Does intrathecal baclofen therapy decrease the progression of hip displacement in young patients with cerebral palsy?

AIM: To evaluate the effects of intrathecal baclofen pump (ITBP) therapy on hip dysplasia in young patients with cerebral palsy (CP). METHOD: This was a retrospective cohort series of prospectively collected data. Inclusion criteria were all patients with CP in Gross Motor Function Classification System (GMFCS) levels IV or V who underwent ITBP placement under 8 years old with at least 5 years of follow-up. Thirty-four patients were matched to a control group of 71 patients based on GMFCS level, motor type, medical comorbidities, worst hip migration percentage at ITBP placement, age, and Modified Ashworth scale scores. Patients were followed for at least 5 years or until they had hip reconstructive surgery. The primary outcome was the development of hip displacement as measured by the migration percentage at the latest follow-up or the preoperative migration percentage before hip reconstruction. RESULTS: The migration percentage at last follow-up was not statistically different between groups (ITBP: 36.2%, non-ITBP: 44.4%, p = 0.14). The rates of future preventative, reconstructive, and recurrent hip surgery were not different between groups. INTERPRETATION: The use of ITBP as an early treatment of spasticity did not alter the natural history of progressive hip displacement in non-ambulatory patients with CP and hip displacement is likely multifactorial, not solely due to spasticity.

Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia.

BACKGROUND AND OBJECTIVES: The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery. MATERIALS AND METHODS: This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period. RESULTS: This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]). CONCLUSION: For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.

Effects of Reticulated Hyaluronic Acid Alone or Associated With Whole-Body Vibration in Dogs With Osteoarthritis Due to Hip Dysplasia.

This study aimed to evaluate the effects of reticulated hyaluronic acid (HA) alone or associated with whole-body vibration (WBV) in dogs with osteoarthritis due to hip dysplasia. Fourteen dogs were randomized assigned into 2 groups of 7 animals: Group 1 (G1) - single intra-articular injection of hyaluronic acid; Group 2 (G2) - single intra-articular injection of hyaluronic acid associated with WBV sessions. The affected hip joint received 0.70 mL of reticulated HA guided by ultrasound. Dogs were submitted to a single session of WBV (30 and 50 Hz, for 15 min) every 48 hours for 12 weeks. Dogs were evaluated for morphometric measurements; orthopedic, radiographic and lameness scores of the hip joints; kinetic analysis; and ultrassonographic measurement of the following muscles: middle gluteal, vastus lateralis and biceps femoris. The morphometric measurements, lameness scores, and muscle measurements were conducted at 10 minutes before treatments (TP0), and at days 30 (TP30), 60 (TP60) and 90 (TP90) after treatments. The orthopedic and radiographic scores and kinetic analysis were performed at TP0 and TP90. The scores of lameness showed a statistical decrease in G1 and G2 between time-points. Significant decreases (P = .01) were observed in orthopedic scores in both groups between time-points. The Peak Vertical Force between TP0 and TP90 was significantly higher in G2 (P = .01). Vertical Impulse was null in G1 and positive in G2. Dogs treated with single intra-articular injection of hyaluronic acid alone and associated with WBV had beneficial effects in dogs with osteoarthritis due to hip dysplasia, however the association of viscosupplementation with hyaluronic acid and WBV had an earlier improvement clinical outcome and allowed better kinetic results.

Effect of Botulinum Toxin Injection on the Progression of Hip Dislocation in Patients with Spastic Cerebral Palsy: A Pilot Study.

Hip adductor spasticity is a contributing factor to hip dislocation in patients with cerebral palsy (CP). We hypothesized that botulinum toxin injected into the hip adductor muscles would reduce spasticity and help prevent hip dislocation. Twenty patients with bilateral spastic CP aged 2 to 10 years with gross motor function classification system level IV or V were included. Botulinum toxin was injected into the hip adductor muscles at baseline and at 6-month follow-up. Muscle tone was measured with an eight-channel surface electromyography (EMG) recorder. A hip X-ray was performed, and Reimer's hip migration index (MI) was measured. The Wilcoxon signed-rank test was used to compare the surface EMG values of the hip muscles at baseline and follow-up. The mean root mean square surface EMG value of the hip adductor muscles was significantly reduced at 1, 2, 3, and 7 months after the first injection, up to approximately 53% of the baseline. The 1-year progression of the hip MI was -0.04%. Repeated sessions of botulinum toxin injections at the hip adductor muscles significantly reduced muscle tone and hip displacement. A botulinum toxin injection may be used as an adjunctive treatment in the prevention of hip dislocation.

Is paracetamol responsible for fatal acute liver failure in pediatric patients after hip dysplasia surgery?

