Aims. The Uppföljningsprogram för cerebral pares (CPUP) Hip Score distinguishes between children with cerebral palsy (CP) at different levels of risk for displacement of the hip. The score was constructed using data from Swedish children with CP, but has not been confirmed in any other population. The aim of this study was to determine the calibration and discriminatory accuracy of this score in children with CP in Scotland. Methods. This was a total population-based study of children registered with the Cerebral Palsy Integrated Pathway Scotland. Displacement of the hip was defined as a migration percentage (MP) of > 40%. Inclusion criteria were children in Gross Motor Function Classification System (GMFCS) levels III to V. The calibration slope was estimated and Kaplan-Meier curves produced for five strata of CPUP scores to compare the observed with the predicted risk of displacement of the hip at five years. For discriminatory accuracy, the time-dependent area under the receiver operating characteristic curve (AUC) was estimated. In order to analyze differences in the performance of the score between cohorts, score weights, and subsequently the AUC, were re-estimated using the variables of the original score: the child’s age at the first examination, GMFCS level, head shaft angle, and MP of the worst hip in a logistic regression with imputation of outcomes for those with incomplete follow-up. Results. The discriminatory accuracy of the score in the new population of 367 children was high (AUC 0.78 (95% confidence interval (CI) 0.71 to 0.86)). The calibration of the score was insufficient (slope 0.48 (95% CI 0.31 to 0.65)), and the absolute risks of displacement of the hip in this population were overestimated. The AUC increased with re-estimated weights (0.85 (95% CI 0.79 to 0.91)). Conclusion. The CPUP Hip Score had a high ability to discriminate between children at different levels of risk for displacement of the hip. The score overestimated the absolute risks of displacement in this population, which may have resulted from differences in the way children were initially registered in the two programmes. The results are promising, but the score weights may need re-estimation before its clinical application in Scotland. Cite this article: Bone Joint J 2022;104-B(5):640–644

Aims. Hip disease is common in children with cerebral palsy (CP) and can decrease quality of life and function. Surveillance programmes exist to improve outcomes by treating hip disease at an early stage using radiological surveillance. However, studies and surveillance programmes report different radiological outcomes, making it difficult to compare. We aimed to identify the most important radiological measurements and develop a core measurement set (CMS) for clinical practice, research, and surveillance programmes. Methods. A systematic review identified a list of measurements previously used in studies reporting radiological hip outcomes in children with CP. These measurements informed a two-round Delphi study, conducted among orthopaedic surgeons and specialist physiotherapists. Participants rated each measurement on a nine-point Likert scale (‘not important’ to ‘critically important’). A consensus meeting was held to finalize the CMS. Results. Overall, 14 distinct measurements were identified in the systematic review, with Reimer’s migration percentage being the most frequently reported. These measurements were presented over the two rounds of the Delphi process, along with two additional measurements that were suggested by participants. Ultimately, two measurements, Reimer’s migration percentage and femoral head-shaft angle, were included in the CMS. Conclusion. This use of a minimum standardized set of measurements has the potential to encourage uniformity across hip surveillance programmes, and may streamline the development of tools, such as artificial intelligence systems to automate the analysis in surveillance programmes. This core set should be the minimum requirement in clinical studies, allowing clinicians to add to this as needed, which will facilitate comparisons to be drawn between studies and future meta-analyses. Cite this article: Bone Jt Open 2023;4(11):825–831

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels. . The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services. . The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery. . Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients. . The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpe’s angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity. . The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy. Cite this article: Bone Joint J 2015;97-B:1435–40

The aims of this study were to report functional outcomes of salvage procedures for patients with cerebral palsy (CP) who have chronic dislocation of the hip using validated scoring systems, and to compare the results of three surgical techniques. We reviewed 37 patients retrospectively. The mean age at the time of surgery was 12.2 years (8 to 22) and the mean follow-up was 56 months (24 to 114). Patients were divided into three groups: 14 who underwent proximal femoral resection arthroplasty (PFRA group 1), ten who underwent subtrochanteric valgus osteotomy (SVO group 2), and 13 who underwent subtrochanteric valgus osteotomy with resection of the femoral head (SVO with FHR group 3). All patients were evaluated using the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) and the Pediatric Quality of Life Inventory (PedsQL). Significant improvements occurred in most CPCHILD and PedsQL subsection scores following surgery in all patients, without significant differences between the groups. There were 12 post-operative complications. Less severe complications were seen in group 1 than in groups 2 and 3. Salvage surgery appears to provide pain relief in patients with CP who have painful chronic dislocation of the hip. The three salvage procedures produced similar results, however, we recommend the use of PFRA as the complications are less severe. Take home message: Salvage surgery can be of benefit to patients with CP with chronic painful hip dislocation, but should be limited to selected patients considering complications. Cite this article: Bone Joint J 2016;98-B:137–43

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. Methods. This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results. Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion. The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP. Cite this article: Bone Jt Open 2023;4(8):580–583

Aims. To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity. Methods. Five databases (CENTRAL, CINAHL, PubMed, Embase, Web of Science) were systematically screened for studies investigating split tibialis anterior or split tibialis posterior tendon transfer for spastic equinovarus foot deformity, with gait-related outcomes (published pre-September 2022). Study quality and evidence were assessed using the Methodological Index for Non-Randomized Studies, the Risk of Bias In Non-Randomized Studies of Interventions, and the Grading of Recommendations Assessment, Development and Evaluation. Results. Overall, 17 studies (566 feet) were included: 13 studies used clinical grading criteria to report a postoperative ‘success’ of 87% (75% to 100%), 14 reported on orthotic use with 88% reduced postoperative use, and one study reported on ankle kinematics improvements. Ten studies reported post-surgical complications at a rate of 11/390 feet (2.8%), but 84 feet (14.8%) had recurrent varus (68 feet, 12%) or occurrence of valgus (16 feet, 2.8%). Only one study included a patient-reported outcome measure (pain). Conclusion. Split tendon transfers are an effective treatment for children and youth with CP and spastic equinovarus foot deformities. Clinical data presented can be used for future study designs; a more standardized functional and patient-focused approach to evaluating outcomes of surgical intervention of gait may be warranted. Cite this article: Bone Jt Open 2023;4(5):283–298

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles. Cite this article: Bone Joint J 2015;97-B:564–71

