Aims

The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V.

The February 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

Aims. Hip displacement, common in patients with cerebral palsy (CP), causes pain and hinders adequate care. Hip reconstructive surgery (HRS) is performed to treat hip displacement; however, only a few studies have quantitatively assessed femoral head sphericity after HRS. The aim of this study was to quantitatively assess improvement in hip sphericity after HRS in patients with CP. Methods. We retrospectively analyzed hip radiographs of patients who had undergone HRS because of CP-associated hip displacement. The pre- and postoperative migration percentage (MP), femoral neck-shaft angle (NSA), and sphericity, as determined by the Mose hip ratio (MHR), age at surgery, Gross Motor Function Classification System level, surgical history including Dega pelvic osteotomy, and triradiate cartilage status were studied. Regression analyses using linear mixed model were performed to identify factors affecting hip sphericity improvement. Results. A total of 108 patients were enrolled. The mean preoperative MP was 58.3% (SD 31.7%), which improved to 9.1% (SD 15.6%) at the last follow-up. NSA and MHR improved from 156.5° (SD 11.5°) and 82.3% (SD 8.6%) to 126.0° (SD 18.5°) and 89.1% (SD 9.0%), respectively. Factors affecting the postoperative MHR were preoperative MP (p = 0.005), immediate postoperative MP (p = 0.032), and history of Dega osteotomy (p = 0.046). Conclusion. We found that hip sphericity improves with HRS. Preoperative MP, reduction quality, and acetabular coverage influence femoral head remodelling. We recommend that surgeons should consider intervention early before hip displacement progresses and that during HRS, definite reduction and coverage of the femoral head should be obtained. Cite this article: Bone Joint J 2021;103-B(1):198–203

We investigated the incidence and risk factors for the development of avascular necrosis (AVN) of the femoral head in the course of treatment of children with cerebral palsy (CP) and dislocation of the hip. All underwent open reduction, proximal femoral and Dega pelvic osteotomy. The inclusion criteria were: a predominantly spastic form of CP, dislocation of the hip (migration percentage, MP > 80%), Gross Motor Function Classification System, (GMFCS) grade IV to V, a primary surgical procedure and follow-up of > one year. There were 81 consecutive children (40 girls and 41 boys) in the study. Their mean age was nine years (3.5 to 13.8) and mean follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included measurement of the MP, the acetabular index (AI), the epiphyseal shaft angle (ESA) and the pelvic femoral angle (PFA). The presence and grade of AVN were assessed radiologically according to the Kruczynski classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and Dega osteotomy is an effective form of treatment for children with CP and dislocation of the hip, there were signs of avascular necrosis in about two-thirds of the children. There was a strong correlation between post-operative pain and the severity of the grade of AVN. Cite this article: Bone Joint J 2015;97-B:270–6

In 1994 a cerebral palsy (CP) register and healthcare programme was established in southern Sweden with the primary aim of preventing dislocation of the hip in these children.

The results from the first ten years were published in 2005 and showed a decrease in the incidence of dislocation of the hip, from 8% in a historical control group of 103 children born between 1990 and 1991 to 0.5% in a group of 258 children born between 1992 and 1997. These two cohorts have now been re-evaluated and an additional group of 431 children born between 1998 and 2007 has been added.

By 1 January 2014, nine children in the control group, two in the first study group and none in the second study group had developed a dislocated hip (p < 0.001). The two children in the first study group who developed a dislocated hip were too unwell to undergo preventive surgery. Every child with a dislocated hip reported severe pain, at least periodically, and four underwent salvage surgery. Of the 689 children in the study groups, 91 (13%) underwent preventive surgery.

A population-based hip surveillance programme enables the early identification and preventive treatment, which can result in a significantly lower incidence of dislocation of the hip in children with CP.

Cite this article: Bone Joint J 2014; 96-B:1546–52.