OBJECTIVE: It is well known that local complications, such as avascular necrosis and arthrosis can develop after surgery for developmental dysplasia of the hip (DDH). Thus far, systemic complications that may develop in such cases have not been identified in the literature. This study is the first case series to evaluate acute liver failure (ALF) development after DDH surgery in pediatric patients. PATIENTS AND METHODS: Six patients, five female and one male, who underwent DDH surgery were selected for this study. Perioperative fasting time, laboratory values, treatments, histopathological evaluations, and prognoses after ALF in these patients were evaluated retrospectively. RESULTS: All the patients were administered paracetamol and sevoflurane in therapeutic doses. The patients were referred postoperatively to our pediatric emergency department after 5 ± 1.67 days (range = 3-7 days) on average. The average perioperative fasting time was 9.3 ± 0.82 hours (range = 8-10 hours). Due to the very high aminotransferases and use of paracetamol, intravenous N-acetylcysteine was administered alongside supportive treatments to all the patients. After liver transplantation, two of three patients with grade 3 encephalopathy, died in the early postoperative period. Histopathological evaluations of the three patients' explants were compatible with toxic hepatitis due to paracetamol. CONCLUSIONS: Paracetamol is a commonly used analgesic after pediatric surgery. The therapeutic dose of paracetamol remains uncertain in children who have been fasting for a long time and have been exposed to hepatotoxic drugs due to previous surgery. In conclusion, caution should be exercised in the use of paracetamol in children with DDH who will undergo surgery, and careful perioperative clinical and laboratory monitoring for ALF is essential.

Efectividad de los antiinflamatorios no esteroideos en el tratamiento del dolor de rodilla y de cadera / Efficacy of anti-inflammatory non-steroidal drugs in the treatment of knee and hip pain

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Functional status and amount of hip displacement independently affect acetabular dysplasia in cerebral palsy.

AIM: Acetabular dysplasia is the one of main causes of hip displacement in patients with cerebral palsy (CP). Although several studies have shown a relationship between hip displacement and acetabular dysplasia, relatively few have evaluated the association between quantitative acetabular dysplasia and related factors, such as Gross Motor Function Classification System (GMFCS) level. METHOD: We performed a morphometric analysis of the acetabulum in patients with CP using multiplanar reformation of computed tomography data. The three directional acetabular indices (anterosuperior, superolateral, and posterosuperior) were used to evaluate acetabular dysplasia. Consequently, linear mixed-effects models were used to adjust for related factors such as age, sex, GMFCS level, and migration percentage. RESULTS: A total of 176 patients (mean age 9y 5mo, range 2y 4mo-19y 6mo; 104 males, 72 females) with CP and 55 typically developing individuals (mean age 13y 6mo, range 2y 5mo-19y 10mo; 37 males, 18 females) in a comparison group were enrolled in this study. Statistical modelling showed that all three directional acetabular indices independently increased with GMFCS level (p<0.001) and migration percentage (p<0.001). INTERPRETATION: Acetabular dysplasia was independently affected by both the amount of hip displacement and the GMFCS level. Thus, physicians should consider not only the migration percentage but also three-dimensional evaluation in patients at high GMFCS levels.

Pilot study of ultrasound-guided corticosteroid hip injections by emergency physicians.

INTRODUCTION: Our objective was to assess the efficacy of ultrasound-guided hip injections performed by emergency physicians (EPs) for the treatment of chronic hip pain in an outpatient clinic setting. METHODS: Patients were identified on a referral basis from the orthopedic chronic pain clinic. The patient population was either identified as having osteoarthritis of the hip, osteonecrosis of varying etiologies, post-traumatic osteoarthritis of the hip, or other non-infectious causes of chronic hip pain. Patients had an ultrasound-guided hip injection of 4 ml of 0.5% bupivacaine and 1 ml of triamcinolone acetate (40 mg/1 ml). Emergency medicine resident physicians under the supervision of an attending EP performed all injections. Pain scores were collected using a Likert pain scale from patients prior to the procedure, and 10 minutes post procedure and at short-term follow-up of one week and one month. The primary outcome was patient-reported pain score on a Likert pain scale at one week. RESULTS: We performed a total of 47 ultrasound-guided intra-articular hip injections on 44 subjects who met inclusion criteria. Three subjects received bilateral injections. Follow-up data were available for 42/47 (89.4%) hip injections at one week and 40/47 (85.1%) at one month. The greatest improvement was at 10 minutes after injection with a mean decrease in Likert pain score from pre-injection baseline of 5.57 (95% CI, 4.76-6.39). For the primary outcome at one week, we found a mean decrease in Likert pain score from pre-injection baseline of 3.85 (95% CI, 2.94-4.75). At one month we found a mean decrease in Likert pain score of 1.8 (95% CI, 1.12-2.53). There were no significant adverse outcomes reported. CONCLUSION: Under the supervision of an attending EP, junior emergency medicine resident physicians can safely and effectively inject hips for chronic pain relief in an outpatient clinical setting using ultrasound guidance.

Proximal femoral resection for the painful dislocated hip in cerebral palsy: does indomethacin prevent heterotopic ossification?

