Long-term results of a modified Spitzy shelf operation for hip dysplasia: 79 adults with a mean follow-up of 33 years.

BACKGROUND: There is no consensus regarding the treatment of symptomatic hip dysplasia in adolescents and adults. Most previous studies have insufficient follow-up time. AIM: The aim of this study was to assess the long-term outcome of a modified Spitzy shelf procedure. METHODS: We reviewed 79 adults with 94 acetabular shelf operations between 1976 and 2000. Mean age at surgery was 33.7 years (range 13-54). Indication for surgery was acetabular dysplasia with or without hip pain. Outcome was evaluated using hip pain pre- and postoperatively and Kaplan-Meier survival analysis with conversion to total hip replacement (THR) as the endpoint. RESULTS: Hip pain was reported in 84% of the hips preoperatively and in 21% one year postoperatively. 63 hips (65%) had undergone THR at a mean patient age of 54.3 years (range 29-76). The mean survival time from Spitzy operation to THR was 17.2 years (range 1-39). Survival was 86% at 10-year follow-up, 56% at 20-year follow-up, and 36% at 30-year follow-up. Predictors of THR were age at surgery ≥ 30 years and preoperative osteoarthritis (OA). The rate of complications was 12%, but most were mild to moderate. CONCLUSIONS: The modified Spitzy shelf operation had a good effect on hip pain. The long-term survival with conversion to THR as the endpoint in hips without preoperative OA was similar to that reported after periacetabular osteotomy. This indicates that the shelf procedure may be a suitable option in adolescents and young adults with milder degrees of hip dysplasia without OA.

The relationship between hip displacement, scoliosis, and pelvic obliquity in 106 nonambulatory children with cerebral palsy: a longitudinal retrospective population-based study.

BACKGROUND AND PURPOSE: The relationship between hip displacement (HD), pelvic obliquity (PO), and scoliosis in nonambulatory children with cerebral palsy (CP) has not been clearly elucidated. The aims of this population-based study were to examine the prevalence and temporal sequence of these deformities in nonambulatory children with CP and to evaluate how probable it is that severe unilateral HD contributes to development of scoliosis. PATIENTS AND METHODS: This longitudinal study comprised 106 nonambulatory children, enrolled in a surveillance program. Pelvic radiographs for measurements of migration percentage (MP) and PO were taken once a year from the diagnosis of HD. Spine radiographs were taken in patients with clinically detected scoliosis. Radiographic follow-up continued until skeletal maturity. RESULTS: Clinically significant scoliosis (Cobb angle ≥ 40°) occurred in 60 patients at a mean age of 11.8 years. 65 patients developed clinically significant HD (MP ≥ 40%) at a mean age of 4.8 years. 24 patients had no significant hip or spine deformities, 22 had HD only, 17 had scoliosis only, and 43 had both deformities. HD was diagnosed before scoliosis in all except 1 of the patients with both deformities. 14 of 19 patients with severe unilateral HD (MP ≥ 60%) had scoliosis convexity to the opposite side of the displaced hip. CONCLUSION: The combination of scoliosis and HD was frequent, and HD was diagnosed first in almost all the patients. HD might be a contributory cause of scoliosis in patients with severe, unilateral HD, PO, and later scoliosis with convexity to the opposite side.

Scoliosis in children with severe cerebral palsy: a population-based study of 206 children at GMFCS levels III-V.