We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome. We present the history and operative management. The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate. No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged. To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position

We reviewed the long-term radiological outcome, complications and revision operations in 19 children with quadriplegic cerebral palsy and hip dysplasia who underwent combined peri-iliac osteotomy and femoral varus derotation osteotomy. They had a mean age of 7.5 years (1.6 to 10.9) and comprised 22 hip dislocations and subluxations. We also studied the outcome for the contralateral hip. At a mean follow-up of 11.7 years (10 to 15.1) the Melbourne cerebral palsy (CP) hip classification was grade 2 in 16 hips, grade 3 in five, and grade 5 in one. There were five complications seen in four hips (21%, four patients), including one dislocation, one subluxation, one coxa vara with adduction deformity, one subtrochanteric fracture and one infection. A recurrent soft-tissue contracture occurred in five hips and ten required revision surgery.

In pre-adolescent children with quadriplegic cerebral palsy good long-term outcomes can be achieved after reconstruction of the hip; regular follow-up is required.

Cite this article: Bone Joint J 2013;95-B:259–65.

Purpose. Introduction: The Dega osteotomy is a versatile procedure that is widely used to treat neuromuscular hip dysplasia. There is a paucity of English-language literature on its use in acetabular dysplasia seen in developmental dysplasia of the hip (DDH). Method. A retrospective radiographic and chart review was performed for all patients diagnosed with DDH who underwent a modified Dega osteotomy between March 1995 and December 2008 at the Shriners Hospital for Children or the Montreal Children's Hospital (Montréal, Canada) by two orthopedic surgeons. Radiographic parameters were measured at the preoperative, immediate postoperative and final follow-up time points. These parameters included the acetabular index (AI), center edge angle (CEA), Reimer's extrusion index, Shenton's line and grading by the Severin classification. Results. A total of 21 patients (22 hips) of which 18 were female, underwent a modified Dega osteotomy at an average age of 55.4 months (range: 20 to 100 months). Out of the 22 hips (1 bilateral and 19 single cases), 9 involved the right side and 13 involved the left side. Prior to surgery, 10 patients had a subluxated hip, 7 had a dislocated hip and 5 had a dysplastic hip. Twelve hips underwent concomitant procedures including 10 open reductions with capsulorraphy. The AI improved from 36 degrees (St. Dev 8) preoperatively to 19 degrees (St. Dev 7) on the date of last visit. The CEA improved from 4 (St. Dev 17) to 22 degrees (St. Dev 12). Conclusion. Results from this study demonstrate that the modified Dega osteotomy produces nearnormal lateral coverage parameters in children with DDH

Introduction and Objectives: The aim of this study is to analyze changes seen on X-ray of the acetabular index, Wiberg’s angle, Sharp’s angle and the continuity of Shenton’s line after osteotomy performed by means of the Dega technique in developmental dysplasia of the hip (DDH). Materials and Methods: We retrospectively analyzed 72 histories of children that underwent surgery performed using the Dega technique at the Niño Jesús Hospital over the last 15 years. We measured the rupture of the Shenton line, the acetabular index, Wiberg’s centre-edge angle and Sharp’s acetabular angle preoperatively; and then approximately 1 year after surgery and at the last X-ray control in the medical history. Results: The acetabular index changed from 33° preoperatively to 24° one year after surgery. At the last X-ray control the acetabular index was 23°. Wiberg’s centre-edge angle is normalized by osteotomy, and changed from 6° preoperatively to 20° after surgery. At the last X-ray it was 23°. However, Sharp’s acetabular angle only suffered slight modifications. It changed from 50° to 48° with surgery. Discussion and Conclusions: The Dega osteotomy is an effective technique to provide acetabular coverage in hips suffering from dysplasia before the closure of the triradiate cartilage. Both the acetabular index and Wiberg’s angle vary significantly with surgery, and become normalized in most cases. This correction is stable over time. However, the same cannot be said for Sharp’s acetabular angle which barely changes with osteotomy