Purpose. The incidence of hip displacement in children with cerebral palsy is approximately 30% in large population based studies. The purpose of this study was to report the long-term effect of hip surgery on the incidence of hip displacement using a newly validated Cerebral Palsy (CP) hip classification. Method. Retrospectively, a sub-group of 100 children who underwent surgery for hip displacement were identified from a large-population based cohort of children born with CP between January 1990 and December 1992. These children were followed to skeletal maturity and closure of their tri-radiate cartilage. All patients returned at maturity for clinical and radiographic examination, while caregivers completed the disease specific quality of life assessments. Patients were grouped according to motor disorder, topographical distribution and GMFCS. Radiographs were independently graded according to CP hip classification scheme to ensure reliability. Surgical Failures were defined as CP Grade > IV. Results. Ninety-seven children and 194 hips were available for final review. According to GMFCS, greater than half the children were GMFCS IV and V (67/94, 67%), 12 were II and 18 were III. Fifteen hips were dislocated or had salvage surgery for dislocation (15/194, 7.7%) at time of skeletal maturity. The majority of hips were graded Grade II and III (149/194, 76.8%). A total of 39 (39/194, 20%) hips were classified as surgical failure with 95% (37/39) hips occurring in GMFCS IV and V children. Conclusion. Using the CP hip classification scheme, the natural history and outcome of 100 children with CP at skeletal maturity have been described. Despite hip surveillance and surgical intervention GMFCS IV and V children are at the greatest risk for surgical failure at skeletal maturity. In this study, the majority of failures were associated with either no hip surveillance and/or index surgery at a non-specialist centre. In contrast, hip surveillance and index surgery at a specialist tertiary centre was associated with a very high probability of a successful outcome. This is the first population based cohort study of children with cerebral palsy followed from index surgery to skeletal maturity for hip displacement. Surgical success rates for the treatment of hip displacement in children with cerebral palsy have not previously been reported. This information will aid surgeons in the treatment of hip displacement in children with cerebral palsy

Aims. The migration percentage (MP) is one criterion used for surgery in dislocated or displaced hips in children with cerebral palsy (CP). The MP at which a displaced hip can no longer return to normal is unclear. The aim of this paper was to identify the point of no return of the MP through a large population-based study. Methods. All children registered on the Cerebral Palsy Integrated Pathway Scotland surveillance programme undergo regular pelvic radiographs. Any child who had a MP measuring over 35% since the programme’s inception in 2013, in at least one hip and at one timepoint, was identified. The national radiography database was then interrogated to identify all pelvic radiographs for each of these children from birth through to the date of analysis. A minimum of a further two available radiographs following the initial measurement of MP ≥ 35% was required for inclusion. Results. A total of 239 children (346 hips) were identified as suitable for analysis at a mean of 6.5 years (2.0 to 14.8) follow-up. In all, 1,485 radiographs taken both prior to and after a hip had a MP ≥ 35% were examined and the MP measured to identify any progression of displacement. Interrogation of the data identified that hips with a MP up to 46% returned to a MP below 40% without intervention, and all hips with a MP equal to or greater than 46% displaced further and the MP did not return to the normal range. Statistical analysis showed the result to be 98% specific with this degree of certainty that hips reaching a MP ≥ 46% would not spontaneously regress. Conclusion. These findings are clinically relevant in showing that it may be reasonable to continue to monitor hips with a MP not exceeding 46%. This threshold will also guide referral for further management of a displacing hip. Cite this article: Bone Joint J 2021;103-B(2):411–414

There is much debate about the nature and extent of deformities in the proximal femur in children with cerebral palsy. Most authorities accept that increased femoral anteversion is common, but its incidence, severity and clinical significance are less clear. Coxa valga is more controversial and many authorities state that it is a radiological artefact rather than a true deformity. We measured femoral anteversion clinically and the neck-shaft angle radiologically in 292 children with cerebral palsy. This represented 78% of a large, population-based cohort of children with cerebral palsy which included all motor types, topographical distributions and functional levels as determined by the gross motor function classification system. The mean femoral neck anteversion was 36.5° (11° to 67.5°) and the mean neck-shaft angle 147.5° (130° to 178°). These were both increased compared with values in normally developing children. The mean femoral neck anteversion was 30.4° (11° to 50°) at gross motor function classification system level I, 35.5° (8° to 65°) at level II and then plateaued at approximately 40.0° (25° to 67.5°) at levels III, IV and V. The mean neck-shaft angle increased in a step-wise manner from 135.9° (130° to 145°) at gross motor function classification system level I to 163.0° (151° to 178°) at level V. The migration percentage increased in a similar pattern and was closely related to femoral deformity. Based on these findings we believe that displacement of the hip in patients with cerebral palsy can be explained mainly by the abnormal shape of the proximal femur, as a result of delayed walking, limited walking or inability to walk. This has clinical implications for the management of hip displacement in children with cerebral palsy

In 1994, a register for cerebral palsy and a health-care programme were started in southern Sweden with the aim of preventing dislocation of the hip in children with cerebral palsy. It involved all children with cerebral palsy born in 1992 or later. None of the 206 affected children born between 1992 and 1997 has developed a dislocation following the introduction of the prevention programme. Another 48 children moved into the area and none developed any further dislocation. Of the 251 children with cerebral palsy, aged between five and 11 years, living in the area on January 1, 2003, only two had a dislocated hip. One boy had moved into the area at age of nine with a dislocation and a girl whose parents chose not to participate in the programme developed bilateral dislocation. One boy, whose condition was considered to be too poor for preventative surgery, developed a painful dislocation of the hip at the age of five years and died three years later. Eight of 103 children in a control group, consisting of all children with cerebral palsy living in the area between 1994 and 2002, and born between 1990 and 1991, developed a dislocation of the hip before the age of six years. The decreased incidence of dislocation after the introduction of the prevention programme was significant (p < 0.001). Dislocation of the hip in cerebral palsy remains a serious problem, and prevention is important. Our screening programme and early intervention when lateral displacement of the femoral head was detected appear to be successful

Aims. The purpose of this study was to compare the prevalence of hip displacement and dislocation in a total population of children with cerebral palsy (CP) in Scotland before and after the initiation of a hip surveillance programme. Patients. A total of 2,155 children with CP are registered in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) surveillance programme, which began in 2013. Physical examination and hip radiological data are collected according to nationally agreed protocols. Methods. Age, Gross Motor Function Classification System (GMFCS) level, subtype of CP, migration percentage (MP), and details of hip surgery were analyzed for all children aged between two and 16 years taken from a time of census in March 2019 and compared to the same data from the initial registration of children in the CPIPS. Displacement of the hip was defined as a MP of between 40% and 99%, and dislocation as a MP of 100%. Results. A total of 1,646 children were available for analysis at the time of the census and 1,171 at their first registration in CPIPS. The distribution of age, sex, and GMFCS levels were similar in the two groups. The prevalence of displacement and dislocation of the hip before surveillance began were 10% (117/1,171) and 2.5% (29/1,171) respectively, and at the time of the census were 4.5% (74/1,646) and 1.3% (21/1,646), respectively. Dislocation was only seen in GMFCS levels IV and V and displacement seen in 90.5% (67/74) of these levels and 9.5% (7/74) in levels I to III. In total, 138 children had undergone hip surgery during the study period. The hip redisplaced after the initial surgery in 15 children; seven of these had undergone a second procedure and at the time of the census the hips in all seven had a MP < 40. Conclusion. Hip surveillance appears to be effective and has reduced the prevalence of hip displacement by over half and dislocation almost by half in these children. Cite this article: Bone Joint J 2020;102-B(3):383–387

