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Cerebral Palsy with Dislocated Hip and Scoliosis: What to Deal with First?

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Cerebral Palsy with Dislocated Hip and Scoliosis: What to Deal with First? Current Concepts Review Cerebral palsy with dislocated hip and scoliosis: what to deal with first? Ilkka J. Helenius1 Cite this article: Helenius IJ, Viehweger E, Castelein RM. Cer- Elke Viehweger2 ebral palsy with dislocated hip and scoliosis: what to deal Rene M. Castelein3 with first?J Child Orthop 2020;14: 24-29. DOI: 10.1302/1863- 2548.14.190099 Abstract Keywords: cerebral palsy; hip dislocation; neuromuscular Purpose Hip dislocation and scoliosis are common in children scoliosis; CP surveillance; hip reconstruction; spinal fusion with cerebral palsy (CP). Hip dislocation develops in 15% and surgery 20% of children with CP, mainly between three and six years of age and especially in the spastic and dyskinetic subtypes. The risk of scoliosis increases with age and increasing disabili- Introduction ty as expressed by the Gross Motor Function Score. Hip dislocation develops in 15% and 20% of children with Methods A hip surveillance programme and early surgical cerebral palsy (CP), mainly between three and six years 1 treatment have been shown to reduce the hip dislocation, of age, and especially in the spastic dyskinetic subtypes. but it remains unclear if a similar programme could reduce Children with Gross Motor Function Classification System the need for neuromuscular scoliosis. When hip dislocation (GMFCS) level V demonstrate an incidence of hip dis- 2 and neuromuscular scoliosis are co-existent, there appears to placement up to 90%. The risk of scoliosis increases with 3 be no clear guidelines as to which of these deformities should age and increasing disability (increasing GMFCS level). be addressed first: hip or spine. The risk of scoliosis is 1% for GMFCS level I at ten years of age and 5% at 20 years, but 30% for GMFCS V at ten Results Hip dislocation or windswept deformity may cause years and 80% at 20 years. Hip dislocation may cause pel- pelvic obliquity and initiate scoliosis, while neuromuscular vic obliquity and initiate scoliosis, usually with the side of scoliosis itself leads to pelvic obliquity and may increase the the adducted dislocated hip corresponding to the high risk of hip dislocation especially on the high side. It remains hemi-pelvis (windswept deformity), while neuromus- unclear if treating imminent hip dislocation can prevent de- cular scoliosis itself can lead to pelvic obliquity and may velopment of scoliosis and vice versa, but they may present increase the risk of hip dislocation especially on the high at the same time for surgery. Current expert opinion suggests side4,5 (Fig. 1a). It remains unclear if treating imminent hip that when hip dislocation and scoliosis present at the same dislocation can prevent development of scoliosis and vice time, scoliosis associated pelvic obliquity should be corrected versa, but they may present at the same time for surgery. before hip reconstruction. If the patient is not presenting with There appears to be no clear guidelines as to which of pelvic obliquity the more symptomatic condition should be these deformities should be addressed first: hip or spine. addressed first. This article was conceived by the neuromuscular and Conclusion Early identification of hip displacement and neu- spine study groups of the European Paediatric Ortho- romuscular scoliosis appears to be important for better sur- paedic Society based on the presentations of the authors gical outcomes. given at the society’s 37th annual meeting in Tel Aviv, Israel (05 April 2019) in a two-hour focus session on CP and associated spine deformities. 1 Department of Pediatric Orthopedic Surgery, University of Turku and Turku University Hospital, Turku, Finland 2 Department of Pediatric Orthopedic Surgery, Aix-Marseille University Hip dislocation and Timone Children’s Hospital, Marseille, France 3 Department of Orthopedic Surgery, University Medical Center A hip surveillance programme and early surgical treatment Utrecht, The Netherlands have been shown to reduce the risk of hip dislocation.6 In a Swedish hip surveillance programme,6 every child with Correspondence should be sent to Ilkka J. Helenius, Department suspected CP is evaluated by a neuropaediatrician at the of Pediatric Orthopedic Surgery, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland. age of four years and receives a pelvic radiograph. There- E-mail: [email protected] after, the child is followed up twice annually by a phys- CEREBRAL PALSY: HIP OR SPINE FIRST? (a) (b) Fig. 1 a) Hip subluxation before spine surgery on the high side; b) improvement of hip subluxation after spine surgery. iotherapist and receives pelvic radiographs annually until avoid biomechanical conditions that can allow scoliosis the age of eight years. Hips demonstrating a migration to evolve.10 Surgery of a dislocated hip may not cure sit- percentage of 33% (the percentage of the ossified femo- ting and positioning asymmetry, and may even worsen it ral head outside of the lateral margin of the ossified ace- when