The impact of asymmetry on the radiographical outcomes following hip reconstruction in patients with cerebral palsy

Purpose: The purpose of this study was to evaluate the impact of asymmetric hip dysplasia on the outcome of hip reconstruction in patients with cerebral palsy according to preoperative migration percentage (MP). Methods: This study was institutional review board-approved for retrospective cohort review. From 2008 to 2018, 65 patients met inclusion criteria: Gross Motor Function Scale Classification (GMFSC) III to V with spastic hips (MP > 30%) who underwent bilateral hip reconstruction, with a follow-up > 24 months. Main exclusion criteria: children with associated syndromes or chromosomal disorders. The cohort was subdivided into three groups according to preoperative MP difference between hips: Group A > 50%, group B 20% to 50% and Group C < 20%. Subsequently, the groups were analyzed individually and then compared. The asymmetry of extended abduction of the hip was also evaluated and separated into three groups: no asymmetry (< 20° difference), mild asymmetry (20° to 50° difference) and severe (> 50° difference). Results: In total, 65 patients underwent bilateral bony reconstructive surgery (130 hips). Mean age at surgery was 10.1 years (sd 3.6; 3.6 to 18.4). Mean age at follow-up was 14.7 years (sd 3.8; 8 to 21). Preoperative GMFSC distribution was grade III (four, 6%), IV (15, 23%) and V (46, 71%). In all, 21 symmetric hips (< 20% MP difference) had a preoperative MP difference of 9% and a follow-up MP difference of 18% (p > 0.05); 32 had a preoperative MP difference of 34% and a follow-up MP difference of 16% (p < 0.0001); 12 had a preoperative MP difference of 80% and a follow-up difference of 6% (p < 0.0001). According to pre- and postoperative abduction values, the mean high hip abduction preoperatively was 34° (sd 17°), whereas low hip abduction was 23° (sd 17°). Conclusion: Hips with asymmetrical dysplasia and/or abduction undergoing bilateral reconstructive surgery focused on symmetric abduction, and corrected dysplasia in patients with cerebral palsy has improved symmetry in hip abduction and MP. Obtaining this goal immediately postoperatively is maintained to medium-term follow-up. Level of Evidence: IV

Reconstruction surgery for dislocated hips in children with cerebral palsy

Introduction The article is a literature review focusing on reconstruction surgery for dislocated hips in children with cerebral palsy (CP). Material and methods Publications in Scopus, PubMed, RSCI indexed journals over the past 20 years were reviewed for hip dislocation in children with CP. Results and discussion The article discusses the prevalence of the orthopaedic complication of cerebral palsy, pathogenesis, diagnosis, indications to surgery, choice of surgical technique, early rehabilitation and long-term outcomes. A report made for the first educational meeting of the European Pediatric Orthopaedic Society held in Russia at the Ilizarov Center in 2021 was used for the contribution. Conclusion Surgical treatment is indicated for hip dislocation in children with CP using holistic approach and principles of single-event multilevel surgery that suggest hip reconstruction, addressing contractures and deformities of the subjacent segments and creating conditions for postoperative postural management. Standardized indications, patient selection and optimal time for intervention are to be carefully considered for the procedure with the use of customized orthopaedic implants and techniques.

Is arthroplasty inevitable after Ilizarov hip reconstruction of unstable hip joints in adolescents and young adults? Long-Term Evaluation of 136 Cases

Introduction Whereas hip joint destroying trauma and diseases are difficult situations, the problem is more complex when it is complicated by hip instability. This could be a sequel of several hip affections such as trauma, septic or tuberculous arthritis, neglected developmental dysplasia of the hip, postoperative conditions, and neurologic pathologies (cerebral palsy, myelomeningocele, poliomyelitis). Purpose The purpose of this study is to evaluate long-term radiographic and clinical outcomes of the Ilizarov hip reconstruction for the treatment of painful and unstable hips in adolescents and young adults. Materials and methods The study included 136 patients with an average age of 18.3 years (range, 6 to 34 years); 75 patients were males (55.1%) and 61 females (44.9%). The primary causes of the hip instability were untreated or unsuccessfully treated cases of septic arthritis (40 cases; 29.4 %), congenital hip dislocation (28 cases; 20.6 %), paralytic hip dislocation (36 cases; 26.5 %), proximal femoral focal deficiency (14 cases; 10.3 %), neglected fracture of the femoral neck (10 cases; 7.4 %), osteoarthritis (6 cases; 4.4 %), and tuberculous hip arthritis (2 cases; 1.5 %). The intervention consisted in the performance of two osteotomies (proximal and distal) of the femur with pelviс support and placement of the Ilizarov apparatus of a specific assembly. Results The external fixation period ranged from 4 to 12 months (6.5 months on average). Patients were followed up for an average of 17.4 years (range, 5 to 27 years). Multiple clinical parameters at final follow-ups showed significant improvement, including pain relief, pain-free walking distance, lameness, hip flexion and abduction, hip contracture, and lumbar lordosis. Functionally, the mean Harris Hip Score improved with a statistically significant difference from 48 points (range, 35–65) before surgery to 83 points (range 70–90) after surgery. The pain disappeared in all patients, with the exception of six cases of pain in the early postoperative period. In all cases, supportive walking aids were no longer necessary, with the exception of two cases of persistent pain by physical activities. Walking ability and painless walking distance improved in all patients from an average of 35 m (range, 10 to 50 m) before surgery to 1,150 m (range, 1,000 to 1,500 m) after surgery, showing significant difference. Conclusion Ilizarov pelvic support osteotomy provided a multi-purpose solution to the complex challenging problem of hip instability in adolescents and young adults with variable primary etiologies. The improvements in the hip motion, mechanical axis, and correction of limb-length discrepancy lead to good functional outcomes over a long-term follow-up. This treatment modality might avoid or postpone the need for total hip arthroplasty for several years.