We have tested the reliability of a recently reported classification system of hip morphology in adolescents with cerebral palsy in whom the triradiate cartilage was closed. The classification is a six-grade ordinal scale, based on the measurement of the migration percentage and an assessment of Shenton’s arch, deformity of the femoral head, acetabular deformity and pelvic obliquity. Four paediatric orthopaedic surgeons and four physiotherapists received training in the use of the classification which they applied to the assessment of 42 hip radiographs, read on two separate occasions. The inter- and intra-observer reliability was assessed using the intraclass correlation coefficient and found to be excellent, with it ranging from 0.88 to 0.94. The classification in our study was shown to be valid (based on migration percentage), and reliable. As a result we believe that it can now be used in studies describing the natural history of hip displacement in cerebral palsy, in outcome studies and in communication between clinicians

In cerebral palsy, the site and severity of the brain lesion are directly linked to gross motor function and the development of musculoskeletal deformities. The relationship between walking ability and orthopaedic surgery in children with cerebral palsy is not fully understood. The development of new tools such as the Functional Assessment Questionnaire and the Functional Mobility Scale can be used to give new insights on the functional impact of multilevel surgery. These scales are most useful as part of systematic, long-term follow-up

1. Correction of equinus deformity in cerebral palsy either by elongation of the tendo calcaneus or by gastrocnemius recession gives satisfactory results without splintage or bracing after operation. 2. Gastrocnemius recession is the operation of choice in paraplegic spastic cerebral palsy, and wherever possible in tetraplegic cerebral palsy. In hemiplegia the whole of the triceps surae is usually involved, and elongation of the tendo calcaneus is almost always needed. 3. Correction at operation should aim to result in a mild degree of equinus deformity at the end of the growth period in hemiplegic spastic cerebral palsy. Over-enthusiastic gastrocnemius recession can lead to excessive weakness of the calf in some patients

Aims. Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app). Methods. A total of 20 pelvis radiographs (40 hips) were used to measure MP by using the HS app. Measurements were performed by five different members of the multidisciplinary team, with varying levels of expertise in MP measurement. The same measurements were repeated two weeks later. A senior orthopaedic surgeon measured the MP on picture archiving and communication system (PACS) as the gold standard and repeated the measurements using HS app. Pearson’s correlation coefficient (r) was used to compare PACS measurements and all HS app measurements and assess validity. Intraclass correlation coefficient (ICC) was used to assess intra- and inter-rater reliability. Results. All HS app measurements (from 5 raters at week 0 and week 2 and PACS rater) showed highly significant correlation with the PACS measurements (p < 0.001). Pearson’s correlation coefficient (r) was constantly over 0.9, suggesting high validity. Correlation of all HS app measures from different raters to each other was significant with r > 0.874 and p < 0.001, which also confirms high validity. Both inter- and intra-rater reliability were excellent with ICC > 0.9. In a 95% confidence interval for repeated measurements, the deviation of each specific measurement was less than 4% MP for single measurer and 5% for different measurers. Conclusion. The HS app provides a valid method to measure hip MP in CP, with excellent inter- and intra-rater reliability across different medical and allied health specialties. This can be used in hip surveillance programmes by interdisciplinary measurers. Cite this article: Bone Jt Open 2023;4(5):363–369

Scoliosis is a common problem in cerebral palsy typified by rapid progression that often leads to large curve magnitudes even after skeletal maturity. The purpose of this study was to determine the relationship between curve progression and disease severity in cerebral palsy according to the Gross Motor Function Classification (GMFCS). This retrospective study reviewed 34 children with a known diagnosis of cerebral palsy who were scheduled for or have already had surgical stabilization for scoliosis. Two patients (6%) were classified as GMFCS level III, 13 (38%) as GMFCS level IV, and 19 (56%) as GMFCS level V. There were no patients in GMFCS levels I or II. Between the more severely involved children in GMFCS levels IV and V, there were no significant differences in curve magnitude at first presentation (means, 41.4 and 45.3 degrees, respectively; p=O.72), peak curve progression (28.2 degrees – interval 1.5 years, 31.4 degrees – interval 1. 75 years, respectively; p=O.35), or age at onset of peak curve progression (12.2 and 11.2 years, respectively). When adjusted for age at presentation, however, there was some indication of a difference in initial curve magnitude between GMFCS levels IV and V (least squares means, 35.7 and 49.2 degrees, respectively; p=O.10). The small number of patients in GMFCS level III precluded statistical analysis. In this study, the nature of scoliosis in cerebral palsy was found to be related to functional level. Once scoliosis has been diagnosed, children in the higher GMFCS levels have an increased risk of rapid and unpredictable curve progression

Purpose. The aim of this study was to identify if perioperative outcomes were different in patients with cerebral palsy undergoing unilateral or bilateral hip reconstruction. Method. All consecutive hip reconstructions for cerebral palsy performed by the senior author (FNT) within a tertiary-referral centre were identified between January 2012 and July 2016. Patients were stratified by age, gender, GMFCS and side of procedure. Length of surgery, pre- and post- operative haemoglobin, length of stay and immediate post-operative complications were measured. Results. 158 procedures were performed; 96 bilateral and 62 unilateral (37 left, 25 right). In bilateral procedures, operative time was 14 minutes longer (p= 0.07) and haemoglobin decrease was 1.85g/l greater (p= 0.34) with equivalent length of stay (average 6.4 days) and complication rate when compared to those undergoing unilateral procedures. Irrespective of procedure, those with a GMFCS level V had a longer length of stay (p< 0.05) and post-operative complication rate (p< 0.05) when compared to patients with GMFCS level IV. Conclusion. No significant differences were noted in the outcome measures when comparing unilateral and bilateral hip reconstructions in our group of patients with cerebral palsy. This suggests that concurrent prophylactic surgical management of the radiologically stable hip is a safe surgical option in this high-risk group of paediatric patients in an appropriate tertiary care setting with multidisciplinary team support

