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Hip Management in Cerebral Palsy for Orthopaedic Exams
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Hip Management in Cerebral Palsy for Orthopaedic Exams
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Segment:0 .
Hello, everybody. Thank you for joining us. Another FRCS mentor group presentation, we are going to be given a talk by Nikki Walsh, who works in royal Lancaster infirmary. She's going to present the topic on surveillance in the cerebral hip surveillance and cerebral palsy.
Just a reminder the mentors are going to do vyver sessions afterwards. These this will not be recorded for the sake of privacy for the participants. We have a good showing from the mentors, including Nicky Walsh, Abdullah and Anwar kiani and Kashif Mahmood, so we look forward to a very lively vibha session at the end. Hi, Nicky, thank you very much.
If you don't mind at the beginning. Sure thank you for introducing me today. I'm going to talk about hip surveillance in children with cerebral palsy. The topic I'm about to do, it's the work. The views are all my own and I've put a link to some references as well. So these are the references that I used.
The first one is a good review article by JS from last year and the cerebral palsy integrated pathway for Scotland at the bottom. That's actually quite a good document, which is available online, and it runs through all examinations in cerebral palsy children, which I think would be quite useful for the exam. So it's the definition of cerebral palsy is that it's actually a non-progressive brain lesion.
But the associated musculoskeletal pathology is progressive and typically results in spasticity and contractors of the muscle tendon units. You also get bony torsional deformity due to the abnormal forces, and eventually this gives rise to joint instability. So the point about cerebral palsy hips is that the hip joint itself is often normal at birth, and therefore what happens as the children grow is that they then developed these fractures and deformities.
So if we can intervene at an early stage, we can probably prevent a lot of the hip dislocations. So the goals of the surveillance program are to identify these children's children who are at risk of hip displacement and monitor their development over time and offer early appropriate intervention. So what happens? Well, the first thing is that you get abnormal muscle forces across the hip joint.
You've got increased activity of the abductors, the hip flexors and the hamstrings, which gradually cause the proximal femur to migrate laterally and superiorly. Now, because the acetabulum development is dependent on a located femoral head, you can often get secondary acetabular changes and most typically, it's a saucer shaped deformity in a crane or lateral direction.
And then, as the hip continues to displace, it's then subjected to some abnormal forces and remodeling. So you get an increase of the next shaft angle. You get increased activation and you get flattening of the femoral head and due to pressure from the hip capsule and the abductors as the hip slides out laterally. You can also get this groove on the superior part of the head, which is from the reflected rectus femoris.
So what's the relevance of this? So if you've got a child that's an ambulatory child, you want to try and preserve that function as far as possible. And if you can locate the hip, then you're giving them a stable platform to allow them to weight there and hopefully maintain their mobility.
The other, the long term outcome of a cerebral palsy hip is that they will usually develop early osteoarthritis, which causes pain. And if you can rotate the hip at an early stage, then you can reduce the risk of this happening in the non-ambulatory children. Then you want to give them a stable platform if they can transfer. You need to maintain some kind of hip abduction in order for perineal hygiene, because a lot of these children end up with flexed, deducted hips and it can be quite difficult to keep up with their perennial hygiene.
The hip subluxation dislocation leads to a pelvic obliquity, which, when they're sitting in their wheelchairs, causes a problem with sitting balance and tolerance, and the pelvic obliquity that develops may in turn worsen the scoliosis and all the inherent risks associated with that. So when these children are sitting in their wheelchair, ideally you want to keep them as balanced as you can to reduce the risk of these things happening and as well as pressure sores.
Now, some people would argue that maybe these hip dislocations are not painful, but there is some evidence that they can be painful, particularly in the elderly, more older child. So hip surveillance now the. Ji MFCs scale is what's going to predict the like, the likelihood of your hip dissipating.
And I think whenever you to see a cerebral palsy child in an exam, the first thing you want to do is work out what is the GMFCS score? Now that's a chart there. As you can see, one is usually ambulatory, 5 is usually wheelchair bound with poor head control. And this is available on the internet, and I'd suggest that you get yourself a little bit familiar with it so that you can recognize it should you be faced with this kind of child in the exam.
And now in the UK, we don't have a definitive screening programme, as they do in Australia and Sweden. I think the Americans are trying to design one. The one that older he uses is this CPAP, which is based on a Scottish model. It's a group of physiotherapists that do all the initial assessments and then refer to an orthopedic surgeon as and when needed. And the common thing with all these surveillance programs is that you do a clinical examination and an AP pelvis.
