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Hip Displacement After Triradiate Closure in Ambulatory Cerebral Palsy: Who Needs Continued Surveillance?
Amelia M Lindgren1, Ali Asma, Kenneth J Rogers
1Department of Orthopedics, Nemours Children's Health, Wilmington, DE.
Insights
Progressive hip displacement after skeletal maturity is a significant concern for ambulatory cerebral palsy (CP) patients, with 21% experiencing adverse outcomes. Annual hip surveillance is recommended for ambulatory CP with a migration percentage of 28% or higher after triradiate cartilage closure.
Area of Science:
- Orthopedic surgery
- Pediatric neurology
- Rehabilitation medicine
Background:
- Hip surveillance is crucial for children with cerebral palsy (CP).
- Evidence-based guidelines exist for skeletally immature individuals.
- Less is known about hip displacement progression in ambulatory CP after skeletal maturity.
Purpose of the Study:
- To determine the prevalence of progressive hip displacement in ambulatory CP after triradiate cartilage (TRC) closure.
- To identify risk factors for hip displacement progression in this population.
- To establish a threshold for monitoring hip health post-skeletal maturity.
Main Methods:
- Retrospective cohort study of ambulatory CP patients (GMFCS I-III).
- Included regular hip surveillance with radiographs before and after TRC closure.
- Analyzed migration percentage (MP) and risk factors including diplegia, epilepsy, and shunt presence.
Main Results:
- 21.1% of patients experienced an "unsuccessful hip" outcome (MP ≥30%, progression ≥10%, or surgery).
- Diplegia and epilepsy were identified as risk factors by chi-square analysis.
- First MP after TRC closure was the significant risk factor (P <0.001), with MP ≥28% as the threshold.
Conclusions:
- Progressive hip displacement after skeletal maturity occurs in a significant portion (21%) of ambulatory CP patients.
- Annual hip surveillance post-TRC closure is recommended for ambulatory CP with MP ≥28%.
- Patients with bilateral CP and epilepsy require particular attention.
Background:
Hip surveillance in cerebral palsy (CP) is an accepted practice with evidence-based guidelines implemented. For the skeletally immature with open triradiate cartilage (TRC), recommendations for radiographic surveillance stemmed from population-based studies. For nonambulatory CP, progression of hip displacement after skeletal maturity has been reported; less is known for ambulatory CP. We aimed to determine the prevalence and risk factors associated with progressive hip displacement after TRC closure, a proxy for skeletal maturity, for ambulatory CP.
Methods:
This is a retrospective cohort study of patients with ambulatory CP (Gross Motor Function Classification System I-III), with unilateral or bilateral involvement, hypertonic motor type, regular hip surveillance (≥3 radiographs after age 10 yr, 1 before TRC closure, ≥1 after age 16 yr), and 2-year follow-up post-TRC closure. The primary outcome was migration percentage (MP). Other variables included previous preventative/reconstructive surgery, topographic pattern, sex, scoliosis, epilepsy, and ventriculoperitoneal shunt. An "unsuccessful hip" was defined by MP ≥30%, MP progression ≥10%, and/or requiring reconstructive surgery after TRC closure. Statistical analyses included chi-square and multivariate Cox regression. Kaplan-Meier survivorship curves were also determined. Receiver operating characteristic analysis was used to determine the MP threshold for progression to an "unsuccessful hip" after TRC closure.
Results:
Seventy-six patients (39.5% female) met the inclusion criteria, mean follow-up 4.7±2.1 years after TRC closure. Sixteen (21.1%) patients had an unsuccessful hip outcome. By chi-square analysis, diplegia ( P =0.002) and epilepsy ( P =0.04) were risk factors for an unsuccessful hip. By multivariate analysis, only first MP after TRC closure ( P <0.001) was a significant risk factor for progression to an unsuccessful hip; MP ≥28% being the determined threshold (receiver operating characteristic curve analysis, area under curve: 0.845, P <0.02).
Conclusions:
The risk of MP progression after skeletal maturity is relatively high (21%), similar to nonambulatory CP. Annual hip surveillance radiographs after TRC closure should continue for Gross Motor Function Classification System I-III with an MP ≥28% after TRC closure, especially for bilateral CP and epilepsy.
Level Of Evidence:
III.
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