Hip screening in children with Cerberal palsy

We just published a paper on the necessity of hip screening in children with CP. It reviews the most up to date literature on this topic. A copy of the article can be found by clicking on the link below

https://authors.elsevier.com/a/1We166z8-CQmF

Common complications of hip procedures in children with cerebral palsy

In the last post, we discussed the different surgical procedures that are typically performed for the treatment of hip disorders in children with cerebral palsy. Parents are always concerned  about the complications associated with these procedures. I will discuss the common complications of these procedures in this post

1- Bleeding requiring blood transfusion: Like any other surgery, hip surgery in children with cerebral palsy can result in blood loss requiring blood transfusion.The risk of this complication is highest in young children undergoing procedures involving reshaping of the pelvis. The risk of blood loss requiring blood transfusion is typically less than 10%. The children on seizure medications may loose more blood during surgery due to the effect of seizure medications on blood.

2-Wound infection: With the current universal use of antibiotics before surgery, wound infection is not a common complication and can typically be treated with antibiotics by mouth. Children with a history of prior MRSA infection, may benefit from receiving a different type of antibiotics prior to surgery. Please mention the history of infection to your physician before surgery.

3- Recurrence: After reconstruction, unfortunately hips may still dislocate in children with cerebral palsy due to the continued spasticity. This risk is highest in children with higher levels of involvement (GMFCS V). The recurrence can be seen in up to 30% of the patients depending on the type of the procedure performed and the level of spasticity. It is very important that hips continue to be monitored with radiographs after surgery until skeletal maturity.

These include the common complications seen after hip reconstructive procedures in children with spastic cerebral palsy.

Treatment of hip disorders in children with cerebral palsy

In the previous two posts, I discussed the necessity of hip screening.  In this post, the various treatment options are discussed.
Treatment of hip disorders in children with cerebral palsy varies on the age of the child and the degree of hip involvement at the time of treatment. If the hip problem is found in early stages, the treatment would be much easier. Treatment options are usually divided into the following three categories:
1- Preventive procedures: These procedures are suitable for mild degree of hip involvement found in younger children (typically younger than 8 years). This is usually done by surgical release (tenotomy) of the adductor tendons (upper inner thighs) through small incisions. Recovery from the surgery typically takes 4-6 weeks. When performed at early stages of hip involvement, these procedures can result in near normal hip development.

2- Reconstructive procedures: These procedures are performed on children with moderate amount of hip disorders who are typically older than 8 years of age. These procedures involve changing the shape of the bones in the femur and/or pelvis (osteotomy). Recovery from these procedures usually takes more than 3 months.

3- Salvage procedures: These procedure are performed in advanced hip disorders which are not suitable for reconstructive procedures due to the severity of the disease. In these patients, the hip joint is almost completely distroyed by arthritis. These procedures include hip replacement, hip resection, and hip fusion. Outcome of these procedures are inferior to preventive and reconstrive procedures.

The goal of hip screening is to find the hip problems in the early stages so it can be treated with preventive and reconstructive procedures. Hip screening programs are shown to complexly eliminate the need for salvage procedures.

How often should the hips be evaluated in children with cerebral palsy?

The frequency of hip screening in children with cerebral palsy varies depending on their level of involvement, age, and preexisting level of hip involvement. In general, children who can ambulate without assistive devices require less frequent screening than children who rely on wheelchairs for ambulation. The level of involvement in children with cerebral palsy is reported mostly by GMFCS level(Growth Motor Function Classification System). The level is measured by the physical ability of the child and higher GMFCS level indicates a higher the level of involvement. The GMFCS is usuallly stable through the child's growth and development.
Currently the best guidelines for the frequency of hip screening in children with cerebral palsy is published by the Australian Academy of Cerberal palsy and Developmental Medicine. The implementation of these guidelines has been very helpful in preventing hip pathology in children in Australia and Europe.  I believe these guidelines should be implemented in the care of all children with cerebral palsy.

Australian guidelines for hip screening in children with cerebral palsy

The Necessity of Hip Surveillance in Children with Cerebral Palsy

The Necessity of Hip Surveillance in Children with Cerebral Palsy

At least every week, I see children with cerebral palsy with advanced hip diseases requiring major reconstructive surgery that may have been easily prevented by proper   screening and preventive procedures. This post describes the necessity of hip surveillance in all children with cerebral palsy.

The hip is the second most common involved joint (after ankle)in children with cerebral palsy. The hip is a ball and socket joint and for its proper function and painless movement, the ball (femoral head) should be located inside the socket (acetabulum). The hip joint is under higher pressure due to tight muscles in children with cerebral palsy. These high pressures could gradually displace the ball out of socket resulting in early arthritis and painful hips. The displaced painful hips are usually debilitating both in the group of children that walk using assistive devices and in children who use wheelchairs for mobility.

Early stages of the hip disease in children with cerebral palsy could easily be overlooked since the child does not complain of any pain. If the treatment is not started in time, this could rapidly progress resulting in a painful displaced hip which could affect the ambulation and the quality of life. By the time to child starts complaining of pain, the hip is usually displaced out of the socket and the treatment options at that stage are very limited.

It is very important that all children with cerebral palsy be evaluated and screened for hip problems during the course of their growth and development. This is usually done by a complete physical examination in addition to x-rays of the hip. X-rays of the hip are required every 6-12 months depending on the level of the spasticity and functional ambulation of the child.

Early stages of hip displacement could be treated by procedures on the muscles of the hip. Advanced stages of hip involvement may require extensive reconstructive procedures involving the hip and the pelvis.

By routine and timely screening of all children with cerebral palsy for hip problems, this debilitating problem can be avoided in most cases.