The pathogenesis of osteoarthritis in cerebral palsy

Total Knee Arthroplasty in Patients with Cerebral Palsy: A Large Database Analysis

Cerebral palsy (CP) is a neurodevelopmental condition that can result in altered gait biomechanics, joint dysfunction, and imbalance. The complications associated with total knee arthroplasty (TKA) in patients with CP have not yet been well described. Therefore, our analysis sought to compare the 90-day and 2-year complications following TKA in patients with and without CP. The PearlDiver Mariner database was utilized to identify patients with CP undergoing primary TKA between 2010 and 2020. This cohort was matched 1:4 to a control cohort without neurodegenerative disorders based on age, sex, Elixhauser Comorbidity Index (ECI), tobacco use, obesity, and diabetes. A total of 3,257 patients (657 CP patients 2,600 controls) were included in our final analysis. A multivariable logistic regression analysis was utilized to determine the risk of CP on medical and surgical complications at 90 days and all-cause revision rates at 2 years. Patients with CP had an increased risk of acute kidney injury (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.07-2.5; p = 0.019), pneumonia (OR: 5.63; 95% CI: 3.69-8.67; p < 0.001), urinary tract infection (OR: 5.01; 95% CI: 3.85-6.52; p < 0.001), and transfusion (OR: 2.21; 95% CI: 1.50-3.23; p < 0.001). CP patients additionally had a higher incidence of emergency department (ED) visits (OR: 5.24; 95% CI: 3.76-7.32; p < 0.001) and readmissions (OR: 5.24; 95% CI: 2.57-4.96; p < 0.001). There were no differences in rates of periprosthetic joint infection (PJI; OR: 1.23; 95% CI: 0.69-2.10; p = 0.463), surgical site infection (SSI; OR: 0.51; 95% CI: 0.12-1.46; p = 0.463), and reoperation (OR: 1.35; 95% CI: 0.71-2.43; p = 0.339) at 90 days postoperatively. The all-cause revision rates at 2 years were comparable (OR: 1.02; 95% CI: 0.67-1.51; p = 0.927). In this database review, we found that CP patients have a higher risk of medical complications in the acute postoperative period following TKA. The 90-day surgical complication and 2-year revision rates in CP patients were comparable to matched controls.

Tools for Nutrition Assessment of Adults with Cerebral Palsy: Development of a Gold Standard

PURPOSE OF REVIEW

Cerebral palsy (CP) is a group of disorders caused by non-stabilized cerebral lesions. Individuals with this disorder are at a higher risk of suffering from malnutrition and other related detrimental effects to their quality of life. For this reason, accurate methods of nutritional assessment are vital for people suffering from this condition. While assessment of nutritional status in children with CP has been extensively studied, very few studies have been carried out on adults. These limitations are due to the great anatomical-functional variability characteristic of this syndrome. Difficulties that derive from this variability in adult patients with CP mean that there remains an urgent need for certain standards of nutritional assessment for this population. The objective of this review is to compile the latest trends in nutritional assessment in adults with CP to guide the development of a conceptual framework for future research.

RECENT FINDINGS

With this aim, relevant studies have been identified. The most commonly used technique to evaluate nutritional status is the BMI because of its ease-of-use. However, its well-known limitations fail to adequately estimate the nutritional status in this population, with measurements of patients with CP yielding results that are much less accurate than those that already exist in the general population. Although more studies are needed, kinanthropometry is considered one of the most reliable techniques; nevertheless, the anatomical limitation characteristic of CP plays a limiting factor.

The effect of an ankle-foot orthosis on tibiofemoral motion during step-up and step-down in healthy adults

BACKGROUND

Solid ankle-foot orthoses (SAFOs) are frequently prescribed in conditions such as cerebral palsy and stroke. Although gait is improved in the short term, long-term effects of limiting ankle and foot motion during functional activities on joints such as the knee have not been investigated. Our study purpose was to compare tibiofemoral (TF) motion in shoe and SAFO conditions in healthy adults to inform future studies in clinical populations.

METHODS

A custom-made device using electromagnetic sensors was used to collect three-dimensional TF rotation data while 29 healthy adult participants (female participants = 19, age = 24.4 ± 4.5 years) performed step-up/step-down in shoe and SAFO conditions.

