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Kiapekos N, von Heideken J, Broström E, Hägglund G, Åstrand P. Treatment of Hip Displacement in Children With Cerebral Palsy: A 5-year Comparison of Proximal Femoral Osteotomy and Combined Femoral-Pelvic Osteotomy in 163 Children. J Pediatr Orthop 2024; 44:e536-e541. [PMID: 38477355 PMCID: PMC11152590 DOI: 10.1097/bpo.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
BACKGROUND This study compared the 5-year outcomes of isolated proximal femoral varus osteotomy (FO) and combined proximal femoral varus and pelvic osteotomy (FPO) for the treatment of hip displacement in children with cerebral palsy (CP) in Sweden, focusing on the number of reoperations and residual hip displacement. METHODS The study included 163 children with a 5-year follow-up after FO or FPO in the national Swedish CP surveillance program, CPUP. Descriptive statistics and univariate and multivariate Cox regression analyses were used to identify whether the age at surgery, sex, Gross Motor Function Classification System level, CP dominant symptom, hip migration percentage (MP), type of surgery (unilateral/bilateral), and history of soft tissue hip surgery were related to the 5-year outcomes after surgery. Failure after hip surgery was defined as a skeletal reoperation involving the hip and/or MP >50%. RESULTS During the period 2001 to 2017, 163 children (65 girls) underwent 246 femoral and/or pelvic osteotomies (154 FO, 47 bilaterally; 92 FPO, 16 bilaterally) and had a 5-year follow-up; 95 and 74 children had ≥1 FO or FPO as the primary skeletal surgery, respectively. The mean preoperative MP (51%±18% for FO and 59%±17% for FPO, P =0.001) and age at surgery (6.2±2.5 years for FO and 7.3±2.8 years for FPO, P =0.014) differed between procedures. At the 5-year follow-up, 5 hips (5%) had reoperations and 5 hips (5%) had radiological failure among the 92 FPOs, and 33 (21%) had reoperations and 14 (9%) radiological failure among the 154 FOs. The difference in outcome failure rate was significant ( P <0.001). Multivariate Cox regression analysis showed a lower risk for failure with FPO [hazard ratio (HR)=0.32, 95% CI: 0.15-0.68] compared with FO. A higher preoperative MP increased the risk for outcome failure (HR=1.21, 95% CI: 1.15-1.36 for each 5% increment). CONCLUSIONS FPO had a higher mean preoperative MP but a lower 5-year outcome failure rate compared with FO. A higher preoperative MP was associated with an increased risk of failure. LEVEL OF EVIDENCE Level II-prospective comparative study.
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Affiliation(s)
- Nikolaos Kiapekos
- Department of Women’s and Children’s Health, Karolinska Institutet
- Department of Highly Specialized Pediatric Orthopedics and Medicine, Astrid Lindgren’s Children Hospital, Karolinska University Hospital, Stockholm
| | | | - Eva Broström
- Department of Women’s and Children’s Health, Karolinska Institutet
- Department of Highly Specialized Pediatric Orthopedics and Medicine, Astrid Lindgren’s Children Hospital, Karolinska University Hospital, Stockholm
| | - Gunnar Hägglund
- Department of Clinical Sciences, Lund, Orthopedics, Lund University, Sweden
| | - Per Åstrand
- Department of Women’s and Children’s Health, Karolinska Institutet
- Department of Highly Specialized Pediatric Orthopedics and Medicine, Astrid Lindgren’s Children Hospital, Karolinska University Hospital, Stockholm
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Faccioli S, Maggi I, Pagliano E, Migliorini C, Michelutti A, Guerra L, Ronchetti A, Cristella G, Battisti N, Mancini L, Picciolini O, Alboresi S, Trabacca A, Kaleci S. Sitting Postural Management to Prevent Migration Percentage Progression in Non-Ambulatory Children with Cerebral Palsy: Randomized Controlled Trial Preliminary Data. J Clin Med 2024; 13:3129. [PMID: 38892841 PMCID: PMC11173266 DOI: 10.3390/jcm13113129] [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: 04/27/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: To determine whether a sitting position with the femoral heads centered into the acetabulum is more effective than the usual sitting position in preventing migration percentage progression in non-ambulatory children with bilateral cerebral palsy. Methods: This was a multicenter, randomized controlled trial. INCLUSION CRITERIA spastic or dyskinetic cerebral palsy, Gross Motor Function Classification System level IV-V, age 1-6 years, migration percentage <41%, and informed consent. EXCLUSION CRITERIA contractures affecting the hip, anterior luxation, previous hip surgery, and lumbar scoliosis. The treatment group sat with their hips significantly abducted to reduce the head into the acetabulum in a customized system for at least five hours/day for two years. Controls sat with the pelvis and lower limbs aligned but the hips less abducted in an adaptive seating system. The primary outcome was migration percentage (MP) progression. Health-related quality of life and family satisfaction were among the secondary outcomes. The study was approved by the local ethics board and conducted in accordance with CONSORT reporting guidelines. CLINICALTRIALS gov ID: NCT04603625. RESULTS Overall median MP progression was 1.6 after the first year and 2.5 after the second year. No significant differences were observed between the groups. MP exceeded 40% and 50% in 1.8% and 0% of the experimental group and 5.4% and 3.6% of controls in years 1 and 2, respectively. Both groups expressed satisfaction with the postural system and stable health-related quality of life. Conclusions: MP remained stable over the two-year period in both groups. Considering outliers which progressed over 50%, a more protective trend of the hip-centering sitting approach emerged, but this needs to be confirmed in a final, larger dataset.
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Affiliation(s)
- Silvia Faccioli
- Pediatric Rehabilitation Unit, Azienda Unità Sanitaria Locale IRCCS of Reggio Emilia, 42122 Reggio Emilia, Italy; (I.M.); (S.A.)