PURPOSE: To evaluate the prevalence of scoliosis and the rate of scoliosis progression in children with severe cerebral palsy (CP) at GMFCS levels III-V. METHODS: Two hundred and six children (86 girls, 120 boys), born 2002-2008, were recruited from The Norwegian Quality and Surveillance Registry for Cerebral Palsy (NorCP). Inclusion criteria were bilateral CP and GMFCS levels III-V. Scoliosis was evaluated annually by examination of the spine by a physiotherapist. Radiographic examination was performed in children with moderate or severe scoliosis at clinical evaluation. The Cobb angle was used as a measure of curve magnitude. RESULTS: Scoliosis, defined as Cobb angle ≥ 10°, occurred in 121 children (59%). Severe scoliosis (Cobb angle ≥ 40°) developed in 80 of the 206 patients (39%) at a mean age of 10.9 years (range 5-16) and was more prevalent in children at GMFCS level V (62%) than at levels IV (19%) and III (6%). Initial Cobb angle, Cobb angle ≥ 30° at age 10 years, and GMFCS level V were independent risk factors for severe scoliosis. In children at GMFCS level V, the rate of scoliosis progression decreased with age from a mean of 9.7° per year at age 3-5 years to 2-3° per year in children ≥ 11 years. CONCLUSIONS: The prevalence of scoliosis among children with CP increased with decreasing motor functional level. The most important risk factors for progression of scoliosis were high initial Cobb angle, Cobb angle ≥ 30° at age 10 years, and GMFCS level V.

The natural history of acetabular dysplasia and later total hip arthroplasty in late-detected DDH: 48 patients with closed reduction followed to a mean age of 62 years.

BACKGROUND AND PURPOSE: The long-term prognosis of acetabular dysplasia without subluxation in developmental dislocation of the hip (DDH) is uncertain. The aim of this study was to assess the consequence of having acetabular dysplasia at skeletal maturity on the need for having a total hip arthroplasty (THA) up to the age of 60 years. PATIENTS AND METHODS: Inclusion criteria were age at diagnosis 0.5-3.0 years, initial treatment with skin traction to obtain closed reduction during 1958-1962, and no acetabular procedures to improve femoral head coverage. 48 patients (57 hips) met these criteria, 41 girls and 7 boys. Hip dysplasia was defined as a center-edge (CE) angle at skeletal maturity of 10-19°, and hips with CE angles in the range 20-25° were termed borderline dysplastic. RESULTS: At skeletal maturity, 18 hips had acetabular dysplasia with a mean CE angle of 15.8° (10-19), whereas 19 hips were borderline with CE angles 20-25°, and 20 hips were normal (CE angles ≥ 26°). During the follow-up period 16 hips had undergone THA, 11 of 18 hips with dysplasia, 4 of 19 with borderline dysplasia, and 1 of 20 hips without dysplasia (p < 0.001). Hip survival in the 18 dysplastic hips, with THA as the endpoint, was 100% up to patient age 40 years; thereafter survival fell to 83% at 50 years and 39% at 60 years. There was no significant correlation between CE angle at skeletal maturity and age at THA (p = 0.2). The mean age at the last follow-up in patients without THA was 62 years (60-64). CONCLUSION: Acetabular dysplasia without subluxation was a risk factor for THA, but less than one-fifth of the hips had undergone THA up to patient age 50 years.

Health-related quality of life in adolescents with cerebral palsy; a cross-sectional and longitudinal population-based study.

AIMS: The aims of this population-based cross-sectional and longitudinal study were to investigate different aspects of health-related quality of life (HRQoL) in adolescents with cerebral palsy (CP), to define possible changes in HRQoL from childhood to adolescence and to identify factors associated with low HRQoL in adolescence. METHODS: Proxy-reports of 64 adolescents, aged 12-17 years, with bilateral CP in GMFCS levels III-V participating in a surveillance programme, included five of the six domains from the HRQoL instrument Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD): (1) Activities of Daily Living and Personal Care, (2) Positioning, Transfer and Mobility, (3) Comfort and Emotions, (5) General Health and (6) Overall Quality of Life, and the two questions on pain from the Child Health Questionnaire (CHQ). Fifty-eight participants comprised the longitudinal sample. RESULTS: From childhood to adolescence, the mean CPCHILD domain scores decreased slightly in General Health and remained unchanged in the other four domains. In the domain General Health, the number of medications increased, which was the reason for the score decrease. Pain severity increased significantly. Severe motor impairment was associated with low scores in domains 1, 2, 3 and 5, and more severe pain with low scores in domains 2, 3, 5 and 6. A low domain score in childhood was associated with a low score in each corresponding domain in adolescence. INTERPRETATION: An assessment of HRQoL should be included in CP surveillance programmes because this could identify needs for interventions in individuals with severe CP. This study indicates the importance of improved pain management in both children and adolescents with severe CP.