RESULTS

In the SAFO condition during step-up, extent of motion was greater in frontal and transverse planes and less in the sagittal plane. Discrete values at 0%-10% of the cycle in sagittal, 50%-100% in frontal, and 40%-100% in transverse planes were statistically different, producing more abduction and external rotation. In the SAFO condition during step-down, extent of motion was significantly greater in the frontal and transverse planes. Discrete values were statistically different in 40%-60% of the cycle in sagittal, 0%-30% and 70%-90% in frontal, and 0%-30% and 70%-90% in transverse planes, producing more abduction and external rotation in the first half of the cycle and more adduction and internal rotation in the second half of the cycle.

CONCLUSIONS

An SAFO affects triplanar TF kinematics in healthy adults during step-up/step-down. Future investigations into ankle-foot orthosis prescription and TF motion in clinical populations will facilitate optimal ankle-foot orthosis prescription and knee function in the long term.

Hip Displacement in MECP2 Disorders: Prevalence and Risk Factors

BACKGROUND

Methyl-CpG binding protein 2 (MECP2) disorders, including Rett syndrome and MECP2 duplication syndrome, are typified by profound intellectual disability, spasticity, and decline in gross motor function. Unlike scoliosis, linked to disease severity, little has been reported regarding the hip. The aim of this study was to report the prevalence and risk factors of hip displacement (HD) in MECP2 disorders.

METHODS

This was a retrospective, comparative study. Children with a genetically confirmed MECP2 disorder were included. The primary outcome measure was the prevalence of HD (migration percentage>30%). Secondary outcomes included age at HD onset, ambulatory status, presence of clinically relevant scoliosis, genetic severity, presence of seizures, and associated comorbidities. Analysis of proportions of categorical variables was performed using χ2 testing (P=0.05).

RESULTS

Fifty-six patients (54 Rett syndrome and 2 MECP2 duplication syndrome), diagnosed at 6.6 (SD: 4.7) years, met the inclusion criteria. The prevalence of HD was 36% [onset, 7.7 (SD: 3.8) y]. Risk factors for HD were nonwalker status (P=0.04), scoliosis (P=0.001), and refractory epilepsy (P=0.04).

CONCLUSIONS

The prevalence of HD in MECP2 disorders is comparable to cerebral palsy, associated with proxy measures of disease severity. These results can be used to develop hip surveillance programs for MECP2 disorders, allowing for timely management.

LEVEL OF EVIDENCE

Level III.

Ultrasonographic Measurement of Talar Cartilage Thickness in Patients With Cerebral Palsy

OBJECTIVE

Foot deformities are one of the most common musculoskeletal problems in children with cerebral palsy (CP). These deformities affect the walking ability and function of the patients. Talar cartilage is the hyaline joint cartilage of the tibiotalar joint that plantarflexes and dorsiflexes of the ankle. The aim of this study was to determine whether talar cartilage thickness was affected in children with ambulant diplegic CP.

DESIGN

Forty patients with diplegic CP (19 boys, 21 girls) and 40 age-, sex-, and weight-matched healthy control subjects (20 boys, 20 girls) were included in the study. The demographic and clinical characteristics of the patients, including age, sex, and body mass index, were recorded. Patients were classified using the Gross Motor Function Classification System. A 12-MHz linear probe was used for ultrasonographic cartilage measurements at the tibiotalar joint according to European Musculoskeletal Ultrasound Study Group (EURO-MUSCULUS) and the Ultrasound Study Group in Physical and Rehabilitation Medicine (USPRM) scanning protocols.

RESULTS

Mean talar cartilage thickness was significantly decreased in the CP group compared with the healthy control group (P < 0.001). There was a significant negative correlation between Gross Motor Function Classification System levels and talar cartilage thickness measurements (P < 0.001, Tb = -0.695).

CONCLUSION

This study demonstrates that patients with CP have a thinner talar cartilage compared with healthy control subjects.

Shoulder arthroplasty in patients with cerebral palsy: a matched cohort study to patients with osteoarthritis

BACKGROUND

Patients with cerebral palsy (CP) often experience shoulder impairment via spasticity, muscle contractures, and joint instability. Currently, few studies investigate shoulder arthroplasty (SA) in patients with CP. This study reviewed the outcomes of both anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) in patients with CP.