performed unilaterally. Bilateral surgery may, there- tabum7) are referred to an orthopaedic surgeon. fore, be needed to correct a pelvic imbalance that would Conservative treatment methods include better posi- hinder activities of daily living.11 tion of the hips into abduction and external rotation as Reconstructive hip surgery in severely dysplastic hips well as regular physiotherapy. Better position of the hips or in the presence of osteoarthritis should be first weighed can be promoted by using a wedge between the legs or against its potential complications and the need for a intermittent serial plaster. Hips presenting with a migration complete preoperative work-up in the severely involved percentage of 40% or more receive early surgery including CP patient to decrease complications. Considering daily adductor and ileopsoas tenotomies or proximal femoral life activities, reducing spasticity using focal hip objec- and pelvic osteotomies.6 Using early surgery, the risk of tive-based toxin injections to improve comfort and main- hip dislocation (defined as migration percentage of 100% tain symmetric movement for daily care may be more or more) has decreased from 9.2% to 0.6% in Southern useful than having a located hip as documented on a Sweden during the last two decades, while the percentage radiograph.12 For reliable orthopaedic management of of children undergoing hip surgery has remained at 13%. hip problems in CP patients, it is most important to be Similar findings have been obtained in Australia as well.8 aware of long-term issues of daily living. It’s essential to Hip reconstruction surgery using femoral and/or pelvic ask ‘good’ questions to be able to propose a daily living osteotomies has improved the health-related quality of life objective-based therapy programme. Good questions can even in non-ambulatory children with CP.9 Children with be for example: is the hip deformity or asymmetry annoy- a lower migration precentage (< 50%) had a higher preop- ing more the child, the parents, or the physiotherapist? Are erative Caregiver Priorities and Child Health Index of Life there any objective findings to support more active con- with Disabilities (CPCHILD) total score than those with a servative or surgical management for the hip dislocation? larger migration percentage (> 50%), but improvements in the CPCHILD were similar in both groups resulting in higher health-related quality of life in children with < 50% Scoliosis migration percentage preoperatively. Based on a daily living point of view it is most import- In a population based study on 962 children with CP, the ant to keep the hips well centred with a level pelvis in risk of scoliosis was closely associated with disability i.e. order to achieve good sitting comfort, prevent pain and increasing GMFCS score and age.3 Of these children with J Child Orthop 2020;14:24-29 25 CEREBRAL PALSY: HIP OR SPINE FIRST? GMFCS I, 1% presented with scoliosis at ten years of age Table 1 Factors affecting decision making as to whether to perform and 5% at 20 years, but 30% had scoliosis with GMFCS V spine or hip reconstruction first on a cerebral palsy child with both scoliosis and hip dislocation at ten years and 80% at 20 years. The risk of scoliosis > 40° was 0% in the GMFCS 1, but 75% in GMFCS V at the age Factors of 20 years. The risk factors for progressive neuromuscular Symptoms scoliosis include scoliosis of 40° or more, thoracolumbar The more symptomatic (hip or spine) should be addressed first Mobile and pain-free dislocated hip => Scoliosis surgery first 13 curves and total body involvement. The progression of Fixed, non-mobile, painful hip => Consider hip salvage or reconstruction scoliosis does not stop at skeletal maturity in curves 40° or first Type of scoliosis more. In children with CP associated scoliosis the internal Early-onset scoliosis ≥ 60° => Growing rods (age < 8 yrs) or spinal fusion rotation and reduced range of flexion on the high side hip (age > 8 yrs) 14 Flexible adolescent neuromuscular scoliosis < 60° => Hip surgery can be may result into sitting problems. performed first Senaran et al5 evaluated the effect of unilateral hip dis- Rigid or more severe neuromuscular scoliosis ≥ 60° => Spinal fusion (age location on the CP scoliosis. They followed up 23 spas- > 8 yrs) Pelvic obliquity tic tetraplegic CP children with untreated unilateral hip < 10° and flexible scoliosis < 60° => Hip reconstruction can be performed dislocation and scoliosis and compared their outcomes first ≥ 10° => Spinal fusion first to level the pelvis with 83 spastic tetraplegic CP with well-located hips and scoliosis. The progression of scoliosis was similar in both groups (12.9°versus 12.2°per year), while the incidence of guidelines as to which of the conditions should be pelvic obliquity was higher in the group with hip disloca- addressed first. Daily living has to be the basis for long- tion (74% versus 63%). Pelvic obliquity was corrected after term decision-making regarding the concommitent ortho- posterior spinal fusion to the pelvis without reducing the paedic problems and good and painless sitting posture hip at the same surgery.
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