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Background/Objectives: Hip displacement is a common problem in children with cerebral palsy (CP). Typically, the recommended hip surveillance imaging for these children consists of an anteroposterior pelvic radiograph, from which we calculate the migration percentage (MP) to determine treatment plans (conservative/preventive therapy, femoral osteotomy, femoral and pelvic osteotomies, and salvage surgery). However, little is known about the accuracy of MP for treatment planning. We aim to compare treatment plans based on MP thresholds with plans determined by an orthopedic surgeon following review of the hip CTs. Methods: We retrospectively identified hip CTs performed in children who were ≤18 years old with CP (11/2018—07/2024). The inclusion criteria were: (1) a pelvic radiograph performed 6 months prior to the hip CT; and (2) no surgeries between the pelvic radiograph and the hip CT. These hip CTs were randomized and blindly reviewed by an orthopedic surgeon to determine each child’s treatment plan (CT-treatment). Separately, a pediatric radiologist blindly reviewed the randomized pelvic radiographs and measured each hip’s MP to determine each child’s treatment plan (XR-treatment). We used kappa-agreement and Bland–Altman analyses to compare XR- and CT-treatments. Results: Our study cohort consisted of 139 children (mean age = 9.3 ± 3.8 years; male = 90) with 278 hips. The proportion of agreement and unweighted kappa between XR- and CT-treatment were both low: 0.532 (148/278) and 0.339, respectively. Bland–Altman analyses showed that XR-treatment and CT-treatment were exchangeable when MP ≤ 10% but were not exchangeable otherwise. Conclusions: We should be cautious about relying exclusively on pelvic radiographs and subsequent MP calculation in making treatment decisions for hip displacement in children with CP since many anatomic details become evident on 3D imaging.

Background Hip displacement in children with cerebral palsy (CP) is monitored by measuring migration percentage on anteroposterior pelvis radiographs. However, proper positioning for radiography in children with spasticity is difficult. The reliability and accuracy of migration percentage as a function of patient positioning is unknown. Objective To determine the effects of patient positioning on migration percentage measurements in children with CP. Materials and methods We identified children with CP (≤18-year-old) with pelvis CT and anteroposterior pelvis radiograph obtained <6 months apart (10/2018–11/2021). Digitally reconstructed radiographs were generated from each pelvis CT, to simulate nine different patient positions: neutral; 10° and 20° lordosis and kyphosis; and 10° and 20° right rotation and left rotation. Two radiologists measured migration percentages from the simulated and real pelvis radiographs. We used Spearman’s rho to assess inter-rater reliability, and Wilcoxon signed rank test to determine statistical significance. Results We studied sixty-three children (male=41; median age=8 years; range=4–18 years). The two radiologists’ migration percentage measurements were highly correlated with each other across all simulated and real radiographs (Spearman’s rho=0.86–0.99, P <0.01). For both readers and hips, migration percentages measured from real radiographs were significantly different from those measured from neutral simulated radiographs ( P <0.01), with median absolute difference=5–6 percentage points (PP) and interquartile range (IQR)=9–12 PP. When comparing migration percentage measurements from neutral simulated radiographs to those in kyphosis/lordosis and right/left rotations, median absolute differences were 2–4 PP (IQR=3–8 PP) and 4–15 PP (IQR=6–17 PP), respectively. Conclusion Inter-rater reliability of measured migration percentages is high, but accuracy decreases with patient positional changes. Graphical abstract

Hip displacement is the second most common musculoskeletal deformity in children with cerebral palsy. Hip surveillance programs have been implemented in many countries to detect hip displacement early when it is usually asymptomatic. The aim of hip surveillance is to monitor hip development to offer management options to slow or reverse hip displacement, and to provide the best opportunity for good hip health at skeletal maturity. The long-term goal is to avoid the sequelae of late hip dislocation which may include pain, fixed deformity, loss of function and impaired quality of life. The focus of this review is on areas of disagreement, areas where evidence is lacking, ethical dilemmas and areas for future research. There is already broad agreement on how to conduct hip surveillance, using a combination of standardised physical examination measures and radiographic examination of the hips. The frequency is dictated by the risk of hip displacement according to the child’s ambulatory status. Management of both early and late hip displacement is more controversial and the evidence base in key areas is relatively weak. In this review, we summarise the recent literature on hip surveillance and highlight the management dilemmas and controversies. Better understanding of the causes of hip displacement may lead to interventions which target the pathophysiology of hip displacement and the pathological anatomy of the hip in children with cerebral palsy. We have identified the need for more effective and integrated management from early childhood to skeletal maturity. Areas for future research are highlighted and a range of ethical and management dilemmas are discussed.