The clinical examination is not always reliable in these patients detecting when the hips are dislocated or the ones that are at risk of progression. But the AP pelvis is important to look at the migration percentage, which we're going to come onto shortly. So this is what happens in the Scottish model, which I understand is what we use in Alder.
Hey so you have a child with a diagnosis of cerebral palsy and you confirm what their MFCs level is. Then you talk to the family about the program, which we're going to come onto and shortly. And the X-ray protocol. And usually we start screening around about two years old, that's when most of the diagnoses are made. But obviously, if they're not diagnosed till later, then they can just enter into the program at whatever stage they're at.
So one of the first things you want to do is the Thomas test. So this is from the C. C Pip's website. And essentially, you just want to measure how much reflection contractor they've got. Initially, the next stage is to look at their hip abduction. And again, we measure the angles of that. Often, if they're hemiplegia, they might have one hip that's worse than the other. But you want to measure both sides so you can compare them and you want to see what happens to that over time.
Internal and external rotation of the hip, so they break it up, it's slightly different, so the GMF sees 1 to 3. You do it the way we would standard. We look at an adult assessing their internal and external rotation and measure the angles and in the patients that are 4 and 5. You start in a slightly different position and again measure their rotation and it's something that you're going to monitor with each session.
Leg length, so leg lengths down the bottom here. Standard bearing in mind, they're going to have flexion and aid reduction contractures that you'll need to take into account when you're looking at leg length. The other test you can do is a Duncan l.I test looking for tightness of the rectum femoris. And these kind of tests become important when you're thinking about soft tissue releases or botulism toxin.
And again, hip extension. Yes so this is the. Protocol for X rays, according to the CPT guidelines, and you'll see that the GMF s ones and twos in this model. We're going to X-ray them at 2 and we're going to X-ray them at six. I'm going to X-ray them at skeletal maturity when you're getting into the three fours and fives. We're usually going to do it once a year or twice a year.
I'm going to be looking at the migration percentage. So the important thing that your X-ray department needs to know is that because these children have got flexion deformities and a load otic lumbar spine, then they need to modify the positioning when they take the X-rays. Otherwise your measurements will be incorrect. So I'm going to talk about this again in a second, but the main thing is this immigration percentage index and the way that you look for it is you identify hook and lines line and Perkins line, and then you're looking for the percentage of the ossified femoral head that's lateral to Perkins line.
So you measure the whole width of the hips here and then you measure the degree that's lateral to Perkins line. Divide one by the other and multiply it by 100, and that will give you a migration percentage. The other thing that you can measure is the head shaft angle. Obviously, the more Vargas the hips are, the more likely they are to dislocate. So this is the migration percentage, and it's a measure of the femoral head containment within the acetabulum on the coronal plane.
And this is why it's important that your X-ray is correct. So you don't get these measurements wrong. The migration percentage is the most accepted and reproducible measurements, and all the surveillance systems use the migration percentage in determining follow up and management of cerebral palsy hips. And as I said before, it's a percentage of the ossified femoral head, which is lateral to Perkins line.
And that's just a larger picture. You can also look at the acetabular index, but the main thing that I want you to take away from this talk is the importance of the migration percentage and how to work it out. So if we look at migration percentages, migration percentage of 10 is normal migration percentage of between 30 and 33, we would describe that type of hip as displaced and a migration percentage of 90% to 100% We describe as dislocated now some hips with a.
Migration percentage of less than 40% do not progress, but almost all of them with a migration percentage of 40% or more will progress to dislocation. And the most common age for picking this up is usually a child around the age of three or four. With a migration percentage of more than 33 percent, the amount of displacement is strongly correlated to the CP subtype. So somebody with a MFCs of 1 would be considered to be low or negligible risk of developing hip dislocation.
However, if you look at two, it's 53, is 40 for 70, and GMFCS five has got a 90% chance of developing a cellblocks or dislocated hips. And then there is this subtype typekit or hemiplegia, where they, because of their spasticity, they are at risk of developing a dislocated hip as well. So that's one category that you would follow up, maybe as strongly as the MFCs 5s.
So the KPIX system use this traffic light system, and I guess you need to be aware of it, but we're really only going to see the red ones. So in Scotland, the physiotherapists see most of these patients and they do their examination here and then depending on what their examinations are and what the MP is on the X-rays. So if they fall into the red category, they're going to be referred to an orthopedic surgeon, whereas green, they're probably going to stay under the physiotherapists unless they enter into the ambush stage.
