Abstract
Background
The purpose of this study was to assess Indian orthopaedic surgeons’ current practices and beliefs regarding hip surveillance for children with cerebral palsy (CP), to determine potential support for developing hip surveillance guidelines, and to identify knowledge gaps and key obstacles to guideline implementation in India.
Methods
An anonymous, cross-sectional online survey was sent to approximately 350 Paediatric Orthopaedic Society of India (POSI) members who were queried on their practices and beliefs about hip surveillance for children with CP, as well as perceived challenges and requirements for the successful implementation of hip surveillance guidelines in the Indian context.
Results
Out of 107 responses obtained from POSI members, almost all (96.2%) agreed that hip displacement requires standardized monitoring, using surveillance and surgery to prevent hip dislocation. Approximately half (51.5%) of respondents reported using existing hip surveillance guidelines, with most (41.2%) using the Australian guidelines. Almost all (97%) surgeons indicated that hip surveillance guidelines in India are needed, with 100% expressing interest in following guidelines specific to India. Respondents most frequently indicated late referrals to orthopaedics (81.2%), loss of patients to follow-up (78.2%), and lack of resources (43.6%) as challenges to successful hip surveillance in India. Perceived requirements for implementation included developing Indian-specific guidelines (83.2%) as well as educating surgeons (56.4%), physiotherapists/pediatricians (90.1%), and families (82.2%).
Conclusion
Orthopaedic surgeons practicing in India understand the importance of preventing hip dislocations in children with CP through hip surveillance and timely surgical intervention. The results demonstrated strong support for the development of hip surveillance guidelines designed specifically for the Indian healthcare system.
Supplementary Information
The online version contains supplementary material available at 10.1007/s43465-021-00432-3.
Keywords: Cerebral palsy, Hip surveillance, Hip displacement, Survey
Introduction
Cerebral palsy (CP) describes a group of conditions, affecting the development of movement and posture, that are attributed to non-progressive disturbances in the fetal or infant brain [1]. In children with CP, hip displacement is the second most common musculoskeletal deformity, with an estimated incidence of approximately 35% [2, 3]. For most children with CP, the hip joint is normal at birth; however, the musculoskeletal pathology leads to progressive hip displacement [4–6]. Hip displacement often remains asymptomatic until the hip is dislocated, which can subsequently cause pain, impaired ability to stand, sit, or walk, and may negatively impact a child’s quality of life [3, 7–9]. The timing at which hip displacement is identified can impact the treatment options available. Preventive and reconstructive surgeries are recommended to treat progressive hip displacement prior to dislocation [4, 10–12]. Left undetected and untreated, salvage surgeries such as a femoral head resection with valgus osteotomy may be necessary if the severity of femoral head damage is too great to allow for reconstruction [11, 13, 14]. Salvage procedures are associated with inconsistent pain relief, high rates of revisions, and greater risk of complications, and are thus reserved as a last option for painful, dislocated hips [15, 16].
Hip surveillance is defined as the process of identifying and monitoring early indicators of hip displacement through systematic screening [17]. The goal of hip surveillance is to identify hip displacement early and ensure a child is seen by an orthopaedic surgeon when all treatment options are available [18]. To date, national and regional surveillance programs have been developed and adopted in parts of Australia, Canada, and Europe, with evidence supporting the use of surveillance to prevent dislocations and avoid the need for salvage surgery [17, 19–22]. Although there is growing evidence to support the need for hip surveillance for children with CP, there are currently no standardized guidelines in India, the world’s second-most populous country with an estimated population of 1.37 billion people in 2019 [23]. Existing surveillance programs are designed to meet the needs of the local populations and healthcare systems and may not be transferrable to developing countries such as India. Creating a national standard for hip surveillance in India would require the support of pediatric orthopaedic surgeons providing care to children with CP, as hip surveillance is successful only when combined with timely orthopaedic intervention. The purpose of this study was to investigate the variation in beliefs, practices, and attitudes related to hip surveillance in children with CP among pediatric orthopaedic surgeons in India. A secondary objective was to investigate surgeons’ perceived obstacles to implementing hip surveillance in India and possible strategies for success.
Materials and Methods
A 31-item survey was developed, based on current literature and consensus opinions, and reviewed by all authors (Appendix 1). The study was approved by the institutional Research Ethics Board and the Paediatric Orthopaedic Society of India (POSI) Research and Grants Committee. The anonymous survey was electronically distributed by email and the messaging platform WhatsApp to approximately 350 orthopaedic surgeons who were members of POSI.
