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Hip Surveillance is Important to Children with Cerebral Palsy

Stop Waiting, Start Now

Miller, Stacey D., BSc, MRSc; Shore, Benjamin J., MD, MPH, FRCSC; Mulpuri, Kishore, MBBS, MS (Ortho), MHSc (Epi)

JAAOS Global Research & Reviews: April 2019 - Volume 3 - Issue 4 - p e021
doi: 10.5435/JAAOSGlobal-D-19-00021
Editorial
Open
SDC

From BC Children's Hospital (Ms. Miller, Dr. Mulpuri), University of British Columbia, Vancouver, British Columbia, Canada (Ms. Miller, Dr. Mulpuri), and Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Shore).

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Ms. Miller, Dr. Shore, and Dr. Mulpuri.

This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0 (CC BY-ND) which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author.

One in three children with cerebral palsy (CP) will develop hip displacement.1,2 Displacement is often silent, with no clinical symptoms. Left undetected and untreated, displacement can progress to dislocation and cause pain and decreased quality of life.3,4

Population-based hip surveillance programs for children with CP are effective in preventing hip dislocations in children with CP.5,6 Programs in Sweden and Australia have demonstrated that systematic screening can identify hip displacement early and, when combined with timely orthopaedic management, reduce the prevalence of hip dislocations in children with CP.5,6 The development of such programs is complex with implementation highly dependent on the local system of care for children with CP. Population-based programs should always be the aim of hip surveillance initiatives, but the challenge of designing a system-wide approach should not discourage individuals from acting.

All clinicians should be following guidelines within their individual practice. Despite the awareness that surveillance is effective, established guidelines for hip surveillance are underutilized. A 2016 survey of the Pediatric Orthopaedic Society of North America membership found widespread agreement that a dislocated hip in a child with CP should be prevented by hip surveillance (93%), yet only a small proportion (18%) followed a regular surveillance program.7 In 2017, the American Academy of Cerebral Palsy and Developmental Medicine released a hip surveillance care pathway that was developed by a group of international experts (AACPDM.org [Internet]. Wilwaukee, WI, AACPDM, c2017. http://www.aacpdm.org/publications/care-pathways/hip-surveillance). The resultant pathway represents the consensus reached on the recommended components of surveillance, frequency, and referral criteria. Using such resources is a good starting point to initiate hip surveillance and can have an immediate impact. Notably, the authors from the Child Health BC Hip Surveillance Program saw a difference in the rate of dislocations and surgical interventions required once a systematic approach to hip surveillance was established in their center, even before a formal program was initiated (Child Health BC Hip Surveillance Program for Children with Cerebral Palsy [Internet]. Vancouver, BC, Child Health BC, c2018. www.childhealthbc.ca/hips). The introduction of mobile solutions, such as the HipScreen app (www.hipscreen.org, Shriners Hospitals for Children, Sacramento, California), makes hip surveillance resources and guidelines readily accessible in a busy clinical practice.

Patients and families are strong advocates for system change and should be educated on hip displacement and the importance of hip screening. Similarly, every opportunity should be undertaken to educate the team of clinicians within one's healthcare system that support children with CP, including pediatricians, physical and occupational therapists, nurses, and social workers. All can become advocates for hip health in this population and collaborate to implement systematic screening.

Just like the Australasian Academy of Cerebral Palsy and Developmental Medicine, American Academy of Cerebral Palsy and Developmental Medicine, and Pediatric Orthopaedic Society of North America, professional societies have a role to play in establishing hip surveillance. These societies must work with their membership to determine which guidelines are best suited to their systems of care and, where appropriate, foster collaborations with key stakeholders to facilitate guideline development and system-wide implementation.

Offered the choice, surely children with CP and their families will choose hip surveillance and its proven benefits over the alternative. Those waiting for system-wide implementation are missing an opportunity to provide quality care to the patients in their practice.

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References

1. Hägglund G, Lauge-Pedersen H, Wagner P: Characteristics of children with hip displacement in cerebral palsy. BMC Musculoskelet Disord 2007;8:101–106.
2. Soo B, Howard JJ, Boyd RN, et al: Hip displacement in cerebral palsy. J Bone Joint Surg Am 2006;88:121–129.
3. Ramstad K, Terjesen T: Hip pain is more frequent in severe hip displacement: A population-based study of 77 children with cerebral palsy. J Pediatr Orthop B 2016;25:217–221.
4. Jung NH, Pereira B, Nehring I, et al: Does hip displacement influence health-related quality of life in children with cerebral palsy? Dev Neurorehabil 2014;17:420–425.
5. Hagglund G, Alriksson-Schmidt A, Lauge-Pedersen H, Robdy-Bousquet E, Wagner P, Westbom L: Prevention of dislocation of the hip in children with cerebral palsy: 20 year results of a population-based prevention programme. Bone Joint J 2014;96-B:1546–1552.
6. Wynter M, Gibson N, Willoughby KL, et al: Australian hip surveillance guidelines for children with cerebral palsy: 5-year review. Dev Med Child Neurol 2015; 57:808–820.
7. Shore BJ, Shrader MW, Narayanan U, Miller F, Graham HK, Mulpuri K: Hip surveillance for children with cerebral palsy: A survey of the POSNA membership. J Pediatr Orthop 2017;37:e409–e414.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons