Primary surgery to prevent hip dislocation in children with cerebral palsy in Sweden: a minimum 5-year follow-up by the national surveillance program (CPUP)

Abstract

Background and purpose - Children with cerebral palsy (CP) have an increased risk of hip dislocation. Outcome studies after surgery to prevent hip dislocation in children with CP are usually retrospective series from single tertiary referral centers. According to the national CP surveillance program in Sweden (CPUP), hip surgery should preferably be performed at an early age to prevent hip dislocation. Preventive operations are performed in 12 different Swedish hospitals. We compared the outcomes between soft tissue release and femoral osteotomy in children with CP treated in these hospitals. Patients and methods - 186 children with CP underwent either adductor-iliopsoas tenotomy (APT) or femoral osteotomy (FO) as the primary, preventive surgery because of hip displacement. They were followed for a minimum of 5 years (mean 8 years) regarding revision surgery and hip migration. A good outcome was defined as the absence of revision surgery and a migration percentage (MP) < 50% at the latest follow-up. Logistic and Cox regression analysis were used to investigate the influence of age, sex, preoperative MP, Gross Motor Function Classification System (GMFCS) level, and CP subtype. Results - APT was performed in 129 (69%) children. After 5 years, the reoperation rate was 43%, and 2 children (2%) had an MP > 50%. For the 57 children who underwent FO, the corresponding figures were 39% and 9%. Of the potential risk factors studied, the outcome was statistically significantly associated with preoperative MP only in children who underwent APT, but not in those who underwent FO. None of the other factors were significantly associated with the outcome in the 2 procedure groups. Interpretation - Reoperation rates after preventive surgery are high and indicate the importance of continued postoperative follow-up. Age, sex, GMFCS level, and CP subtype did not influence the outcome significantly.

Figure 1.

Kaplan–Meier curves showing the proportion of failures with time after the index operation, bilateral adductor–psoas tenotomy, grouped according to the Gross Motor Function Classification System (GMFCS). GMFCS I–III and GMFCS IV–V are pooled for comparison of children who rely on a wheelchair for transport (GMFCS IV–V) with children more capable of walking (GMFCS I–III). Shaded areas represent 95% confidence intervals.

Figure 2.

Kaplan–Meier curves showing the proportion of failures with time after the index operation, femoral osteotomy, for all patients. Gross Motor Function Classification System (GMFCS) levels I–III are not shown because of the small numbers of patients. Shaded areas represent 95% confidence intervals. The vertical end of the red curve indicates that the last patient followed was reoperated.