BACKGROUND: Painful hip displacement is difficult to treat in severe cerebral palsy. Proximal femoral resection (PFR) is an excellent procedure for pain relief but has a high rate of heterotopic ossification (HO). Indomethacin is the gold standard therapy used for prevention in hip and acetabular surgery. There is no evidence of its benefit in this complex patient group. METHODS: Forty-one consecutive patients with severe cerebral palsy underwent 52 primary PFRs for severe pain in 2 pediatric orthopaedic units in London, UK. Twenty-one patients received a prophylactic postoperative dose of indomethacin for the prevention of HO. Notes and radiographs were reviewed independently by 2 orthopaedic trainees. RESULTS: The mean age of patients was 14.3 and 14.8 years in the group administered with and administered without indomethacin, respectively, and mean follow-up was 4.5 and 4.3 years. Five patients in each group developed HO. One patient in the indomethacin group was offered reexcision for HO but declined. Two in the nonindomethacin group were offered reexcision and one accepted and made a good recovery. There was no difference in pain relief between the groups and no correlation between the degree of HO and level of postoperative pain. CONCLUSIONS: This study does not support the use of prophylactic indomethacin in severe cerebral palsy patients undergoing PFR. We also question the importance of HO in the outcome of this procedure. LEVEL OF EVIDENCE: Level III.

The impact of botulinum toxin A and abduction bracing on long-term hip development in children with cerebral palsy.

AIM: To study the long-term impact of 3 years of botulinum toxin A (BoNT-A) injections and abduction bracing on hip development in children with bilateral spastic cerebral palsy (CP). We wanted to know if early treatment improved hip development and reduced the need for surgery. METHOD: A long-term review of hip morphology and surgery requirements in children who participated in a multicentre, randomized controlled trial. The trial investigated short-term effects of BoNT-A injections combined with an abduction brace, compared with usual care, on hip displacement in children with bilateral spastic CP. RESULTS: Forty-six children with bilateral spastic CP (31 males, 15 females; 10 with diplegia, 36 with quadriplegia; mean age at enrolment of 3 y 2 mo, mean age at most recent clinical review 13 y 11 mo [range 10 y 6 mo-16 y 8 mo]; three children in Gross Motor Function Classification System level II, 11 in level III, 20 in level IV, 12 in level V) were followed for a mean of 10 years 10 months from recruitment to the trial. Mean migration percentage was 15.9% in the BoNT-A group and 15.2% in the comparison group (t = 0.26, p = 0.79). Eighty-nine percent of hips in the treatment group and 91% hips in the comparison group had satisfactory development, using a valid scale (Mann-Whitney U test = 867.50, z = -1.59, p = 0.11). Forty children had preventive surgery (21 treatment group, 19 comparison group) and 18 children had reconstructive surgery (10 treatment, 8 comparison). INTERPRETATION: In children with bilateral spastic CP, early treatment with BoNT-A and hip abduction bracing does not reduce the need for surgery or improve hip development at skeletal maturity.

Papel de la toxina botulínica tipo A en la prevención de la luxación de cadera en niños con parálisis cerebral / Role of botulinum toxic in the prevention of hip dislocation in children with cerebral palsy

Objetivo. Determinar el efecto del tratamiento con TXB-A en la capacidad de abducción de las caderas, el tono de la musculatura aductora y la prevención de la progresión de la subluxación de las caderas en niños con parálisis cerebral. Material y método. Estudio prospectivo preliminar de 10 pacientes (20 caderas) tratados con toxina botulínica tipo A (Botox®) a nivel de aductores. Se valoró la movilidad articular en abducción y flexión de cadera y la espasticidad al inicio, al mes, a los 3 y a los 6 meses, así como el índice de migración de Reimer, que se valoró al inicio y a los 3 meses del tratamiento. Resultados. De los 10 pacientes, 4 eran niñas y 6, niños; 8 tenían diparesia espástica y 2, tetraparesia espástica. Su media de edad era 5,5 (3-9) años. Se objetivaron cambios tras la intervención en los valores de flexión de cadera y tono muscular; igualmente se constató una disminución del índice de migración de Reimer. Conclusiones. El tratamiento con toxina botulínica de los aductores de caderas que presentan espasticidad y subluxación de cadera inferior al 40% es efectivo en la disminución del tono muscular y frenar la progresión de la subluxación de la cadera(AU)

Aims. To determine the effect of treatment with botulinum toxin type-A (BoNT A) on hip abduction capacity, adductor muscle tone and prevention of hip dislocation in children with cerebral palsy (CP). Methods. Preliminary prospective study of 10 patients (20 hips) treated with BoNT A (Botox®). Articular abduction mobility, hip flexion and spasticity at pre-treatment and 1, 3 and 6 months post-treatment were assessed. Reimer Migration Index (RMI) was also evaluated at pre-treatment and 3 months post-treatment. Results. Six males and four females were included in the study. Eight children had spastic diparesis and two had spastic tetraparesis. Mean age was 5.5±2.27 (range 2-9) years. Improvements were detected following BoNT A treatment in hip flexion and muscle tone and a reduction in RMI was observed. Conclusions. BoNT A treatment is effective in reducing muscle tone and detaining the progression of hip dislocation(AU)

Hip dislocations in chronic osteomyelitis.

We present two cases of spontaneous dislocation of the hip joint due to chronic osteomyelitis of the upper femur. Spontaneous hip dislocations occur in certain pathological conditions such as poliomyelitis (Ingram, 1980), cerebral palsy (Howard et al., 1985), osteomyelitis and neurofibromatosis.