We studied prospectively the impact of a hip surveillance clinic on the management of spastic hip disease in children with cerebral palsy in a tertiary referral centre. Using a combination of primary clinical and secondary radiological screening we were able to detect spastic hip disease at an early stage in most children and to offer early surgical intervention. The principal effect on surgical practice was that more preventive surgery was carried out at a younger age and at a more appropriate stage of the disease. The need for reconstructive surgery has decreased and that for salvage surgery has been eliminated. Displacement of the hip in children with cerebral palsy meets specific criteria for a screening programme. We recommend that hip surveillance should become part of the routine management of children with cerebral palsy. The hips should be examined radiologically at 18 months of age in all children with bilateral cerebral palsy and at six- to 12-monthly intervals thereafter. A co-ordinated approach by orthopaedic surgeons and physiotherapists may be the key to successful implementation of this screening programme

We reviewed the evidence for hip surveillance in children with cerebral palsy from the published literature. Publications were identified using the Cochrane controlled trials register, the MEDLINE, EMBASE and CINAHL databases and by hand searching key journals and their references. Studies were included if they reported the frequency, associated risk factors or surveillance measures undertaken to identify subluxation or dislocation of the hip in children with cerebral palsy. Assessment of the quality of the methodology was undertaken independently by two researchers. Four studies described the natural history, incidence and risk factors for dislocation of the hip. Two reported their surveillance results. Approximately 60% of children who were not walking by five years of age were likely to develop subluxation of the hip, with the greatest risk in those with severe neurological involvement. The introduction of surveillance programmes allowed earlier identification of subluxation and reduced the need for surgery on dislocated hips. Surveillance can identify children most at risk of subluxation using radiological methods which are widely available

Botulinum toxin A (BoNT-A) is a substance that requires repeated application due to its effectiveness being lost 12–16 weeks post application. Performing these intra-muscular injections under anesthesia reduces pain and distress during applications, ensuring effective and successful functional results. This study evaluates motor development of patients undergoing 3 or more repeated BoNT-A application in a tertiary pediatric hospital and the safety as well as effect of 3 different types of anesthesia. 75 children with cerebral palsy who underwent BoNT-A application at least three times consecutively with 6-month intervals and a total of 320 procedures admitted between January 2008 and January 2018 were retrospectively examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. To observe the improvement in motor development, those with 2-1-0 level decreases in GMFCS classes were grouped and compared in terms of birth time, birth weight, cerebral palsy type and first BoNT-A application age. The 3 types of anesthesia methods (sedation analgesia, larengeal mask anesthesia (LMA) and inhalation mask anesthesia) applied during the procedures were compared in terms of sedation, procedure, recovery and total operation room time. The mean age of the children for all procedures was 45.51 ± 22.40 months. As a result of procedures, significant motor development was observed in 60 (80%) patients (p <0,000∗). No significant difference was observed when the children with cerebral palsy whose GMFCS declined in the form of level 2, 1 and unchanged were compared in terms of first application age, birth weight and gestational age. It was found that 106 (33.1%) were applied sevoflurane with anesthesia mask, 103 (32.1%) were administered sevoflurane with laryngeal mask, and 111 (34.6%) were sedation-analgesia. Only 10 out of 320 procedures were seen to develop side effects (8 vomiting, 2 bronchospasm). In the patients who underwent sedation analgesia during the first 3 BoNT-A procedures, the duration of recovery and total operating room time was seen to be significantly shorter than the others, while there was no difference between the anesthesia methods in the 4th and subsequent procedures. Regardless of the type of anesthesia, the recovery and total operating room times of those having undergone 6 or more procedures were longer than those with less than 6 procedures (p <0.009, p <0.016, respectively). As conclusion, repeated BoNT-A applications in children with CP provides progress in motor steps, it can be applied safely and effectively under anesthesia. Sedation analgesia application provides easier recovery compared to general anesthesia with LMA and mask only in the first three applications. However, recovery time increases with 4 and more repeated applications as the number of applications increases

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

1. Thirteen years of experience in charge of treatment in a Residential School for Cerebral Palsy, and a review of 466 operations performed on children handicapped by this condition, form the basis for this attempt to frame the indications and contra-indications for operation. 2. A brief description is given of the more commonly performed operations, with an indication of the results that are likely to be obtained. 3. Orthopaedic surgery has a worth-while contribution to make in the treatment of cerebral palsy. When the cases are selected with care, when the appropriate orthopaedic measures are skilfully performed and when the patients are adequately supervised afterwards, the benefits of surgery are greater than those provided by any other treatment, and they are achieved more quickly. 4. The desire to improve and the "inner urge" of the patient to succeed may be the most important single factor in his rehabilitation

This study compares the initial outcomes of minimally invasive techniques for single-event multi-level surgery with conventional single-event multi-level surgery. The minimally invasive techniques included derotation osteotomies using closed corticotomy and fixation with titanium elastic nails and percutaneous lengthening of muscles where possible. A prospective cohort study of two matched groups was undertaken. Ten children with diplegic cerebral palsy with a mean age of ten years six months (7.11 to 13.9) had multi-level minimally invasive surgery and were matched for ambulatory level and compared with ten children with a mean age of 11 years four months (7.9 to 14.4) who had conventional single-event multi-level surgery. Gait kinematics, the Gillette Gait Index, isometric muscle strength and gross motor function were assessed before and 12 months after operation. The minimally invasive group had significantly reduced operation time and blood loss with a significantly improved time to mobilisation. There were no complications intra-operatively or during hospitalisation in either group. There was significant improvement in gait kinematics and the Gillette Gait Index in both groups with no difference between them. There was a trend to improved muscle strength in the multi-level group. There was no significant difference in gross motor function between the groups. We consider that minimally invasive single-event multi-level surgery can be achieved safely and effectively with significant advantages over conventional techniques in children with diplegic cerebral palsy

We performed rotational acetabular osteotomy in order to treat dysplasia of the hip in five ambulatory adults with cerebral palsy. There was one man and four women, with a mean age of 21 years (16 to 27) who were followed up for a mean of 12 years and two months. The mean Sharp angle improved from 52° to 43°, the mean acetabular index from 30.2° to 2.8°, the mean centre-edge angle from −5.6° to 29.2°, and the mean acetabular head index from 49.2 to 88.2. There was no progression of joint degeneration and relief from pain was maintained. Our results suggest that rotational acetabular osteotomy is a valuable option for the treatment of acetabular dysplasia in adults with cerebral palsy who have incapacitating pain in the hip

