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Early hip development in the young child with cerebral palsy risk status and relationship to motor development in an early natural history study

R BOYD PHD MSC PT 1,2, C HARRISON 1, A MOODIE 1,2,
B LUTHER 1,2, P LUCK 1, M FAHEY 2, B RAWICKI 2

1. Queensland Cerebral Palsy Research Centre, University of Queensland, Brisbane, QLD, Australia;
2. Rehabilitation Sciences, Monash Medical Centre, Melbourne, VIC, Australia

Background/Objectives: Background: Little is known about early prospective hip development in children with CP and the relationship to motor function. Objective: To evaluate the relationship between the early hip displacements, motor type and gross motor functional classification level (GMFCS).

Design: Design: Prospective population based early natural history study.

Participants and Setting: Participants 103 children (53, 52% males), primary motor type (spasticity=77 (76%); 17 (17%) dystonia, 9 (7%) hypotonia) with GMFCS levels (I=34 (33%); II=18 (18%); III=12 (12%); IV=16 (16%); V=23 (21%).

Materials/Methods: Children were assessed at 6 monthly intervals from 18 months to 3 years corrected age by 2 independent raters. Outcomes measures were – GMFCS level (status and change), Migration Percentage (MP) and Acetabular dysplasia (AI≥ 27 0) of each hip, Hip asymmetry (≥10% difference in MP), Status of worst hip at 30 months (no risk MP≤ 10%, Moderate risk 11-29%, High risk MP≥ 30%), rate of change of worst hip (better≤10% change, same where rate was ± 10% MP change, and worse if ≥ 10% change) and progression to orthopaedic treatment. Hip radiographs were measured by 2 independent raters.

Results: (i) GMFCS (status and change): 66 (65%) did not change from 18-36 months ca, 32 (31%) improved [II to I (n=12), III to II (n=12), VI to III (n=2) and V to IV (n=6] and 5 subjects deteriorated (from II to III). (ii) Migration Percentage (MP) status of worst hip at 3 years:- 12 subjects (9%) subjects had normal MP (≤10%) and these were GMFCS levels I=6, II & III=2, IV=2, V=2. 68 subjects (68%) had moderate displacement (MP 11-30%) and were GMFCS I=23, II=17, III=12, IV=8, V=8. 23 subjects (23%) high risk hips (MP>30%) were GMFCS I=4, II=3, III=4, IV=4, V=8.(iii) Change in MP of worst hip over 12 months were: 53 (52%) were unchanged (MP change ±10%); 24 (23%) improved (MP decreased by ≥10%) and 26 (25 %) deteriorated (MP increased by ≥10%). (iii) Acetabular development (AI>27 0):- 28 subjects (27%) had AI >27 0. Of these 12 remained abnormal; 12 improved; and 4 deteriorated.(iv) Hip asymmetry: 63 subjects (61%) had a 10% difference in MP between hips. (v) Orthopaedic Rx: 8 subjects (GMFCS II=1; III=1; IV=2; V=4) underwent surgical intervention (6 STR adductors ±psoas, 2 BTX-A). Six subjects are under close review (GMFCS I=1, III=1, IV=2; V=2).

Conclusions/Significance: In young children with CP there is some change in gross motor levels (GMFCS) (mostly improvement), and this can occur across all levels. Marked hip displacement is quite common and can occur across the GMFCS levels. Acetabular index may start high and sometimes improves with age. GMFCS should be reclassified at 2 and 3 years. Standardized serial measures of MP and AI and GMFCS levels are recommended for early comprehensive surveillance of CP to examine amount of displacement as well as asymmetry between sides.

 
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