The survey included questions related to surgeon demographics, practice, and beliefs about hip surveillance. Respondents were asked to estimate compliance for getting X-rays and surgery among their patients with CP and were also asked to report their confidence in completing different components of hip surveillance. To understand attitudes and beliefs towards hip surveillance, respondents were given a series of five statements regarding hip surveillance and were asked to select their agreement on a 5-point Likert scale. Questions then explored whether surgeons believed there was a need for hip surveillance, when a child should be referred to an orthopaedic surgeon, as well as critical elements and perceived obstacles to implementing hip surveillance for children with CP in India. Finally, respondents were asked to identify if they currently follow surveillance guidelines. These respondents were further asked to indicate the type of guidelines, perceived effectiveness of the guideline, and frequency with which the guideline was followed. Survey responses were collected and managed using the Research Electronic Data Capture (REDCap), a secure web application designed for building and managing online surveys and databases, hosted at our research institution. Data were analyzed using descriptive statistics.
Results
Demographic Data
A total of 107 responses were collected from orthopaedic surgeons who were members of POSI (30.6% response rate). It was not mandatory for the respondents to answer every question of the survey. If > 90% of the survey questions were answered, the responses were included in the final analysis. The entire questionnaire was completed by 99/107 (92.5%) respondents and the remaining 8 completed > 90% of the survey questions. The respondents’ demographics and practice characteristics are summarized in Table 1. The mean years in practice was 12 years (ranging from 1 to 48 years). Most respondents indicated having received fellowship training in an orthopaedic sub-specialty, with 90.3% of those with sub-specialty training selecting Pediatric Orthopaedics (Table 1).
Table 1.
Summary of respondent demographics and practice characteristics
| Years in practice (n = 107) | |
| 0–5 years | 31 (29.0%) |
| 6–10 years | 30 (28.0%) |
| 11–15 years | 16 (15.0%) |
| 16–20 years | 11(10.3%) |
| 21 + years | 19 (17.8%) |
| Orthopaedic sub-specialty fellowship training (n = 93) | |
| Pediatric orthopaedics | 84 (90.3%) |
| Other | 9 (9.7%) |
| Urban vs. Rural (n = 107) | |
| Urban | 92 (86.0%) |
| Rural | 10 (9.3%) |
| Semi-urban | 5 (4.7%) |
| Practice setting (n = 106) | |
| Private clinic or nursing home | 26 (24.5%) |
| Corporate hospitals | 16 (15.1%) |
| University or teaching hospital | 23 (21.7%) |
| Combined private and teaching hospital | 40 (37.7%) |
| Other | 1 (0.9%) |
| Pediatric caseload (n = 107) | |
| 0–20% | 10 (9.3%) |
| 21–40% | 11 (10.3%) |
| 41–60% | 10 (9.3%) |
| 61–80% | 21 (19.6%) |
| 81–100% | 55 (51.4%) |
| CP Caseload (n = 102) | |
| 0–20% | 52 (51.0%) |
| 21–40% | 36 (35.3%) |
| 41–60% | 10 (9.8%) |
| 61–80% | 3 (2.9%) |
| 81–100% | 1 (1.0%) |
| Follow-up frequency (n = 106) | |
| As needed | 19 (17.9%) |
| Once per year | 8 (7.5%) |
| Twice per year | 32 (30.2%) |
| More than twice per year | 47 (44.3%) |
| Age of referral to orthopaedic surgeon (n = 107) | |
| < 2 years old | 13 (12.1%) |
| 2–5 years old | 70 (65.4%) |
| 6–10 years old | 24 (22.4%) |
| > 10 years old | 0 (0%) |
Surgeon caseloads were, on average, 74.9% pediatric, with an average 26.4% of pediatric caseloads being children with CP. Surgeons reported seeing an average of seven (range 0 to 50) patients with CP who had a Reimer’s migration percentage of 100% in the past 12 months. Referral and follow-up frequency practices among respondents are shown in Table 1.