Cerebral palsy (CP) is a neural condition that impacts and impairs the musculoskeletal system. Skeletal muscles, particularly in the lower limb, have previously been shown to be significantly reduced in volume in CP compared to typical controls. Muscle volume is a gross measure, however, and does not capture shape characteristics which—if quantified—could offer a robust and novel assessment of how this condition impacts skeletal muscle form and function in CP. In this study, we used mathematical shape modelling to quantify not just size, but also the shape, of soleus muscles in CP and typically developing (TD) cohorts to explore this question. Shape modelling is a mathematical technique used previously for bones, organs, and tumours. We obtained segmented muscle data from prior MRI studies in CP. We generated shape models of CP and TD cohorts and used our shape models to assess similarities and differences between the cohorts, and we statistically analysed shape differences. The shape models revealed similar principal components (PCs), i.e. the defining mathematical features of each shape, yet showed greater shape variability within the CP cohort. The model revealed a distinct feature (a superior –> inferior shift of the broad central region), indicating the model could identify muscular features that were not apparent with direct observation. Two PCs dominated the differences between CP and TD cohorts: size and aspect ratio (thinness) of the muscle. The distinct appearance characteristic in the CP model correspond to specific muscle impairments in CP to be discussed further. Overall, children with CP had smaller muscles that also tended to be long, thin, and narrow. Shape modelling captures shape features quantitatively, which indicate the ways that muscles are being impacted in CP. In the future, we hope to tailor this technique toward informing diagnosis and treatments in CP

Purpose: The purpose of this work was to compare outcome after simple posterior fusion with that after double anterior and posterior fusion for the treatment of scoliosis in cerebral palsy children. Material and methods: We reviewed the files of 33 cerebral palsy children (mean age 16 years). Twenty-one children had a posterior fusion and twelve a double anterior-posterior fusion. The classical causes of cerebral palsy were represented. Simple posterior fusion was used for more moderate scoliosis (Cobb angle 50–80°), 31% could be reduced during the bending test. Double fusion was used for more severe cases (Cobb > 80°), 18% reducible. Classical procedures were used: CD instrumentation posteriorly, simple release or Colorado rod anteriorly. Thoracophreno-laparotomy (n=6) or thoracoscopy (n=3) was used for anterior fusion. For the double fusions, the posterior procedure was performed the same day in 11/12 patients. Results: Operative time for double fusion was twice that for posterior fusions. There was no significant difference in blood loss between the two techniques. Complications were more frequent for double fusion but there were no deaths (one death due to respiratory failure after posterior fusion). All the double fusion patients remained in the intensive care unit for 2.5 – 21 days (mean 6.5 days). There was no significant difference between hospital stay (mean 18 days). Gain was better for double fusion (62% versus 52%). Discussion: Double fusion for cerebral palsy scoliosis treated late is a major operation with significant but tolerable morbidity, particularly for major scoliosis > 80°. The double procedure enables good reduction and quality fusion. Considering the current reduction and fixation options, isolated posterior fusion can still be indicated in younger children with a reducible curvature

Aims. To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP). Methods. A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded. Results. In both groups, GPS improved from the preoperative gait analysis to the six-month assessment with maintenance at 12 and 24 months postoperatively. While reduced at six months in both groups, walking speed returned to preoperative speed by 12 months. The overall pattern of change in GPS and walking speed was similar over time following C-MLS and MI-MLS. There was a median of ten procedures per child as part of both C-MLS (interquartile range (IQR) 8.0 to 11.0) and MI-MLS (IQR 7.8 to 11.0). Surgical adverse events occurred in seven (37%) and 13 (36%) children, with four (21%) and 13 (36%) patients requiring subsequent surgery following C-MLS and MI-MLS, respectively. Conclusion. This study indicates similar improvements in gait kinematics and walking speed 24 months after C-MLS and MI-MLS for children with diplegic CP. Cite this article: Bone Joint J 2021;103-B(1):192–197

The objective and dynamic documentation of the knee kinematics in ambulatory children with spastic cerebral palsy and the examination of possible causes of differences when compared to normals. 17 ambulatory patients with an average age of 10,5 years (6–17 years) with cerebral palsy, spastic diplegia where examined clinically including Duncan-Ely test. They were also examined with 3-D instrumented gait analysis. The Elite system with six cameras was used and the knee kinematics in the sagittal plane was recorded. Almost all patients (16/17) had a positive Duncan-Ely test during clinical examination. The knee kinematics in the sagittal plane showed that in 20/34 knees the range of motion was decreased compared to normal values. In 30/34 knees there was a delayed maximum knee flexion in swing phase and in 16/34 knees the amplitude of the maximum knee flexion was decreased compared to normals. Patients with severe crouch or mild rectus spasticity had almost normal knee flexion. Foot clearance in swing phase is one of the basic prerequisites of normal gait. Patients with spastic cerebral palsy who are able to walk have an impaired foot clearance because of the pathological action of the rectus femoris. In our study the majority of the patients with clinically confirmed rectus spasticity had decreased timing and amplitude of max. knee flexion in swing. In patients with severe co-contraction of the knee flexors and extensors max. knee flexion within normal range. Therefore it should not be considered as the only evaluation parameter in rectus femoris spasticity

Aims. A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood. Patients and Methods. At a mean of 22.9 months (standard deviation 12.9), after single event multi level surgery, 3D gait analysis was undertaken pre- and post-operatively for 37 adult patients with bilateral cerebral palsy and a fixed knee gait. Results. There was a significant improvement of indices and clinical and kinematic parameters including extension of the hip and knee, reduction of knee flexion at initial contact, reduction of minimum and mean knee flexion in the stance phase of gait, improved range of movement of the knee and a reduction of mean flexion of the hip in the stance phase. Genu recurvatum occurred in two patients (n = 3 legs, 4%) and an increase of pelvic tilt (> 5°) was found in 12 patients (n = 23 legs, 31%). Conclusion. Adult patients with bilateral cerebral palsy and a flexed knee gait benefit from multilevel surgery including hamstring lengthening. The risk of the occurence of genu recurvatum and increased pelvic tilt is lower than has been previously reported in children. Cite this article: Bone Joint J 2017;99-B:1256–64

