Treatment for hip displacement in children and youth with cerebral palsy (CP) is dependent upon when the problem is detected. Hip surveillance aims to identify hip displacement early through systematic screening and, together with timely orthopaedic intervention, can eliminate the need for salvage hip procedures. Here we report the impact on surgical practice of 1) hip surveillance program advocacy and knowledge translation efforts and 2) initial population-based program implementation. A retrospective review was completed of all children with CP undergoing surgery for hip displacement at a provincial tertiary pediatric hospital in the years 2004 to 2018. Date and type of surgery, age at surgery, Gross Motor Function Classification System (GMFCS) level, and pre-operative migration percentages (MP) were collected. Surgeries were categorized as soft-tissue release, reconstructive, and salvage procedures. Results were collected for three time periods: historical (September 2004- June 2010), hip surveillance advocacy and knowledge translation (July 2010- August 2015), and post provincial hip surveillance program implementation (September 2015 – December 2018). A total of 261 surgeries on 321 hips were reviewed. The rate of salvage procedures dropped from 29% (24) of surgeries performed in the historical period to 12% (14) during the period that included targeted hip surveillance knowledge translation and development of provincial guidelines. Since implementation of the surveillance program, salvage procedures have accounted for 7% (4) of interventions performed; all of these were in patients new to the province or existing patients. During the three study periods, reconstructive surgeries accounted for 64%, 81%, and 80% of the interventions performed. The mean initial MP at time of reconstructive surgery has decreased from 66% (SD 20%) in the historical time period to 57% (SD 25%) and 57% (SD 22%) in the subsequent time periods. There were a greater number of children at GMFCS levels III and IV in the two more recent time periods suggesting surveillance may assist in identifying children at these levels of impairment. The rate of soft-tissue surgeries was low during all time periods with the number trending higher since program implementation (7%, 7%, 10%). Knowledge translation and use of standardized surveillance guidelines can have a significant impact on the prevalence of salvage hip surgeries. Centers should utilize existing surveillance guidelines and educate key stakeholders about the importance of hip surveillance in the absence of a formal hip surveillance program.
Children with cerebral palsy (CP) have an increased risk of progressive hip displacement. While the cause of hip displacement remains unclear, spasticity and muscle imbalance around the hip are felt to be a major factor. There is strong evidence demonstrating that a selective dorsal rhizotomy (SDR) reduces spasticity. However, the impact of this decreased spasticity on hip displacement is unknown. Past studies, which are small and lack long-term follow-up, do not provide a clear indication of the effect of SDR on hip displacement. The purpose of this study was to determine the influence of SDR on hip displacement in children with CP a minimum of five years post-SDR. A retrospective chart review was completed. Participants were selected from a consecutive series of children who had an SDR before January 1, 2013 at one tertiary care facility to ensure a minimum five year follow-up. Pre-operative and minimum five year post-SDR AP pelvis radiographs were required for inclusion. Hip displacement was evaluated using change in MP between radiographs completed pre-SDR and minimum five years post-SDR, or until orthopaedic hip surgery. In total, 77 participants (45 males, 32 females) at GMFCS levels of I (1), II (11), III (22), IV (35) and V (8) were included in the review. Mean age at time of SDR was 5 years (2.8– 11.6yrs). Pre-SDR mean MP of the 154 hips was 29% (0–100%). Post-SDR, 67 (43.5%) hips in 35 children had soft tissue, reconstructive, or salvage hip procedures at an average of 4.9 years (0.5–13.8yrs) post-SDR and an average MP of 46% (11–100%). In addition, seven hips (5%) had a MP ≥ 40% (40–100%) at most recent radiographic review that averaged 11 years (5.6–18.6yrs). Overall, the total number of subjects with hip displacement measuring MP >40% or who had a surgical hip intervention, by GMFCS level, was: 0 (0%) at level I, 0 (0%) at level II, 20 (45%) at level III, 22 (59%) at level IV, and 5 (81%) at level V. The incidence of hip displacement in children with CP post-SDR did not substantially differ from the overall incidence reported in the literature when evaluated by GMFCS level. This study is the largest long-term follow-up study investigating the effect of hip displacement post-SDR. Results suggest that SDR does not impact hip displacement in CP, however, further prospective study will be required to strengthen the evidence in this regard.