Background Patient-controlled analgesia is a widely used and effective method of controlling pain after THA. This method is associated with substantial undesirable side effects. Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively, but its ability to reduce pain without complications is still questioned. Questions/Purposes We evaluated patient-controlled analgesia use, pain and satisfaction scores, complication rates, and ropivacaine levels associated with the use of periarticular multimodal drug infiltration in THA. Patients and Methods We randomized 64 patients undergoing THA to receive a periarticular intraoperative multimodal drug injection or to receive no injection. All patients received patient-controlled analgesia for 24 hours after surgery. The final assessment was at 6 weeks. Results Patients receiving the periarticular injection used less patient-controlled analgesia 6 hours postoperatively. The 24-hour patient-controlled analgesia requirement postsurgery also was less. The visual analog scale score for pain on activity in the postanesthetic care unit was less for patients who received an injection. The visual analog scale satisfaction score was similar in the two groups throughout the followup period. Recorded unbound ropivacaine levels were 2.5 times lower than toxic levels. Conclusions Periarticular intraoperative injection with multimodal drugs can reduce postoperative patient-controlled analgesia requirements and pain on activity in patients undergoing THA with no apparent increase in risk. Level of Evidence Level I, therapeutic study. See the guidelines online for a complete description of level of evidence.

Objectives Cerebral palsy (CP) is the most common childhood motor disability, yet its link to single‐gene disorders is under‐characterized. To explore the genetic landscape of CP, we conducted whole exome sequencing (WES) in a cohort of patients with CP. Methods We performed comprehensive phenotyping and WES on a prospective cohort of individuals with cryptogenic CP (who meet criteria for CP; have no risk factors), non‐cryptogenic CP (who meet criteria for CP; have at least one risk factor), and CP masqueraders (who could be diagnosed with CP, but have regression/progressive symptoms). We characterized motor phenotypes, ascertained medical comorbidities, and classified brain MRIs. We analyzed WES data using an institutional pipeline. Results We included 50 probands in this analysis (20 females, 30 males). Twenty‐four had cryptogenic CP, 20 had non‐cryptogenic CP, five had CP masquerader classification, and one had unknown classification. Hypotonic‐ataxic subtype showed a difference in prevalence across the classification groups (p = 0.01). Twenty‐six percent of participants (13/50) had a pathogenic/likely pathogenic variant in 13 unique genes (ECHS1, SATB2, ZMYM2, ADAT3, COL4A1, THOC2, SLC16A2, SPAST, POLR2A, GNAO1, PDHX, ACADM, ATL1), including one patient with two genetic disorders (ACADM, PDHX) and two patients with a SPAST‐related disorder. The CP masquerader category had the highest diagnostic yield (n = 3/5, 60%), followed by the cryptogenic CP category (n = 7/24, 29%). Fifteen percent of patients with non‐cryptogenic CP (n = 3/20) had a Mendelian disorder on WES. Interpretation WES demonstrated a significant prevalence of Mendelian disorders in individuals clinically diagnosed with CP, including in individuals with known CP risk factors.

: To assess changes in the developmental trajectory of corticospinal tracts (CST) maturation in children with hemiplegic cerebral palsy (HCP). : Neuroimaging data were obtained from 36 children with HCP for both the more affected (MA) and less affected (LA) hemispheres, and, for purposes of direct comparison, between groups, 15 typically developing (TD) children. With diffusion tensor imaging (DTI), we estimated the mean fractional anisotropy (FA), axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) of the corticospinal tract, parameters indicative of factors including myelination and axon density. Transcranial magnetic stimulation (TMS) was performed as a neurophysiologic measure of corticospinal tract integrity and organization. Resting motor threshold (rMT) was obtained per hemisphere, per patient. : We observed a significant AD and MD developmental trajectory, both of which were inversely related to age (decrease in AD and diffusivity corresponding to increased age) in both hemispheres of TD children ( < 0.001). This maturation process was absent in both MA and LA hemispheres of children with HCP. Additionally, the TMS-derived previously established rMT developmental trajectory was preserved in the LA hemisphere of children with HCP ( = 26; < 0.0001) but this trajectory was absent in the MA hemisphere. : Corticospinal tract maturation arrests in both hemispheres of children with HCP, possibly reflecting perinatal disruption of corticospinal tract myelination and axonal integrity.