Risk factors for hip displacement in cerebral palsy: A population-based study of 121 nonambulatory children.

Purpose: The aim was to evaluate which clinical and radiographic variables are independent (true) risk factors for hip subluxation in nonambulatory children below 5 years of age with cerebral palsy. Methods: Patients were recruited from a population-based hip surveillance program. Inclusion criteria were birth during 2002-2006, age below 5 years, and gross motor function classification system levels III-V. In all, 121 children (71 boys) met these criteria. Gross motor function classification system was level III in 29 patients, level IV in 28, and level V in 64. Anteroposterior radiographs at diagnosis and during follow-up were assessed, and only the worst hip of each patient was used for the analyses. The mean age at the initial radiograph was 2.5 years (range: 0.7-4.9 years), and the mean follow-up time was 4.0 years (range: 0.5-11.8 years). Results: At the last follow-up, 67 children had a clinically significant hip displacement, defined as migration percentage ≥40%. Univariable regression analysis defined these risk factors: gross motor function classification system level V, spastic bilateral cerebral palsy, initial migration percentage, yearly rate of migration percentage progression, and initial acetabular index. When these variables were analyzed with multivariable regression in 107 patients with initial migration percentage <50% and follow-up ≥1.0 year, the independent risk factors were initial migration percentage (p = 0.003) and yearly rate of migration percentage progression (p < 0.001). Conclusion: The parameters that need to be assessed in hip surveillance in children below 5 years of age are initial migration percentage and rate of migration percentage progression. Acetabular index and femoral head-shaft angle might be useful later for decision-making regarding choice of treatment. Level of evidence: Level II, development of diagnostic criteria.

Recurrent pain in adolescents with cerebral palsy: a longitudinal population-based study.

AIM: To investigate the pain characteristics, pain interference with activities of daily living, and use of analgesics in adolescents with cerebral palsy (CP) and compare the results with previous findings. METHOD: Sixty-seven adolescents (median age 14y 4mo, range 12y 2mo-17y, 28 females, 39 males) classified in Gross Motor Function Classification System (GMFCS) levels III to V, who participated in a CP surveillance programme, were assessed on pain measures twice, 5 years apart. Primary caregivers marked recurrent pain sites and graded pain interference with activities of daily living and sleep. Information on pain severity was obtained through two questions from the Child Health Questionnaire (CHQ) and were transformed into a pain score scaled from 0 to 100, where 100 represented no pain. The use of short-acting analgesics was recorded. RESULTS: Over 5 years, the prevalence of recurrent pain, number of pain sites, pain intensity, and pain frequency all increased significantly. The most frequent pain sites were the hip/thigh in GMFCS level V and knee in GMFCS level III. The median CHQ pain score decreased from 60 to 40 (p<0.001). Pain interference with activities of daily living increased (p=0.011) but not for sleep. Twenty-eight of 54 participants with moderate or severe pain (CHQ pain score ≤60) received no short-acting analgesics. INTERPRETATION: In adolescents with CP, pain increased over 5 years despite follow-up in a surveillance programme. For enhanced management of pain, we propose that an algorithm on pain should be included in surveillance programmes.

The modified Stulberg classification is a strong predictor of the radiological outcome 20 years after the diagnosis of Perthes' disease.