- PhD Program in Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Irene Maggi
- Pediatric Rehabilitation Unit, Azienda Unità Sanitaria Locale IRCCS of Reggio Emilia, 42122 Reggio Emilia, Italy; (I.M.); (S.A.)
| | - Emanuela Pagliano
- Neurodevelopmental Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | | | | | - Liliana Guerra
- Pediatric Neuropsychiatric Unit, Azienda Unità Sanitaria Locale Modena, 41122 Modena, Italy;
| | - Anna Ronchetti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy;
| | | | - Nicoletta Battisti
- Pediatric Physical Medicine and Rehabilitation Unit, IRCCS Institute of Neurological Sciences, 40124 Bologna, Italy;
| | - Lara Mancini
- Physical Medicine and Rehabilitation Unit, Santa Maria delle Croci Hospital, Azienda Unità Sanitaria Locale Romagna, 48100 Ravenna, Italy;
| | - Odoardo Picciolini
- Pediatric Physical Medicine and Rehabilitation Unit, IRCCS Ca’ Granda Ospedale Maggiore Polyclinic Hospital, 20122 Milan, Italy;
| | - Silvia Alboresi
- Pediatric Rehabilitation Unit, Azienda Unità Sanitaria Locale IRCCS of Reggio Emilia, 42122 Reggio Emilia, Italy; (I.M.); (S.A.)
| | - Antonio Trabacca
- Unit for Severe Disabilities in Developmental Age and Young Adults, Scientific Institute IRCCS E. Medea, 72100 Brindisi, Italy;
| | - Shaniko Kaleci
- Surgical Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41125 Modena, Italy;
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Chiu AK, Dance S, Ferraro SL, O'Mara A, Thakkar SC, Tabaie S. A National Observational Study From 2010 to 2021 of the Trends in the Timing of Hip Surgery in Children With Cerebral Palsy: Is Surgery Being Performed Earlier? Cureus 2024; 16:e57536. [PMID: 38572177 PMCID: PMC10990000 DOI: 10.7759/cureus.57536] [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: 04/03/2024] [Indexed: 04/05/2024] Open
Abstract
Background Hip instability is a concern in pediatric cerebral palsy (CP) patients, with approximately one-third developing hip displacement. This may lead to pain, functional limitations, and decreased quality of life. Due to the progressive nature of hip displacement in CP, earlier surgical interventions may be beneficial. However, any shifts in practice to earlier surgical intervention, on a national scale, is not well described. The purpose of this study was to determine the recent trends in the surgical timing of hip interventions in children with CP. Methods A retrospective study was conducted using the PearlDiver Mariner all-payer claims database (PearlDiver Technologies, Colorado Springs, Colorado, United States). CP patients aged 10 years and younger were identified between 2010 and 2021. Hip surgeries including open reduction, adductor tenotomy, and pelvic osteotomy were identified. Patients were stratified by their age on the date of surgery and the year of the procedure. Linear regression analysis was conducted for temporal trends. Further, the compounded annual growth rate (CAGR) was calculated. Results A total of 309,677 CP patients were identified. For those aged one to four years old, the percentage undergoing hip surgery increased from 10.2% in 2010 to 19.4% in 2021. In the five- to 10-year-old age group, the surgery rate peaked at 14.9% in 2016 and steadily declined to 11.5% in 2021. The overall CAGR from 2010 to 2021 was +6.03% for the one- to four-year-old group and +0.88% for the five- to 10-year-old group. Linear regression demonstrated a significant association between year and the percentage of operations for patients ages one to four (R2=0.792, p<0.001), but not ages five-10 (R2=0.019, p=0.704). Conclusions Rates of surgical hip procedures in one- to four-year-old CP patients have been increasing since 2010, whereas the rate in five- to 10-year-old CP patients has been decreasing since 2016. Recently, CP patients may be undergoing hip surgery at younger ages.
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Affiliation(s)
- Anthony K Chiu
- Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Sarah Dance
- Orthopaedic Surgery, Children's National Hospital, Washington DC, USA
| | - Samantha L Ferraro
- Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Alana O'Mara
- Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | | | - Sean Tabaie
- Orthopaedic Surgery, Children's National Hospital, Washington DC, USA
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Joseph PJS, Khattak M, Masudi ST, Minta L, Perry DC. Radiological assessment of hip disease in children with cerebral palsy: development of a core measurement set. Bone Jt Open 2023; 4:825-831. [PMID: 37909150 PMCID: PMC10618048 DOI: 10.1302/2633-1462.411.bjo-2023-0060.r1] [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] [Indexed: 11/02/2023] Open
Abstract
Aims Hip disease is common in children with cerebral palsy (CP) and can decrease quality of life and function. Surveillance programmes exist to improve outcomes by treating hip disease at an early stage using radiological surveillance. However, studies and surveillance programmes report different radiological outcomes, making it difficult to compare. We aimed to identify the most important radiological measurements and develop a core measurement set (CMS) for clinical practice, research, and surveillance programmes. Methods A systematic review identified a list of measurements previously used in studies reporting radiological hip outcomes in children with CP. These measurements informed a two-round Delphi study, conducted among orthopaedic surgeons and specialist physiotherapists. Participants rated each measurement on a nine-point Likert scale ('not important' to 'critically important'). A consensus meeting was held to finalize the CMS. Results Overall, 14 distinct measurements were identified in the systematic review, with Reimer's migration percentage being the most frequently reported. These measurements were presented over the two rounds of the Delphi process, along with two additional measurements that were suggested by participants. Ultimately, two measurements, Reimer's migration percentage and femoral head-shaft angle, were included in the CMS. Conclusion This use of a minimum standardized set of measurements has the potential to encourage uniformity across hip surveillance programmes, and may streamline the development of tools, such as artificial intelligence systems to automate the analysis in surveillance programmes. This core set should be the minimum requirement in clinical studies, allowing clinicians to add to this as needed, which will facilitate comparisons to be drawn between studies and future meta-analyses.