We carried out a morphometric analysis of the acetabulum following Dega osteotomy in patients with cerebral palsy using three-dimensional CT. We assessed 17 acetabula in 12 patients with instability of the hip. A Dega osteotomy and varus derotation femoral osteotomy were performed in all 17 hips. Three-dimensional CT scans were taken before and approximately one year after operation. Acetabular cover was evaluated using anterosuperior, superolateral and posterosuperior acetabular indices, and the change in the acetabular volume was calculated. Inter- and intra-observer reliability was assessed using the intraclass correlation coefficient. After the osteotomy, the anterosuperior, superolateral and posterosuperior cover had improved significantly towards the value seen in a control group. The mean acetabular volume increased by 68%

A total of 47 non-walking patients (52 hips) with severe cerebral palsy and with a mean age of 14 years, (9 to 27) underwent a Dega-type pelvic osteotomy after closure of the triradiate cartilage, together with a derotation varus-shortening femoral osteotomy and soft-tissue correction for hip displacement which caused pain and/or difficulties in sitting. The mean follow-up was 48 months (12 to 153). The migration percentage improved from a pre-operative mean of 70% (26% to 100%) to 10% (0% to 100%) post-operatively. In five hips the post-operative migration percentage was greater than 25%, which was associated with continuing pain in two patients. Three patients had persistent hip pain and a migration percentage less than 25%. In five hips a fracture through the acetabulum occurred, and in another there was avascular necrosis of the superior acetabular segment, but these had no adverse effect on functional outcome. We conclude that it is possible to perform a satisfactory pelvic osteotomy of this type in these patients after the triradiate cartilage has been closed.

Objective: To review our results with hip joint reconstruction in severe spastic hip disease. Design: Descriptive case series. Setting: A tertiary referral medical center. Subjects: All the patients who underwent a hip reconstruction procedure because of SHD were retrospectively evaluated. Twenty-five patients with 32 involved femoral necks were treated between 1997 and 2003. All of the patients had a migration index greater than 40% with 8 of them having a migration index of over 65%. 15 patients had total involvement type CP and 10 patients had diplegic type CP. Intervention: Hip joint reconstruction comprised of varus derotation osteotomy and a periacetabular osteotomy such as the Dega osteotomy, and when necessary an open reposition of the hip joint was performed. Results: Good coverage of the femoral head was achieved in 23 of the patients and in 30 of the femoral heads. There was no difference between the high migration index group and the low migration index group. In two cases progressive posterior dislocation continued following the operation, attributed to incomplete correction of the posterior acetabulum. One patient had an intra-operative fracture of the femoral neck. The results were similar in the more severe and less severe groups. Conclusions: Hip reconstruction has favorable results in all types of CP. We found no difference between the group with high migration index and the low migration index concerning complications and outcome. A high migration index should not be considered as reason not to reconstruct the hip joint. The only contraindication for this procedure is osteoarthritic changes of the hip joint

We carried out a morphometric analysis of acetabular dysplasia in patients with cerebral palsy requiring hip surgery using three-dimensional CT. We evaluated 54 hips in 27 patients. The contralateral normal hips of ten patients with unilateral Perthes’ disease were used as a control group. The acetabular defects were assessed qualitatively as anterior, posterior or global. Quantitative assessments were made using three-directional acetabular indices (anterosuperior, superolateral and posterosuperior) and measured by multiplanar reformation, from which we calculated the acetabular volume.

In the qualitative study, posterior defects were most common in the subluxation group whereas global defects predominated in the dislocation group. In the quantitative study, all acetabular indices in both the subluxation and dislocation groups were higher than those in the control group and the superolateral indices showed a tendency to elevation in the dislocation group. The acetabular volume was largest in the control group, smallest in the dislocation group, and intermediate between the two in the subluxation group.

A percutaneous supramalleolar osteotomy with multiple drill holes and closed osteoclasis was used to correct rotational deformities of the tibia in patients with cerebral palsy. The technique is described and the results in 247 limbs (160 patients) are reported. The mean age at the time of surgery was 10.7 years (4 to 20). The radiographs were analysed for time to union, loss of correction, and angulation at the site of the osteotomy.