Abstract Purpose Equinus is the most common deformity in cerebral palsy (CP) and gastrocsoleus lengthening (GSL) is the most commonly performed surgery to improve gait and function in ambulatory children with CP. Substantial variation exists in the indications for GSL and surgical technique. The purpose of this study was to review surgical anatomy and biomechanics of the gastrocsoleus and to utilize expert orthopaedic opinion through a Delphi technique to establish consensus for surgical indications for GSL in ambulatory children with CP. Methods A 17-member panel, of Fellowship-trained paediatric orthopaedic surgeons, each with at least 9 years of clinical post-training experience in the surgical management of children with CP, was established. Consensus for the surgical indications for GSL was achieved through a standardized, iterative Delphi process. Results Consensus was reached to support conservative Zone 1 surgery in diplegia and Zone 3 surgery (lengthening of the Achilles tendon) was contraindicated. Zone 2 or Zone 3 surgery reached general agreement as a choice in hemiplegia and under-correction was preferred to any degree of overcorrection. Agreement was reached that the optimum age for GSL surgery was 6 years to 10 years and should be avoided in children aged under 4 years. Physical examination measures with the child awake and under anaesthesia were important in decision making. Gait analysis was supported both for decision making and for assessing outcomes, in combination with patient reported outcomes (PROMS). Conclusions The results from this study may encourage informed practice evaluation, reduce practice variability, improve clinical outcomes and point to questions for further research. Level of Evidence V

This review brings together a multidisciplinary, multinational team of experts to discuss the current state of knowledge in the detection and treatment of hip displacement in cerebral palsy (CP), a global public health problem with a high disease burden. Though common themes are pervasive, different views are also represented, reflecting the confluence of traditional thinking regarding the aetiology and treatment of hip displacement in CP with emerging research that challenges these tried-and-true principles. The development of hip displacement is most closely related to gross motor function, with radiographic surveillance programs based on the Gross Motor Function Classification System (GMFCS), the goal being early detection and timely treatment. These treatments may include non-operative methods such as abduction bracing and Botulinum Neurotoxin A (BoNT-A), but outcomes research in this area has been variable in quality. This has contributed to conflicting opinions and limited consensus. Soft tissue lengthening of the hip adductors and flexors has traditionally been employed for younger patients, but population-based studies have shown decreased survivorship for this treatment when performed in isolation. Concerns with the identification of hip displacement in very young children are raised, noting that early reconstructive surgery has a high recurrence rate. This has prompted consideration of viable minimally invasive alternatives that may have better success rates in very young children with CP, or may at least delay the need for osteotomies. Recent reports have implicated the role of abnormal proximal femoral growth and secondary acetabular dysplasia as a primary cause of hip displacement, related to ambulatory status and abductor function. As such, guided growth of the proximal femur has emerged as a possible treatment that addresses this purported aetiology, with promising early results.

Abstract Purpose Supracondylar humerus fractures are among the most common injuries in the paediatric population, accounting for 16% of all paediatric fractures and roughly 60% to 70% of all paediatric elbow fractures. Typical treatment for displaced and unstable supracondylar humerus fractures is surgical intervention, often with percutaneous Kirschner-wire (K-wire) fixation. Timing of surgery is dependent on the patient's neurovascular status on presentation, with surgical emergencies being performed at all hours of day and night. Percutaneous fixation of paediatric elbow fractures can be challenging as a result of the propensity for the elbow to become quite swollen with these fractures, particularly in smaller and physiologically more immature elbows. Methods We have developed a simple operative technique to guide placement of percutaneous wires for supracondylar humerus fractures using a hypodermic needle as a reference marker. Results In our experience, trainees utilizing this technique demonstrate greater appreciation for start point and trajectory of wires during percutaneous pinning, with better communication amongst surgical team members about necessary adjustment for optimal placement of K-wires. Conclusion Utilization of this technique has the potential to refine surgical technique by minimizing errant wire passes, radiation and operative time when performing percutaneous pinning of reduced type III supracondylar humerus fractures. Level of Evidence V, Novel Surgical Technique

Background Two decision analyses on managing the contralateral, unaffected hip after unilateral slipped capital femoral epiphysis (SCFE) have failed to yield consistent recommendations. Missing from both, however, are sufficient data on the risks associated with prophylactic pinning using modern surgical techniques. Questions/purposes We determined the incidence and nature of complications after contemporary prophylactic fixation of the contralateral, unaffected hip in patients with a unilateral SCFE. Methods We retrospectively identified and reviewed 99 children (mean age, 11 years; range, 8–15 years) who underwent prophylactic pinning of the contralateral hip after treatment of a unilateral SCFE at four tertiary-care children’s hospitals from 2001 to 2010. Complications on the prophylactic side, such as avascular necrosis (AVN), chondrolysis, fractures, implant pain, and need for further surgery, were recorded. Minimum followup was 12 months (median, 26 months; range, 12–110 months). Results On the prophylactic side, we found two cases of focal AVN (2%) and no cases of chondrolysis (0%). Two patients sustained periimplant femur fractures (2%). Three patients had symptomatic hardware (3%), two of whom required surgery for implant removal. In three patients (3%), growth occurred off the end of the prophylactic screw before physeal closure, but they did not require revision fixation. No patients developed a subsequent slip on the side of the prophylactic pinning. Conclusions While prophylactic pinning prevents SCFE, it is not an entirely benign procedure. The possibility of developing complications such as AVN and periimplant fracture should be considered when determining the best management for the contralateral hip in patients who present with unilateral SCFE. Level of Evidence Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.