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Affiliation(s)
| | - Mohammed Khattak
- University of Liverpool, Liverpool, UK
- Alder Hey Children’s Hospital, Liverpool, UK
| | | | | | - Daniel C. Perry
- University of Liverpool, Liverpool, UK
- Alder Hey Children’s Hospital, Liverpool, UK
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Kulkarni VA, Cung-Shahlaie NQ, Bagley AM, Yang NT, Taylor SL, Davids JR. HipScreen mobile app for the measurement of hip migration percentage in children with cerebral palsy: Accuracy, reliability, and discriminatory ability. Dev Med Child Neurol 2023; 65:1486-1492. [PMID: 37143284 PMCID: PMC10983771 DOI: 10.1111/dmcn.15612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 05/06/2023]
Abstract
AIM To assess the accuracy, reliability, and discriminatory ability of a mobile app for measurement of migration percentage in hip surveillance radiographs of children with cerebral palsy (CP). METHOD The free mobile app HipScreen (www.hipscreen.org) was utilized by a diverse group of users to measure the migration percentage of 40 hips at two time points after completing an online tutorial and competency test. The mean absolute error (MAE) was calculated against the reference standard obtained on a radiology workstation. Statistical analyses included linear regression, intraclass correlation coefficient (ICC), and area under receiver-operating characteristic curve (AUC). RESULTS Thirty-seven users completed the study, with 30 having a healthcare professional background, but only 15 with x-ray interpretation expertise. The overall MAE of migration percentage measurement using the HipScreen app was 5.72% (95% confidence interval [CI]: 5.38-6.06), with good reliability between time points (ICC = 0.83). With a migration percentage less than 30% considered as a positive case, the HipScreen app had a sensitivity of 94% (95% CI: 87-97), specificity of 66% (95% CI: 61-77), and an AUC of 0.92 (95% CI: 0.88-0.96). INTERPRETATION Users from a broad range of backgrounds can utilize the HipScreen app to measure hip surveillance radiographs with clinically acceptable accuracy, reliability, and discriminatory ability. WHAT THIS PAPER ADDS The HipScreen app can accurately and reliably measure migration percentage. As a screening tool, HipScreen has excellent sensitivity and discriminatory ability. A broad range of HipScreen users achieve clinically acceptable performance.
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Affiliation(s)
- Vedant A. Kulkarni
- Department of Orthopaedic Surgery, Shriners Children’s Northern California, Sacramento, California, USA
| | - Nina Q. Cung-Shahlaie
- Department of Orthopaedic Surgery, Shriners Children’s Northern California, Sacramento, California, USA
| | - Anita M. Bagley
- Department of Orthopaedic Surgery, Shriners Children’s Northern California, Sacramento, California, USA
| | - Nuen-Tsang Yang
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, California, USA
| | - Sandra L. Taylor
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, California, USA
| | - Jon R. Davids
- Department of Orthopaedic Surgery, Shriners Children’s Northern California, Sacramento, California, USA
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Wang NK, Shen SH, Chen BPJ, Chang CH, Kuo KN. Definition of hip displacement and dislocation by acetabular dysplasia in children with cerebral palsy. J Child Orthop 2023; 17:315-321. [PMID: 37565006 PMCID: PMC10411378 DOI: 10.1177/18632521231185294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/01/2023] [Indexed: 08/12/2023] Open
Abstract
Purpose The acetabulum interacts with the femoral head in daily activities and may exhibit structural changes in the presence of hip disorders. This study aims to redefine hip disorders in children with cerebral palsy by structural characteristics of the acetabulum in relation to the degree of the migration percentage. Methods The clinical and radiographic data of 70 patients (36 males, 34 females; mean age 8.2 years) with spastic cerebral palsy were retrospectively analyzed. The acetabular structure was measured by the acetabular index on reconstructed three-dimensional computerized tomography for precision of measurement. Any significant change in acetabular index measured on the reconstructive computerized tomography related to every 10% increment of migration percentage was regarded as clinically significant in hip disorders. Results The acetabular index measured on the reconstructive computerized tomography showed an increasing trend with the increment of migration percentage. The most significant acetabular index measured on the reconstructive computerized tomography change occurred between the 20%-29% and 30%-39% migration percentage groups (p < 0.001), suggesting that a migration percentage of 30% is the starting point of hip disorder. A significant increase in the posterolateral acetabular index measured on the reconstructive computerized tomography occurred in migration percentages >50%, indicating posterolateral acetabular dysplasia. Hips with migration percentages from 80% to 100% had consistent acetabular indexes measured on the reconstructive computerized tomography values, suggesting complete dislocation and no more contact and interaction between the femoral head and acetabular fossa. Conclusion Structural characteristics in the acetabulum reflect hip dysfunction and potentially classify hip disorders. Results suggest the migration percentage 30% as a starting point of hip disorder and 80% as a turning point of hip dislocation in children with cerebral palsy. Level of evidence level IV, diagnostic study.