Objectives: To measure the abductor moment at the hip joint in internal and external rotation and neutral position. To study the relationship between femoral ante-version and the abductor moment generated. Design: A controlled prospective study comparing a group of children with cerebral palsy with an age-matched control group. Setting: Gait Analysis Laboratory. Subjects: The study group of 15 children with cerebral palsy was selected from new referrals with internal rotation sent to the gait lab and our existing database, aged between 6 and 8 years. The control group was recruited from siblings of patients and children of staff. Methods: The child is positioned supine on a table with their legs hanging over the edge. The knee is bent and the shank placed in a frame at a given position of either 30° internal, neutral or 30° external rotation. An abduction wedge of 15° is inserted between the thighs to give a starting point. The table height is adjusted so that the hip is in 0° flexion and the knee remains in 90° flexion. The position for the dynamometer is marked on the leg, a known distance from the Anterior Superior Iliac Spine. The pelvis is stabilised by an assistant. The child is asked to push the dynamometer away as hard as possible. The maximum force generated is recorded. 3 consecutive readings are taken with a 30 second recovery period between each trial. The test is repeated for each leg position. An MRI scan of the pelvis and femur is performed. Femoral anteversion and abductor cross sectional area are measured. Results: Wilcoxon Signed Ranks Tests and paired t-tests were performed. The maximum moment generated increased with internal rotation – p< 0.002. Children with cerebral palsy generated less moments than the control group – p< 0.05. No significant difference in femoral anteversion (hence lever arm) between groups – p< 0.12. Cross sectional muscle area (CSA) was reduced in the study group, st dev 327mm. 2. , p< 0.037. Conclusion: Moments are a product of lever arm length x muscle strength. Differences between groups in abductor moments cannot be attributed to changes in lever arm length. In children with cerebral palsy there is a clear reduction in muscle CSA and therefore strength. These findings suggest that the internal rotation is a compensation for muscle weakness. Initial treatment should therefore entail extensive strengthening exercises, not derotation osteotomy

Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit. A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed. Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%). Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition

Purpose: In this study we comprehensively evaluate a cohort of profoundly affected adults with Cerebral Palsy. We document hip disability and pain and statistically evaluate the effect of demographic, physical examination (PE) and radiographic parameters on pain and function of the hip. Methods: We evaluated 77 institutionalized patients with cerebral palsy. Medical history, level of function, pain, and analgesic requirements were obtained from record review and through caregiver interview. Range of motion (ROM), degree of spasticity, decubitus ulcers were documented as well as changes in vital signs and the FLACC pain scale during PE. Radiographs of the pelvis and spine were blindly evaluated without knowledge of the above data. Statistical analysis was performed in order to identify correlations between subjective and objective findings from the history and PE with radiographic parameters in these patients. Results: Participants included 38 men and 39 women with a mean age of 40 years (range, 22-81), 94 % had severe spastic quadriplegia. Fifteen percent of hips were dislocated and radiographic evidence of arthritis was noted in 23 %. Eighteen percent of hips were definitely painful and 45 % were definitely not painful. Higher rates of dislocation and arthritis were noted in older patients (p< .05). Increased hip pain and perineal care problems were noted in patients with decreased hip abduction (p=.01), windswept hip deformities (p=.02) or flexion contractures (p=.07). Increased spasticity was associated with higher rates of arthrosis, dislocation, pain and decubiti. Hip dislocation and subluxation sig-nificantly correlated with osteoarthritis (p< .0001) but not hip pain. Patients with lower CE (< 20°) or higher Sharps (> 40°) angles were more likely to have a history of hip pain (p=.02). No radiographic parameter correlated with increased analgesic use, or change in FLACC score or vital signs during PE of the hip. Conclusions: From these adult cerebral palsy patients we document pain and poor perineal care in patients with diminished hip range of motion and windswept hip posture. Hip dislocation and arthritis was noted in 15 and 23 % of hips, with definite pain noted in 18 %. Ace-tabular dysplasia was statistically associated with hip pain; however, in this study we could not correlate hip displacement or arthritis with a history of hip pain or diminished function. Because the incidence of hip pain is low and does not correlate with dislocation or arthritis, we suggest that surgical treatment of hips in severely affected immature patients with cerebral palsy be based on presence of pain or contractures and not on radiographic signs of hip displacement

Patients with hemiplegic cerebral palsy walk with a well recognised characteristic gait pattern. They also commonly have a significant leg length discrepancy which is less well appreciated. The typical equinus gait in these patients is assumed to be an integral part of the disease process of spasticity and a tendency to develop joint contractures. However an alternative explanation for the presence of an equinus deformity may be that it is a response to the development of a significant leg length discrepancy in these patients. The development of such an equinus deformity would have the effect of functionally lengthening the short hemiplegic leg. We set up a study to examine the correlation between leg length discrepancy and equinus deformity. We reviewed the gait analyses and clinical examinations of 183 patients with hemiplegic cerebral palsy. While 22% had no significant leg length discrepancy, 65% had a measured discrepancy of greater than 1cm. There was a linear correlation between age and limb length discrepancy. We also found that there was a linear relationship between leg length discrepancy and ankle equinus at the point of ground contact. We propose that the equinus deformity seen in the hemiplegic cerebral palsy patient is multifactorial and is related not only to the disease state but also to the presence of leg length discrepancy. The equinus deformity functionally lengthens the short hemiplegic leg. Indeed it may represent an attempt by these patients to functionally equalise their leg lengths. This factor must be taken into account when considering correction of an equinus deformity in patients with hemiplegic cerebral palsy in order to avoid either recurrence of the deformity or the production of functionally unequal leg lengths. We have also highlighted the presence of significant shortening of the hemiplegic leg in these patients

The purpose of the study was to identify risk factors that are associated with re-displacement of the hip after surgical reconstruction in cerebral palsy. Retrospective review of children with cerebral palsy who had hip reconstruction with proximal femoral varus derotation osteotomy (VDRO) and Dega-type pelvic osteotomy, between 2005–2012, at a UK and European institution, was performed. Patient demographics, GMFCS, clinical and radiological outcome were assessed as well as the presence of pelvic obliquity and significant scoliosis (Cobb angle > 10 degrees). Redisplacement was defined as Reimer's Migration Index (MI) >30% at final follow-up. Logistic regression analysis was used to assess which factors were predictive of redisplacement and adjusted for clustered variables (α = 0.05). Eighty hips were identified in 61 patients. The mean age at surgery was 8.8 years (± 3.3). Mean MI pre-op was 68% (± 23%) and post-op was 8% (± 12%). At a mean follow-up, of 3.2 years (± 2.0), 23 hips had a MI >30%. Of these; five were symptomatic, and one had required a salvage procedure. Metalwork removal was undertaken in 14 hips. Logistic regression demonstrated that the pre-operative MI and the percentage of acute correction were significant predictors of re-displacement. If the pre-operative MI was greater than 65 percent, the odds ratio (OR) for redisplacement was 5.99 (p = 0.04). If correction of the MI was less than 90% of the pre-operative MI, the OR for re-displacement was 4.6 (p = 0.03). Age at the time of surgery, GMFCS, pelvic obliquity and scoliosis were not predictive of re-displacement. These results, firstly, highlight the importance of hip surveillance in children with cerebral palsy to allow timely intervention to ensure adequate radiological outcomes. Secondly, as in developmental hip dysplasia, full concentric reduction is essential to reduce the risk of re-displacement, with its associated clinical consequences

