Page 31 - Delaware Medical Journal - March/April 2019
P. 31
CASE REPORT
Table 2. Radiographic measurements for patients who underwent hip reconstruction (4 children and 6 hips), showing the improvement after surgery
No.
Side
MP (%)
AI (°)
Lateral CEA (°)
NSA (°)
Preop
LFU
Preop
LFU
Preop
LFU
Preop
LFU
1
R
58
0
25
5
7
33
162
122
L
53
6
24
10
7
22
166
114
2
R
58
11
18
6
10
23
162
138
L
52
18
17
8
13
20
158
128
3
R
59
15
20
9
17
27
156
125
4
L
68
15
32
8
16
25
161
122
AI=acetabular index, CEA=center edge angle, LFU=last follow up, L=left, MP=migration percentage, NSA=neck shaft angle, Preop=preoperatively, R=right
was performed. Otherwise, and apart from implant removal, none of the patients needed other surgeries on their hips during the follow-up period. No complications were recorded in these four surgical cases. Postoperative follow-
up ranged between 1.6 and 6.7 years. Functional status (GMFCS level) did not show any change after surgery and all four patients were pain-free at last follow- up visit.
DISCUSSION
Developmental delays have been reported in central hypotonia2 with prevalence 15 to almost 100%.5,15 of children had developmental delays.
As reported in previous studies,12,15 most children with the non-spastic form of cerebral palsy (including hypotonic and ataxic forms) were at GMFCS I, II, in our study with 48 children (76%) at GMFCS I, II, and III. However, in the 1950s, although good walking ability was reported for children with ataxia,
ambulation prognosis was considered extremely poor for children with atonia.5 Contractures around the hip, knee, and ankle joints were blamed for this poor prognosis in addition to developmental delays.5 Advances in the medical approach and the perspectives of care towards these children might have played an important role in improving their ambulation prognosis.
In spastic hip surveillance studies,6,16
hip displacement with MP > 33% was most common around 3 to 4 years of
age, and some children presented with earlier displacement at 2 years of age.
In our study, hips with MP > 33% were most common in children older than 8 years (Table 1, Figure 2). However, this from the longitudinal data of children who were followed for an average of 3.3 years. Moreover, it is not known if MP
> 33% in hypotonic hips would predict further displacement, or if hypotonic
hip displacement is as progressive as the spastic displacement. Further studies with longer follow-up are needed to evaluate the long-term progress of these hips.
The GMFCS level is a known predictive factor for hip displacement in spastic cerebral palsy.6,12 In our study, although a based on the small number of patients, higher MP was found more frequently with higher GMFCS levels (Figures 1 and 3).
The hypotonic muscular imbalance around the hip is not well understood. Therefore, preventive interventions to stop hip displacement have not taken place in hypotonic hips (other than Down syndrome) as they have in spastic hips. Surgery was performed for our patients to preserve their level of function and the quality of daily activities. Although it is not known whether these children might have pain or a lower level of function without surgery, available data from children with Down syndrome show that hip dislocation eventually affects their walking ability.17
All of the surgical patients had improved hip measurements with no recurrent displacement or hip pain at the last
visit. However, the postoperative
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