Bone healing was obtained in all patients except one in a mean period of seven weeks (5 to 12). Malunion after loss of reduction at the site of the osteotomy developed in one tibia.

Percutaneous supramalleolar osteotomy of the tibia is a safe and simple surgical procedure.

Reorientation of the dysplastic acetabulum can be achieved with a simple Salter or Dega osteotomy. While this may be beneficial in children, it is usually insufficient in more severe adolescent or adult dysplasias. Improvement in coverage with double and triple oste-otomies is limited by the size of the acetabular fragment and the ligaments connected to the sacrum. Correction is achieved with the notable asymmetry of the pelvis. The development of these osteotomies results in making the acetabular fragment smaller and smaller and without ligamentous connection between sacrum and sciatic bone. The periacetabular Ganz osteotomy (PAO) is a compromise of the size of acetabular fragment between triple and dial (spherical) osteotomies. The acetabular fragment as in triple Carlioz and Tonnis osteotomies has no connection with the sacrum, what results in enormous possibilities for correction . Finally, the pelvic ring is left untouched. The aim of the study is to present our experience and early results in using this technique in the treatment of dysplasia with subluxation in adolescent and young adults. Our material consists of 42 hips in 35 patients (29 females and 6 males) operated in years 1998 – 2001. In 7 cases there was bilateral involvement, the rest were unilateral. The age at operation was between 11 and 39 years, mean 17,5 years. The indication for the PAO in all cases was acetabular dysplasia with different degree of subluxation. In 10 hips there was severe subluxation with CE below 0°, in 4 hips the signs of osteoarthritis were found. The follow-up ranged from 1 to 4 years. Methods. The PAO as a single procedure was done in 39 hips. In only 3 hips the subtrochanteric DVO was done simultaneously. In clinical pre-op. and post-op. examination the following factors were regarded: pain, limping, Trendelenburg sign, range of motion, leg length discrepancy. Radiographic pre-op. and post-op. examination consisted of AP view of the pelvis, false profile and AP view with leg in abduction. Classic and anterior CE angles were measured. Results. Flexion slightly decreased from pre-op. 90-140° (av.118°) to 80-130° (av.104°) post-op., abduction left unchanged 15-80° (av.40°) and 15-80° (40°) respectively, adduction slightly increased 15-50° (av.31°) and 20-50° (av. 33°). The range of rotation did not change after operation. The sign of Trendelenburg was found in 27 hips pre-op. and in 8 hips post-op. Pain was found in 29 hips before operation and in 4 after surgery. Either classic or anterior CE angle increased after surgery to the normal value in almost all cases from −14° to 34° and from −10° to 35° respectively. We had a rather low complication rate. In our group 35 operations were done without any complications. In 7 hips the following complications were found: in 1 hip overcorrection and in 2 others insufficient correction, 2 urinary infections, ectopic bone formation in 1 hip, local soft tissue infection in 1 hip and in 1 bad scar formation. We did not find any signs of AVN in our series

We report 16 patients (18 hips) treated between 1997 and 1999. The average age was 5 years and 3 months (range, 2–9 years). Of all the hips evaluated, 13 (72%) corresponded to diplegic patients and 5 (28%) to tetra-plegic patients. The surgical plan consisted on femoral osteotomy combined with Dega pericetabular osteotomy coupled with adductor and psoas tenotomy using as a variable the reduction of the hip by the anterior approach depending on each case. We used the following criteria to evaluate results: 1 – pain, 2 – abduction range, 3 – Reimmers index, 4 – acetabular index. Diplegic patients had good (78%), fair (12%) and poor (12%) results. Tetraplegic patients had good (25%), fair (50%) and poor (25%) results in this short follow up. On analyzing the cases, we observed an adequate development of the neurologic hips when using the acetabuloplasty with the Dega technique because it minimized the risk of coverage loss, as commonly seen in these kind of patients due to the progressive valgus during the postoperative period