Blood Loss and Related Laboratory Changes after Single-Event Multilevel Surgery and Hip Reconstructive Surgery in Patients with Cerebral Palsy

BackgroudSingle-event multilevel surgery (SEMLS) and hip reconstructive surgery (HRS) often cause intraoperative bleeding, consequently increasing the probability of transfusion and postoperative laboratory changes. Therefore, it is important to assess risk factors to predict the amount of blood loss. This study aimed to evaluate blood loss, its influencing factors, and the related laboratory changes during SEMLS and HRS in patients with cerebral palsy (CP).MethodsWe retrospectively examined consecutive CP patients who underwent SEMLS and HRS. Surrogate markers of blood loss, including preoperative and postoperative hemoglobin (Hb), hematocrit, and changes in Hb concentration, were assessed. Albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatine levels were also analyzed for related laboratory changes. Risk factors were analyzed using multiple regression and logistic regression models.ResultsThe overall cohort comprised 1,188 patients. Of them, 1,007 and 181 underwent SEMLS and HRS, respectively. Furthermore, 72 of 181 patients underwent a concomitant Dega osteotomy. The regression model showed that low preoperative Hb concentration (p < 0.001), high albumin level (p = 0.007), low body mass index (BMI) (p = 0.002), and bilateral HRS (p < 0.001) were significant risk factors of postoperative anemia. Valproate medication was associated with Hb drop, and the risk factors for Hb level < 8 g/dL on postoperative day 2 were bilateral HRS and Dega osteotomy in the HRS subgroup. In total, 21.6% had elevated AST levels on postoperative day 2, and bilateral HRS (p < 0.001), Gross Motor Function Classification System (GMFCS) level V (p = 0.041), Dega osteotomy (p < 0.001), and high preoperative AST level (p < 0.001) increased the risk of AST elevation.ConclusionsWe have summarized the estimated blood loss and related laboratory changes after SEMLS and HRS in patients with CP and identified the risk factors. Clinical guidelines should be accordingly developed to include assessment of these risk factors and their impact in the outcomes of CP patients undergoing SEMLS and HRS.     

Hip Surveillance for Children with Cerebral Palsy: A Survey of Orthopaedic Surgeons in India

BackgroundThe purpose of this study was to assess Indian orthopaedic surgeons’ current practices and beliefs regarding hip surveillance for children with cerebral palsy (CP), to determine potential support for developing hip surveillance guidelines, and to identify knowledge gaps and key obstacles to guideline implementation in India.MethodsAn anonymous, cross-sectional online survey was sent to approximately 350 Paediatric Orthopaedic Society of India (POSI) members who were queried on their practices and beliefs about hip surveillance for children with CP, as well as perceived challenges and requirements for the successful implementation of hip surveillance guidelines in the Indian context.ResultsOut of 107 responses obtained from POSI members, almost all (96.2%) agreed that hip displacement requires standardized monitoring, using surveillance and surgery to prevent hip dislocation. Approximately half (51.5%) of respondents reported using existing hip surveillance guidelines, with most (41.2%) using the Australian guidelines. Almost all (97%) surgeons indicated that hip surveillance guidelines in India are needed, with 100% expressing interest in following guidelines specific to India. Respondents most frequently indicated late referrals to orthopaedics (81.2%), loss of patients to follow-up (78.2%), and lack of resources (43.6%) as challenges to successful hip surveillance in India. Perceived requirements for implementation included developing Indian-specific guidelines (83.2%) as well as educating surgeons (56.4%), physiotherapists/pediatricians (90.1%), and families (82.2%).ConclusionOrthopaedic surgeons practicing in India understand the importance of preventing hip dislocations in children with CP through hip surveillance and timely surgical intervention. The results demonstrated strong support for the development of hip surveillance guidelines designed specifically for the Indian healthcare system.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00432-3.     

Contemporary Ceramic Total Hip Arthroplasty in Patients with Cerebral Palsy: Does It Work?