Hip displacement is the second most common deformity in children with cerebral palsy (CP). A displaced, and particularly a dislocated hip, can have significantly adverse effects on an individual. Surgical intervention to correct progressive hip displacement or dislocation is recommended for children with CP. Success of surgical intervention is often described using radiological outcomes. There is evidence that surgical treatment for displaced or dislocated hips decreases pain and hip stiffness and improves radiological outcomes. However, there is no information in the literature regarding the impact of surgical treatment on the health related quality of life (HRQOL) in these children. The aim of our study was to examine the impact of surgical treatment of hip displacement or dislocation on HRQOL in children with CP. This prospective longitudinal cohort study involved children attending a tertiary care hospital orthopaedic department. Children with CP between the ages of 4 and 18 years, with hip displacement/dislocation, defined as a Reimer's migration percentage (MP) of >40% on a pre-operative x-ray, and undergoing surgical reconstruction were eligible for inclusion. Quality of life was measured pre-operatively and post-operatively using the CPCHILD Questionnaire. Twelve patients (one child was GMFCS level III, 4 were level IV, and 7 were level V), aged 4.0 to 17.3 years, were assessed pre-operatively and then again at least six months post-operatively. All underwent unilateral (5) or bilateral (7) reconstructive hip surgery. The migration percentage of hips undergoing reconstruction was reduced by an average of 52% (9–100%). The average change in CPCHILD score showed an increase of 6.4 points [95% CI: −1.4–14.2]. In this pilot study, no significant change was noted in HRQOL following reconstructive hip surgery, despite a marked reduction in Reimer's MP. However, only 4 of 12 parents reported that their child had daily pain pre-operatively. A larger sample size will be required to draw more accurate conclusions from these findings. There is an evident need for a multicentre study examining this issue in a larger patient population in order to determine the long-term impact of different hip interventions on quality of life in children with CP.
Chondral defects on the patella are a difficult problem in the young active patient and there is no consensus on how to treat these injuries. Fresh osteochondral allografts are a valid option for the treatment of full-thickness osteochondral defects and can be used to restore joint function and reduce pain. The primary purpose of this study was to investigate the clinical and subjective outcomes of a series of patients following fresh osteochondral allograft transplantation for isolated chondral defects of the patella. A series of 5 patients underwent surgery using an open approach for graft transplantation. A strict protocol for the allograft tissue was followed. Transplant recipients must be aged <60, have a full-thickness, isolated chondral lesion and have failed previous traditional treatments. The fresh allografts are hypothermically stored at 4°C in X-VIVO10 media for up to 30 days to maintain cartilage viability. Pre- and post-operative clinical measures including knee stability, range of motion, and quadriceps girth were completed. Post-operative plain radiographs were completed including weight-bearing AP, lateral and skyline views. Patient-centred outcome measures including the Knee Osteoarthritis Outcome Score (KOOS) and the Knee Society Score (KSS) were gathered a minimum of 1-year post-operative. Descriptive and demographic data were collected for all patients. A paired t-test was employed to determine the difference between the pre-operative and post-operative outcomes. All patients were female, with a mean age of 27.4 (SD 3.65). Knee ligament stability was similar pre- and post-operatively. Knee ROM assessment of flexion and extension demonstrated a less than 10° increase from pre to post-operative. Quadriceps girth measurements demonstrated a mean change of 0.5 cm from pre- to post-operative for the surgical limb. Post-operative radiographs demonstrated incorporation of the graft in 4/5 cases within 6-months of surgery. One patient developed fragmentation of the graft after 18-months, and one patient had a subsequent trochleoplasty for persistent pain. The mean KOOS domain scores demonstrated significant improvement (p<0.05) as follows: Symptoms pre-op = 28.57, post-op = 55; Pain pre-op 28.89, post-op = 57.22; ADLs pre-op = 48.92, post-op = 66.18; Sports/Recreation pre-op = 6, post-op = 32; and QoL pre-op = 12.5, post-op = 42.5. Mean pre-op surgical versus non-surgical limb KSS scores were 107.4 and 179 respectively. The mean post-op surgical versus non-surgical limb KSS scores were 166 and 200. Isolated chondral defects of the patella can cause substantial pain, reduced function, and can be challenging to address surgically. This series of 5 cases demonstrated improved function, KOOS and KSS for 4/5 patients. To our knowledge this is a novel biological procedural technique for this problem, which has shown promising results making it a viable treatment option for young active patients with osteochondral defects of the patella.
Important factors affecting quality of life (QOL) after total knee arthroplasty (TKA) include postoperative knee kinematics and geometry, influenced by implant design and placement (Matsuda 2001; Nishikawa 2013; Noble 2005). Although specific design factors and their effect on kinematics or QOL have been investigated previously, the inter-relationships between preop-postop changes in kinematics, geometry and the resulting QOL have not been studied to our knowledge. These are essential to understand the interplay between the different factors, and to determine which factors manufacturers and surgeons should focus on when designing and implanting knee prostheses. In addition, the majority of TKA studies focus on the tibiofemoral (TF) joint, although the patellofemoral (PF) joint is routinely the source of postop complications; the PF joint is difficult to study due to polyethylene radio-transparency and because the femoral component obscures the patella from most directions. The purpose of this pilot study was to correlate changes in knee articular shape, over which the implant designers and surgeons have some control, to changes in kinematics and postop QOL, with a particular focus on the PF joint, to answer the following research questions for a sample population with a given implant design and surgeon: (1) Do changes in knee shape affect knee kinematics? In particular, is patellar tracking affected by groove location? (2) Do changes in knee kinematics affect QOL? (3) Do changes in knee shape (resulting from implant design and placement) affect QOL? (4) Do individuals with worse QOL differ from those with better QOL?