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Affiliation(s)
- Nai Kuang Wang
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Shih Hsien Shen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi
| | - Brian Po Jung Chen
- Department of Pediatric Orthopaedics, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan
| | - Chia Hsieh Chang
- Department of Pediatric Orthopaedics, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan
| | - Ken N Kuo
- Cochrane Taiwan, Taipei Medical University, Taipei
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei
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Pham TT, Le LH, La TG, Andersen J, Lou EH. Ultrasound Imaging of Hip Displacement in Children With Cerebral Palsy. ULTRASOUND IN MEDICINE & BIOLOGY 2023:S0301-5629(23)00139-4. [PMID: 37277305 DOI: 10.1016/j.ultrasmedbio.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/08/2023] [Accepted: 04/22/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE An approach to estimation of hip displacement on ultrasound (US) images is described. Its accuracy is validated through numerical simulation, an in vitro study with 3-D-printed hip phantoms and pilot in vivo data. METHODS A diagnostic index, migration percentage (MP), is defined by the ratio of acetabulum-femoral head distance to femoral head width. The acetabulum-femoral head distance could be measured directly on hip US images, while the femoral head width was estimated from the diameter of a best-fit circle. Simulation was performed to evaluate the accuracy of circle fitting with noiseless and noisy data. Surface roughness was also considered. Nine hip phantoms (three different sizes of femur head × three MP values) and 10 US hip images were used in this study. RESULTS The maximum diameter error was 16.1 ± 8.5% when the roughness and noise were 20% of the original radius and 20% of the wavelet peak, respectively. In the phantom study, the percentage errors of MPs between the 3-D-design US and X-ray US were 0.3%-6.6% and 0.0%-5.7%, respectively. From the pilot clinical trial, the mean absolute difference between the X-ray-US MPs was 3.5 ± 2.8% (1%-9%). CONCLUSION This study indicates that the US method can be used to evaluate hip displacement in children.
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Affiliation(s)
- Thanh-Tu Pham
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada; Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Lawrence H Le
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada; Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Thanh-Giang La
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - John Andersen
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Edmond H Lou
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada; Department of Electrical and Computer Engineering, University of Alberta, Edmonton, Alberta, Canada.
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Faccioli S, Sassi S, Ferrari A, Corradini E, Toni F, Kaleci S, Lombardi F, Picelli A, Benedetti MG. Prevalence and determinants of hip pain in non-ambulatory cerebral palsy children: a retrospective cohort study. Eur J Phys Rehabil Med 2023; 59:32-41. [PMID: 36507793 PMCID: PMC10035438 DOI: 10.23736/s1973-9087.22.07725-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hip pain is common in cerebral palsy children, particularly at Gross-Motor Function Classification System level IV-V. It is associated to hip displacement and relates to the migration percentage. Recent literature suggested early reconstructive bone surgery, as the best approach to prevent hip luxation, then hip pain. Still, high rates of hip pain are reported. AIM To investigate prevalence and determinants of hip pain in an Italian cerebral palsy sample. DESIGN Single-center retrospective cohort study. SETTING Inpatient and outpatient. POPULATION Patients with spastic or dyskinetic cerebral palsy, Gross-Motor Function Classification System level IV or V, age 0-18. METHODS A chart review was implemented to report hip pain, as a dichotomous variable (pain/no pain), age, sex, cerebral palsy subtype, Gross-Motor Function level, lumbar scoliosis, migration percentage, previous orthopedic surgery, or botulinum injections, oral or intrathecal baclofen, drug-resistant epilepsy, assistive devices for standing or walking. Descriptive statistics and a multivariate logistic stepwise regression were performed. RESULTS A total of 504 subjects were included: 302 level V, 209 females, 432 spastics. The mean length of follow-up was 6 years. The overall prevalence of hip pain was 8.9% (6.3% were at level V) and of hip dislocation was 19% (15.9% were at level V). Just 39% of dislocated hips were painful. Children at spastic subtype and level V were predominantly affected. Botulinum and soft tissue surgery related to lower rates of hip pain, without statistical significance. Age (OR 1.19, 95%CI 1.14-1.25, P value 0.000), sex (OR 1.72, 95%CI 1.18-2.52, P value 0.005), migration percentage (OR 1.02, 95%CI 1.02-1.03, P value 0.000) and lumbar scoliosis (OR 1.32, 95%CI 0.86-2.01, P value 0.200) resulted significant independent determinants of hip pain. CONCLUSIONS Hip pain relates with the migration percentage, but not all dislocated hips become painful. Hip pain may be transient and requires a targeted and individualized approach. Children at spastic subtype and level V were predominantly affected. Age and sex are confirmed as determinants. Specific validated measures are to be implemented to assess hip pain. CLINICAL REHABILITATION IMPACT Considering severe non-ambulatory cerebral palsy patients, pain and quality of life should be considered as outcomes, in the management of hip luxation.
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Affiliation(s)
- Silvia Faccioli
- Unit of Children Rehabilitation, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy -
- PhD Program in Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy -
| | - Silvia Sassi
- Unit of Children Rehabilitation, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Adriano Ferrari
- Unit of Children Rehabilitation, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elena Corradini
- Unit of Children Rehabilitation, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Toni
- Unit of Physical Medicine and Rehabilitation, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Shaniko Kaleci
- Surgical Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Lombardi
- Unit of Neurorehabilitation, S. Sebastiano Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alessandro Picelli
- Neuromotor and Cognitive Rehabilitation Research Center, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Canadian Advances in Neuro-Orthopaedics for Spasticity Congress (CANOSC), Kingston, ON, Canada
| | - Maria G Benedetti
- Unit of Physical Medicine and Rehabilitation, Rizzoli Orthopedic Institute IRCCS, Bologna, Italy
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Oladeji AK, Cummings J, Minaie A, Landau AJ, Gordon JE, Hosseinzadeh P. Blade plate versus locking plate fixation of proximal femoral varus osteotomy in children with cerebral palsy. J Pediatr Orthop B 2023; 32:72-79. [PMID: 35170574 DOI: 10.1097/bpb.0000000000000962] [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: 12/16/2022]
Abstract
The hip is commonly affected in children with cerebral palsy (CP), requiring proximal femoral varus derotational osteotomies. Novel locking plates afford a popular alternative to traditional blade plates. The purpose of this study was to compare the effectiveness of blade plate versus locking plate fixation in children with CP undergoing proximal femoral osteotomy. We conducted a retrospective review of patients who underwent proximal femoral osteotomy over an 8-year period. Incidence of healing, failure of the procedure, and loss of varus correction were compared between the two groups (blade plate vs. locking plate). Independent samples t -tests and Chi-square analysis were employed to compare differences between continuous and categorical variables, respectively. A total of 268 hips [137 right (51.1%)] met inclusion criteria. Ninety-eight hips (36.6%) were fixed with blade plates [170 (63.4%) locking plates]. Although those in the blade plate cohort were more likely to achieve complete radiographic healing by 6 weeks postoperatively (41.09% vs. 18.84%; P < 0.050), there was no significant difference ( P > 0.050) between the two groups for healing at 3, 6, and 12 months ( P > 0.050). There was no significant difference between the two cohorts regarding the number of patients experiencing migration percentage at least 50% at 6 (3.06% vs. 3.53%) and 12 (3.06% vs. 5.88%) months ( P > 0.050) or in those undergoing revision surgery at 12 (5.33% vs. 1.18%) and 24 (2.04% vs. 1.76%) months ( P > 0.050). The findings of this retrospective study show similar outcomes between blade plate and proximal femoral locking plates in proximal femoral varus osteotomy in children with CP.
