The role for hip surveillance in children with cerebral palsy

  • Benjamin ShoreEmail author
  • David Spence
  • HK Graham
Pediatrics (M Glotzbecker, Section Editor)


Spastic hip displacement is the second most common deformity seen in children with cerebral palsy (CP), and the long-term effects can be debilitating. Progressive hip displacement leading to dislocation can result in severe pain as well as impaired function and quality of life. Recent population-based studies have demonstrated that a child’s Gross Motor Functional Classification System (GMFCS) level is most predictive for identifying hips “at-risk” for progressive lateral displacement. As a result, in many developed countries, hip surveillance has now been adopted as an integral piece of the comprehensive care puzzle for the management of children with spastic hip displacement. This paper reviews the spectrum of treatments available for progressive hip displacement, examines the current literature on the success of hip surveillance, and illustrates an example of a current hip surveillance program stratified by the GMFCS level.


Pediatric Cerebral palsy Hip surveillance Gross motor functional classification system Proximal femoral varus osteotomy Adductor surgery Botulinum toxin Hip salvage surgery 



B. Shore: none; D. Spence: none; HK Graham: consultant for Merz Pharmaceuticals.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Bax M, Goldstein M, Rosenbaum P, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005;47:571–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Soo B, Howard JJ, Boyd RN, et al. Hip displacement in cerebral palsy. J Bone Joint Surg Am. 2006;88:121–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Lonstein JE, Beck K. Hip dislocation and subluxation in cerebral palsy. J Pediatr Orthop. 1986;6:521–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Bagg MR, Farber J, Miller F. Long-term follow-up of hip subluxation in cerebral palsy patients. J Pediatr Orthop. 1993;13:32–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Hagglund G, Lauge-Pedersen H, Wagner P. Characteristics of children with hip displacement in cerebral palsy. BMC Musculoskelet Disord. 2007;8:101.PubMedCrossRefGoogle Scholar
  6. 6.
    Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214–23.PubMedCrossRefGoogle Scholar
  7. 7.
    Howard CB, McKibbin B, Williams LA, Mackie I. Factors affecting the incidence of hip dislocation in cerebral palsy. J Bone Joint Surg Br. 1985;67:530–2.PubMedGoogle Scholar
  8. 8.
    Terjesen T. Development of the hip joints in unoperated children with cerebral palsy: a radiographic study of 76 patients. Acta Orthop. 2006;77:125–31.PubMedCrossRefGoogle Scholar
  9. 9.
    Flynn JM, Miller F. Management of hip disorders in patients with cerebral palsy. J Am Acad Orthop Surg. 2002;10:198–209.PubMedGoogle Scholar
  10. 10.
    Dobson F, Boyd RN, Parrott J, et al. Hip surveillance in children with cerebral palsy. Impact on the surgical management of spastic hip disease. J Bone Joint Surg Br. 2002;84:720–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Cooperman DR, Bartucci E, Dietrick E, Millar EA. Hip dislocation in spastic cerebral palsy: long-term consequences. J Pediatr Orthop. 1987;7:268–76.PubMedCrossRefGoogle Scholar
  12. 12.
    Scrutton D, Baird G. Surveillance measures of the hips of children with bilateral cerebral palsy. Arch Dis Child. 1997;76:381–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Scrutton D, Baird G, Smeeton N. Hip dysplasia in bilateral cerebral palsy: incidence and natural history in children aged 18 months to 5 years. Dev Med Child Neurol. 2001;43:586–600.PubMedCrossRefGoogle Scholar
  14. 14.
    Hagglund G, Andersson S, Duppe H, et al. Prevention of dislocation of the hip in children with cerebral palsy. The first ten years of a population-based prevention programme. J Bone Joint Surg Br. 2005;87:95–101.PubMedCrossRefGoogle Scholar
  15. 15.