Alumina bearings are an available option in total hip replacements in the United States. Alumina has high strength and low friction and wear as an articulating surface. To determine the potential damage that can occur to alumina surfaces during implantation and dislocation of such bearings, we examined several explanted bearins at a microscopic and microchemical level. Alumina femoral heads and acetabular liners that-were rejected during surgery because of metal staining, or removed from patients after known times of implantation were examined in the scanning electron microscope to observe the extent of surface degradation. 13 samples were examined. Four samples consisted of a femoral heads that had come in to contact with the metal acetabular shell during implantation, and therefore had metal staining on the surface. Nine femoral heads and a cetabular linerpairs were removed from patients with a history of recurrent dislocations of the prosthetic hip. Of these 5 pairs had grossly visible surface damage, and four did not. These latter four pairs, and the four femoral heads with surface staining were each coated with carbon and observed in a scanning electron microscope fitted with an energy dispersive X-ray analysis (EDAX) attachment for microchemical analysis. Alumina heads that had inadvertently rubbed against the metalacetabular shell during surgery demonstrated dark metallic staining on the surface. EDAX analysis indicated that the stain had a composition very close to a Ti-6Al-4V alloy. Closer examination in the SEM revealed that the metal stain has a particulate structure, with the size of the particles ranging from sub-micron to several tens of microns. These titanium stains could be removed by a benign chemical etch, leaving no corrosion of the a lumina bearing surface. In contrast, alumina heads and liners removed after various times of implantation show significant surface deterioration. A wide range of features were observed, including uneven wear, cracks, embedded particles, deep groves and pits. Considerable surface staining of aluminafemoral heads can occur during surgery if they come into contact with metal. This staining occurs due to surface deposition of metal particles which can be easily removed by wiping the surface with a benign etchant. If not removed, the presence of metal reduces the smoothness of the alumina, and may contribute to three-body wear. In contrast, alumina bearings removed from patients with multiple hip dislocations show significant, non-uniform-surface degradation. The observed features, such as embedded particles, cracks, and pits can contribute significantly to surface wear, which was grossly evident in 5 alumina head/liner pairs retrieved for this study. These data suggest that multiple dislocations in total hips with alumina bearings may need earlier surgical intervention because of the surface damage to the bearings, and potential for catastrophic wear.
Ten New Zealand White rabbits underwent anterior cruciate ligament transection (ACLX), then reconstruction using a mersiline tape graft and mitek mini anchors. Animals were divided into two groups and sacrificed at six and fourteen week after surgery. Medial collateral ligament (MCL)-complexes were evaluated for joint laxity, and periarticular tissues evaluated for changes in vascular volume. Both reconstructed groups showed significantly reduced MCL-complex laxity and inflammatory angiogenesis compared to ACLX controls. This reconstructive method (using an artificial graft) provided transient restabilization out to 6 and 14 wk after ACLX in the rabbit, with a high 80% success rate of intact grafts. To refine a method of ACL reconstruction in the New Zealand White (NZW) rabbit to study angiogenic adaptations in a restabilized knee joint. The artificial graft approach provided transient restabilization out to six and fourteen week post ACLX with an 80% success rate, and reduced MCL-complex laxity and inflammatory angiogenesis. Addressing joint instability after ACLX reduces inflammatory angiogenesis and mechanical deterioration in peri-articular tissues, and delays the progression of OA. Compared to normal control tissues, loss of the ACL resulted in marked joint instability, and significantly increased vascular volumes in all periarticular tissues examined six and fourteen week post-ACLX. However, following transient restabilization using reconstructive surgery, MCL-complex laxity and periarticular tissue vascular volume were significantly reduced at both the six and fourteen week intervals compared to ACLX controls. ACL reconstructive surgery was performed on the right knee of ten skeletally mature NZW rabbits using a mersiline tape graft and mitek mini anchors, immediately after the ACL had been transected. MCL-complex laxity was measured in all joints using established biomechanical procedures. To assess the effect of joint restabilization six and fourteen week after ACL reconstruction, limbs were infused with a 5% carmine red dye/5% gelatin solution, and the vascular volume of periarticular tissues was detemined. The artificial graft approach to rabbit ACL reconstruction resulted in a high success rate of intact grafts 6 and 14 wk post-ACLX. The transient restabilization of an ACLX knee joint results in less inflammatory angio-genesis in periarticular tissues.