METHODS

Over a 30-year-period, 5 patients undergoing SA (2 TSA, 3 RSA) with a diagnosis of CP were identified. The cohort included 4 male patients with a mean age of 50.4 years (range, 44-58 years). CP patients were matched 1:2 based on age, sex, body mass index, and year of surgery with a group of patients undergoing SA for osteoarthritis (OA).

RESULTS

Survival from implant revision for both TSA and RSA in CP was 100% at both 2 and 5 years postoperatively. Clinical complications were only observed in 2 patients after TSA, with 1 patient requiring revision at 14 years postoperatively. Collectively, there was no difference in the rate of complications and implant survival between patients with CP vs. OA. Prior to the surgical procedure, all CP patients had severe or moderate pain, with no moderate or severe pain postoperatively. Notable postoperative increases from preoperative baselines were noted in forward elevation (57°-106°), abduction (48°-84°), and external rotation (30°-64°). RSA had significantly improved postoperative abduction compared to TSA (97° vs. 64°, P < .01).

CONCLUSIONS

SA is a safe, durable procedure in patients with CP to clinically improve pain, function, and satisfaction. RSA was associated with better function and fewer complications than TSA.

Total Joint Arthroplasty in Patients With Cerebral Palsy

INTRODUCTION

Cerebral palsy (CP) is a neurodevelopmental condition with a wide range of presentations that usually lead to muscle imbalance culminating with precocious knee and hip arthrosis, often leading to total hip (THA) and knee arthroplasty (TKA). This study sought to determine the following: (1) the inherent differences of in-hospital characteristics and comorbidities between CP and non-CP patients undergoing total joint arthroplasty (TJA) and (2) do patients with CP have an increased risk of perioperative complications after TJA?

METHODS

The Nationwide Inpatient Sample database from 2005 to 2014 was queried in this retrospective cohort study to compare patient demographics and comorbidities, hospital characteristics, perioperative complications, and length of stay in patients with CP undergoing TJA compared with their non-CP counterparts. Statistical analyses were performed using the Rao-Scott chi-square test and analysis of variance. All analyses took into account the sampling procedure and weighting.

RESULTS

A total of 2,062 and 2,193 patients with CP underwent THA and TKA, respectively, during the study period. Both CP groups were younger (P < 0.0001), were more likely to have Medicaid insurance (P < 0.0001), and had longer lengths of hospital stay (P < 0.0001) compared with their non-CP counterparts. Non-CP patients had significantly higher rates of obesity, coronary artery disease, diabetes, and peripheral vascular disease (P < 0.05). However, patients with CP undergoing THA had a lower Charlson Comorbidity Index (P = 0.0002), whereas those undergoing TKA had similar comorbidity profile as the non-CP group (P = 0.097). Both THA and TKA CP patients had a higher risk of overall postoperative complications (P < 0.05) and surgical complications (P < 0.05), in particular acute postoperative anemia (P < 0.05).

CONCLUSION

Despite being younger with fewer comorbidities, patients with CP are at an increased risk of immediate perioperative complications after TJA compared with the general osteoarthritis population. Given that these patients have satisfactory long-term outcomes after TJA, these procedures can be performed successfully for patients with CP with careful medical management and surgical planning.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Adaptive Sports, Arts, Recreation, and Community Engagement

Adaptive sports and recreation have an important role in the lifestyle of individuals with cerebral palsy (CP). This article discusses the history of adaptive sports and the benefits of adaptive sports and recreation. Barriers and medical challenges are also thoroughly discussed, including common musculoskeletal issues, methods to prevent musculoskeletal injury, pain, fatigue, maximal exertion, and other medical comorbidities and illness. The role of health care providers such as physiatrists is emphasized to provide support to individuals with CP who either are interested in starting exercise or a sport or are already an athlete.

Visual kinematic feedback enhances the execution of a novel knee flexion gait pattern in children and adolescents

BACKGROUND

Altered knee motion is one of the most common gait deviations in pediatric populations with gait disorders. The potential for pediatric gait retraining using visual feedback based on knee kinematic patterns is under-explored.

RESEARCH QUESTION

This study investigated whether pediatric participants could successfully modify knee flexion patterns in response to a visual kinematic feedback system (VKFS).