    Connelly A, Flett P, Graham HK, Oates J. Hip surveillance in Tasmanian children with cerebral palsy. J Paediatr Child Health. 2009;45:437–43.PubMedCrossRefGoogle Scholar
  16. 16.
    Beals RK. Spastic paraplegia and diplegia. An evaluation of non-surgical and surgical factors influencing the prognosis for ambulation. J Bone Joint Surg Am. 1966;48:827–46.PubMedGoogle Scholar
  17. 17.
    Samilson RL, Carson JJ, James P, Raney Jr FL. Results and complications of adductor tenotomy and obturator neurectomy in cerebral palsy. Clin Orthop Relat Res. 1967;54:61–73.PubMedCrossRefGoogle Scholar
  18. 18.
    •• Wynter M, Gibson N, Kentish M, et al. The development of Australian Standards of Care for Hip Surveillance in Children with Cerebral Palsy: How did we reach consensus? J Pediatr Rehabil Med. 2011;4:171-182. This study reviews the evidence in favor of hip surveillance in children and adolescents with CP and discusses the process of developing the Consensus Statement on Hip Surveillance in Children with Cerebral Palsy which has been adopted and endorsed by the Australian Academy of Cerebral Palsy and Developmental Medicine. PubMedGoogle Scholar
  19. 19.
    Kentish M, Wynter M, Snape N, Boyd R. Five-year outcome of state-wide hip surveillance of children and adolescents with cerebral palsy. J Pediatr Rehabil Med. 2011;4:205–17.PubMedGoogle Scholar
  20. 20.
    Gordon GS, Simkiss DE. A systematic review of the evidence for hip surveillance in children with cerebral palsy. J Bone Joint Surg Br. 2006;88:1492–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Cornell MS, Hatrick NC, Boyd R, et al. The hip in children with cerebral palsy. Predicting the outcome of soft tissue surgery. Clin Orthop Relat Res. 1997;340:165–71.Google Scholar
  22. 22.
    Letts M, Shapiro L, Mulder K, Klassen O. The windblown hip syndrome in total body cerebral palsy. J Pediatr Orthop. 1984;4:55–62.PubMedCrossRefGoogle Scholar
  23. 23.
    Graham HK. Painful hip dislocation in cerebral palsy. Lancet. 2002;359:907–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Sharrard WJ, Allen JM, Heaney SH. Surgical prophylaxis of subluxation and dislocation of the hip in cerebral palsy. J Bone Joint Surg Br. 1975;57:160–6.PubMedGoogle Scholar
  25. 25.
    Dunlap K, Shands Jr AR, Hollister Jr LC, et al. A new method for determination of torsion of the femur. J Bone Joint Surg Am. 1953;35-A:289–311.PubMedGoogle Scholar
  26. 26.
    Laplaza FJ, Root L, Tassanawipas A, Glasser DB. Femoral torsion and neck-shaft angles in cerebral palsy. J Pediatr Orthop. 1993;13:192–9.PubMedGoogle Scholar
  27. 27.
    Robin J, Graham HK, Selber P, et al. Proximal femoral geometry in cerebral palsy: a population-based cross-sectional study. J Bone Joint Surg Br. 2008;90:1372–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Cooke PH, Cole WG, Carey RP. Dislocation of the hip in cerebral palsy. Natural history and predictability. J Bone Joint Surg Br. 1989;71:441–6.PubMedGoogle Scholar
  29. 29.
    Wynter M, Gibson N, Kentish M, et al. The consensus statement on hip surveillance for children with cerebral palsy: australian standards of care. J Pediatr Rehabil Med. 2011;4:183–95.PubMedGoogle Scholar
  30. 30.
    Graham HK, Boyd R, Carlin JB, et al. Does botulinum toxin a combined with bracing prevent hip displacement in children with cerebral palsy and “hips at risk”? A randomized, controlled trial. J Bone Joint Surg Am. 2008;90:23–33.PubMedCrossRefGoogle Scholar
  31. 31.