So this is the Australian protocol, and I use this as an example as to how the surveillance system works, so has one. We're going to do an X-ray when the 3 and an X-ray when they're five. And we're not expecting them to progress for a 2. We do it once a year until the migration percentage is stable, then we'll do one at 5 and then we'll do 1 to 8 for the 3's and fours, probably twice a year until they're age seven.
And then if their migration percentage at that stage is less than 30 percent, we discontinue X raying until they reach skeletal maturity. We just give you X-ray until puberty. And then we X-ray them until skeletal maturity for the 5s. We're going to X-ray them twice a year. And until that, oops, until they're 7 and then we're going to do them annual until they reach skeletal maturity because these are the ones that are going to progress.
So how are we going to manage it? Well, the initial management is non operative, and I'd suggest that all patients with cerebral palsy to some extent should have things like positioning to avoid this prolonged adoption and flexion position. Racing has been used, but it's not thought to be effective. Botulism toxin a intrathecal, baclofen and selective dorsal ostomy and all of these things, they might reduce the spasticity, but they're not actually proven to reduce the risk of hip dysplasia.
So what are the operative options? Well, the first thing that you can do is soft tissue release, so release the abductors. You can also release the earlier source and sometimes the rectus femoris if that's tight. There's I think there's some evidence in the literature that there was some suggestion in the literature that. So is caught. Release ability is so is causes some flexion weakness, but it's not actually been proven to do that.
And there's papers out there that say it's a reasonable option. We normally do them bilaterally and to avoid the. Contralateral hip taking over the adopted position provided your acetabulum is not deformed, you can consider a various de rotation osteotomy, and if you're acetabulum is deformed, then you can consider Pemberton, dega or piao, and you can combine an acetabular osteotomy with a very stiff rotation osteotomy or with a shortening osteotomy of the femur in order to get the hip located.
Salvage procedures, so when you've got osteoarthritis or when it's really dislocated and you can't reduce it, then there's this hassle and shoulder procedure, which there is 6 proximal femur and interpose gluteus medius as a cap over the end of it's supposed to reduce pain. Total hip replacement is an option and hip arthritis. So in conclusion, we can reduce the risk of hip dislocation in these patients with a surveillance program.
It's based on clinical and radiological examination. The important things to consider are the child's age. The migration percentage and the GMFCS level non operative prevention should be offered to all children and with an MP of more than 33 percent, consider operative intervention, follow them up until skeletal maturity. And that's it. Anyone got any questions?
And if anyone has any questions, feel free to ask or type it into the chat box and we'll read it out. Thank you, KneeKG. That's a very good presentation. Can I ask you a couple of really basic questions just for the non operative options? They include stretching and is there any orthotics or any supplementation to chairs and sleeping habits?
And so, yes, I do say stretching. They say that bracing doesn't work, but I think it's reasonable when you take care with positioning. So try and keep the legs, the hips abducted to some extent and with their general peritoneal, perennial toileting and stuff like that, I think they all benefit from some stretching, some physiotherapy, but actual. I think we used to when I was in Australia, sometimes we'd put them into a hip Spiker, but it's not been shown them in the Scottish right brace.
They've not really been shown to reduce the chances of the hip dislocating, and they can be quite cumbersome for the patients, especially if they're a GMF five. So I don't think there's any option for bracing, but certainly the stretching and the positioning and the pressure area care should be offered to all of them. Absolutely And also, the use of cushioning and supplementation in the wheelchair can help patients with cerebral palsy, such as an abduction cushion between the knee and from a genuine for migration percentage more than 66.
What is the management? I would say that would be the migration percentage is more than 66. Then I think you'd be looking at operative management for that, and it will depend on the child's age, the MFCs score, whether the acetabulum is involved or not, what their clinical examination findings are, whether it's something that you could offer a various shortening femoral osteotomy, whether you need to include the acetabular osteotomy in it as well, I would think, but that would certainly be someone that I would think would benefit from operative surgery.
OK and for complete dislocation. Again, it depends on the age of the child and their MFCs. If you can get a located hip with a combination of femoral and acetabular osteotomy, I think that would be the way forward. If you can't, then you're looking at the salvage procedures, which again, depending on the child's age and mfcc's, you know, possibly not suitable for a total hip, but it would depend on the child and the circumstances where you could consider the castle procedure or an arthritis and for the GMF five five, you can consider excision arthroplasty as their own.