AIMS: The aim of this study was to assess the prognostic value of the modified three-group Stulberg classification, which is based on the sphericity of the femoral head, in patients with Perthes' disease. METHODS: A total of 88 patients were followed from the time of diagnosis until a mean follow-up of 21 years. Anteroposterior pelvic and frog-leg lateral radiographs were obtained at diagnosis and at follow-up of one, five, and 21 years. At the five- and 21-year follow-up, the femoral heads were classified using a modified three-group Stulberg classification (round, ovoid, or flat femoral head). Further radiological endpoints at long-term follow-up were osteoarthritis (OA) of the hip and the requirement for total hip arthroplasty (THA). RESULTS: There were 71 males (81%) and 17 females. A total of 13 patients had bilateral Perthes' disease; thus 101 hips were analyzed. At five-year follow-up, 37 hips were round, 38 ovoid, and 26 flat. At that time, 66 hips (65%) were healed and 91 (90%) were skeletally immature. At long-term follow-up, when the mean age of the patients was 28 years (24 to 34), 20 hips had an unsatisfactory outcome (seven had OA and 13 had required THA). There was a strongly significant association between the modified Stulberg classification applied atfive-year follow-up and an unsatisfactory outcome at long-term follow-up (p < 0.001). Between the five- and 21-year follow-up, 67 hips (76%) stayed in their respective modified Stulberg group, indicating a strongly significant association between the Stulberg classifications at these follow-ups (p < 0.001). CONCLUSION: The modified Stulberg classification is a strong predictor of long-term radiological outcome in patients with Perthes' disease. It can be applied at the healing stage, which is usually reached five years after the diagnosis is made and before skeletal maturity. Cite this article: Bone Joint J 2021;103-B(12):1815-1820.

Slipped capital femoral epiphysis. / Epifysiolyse av lårbenshodet.

Slipped capital femoral epiphysis is a paediatric hip disorder that affects around 30 children in Norway each year. The symptoms are a limping gait and pain in the hip or knee. The condition is diagnosed by normal x-ray and treatment is surgical. It is essential to make the diagnosis as quickly as possible, and children with persistent hip symptoms should be rapidly examined by means of a hip x-ray.

The Femoral Head-Shaft Angle Is Not a Predictor of Hip Displacement in Children Under 5 Years With Cerebral Palsy: A Population-based Study of Children at GMFCS Levels III-V.

BACKGROUND: The aim of this study was to evaluate whether the femoral head-shaft angle (HSA) is a predictor of hip displacement in children with cerebral palsy (CP). METHODS: The patients were recruited from a population-based hip surveillance program. Inclusion criteria were age under 5 years, bilateral CP, Gross Motor Function Classification System (GMFCS) levels III-V, and migration percentage (MP) of both hips <40% at the primary radiograph. With these criteria, 101 children (61 boys) were included. GMFCS was level III in 26 patients, level IV in 23, and level V in 52. An anteroposterior radiograph of the pelvis was taken at diagnosis and at the last follow-up. Only the worst hip of each patient (the hip with the largest MP) was used for the analyses. RESULTS: The mean age at the primary radiograph was 2.4 years (range, 0.8 to 4.9 y). The mean primary HSA was 171.0 degrees (range, 152 to 190 degrees). The mean follow-up time was 4.3 years (range, 0.9 to 11.8 y). The mean MP at the primary radiograph was 17.5% (range, 0% to 39%) and at the last follow-up 41.9% (range, 0% to 100%). At that point, MP was <40% in 54 hips and ≥40% in 47 hips. There was no significant difference in primary HSA between patients with final MP<40% and those with final MP≥40% (170.8 and 171.3 degrees, respectively; P=0.761). At the last follow-up, the mean HSA was significantly larger in hips with final MP≥40% than in hips with final MP<40% (171.1 vs. 167.4 degrees; P=0.029). CONCLUSIONS: There was a markedly increased valgus position of the proximal femur in nonambulatory children with CP. However, the primary HSA in children below 5 years of age was not a predictor of later hip displacement, defined as MP≥40%. CLINICAL RELEVANCE: Measurement of HSA is not necessary in routine hip surveillance in children below 5 years. LEVEL OF EVIDENCE: Level I-investigating a diagnostic test.

Compensation claims in pediatric orthopedics in Norway between 2012 and 2018: a nationwide study of 487 patients.