Compliance with X-rays and Surgery
On average, respondents reported that 65.1% of patients follow their advice for getting repeated/regular X-rays and less than half of parents/families (48.5%) comply with surgeon recommendations to undergo surgery for hip displacement. Table 2 shows the probable reasons why patients may not comply with either X-ray or surgery. While cost (selected by 24.3% of respondents) may be a factor, more than two-thirds of respondents felt that lack of awareness of the importance of hip surveillance may prevent parents from complying with their surgeon’s recommendations for regular X-rays. Lack of finances and fear of surgery were selected by > 60% of respondents and over one-fifth (21.5%) of respondents felt that other healthcare providers involved in the care of these children, including physiotherapists, neurologists, and primary care physicians, occasionally advise against timely hip surgery.
Table 2.
Reasons for lack of X-ray and surgery compliance among respondents’ patients with CP
| X-ray noncompliance reasons (n = 107) | |
| Cost | 26 (24.3%) |
| Worry about radiation from repeated X-rays | 14 (13.1%) |
| Not understanding the importance of hip surveillance | 73 (68.2%) |
| Difficulty accessing X-ray | 6 (5.6%) |
| Another healthcare provider advises against X-ray | 9 (8.4%) |
| Physiotherapist | 6 (66.7%) |
| Neurologist | 3 (33.3%) |
| General practitioner or family doctor | 9 (100%) |
| Pediatrician | 4 (44.4%) |
| Other healthcare provider | 2 (22.2%) |
| Other | 9 (8.4%) |
| Surgery noncompliance reasons (n = 107) | |
| Lack of proper counselling | 7 (6.5%) |
| Cost/Lack of resources | 68 (63.6%) |
| Fear of surgery | 67 (62.6%) |
| Poor health and nutrition | 31 (29.0%) |
| Another healthcare provider advises against surgery | 23 (21.5%) |
| Physiotherapist | 19 (82.6%) |
| Neurologist | 10 (43.5%) |
| General practitioner or family doctor | 17 (73.9%) |
| Pediatrician | 10 (43.5%) |
| Other healthcare provider | 5 (21.7%) |
| Other | 12 (11.2%) |
Beliefs about Hip Displacement and Surveillance in CP
Responses related to beliefs about hip displacement and surveillance are shown in Table 3. More than 80% of respondents strongly felt that hip displacement in children with CP is a problem that requires standardized monitoring and is preventable with regular surveillance and timely surgical intervention. Levels of confidence in completing different aspects of hip surveillance are summarized in Table 4. When queried specifically about hip surveillance in India, almost all surgeons (97.0%, 96/99) expressed a need for an Indian hip surveillance guideline, with 100% (99/99) expressing interest in following a guideline. Table 5 shows when respondents thought a child should be seen by an orthopaedic surgeon for concerns about hip displacement and perceived challenges to successful surveillance in India. Approximately two-thirds of respondents (65.3%) selected that the child should be referred to the orthopaedic surgeon once the migration percentage exceeds 30%.
Table 3.
Respondents’ agreement with statements about beliefs and practice related to hip surveillance in children with CP
| Level of agreement | 1 Not at all (%) | 2 (%) | 3 (%) | 4 (%) | 5 Very much so (%) |
|---|---|---|---|---|---|
| A dislocated hip will become painful in a child with CP (n = 104) | 0 | 2.9 | 10.6 | 26.9 | 59.6 |
| Hip displacement in children with CP is a problem that requires standardized monitoring (n = 104) | 0 | 1.0 | 2.9 | 14.4 | 81.7 |
| Hip dislocation should be prevented by hip surveillance and surgical treatment (n = 104) | 0 | 1.0 | 2.9 | 13.5 | 82.7 |
| Hip displacement should be assessed by measuring Reimer’s migration percentage on an AP pelvis radiograph (n = 102) | 0 | 2.0 | 2.9 | 17.6 | 77.5 |
| I identify Gross Motor Function Classification System (GMFCS) levels for all my patients with CP. (n = 104) | 1.0 | 1.9 | 2.9 | 10.6 | 83.7 |
Table 4.
Respondents’ confidence in completing components of hip surveillance
| Level of confidence | 1 Not at all (%) | 2 (%) | 3 (%) | 4 (%) | 5 very much so (%) |
|---|---|---|---|---|---|
| Determining a child’s GMFCS level (n = 99) | 1.0 | 0.0 | 2.0 | 21.2 | 73.7 |
| Determining that a child has Group IV hemiplegic gait pattern (n = 99) | 2.0 | 3.0 | 6.1 | 35.4 | 53.5 |
| Determining how frequently a child with CP should have a hip X-ray for hip surveillance (n = 100) | 1.0 | 2.0 | 12.0 | 31.0 | 54.0 |
| Knowing which position the child should be placed in when having a hip X-ray (n = 99) | 1.0 | 2.0 | 12.1 | 19.2 | 65.7 |
Table 5.
