Volume 10 | Issue 1 | January-April 2024 | Page: 02-08 | Ashok N Johari, Dhiren Ganjwala, Alaric Aroojis

DOI- https://doi.org/10.13107/ijpo.2024.v10i01.171

Submitted: 12/01/2024; Reviewed: 09/02/2024; Accepted: 18/02/2024; Published: 10/04/2024

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Authors: Ashok N Johari MS Ortho [1], Dhiren Ganjwala MS Ortho [2], Alaric Aroojis MS Ortho [3]

[1] Department of Paediatric Orthopaedic & Spine Surgery, Children’s Orthopaedic Centre, Mumbai, Maharashtra, India.
[2] Department of Paediatric Orthopaedic Surgery, Ganjwala Orthopaedic Hospital, Ahmedabad, Gujarat, India.
[3] Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Alaric Aroojis
Hon. Consultant, Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India.
E-mail: aaroojis@gmail.com

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Guidelines

Preamble:
Hip displacement is the second most common musculoskeletal impairment in children with cerebral palsy (CP). More than one-third of the children are affected by this problem. Hip displacement in children with CP is often asymptomatic until the hip is partially or fully dislocated, resulting in pain, gait disturbances, impaired sitting balance, difficulty in perineal care and pressure sores. The incidence of hip displacement is much higher in non-ambulatory children.

It is now well-known that hip surveillance programmes can effectively detect hip displacement early, leading to earlier proactive management with better outcomes. National and provincial hip surveillance programmes have been developed and adopted in various regions of the world, with evidence supporting the role of surveillance in preventing dislocations and avoiding the need for salvage surgery.

To offer similar benefits to Indian children with CP, a guidelines development project on National Hip Surveillance Program for Cerebral Palsy was initiated in May 2020. Based on the outcome of the one-year guidelines’ development project, this guidelines document was prepared from an Indian practice perspective.

About development of this Indian guideline:
Professional organisations whose members are involved in the care of children with CP were involved in the formation of this guideline. A National Expert Committee was constituted with representatives of these organisations. Advice was sought from international experts on this topic who acted as the Advisory Committee.

In phase 1: The Expert Committee reviewed more than 80 published research articles related to various aspects of hip displacement in CP. Key points from these articles were listed. National guidelines from other countries/regions were also reviewed, discussed and referred.

In phase 2: All important questions related to hip surveillance were listed. These questions were circulated to all the members of the expert committee. The Delphi process was used to develop consensus on these practical questions. When more than 80% of group members agreed to a particular viewpoint, it was considered as a consensus. With two rounds of the Delphi process, the committee reached a consensus on every single question. Consensus statements were listed.

In phase 3: The guideline was drafted based on these consensus statements. The main document was written keeping the from a healthcare professional’s perspective. A simple version of this guideline was also prepared to spread awareness about this important message to the caregivers / family / healthcare aid workers.

NATIONAL GUIDELINES COMMITTEE

STEERING COMMITTEE
Dr. Ashok N. Johari
Paediatric Orthopaedic & Spine Surgeon, Children’s Orthopaedic Centre, Mumbai, India

Dr. Dhiren Ganjwala
Consultant Paediatric Orthopaedic Surgeon, Ganjwala Orthopaedic Hospital, Ahmedabad, India

Dr. Alaric Aroojis
Hon. Consultant, Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, India

ADVISORY BOARD
Dr. Kishore Mulpuri
Paediatric Orthopaedic Surgeon, BC Children’s Hospital, Vancouver, Canada

Stacey Miller
Lead Physiotherapist, BC Children’s Hospital, Vancouver, Canada

Dr. Abhay Khot
Paediatric Orthopaedic Surgeon, Royal Children’s Hospital, Melbourne, Australia

Dr. Mohan Belthur
Attending Paediatric Orthopaedic Surgeon, Phoenix Children’s Hospital, Phoenix, Arizona, USA