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Affiliation(s)
- Afolayan K Oladeji
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, Missouri, USA
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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.
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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
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11
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Yoo IH, Yang HR. Pelvic radiography as a non-invasive screening tool for hiatal hernia in children with cerebral palsy. Medicine (Baltimore) 2022; 101:e29522. [PMID: 35984193 PMCID: PMC9387974 DOI: 10.1097/md.0000000000029522] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The diagnosis of hiatal hernia (HH), causing severe gastroesophageal reflux disease and complications in children with cerebral palsy (CP) is cumbersome because invasive investigations are required for diagnosis. Hip displacement, one of the most common complications in children with CP, can be diagnosed with a simple pelvic radiograph. This study aimed to evaluate the association between the severity of hip displacement and HH and the diagnostic accuracy of Reimers' hip migration percentage (MP) on pelvic radiography in assessing the presence of HH. A total of 52 children with CP (27 boys, 25 girls; mean age, 6.3 years; range, 0.6-17.4 years) who underwent esophagogastroduodenoscopy, upper gastrointestinal series and pelvic radiography between March 2013 and February 2020 were recruited. Demographic and clinical characteristics, as well as endoscopic and radiological findings, were evaluated and statistically analyzed. HH was defined as ≥ 2 cm proximal displacement of the gastroesophageal junction identified in esophagogastroduodenoscopy or upper gastrointestinal series, and MP was calculated by evaluating the pelvic radiograph. Of the 52 children enrolled in this study, HH was diagnosed in 18 children (34.6%). When the patients were classified and analyzed according to the MP result, HH was observed in 10%, 26.7%, and 70.6% in MP <33%, MP 33%-39%, and MP > 40% groups, respectively (P < .001). The optimal MP cutoff of 36.5% distinguished pediatric CP patients with HH from those without HH with a sensitivity of 78%, specificity of 68%, a positive predictive value of 56.0%, and a negative predictive value of 85.2%, respectively. The application of MP and the severity of hip displacement, which can be easily measured by simple radiography, may be useful and reliable in screening for detecting HH in children with CP. Retrospectively registered. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2007-627-106).
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Affiliation(s)
- In Hyuk Yoo
- Department of Pediatrics, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- *Correspondence: Hye Ran Yang, Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea (e-mail: , )
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12
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Miller SD, Coates J, Bone JN, Farr J, Mulpuri K. A Review of Radiology Reports From Hip Surveillance Radiographs for Children With Cerebral Palsy. J Pediatr Orthop 2022; 42:e742-e746. [PMID: 35550421 DOI: 10.1097/bpo.0000000000002183] [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: 02/07/2023]
Abstract
BACKGROUND Measurement of migration percentage (MP) is fundamental to successful hip surveillance for children with cerebral palsy (CP). In British Columbia, Canada, children enrolled in the province's hip surveillance program get radiographs at the province's tertiary care pediatric hospital or their local community hospital. This study aimed to review the radiology reporting of images completed as part of hip surveillance. METHODS Pelvis radiographs completed between September 2015 and December 2019 of 960 children enrolled in the province's hip surveillance program were included. MP values measured by the program coordinator and corresponding value measured by the facility's radiologist, when present, were retrieved. Agreement in MP between the program coordinator and the radiologist was measured using Bland-Altman plots and intraclass correlation coefficients. Radiology reports for images completed at community facilities that prompted a referral to a pediatric orthopaedic surgeon, when reviewed by the hip surveillance team, were further reviewed for qualitative comments. RESULTS In total, 1849 radiographs were reviewed with 69.3% (1282) completed at the pediatric hospital and 30.7% (567) at 64 different hospitals or clinics. MP was reported for 20.6% (264/1282) of radiographs completed at the pediatric hospital and 3.0% (17/567) of the radiographs completed at community hospitals. Bland-Altman plot analyses found a MP mean difference of 1.2% (95% confidence interval=0.6%-1.8%) between the program coordinator and all radiologist reports with an intraclass correlation coefficient of 0.88 (95% confidence interval=0.86-0.90). There were 47 radiographs completed at community hospitals that resulted in a referral to a pediatric orthopaedic surgeon after review by the hip surveillance team. Eleven of these reports stated normal or unremarkable findings. CONCLUSIONS Radiologic reporting of images completed for hip surveillance for children with CP was inadequate to allow for the detection of hip displacement. Reporting of MP was rare, particularly in community hospitals. If radiology reporting will be utilized for hip surveillance in children with CP, education of radiologists is required.