    Krach LE, Kriel RL, Gilmartin RC, et al. Hip status in cerebral palsy after one year of continuous intrathecal baclofen infusion. Pediatr Neurol. 2004;30:163–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Shore B, Yu X, Desai S, et al. Adductor surgery to prevent hip displacement in children with cerebral palsy: The predictive role of the Gross Motor Function Classification System. J Bone Joint Surg Am. 2012; in press.Google Scholar
  33. 33.
    Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987;67:206–7.PubMedGoogle Scholar
  34. 34.
    Hodgkinson I, Jindrich ML, Duhaut P, et al. Hip pain in 234 non-ambulatory adolescents and young adults with cerebral palsy: a cross-sectional multicentre study. Dev Med Child Neurol. 2001;43:806–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Boyd R, Graham HK. Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. Eur J Neurol. 1999;6:23–35.CrossRefGoogle Scholar
  36. 36.
    Bartlett MD, Wolf LS, Shurtleff DB, Stahell LT. Hip flexion contractures: a comparison of measurement methods. Arch Phys Med Rehabil. 1985;66:620–5.PubMedGoogle Scholar
  37. 37.
    Grohmann JE. Comparison of two methods of goniometry. Phys Ther. 1983;63:922–5.PubMedGoogle Scholar
  38. 38.
    Delp SL, Arnold AS, Speers RA, Moore CA. Hamstrings and psoas lengths during normal and crouch gait: implications for muscle-tendon surgery. J Orthop Res. 1996;14:144–51.PubMedCrossRefGoogle Scholar
  39. 39.
    Schutte LM, Hayden SW, Gage JR. Lengths of hamstrings and psoas muscles during crouch gait: effects of femoral anteversion. J Orthop Res. 1997;15:615–21.PubMedCrossRefGoogle Scholar
  40. 40.
    Trost J. Clinical assessment. London: Mac Keith Press; 2009.Google Scholar
  41. 41.
    Yam WK, Leung MS. Interrater reliability of Modified Ashworth Scale and Modified Tardieu Scale in children with spastic cerebral palsy. J Child Neurol. 2006;21:1031–5.PubMedCrossRefGoogle Scholar
  42. 42.
    Reimers J. The stability of the hip in children. A radiological study of the results of muscle surgery in cerebral palsy. Acta Orthop Scand Suppl. 1980;184:1–100.PubMedGoogle Scholar
  43. 43.
    Parrott J, Boyd RN, Dobson F, et al. Hip displacement in spastic cerebral palsy: repeatability of radiologic measurement. J Pediatr Orthop. 2002;22:660–7.PubMedCrossRefGoogle Scholar
  44. 44.
    Miller F, Bagg MR. Age and migration percentage as risk factors for progression in spastic hip disease. Dev Med Child Neurol. 1995;37:449–55.PubMedCrossRefGoogle Scholar
  45. 45.
    Faraj S, Atherton WG, Stott NS. Inter- and intra-measurer error in the measurement of Reimers’ hip migration percentage. J Bone Joint Surg Br. 2004;86:434–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Tonnis D. Normal values of the hip joint for the evaluation of X-rays in children and adults. Clin Orthop Relat Res. 1976:39-47.Google Scholar
  47. 47.
    • Robin J, Graham HK, Baker R, et al. A classification system for hip disease in cerebral palsy. Dev Med Child Neurol. 2009;51:183-192. This study reviewed one hundred and thirty-four radiographs of adolescents with CP at or near maturity and developed a new classification system that encapsulates the full spectum of hip morphology.PubMedCrossRefGoogle Scholar
  48. 48.
    Murnaghan ML, Simpson P, Robin JG, et al. The cerebral palsy hip classification is reliable: an inter- and intra-observer reliability study. J Bone Joint Surg Br. 2010;92:436–41.PubMedGoogle Scholar
  49. 49.