COMMITTEE MEMBERS
Dr. Sakti Prasad Das
Director, SV NIRTAR, Orissa, India

Dr. Anand Varma
Dept. of Physical Medicine & Rehabilitation, Karnataka Institute of Medical Sciences, Hubballi, India

Asha Chitnis
Consultant Paediatric Therapist, Vedanta Programs, Mumbai, India

Madhavi Kelapure
Paediatric Physiotherapist, Deenanath Mangeshkar Hospital, Pune, India

Trupti Nikharge
Occupational Therapist, B.Y.L.Nair Hospital, Mumbai, India

Dr. Meenakshi Murthy Girish
Professor & Head, Paediatrics, AIIMS, Nagpur, India

Dr. Leena Srivastava
Head, Child Development and Guidance Centre, Bharati Vidyapeeth Medical College and Hospital, Pune, India

Dr. Anaita Udwadia-Hegde
Consultant Paediatric Neurologist, Jaslok Hospital and Research Centre, Mumbai, India.
 
Dr. Surekha Rajadhyaksha
Professor and Chief of Paediatric Neurology and Epilepsy, Bharati Vidyapeeth Hospital, Pune, India

Dr. Mahesh Kamate
Professor of Paediatric Neurology, KAHER’s JN Medical College, Belagavi, India

Dr. Sandeep Patwardhan
Professor of Orthopaedics, Paediatric orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, India

Dr. T.S. Gopakumar
Professor of Orthopaedics, MES Medical College, Perinthalmanna, Malappuram, India

Dr. P N Gupta
Professor, Department of Orthopaedics, Govt. Medical College Hospital, Chandigarh, India

Dr. Jayanth Sampath
Consultant Paediatric Orthopaedic Surgeon, Rainbow Children’s Hospital, Bangalore, India

Dr. Binu Kurian
Consultant Paediatric Orthopaedic Surgeon, St. John’s Medical College Hospital, Bangalore, India

Dr. Abhay Gahukamble
Assistant Professor, Dept of Orthopaedic Surgery at Christian Medical College and Hospital, Vellore, India

Dr. Sanjay Wadhwa
Professor, Dept. of PMR, AIIMS, New Delhi, India

Punita V. Solanki
Occupational Therapist, Mumbai, India

Dr. Rekha MittalAdditional Director (Paediatric Neurology), Madhukar Rainbow Children’s Hospital, New Delhi, India

Aijaaz Ashai
Director & HOD, Adams Wylie Physio Rehab Center, Mumbai, India

 
This guideline is for the medical professionals who are involved in the care of children with cerebral palsy (CP).

Children with cerebral palsy are at increased risk for hip displacement. Hip displacement may occur gradually and may not be painful initially. However, many dislocated hips become painful eventually and lead to reduced function and impaired quality of life. [1]

What is hip surveillance?
Hip surveillance is a process of actively monitoring the child for early identification of hip displacement. It is carried out by clinical and radiographic examinations at regular intervals, so that silent hip impairments are identified. When hip impairments are identified early, they can be managed by less aggressive surgical interventions, thus leading to better structural and functional outcomes. Hip surveillance has been found to be effective in several large population-based studies. [2]

Who should be surveilled?
All children and youth diagnosed with CP and those children not yet diagnosed with CP but for whom there is a clinical suspicion of having CP should be enrolled for surveillance. Besides the spastic variety, dystonic, athetoid, ataxic and hypotonic types of CP are included in hip surveillance.

By whom should the child be surveilled?
All trained clinicians working with children with CP can carry out hip surveillance. These include paediatricians, developmental paediatricians, paediatric neurologists, physical therapists, occupational therapists, physical medicine & rehabilitation experts, orthopaedic surgeons, and paediatric orthopaedic surgeons.

How the child should be surveilled?
Each visit for surveillance consists of two components: a clinical examination and a radiographic examination.

The clinical examination includes determining / re-confirming the Gross Motor Function Classification System (GMFCS) level. Inquiring about hip pain that may be present when moving the hip, changing positions, when looking after personal care.