Respondents’ beliefs about the timing of referral, challenges, and requirements for successful hip surveillance in India
| Timing of referral to an orthopaedic surgeon (n = 101) | |
| Once migration percentage is greater than 30% | 66 (65.3%) |
| Once migration percentage is greater than 40% | 19 (18.8%) |
| Once migration percentage is greater than 50% | 11 (10.9%) |
| Function has decreased, related to the hip | 51 (50.5%) |
| Hip abduction, with hips and knees in 90° of flexion, is < 30° | 45 (44.6%) |
| Hip abduction, with hips and knees in 0° of flexion, is < 30° | 48 (47.5%) |
| There is asymmetrical hip abduction | 66 (65.3%) |
| The child has increased pain, related to the hip | 64 (63.4%) |
| I don't know/I prefer not to answer | 1 (1.0%) |
| Other | 5 (5.0%) |
| Surveillance challenges (n = 101) | |
| Lack of buy-in from other healthcare professionals | 40 (39.6%) |
| Late referrals to the orthopaedic surgeon | 82 (81.2%) |
| Lack of resources | 44 (43.6%) |
| Loss to follow-up | 79 (78.2%) |
| Lack of standardized X-rays | 32 (31.7%) |
| Families worry about too many X-rays | 13 (12.9%) |
| Other | 7 (6.9%) |
| Surveillance requirements (n = 101) | |
| Designing a guideline considering the Indian factors in mind | 84 (83.2%) |
| Better training to pediatric orthopaedic surgeons | 57 (56.4%) |
| Making physiotherapists/pediatricians more aware about its importance | 91 (90.1%) |
| Making family members more aware about its importance | 83 (82.2%) |
| Other | 7 (6.9%) |
Table 5 also shows the orthopaedic surgeons’ requirements for successful surveillance in India. When queried further on which healthcare providers would be critical to successful guidelines in India, the most frequently selected healthcare providers were orthopaedic surgeons (88.0%, 88/100), followed by physiotherapists (86.0%, 86/100), neurologists (65.0%, 65/100), and occupational therapists (45.0%, 45/100). Respondents also identified pediatricians, general practitioners, non-governmental organizations, special education facilities, accredited social health activist (ASHA) workers, and government rural healthcare workers as being important to the success of hip surveillance in India.
Use of Existing Hip Surveillance Guidelines
Utilization of guidelines, their perceived effectiveness, and adherence to guidelines are shown in Table 6. Approximately half (51.5%, 51/99) of surgeons reported using a hip surveillance guideline in their own practice, with most using the Australian Standards of Care (41.2%). Of those respondents who did not follow a guideline, 43.2% (19/44) indicated that they were aware of guidelines for CP hip surveillance, most notably the Australian guidelines and the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) Care Pathway.
Table 6.
Characteristics of respondents who reported following a hip surveillance guideline
| Guideline type (n = 51) | |
| Australian Standards of Care | 21 (41.2%) |
| Sweden’s CPUP | 0 (0%) |
| British Columbia, Canada’s Hip Surveillance Consensus | 4 (7.8%) |
| AACPDM Hip Surveillance Care Pathway | 12 (23.5%) |
| Alfred I. duPont Institute (Freeman Miller) recommendations | 10 (19.6%) |
| Other | 4 (7.8%) |
| Guideline effectiveness (n = 51) | |
| Effective | 50 (98.0%) |
| Not effective | 1 (2.0%) |
| Frequency of guideline adherence (n = 51) | |
| < 25% | 0 (0%) |
| 25–50% | 3 (5.9%) |
| 50–75% | 17 (33.3%) |
| > 75% | 31 (60.8%) |
Discussion
Pediatric orthopaedic surgeons in India support the prevention of hip dislocations in children with CP through regular hip surveillance and timely surgical intervention, despite some variation in practice with regards to hip surveillance. There is also strong support among orthopaedic surgeons for the development of Indian-specific hip surveillance guidelines for children with CP, with almost all respondents indicating both a need for and interest in implementing national guidelines. Despite agreement on the importance of hip surveillance in children with CP, just 51.5% of respondents reported using existing guidelines in their own practice, and even of those that do, only 39.2% follow those guidelines 75% of the time or less. These findings draw similarities to the findings of a survey of POSNA membership, which found that 18% of their respondents followed a specific CP hip surveillance protocol, with 21% following the guidelines 75% of the time or less [24]. Inconsistent use of guidelines contributes to the variation in screening, diagnosis and management of hip displacement, thereby increasing costs and impacting the quality of care that is provided [24]. The inconsistent use of hip surveillance but high guideline awareness among respondents may also suggest that the current hip surveillance protocols are not entirely applicable to the Indian context, emphasizing the need to develop and implement a tailored hip surveillance guideline in India.
