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who underwent shoulder interposition arthroplasty had pain relief, with improved perineal access and sitting tolerance. Also, all 10 caregivers stated that they would recommend the surgery for other children with similar conditions.13 Silverio et al. report excellent outcomes for pain management in nine of 16 hips that underwent interposition arthroplasty.14 Kolman et al. demonstrate that pain relief rates in non-ambulatory children with CP who underwent total
hip arthroplasty with shoulder prosthesis interposition were 93.8% and 90.9%, respectively.16 Wright et al. compare the clinical outcomes of proximal resection arthroplasty, subtrochanteric valgus osteotomy, and interposition arthroplasty for the treatment of painful hip dislocations in children with CP. Although the differences in outcome among these three procedures were toward interposition arthroplasty with better outcomes.15
Combining all hips with interposition arthroplasty in the previous studies13,14 and
in our study, the rate of pain relief is above 90%. The most frequent reasons for revision included infection, inadequate femoral resection, further femoral shortening, prominent prosthesis, osteolysis, recurrent soft-tissue contracture, and HO. The most common complication after interposition arthroplasty was HO, at a rate of 21%. Gabos that was not present preoperatively around the hip joints.13 Silverio et al. report half
of their cases developed HO;14 three of 15 procedures developed HO in their study. One hip in our study, which had no previous hip surgery, was revised due to recurrent HO. Two cases with HO who had previous bone surgery were asymptomatic. The infection rate was 6% in the literature. Wright et al. report two cases with deep infection who underwent implant removal.15 Silverio et al. infection in their studies.13,14
The other risk is to cause a femoral fracture
during preparation of the femoral side, which may incur a longer hospital stay and delay
in rehabilitation. Non-ambulatory children with CP often have low bone-mineral density, making them prone to fracture.
Hip arthroplasty with hip components is preferred in children with ambulatory CP to reduce the pain in degenerative hips.11,19,23,24 Complete pain relief or reduction in pain after THR was reported at greater than 80%.20,23 This procedure also provided functional improvement of 80% in gait and hygienic care11,20,23 and is recommended for ambulatory patients with hip degeneration
in CP. Complications related to THR
include dislocation, acetabular component loosening, wound dehiscence, deep infection, deep venous thrombosis, HO, trochanteric nonunion, trochanteric bursitis, pulmonary embolism, and periprosthetic fracture. The infection rate of THR in patients with CP is reported as 2% to 5% in the literature.11,19,20 rate of infection of 0 to 2.5%11,19 when compared with shoulder implants. The
most commonly reported complications
in THR are dislocation (7%-14%)11,20
and aseptic loosening (5%-17%).11,19 The and adduction contractures of the hip, subluxation, coxa valga, and increased femoral anteversion in patients with CP.11 In cases with pseudoacetabulum, the acetabular cup is placed into the pseudoacetabulum for total arthroplasties. Shoulder interposition arthroplasty is an interposition procedure
for which the purpose is not to keep the prosthesis located but to gain pain-free
hip motion. Because of this purpose, the component positioning is not as crucial as in THR. Either dislocation or subluxation of the prosthesis is not considered as a complication in non-ambulatory children with CP. Compared with shoulder interposition arthroplasty, the case series on THR report excellent functional outcomes and relatively low rates of revision surgery; however, almost all the total hip implants are placed in patients with GMFCS levels I to III. Total hip
replacement in CP is uncommon, but it can provide a high degree of patient satisfaction. Reduction of pain was reported in 77% to 93% of cases in the past literature.19,23,25,26 Revision rates were higher than in the non- CP group, and the reasons for revision were different as well (recurrent pain, dislocation/ subluxation, aseptic loosening, and periprosthetic fracture).27
Our study does not include a validated questionnaire. None of the previous studies assessed pre- and postoperative quality of life with a validated scoring system. One advantage of prosthetic interposition with
a shoulder prosthesis is that in cases of failure, such as infection or recurrent pain, the prosthesis can be removed and the hip can be converted to a resection arthroplasty. This procedure provides pain relief; however, it is not appropriate for weight bearing. Based on published results, in patients with higher motor function, outcomes of total
hip arthroplasty are excellent. Total hip arthroplasty is clearly the superior choice
of salvage in any patient with ambulatory function. This raises the question of whether a standard THR might also be a better option in GMFCS levels IV and V.
In conclusion, based on published data, there is no well-accepted salvage method that is superior to others for severely degenerated hips in individuals with CP. Our results demonstrate that interposition arthroplasty is one alternative, and it is an effective salvage surgical procedure for degenerative hips in non-ambulatory children with CP.
COMPLIANCE WITH ETHICAL STANDARDS
Funding: None
All authors declare that
This study was approved by our Institutional Review Board. All
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Del Med J | May/June 2020 | Vol. 92 | No. 3