1. Ten children with scoliosis and cerebral palsy of various types have been reviewed. All underwent operation for correction and stabilisation of the spinal curve, and spinal fusion. 2. Three of the ten patients required supplemental surgery in the form of regrafting, with or without reinsertion of Harrington rods. All have shown considerable correction of the curve, and in all cases the fusion appears to be consolidated. Operation has given these children stable spines which are compensated. Their ability to sit, and in some cases to stand, has improved. 3. In many such cases of scoliosis complicating cerebral palsy Harrington instrumentation and spinal fusion is the only feasible effective form of treatment

In developed countries, children with cerebral palsy are treated from the time of diagnosis. This is usually not the case in developing countries where such patients often present at an age when it is traditionally believed that if walking has not already commenced, it is unlikely to. This study reports the outcome of the surgical treatment of 85 spastic diplegic patients at a mean of 8.5 years (5 to 12). All presented as untreated non-walkers and had achieved sitting balance by the age of five to six years. They underwent single-event multilevel surgery followed by physiotherapy and orthotic support. For outcome assessment, a modified functional walking scale was used at a mean of 3.5 years (2 to 5) post-operatively. At all levels, static joint contractures had resolved almost completely. All patients improved and became walkers, 18 (21.2%) as exercise, 39 (45.9%) as household and 28 (33%) as community walkers. This study shows that children with cerebral palsy who cannot walk and have not been treated can be helped by single-event multilevel surgery, provided that inclusion criteria are followed and a structural, supervised rehabilitation programme is in place

The purpose was to compare the results of two different surgical techniques in the treatment of severe cerebral palsy scoliosis. This is a retrospective review of 12 consecutive cerebral palsy patients with scoliosis greater than 90 degrees undergoing simultaneous anterior and posterior spinal fusion. The clinical notes were reviewed along with sequential radiographs. Twelve patients were operated on between March 1997 and October 2001. There were 6 patients who had anterior release and fusion followed by posterior fusion from T2 to the sacrum using the Luque-Galveston technique. (Group 1). The other 6 patients had identical surgery but with the addition of anterior instrumentation as well. (Group 2). There was no loss of fixation or metalware failure. There was no pseudarthrosis. One patient died at the time of rod removal for infection 2 years following their index operation. These results show that a good outcome is achieved in this group of severely affected cerebral palsy patients using either of the techniques described. The addition of anterior instrumentation may make the surgery easier and was not associated with significant increase in complications

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

Sitting is the main activity of daily living for the majority of patients with cerebral palsy. More than 60% of dependent sitters have hip disorders. Surgical management of hip and pelvic postural mal-alignment remains controversial. The aim of this study was to investigate effectiveness of open hip release in patients with spastic hip deformities. Seventeen patients with spastic cerebral palsy were treated with a selective release of the adductors, hamstrings, and iliopsoas, and capsulotomy of the hip joint. There were 6 females and 9 males. Ten of the patients were nonambulatory and seven were ambulatory. The average age at operation was 6 years 4 months (4 to 14 years). The follow-up period ranges from 2 to 9 years (average of 4.8 years). The patients were evaluated clinically and radiologically. The migration and acetabular indices were measured on the pre-operative and follow-up radiographs. The results of hip release were rated satisfactory in 12 patients and unsatisfactory in 5 patients. The latter was due to severe acetabular dysplasia and posterior instability that was later improved by acetabuloplasty. We concluded that a soft tissue release of spastic hip deformities improved sitting stability in nonambulatory and walking posture in ambulatory patients

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

Aims. Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth. Methods. We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer’s migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw. Results. A total of 37 hips in Group 1 and 24 hips in Group 2 were compared. Group 1 showed a more substantial decrease in the HSA (p = 0.003) and the MP (p = 0.032). Both groups had significant and similar improvements in the AI (p = 0.809) and the FAVA (p = 0.304). Group 1 presented a higher incidence of the physis growing-off the screw (p = 0.038). Results of the regression analysis indicated that the eccentricity of screw position correlated with HSA correction and increases the risk of the physis growing-off the screw. Conclusion. Guided growth is effective in improving coxa valga and excessive femoral anteversion in CP children. For younger children, despite compromised efficacy of varus correction, we recommend a more centered screw position, at least across the middle quarter of the medial physis, to avoid early revision. Cite this article: Bone Joint J 2020;102-B(9):1242–1247

The results of a functional, clinical and radiological study of 30 children (60 hips) with whole-body cerebral palsy were reviewed at a mean follow-up of 10.2 years (9.5 to 11). Correction of windsweep deformity of the hips was performed by bilateral simultaneous combined soft-tissue and bony surgery at a mean age of 7.7 years (3.1 to 12.2). We were able to recall 22 patients; five had died of unrelated causes and three were lost to follow-up. Evaluation involved interviews with patients/carers and clinical and radiological examination. The gross motor functional classification system was used to assess overall motor function and showed improvement in seven patients. Of the 12 patients thought to have pain pre-operatively, only one had pain post-operatively. Improved handling was reported in 18 of 22 patients (82%). Those with handling problems were attributed by the carers to growth of the patients. All patients/carers considered the procedure worthwhile. The range of hip movements improved, and the mean windsweep index improved from 50 pre-operatively to 36 at follow-up. The migration percentage and centre-edge angle were assessed on plain radiographs. Radiological containment improved, the mean migration percentage improved from 50 pre-operatively to 20 at follow-up and the mean centre-edge angle improved from −5° to 29°. No statistical difference was noted between the three-year and ten-year follow-up results, indicating that the improvements in clinical and radiological outcome had been maintained

Hip displacement, defined in this study as a migration percentage (MP) of more than 40%, is a common, debilitating complication of cerebral palsy (CP). In this prospective study we analysed the risk of developing hip displacement within five years of the first pelvic radiograph. . All children with CP in southern and western Sweden are invited to register in the hip surveillance programme CPUP. Inclusion criteria for the two groups in this study were children from the CPUP database born between 1994 and 2009 with Gross Motor Function Classification System (GMFCS) III to V. Group 1 included children who developed hip displacement, group 2 included children who did not develop hip displacement over a minimum follow-up of five years. A total of 145 children were included with a mean age at their initial pelvic radiograph of 3.5 years (0.6 to 9.7). The odds ratio for hip displacement was calculated for GMFCS-level, age and initial MP and head-shaft angle. A risk score was constructed with these variables using multiple logistic regression analysis. The predictive ability of the risk score was evaluated using the area under the receiver operating characteristics curve (AUC). . All variables had a significant effect on the risk of a MP > 40%. The discriminatory accuracy of the CPUP hip score is high (AUC = 0.87), indicating a high ability to differentiate between high- and low-risk individuals for hip displacement. The CPUP hip score may be useful in deciding on further follow-up and treatment in children with CP. Cite this article: Bone Joint J 2015;97-B:1441–4