Background and purpose - In Norway all compensation claims based on healthcare services are handled by a government agency (NPE, Norsk Pasientskade Erstatning). We provide an epidemiological overview of claims within pediatric orthopedics in Norway, and identify the most common reasons for claims and compensations.Patients and methods - All compensation claims handled by NPE from 2012 to 2018 within pediatric orthopedics (age 0 to 17 years) were reviewed. Data were analyzed with regard to patient demographics, diagnoses, type of injury, type of treatment, reasons for granted compensation, and total payouts.Results - 487 compensation claims (259 girls, 228 boys) within orthopedic surgery in patients younger than 18 years at time of treatment were identified. Mean age was 12 years (0-17). 150 out of 487 claims (31%) resulted in compensation, including 79 compensations for inadequate treatment, 58 for inadequate diagnostics, 12 for infections, and 1 based on the exceptional rule. Total payouts were US$8.45 million. The most common primary diagnoses were: upper extremity injuries (26%), lower extremity injuries (24%), congenital malformations and deformities (12%), spine deformities (11%), disorders affecting peripheral joints (9%), chondropathies (6%), and others (12%).Interpretation - Most claims were submitted and granted for mismanagement of fractures in the upper and lower extremity, and mismanagement of congenital malformations and disorders of peripheral joints. Knowledge of the details of malpractice claims should be implemented in educational programs and assist pediatric orthopedic surgeons to develop guidelines in order to improve patient safety and quality of care.

Hip pain in adolescents with cerebral palsy: a population-based longitudinal study.

AIM: To investigate the prevalence, characteristics, and risk factors of hip pain in adolescents with cerebral palsy (CP) and compare the findings with those of the same individuals 5 years earlier. METHOD: Sixty-seven adolescents (28 females, 39 males; mean age 14y 7mo; SD 1y 5mo; range 12-17y) with bilateral CP, in Gross Motor Function Classification System (GMFCS) levels III to V enrolled in a CP surveillance programme were assessed for hip pain. Their caregivers responded to the questions on the intensity and frequency of hip pain from the Child Health Questionnaire (CHQ) (transformed to CHQ hip pain score; 100 indicates no pain). Interference of hip pain with daily activities and sleep was recorded on numeric rating scales. Hip displacement was measured radiographically by the migration percentage. RESULTS: Twenty-eight participants had 44 painful hips. Their mean CHQ hip pain score was 40 (SD 21.4; range 10-80). Independent risk factors for hip pain, low CHQ hip pain score, and interference with sleep were severe hip subluxation (migration percentage 50-89%) and GMFCS level V. A migration percentage of 50% to 89% was the only independent risk factor for interference with daily activities. Over 5 years, the number of participants with hip pain increased from 18 to 28, while the mean migration percentage of the most displaced hip was unchanged. INTERPRETATION: Our CP hip surveillance programme did not protect the participants against increasing prevalence of hip pain during adolescence. We suggest that surveillance programmes for CP should include guidelines on the characteristics and management of hip pain. WHAT THIS PAPER ADDS: Hip pain prevalence increased in adolescents over a 5-year period in a cerebral palsy surveillance programme. Risk factors for hip pain were Gross Motor Function Classification System level V and severe hip subluxation.

Hip disorders in children and adolescents ­ assessment and treatment of sequelae. / Hoftelidelser hos barn og unge ­ utredning og behandling av senfølger.

The consequences of hip disorders and hip injuries in children and adolescents may require surgical intervention. Joint-preserving procedures performed between the ages of 12 and 21 years often give good long-term results and may postpone the need for prostheses. In patients aged less than 21 years, more than 90 % of modern hip prostheses implanted in the last two decades are intact after ten years.

Management of late-detected DDH in children under three years of age: 49 children with follow-up to skeletal maturity.

