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Do Adductor Tenotomies Prevent Progressive Migration in Children with Cerebral Palsy?: A Systematic Review
Renée Anne van Stralen1, Merel Charlotte Rosalie Roelen1, Pranai Buddhdev2
1Department of Orthopedics and Sports Medicine, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
Insights
Extensive soft-tissue release surgery is more effective than isolated adductor tenotomy for preventing hip migration in children with cerebral palsy (CP). This review highlights the importance of surgical approach for managing hip instability in CP.
Area of Science:
- Pediatric Orthopedics
- Cerebral Palsy Research
- Systematic Review and Meta-Analysis
Background:
- Hip migration affects up to one-third of children with cerebral palsy (CP), with risk increasing with higher Gross Motor Function Classification System (GMFCS) levels.
- Adductor tenotomy is a common treatment for progressive hip migration in young children, but results vary significantly.
- This systematic review evaluates the effectiveness of soft-tissue release in preventing hip migration in pediatric CP patients.
Purpose of the Study:
- To determine the effectiveness of soft-tissue release in preventing progressive hip migration in children with CP.
- To analyze failure rates and changes in migration percentage (MP) after surgical intervention.
- To assess the impact of specific surgical techniques and patient factors on outcomes.
Main Methods:
- Systematic review and meta-analysis adhering to Cochrane and PRISMA guidelines.
- Inclusion of skeletally immature pediatric CP patients with hips at risk for migration; exclusion of bony reconstructions and studies with <1 year follow-up.
- Primary outcomes: failure rate (hip migration/reoperation) and change in MP; secondary outcomes: surgical subtypes, iliopsoas lengthening, obturator neurectomy, age, GMFCS, and postoperative management.
Main Results:
- Analysis of 27 studies (2,213 hips) with mean follow-up of 12-148.8 months.
- Overall failure rate was 39%; isolated adductor longus release had an 87% failure rate.
- Extensive soft-tissue releases showed significantly lower failure rates (0-44%), while iliopsoas lengthening and obturator neurectomy had no significant impact.
Conclusions:
- Adductor tenotomies have a substantial failure rate (39%) in preventing hip migration in children with CP.
- Isolated adductor longus release is associated with significantly higher failure rates.
- Findings support informed clinical decision-making for managing early hip migration in pediatric CP.
Background:
Up to one-third of children with cerebral palsy (CP) develop migration of the hip, and the risk increases with a higher Gross Motor Function Classification System (GMFCS). In progressive hip migration in young children, adductor tenotomy is an accepted treatment option to delay or prevent progressive hip migration. However, there is quite a large variability in reported results. This systematic review aims to determine the effectiveness of a soft-tissue release in the prevention of progressive hip migration in children with CP.
Methods:
This systematic review was performed in accordance with the guidelines of the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statements. Our inclusion criteria were studies describing pediatric, skeletally immature patients with CP and a "hip at risk" of progressive hip migration. Exclusion criteria were simultaneous bony reconstructions, case reports, technical notes, published abstracts, or studies with a follow-up under 1 year postoperatively. The primary outcomes were defined as failure rate (progressive hip migration and/or need for bony surgery, as defined by each paper) and change in migration percentage (MP) at final follow-up. As secondary analyses, we evaluated the outcome after specific subtypes of surgeries and assessed whether performing lengthening of iliopsoas, neurectomy of the anterior branch of the obturator nerve, age at the time of surgery, GMFCS level, and postoperative management impact the outcome.
Results:
Our literature search identified 380 titles. Eighty-four articles underwent full-text review, of which 27 met our inclusion/exclusion criteria and were subsequently selected for quantitative analysis. A prevalence meta-analysis was performed including 17 studies (2,213 hips). Mean follow-up ranged from 12 to 148.8 months. The mean preoperative MP was 33.4% (2,740 hips) and 29.9% at follow-up. The overall reported failure rate was 39% (95% confidence interval, 26%-52%). Performing a release of only adductor longus had a failure rate of 87%, whereas more extensive soft-tissue releases showed significantly better results with failure rates ranging from 0 to 44% (p < 0.001). Lengthening of the iliopsoas had no significant impact on failure rate (p = 0.48), nor did performing an obturator neurectomy (p = 0.92).
Conclusion:
The failure rate of adductor tenotomies to prevent progressive hip migration appears to be as high as 39% in studies with a varying follow-up. The failure rates are significantly higher when isolated release of the adductor longus is performed. This systematic review supports clinical decision making in children with CP and early hip migration.
Level Of Evidence:
Level IIA. See Instructions for Authors for a complete description of levels of evidence.