METHODS

Knee flexion angles from twelve typically developing children and adolescents (6 M, 6 F; 11.9 ± 2.7 years) were calculated using wearable inertial measurement units. Participants were tested while walking on a treadmill using pattern based visual feedback (FB). Four novel target patterns which amplified or attenuated swing phase peak knee flexion were tested. No feedback (NFB) tests assessed the participant's ability to independently reproduce the patterns. Mean absolute cycle error (MACE) and magnitude of peak knee flexion error (PK) were calculated during the last 10 strides of FB and NFB trials. Pre-exposure reference values (R) were also calculated.

RESULTS AND SIGNIFICANCE

PK-FB was significantly smaller (p < 0.05) than PK-R for all targets. Average values for PK-NFB were higher than for PK-FB, although PK-NFB remained significantly lower than PK-R for two targets. Contrary to one of the study's hypotheses, MACE-FB and MACE-NFB were larger than MACE-R. The study provided evidence that pediatric participants were able to modify peak knee flexion during gait in the sense targeted by the VKFS. Analysis suggested that MACE increases were explained by increases in gait cycle deviation outside of the changed region.

Incidence of osteoarthritis, osteoporosis and inflammatory musculoskeletal diseases in adults with cerebral palsy: A population-based cohort study

BACKGROUND

People with cerebral palsy (CP) may be at increased risk of musculoskeletal conditions due to various factors including malnutrition and abnormal levels of skeletal loading. This study aimed to compare the incidence of osteoporosis, osteoarthritis and inflammatory musculoskeletal diseases between adults with and without CP.

METHODS

A population based cohort study was conducted using data from the Clinical Practice Research Datalink collected between 1987 and 2015. Adults with CP were matched to adults without CP for age, sex and general practice. Cox models, stratified by matched set and adjusted for potential confounders, were fitted to compare the risk of osteoporosis, osteoarthritis and inflammatory musculoskeletal diseases.

RESULTS

1705 adults with CP were matched to 5115 adults without CP. Adults with CP had an increased risk of osteoporosis in unadjusted (Hazard Ratio (HR) 3.67, 95% Confidence Interval (CI) 2.32 to 5.80, p < 0.001) and adjusted (HR 6.19, 95% CI 3.37 to 11.39, p < 0.001) analyses. No evidence of increased risk of inflammatory musculoskeletal diseases was observed in unadjusted or adjusted analyses. For osteoarthritis no evidence of increased risk was seen in the unadjusted analysis, but evidence of an increased risk was seen when the analysis was adjusted for alcohol consumption, smoking status, and mean yearly general practice (GP) visits (HR 1.54, 95% CI 1.17 to 2.02, p < 0.001).

CONCLUSIONS

After accounting for potential confounding variables, we found that CP is associated with increased risk of osteoporosis and osteoarthritis. These findings provide the strongest epidemiological evidence to date for increased risk of osteoporosis and osteoarthritis in people with CP, and highlight need for clinical awareness of such conditions in this population.

Prevalence of metabolic syndrome and cardiovascular disease risk factors in adults with cerebral palsy

AIM

To investigate the prevalence of metabolic syndrome and cardiovascular disease (CVD) risk factors and the association between common metabolic markers and Gross Motor Function Classification System (GMFCS) levels in ambulatory adults with cerebral palsy (CP).

METHOD

Metabolic markers and GMFCS levels were evaluated in a cross-sectional study of 70 ambulatory adults with CP (34 males, 36 females; mean age 24y 5mo [SD 5y 4mo], range 18y 6mo-48y 8mo) to determine the prevalence of metabolic syndrome and CVD risk factors, and were compared to age-matched, population norms from the National Health and Nutrition Examination Survey (NHANES) registry. The Framingham Heart Study (FHS) CVD risk estimation was also used to evaluate an individual's risk for CVD.

RESULTS

Metabolic syndrome was identified in 17.1% of the cohort, higher than the 10% in the NHANES registry. The FHS CVD 30-year lipid and body mass index (BMI)-based risk factor results showed that 20% to 40% of the cohort was at greater risk of developing CVD (BMI-based: 39.7% 'full' CVD risk factor; lipid-based: 26.5% 'full' CVD risk factor) as compared to the FHS normative population data. There was a positive correlation between GMFCS level, waist circumference (r=0.28, p=0.02), and waist-to-hip ratio (r=0.28, p=0.02).