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Affiliation(s)
| | - Jaimy Coates
- Department of Orthopaedic Surgery, BC Children's Hospital
| | - Jeffrey N Bone
- Research Informatics, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Jennifer Farr
- Department of Orthopaedic Surgery, BC Children's Hospital
| | - Kishore Mulpuri
- Department of Orthopaedic Surgery, BC Children's Hospital
- Orthopaedics, University of British Columbia
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13
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Faccioli S, Sassi S, Corradini E, Toni F, Kaleci S, Lombardi F, Benedetti MG. A retrospective cohort study about hip luxation in non-ambulatory cerebral palsy patients: The point of no return. J Child Orthop 2022; 16:227-232. [PMID: 35800654 PMCID: PMC9254025 DOI: 10.1177/18632521221106361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/28/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The migration percentage is a widely used criterion for surgery in displaced hips. Literature suggests that no hip can spontaneously improve if the migration percentage exceeds 45%, in a mixed population of cerebral palsy children. The aim of the present article was to identify the point of no return of the migration percentage in a selected sample of non-ambulatory cerebral palsy children, being the most exposed to hip luxation. METHODS This single-center retrospective cohort study included patients with spastic or dyskinetic cerebral palsy, Gross Motor Function Classification System level IV or V, age 0-18, having at least three pelvic radiographies, excluding radiographies relative to hips having previously undergone surgery. The following information was collected: sex, cerebral palsy subtype, Gross Motor Function Classification System level, presence of drug-resistant epilepsy, migration percentage, age at assessment, use of walking or standing assistive devices, previous botulinum injection, oral or intrathecal baclofen, and hip pain. Data were analyzed at the level of the individual hips. Descriptive statistics were presented. Receiver operating characteristic curve analysis was conducted to investigate which value of the migration percentage could be adopted as the "point of no return": that is, the cutoff value beyond which no migration percentage reduction, by more than 5%, could be expected. RESULTS The optimal cutoff value was identified as migration percentage ≥50%, with a sensitivity of 84.5% and a specificity of 100% (p-value <0.001). CONCLUSION Based on the present study, migration percentage ≥50% is the "point of no return" for Gross Motor Function Classification System IV-V cerebral palsy patients, representing the cutoff value beyond which no spontaneous cerebral palsy reduction may be expected, unless addressing surgery. LEVEL OF EVIDENCE level II-retrospective study.
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Affiliation(s)
- Silvia Faccioli
- Children Rehabilitation Unit of S. M.
Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio
Emilia, Italy,Clinical and Experimental Medicine,
Department of Biomedical, Metabolic and Neural Sciences, University of Modena and
Reggio Emilia, Modena, Italy,Silvia Faccioli, Children Rehabilitation
Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio
Emilia, 42122 Reggio Emilia, Italy. Emails:
;
| | - Silvia Sassi
- Children Rehabilitation Unit of S. M.
Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio
Emilia, Italy,Silvia Faccioli, Children Rehabilitation
Unit of S. M. Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio
Emilia, 42122 Reggio Emilia, Italy. Emails:
;
| | - Elena Corradini
- Children Rehabilitation Unit of S. M.
Nuova Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio
Emilia, Italy
| | - Francesca Toni
- Physical Medicine and Rehabilitation
Unit, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia,
Italy
| | - Shaniko Kaleci
- Surgical Medical and Dental Department
of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine,
University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Lombardi
- Neurorehabilitation Unit of S.
Sebastiano Hospital, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio
Emilia, Italy
| | - Maria Grazia Benedetti
- Physical Medicine and Rehabilitation
Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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14
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MARQUES MARCUSVINICIUSBRITO, MISTRO NETO SYLVIO, ROSSANEZ ROBERTO, CAVALI PAULOTADEUMAIA, ROSSATO ALEXANDERJUNQUEIRA, LANDIM ELCIO, RISSO NETO MARCELOÍTALO. COMPARISON BETWEEN TWO METHODS OF MEASURING PELVIC OBLIQUITY IN CEREBRAL PALSY AND MYELOMENINGOCELE. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222103147809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To evaluate the intra- and inter-observer reproducibility of the evaluation of the pelvic obliquity (PO) in patients with neuro-muscular deformities via the method that uses the iliac crests and the method that uses the upper endplate of S1 and to determine whe ther there is a relationship between the methods. Methods: The digitized panoramic radiographies of thirty patients with cerebral paralysis or myelomeningocelein outpatient monitoring were evaluated by four examiners: two experienced spinal surgeons and two fellows. Two radiographs were excluded because analysis was impossible. All exams were obtained in accordance with the periodic monitoring protocol in the sitting position, using digitized film and a film-focus distance of 110 cm Results: High intra- and inter-observer agreement was observed both for method that uses the iliac crests and the method that evaluates the S1 endplate. However, no significant relationship between the two methods was observed. Conclusions: The methods evaluated had good reproducibility and agreement among the observers. It was confirmed that, on account of the existent linear relation, it is possible to estimate the value of the iliac crest method knowing the value obtained by the S1 plateau multiplied by 0.76. There was no agreement between the iliac crest and S1 plateau PO evaluation methods. Level of evidence IV; Retrospective cross-sectional study.
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Affiliation(s)
| | - SYLVIO MISTRO NETO
- Universidade Estadual de Campinas - UNICAMP, Brazil; Hospital Alemão Oswaldo Cruz, Brazil
| | | | | | | | - ELCIO LANDIM
- Universidade Estadual de Campinas - UNICAMP, Brazil; Hospital Alemão Oswaldo Cruz, Brazil
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15
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Milks KS, Whitaker AT, Ruess L. Radiographic hip screening for children with cerebral palsy: an imaging and reporting update. Pediatr Radiol 2022; 52:12-21. [PMID: 34518936 DOI: 10.1007/s00247-021-05197-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 07/20/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022]
Abstract
Children with cerebral palsy are at increased risk of hip dislocation. Detecting hip subluxation through radiographic hip screening is an essential component of hip surveillance and has been shown to prevent hip dislocations. Large-scale hip surveillance programs are being implemented nationwide, highlighting the importance of uniform technical and reporting standards.