The passive range of abduction is measured for each hip with maximum possible extension at the hips and knees (Figure 1). Attention is given to the presence of pain while moving the hip. Gait observation should identify cases having Winters, Gage & Hicks (WGH) type 4 gait pattern. They form a subset that deserves special attention.

The examiner also looks for pelvic asymmetry and scoliosis (Figure 2).

The radiographic examination consists of taking an antero-posterior (AP) pelvis radiograph in a supine position with standardized positioning. The pelvis is squared whilst positioning. The hips are kept in neutral abduction/adduction (Figure 3). The patellae should face upwards. For children having flexion deformity at the hips, both lower limbs are flexed at the hips till lumbar lordosis is obliterated. This prevents anterior tilting of the pelvis (Figure 4 & 5).

Migration percentage (MP) is measured on an anteroposterior radiograph. [3] It measures the percentage of the ossified femoral head that lies outside the ossified acetabular roof. To measure the MP, a horizontal line is drawn through each triradiate cartilage (solid horizontal line) and a vertical line is drawn perpendicular to it at the lateral margin of the ossified acetabulum (solid vertical line). Two lines are drawn parallel to this solid vertical line at the medial and lateral border of the ossified femoral head (dotted lines). The distance between these two dotted lines is the width of the ossified femoral head (B). The width of the femoral head which is lateral to the solid vertical line (A) is divided by the width of the ossified femoral head (B). Migration percentage = A/B x 100 (Figure 6).

Migration percentage (MP) is measured for each hip separately.

How frequently should the child be surveilled?
Surveillance should preferably start by the of 2 years for children for whom the diagnosis of CP is made, or even at an earlier age when the diagnosis of CP is suspected. Surveillance frequency depends mainly on the GMFCS level, age of the child, and the age at which hip surveillance is started.
For the sake of easy understanding, the CP population is divided into 3 groups.
• GMFCS level I & II
• GMFCS level III
• GMFCS level IV & V

Children with GMFCS level I & II function should have a clinical and radiographic examination at 2, 6, and 10 years. In addition, they should have clinical examination at age 4 years and 8 years. Children with a Group IV hemiplegic gait pattern should have a clinical exam and x-ray every 2 years after the age 10 years till skeletal maturity.

Children with GMFCS level III function require clinical and radiographical examination every year till the age of 8 years. After 8 years, hip surveillance is carried out every 2 years till skeletal maturity if MP remains less than 30% and MP is stable (stability defined as <10% change in MP over a 12-month period). If a child enters hip surveillance after the age of 8 years, the child should have yearly radiograph for first 2 years and thereafter the frequency is reduced to once in 2 years..

Children with GMFCS level IV and V function should have a clinical and radiographic examinations every 6 months for the first two years. If the MP is less than 30% and MP is stable (stability defined as <10% change in MP over a 12-month period), clinical exams and imaging may be reduced to annual visit. Children at GMFCS level IV and V should have a clinical and radiographic examination every year till skeletal maturity. If a child enters hip surveillance after the age of 4 years, the child should have a radiograph every 6 months for the first 2 years and thereafter the frequency is reduced to annual x-rays.

If in doubt about the GMFCS level, consider the child to have a more severe GMFCS level and accordingly follow guidelines for that GMFCS level.

For quick visual reference please see the figure 7.

Time of discharge from hip surveillance

Children at GMFCS levels I & II are discharged at 10 years if the MP is stable and less than 30%. An exception is a child with Winter & Gage hemiplegic type 4 gait, who should be followed up till skeletal maturity.

Children at GMFCS levels III, IV & V are discharged when they attain skeletal maturity, have MP < 30%, and when pelvic obliquity and scoliosis are not progressive on clinical examinations. Closure of the triradiate cartilage on the AP pelvis x-ray is used to indicate skeletal maturity (Figure 8).

Exception: Child having MP > 30% or progressive pelvic obliquity or scoliosis requires continued surveillance.