While developing CP hip surveillance guidelines, education of orthopaedic surgeons on the clinical and radiographic components of hip surveillance will be necessary. Encouragingly, 83.7% of respondents indicated that they identify the Gross Motor Function Classification System (GMFCS) level for all of their patients with CP; however, only 73.7% indicated that they were very confident in determining the GMFCS level. The ability to confidently identify the GMFCS level is critical, as existing hip surveillance guidelines use GMFCS levels to guide the frequency of hip surveillance [17, 19, 20, 25]. Future studies are needed to evaluate the knowledge and use of GMFCS among general orthopaedic surgeons in India. Migration percentage (MP) is the most widely accepted and most frequently used radiological measure to monitor and identify risk of hip displacement [26]. The standardized positioning of the pelvis with neutral adduction/abduction, flattened lordosis, neutral pelvic obliquity, and patella facing upwards is of critical importance to correctly measure MP—this also ensures the reliability of measurements taken between subsequent radiographs [17, 19, 25, 27]. While almost all respondents (95.1%) agreed that hip displacement should be assessed by measuring Reimer’s MP on an AP pelvis radiograph, 15.1% of surgeons indicated that they were not at all or only somewhat confident with knowing in which position a child should be placed for a hip X-ray.
Surgeons reported that only two-thirds of their patients follow their recommendation for regular/repeated X-rays, with the most common reasons for not following recommendations being the patient/family’s lack of understanding about the importance of X-rays, followed by cost and radiation concerns. A study by Toovey et al. examining the experiences of parents of children with CP when engaging with hip surveillance in Australia, similarly identified a lack of knowledge among parents as a barrier to engagement [28]. These findings emphasize the need to educate parents and families on the value of hip surveillance and the importance of following the schedule of clinical and radiographic examinations. Parents and families who are educated about the subject may be more likely to play an active role in their child’s hip surveillance [28]. Education may also aid in decreasing the number of patients lost to follow-up, which was one of the most frequently identified challenges to implementing guidelines in India. Recommendations for surgery were reported to be followed less often than recommendations for imaging at just 48.5%. Fear of surgery, lack of finances, and poor health and nutrition were the most frequent reasons surgeons reported for their patients refusing surgery. Further exploration of why patients may not be undergoing surgery will be important, as hip surveillance is only advantageous if the child undergoes surgery when recommended. Taken together, these results highlight a need to increase awareness of the value of hip surveillance and treatment of hip displacement among families of children with CP in India. Ensuring that the perspectives of Indian parents and families are included and understood will be important for future guideline development. In British Columbia, Canada, the Child Health BC Hip Surveillance Program involved parents of children with CP in the consensus-building and program implementation process, emphasizing the need to consider the child and family when establishing and implementing a surveillance guideline [29].
Although it is evident that orthopaedic surgeons in India are willing to adopt national guidelines, there must be a collaborative effort among all critical members of a child’s healthcare team for hip surveillance to be successful. The results of the survey showed that 21.5% of respondents had other healthcare providers occasionally advise against surgery. This corresponds to the opinion of many respondents who felt that a lack of buy-in from other healthcare professionals and late referrals may be a significant barrier to guideline implementation. Important healthcare providers that were identified in this survey include neurologists, pediatricians, and physiotherapists. It will be important to work collaboratively with these groups to examine these potential challenges in more depth. Involving and educating other healthcare providers will be especially important, as orthopaedic surgeons may not see patients with CP at an early enough age for hip surveillance to be effective. Lack of resources was identified as a challenge to surgery compliance (63.6%) and guideline implementation (43.6%) and will also need to be considered when developing feasible guidelines for the Indian healthcare system.