BackgroundAdult patients with cerebral palsy (CP), who have advanced degenerative arthritis of the hip, have been treated with resection arthroplasty and arthrodesis. Although total hip arthroplasty (THA) has also been used as one of the alternative options, there are few studies on contemporary bearings used in THA. Therefore, we evaluated the results of the contemporary ceramic-on-ceramic THA in adult patients with CP.MethodsFrom January 2005 to December 2007, five adult CP patients (5 hips) underwent THA using contemporary ceramic-on-ceramic bearings. All patients were able to stand or ambulate with intermittent use of assistive devices at home. We retrospectively reviewed the series to determine the results of THA in terms of pain relief, improved function, and durability of prosthesis.ResultsThere were 3 men and 2 women with a mean age of 35.9 years. All patients had pain relief without decline in mobility postoperatively. One hip was dislocated, which was treated successfully with closed reduction and an abduction brace for 2 months. There was no ceramic fracture, loosening, or osteolysis during the mean follow-up of 6.8 years (range, 5.8 to 8.3 years).ConclusionsCementless THA using contemporary ceramic-on-ceramic bearings is a useful option for the treatment of advanced degenerative arthritis of the hip in ambulatory adults with CP.     

Hip Displacement in Cerebral Palsy: The Role of Surveillance

IntroductionHip displacement is common in cerebral palsy (CP) and is related to the severity of neurological and functional impairment. It is a silent, but progressive disease, and can result in significant morbidity and decreased quality of life, if left untreated. The pathophysiology of hip displacement in CP is a combination of hip flexor-adductor muscle spasticity, abductor muscle weakness, and delayed weight-bearing, resulting in proximal femoral deformities and progressive acetabular dysplasia. Due to a lack of symptoms in the early stages of hip displacement, the diagnosis is easily missed. Awareness of this condition and regular surveillance by clinical examination and serial radiographs of the hips are the key to early diagnosis and treatment.Hip surveillance programmesSeveral population-based studies from around the world have demonstrated that universal hip surveillance in children with CP allows early detection of hip displacement and appropriate early intervention, with a resultant decrease in painful dislocations. Global hip surveillance models are based upon the patients’ age, functional level determined by the Gross Motor Function Classification system (GMFCS), gait classification, standardized clinical exam, and radiographic indices such as the migration percentage (MP), as critical indicators of progressive hip displacement.ConclusionDespite 25 years of evidence showing the efficacy of established hip surveillance programmes, there is poor awareness among healthcare professionals in India about the importance of regular hip surveillance in children with CP. There is a need for professional organizations to develop evidence-based guidelines for hip surveillance which are relevant to the Indian context.     

Hip displacement in relation to age and gross motor function in children with cerebral palsy

Purpose

Hip dislocation in cerebral palsy (CP) is a serious complication. By radiographic screening and prophylactic surgery of children at risk most dislocations can be prevented. CPUP, the Swedish CP registry and follow-up program, includes annual radiographic examinations of children at Gross Motor Function Classification System (GMFCS) levels III–V. Data from CPUP were analysed to assess the risk of hip displacement in relation to GMFCS levels and age.

Methods

All children at GMFCS levels III–V (N = 353) whose first radiographic screening occurred before 3 years of age were followed between the ages 2–7 years. Migration percentages (MPs) were recorded annually (1,664 pelvic radiographs) and analysed using discrete time survival analysis.

Results

The risk of hip displacement between 2 years and 7 years of age was significantly (p < 0.05) higher for children at GMFCS level V during the entire study period. The risk was highest at 2–3 years of age and decreased significantly (p < 0.001) with each year of age (OR = 0.71, 95 % CI 0.60–0.83). The cumulative risk at age 7 years for those at GMFCS V for MP ≥ 40 % was 47 % (95 % CI 37–58). The corresponding risk at GMFCS IV was 24 % (16–34) and at GMFCS III 23 % (12–42).

Conclusions

Children at GMFCS V have a significantly higher risk of hip displacement compared with children at GMFCS III–IV. The risk is highest at 2–3 years of age. The results support a surveillance program including radiographic hip examinations as soon as the diagnosis of severe CP is suspected.     