1. Analysis of the static and dynamic conditions in spastic cerebral palsy leads to the conclusion that contractures of the hip, knee and ankle should be released from above downwards, and that the full benefit is obtained only when all contractures have been corrected. 2. Only when these joints are mobilised by removal of the significant contractures is the spastic patient able, despite other handicaps, to sit, stand and walk with the least hindrance and the least cosmetic fault. 3. In our Danish experience, inadequate or poor results from the orthopaedic surgery of cerebral palsy are mainly due to the fact that patients with contractures are operated on too little and too late, or not in the correct sequence

When cerebral palsy involves the entire body pelvic asymmetry indicates that both hips are ‘at risk’. We carried out a six-year retrospective clinical, radiological and functional study of 30 children (60 hips) with severe cerebral palsy involving the entire body to evaluate whether bilateral simultaneous combined soft-tissue and bony surgery of the hip could affect the range of movement, achieve hip symmetry as judged by the windsweep index, improve the radiological indices of hip containment, relieve pain, and improve handling and function. The early results at a median follow-up of three years showed improvements in abduction and adduction of the hips in flexion, fixed flexion contracture, radiological containment of the hip using both Reimer’s migration percentage and the centre-edge angle of Wiberg, and in relief of pain. Ease of patient handling improved and the satisfaction of the carer with the results was high. There was no difference in outcome between the dystonic and hypertonic groups

Objective: In cerebral palsy the ßexor spasticity in the arm causes a nonfunctional position of the elbow and the wrist. The peripheral contribution to differences between extensors and ßexors are not thoroughly understood. Materials/Methods: We studied muscle protein expression in 17 consecutive children with cerebral palsy (age 4–19 years, mean 8,8 years, tetraplegic CP n=3, diplegic CPn=4, hemiplegic CP n=10), who underwent hand surgery. Transverse serial cryosections were cut, and stained for myosin-ATPase, as well as with monoclonal antibodies. Morphometric analysis was performed using a computerized image analysis system. Results: Immunohistochemical stainings showed signiþcantly more developmental myosin (embryonic and fetal) in the ßexors compared to the extensors. Developmental myosins are normally not found in childrenñs muscles. In the ßexors, there were signs of ongoing transformation of type 2A þbers to type 2B þbers, indicated by a higher proportion of type 2B þbers and a larger size variability in the type 2AB and the type 2 B þbers compared to the extensors. The tetraplegic patients had, compared to the hemiplegic patients, signiþcant signs of transformation from type 1 towards type 2AB and type 2B þbers. Conclusions: These þndings indicate more aberrant regeneration and faster contracting myosins in ßexors compared to extensors, and more in tetraplegic cerebral palsy compared to hemiplegic cerebral palsy. This could affect the muscle adaptability after tendon transfer

Due to abnormal neuromuscular development, functional capability in children with cerebral palsy is often severely compromised. Single event multi-level surgery (SEMLS) is the gold standard surgical treatment for patients with cerebral palsy. It has been demonstrated to improve gait, however, how standing posture is affected is unknown. The aim was to investigate the effect of SEMLS in patients with spastic cerebral palsy on walking and standing posture using 3D gait analysis. Participants were identified from the One Small Step Gait Laboratory database. Standardised 3D-Gait analysis was performed within 2 years pre- and post-SEMLS. Gait abnormality was measured using the Gait Profile Score (GPS) index; standing abnormality was measured using the newly-developed Standing Profile Score (SPS) index. A control group (n=20) of age/sex-matched CP patients who did not undergo surgery were also assessed. 104 patients (73 boys, 31 girls) with spastic cerebral palsy underwent SEMLS with appropriate pre- and post-gait analyses (2000–2015). 91 patients had bilateral limb involvement, 14 had unilateral limb involvement. Average age at surgery was 10.38 years (range 4.85–15.60 years). A total of 341 procedures were performed, with hamstring and gastrocnemius lengthening representing approximately 65% of this. There was a 20% mean improvement in walking (GPS reduced 2.4°, p<0.001) and standing (SPS reduced 3.4°, p<0.001) following SEMLS. No improvement was noted in the control group. Significant correlations were observed between the changes in SPS and GPS following surgery (r2, p<0.001). Patients with poorer pre-operative standing posture (SPS) reported the most significant improvement following surgery. We confirmed improvement in walking following SEMLS using the Gait Profile Score (GPS). This is the first paper to report that standing posture is also improved following surgery using a novel index, the Standing Posture Score (SPS). SPS could be adopted as a tool to assess functional capability and predict post-operative changes

Objective: To evaluate the effect of spinal fusion from T1, T2 to the sacrum with pelvic fixation using unit rod instrumentation on the ambulatory potential of pediatric patients with cerebral palsy. Study Design: A retrospective study of 24 ambulatory pediatric patients with spastic cerebral palsy and neuro-muscular scoliosis was performed. Summary of Background Data: Spinal deformities, occurring in patients with cerebral palsy and good ambulatory capacity, are infrequently associated with pelvic obliquity, and so instrumented spinal fusions traditionally do not extend to the pelvis. Methods: The medical charts and radiographs were reviewed, and the patients’ ambulatory ability was assessed clinically, with video tape or complete gait analysis. A questionnaire assessing patients’ functional improvement was given to the caretakers. Results: The study group included 17 female and 7 male patients, 19 quadriplegics and 5 diplegics. Follow-up evaluations for ambulatory function occurred at a mean of 2.86 years after surgery. Mean age at surgery was 15.4 years. Twenty patients underwent posterior spinal fusions and 4 patients combined anterior-posterior procedures. The patients were evaluated clinically pre-operatively, postoperatively and at follow-up with no alteration in their ambulatory status, except one patient who developed bilateral hip heterotopic ossification and gradually lost her ability to ambulate. Thirteen patients had both preoperative and postoperative gait analysis, showing no change in their ambulatory function. The surgical outcome survey demonstrated significant improvement in the child’s physical appearance, head and trunk balance, sitting ability, amount of back pain, respiration, and no change in ambulatory capacity. Conclusions: Spine surgery with fusion extending to the pelvis in ambulatory patients with cerebral palsy provided excellent deformity correction and preserved their ambulatory function

We describe a patient with cerebral palsy, of normal intelligence, who could not walk but who by the age of 16 had been successfully managed with a staged bilateral total hip arthroplasty using a constrained liner