Yeah OK. Any other questions? Oh, sorry, I should clarify, you should consider excision or not. Any other questions? OK, there's a couple of other comments I'd just like to make if there's anything else the mentors would like to add.
You know, a couple of comments in terms of cerebral palsy going down to the basic science, and I know it's very simple, but it's quite important because quite a few people seem to not grasp the concept of why cerebral palsy patients have flexor problems and adductor problems. And it's literally as simple as it's not that only the flexor-pronator doctor doctors are tight. It's all muscle groups are tight in the cerebral palsy patients, especially the higher GMF cases.
But the reason is the cross-sectional area or the lever arm of each of those muscles outweigh the sensors and the abductors, abductors, doctors. So, for example, in the hip. So this is a very thick heart big muscle, so it can flex much more powerfully than the extenders of the hip. And similarly, for the doctors, the doctors have a long lever arm down right down to the knee while the abductors, though they are thick muscles.
They are very short. Leveron and if you think about it, it's literally the explanation for the classical cerebral palsy positioning. So if you remember the cerebral palsy positioning, you can correlate very quickly as to which muscle groups are the problem in these patients. Also, the rationale behind why this position of the hip deformities and acetabular deformity, as KneeKG correctly pointed out, they are normal in birth, but they progressively get worse.
The reason they do get worse is because of the constant dynamic spasm of the muscles, which causes a forced about this position on the hip and also the proximal migration of the hip against the acetabulum causes a more vertical as the abdomen gradually causes the abnormal acetabular where so it can all be brought back to the basic science, which is something I keep reminding everyone. It's you can't get away from it in every part of your station in the exam mentors anything else that.
And any other questions? No, Nicky, seems you've explained this perfectly well, they all understand it really well, and to be fair, I think it was a brilliant presentation. Thank you so much. Participation list is very good today considering we just finished the exams.
26 participants so far today. Thank you so much for presenting. Quite an important topic. Cerebral palsy, surveillance, hip surveillance, which is not adequately covered in most places. And I think it's an important question to have prepared for the first exam. Thank you very much. We'll stop recording now and proceed to the viva section section of our session tonight.
Segment:0 .
Hello, everybody. Thank you for joining us. Another FRCS mentor group presentation, we are going to be given a talk by Nikki Walsh, who works in royal Lancaster infirmary. She's going to present the topic on surveillance in the cerebral hip surveillance and cerebral palsy.
Just a reminder the mentors are going to do vyver sessions afterwards. These this will not be recorded for the sake of privacy for the participants. We have a good showing from the mentors, including Nicky Walsh, Abdullah and Anwar kiani and Kashif Mahmood, so we look forward to a very lively vibha session at the end. Hi, Nicky, thank you very much.
If you don't mind at the beginning. Sure thank you for introducing me today. I'm going to talk about hip surveillance in children with cerebral palsy. The topic I'm about to do, it's the work. The views are all my own and I've put a link to some references as well. So these are the references that I used.
The first one is a good review article by JS from last year and the cerebral palsy integrated pathway for Scotland at the bottom. That's actually quite a good document, which is available online, and it runs through all examinations in cerebral palsy children, which I think would be quite useful for the exam. So it's the definition of cerebral palsy is that it's actually a non-progressive brain lesion.
But the associated musculoskeletal pathology is progressive and typically results in spasticity and contractors of the muscle tendon units. You also get bony torsional deformity due to the abnormal forces, and eventually this gives rise to joint instability. So the point about cerebral palsy hips is that the hip joint itself is often normal at birth, and therefore what happens as the children grow is that they then developed these fractures and deformities.
So if we can intervene at an early stage, we can probably prevent a lot of the hip dislocations. So the goals of the surveillance program are to identify these children's children who are at risk of hip displacement and monitor their development over time and offer early appropriate intervention. So what happens? Well, the first thing is that you get abnormal muscle forces across the hip joint.
You've got increased activity of the abductors, the hip flexors and the hamstrings, which gradually cause the proximal femur to migrate laterally and superiorly. Now, because the acetabulum development is dependent on a located femoral head, you can often get secondary acetabular changes and most typically, it's a saucer shaped deformity in a crane or lateral direction.
