A Comparison of Hip Spica Casting to Short Leg Casts and Bar after Hip Reconstruction in Cerebral Palsy

Abstract

Background Immobilization after hip reconstruction in children with cerebral palsy varies according to surgeon preference. The effect of postoperative immobilization on postoperative pain is unknown. Success in achieving hip stability and complications may also differ depending on the immobilization technique utilized. Questions/purposes Using retrospective data, we aimed to evaluate: (a) what effect does postoperative immobilization with hip spica casting versus short leg casts and bar (SLCaB); have on pain and pain management in children with quadriplegic cerebral palsy undergoing femoral and/or pelvic osteotomy? and (b) Do complications and radiographic outcomes differ between those treated postoperatively with hip spica casting and those in short leg casts? Materials and Methods Children with quadriplegic cerebral palsy (GMFCS IV-V, mean age 7.8 years [range: 3-15 years]) undergoing femoral or pelvic osteotomy between 2012 and 2014 in the treatment of spastic hip subluxation were reviewed. Modes of immobilization were compared, between spica casting (n=15) and SLCaB (n=12). Preoperative, perioperative, and postoperative pain was quantified between groups. In-hospital epidural dosage, morphine equivalent dosages (MED), adjunctive medications, early maintenance of radiographic hip stability, and all complications were noted and analyzed. Results Children were more likely to have spica cast immobilization if they were younger. Postoperative pain scores were similar between groups, with comparable patterns of epidural and MED administered during hospitalization. Spica casts were often flared up during hospitalization, but skin ulcers were uncommon and comparable between the two groups. Within 12 months of surgery, more ipsilateral femur fractures were observed distant to implants in the hip spica group, although the incidence of fractures did not meet statistical thresholds. Conclusion Spica casting and SLCaB after neuromuscular hip reconstruction did not show a difference in hip stability, narcotic pain medication usage or complication profile.

Keywords: cerebral palsy; neuromuscular hip subluxation; spastic hip subluxation; spica cast.

Figure 1. Treatment pathways for immobilization

Cerebral palsy (CP), Gross Motor Function Classification System (GMFCS), short leg casts and bar (SLCaB), short leg cast (SLC), knee immobilizer (KI), abduction pillow (Pillow), abduction brace (Brace), postoperative (PO), unilateral pelvic osteotomy (UPO).

Figure 2. Pain scores, morphine equivalent dosing, and epidurals during inpatient stay

The data in the above table represents mean and standard deviation. The main effects of the two-way analysis of variance (ANOVA) are listed above the bars. Holmes-Sidak post hoc test results: A) Main effect of time on Maximum Pain Score: Postoperative day one versus zero, one versus four, one versus five (P<0.001 for all). Postoperative day one versus six (P=0.004), two versus four (P=0.031), two versus five (P=0.034), two versus six (P=0.034). B) Epidural interactions: Within-group differences were the same for both spica and short leg casts and bar (SLCaB) and include postoperative day zero versus one, zero versus two, zero versus three, one versus three and two versus three (P<0.01 for all). C) Main effect of time on morphine equivalent dosing: Postoperative day zero versus three (P<0.001), zero versus four (P<0.001), zero versus five (P<0.001), one versus three (P=0.018), one versus four (P<0.001), two versus three (P<0.001), two versus four (P<0.001), two versus five (P=0.003). These results suggest no difference in overall pain scores between treatment groups, and no difference in epidural dosage or morphine equivalent dosages (MED) between spica or SLCaB groups. Epidural dosage peaked on days one and two in both groups, and MED peaked during days three to five in both groups.