Cutting-Edge Pediatric Orthopaedics 2017: A Global Perspective
The May 2017 EPOSNA meeting in Barcelona has brought experts throughout the world to share their experience and present current scientific information on many children’s orthopaedic conditions. Fortunately a segment of the EPOSNA precourse was devoted to the hip in CP and included individual presentations by Professor Gunnar Hagglund of Lund University, Sweden and Dr Jon Davids from the Shriners Hospital and University of California, Davis, CA. Each of these 2 experts is a recognized authority on the CP hip in their respective countries/continents and I was honored to co-moderate the sessions.
Dr Hagglund’s masterful presentation focused on methods used in Sweden to develop a hip registry for CP and to develop a monitoring program that allows a medical system to minimize the chance that a CP hip will progress to subluxation and dislocation. This system includes the development of a program (app) which can be easily used by physical therapists, orthopaedic surgeons, and others to determine the risk of progressive hip subluxation based upon age, motor impairment level, and radiographic measurements. With proper application of this organized registry/radiographic monitoring system, the need for complex hip reconstruction for CP hip dislocation in Sweden has plummeted and now is considered a rare event. Professor Hagglund’s presentation brilliantly summarized how a state, country, or region can organize itself to deal with an orthopaedic problem such as hip dislocation in CP, in an economical and scientifically driven manner. The benefits to society, a health care system, and most of all, the well-being of children with CP were clearly apparent. Such a system can be most readily developed and applied in a country with an organized and adequately funded national health care system.
Dr Davids’ presentation was equally informative and provided a clear overview of CP hip care in the United States, noting the difficulty of preventing the evolution to hip subluxation/dislocation in CP when one does not have a registry or nationally organized medical system that allows one to monitor each at-risk child. Organizing early diagnosis and preventive early hip surgery in a nation with multiple health care administrations and insurance payment systems is difficult. In the United States, each region and/or state has a somewhat independent approach to the problem. Despite the circumstance, Davids has worked with the state of California through their California Children’s Services Department to begin an organized CP hip monitoring program in California. Dr Davids and his colleagues have also developed a novel hip radiograph app, based on a cell phone–based camera that allows easy hip subluxation measurement with advice as to when the local therapists/physicians should refer an at-risk hip to an orthopaedic surgeon.
Dr Davids’ presentation also included the management of both early hip subluxation as well as more complex hip dislocations. He demonstrated how complex operations such as muscle lengthening combined with proximal femoral varus osteotomy and acetabular osteotomy can predictably reestablish hip stability. He noted the importance of eventually treating all at-risk CP hips at an early stage (as noted by Professor Hagglund) but clarified that orthopaedic surgeons throughout the world still need to understand the surgical methods needed to treat more complex cases.
Overall, this session nicely summarized the current world overview of the management of hip subluxation for the child with CP.
Dennis R. Wenger, MD
Rady Childrens Hospital The University of California San Diego, CA