And then, as the hip continues to displace, it's then subjected to some abnormal forces and remodeling. So you get an increase of the next shaft angle. You get increased activation and you get flattening of the femoral head and due to pressure from the hip capsule and the abductors as the hip slides out laterally. You can also get this groove on the superior part of the head, which is from the reflected rectus femoris.
So what's the relevance of this? So if you've got a child that's an ambulatory child, you want to try and preserve that function as far as possible. And if you can locate the hip, then you're giving them a stable platform to allow them to weight there and hopefully maintain their mobility.
The other, the long term outcome of a cerebral palsy hip is that they will usually develop early osteoarthritis, which causes pain. And if you can rotate the hip at an early stage, then you can reduce the risk of this happening in the non-ambulatory children. Then you want to give them a stable platform if they can transfer. You need to maintain some kind of hip abduction in order for perineal hygiene, because a lot of these children end up with flexed, deducted hips and it can be quite difficult to keep up with their perennial hygiene.
The hip subluxation dislocation leads to a pelvic obliquity, which, when they're sitting in their wheelchairs, causes a problem with sitting balance and tolerance, and the pelvic obliquity that develops may in turn worsen the scoliosis and all the inherent risks associated with that. So when these children are sitting in their wheelchair, ideally you want to keep them as balanced as you can to reduce the risk of these things happening and as well as pressure sores.
Now, some people would argue that maybe these hip dislocations are not painful, but there is some evidence that they can be painful, particularly in the elderly, more older child. So hip surveillance now the. Ji MFCs scale is what's going to predict the like, the likelihood of your hip dissipating.
And I think whenever you to see a cerebral palsy child in an exam, the first thing you want to do is work out what is the GMFCS score? Now that's a chart there. As you can see, one is usually ambulatory, 5 is usually wheelchair bound with poor head control. And this is available on the internet, and I'd suggest that you get yourself a little bit familiar with it so that you can recognize it should you be faced with this kind of child in the exam.
And now in the UK, we don't have a definitive screening programme, as they do in Australia and Sweden. I think the Americans are trying to design one. The one that older he uses is this CPAP, which is based on a Scottish model. It's a group of physiotherapists that do all the initial assessments and then refer to an orthopedic surgeon as and when needed. And the common thing with all these surveillance programs is that you do a clinical examination and an AP pelvis.
The clinical examination is not always reliable in these patients detecting when the hips are dislocated or the ones that are at risk of progression. But the AP pelvis is important to look at the migration percentage, which we're going to come onto shortly. So this is what happens in the Scottish model, which I understand is what we use in Alder.
Hey so you have a child with a diagnosis of cerebral palsy and you confirm what their MFCs level is. Then you talk to the family about the program, which we're going to come onto and shortly. And the X-ray protocol. And usually we start screening around about two years old, that's when most of the diagnoses are made. But obviously, if they're not diagnosed till later, then they can just enter into the program at whatever stage they're at.
So one of the first things you want to do is the Thomas test. So this is from the C. C Pip's website. And essentially, you just want to measure how much reflection contractor they've got. Initially, the next stage is to look at their hip abduction. And again, we measure the angles of that. Often, if they're hemiplegia, they might have one hip that's worse than the other. But you want to measure both sides so you can compare them and you want to see what happens to that over time.
Internal and external rotation of the hip, so they break it up, it's slightly different, so the GMF sees 1 to 3. You do it the way we would standard. We look at an adult assessing their internal and external rotation and measure the angles and in the patients that are 4 and 5. You start in a slightly different position and again measure their rotation and it's something that you're going to monitor with each session.
Leg length, so leg lengths down the bottom here. Standard bearing in mind, they're going to have flexion and aid reduction contractures that you'll need to take into account when you're looking at leg length. The other test you can do is a Duncan l.I test looking for tightness of the rectum femoris. And these kind of tests become important when you're thinking about soft tissue releases or botulism toxin.
And again, hip extension. Yes so this is the. Protocol for X rays, according to the CPT guidelines, and you'll see that the GMF s ones and twos in this model. We're going to X-ray them at 2 and we're going to X-ray them at six. I'm going to X-ray them at skeletal maturity when you're getting into the three fours and fives. We're usually going to do it once a year or twice a year.
I'm going to be looking at the migration percentage. So the important thing that your X-ray department needs to know is that because these children have got flexion deformities and a load otic lumbar spine, then they need to modify the positioning when they take the X-rays. Otherwise your measurements will be incorrect. So I'm going to talk about this again in a second, but the main thing is this immigration percentage index and the way that you look for it is you identify hook and lines line and Perkins line, and then you're looking for the percentage of the ossified femoral head that's lateral to Perkins line.