INTERPRETATION

Adults with CP are at higher risk of CVD and metabolic syndrome compared to the general population, which is probably because of impaired mobility.

Self-reported physical function is associated with walking speed in adults with cerebral palsy

PURPOSE

To understand the relationship of walking speed to self-reported pain, fatigue, and physical function in adults with CP.

METHODS

Design: Cross-sectional study.

SETTING

Accredited clinical motion analysis laboratory in a regional children's hospital.

PARTICIPANTS

72 ambulatory patients ⩾ 18 years of age, diagnosed with CP, who previously had ⩾ 1 prior instrumented gait analysis at our facility.

MAIN OUTCOME MEASURES

PROMIS-57 pain interference/intensity, physical function, and fatigue measures and walking speed.

RESULTS

Physical function was significantly lower than able-bodied normal values by 1-2 standard deviations (40.3 ± 8.5). Pain interference (51.4 ± 9.0) and fatigue (50.2 ± 9.2) were not significantly different when compared to able-bodied normal values. Only physical function was statistically correlated with walking speed (p< 0.001), while pain interference (p= 0.39), pain intensity (p= 0.36), and fatigue (p= 0.75) were not. Pain interference, pain intensity, and fatigue were not statistically significant factors in the multiple regression of walking speed. Fatigue could significantly predict physical function, pain interference, and pain scores (p= 0.032, p< 0.001, p< 0.01, respectively), however, fatigue did not directly predict walking speed (p= 0.747).

CONCLUSIONS

Self-reported physical function correlates with objectively measured walking speed in young adults with CP while patient-reported pain and fatigue did not, contrary to what would be predicted by the literature.

Athletes with Brain Injury: Pathophysiologic and Medical Challenges

Participation in elite sporting activities is becoming increasingly popular for individuals with brain injury. This article outlines the types of brain injury and the associated movement dysfunctions. In addition, specific pathophysiologic and medical challenges facing athletes with brain injury are discussed. Further research conducted using athletes with brain injury will add to the existing literature indicating the benefits of athletic training in this population. Increased scientific study within this area stands to further improve understanding of the complex interaction between neuromuscular impairment and athletic performance.

Ultrasonographic Assessment of Femoral Cartilage Thickness in Patients With Cerebral Palsy

BACKGROUND

Cerebral palsy (CP) is one of the most disabling syndromes in children. To our knowledge, there has not yet been any reported evaluation by ultrasonography of the effect of CP on distal femoral cartilage. The value of understanding this effect on cartilage is that sonographic evaluation of cartilage thickness may help physicians to predict the joint health of these children.

OBJECTIVE

To determine whether femoral cartilage thickness in patients with CP is different from that in healthy control subjects.

DESIGN

Cross-sectional study.

SETTING

National tertiary rehabilitation center.

PATIENTS

The study included 40 patients with diplegic CP (23 male and 17 female) and 51 healthy control subjects (29 male and 22 female).

METHODS

Demographic and clinical characteristics were recorded. Cartilage thicknesses were measured.

MAIN OUTCOME MEASURE

Cartilage thickness measurements were taken from the medial and lateral condyles, and intercondylar areas of both knees.

RESULTS

Both groups were similar in terms of age, gender, and weight (P > .05). The mean cartilage thickness measurements of the medial condyle and intercondylar area of knees in the CP group were significantly less than those in the healthy control group (all P < .05). There was moderate negative correlation between age and all femoral cartilage thickness measurements in the CP group. There was no correlation between age and femoral cartilage thickness measurements in the healthy group. There was a negative correlation between Gross Motor Functional Classification System levels and cartilage thickness in the CP group. The highest cartilage thickness measurements were detected in level 1 patients, and the lowest measurements were detected in level 5 patients.

CONCLUSION

This study showed that patients with CP have a thinner femoral cartilage than healthy control subjects. Management of patients with CP should include close surveillance.

LEVEL OF EVIDENCE

III.

Total Knee Arthroplasty in Patients With Cerebral Palsy: A Matched Cohort Study to Patients With Osteoarthritis

INTRODUCTION

Currently, few data examine the use of total knee arthroplasty (TKA) in patients with cerebral palsy (CP). This study reviewed the outcomes of TKA in patients with CP compared with a matched cohort undergoing TKA for primary osteoarthritis.

