Complications related to postoperative casting after surgical treatment of subluxed/dislocated hips in patients with cerebral palsy

Bony hip reconstruction for displaced hips in patients with cerebral palsy: Is postoperative immobilization indicated?

Purpose

Decisions for postoperative immobilization after bony hip reconstructive surgery in cerebral palsy are controversial in current practice. The aim of this study was to check if choosing not to use any kind of postoperative immobilization is a safe practice.

Methods

A retrospective cohort study was conducted in a pediatric orthopedic tertiary referral center. The study included 148 patients (228 hips) with cerebral palsy, who had bony hip surgery. Medical records were reviewed for incidence of complications, methods of pain control, and length of hospital stay. Three radiographic measures (neck-shaft angle, Reimers migration index, and acetabular index) were performed on preoperative and postoperative X-rays. X-rays were also checked for mechanical failure of implant, recurrent dislocation/subluxation, and fractures in the first 6 months postoperatively.

Results

In total, 94 (64%) were male and 54 (36%) were female. Seventy-seven (52%) were Gross Motor Function Classification System V, mean age at surgery was 8.6 years (2.5-18.4 years). Length of hospital stay was 6.25 days (SD 4.64 days). Medical complications that may have prolonged hospital stay occurred in 41 patients (27.7%). Radiological measurements showed significant improvement postoperatively (p = 0.001). Seven patients (4.7%) had another surgery in first 6 months (three for recurrent dislocation/subluxation, three for implant failure, and one for ipsilateral femur fracture).

Conclusion

Avoiding postoperative immobilization following bony hip surgery in cerebral palsy is a safe practice and associated with reduced rate of medical and mechanical problems compared to the current literature. This approach should be utilized with optimal pain and tone management.

Foam Padding in Postoperative Lower Extremity Casting: An Inexpensive Way to Protect Patients

BACKGROUND

Although postoperative cast immobilization is routinely used in children, it is not without complications. Few studies have focused on interventions to decrease their frequency. The purpose of this study was to determine if foam padding in postoperative lower extremity casts decreased the rate of cast complications.

METHODS

A retrospective review of patients who underwent lower extremity casting after elective surgery at a tertiary pediatric hospital from 2006 to 2013 was conducted. Postoperative casts were classified by type (A-frame, short leg, long leg, spica) and the presence of foam. Charts were reviewed for skin complications, cast splits for apparent neurovascular deficits, cast splits for patient complaints, unplanned outpatient returns for cast-related issues, and compartment syndrome.

RESULTS

In total, 920 patients with 2,481 casts were included. In total, 612 (24.7%) casts had foam placed during casting. The incidence of skin complications was significantly lower in A-frame casts with foam (4.5%, 5/112) than without (13.4%, 11/82) (P=0.03) and long leg casts with foam (0.9%, 2/225) than without (4.3%, 19/444) (P=0.02). Patients with static encephalopathy casted with foam had a lower incidence of skin complications (0.7%, 2/279) than those without (3.6%, 22/615) (P=0.01). There was no difference in the overall incidence of skin complications in casts with and without foam (P=0.44), short leg casts (P=0.37), and spica casts (P=0.34). Patients with skin complications (20.3±7.1 kg/m) had a higher body mass index than those without (18.9±5.4 kg/m) (P=0.04). Postoperative A-frame casts with foam (0.0%, 0/112) were split less often for apparent neurovascular deficits than those without foam (4.5%, 3/67) (P=0.05). The cast split rates for apparent neurovascular deficits in casts with and without foam (P=0.58), long leg casts (P=0.67), short leg casts (P=0.63), and spica casts (P=1.0) were comparable.

CONCLUSIONS

The use of foam in postoperative lower extremity casting is an effective intervention to reduce the incidence of skin complications in patients with static encephalopathy, in an A-frame cast, or in a long leg cast.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Epidural analgesia is superior to local infiltration analgesia in children with cerebral palsy undergoing unilateral hip reconstruction

BACKGROUND AND PURPOSE

Treatment of postoperative pain in children with cerebral palsy (CP) is a major challenge. We investigated the effect of epidural analgesia, high-volume local infiltration analgesia (LIA), and an approximated placebo control on early postoperative pain in children with CP who were undergoing unilateral hip reconstruction.

PATIENTS AND METHODS

Between 2009 and 2014, we included 18 children with CP. The first part of the study was a randomized double-blind trial with allocation to either LIA or placebo for postoperative pain management, in addition to intravenous or oral analgesia. In the second part of the study, the children were consecutively included for postoperative pain management with epidural analgesia in addition to intravenous or oral analgesia. The primary outcome was postoperative pain 4 h postoperatively using 2 pain assessment tools (r-FLACC and VAS-OBS) ranging from 0 to 10. The secondary outcome was opioid consumption over the 21-h study period.

RESULTS

The mean level of pain 4 h postoperatively was lower in the epidural group (r-FLACC: 0.7; VAS-OBS: 0.6) than in both the LIA group (r-FLACC: 4.8, p = 0.01; VAS-OBS: 5.2, p = 0.02) and the placebo group (r-FLACC: 5.2, p = 0.01; VAS-OBS: 6.5, p < 0.001). Corrected for body weight, the mean opioid consumption was lower in the epidural group than in the LIA group and the placebo group (both p < 0.001).

INTERPRETATION

Epidural analgesia is superior to local infiltration analgesia for early postoperative pain management in children with cerebral palsy who undergo unilateral hip reconstruction.

Fractures in children with cerebral palsy

Children with moderate to severe cerebral palsy are at increased risk of sustaining fracture following minimal trauma. Such fractures predominantly occur in lower limb bones and are associated with low bone mineral density. Risk factors for fracture in this group include nonambulatory status, anticonvulsant use, presence of a joint contractures, immobilization after surgery, and poor nutrition. Aims of this review are to describe the prevalence and pathogenesis of fractures in nonambulant children with cerebral palsy. Interventions and treatments that improve low bone mineral density and which may help to reduce the fracture risk in this population are also discussed.

Treatment of femur fractures in children with cerebral palsy

PURPOSE

Children with cerebral palsy may have low bone density stemming from various etiologies and are, thereby, at risk for fractures. The treatment of femur fractures in children with cerebral palsy may need to be tailored to address the management of spastic muscle tone and multiple medical co-morbidities.

METHODS

Our study is a retrospective review that evaluates the treatment of 47 femur fractures in children with cerebral palsy in both ambulatory and non-ambulatory patients.

RESULTS

Thirty-two fractures in non-ambulators were treated non-operatively, 11 of which resulted in malunions and five developed pressure sores. Six fractures in non-ambulators were treated operatively, one of which resulted in a malunion. In ambulators, five fractures were treated non-operatively; one of these fractures lost reduction after 2 weeks and required surgical intervention. One of four fractures in ambulators treated operatively developed a malunion.

CONCLUSION

Our study results suggest that femur fractures in children with cerebral palsy can be treated non-operatively; however, because of the high risk of malunion in this patient population, fracture alignment needs to be followed closely during healing. Careful attention during casting is necessary to prevent pressure sores. Strong consideration should be given to initial operative treatment in ambulatory patients in order to preserve function.