选择性脊神经后根切断结合矫形手术治疗脑瘫所致肢体痉挛

作者采用选择性脊神经后根切断术(SPR)结合矫形术治疗39例脑瘫所致肢体痉挛患者,通过临床实践和6月～4年随访观察,发现SPR能够有效地解除肌肉痉挛,纠正动力性畸形,不易复发,但对于较明显的固定挛缩畸形,必须同时配合Ⅱ期矫形手术,方能达到预期效果。强调术后肌力强化训练的必要性。对于手术患者年龄选择、手术适应证、手术操作技术、神经根切断比例及疗效判断标准提出了自己的看法。     

综合康复治疗对小儿脑瘫患者的疗效观察

目的探讨综合康复治疗对小儿脑瘫患者的治疗效果。方法 40例脑瘫患儿为对照组,使用运动治疗;40例脑瘫患儿为治疗组,采用综合康复治疗,比较两组患儿的康复效果。结果治疗组总有效率为91,对照组总有效率为81;两组患儿治疗后GMFM评分与治疗前相比均有提高（P〈0.05）;其中治疗后评分,治疗组高于对照组（P〈0.05）。结论对小儿脑瘫患者综合康复治疗较单一运动法治疗有更好疗效。     

The Impact of Spinal Fusion on Hip Displacement in Cerebral Palsy

Background and study aimsThe aims of this study were to determine the risk of progressive hip subluxation in children with CP after spinal fusion for scoliosis and how frequent the hips follow-up should be scheduled.Patients and methodsPelvis radiography [migration index (MI) and pelvic obliquity (PO)] of Gross Motor Function Classification System (GMFCS) levels IV and V children with CP who received spinal fusion and pelvic fixation were reviewed retrospectively. This population was categorized into three groups based on the MI at spinal fusion: G1 = 0–29%; G2 = 30–59%; and G3 = 60–100%.ResultsFifty children (age 7.5–15.0 years) and categorized into 3 groups (G1 = 19, G2 = 23, G3 = 8; 100 hips in total). Preoperative and last follow-up MI were 22 ± 7% and 30 ± 20% (G1), 41 ± 9% and 43 ± 22% (G2), 92 ± 15% and 97 ± 10% (G3). The MIs at spinal fusion between groups were statistically different (p < 0.001). In G1, the mean MI progression was 5% and 25% at 12 months and 62 months, respectively. In G2, the mean MI progression was 9% and 25% at 12 months and 32 months, respectively. The progression more than 10% occurred within 2 years in G1 and within 1 year in G2. There was no difference between groups based on preoperative degree of PO (p = 0.653) and correction rate in PO (p = 0.421).ConclusionsIn GMFCS IV and V children with the highest risk for progression occurred with increasing preoperative MI, especially over 50%. Hips should be monitored continuously after spinal fusion until hip stability is documented.     

Radiographic threshold values for hip screening in cerebral palsy

Purpose To analyse the consequences of using different radiographic measurements and different threshold values for hip screening in children with cerebral palsy (CP). Methods In a total sample of children with CP a standardised radiological follow-up of the hips was carried out as a part of a hip prevention programme. Acetabular index (AI) and migration percentage (MP) were measured on all radiographs. In this study, 1,067 radiographs of 272 children born 1992–1998 were analysed. Results Lateral displacement of the femoral head was common without acetabular dysplasia, and acetabular dysplasia occurred at a later stage than femoral head lateralisation. Hip dysplasia without lateral displacement of the femoral head was rare. In 16 of the 56 hips (29%) with AI ≥ 27° and in 23 of the 71 (32%) hips with MP ≥ 33% the values decreased below the threshold value without operative treatment. In hips with AI ≥ 30° only 2 of 31 hips (6%) and in hips with MP ≥ 40% only 5 of 44 hips (11%) decreased below the threshold values without operative treatment. Conclusions Radiographic follow-up with only measurement of the MP seems sufficient in screening for dislocation in children with CP. MP ≥ 33% is recommended as threshold for reaction or intensified observation. In children with MP ≥ 40%, the lateral displacement increased over time in most hips, thus indicating the need for operative intervention. In children with MP 33–40%, treatment should be based on other clinical signs and the progression of MP over time.