There was a substantial variation among respondents as to what MP warrants a referral to an orthopaedic surgeon. While over 60% of respondents selected MP > 30%, 18.8% selected MP > 40% and 10.9% selected MP > 50%. Existing guidelines most commonly use MP > 30% as an indication for a child to be referred to an orthopaedic surgeon as this is the threshold for an “at risk” hip [3, 17, 19, 25, 26]. In contrast, surgical intervention is often considered once MP exceeds 40% or 50% [27, 30]. While developed countries with universal healthcare may have the capacity to support the referral of children at a lower MP, the Indian healthcare system may not be able to support this practice. Surgeons in India may wish to see children when they are more likely to require surgical intervention. Alternatively, since an overwhelming majority (81.2%) felt that late referrals posed a challenge to hip surveillance in India, healthcare providers may elect to set the threshold lower to account for the time delay that often occurs between examination and referral, particularly in rural or underserved areas.
These survey results offer important insights into developing hip surveillance guidelines in a developing country and will be used to inform future discussions regarding guideline development in India. Current hip surveillance guidelines have been developed and applied in first world countries with universal healthcare and may not be relevant to the Indian context. While the development of a nation-wide program may be challenging, given India’s large population size and diversity of practice settings, it is important for healthcare providers in India to adopt a standardized guideline for hip surveillance in children with CP that works within their own setting. With a population of approximately 1.37 billion people [23], the development of national guidelines has the potential to benefit many children with CP and their families.
This study has several limitations. Most respondents reported practicing in urban areas, thus the results here may not apply to orthopaedic surgeons who practice in a rural setting. The use of a survey to collect information is also an inherent limitation. The responses collected may only reflect a particular viewpoint, and non-respondents may have very different beliefs and attitudes about hip surveillance which we were unable to collect. Additionally, although the survey aimed to capture all aspects of practice, beliefs, and attitudes towards hip surveillance, it could not capture a complete understanding of the respondents’ feelings, opinions, or experiences with regards to surveillance. Despite these limitations, this study provides valuable information in understanding current practice and informing next steps toward guideline development in India.
Conclusion
There is strong support among pediatric orthopaedic surgeons in India for the prevention of hip dislocations in children with CP through hip surveillance and surgical intervention. In order for successful implementation to occur, it will be necessary to resolve context-specific barriers to surveillance that were identified in this survey. Solutions include educating families and members of the child’s healthcare team on the importance of hip surveillance and more training to orthopaedic surgeons and allied professionals on the components of surveillance.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors would like to acknowledge the Executive Council and the Research and Grants Committee of the Paediatric Orthopaedic Society of India (POSI) for permission to conduct this survey. We would also like to acknowledge Benjamin Shore for his contributions toward this work.
Authors’ Contributions
The survey was conceptualized and designed by JL, SM, EKS and KM. DG, AJ and AA adapted the survey for an Indian population, developed the study protocol and distributed the survey. JL, SM and EKS aided in data collection, data analysis, and data interpretation. The first draft of the manuscript was written by JL and edited by DG, AJ, SM, EKS and AA. All authors read and approved the final manuscript.
Funding
This work was partially funded by I’m a HIPpy Foundation, the Peterson Fund for Global Hip Helath, and Divis Foundation for Gifted Children.
Declarations
Conflict of Interest
Kishore Mulpuri has received research support from Allergan, Pega Medical and Depuy Synthes (Johnson and Johnson). None are directly relevant to the research in this paper. For the remaining authors none were declared.
Contributor Information
Jacqueline Li, Email: jacqueline.li@bcchr.ca.
Dhiren Ganjwala, Email: ganjwala@gmail.com.
Ashok Johari, Email: drashokjohari@hotmail.com.
Stacey Miller, Email: smiller4@cw.bc.ca.
Emily K. Schaeffer, Email: emily.schaeffer@cw.bc.ca
Kishore Mulpuri, Email: kmulpuri@cw.bc.ca.
Alaric Aroojis, Email: aaroojis@gmail.com.