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Affiliation(s)
- Kathryn S Milks
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA. .,Department of Radiology, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Amanda T Whitaker
- Department of Orthopedic Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Orthopedic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lynne Ruess
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.,Department of Radiology, The Ohio State University College of Medicine, Columbus, OH, USA
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16
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Standardized Process Measures in Radiographic Hip Surveillance for Children with Cerebral Palsy. Pediatr Qual Saf 2021; 6:e485. [PMID: 34934874 PMCID: PMC8677969 DOI: 10.1097/pq9.0000000000000485] [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: 11/28/2020] [Accepted: 06/30/2021] [Indexed: 11/30/2022] Open
Abstract
Detection of hip migration in children with cerebral palsy (CP) through radiographic surveillance can prevent dislocations. Migration Percentage (MP) is the accepted method for quantifying hip subluxation in CP on pelvis x-ray but was not being reported at our institution. Our objective was to improve care for children with CP by standardizing radiographic techniques and reporting radiographs obtained as part of a hip surveillance program.
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17
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Pham TT, Le MB, Le LH, Andersen J, Lou E. Assessment of hip displacement in children with cerebral palsy using machine learning approach. Med Biol Eng Comput 2021; 59:1877-1887. [PMID: 34357510 DOI: 10.1007/s11517-021-02416-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
Manual measurements of migration percentage (MP) on pelvis radiographs for assessing hip displacement are subjective and time consuming. A deep learning approach using convolution neural networks (CNNs) to automatically measure the MP was proposed. The pre-trained Inception ResNet v2 was fine tuned to detect locations of the eight reference landmarks used for MP measurements. A second network, fine-tuned MobileNetV2, was trained on the regions of interest to obtain more precise landmarks' coordinates. The MP was calculated from the final estimated landmarks' locations. A total of 122 radiographs were divided into 57 for training, 10 for validation, and 55 for testing. The mean absolute difference (MAD) and intra-class correlation coefficient (ICC [2,1]) of the comparison for the MP on 110 measurements (left and right hips) were 4.5 [Formula: see text] 4.3% (95% CI, 3.7-5.3%) and 0.91, respectively. Sensitivity and specificity were 87.8% and 93.4% for the classification of hip displacement (MP-threshold of 30%), and 63.2% and 94.5% for the classification of surgery-needed hips (MP-threshold of 40%). The prediction results were returned within 5 s. The developed fine-tuned CNNs detected the landmarks and provided automatic MP measurements with high accuracy and excellent reliability, which can assist clinicians to diagnose hip displacement in children with CP.
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Affiliation(s)
- Thanh-Tu Pham
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Minh-Binh Le
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada.,Department of Computer Science, Ho Chi Minh City University of Science, Ho Chi Minh City, Vietnam
| | - Lawrence H Le
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - John Andersen
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Edmond Lou
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada. .,Department of Electrical and Computer Engineering, 11-263 Donadeo Innovation Centre for Engineering, University of Alberta, 9211-116 Street, Edmonton, AB, T6G 1H9, Canada.
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18
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Abstract
AIMS The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study. METHODS All children registered on the Cerebral Palsy Integrated Pathway Scotland surveillance programme undergo regular pelvic radiographs. Any child who had a MP measuring over 35% since the programme's inception in 2013, in at least one hip and at one timepoint, was identified. The national radiography database was then interrogated to identify all pelvic radiographs for each of these children from birth through to the date of analysis. A minimum of a further two available radiographs following the initial measurement of MP ≥ 35% was required for inclusion. RESULTS A total of 239 children (346 hips) were identified as suitable for analysis at a mean of 6.5 years (2.0 to 14.8) follow-up. In all, 1,485 radiographs taken both prior to and after a hip had a MP ≥ 35% were examined and the MP measured to identify any progression of displacement. Interrogation of the data identified that hips with a MP up to 46% returned to a MP below 40% without intervention, and all hips with a MP equal to or greater than 46% displaced further and the MP did not return to the normal range. Statistical analysis showed the result to be 98% specific with this degree of certainty that hips reaching a MP ≥ 46% would not spontaneously regress. CONCLUSION These findings are clinically relevant in showing that it may be reasonable to continue to monitor hips with a MP not exceeding 46%. This threshold will also guide referral for further management of a displacing hip. Cite this article: Bone Joint J 2021;103-B(2):411-414.
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Affiliation(s)
| | | | - Paul R Bessell
- Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - James E Robb
- School of Medicine, University of St Andrews, St Andrews, UK
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19
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Miller S, Habib E, Bone J, Schaeffer E, Yang BW, Shea J, Maleki A, Shore BJ, Mulpuri K. Inter-rater and Intrarater Reliabilities of the Identification of a "Gothic Arch" in the Acetabulum of Children With Cerebral Palsy. J Pediatr Orthop 2021; 41:6-10. [PMID: 32558745 PMCID: PMC7727464 DOI: 10.1097/bpo.0000000000001615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Progressive hip displacement in children with cerebral palsy (CP) is monitored by measuring migration percentage (MP) on anteroposterior (AP) pelvis radiographs. Accurate measurement of MP requires the lateral margin of the ossified acetabulum to be identified for the placement of Perkin's line. It has been suggested that when there is an erosion of the acetabular rim, described as a gothic arch, the midpoint of the arch be used for the placement of Perkin's line. However, this requires that there be agreement on what constitutes a gothic arch. The purpose of this study was to evaluate the inter-rater and intrarater reliabilities of identifying a gothic arch on pelvis radiographs. METHODS An online survey with 100 AP pelvis images (200 hips) of children with CP was sent to international experts. Participants were asked to identify which hip(s) had a gothic arch (left, right, both, and neither). The Fleiss κ statistic for inter-rater reliability was calculated. Eight weeks later, the images were shuffled and redistributed to calculate intrarater reliability. RESULTS The initial survey was completed by 10 participants with 9 participants completing the second survey. The average inter-rater κ value was 0.18 [95% confidence interval (CI), 0.14-0.23] and 0.19 (95% CI, 0.14-0.24) for the 2 surveys, respectively. Among the pediatric orthopaedic surgeons subgroup, the κ values were 0.06 (95% CI, 0.02-0.1) and 0.08 (95% CI, 0.03-0.13). The average intrarater reliability κ value was 0.61 (95% CI, 0.2-1), ranging from 0.32 to 0.86. CONCLUSIONS There were poor inter-rater and moderate intrarater reliabilities in identifying a gothic arch on AP pelvis radiographs in children with CP. Further characterization and clarification of what constitutes a gothic arch are required. The lack of agreement on the identification of a gothic arch may negatively impact the measurement of MP and referrals to a pediatric orthopaedic surgeon.