What should be the further line of action after hip surveillance?
A child is referred to paediatric orthopaedic surgeons, if
• MP value is 30% or more
• If MP is less than 30% but a child has hip abduction less than 30 degrees
• If MP is less than 30% but a child has hip pain during a clinical exam
• If MP is less than 30% but child / family reports pain at hip during activities
All other children continue to undergo hip surveillance till they are discharged from the surveillance program.

Additional information:
Gross Motor Function Classification System (GMFCS)
The GMFCS is a validated classification system used to describe the gross motor function of children with CP. [4] The expanded and revised version of the GMFCS which is available online is used as a reference. It can be downloaded free of charge from the website https://www.canchild.ca/system/tenon/assets/attachments/000/000/058/original/GMFCS-ER_English.pdf

The GMFCS classifies the children and young adults into five levels on the basis of their self-initiated movement with particular emphasis on sitting, walking, and wheeled mobility. The GMFCS has five levels for describing differences in severity of motor abilities. Distinctions between levels are based on functional limitations, the need for hand-held mobility devices or wheeled mobility. For different age groups, separate descriptions are provided. Generally, it takes only a few minutes to assign a GMFCS level.
The GMFCS is relatively stable but in small children it is likely to change. [5] So, it is important that during each visit, GMFCS level is reconfirmed or re-evaluated.

GMFCS levels I & II suggest a child who is ambulatory without handheld mobility aid. Figure 9 & 10 represent typical GMFCS I & II children in the age group of 6 to 12 years.

GMFCS level III suggests a child who is ambulatory with handheld mobility aid. Figure 11 represents typical GMFCS III children in the age group of 6 to 12 years.

GMFCS level IV represents a child who is a marginal ambulator. For walking, they need the help of a caretaker and the mobility aid (Figure 12). Child at GMFCS level V is considered non-ambulatory (Figure 13).

Winters, Gage and Hicks (WGH) type 4 gait
Winters, Gage and Hicks described four types of gait pattern in hemiplegic children with CP. [6] This classification was based on the sagittal plane kinematics of the ankle, knee, hip and pelvis. The Australian CP group added frontal and transverse planes kinematics to this classification. Child with type 4 gait walks with hip flexed, adducted and internally rotated, knee flexed and ankle in equinus. (Figure 14) Type 4 child can be distinguished easily by gait observation. One does not need computerised gait analysis for identifying this gait pattern.

Key points
• Hip Surveillance detects hip displacement early and reduces the need for major surgeries.
• Hip surveillance can be carried out by all medical and allied healthcare professionals involved in the care of children with CP.
• Children with all motor types of CP require hip surveillance.
• Surveillance frequency mainly depends on the GMFCS level and the age of the child.
• Migration percentage is used to quantify the severity of hip displacement on standardised AP pelvis radiographs.
• A child is referred to a paediatric orthopaedic / orthopaedic surgeon if MP value is 30% or more, hip abduction is less than 30 degrees, or if hip pain is reported during clinical examination or while performing certain activities.

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References

1. 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.
2. 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.
3. Reimers, J. The stability of the hip in children. A radiological study of the results of muscle surgery in cerebral palsy. Acta Orthop Scand 1980; 184: S1-100.
4. Wood E, Rosenbaum P. The gross motor function classification system for cerebral palsy: a study of reliability and stability over time. Dev Med Child Neurol 2000; 42: 292– 96.
5. Palisano RJ, Cameron D, Rosenbaum PL, Walter SD, Russell D. Stability of the gross motor function classification system. Dev Med Child Neurol 2006; 48: 424– 28.
6. Winters T, Gage J, Hicks R. Gait patterns in spastic hemiplegia in children and young adults. J Bone Joint Surg Am 1987; 69(3): 437-441.

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How to Cite this Article:  Johari AN, Ganjwala D, Aroojis A | Indian Hip Surveillance Guidelines for Children with Cerebral Palsy | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 02-08 . https://doi.org/10.13107/ijpo.2024.v10i01.171

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