References
- 1.Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy April 2006 [published correction appears in Dev Med Child Neurol. 2007;49(6):480] Developmental Medicine and Child Neurology Supplement. 2007;109:8–14. [PubMed] [Google Scholar]
- 2.Cornell MS. The hip in cerebral palsy. Developmental Medicine and Child Neurology. 1995;37(1):3–18. doi: 10.1111/j.1469-8749.1995.tb11928.x. [DOI] [PubMed] [Google Scholar]
- 3.Soo B, Howard JJ, Boyd RN, et al. Hip displacement in cerebral palsy. Journal of Bone Joint Surgery American. 2006;88(1):121–129. doi: 10.2106/JBJS.E.00071. [DOI] [PubMed] [Google Scholar]
- 4.Flynn JM, Miller F. Management of hip disorders in patients with cerebral palsy. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2002;10(3):198–209. doi: 10.5435/00124635-200205000-00006. [DOI] [PubMed] [Google Scholar]
- 5.Graham HK. Painful hip dislocation in cerebral palsy. The Lancet. 2002;359(9310):907–908. doi: 10.1016/s0140-6736(02)08015-7. [DOI] [PubMed] [Google Scholar]
- 6.Graham HK, Selber P. Musculoskeletal aspects of cerebral palsy. Journal of Bone Joint Surgery American. 2003;85(2):157–166. doi: 10.1302/0301-620x.85b2.14066. [DOI] [PubMed] [Google Scholar]
- 7.Bagg MR, Farber J, Miller F. Long-term follow-up of hip subluxation in cerebral palsy patients. Journal of Pediatric Orthopaedics. 1993;13(1):32–36. doi: 10.1097/01241398-199301000-00007. [DOI] [PubMed] [Google Scholar]
- 8.Jung NH, Pereira B, Nehring I, et al. Does hip displacement influence health-related quality of life in children with cerebral palsy? Developmental Neurorehabilitation. 2014;17(6):420–425. doi: 10.3109/17518423.2014.941116. [DOI] [PubMed] [Google Scholar]
- 9.Wawrzuta J, Willoughby KL, Molesworth C, et al. Hip health at skeletal maturity: a population-based study of young adults with cerebral palsy. Developmental Medicine and Child Neurology. 2016;58(12):1273–1280. doi: 10.1111/dmcn.13171. [DOI] [PubMed] [Google Scholar]
- 10.Presedo A, Oh CW, Dabney KW, Miller F. Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. Journal of Bone Joint Surgery American. 2005;87(4):832–841. doi: 10.2106/JBJS.C.01099. [DOI] [PubMed] [Google Scholar]
- 11.Robb JE, Hägglund G. Hip surveillance and management of the displaced hip in cerebral palsy. Journal of Children's Orthopaedics. 2013;7(5):407–413. doi: 10.1007/s11832-013-0515-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Rutz E, Vavken P, Camathias C, Haase C, Jünemann S, Brunner R. Long-term results and outcome predictors in one-stage hip reconstruction in children with cerebral palsy. Journal of Bone Joint Surgery American. 2015;97(6):500–506. doi: 10.2106/JBJS.N.00676. [DOI] [PubMed] [Google Scholar]
- 13.Hogan KA, Blake M, Gross RH. Subtrochanteric valgus osteotomy for chronically dislocated, painful spastic hips. Journal of Bone Joint Surgery American. 2006;88(12):2624–2631. doi: 10.2106/JBJS.E.00918. [DOI] [PubMed] [Google Scholar]
- 14.McHale KA, Bagg M, Nason SS. Treatment of the chronically dislocated hip in adolescents with cerebral palsy with femoral head resection and subtrochanteric valgus osteotomy. Journal of Pediatric Orthopaedics. 1990;10(4):504–509. doi: 10.1097/01241398-199010040-00016. [DOI] [PubMed] [Google Scholar]
- 15.Kolman SE, Ruzbarsky JJ, Spiegel DA, Baldwin KD. Salvage options in the cerebral palsy hip: a systematic review. Journal of Pediatric Orthopedics. 2016;36(6):645–650. doi: 10.1097/BPO.0000000000000501. [DOI] [PubMed] [Google Scholar]
- 16.Wright PB, Ruder J, Birnbaum MA, Phillips JH, Herrera-Soto JA, Knapp DR. Outcomes after salvage procedures for the painful dislocated hip in cerebral palsy. Journal of Pediatric Orthopaedics. 2013;33(5):505–510. doi: 10.1097/BPO.0b013e3182924677. [DOI] [PubMed] [Google Scholar]
- 17.Wynter M, Gibson N, Kentish M, Love S, Thomason P, Kerr GH. The consensus statement on hip surveillance for children with cerebral palsy: australian standards of care. Journal of Pediatric Rehabilitation Medicine. 2011;4(3):183–195. doi: 10.3233/PRM-2011-0174. [DOI] [PubMed] [Google Scholar]
- 18.Wynter M, Gibson N, Willoughby KL, et al. Australian hip surveillance guidelines for children with cerebral palsy: 5-year review. Developmental Medicine and Child Neurology. 2015;57(9):808–820. doi: 10.1111/dmcn.12754. [DOI] [PubMed] [Google Scholar]
- 19.Miller S, Mulpuri K, O’Donnell M. British Columbia’s Consensus on Hip Surveillance for Children with Cerebral Palsy: Information for health care professionals caring for children with cerebral palsy. Child Health BC, Vancouver, BC. 2018. www.childhealthbc.ca/hips. (Accessed 3 Mar 2021).