So you measure the whole width of the hips here and then you measure the degree that's lateral to Perkins line. Divide one by the other and multiply it by 100, and that will give you a migration percentage. The other thing that you can measure is the head shaft angle. Obviously, the more Vargas the hips are, the more likely they are to dislocate. So this is the migration percentage, and it's a measure of the femoral head containment within the acetabulum on the coronal plane.
And this is why it's important that your X-ray is correct. So you don't get these measurements wrong. The migration percentage is the most accepted and reproducible measurements, and all the surveillance systems use the migration percentage in determining follow up and management of cerebral palsy hips. And as I said before, it's a percentage of the ossified femoral head, which is lateral to Perkins line.
And that's just a larger picture. You can also look at the acetabular index, but the main thing that I want you to take away from this talk is the importance of the migration percentage and how to work it out. So if we look at migration percentages, migration percentage of 10 is normal migration percentage of between 30 and 33, we would describe that type of hip as displaced and a migration percentage of 90% to 100% We describe as dislocated now some hips with a.
Migration percentage of less than 40% do not progress, but almost all of them with a migration percentage of 40% or more will progress to dislocation. And the most common age for picking this up is usually a child around the age of three or four. With a migration percentage of more than 33 percent, the amount of displacement is strongly correlated to the CP subtype. So somebody with a MFCs of 1 would be considered to be low or negligible risk of developing hip dislocation.
However, if you look at two, it's 53, is 40 for 70, and GMFCS five has got a 90% chance of developing a cellblocks or dislocated hips. And then there is this subtype typekit or hemiplegia, where they, because of their spasticity, they are at risk of developing a dislocated hip as well. So that's one category that you would follow up, maybe as strongly as the MFCs 5s.
So the KPIX system use this traffic light system, and I guess you need to be aware of it, but we're really only going to see the red ones. So in Scotland, the physiotherapists see most of these patients and they do their examination here and then depending on what their examinations are and what the MP is on the X-rays. So if they fall into the red category, they're going to be referred to an orthopedic surgeon, whereas green, they're probably going to stay under the physiotherapists unless they enter into the ambush stage.
So this is the Australian protocol, and I use this as an example as to how the surveillance system works, so has one. We're going to do an X-ray when the 3 and an X-ray when they're five. And we're not expecting them to progress for a 2. We do it once a year until the migration percentage is stable, then we'll do one at 5 and then we'll do 1 to 8 for the 3's and fours, probably twice a year until they're age seven.
And then if their migration percentage at that stage is less than 30 percent, we discontinue X raying until they reach skeletal maturity. We just give you X-ray until puberty. And then we X-ray them until skeletal maturity for the 5s. We're going to X-ray them twice a year. And until that, oops, until they're 7 and then we're going to do them annual until they reach skeletal maturity because these are the ones that are going to progress.
So how are we going to manage it? Well, the initial management is non operative, and I'd suggest that all patients with cerebral palsy to some extent should have things like positioning to avoid this prolonged adoption and flexion position. Racing has been used, but it's not thought to be effective. Botulism toxin a intrathecal, baclofen and selective dorsal ostomy and all of these things, they might reduce the spasticity, but they're not actually proven to reduce the risk of hip dysplasia.
So what are the operative options? Well, the first thing that you can do is soft tissue release, so release the abductors. You can also release the earlier source and sometimes the rectus femoris if that's tight. There's I think there's some evidence in the literature that there was some suggestion in the literature that. So is caught. Release ability is so is causes some flexion weakness, but it's not actually been proven to do that.
And there's papers out there that say it's a reasonable option. We normally do them bilaterally and to avoid the. Contralateral hip taking over the adopted position provided your acetabulum is not deformed, you can consider a various de rotation osteotomy, and if you're acetabulum is deformed, then you can consider Pemberton, dega or piao, and you can combine an acetabular osteotomy with a very stiff rotation osteotomy or with a shortening osteotomy of the femur in order to get the hip located.
Salvage procedures, so when you've got osteoarthritis or when it's really dislocated and you can't reduce it, then there's this hassle and shoulder procedure, which there is 6 proximal femur and interpose gluteus medius as a cap over the end of it's supposed to reduce pain. Total hip replacement is an option and hip arthritis. So in conclusion, we can reduce the risk of hip dislocation in these patients with a surveillance program.