    Severin E. Congenital dislocation of the hip; development of the joint after closed reduction. J Bone Joint Surg Am. 1950;32-A:507–18.PubMedGoogle Scholar
  50. 50.
    • Gose S, Sakai T, Shibata T, et al. Verification of the Robin and Graham classification system of hip disease in cerebral palsy using three-dimensional computed tomography. Dev Med Child Neurol. 2011;53:1107-1112. This study validated the Robin and Graham classification system of hip disease in children with CP using three-dimensional computed topography. By studying ninety-one children between the ages of two and six, the authors demonstrated that this classification system not only applies to adolescents but also children under the age of seven. PubMedCrossRefGoogle Scholar
  51. 51.
    Kim YJ, Jaramillo D, Millis MB, et al. Assessment of early osteoarthritis in hip dysplasia with delayed gadolinium-enhanced magnetic resonance imaging of cartilage. J Bone Joint Surg Am. 2003;85-A:1987–92.PubMedGoogle Scholar
  52. 52.
    Beals RK. Developmental changes in the femur and acetabulum in spastic paraplegia and diplegia. Dev Med Child Neurol. 1969;11:303–13.PubMedCrossRefGoogle Scholar
  53. 53.
    Kalen V, Bleck EE. Prevention of spastic paralytic dislocation of the hip. Dev Med Child Neurol. 1985;27:17–24.PubMedCrossRefGoogle Scholar
  54. 54.
    Harris NH, Lloyd-Roberts GC, Gallien R. Acetabular development in congenital dislocation of the hip. With special reference to the indications for acetabuloplasty and pelvic or femoral realignment osteotomy. J Bone Joint Surg Br. 1975;57:46–52.PubMedGoogle Scholar
  55. 55.
    Dare C, Clarke N. (v) Proximal femoral osteotomy in childhood. Curr Orthop. 2007;21:115–21.CrossRefGoogle Scholar
  56. 56.
    Houkom JA, Roach JW, Wenger DR, et al. Treatment of acquired hip subluxation in cerebral palsy. J Pediatr Orthop. 1986;6:285–90.PubMedCrossRefGoogle Scholar
  57. 57.
    Miller F, Dabney K, Rang M. Complications in cerebral palsy treatment. Philadelphia: Lippincott Company; 1995.Google Scholar
  58. 58.
    Khot A, Sloan S, Desai S, et al. Adductor release and chemodenervation in children with cerebral palsy: a pilot study in 16 children. J Child Orthop. 2008;2:293–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Presedo A, Oh CW, Dabney KW, Miller F. Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. J Bone Joint Surg Am. 2005;87:832–41.PubMedCrossRefGoogle Scholar
  60. 60.
    Samilson RL, Tsou P, Aamoth G, Green WM. Dislocation and subluxation of the hip in cerebral palsy. Pathogenesis, natural history and management. J Bone Joint Surg Am. 1972;54:863–73.PubMedGoogle Scholar
  61. 61.
    Barrie JL, Galasko CS. Surgery for unstable hips in cerebral palsy. J Pediatr Orthop B. 1996;5:225–31.PubMedCrossRefGoogle Scholar
  62. 62.
    Pirpiris M, Trivett A, Baker R, et al. Femoral derotation osteotomy in spastic diplegia. Proximal or distal? J Bone Joint Surg Br. 2003;85:265–72.PubMedCrossRefGoogle Scholar
  63. 63.
    Brunner R, Baumann JU. Clinical benefit of reconstruction of dislocated or subluxated hip joints in patients with spastic cerebral palsy. J Pediatr Orthop. 1994;14:290–4.PubMedCrossRefGoogle Scholar
  64. 64.
    Mubarak SJ, Valencia FG, Wenger DR. One-stage correction of the spastic dislocated hip. Use of pericapsular acetabuloplasty to improve coverage. J Bone Joint Surg Am. 1992;74:1347–57.PubMedGoogle Scholar
  65. 65.