- 20.Hägglund G, Alriksson-Schmidt A, Lauge-Pedersen H, Rodby-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. The Journal of Bone and Joint Surgery. British Volume. 2014;96(11):1546–1552. doi: 10.1302/0301-620X.96B11.34385. [DOI] [PubMed] [Google Scholar]
- 21.Kentish M, Wynter M, Snape N, Boyd R. Five-year outcome of state-wide hip surveillance of children and adolescents with cerebral palsy. Journal of Pediatric Rehabilitation Medicine. 2011;4(3):205–217. doi: 10.3233/PRM-2011-0176. [DOI] [PubMed] [Google Scholar]
- 22.Gordon GS, Simkiss DE. A systematic review of the evidence for hip surveillance in children with cerebral palsy. The Journal of Bone and Joint Surgery. British Volume. 2006;88(11):1492–1496. doi: 10.1302/0301-620X.88B11.18114. [DOI] [PubMed] [Google Scholar]
- 23.United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects 2019: Highlights. https://population.un.org/wpp/Publications/Files/WPP2019_Highlights.pdf. (Accessed 3 Mar 2021).
- 24.Shore BJ, Shrader MW, Narayanan U, Miller F, Graham HK, Mulpuri K. Hip surveillance for children with cerebral palsy: a survey of the posna membership. Journal of Pediatric Orthopaedics. 2017;37(7):e409–e414. doi: 10.1097/BPO.0000000000001050. [DOI] [PubMed] [Google Scholar]
- 25.O’Donnell M, Mayson T, Miller S et al. AACPDM Hip surveillance in cerebral palsy care pathway. American academy for cerebral palsy and developmental medicine, Milwaukee, WI. 2017. https://www.aacpdm.org/publications/care-pathways/hip-surveillance. (Accessed 3 Mar 2021).
- 26.Reimers J. The stability of the hip in children. A radiological study of the results of muscle surgery in cerebral palsy. Acta Orthopaedica Scandinavica. 1980;184:1–100. doi: 10.3109/ort.1980.51.suppl-184.01. [DOI] [PubMed] [Google Scholar]
- 27.Shore B, Spence D, Graham H. The role for hip surveillance in children with cerebral palsy. Current Reviews in Musculoskeletal Medicine. 2012;5(2):126–134. doi: 10.1007/s12178-012-9120-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Toovey R, Willoughby KL, Hodgson JM, Graham HK, Reddihough DS. More than an X-ray: Experiences and perspectives of parents of children with cerebral palsy when engaging in hip surveillance. Journal of Pediatric Orthopedics and Child Health. 2020;56(1):130–135. doi: 10.1111/jpc.14537. [DOI] [PubMed] [Google Scholar]
- 29.Miller SD, Mayson TA, Mulpuri K, O'Donnell ME. Developing a province-wide hip surveillance program for children with cerebral palsy: from evidence to consensus to program implementation: a mini-review. Journal of Pediatric Orthopedics. Part B. 2020;29(6):517–522. doi: 10.1097/BPB.0000000000000707. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Hägglund G, Lauge-Pedersen H, Persson M. Radiographic threshold values for hip screening in cerebral palsy. Journal of Children’s Orthopaedics. 2007;1(1):43–47. doi: 10.1007/s11832-007-0012-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.