The success of networking –

hip surveillance model for better care

of patients with Cerebral Palsy in Germany

Gunnar Hägglund, MD, PhD

Department of Orthopaedics

University Hospital

Lund, Sweden

GMFCS V

MP = 55%

HSA = 185o

”Dislocation of the hip in

cerebral palsy is

preventable”

M.O. Tachdjian 1956

WHY ?

Follow-up program

for cerebral palsy

1994

Prevent

hip dislocation

Prevent

contractures

Time

Deformity

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

I

II

III

IV

V

Age

GMFCS

Examination once a year

Examination twice a year

Clinical examination PT and OT

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

I

II

III

IV

V

GMFCS

Age

Examination once a year

Individually based examination

Radiographic schedule - hips

CPUP vs Australien

2 3 4 5 6 7 8 9 10 12 13 14 15 16

I

CPUP II

III

IV

V

I

Australien II

III

IV

V

100%

162%

OK

Watch out

Problem !

> 40

33-40

< 33

Early experiences

- Improved collaboration

- Detection of hip displacements

- Early detection of contractures

10-year follow -up

The natural history of hip dislocation

in cerebral palsy

About 15% of the total population

of children with CP would develop

hip dislocation

J Bone Joint Surg 2005;87B:95-101

20-year follow-up

Before CPUP

Born 1990-91

N = 87

CPUP

Born 1992-2007

N = 689

Hip dislocation

N = 9 (10%)

Hip dislocation

N = 2 (0.3%)

Adductor-psoas release

N = 55

Femoral varus osteotomy

N = 36

Femoral varus osteotomy

N= 25

N = 10

N = 5

Preventive surgery among 689 children

GMFCS V

GMFCS IV

GMFCS III

GMFCS I - II

20 %

10 %

30 %

40 %

50 %

Age

Preventive surgery related to age and GMFCS

Surgical prevention of hip dislocation

Adductor –

psoas

release

Femoral

osteotomy

Pelvic

osteotomy

When?

What muscles?

Tenotomy or

lengthening?

When?

What degree?

Shortening?

Derotation?

Uni- or

bilateral?

When?

How?

MP

30

100

Age

MP

30

100

Age

40

Hägglund et al MP > 40

0

10

20

30

40

50

60

70

80

90

100

I II III IV V

BMC Musculoskeletal Disorders 2007, 8:101

Risk factors for hip displacement:

Gross Motor Function (GMFCS)

BMC Musculoskeletal Disorders 2007, 8:101

Risk factors for hip displacement:

Ålder vid RI > 40

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10 11 12

Age

Risk factors for hip displacement:

Migration Percentage (a/D x 100)

Head-shaft angle

Risk factors for hip displacement:

Bone Joint J 2015;97-B:1441-4

GMFCS

Age

MP

HSA

AUC = 0.87

6

170

34

10-20 %

GMFCS IV

HSA 170

MP 34

Age 6

Risk 10 - 20%

170

34

6

50-60 %

GMFCS V

HSA 170

MP 34

Age 6

Risk 50 - 60%

III IV V

170

34

6

50-60 %

GMFCS V

HSA 170

MP 34

Age 6

Risk 50 - 60%

III IV V

180

34

6

70-80 %

GMFCS V

HSA 180

MP 34

Age 6

Risk 70- 80%

III IV V

180

34

3

90-100%

GMFCS V

HSA 180

MP 34

Age 3

Risk 90- 100%

MP

30

100

Age

1994

N = 7500

+ 600 new

cases/year

General

Country-specific

Challenges and obstacles

Identify all individuals with CP

Identify all individuals

BMC Pediatrics 2007, 7:41

Prevalence 2.4 / 1000

Acta Peadiatrica 2007; 90: 1271-1276

Identify all individuals with CP

Hip radiograph from an early age

Hip displacement - age Ålder vid RI > 40

0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10 11 12

Age

N

BMC Musculoskeletal Disorders 2007, 8:101

Identify all individuals with CP

Hip radiograph from an early age

Fast-track to treatment

2012;54:951-957

335 children

12 hip dislocations = 4%

”Long waiting list for op”

Children born 1996-2003

GMFCS III-V

Norway

Prevalence CP 2.65/1000

GMFCS III-V 34%

Hip dislocation 15%

Hip surgery 46%

◦ Tenotomy 24%

◦ Femur osteotomy 9%

◦ Pelvic osteotomy 9%

◦ Salvage surgery 3%

Sweden

2.7/1000

38%

1%

32%

12%

15%

4%

0%

BMC Musculoskeletal Disorders 2011:12:284

Age at first hip operation

0

2

4

6

8

10

12

14

16

18

< 2 2 - < 4 4 - < 6 6 - < 8 8 - < 10 10 - < 12 12 - < 14

Age categories - years

Nu

mb

er o

f ch

ild

ren

Patients hip operated

(Sweden)

Patients hip operated

(Norway)

0

2

4

6

8

10

12

14

16

18

< 2 2 - < 4 4 - < 6 6 - < 8 8 - < 10 10 - < 12 12 - < 14

Age categories - years

Nu

mb

er o

f ch

ild

ren

Patients hip operated

(Sweden)

Patients hip operated

(Norway)

Identify all individuals with CP

Hip radiograph from an early age

Fast-track to treatment

Consensus and collaboration

Reports of individual data

General

Country-specific

Challenges and obstacles

Country-specific:

Economy – funding

Health care organisation

Laws and regulations

Challenges and obstacles

Hip surveillance

in cerebral palsy