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Affiliation(s)
- Stacey Miller
- Departments of Physical Therapy
- Department of Orthopaedics, BC Children’s Hospital, Vancouver, BC, Canada
| | - Eva Habib
- Department of Orthopaedics, BC Children’s Hospital, Vancouver, BC, Canada
| | | | - Emily Schaeffer
- Orthopaedic Surgery, University of British Columbia
- Department of Orthopaedics, BC Children’s Hospital, Vancouver, BC, Canada
| | | | | | - Ava Maleki
- Department of Orthopaedics, BC Children’s Hospital, Vancouver, BC, Canada
| | - Benjamin J. Shore
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Kishore Mulpuri
- Orthopaedic Surgery, University of British Columbia
- Department of Orthopaedics, BC Children’s Hospital, Vancouver, BC, Canada
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20
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Wek C, Chowdhury P, Smith C, Kokkinakis M. Is the Gothic Arch a reliable radiographic landmark for migration percentage in children with cerebral palsy? J Child Orthop 2020; 14:397-404. [PMID: 33204347 PMCID: PMC7666799 DOI: 10.1302/1863-2548.14.200008] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Reimers migration percentage (MP) is the gold standard for measuring hip displacement in children with cerebral palsy (CP). Hip surveillance registries proposed using the top of the Gothic arch (GA) as a modification in patients with acetabular dysplasia because the classical method (CM) described by Reimers may underestimate hip migration. The aim of this study is to assess the inter- and intra-observer reliability of the modified method (MM) versus the CM and identify their effect on the MP. METHODS We performed a retrospective review of 50 children with CP, who had a hip radiograph at our institution between 1st April 2014 and 28th February 2018. All hip radiographs were carefully selected to show the presence of a GA. Four observers measured the MP using the CM and MM for each patient. Interclass coefficient was used to estimate inter- and intra-observer reliability. RESULTS Inter-observer reliability was excellent for the CM with ICC 0.96 (95% CI 0.94 to 0.97) and good for the MM, ICC 0.78 (95% CI 0.51 to 0.89) p < 0.001. Intra-observer reliability was excellent for both methods raging from ICC 0.94 to 0.99 for the CM and ICC 0.89 to 0.95 for the MM. The mean MP was 19% for the CM and 28% for the MM (p < 0.001). CONCLUSION The CM is more reliable than the MM to measure hip migration in children with CP. If the CM is used and acetabular dysplasia with a GA are present on the hip radiograph, then a 9% hip migration underestimation should be considered on decisions for both referral and surgical management. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Caesar Wek
- Evelina London Children’s Hospital, London, UK,Correspondence should be sent to Caesar Wek, King’s College Hospital - Trauma & Orthopaedics, Denmark Hill, London, SE5 9RS, UK. E-mail:
| | | | | | - Michail Kokkinakis
- Evelina London Children’s Hospital, London, UK,King’s College London University, London, UK
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21
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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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Neirynck J, Proost R, Van Campenhout A. The migration percentage measured on EOS® standing full-leg radiographs: equivalent and advantageous in ambulant children with cerebral palsy. BMC Musculoskelet Disord 2019; 20:366. [PMID: 31391039 PMCID: PMC6686540 DOI: 10.1186/s12891-019-2746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 07/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During ambulatory follow-up of patients with cerebral palsy (CP) systematic radiographic screening is required firstly to evaluate hip migration and development in the prevention of hip dislocation and secondly to analyse lower limb alignment and leg length. The Migration Percentage (MP) is a radiographic measurement used to describe the extent of femoral head lateralisation on conventional supine pelvic radiographs. Our goal was to assess the comparability of the MP measured on low radiation dose EOS® standing full-leg radiographs with that of conventional supine pelvic radiographs. METHODS Patients presenting with CP were prospectively selected from our outpatient follow-up consultation at our institutions CP reference centre and underwent conventional supine pelvic and EOS® standing full-leg radiographs the same day for diagnostic and screening reasons. RESULTS Out of 28 prospectively selected patients we included 21 (42 hips), of which 10 were female, with a mean age of 9.25 years and GMFCS levels of I, II and III. Seven out of 28 patients were excluded due to insufficient quality of radiographic images. The absolute differences in MP measured on both conventional supine pelvic and EOS® standing full-leg radiographs ranged between - 8 and 6% with an absolute mean difference of 0% (SD ±3.5) and were not statistically significant (p = 0.99). A Bland-Altman plot showed acceptable agreement between both measurements without proportional bias. CONCLUSION There is no statistical significant difference between the Migration Percentage measured on conventional supine pelvic radiographs and EOS® standing full-leg radiographs in ambulant patients. These images use lower radiation doses and contain more radiographic information. TRIAL REGISTRATION Approved by the Medical Research Ethics committee of the University Hospitals Leuven ( MP001492 ).
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Affiliation(s)
- Jef Neirynck
- University Hospitals Leuven, Herestraat, 49 3000, Leuven, Belgium.
| | - Renee Proost
- University Hospitals Leuven, Herestraat, 49 3000, Leuven, Belgium
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