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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
Transcript of The success of networking hip surveillance model for ... · The success of networking – hip...
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
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