    Cornell MS. The hip in cerebral palsy. Dev Med Child Neurol. 1995;37:3–18.PubMedCrossRefGoogle Scholar
  66. 66.
    Miller F, Girardi H, Lipton G, et al. Reconstruction of the dysplastic spastic hip with peri-ilial pelvic and femoral osteotomy followed by immediate mobilization. J Pediatr Orthop. 1997;17:592–602.PubMedCrossRefGoogle Scholar
  67. 67.
    McNerney NP, Mubarak SJ, Wenger DR. One-stage correction of the dysplastic hip in cerebral palsy with the San Diego acetabuloplasty: results and complications in 104 hips. J Pediatr Orthop. 2000;20:93–103.PubMedCrossRefGoogle Scholar
  68. 68.
    Leet AI, Chhor K, Launay F, et al. Femoral head resection for painful hip subluxation in cerebral palsy: Is valgus osteotomy in conjunction with femoral head resection preferable to proximal femoral head resection and traction? J Pediatr Orthop. 2005;25:70–3.PubMedGoogle Scholar
  69. 69.
    Baxter MP, D’Astous JL. Proximal femoral resection-interposition arthroplasty: salvage hip surgery for the severely disabled child with cerebral palsy. J Pediatr Orthop. 1986;6:681–5.PubMedCrossRefGoogle Scholar
  70. 70.
    McCarthy RE, Simon S, Douglas B, et al. Proximal femoral resection to allow adults who have severe cerebral palsy to sit. J Bone Joint Surg Am. 1988;70:1011–6.PubMedGoogle Scholar
  71. 71.
    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. J Pediatr Orthop. 1990;10:504–9.PubMedGoogle Scholar
  72. 72.
    Widmann RF, Do TT, Doyle SM, et al. Resection arthroplasty of the hip for patients with cerebral palsy: an outcome study. J Pediatr Orthop. 1999;19:805–10.PubMedCrossRefGoogle Scholar
  73. 73.
    Minear WL, Tachdjian MO. Hip dislocation in cerebral palsy. J Bone Joint Surg Am. 1956;38-A:1358–64.PubMedGoogle Scholar
  74. 74.
    Moreau M, Drummond DS, Rogala E, et al. Natural history of the dislocated hip in spastic cerebral palsy. Dev Med Child Neurol. 1979;21:749–53.PubMedCrossRefGoogle Scholar
  75. 75.
    Vidal J, Deguillaume P, Vidal M. The anatomy of the dysplastic hip in cerebral palsy related to prognosis and treatment. Int Orthop. 1985;9:105–10.PubMedCrossRefGoogle Scholar
  76. 76.
    Scrutton D. The early management of hips in cerebral palsy. Dev Med Child Neurol. 1989;31:108–16.PubMedCrossRefGoogle Scholar
  77. 77.
    Little DG, Aiona M, Sussman M. Late hip subluxation in spastic diplegia associated with unrecognized hydrocephalus. J Pediatr Orthop. 1995;15:368–71.PubMedCrossRefGoogle Scholar
  78. 78.
    Miller CJ. The speech therapist and the group treatment of young cerebral palsied children. Br J Disord Commun. 1972;7:176–83.PubMedCrossRefGoogle Scholar
  79. 79.
    Pountney T, Green EM. Hip dislocation in cerebral palsy. BMJ. 2006;332:772–5.PubMedCrossRefGoogle Scholar
  80. 80.
    Persson-Bunke M, Hagglund G, Lauge-Pedersen H. Windswept hip deformity in children with cerebral palsy. J Pediatr Orthop B. 2006;15:335–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryChildren’s Hospital Boston, Harvard Medical SchoolBostonUSA
  2. 2.Department of Orthopaedic SurgeryThe Royal Children’s HospitalParkvilleAustralia

Personalised recommendations