AIMS: When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity. METHODS: From 1996 to 2005, 49 children (52 hips) were treated for late-detected DDH. Their mean age was 13.3 months (3 to 33) at reduction. Prereduction skin traction was used for a mean of 11 days (0 to 27). Gentle closed reduction under general anaesthesia was attempted in all the hips. Concurrent pelvic osteotomy was not performed. The hips were evaluated at one, three and five years after reduction, at age eight to ten years, and at skeletal maturity. Mean age at the last follow-up was 15.7 years (13 to 21). RESULTS: Stable closed reduction was obtained in 36 hips (69%). Open reduction was more often necessary in patients ≥ 18 months of age at reduction (50%) compared with those under 18 months (24%). Residual hip dysplasia/subluxation occurred in 12 hips and was significantly associated with avascular necrosis (AVN) and with high acetabular index and low femoral head coverage the first years after reduction. Further surgery, mostly pelvic and femoral osteotomies to correct subluxation, was performed in eight hips (15%). The radiological outcome at skeletal maturity was satisfactory (Severin grades 1 or 2) in 43 hips (83%). CONCLUSIONS: Gentle closed reduction can be attempted in children up to three years of age, but is likely to be less successful in children aged over 18 months. There is a marked trend to spontaneous improvement of the acetabulum after reduction, even in patients aged over 18 months and therefore simultaneous pelvic osteotomy is not always necessary.

Prognostic value of severity of dislocation in late-detected developmental dysplasia of the hip.

PURPOSE: The aims of this study were to evaluate the reliability of three classifications of severity of dislocation in late-detected developmental dysplasia of the hip (DDH), especially to assess whether they are predictive of long-term outcomes. METHODS: Two groups of patients were analyzed. Group 1 (57 patients, 69 hips) underwent closed reduction between 1958 and 1962. Mean age at reduction was 20.3 months (4 to 65). Group 2 (50 patients, 54 hips) treated between 1996 and 2005, was used for analysis of the association between severity of dislocation and treatment (open or closed reduction). The primary radiographs were graded according to the Tönnis classification, the classification of the International Hip Dysplasia Institute and a new method based on the position of the most lateral point of the proximal femoral metaphysis (lateral metaphysis height classification, LMH). The outcome at a mean age of 51.2 years (55 to 60) was graded according to the occurrence of osteoarthritis (OA) and total hip arthroplasty (THA). RESULTS: There were significant associations between the classifications, and the intra- and interobserver agreements were high. More severe grades of DDH were significantly associated with age ≥ 18 months and with open reduction. None of the classifications were significantly associated with long-term OA. The LMH method was significantly associated with the need for THA, whereas the other classifications were not. CONCLUSION: All the classifications were reliable in grading severity of DDH. The LMH method seems preferable in clinical practice because the main landmarks were easy to define and because it had long-term prognostic value. LEVEL OF EVIDENCE: III.

Femoral and pelvic osteotomies for severe hip displacement in nonambulatory children with cerebral palsy: a prospective population-based study of 31 patients with 7 years' follow-up.

Background and purpose - There is no consensus regarding the optimal treatment of hip displacement in children with cerebral palsy (CP). This prospective study assessed the outcome of femoral and pelvic osteotomies for severe hip displacement in nonambulatory children and analyzed prognostic factors for outcome.Patients and methods - 31 nonambulatory children (20 boys), recruited from a population-based screening program, consecutively underwent unilateral (23) or bilateral (8) osteotomies and bilateral soft-tissue releases at a mean age of 6.1 years (2.2-9.9). The procedures were femoral varus osteotomy alone (20 hips) and combined Dega-type pelvic osteotomy and femoral osteotomy (19 hips). Final outcome was termed good if the patient had not undergone further bony surgery and migration percentage (MP) was < 50%. The mean follow-up time was 7.1 years (3.8-11).Results - The mean preoperative MP was 69% (36-100). The outcome was good in 22 patients (29 hips) and poor in 9 patients (10 hips). Mean time to failure was 3.6 years (1.0-6.0). GMFCS level V and high MP 1-year postoperatively were statistically significant risk factors for poor final outcome. There was a higher rate of good outcome after combined osteotomies compared with isolated femoral osteotomy, but the difference was not statistically significant (p = 0.2).Interpretation - Better primary correction was obtained after combined femoral and pelvic osteotomies than after isolated femoral osteotomy, indicating that combined osteotomies are the preferred method in hips with the most severe degrees of displacement. Prophylactic femoral osteotomy of the contralateral non-subluxated hip is hardly indicated.