Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

Phillips, Lee; Hesketh, Kim; Schaeffer, Emily K.; Andrade, Janice; Farr, Jennifer; Mulpuri, Kishore

doi:10.1302/1863-2548.11.170078

Cited by 11 publications

(23 citation statements)

References 46 publications

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“…However, they were unable to identify any associations between potential risk factors, such as age, preoperative Reimer's MP, or length of follow-up. They noted, however, that this could be due to the poor quality of the included studies and the general lack of demographic data [12]. Two included studies in the Hesketh et al review provided conflicting results.…”

Section: Discussionmentioning

confidence: 99%

“…The risk of AVN after hip procedures for the treatment of developmental dysplasia of the hip is well studied in the literature with little research investigating procedures in children with CP. The true incidence after hip reconstruction in CP patients is difficult to ascertain as the rate reported in the literature varies greatly, between 0 and 69% [12,16]. The subjective nature of radiographic interpretation undoubtedly plays a large role in this variance.…”

Section: Introductionmentioning

confidence: 99%

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Reconstructive hip surgery in children with cerebral palsy: factors influencing risk of femoral head avascular necrosis

Minaie¹,

Smythe²,

Gordon

et al. 2020

Journal of Pediatric Orthopaedics B

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Femoral head avascular necrosis (AVN) is a complication of hip reconstruction in children with cerebral palsy (CP) with uncertain incidence. The purpose of this study was to establish the rate of AVN in children undergoing hip reconstruction and to identify the factors associated with AVN. Medical records and radiographs of patients aged 1-18 with a diagnosis of CP who have undergone hip reconstruction over a 9-year period (2010-2018) with at least 1-year follow-up were reviewed. Age at time of surgery, sex, Gross Motor Function Classification System (GMFCS), procedure(s), preoperative migration percentage (MP), and signs of AVN on anterioposterior pelvis radiographs at routine follow-up visits (3 months, 6 months, and years 1-9, annually) according to the Bucholz-Ogden (BO) and Kalamchi-MacEwen (KM) classification systems were recorded. Univariate analysis was used to test for significance. Three hundred forty-nine hips in 209 patients met our inclusion criteria. Eleven hips (rate; 3%), in 11 patients, developed AVN. Classification of AVN was found to consist of: class I-4 (36%), class II-1 (9%), class III-[BO: 4 (36%)] [KM: 3 (27%)], and Class IV-[BO: 2 (18%)] [KM: 3 (27%)]. Average follow-up was of 3.5 years. The AVN cohort displayed older age (11.0 ± 2.8 vs. 8.1 ± 3.4; P = 0.005). Open reduction was associated with increased AVN, occurring in 9% of the hips (P = 0.004). No significant association was found between preoperative MP, GMFCS, or acetabular osteotomy. The method of open reduction (anterior vs. medial) was not significantly associated with AVN (P = 0.4471). In this large series, the observed rate of AVN was 3%, associated with open reductions at time of hip reconstruction. If possible, closed reduction would be preferred at time of hip reconstruction in children with CP to lower the risk of AVN. Level of evidence: III.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Reconstructive hip surgery in children with cerebral palsy: factors influencing risk of femoral head avascular necrosis

Minaie¹,

Smythe²,

Gordon

et al. 2020

Journal of Pediatric Orthopaedics B

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“…However, many have failed to explain their methodology for diagnosing AVN 8 , 25 – 27 . Furthermore, whilst those that have, simply adopted different AVN classification systems for DDH 5 – 7 , 9 . There are several classification systems used to assess AVN following the treatment of DDH 1 , 28 , 29 .…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, very few have investigated the relationship between remodelling and AVN, making it difficult to determine its influence on outcomes. Exacerbating this, in a recent study investigating remodelling, the authors simply stated the incidence without outlining any clear methodology of recognition 7 . Rutz et al 14 reported that 6.6% of their hips demonstrated early radiographic progression of a femoral head deformity and subsequent delayed remodelling that took up to 2 years to complete.…”

Section: Discussionmentioning

confidence: 99%

Fate of hips complicated by avascular necrosis of the femoral head following reconstructive surgery in nonambulatory patients with cerebral palsy

