Prevalence and treatment of hip displacement in children with cerebral palsy in Finland

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?

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.

HipScreen mobile app for the measurement of hip migration percentage in children with cerebral palsy: Accuracy, reliability, and discriminatory ability

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.

Ankle-foot orthoses among children with cerebral palsy: a cross-sectional population-based register study of 8,928 children living in Northern Europe

BACKGROUND

Cerebral palsy (CP) is an umbrella term where an injury to the immature brain affects muscle tone and motor control, posture, and at times, the ability to walk and stand. Orthoses can be used to improve or maintain function. Ankle-foot orthoses (AFOs) are the most frequently used orthoses in children with CP. However, how commonly AFOs are used by children and adolescents with CP is still unknown. The aims of this study were to investigate and describe the use of AFOs in children with CP in Sweden, Norway, Finland, Iceland, Scotland, and Denmark, and compare AFO use between countries and by gross motor function classification system (GMFCS) level, CP subtype, sex, and age.

METHOD

Aggregated data on 8,928 participants in the national follow-up programs for CP for the respective countries were used. Finland does not have a national follow-up program for individuals with CP and therefore a study cohort was used instead. Use of AFOs were presented as percentages. Logistic regression models were used to compare the use of AFOs among countries adjusted for age, CP subtype, GMFCS level, and sex.

RESULTS

The proportion of AFO use was highest in Scotland (57%; CI 54-59%) and lowest in Denmark (35%; CI 33-38%). After adjusting for GMFCS level, children in Denmark, Finland, and Iceland had statistically significantly lower odds of using AFOs whereas children in Norway and Scotland reported statistically significantly higher usage than Sweden.

CONCLUSION

In this study, the use of AFOs in children with CP in countries with relatively similar healthcare systems, differed between countries, age, GMFCS level, and CP subtype. This indicates a lack of consensus as to which individuals benefit from using AFOs. Our findings present an important baseline for the future research and development of practical guidelines in terms of who stands to benefit from using AFOs.

Hip subluxation in Italian cerebral palsy children and its determinants: a retrospective cohort study

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.