Risk of recurrent dislocation and avascular necrosis after proximal femoral varus osteotomy in children with cerebral palsy

Khalife, Rami; Ghanem, Ismat; Hage, Samer El; Dagher, Fernand; Kharrat, Khalil

doi:10.1097/bpb.0b013e3283320c31

Cited by 37 publications

(52 citation statements)

References 13 publications

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“…10,11,13,18,20,[28][29][30] A recent systematic review 31 on the subject revealed that most authors simply comment on the presence or absence of AVN in their complications, without further detail. Interestingly, the reported rates in our study as well as three others where AVN was the primary outcome measure are among the highest within the literature at 27% to 69%.…”

Section: Discussionmentioning

confidence: 99%

“…[6][7][8][9] Reported complication rates for hip reconstructive surgery in patients with CP have varied dramatically (0% to 81%). 8,[10][11][12][13][14][15][16][17][18] There has been minimal attention paid to the development of avascular necrosis (AVN) as a complication of hip reconstructions. The incidence of AVN reported within the literature is in the range of 0% to 69%.…”

Section: Introductionmentioning

confidence: 99%

“…The incidence of AVN reported within the literature is in the range of 0% to 69%. 10,11,14,15,[17][18][19][20] This variation has made it difficult to quantify and determine the true impact of AVN on children with CP. Idiopathic AVN has been reported to cause pain, limited range of motion (ROM) and an altered gait pattern.…”

Section: Introductionmentioning

confidence: 99%

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Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

2015

Develop Med Child Neuro

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Purpose Progressive hip displacement is one of the most common orthopaedic pathologies in children with cerebral palsy (CP). Reconstructive hip surgery has become the standard treatment of care. Reported avascular necrosis (AVN) rates for hip reconstructive surgery in these patients vary widely in the literature. The purpose of this study is to identify the frequency and associated risk factors of AVN for reconstructive hip procedures.Methods A retrospective analysis was performed of 70 cases of reconstructive hip surgery in 47 children with CP, between 2009 and 2013. All 70 cases involved varus derotation osteotomy (VDRO), with 60% having combined VDRO and pelvic osteotomies (PO), and 21% requiring open reductions. Mean age at time of surgery was 8.82 years and 90% of patients were Gross Motor Function Classification System (GMFCS) 4 and 5. Radiographic dysplasia parameters were analysed at selected intervals, to a minimum of one year post-operatively. Severity of AVN was classified by Kruczynski's method. Bivariate statistical analysis was conducted using Chi-square test and Student's t-test.Results There were 19 (27%) noted cases of AVN, all radiographically identifiable within the first post-operative year. The majority of AVN cases (63%) were mild to moderate in severity. Pre-operative migration percentage (MP) (p = 0.0009) and post-operative change in MP (p = 0.002) were the most significant predictors of AVN. Other risk factors were: GMFCS level (p = 0.031), post-operative change in NSA (p = 0.02) and concomitant adductor tenotomy (0.028). Conclusion AVN was observed in 27% of patients. Severity of displacement correlates directly with AVN risk and we suggest that hip reconstruction, specifically VDRO, be performed early in the 'hip at risk' group to avoid this complication.Cite this article: Phillips L, Hesketh K, Schaeffer EK, Andrade J, Farr J, Mulpuri K. Avascular necrosis in children with cerebral palsy after reconstructive hip surgery. J Child Orthop

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

2015

Develop Med Child Neuro

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“…This branch was subject to operation-related complications, such as non-union, inaccurate correction, avascular necrosis, refracture below the plate, infection, and hematoma, 13,22 which were categorized into 'temporary' and 'permanent' complications. Each complication was branched into 'stable' and 'unstable' hips.…”

Section: The Concurrent Prophylactic Femoral Varization Osteotomy Branchmentioning

confidence: 99%

“…FVO for an unstable hip in CP ranges from 0 to 25%, [22][23][24] and the dislocation rate of a stable hip after a prophylactic FVO was believed to be lower; it was assumed that the baseline value of an unstable hip rate after a FVO for an unstable hip would be 10% 25 and that for a stable hip would be 5% (Table I). This rate was assumed to be the probability that the contralateral stable hip undergoing a prophylactic FVO would become an unstable hip.…”

Section: Probabilitiesmentioning

confidence: 99%

Prophylactic femoral varization osteotomy for contralateral stable hips in non‐ambulant individuals with cerebral palsy undergoing hip surgery: decision analysis

Park

Chung

Kwon

et al. 2012

Develop Med Child Neuro

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FVO Femoral varization osteotomyAIM This study was undertaken to determine the need for concurrent prophylactic femoral varization osteotomy (FVO) of contralateral stable hips at the time of hip reconstructive surgery on unstable hips in non-ambulant individuals with cerebral palsy (Gross Motor Function Classification System levels IV and V).METHOD A decision analysis model was constructed that included (1) the probability of unstable hips during observation of the contralateral stable hips, (2) unstable hip rate (subluxation or dislocation rate) after prophylactic FVO or after delayed reconstructive surgery (including FVO) for unstable hips, and (3) complication rates after concurrent prophylactic FVO or after hip reconstructive surgery. The final outcome score was based on pain utility measures. The probabilities of all cases and the utility score were obtained by literature review. RESULTSThe decision model favoured concurrent prophylactic FVO for the contralateral stable hips over observation (pain utility measure scores 0.814 vs 0.781). In a one-way sensitivity analysis, the decision model favoured concurrent prophylactic FVO when the unstable hip rate of contralateral stable hips during observation was 27% or over. Concurrent prophylactic surgery also demonstrated higher utility scores than observation when the unstable hip rate after FVO was between 0% and 29%.INTERPRETATION The decision analysis model demonstrated that concurrent prophylactic FVO for a contralateral stable hip in individuals with cerebral palsy undergoing hip reconstructive surgery was beneficial from a medical perspective, which was based on current evidence.Studies have reported that a considerable portion of radiographically stable contralateral hips eventually dislocate or subluxate in individuals with cerebral palsy (CP) with a unilateral unstable hip. 1-4 A recent study showed that 44% of severely involved individuals with CP undergoing unilateral femoral varization osteotomy (FVO) required subsequent bony surgical management of the contralateral hip for subluxation or dislocation before reaching skeletal maturity. 5 This high probability of dislocation of the contralateral stable hip during follow-up has generated interest in concurrent prophylactic FVO on the radiographically stable contralateral hip during reconstructive surgery of an unstable hip.Every medical practice must come to terms with the two opposing aspects of risk and benefit represented by optimal treatment and socio-economics. The merits of a procedure include increased life expectancy and improved healthrelated quality of life, and the demerits include complications and costs. Physicians usually weigh up these pros and cons when deciding whether to perform a medical procedure, although such assessments are invariably informal and subjective. These processes necessarily imply that analyses should be performed on the basis of the probabilities of various outcomes.Randomized controlled trials (RCTs) are most commonly used to verify the effectiveness of health-care se...

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Orthopedic Hip Surgery for Patients with Cerebral Palsy

Dodwell

Agarwal

Miller

et al. 2020

Orthopedic Care of Patients With Cerebral Palsy

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Risk of recurrent dislocation and avascular necrosis after proximal femoral varus osteotomy in children with cerebral palsy

Cited by 37 publications

References 13 publications

Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

Prophylactic femoral varization osteotomy for contralateral stable hips in non‐ambulant individuals with cerebral palsy undergoing hip surgery: decision analysis

Orthopedic Hip Surgery for Patients with Cerebral Palsy

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