METHODS

Over a 28-year period, 15 TKAs in patients with a diagnosis of CP were identified. The cohort was 53% men, with a mean age of 58 years. Patients with CP were matched 1:2 based on age, sex, body mass index, and year of surgery with a group of patients undergoing TKA for osteoarthritis.

RESULTS

No difference was reported in implant survival (P = 0.27) or revision surgery (P = 0.79) between groups. All patients were ambulatory postoperatively, and significant increases were noted in the Knee Society score (P < 0.0001) and functional assessment (P = 0.003).

DISCUSSION

TKA is a safe, durable procedure in patients with CP to improve pain and function.

Six-Minute Walk Test in Children With Spastic Cerebral Palsy and Children Developing Typically

PURPOSE

To quantify the 6-minute walk test (6MWT) in children with spastic cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels I to III and to compare with a sample of children with typical development (TD).

METHODS

A total of 145 children with CP and 137 children with TD completed the 6MWT.

RESULTS

Mean 6MWT scores were 439.57 ± 49.81 m for children functioning at GMFCS level I (n = 74), 386.74 ± 66.47 m for GMFCS level II (n = 53), 305.28 ± 66.95 m for GMFCS level III (n = 18), and 528.42 ± 67.77 m for children with TD (n = 137). Results of a pair-wise comparison showed significant differences (P < .001) between 6MWT scores of children with CP across GMFCS levels I to III and children with TD.

CONCLUSION

A range of 6-minute walk distance reference values for children with spastic CP and children with TD were established.

The continuum of care for individuals with lifelong disabilities: role of the physical therapist

Many individuals with lifelong disabilities (LLDs) of childhood onset are living longer, participating in adult roles, and seeking comprehensive health care services, including physical therapy, with greater frequency than in the past. Individuals with LLDs have the same goals of health and wellness as those without disabilities. Aging with a chronic LLD is not yet well understood; however, impairments such as pain, fatigue, and osteoporosis often present earlier than in adults who are aging typically. People with LLDs, especially those living with developmental disabilities such as cerebral palsy, myelomeningocele, Down syndrome, and intellectual disabilities, frequently have complex and multiple body system impairments and functional limitations that can: (1) be the cause of numerous and varied secondary conditions, (2) limit overall earning power, (3) diminish insurance coverage, and (4) create unique challenges for accessing health care. Collaboration between adult and pediatric practitioners is encouraged to facilitate smooth transitions to health practitioners, including physical therapists. A collaborative client-centered emphasis to support the transition to adult-oriented facilities and promote strategies to increase accessibility should become standard parts of examination, goal setting, and intervention. This perspective article identifies barriers individuals with selected LLDs experience in accessing health care, including physical therapy. Strategies are suggested, including establishment of niche practices, physical accessibility improvement, and inclusion of more specific curriculum content in professional (entry-level) doctorate physical therapy schools.

The use of a dual-mobility concept in total hip arthroplasty patients with spastic disorders: no dislocations in a series of ten cases at midterm follow-up

INTRODUCTION

Total hip arthroplasty (THA) is one of the treatment options in patients with cerebral palsy (CP) with painful osteoarthritis of the hip. However, the risk of dislocation of the prosthesis is higher in patients with CP when compared with physically normal patients. In this retrospective study of ten consecutive cases, we hypothesized that the use of a dual-mobility cup could reduce this risk of dislocation combined with good functional results.

MATERIALS AND METHODS

From January 2008 until October 2010, eight patients (ten hips) with CP who consecutively received a THA using a dual-mobility cup were identified. At the time of surgery, the average age of the patient group was 54 years (range 43-61). Latest follow-up took place after on average 39 months (range 22-56 months). All patients or their caregivers were interviewed by telephone. They were asked if dislocation of the prosthesis had occurred. To evaluate quality of life and health in general, patients completed the SF-36 questionnaire.

RESULTS

None of the prostheses had dislocated at the latest follow-up. Reoperation was needed in one patient after a periprosthetic fracture. Radiologic evaluation showed a mean cup inclination of 46 (range 27-58). On average, the quality of life of patients in this study was found to be limited in particular on the domains of physical health and functioning, while a fair to good score was measured at the six other different domains.

CONCLUSION

The use of a dual-mobility cup in THA in patients with CP can lead to favourable results with respect to dislocation and clinical outcome.