplegia following a spontaneous intracerebral haemorrhage. Computed tomography revealed bilateral heterotopic ossification of both the paretic and the non-paretic limbs, with entrapment of the sciatic nerve. The choice of surgical or nonsurgical management of such patients depends on the timing of diagnosis, the symptoms, and the extent of maturation of the ossified lesions. Surgical resection remains the only treatment with proven, evidence-based effectiveness. The choice of surgical approach largely depends on the location of the ossified lesions.

CONCLUSION

We believe the plane of dissection presented is a satisfactory option for resection of a posteromedial mass and sciatic nerve release.

Radiological Outcomes of Femoral Head Resection in Patients with Cerebral Palsy: A Retrospective Comparative Study of Two Surgical Procedures

Background: We conducted this study to compare postoperative radiological outcomes of two surgical procedures (femoral head resection (FHR) and femoral head cap plastic surgery (FCP)) in patients with CP and hip dislocation. Methods: CP patients with Gross Motor Function Classification Score (GMFCS) IV or V, who underwent either FHR or FCP between 2007 and 2018 at Heidelberg University Hospital in Germany, were included. Most participants underwent postoperative traction in an attempt to prevent telescoping. Besides the above-mentioned objectives, we examined the association between telescoping and spasmolytic use, traction weight, and traction duration. Results: Thirty-eight CP patients were included, of whom 15 (25 hips) underwent FHR and 23 (30 hips) underwent FCP. Heterotopic ossification (grades I, II, and III) occurred in 80% and 83.3% of patients in the FHR and FCP groups, respectively. Telescoping occurred in 18.68 and 31.99% of patients in the FHR and FCP groups, respectively (p = 0.999). Other complications were similar between both groups. Conclusions: The postoperative outcomes of FHR and FCP are similar in terms of telescoping, heterotopic ossification, and complications. Although telescoping was encountered more in the FCP group, no significant difference from the FHR group was found. We noted that the weight of traction could reduce the development of telescoping.

Parents and Caregivers Satisfaction After Palliative Treatment of Spastic Hip Dislocation in Cerebral Palsy

Objectives: Pain appearance is one the most common complication of spastic hip disease in children with cerebral palsy (CP). It determines child and caregiver quality of life and life priorities. Reconstruction hip surgery should be considered as a treatment of choice. Some clinical conditions give the inability to perform such a procedure. In our paper, we would like to present four palliative methods of spastic hip dislocation treatment in children with CP.

Material: We analyzed four groups of patients treated because of hip pain. Inclusion criteria were pain appearance (visual analog scale-11 or numeric rating scale-11) and hip joint dislocation (migration percentage >80%). All patients were admitted to our department between 2008 and 2018. In the first group, patients were treated only by steroid injections to hip joints; in the second group, patients were recruits after hip interposition arthroplasty with shoulder spacer; in the third group, they were patients after valgus subtrochanteric osteotomy (Schanz); and in the fourth group, these were patients after proximal femoral resection (Castle procedure). The minimal follow-up time was 2 years. The first group consisted of 15 patients (15 hips) with a mean age of 15.5 (8–17) years; the second group, 20 patients (24 hips) with a mean age of 14.2 (9–22.6) years; the third group, 22 patients (24 hips) with a mean age of 13.5 (7–20.5) years; and the fourth group, 10 patients (15 hips) with a mean age of 12.9 (7–17.6) years.

Methods: Radiological evaluation was based on a standardized anteroposterior X-ray of the hip joints. Pain severity before surgery and at the last follow-up time was measured by visual analog scale-11. Parents or caregivers were asked about their child's pain during sitting, perineal care, and rest. During the visit, all caregivers were asked about treatment satisfaction (no 0 to max 10) and if they would decide again for the same surgery.

Results: In all groups of patients, we observed a decrease in pain complaints. The observed reduction of pain in the first group was from 7.88 (4–10) to 3.08 (0–8) (p = 0.05), but results of injection were observed only for 4 months (2–8), and it has to be repeated (average: two times). In the second group, level of pain was reduced from 4.93 (1–10) to 0.93 (0–5) (p < 0.001); in the third group, from 6.22 (3–10) to 0.59 (0–6) (p < 0.001); and in the fourth group, pain reduces from 5.43 (2–10) to 2.13 (0–5) (p < 0.001). Observed changes concerned mostly sitting position and perineal care. The complication rate was in the second group, 6 of 24 cases of extraarticular ossification; in the third group, 2 of 24 cases with extraarticular ossification, two cases of revision surgery. In the fourth group, two cases needed another femoral resection. In the first group, five patients died during follow-up time, so they were excluded from the study. In the steroid injection group, parents' treatment evaluation was 6.83 (0–10), and only in three cases that they would resign from the treatment. In the hip interposition arthroplasty group, caregivers' evaluation was 7.41 (0–10), and in five cases, parents did not accept the surgery. In the Schanz osteotomy group, parents' evaluation was 5.9 (0–10), and in eight cases, caregivers would not repeat surgery. In the proximal femoral resection group, satisfaction was the highest, 8.3 (3–10), and only two parents would not decide for surgery again.

Conclusion: All procedures can be considered as palliative treatment options for pain complain in a spastic hip joint dislocation in children with CP. Steroid injections to the hip joint need to be repeated, and with the follow-up time, it becomes less effective. Steroid injection seems to be the treatment of choice for patients with general anesthesia contraindications. Interposition arthroplasty of the hip joint seems to give better final results, but the highest parents' satisfaction surprisingly was observed in the proximal femoral resection group, but differences were not statistically significant.