It's based on clinical and radiological examination. The important things to consider are the child's age. The migration percentage and the GMFCS level non operative prevention should be offered to all children and with an MP of more than 33 percent, consider operative intervention, follow them up until skeletal maturity. And that's it. Anyone got any questions?
And if anyone has any questions, feel free to ask or type it into the chat box and we'll read it out. Thank you, KneeKG. That's a very good presentation. Can I ask you a couple of really basic questions just for the non operative options? They include stretching and is there any orthotics or any supplementation to chairs and sleeping habits?
And so, yes, I do say stretching. They say that bracing doesn't work, but I think it's reasonable when you take care with positioning. So try and keep the legs, the hips abducted to some extent and with their general peritoneal, perennial toileting and stuff like that, I think they all benefit from some stretching, some physiotherapy, but actual. I think we used to when I was in Australia, sometimes we'd put them into a hip Spiker, but it's not been shown them in the Scottish right brace.
They've not really been shown to reduce the chances of the hip dislocating, and they can be quite cumbersome for the patients, especially if they're a GMF five. So I don't think there's any option for bracing, but certainly the stretching and the positioning and the pressure area care should be offered to all of them. Absolutely And also, the use of cushioning and supplementation in the wheelchair can help patients with cerebral palsy, such as an abduction cushion between the knee and from a genuine for migration percentage more than 66.
What is the management? I would say that would be the migration percentage is more than 66. Then I think you'd be looking at operative management for that, and it will depend on the child's age, the MFCs score, whether the acetabulum is involved or not, what their clinical examination findings are, whether it's something that you could offer a various shortening femoral osteotomy, whether you need to include the acetabular osteotomy in it as well, I would think, but that would certainly be someone that I would think would benefit from operative surgery.
OK and for complete dislocation. Again, it depends on the age of the child and their MFCs. If you can get a located hip with a combination of femoral and acetabular osteotomy, I think that would be the way forward. If you can't, then you're looking at the salvage procedures, which again, depending on the child's age and mfcc's, you know, possibly not suitable for a total hip, but it would depend on the child and the circumstances where you could consider the castle procedure or an arthritis and for the GMF five five, you can consider excision arthroplasty as their own.
Yeah OK. Any other questions? Oh, sorry, I should clarify, you should consider excision or not. Any other questions? OK, there's a couple of other comments I'd just like to make if there's anything else the mentors would like to add.
You know, a couple of comments in terms of cerebral palsy going down to the basic science, and I know it's very simple, but it's quite important because quite a few people seem to not grasp the concept of why cerebral palsy patients have flexor problems and adductor problems. And it's literally as simple as it's not that only the flexor-pronator doctor doctors are tight. It's all muscle groups are tight in the cerebral palsy patients, especially the higher GMF cases.
But the reason is the cross-sectional area or the lever arm of each of those muscles outweigh the sensors and the abductors, abductors, doctors. So, for example, in the hip. So this is a very thick heart big muscle, so it can flex much more powerfully than the extenders of the hip. And similarly, for the doctors, the doctors have a long lever arm down right down to the knee while the abductors, though they are thick muscles.
They are very short. Leveron and if you think about it, it's literally the explanation for the classical cerebral palsy positioning. So if you remember the cerebral palsy positioning, you can correlate very quickly as to which muscle groups are the problem in these patients. Also, the rationale behind why this position of the hip deformities and acetabular deformity, as KneeKG correctly pointed out, they are normal in birth, but they progressively get worse.
The reason they do get worse is because of the constant dynamic spasm of the muscles, which causes a forced about this position on the hip and also the proximal migration of the hip against the acetabulum causes a more vertical as the abdomen gradually causes the abnormal acetabular where so it can all be brought back to the basic science, which is something I keep reminding everyone. It's you can't get away from it in every part of your station in the exam mentors anything else that.
And any other questions? No, Nicky, seems you've explained this perfectly well, they all understand it really well, and to be fair, I think it was a brilliant presentation. Thank you so much. Participation list is very good today considering we just finished the exams.
26 participants so far today. Thank you so much for presenting. Quite an important topic. Cerebral palsy, surveillance, hip surveillance, which is not adequately covered in most places. And I think it's an important question to have prepared for the first exam. Thank you very much. We'll stop recording now and proceed to the viva section section of our session tonight.
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