Park

et al. 2022

Sci Rep

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The purpose of this study was to evaluate the influence of avascular necrosis of the femoral head (AVN) following hip reconstructions on the future hip development of cerebral palsy (CP) patients. A retrospective study of 394 hips in 205 nonambulatory patients with spastic CP who underwent reconstructive hip surgery was performed. The mean age at surgery was 7.3 ± 2.4 years. The mean follow-up duration was 5.6 ± 2.7 years, and the mean age at the latest follow-up was 12.8 ± 3.4 years. AVN was classified in terms of its severity and location. Femoral head remodelling was assessed by the spherical index and the Mose circle. An unsatisfactory radiological outcome was defined as having a migration percentage of more than 30% at the final follow-up. AVN was observed in 169 (42.9%) hips. Older age at the time of surgery, higher preoperative migration percentage, and open reduction procedures were predictors for the development of AVN. Hips with AVN confined to the lateral epiphysis, and AVN involving the entire epiphysis with preserved height experienced successful remodelling. 27 (65.9%) of the 41 hips with unsatisfactory outcomes experienced AVN. Younger age, higher postoperative migration percentage, and occurrence of AVN were related to unsatisfactory outcomes. The highest incidence of failed remodelling and unsatisfactory outcomes were observed in hips with entire epiphyseal involvement and more than 50% loss of its height. AVN following hip reconstructions is not necessarily associated with poor hip development, however, depending on the severity and location, it is a prognostic factor for unsatisfactory radiological outcomes.

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“…Complications and reoperations are relatively common in acetabuloplasty procedures for patient with CP [ 3 , 21 , 22 , 32 – 34 ]. McNerney et al reported an 8% incidence of AVN in their study [ 3 ], with an even higher incidence in patients with open triradiate cartilage (68.7%) [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Periacetabular osteotomy with or without femoral osteotomy for the treatment of hip subluxation in children and young adults with cerebral palsy

Chen

Shen

et al. 2022

BMC Musculoskelet Disord

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Background This study is aimed to investigate retrospectively the radiographic and clinical outcomes in children and young adults with cerebral palsy (CP) undergoing periacetabular osteotomy (PAO) with or without femoral osteotomy (FO) for hip subluxation. Methods A consecutive cohort of twenty-one patients (23 hips) with symptomatic CP hip subluxation were treated with PAO with or without FO and reviewed retrospectively. Two patients (2 hips) were excluded due to insufficient follow-up and lost to follow-up, respectively. The Reimers migration percentage, lateral center-edge angle (LCEA), Sharp angle, neck-shaft angle (NSA), femoral anteversion (FNA), Gross Motor Function Classification System (GMFCS) and hip pain were assessed. Results Twenty-one hips (19 patients) with CP treated with PAO with or without FO were included. Five hips received PAO. Sixteen hips underwent PAO with FO. Mean age at surgery was 19 ± 6 and 15 ± 4 years for PAO and PAO plus FO, respectively. Mean follow-up was 44.0 ± 28.3 months for PAO and 41.5 ± 17.2 months for PAO + FO. All hips were painful before surgery and painless at final visits. The GMFCS improved by one level in 10 of 19 patients. There was significant increase in LCEA (p < 0.001) and decrease in the Reimer’s MP (p < 0.001), NSA (p < 0.001) and Tonnis angle(p < 0.001) postoperatively. Resubluxation occurred in 7 hips (30%) due to insufficient correction and loosening of fixation. Nervus cutaneus femoris lateralis was impaired in 4 patients after surgery. There was no avascular necrosis of the femoral head, resubluxation or infection. Conclusion PAO with or without FO can be effective for children and young adults with concomitant hip subluxation and CP.

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Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

Cited by 11 publications

References 46 publications

Reconstructive hip surgery in children with cerebral palsy: factors influencing risk of femoral head avascular necrosis

Reconstructive hip surgery in children with cerebral palsy: factors influencing risk of femoral head avascular necrosis

Fate of hips complicated by avascular necrosis of the femoral head following reconstructive surgery in nonambulatory patients with cerebral palsy

Periacetabular osteotomy with or without femoral osteotomy for the treatment of hip subluxation in children and young adults with cerebral palsy

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