This article presents a classification of lower limb musculoskeletal pathology (MSP) for ambulant children with cerebral palsy (CP) to identify key features from infancy to adulthood. The classification aims to improve communication, and to guide referral for interventions, which if timed appropriately, may optimise long-term musculoskeletal health and function. Consensus was achieved by discussion between staff in a Motion Analysis Laboratory (MAL). A four-stage classification system was developed: Stage 1: Hypertonia: Abnormal postures are dynamic. Stage 2: Contracture: Fixed shortening of one or more muscle-tendon units. Stage 3: Bone and joint deformity: Torsional deformities and/or joint instability (e.g., hip displacement or pes valgus), usually accompanied by contractures. Stage 4: Decompensation: Severe pathology where restoration of optimal joint and muscle-tendon function is not possible. Reliability of the classification was tested using the presentation of 16 clinical cases to a group of experienced observers, on two occasions, two weeks apart. Reliability was found to be very good to excellent, with mean Fleiss’ kappa ranging from 0.72 to 0.84. Four-stages are proposed to classify lower limb MSP in children with CP. The classification was reliable in a group of clinicians who work together. We emphasise the features of decompensated MSP in the lower limb, which may not always benefit from reconstructive surgery and which can be avoided by timely intervention.

Background: Guided growth is frequently used to modify lower-limb alignment in children, and recently temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF) has been used for the management of hips at risk of subluxation in cerebral palsy (CP) patients. The aim of our study was to evaluate the efficacy of TMH-PF in the management of neuromuscular hip dysplasia in children with cerebral palsy. Methods: A systematic search of the literature was performed by using PubMed, EMBASE, CINAHL, MEDLINE, Scopus and Cochrane databases. Pre- and postoperative radiographic changes of the migration percentage (MP), head-shaft angle (HSA) and acetabular index (AI) were included in a meta-analysis. Secondary outcomes were treatment complication rates, technical considerations and the limitations of this novel technique. Results: Four studies (93 patients; 178 hips) met the eligibility criteria for inclusion in the meta-analysis. All three radiographic measurements showed significant changes at a minimum of 2 years of follow-up. Mean changes for MP were 8.48% (95% CI 3.81–13.14), HSA 12.28° (95% CI 11.17–13.39) and AI 3.41° (95% CI 0.72–6.10), with I² of 75.74%, 0% and 87.68%, respectively. The serious complication rate was overall low; however, physeal ‘growing off’ of the screw was reported in up to 43% of hips treated. Conclusion: TMH-PF is an effective and predictable method to treat CP patients with ‘hips at risk’, and the overall complication rate is low; however, further work is required to identify the best candidates and surgical timing, as well as choice of technique and implant.

Many surgeons recommend pelvic osteotomy to treat symptomatic hip dysplasia in younger patients. We previously reported a cohort of patients at 10 and 15 years followup in which 65% of the patients showed no progression of osteoarthritis (OA). The purposes of this study were to determine whether the triple osteotomy can provide (1) continuing pain relief and (2) function; and to determine the (3) incidence of OA and (4) number of patients undergoing THAs 23 years or more after triple osteotomy. Between 1980 and 1987, 51 pelvic osteotomies were performed in 43 patients (38 females and five males; mean age, 28 years; range, 14–48 years). Followup was obtained for 40 patients (49 of 51 hips; 96%). Clinical evaluation, including pain, mobility, and ROM, was graded according to the subgroups of the modified scoring system of Merle d’Aubigné and Postel. The minimum followup was 23 years (mean, 25 years; range, 23–29 years). The mean VAS pain score increased from 27 mm to 31 mm at the last followup, but remained substantially lower than before surgery. The mean Merle d’Aubigné-Postel score improved from 13 preoperatively to 15 at a mean of 10 years followup but at last followup, the mean score had decreased to 14, thereby showing a trend to diminish. At 15 years followup, 20 patients showed signs of OA. At 25 years followup, 18 of 33 patients without THAs showed signs of OA (55%). Six patients (six hips) had undergone THAs at 15 years, increasing to 15 patients (16 hips) at 25 years. While the triple osteotomy for symptomatic developmental dysplasia of the hip in young adults provides substantial pain relief and restores function in most patients, these results deteriorate over decades owing to the development of OA. Even in joints without preoperative OA, a THA cannot always be avoided. The triple osteotomy does not normalize the joint and the incidence of THA in this group of patients (32%) is much higher than in the general population. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Introduction Up to one-third of patients with cerebral palsy (CP) develop hip migration. Current standard care for early hip migration is bilateral adductor-psoas tenotomy; however, the failure rate is relatively high with 34%–74% of patients with CP requiring secondary hip surgery. Using temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF), the morphology of the hip can be changed. This technique aims to reduce further hip migration and the need for secondary surgical management. Further research is necessary to determine the benefit of TMH-PF in addition to adductor-psoas tenotomy. The hypothesis of this study is that TMH-PF combined with adductor-psoas release decreases the chance of progressive hip migration and the need for secondary hip surgery, compared with adductor-psoas release alone. Methods and analysis The GUIDANCE study is an open-label multicentre randomised controlled trial. Patients with CP aged between 2 and 8 years, with spastic CP—Gross Motor Function Classification System IV or V, hip abduction ≤40° and hip migration of 30%–50% can be included in this trial. They will be randomised into a control arm (adductor-psoas tenotomy) or an intervention arm (adductor-psoas tenotomy+TMH PH). The primary outcome will be treatment failure at 5-year follow-up. At 2-year follow-up a preliminary analysis will be performed. Secondary outcomes will be differences in patient-reported outcome measures (CPCHILD and CPG pain score), range of motion, radiological measurements including head shaft angle and hip migration percentage and three-dimensional (3D) morphological changes to the proximal femur. Furthermore, an analysis will be performed to identify predictors for treatment failure in both treatment arms. Ethics and dissemination The GUIDANCE study should provide evidence on the effectiveness of TMH-PF in addition to adductor-psoas tenotomy in children with CP with early hip migration. If beneficial, larger hip reconstructive procedures can be delayed or prevented, providing a distinct benefit for these vulnerable children. The study’s strengths lie in its methodological framework, incorporating randomised allocation and intervention assessment. The main limitation is the inability to blind the treating physician or the researcher for the treatment arm the participant is allocated to. The results of the GUIDANCE study will be presented at scientific meetings and published in international peer-reviewed journals. The aim is to publish the results at 2 years follow-up and 5 years follow-up and to publish the results of the analysis on the 3D morphology of the hip after TMH-PF. Individual de-identified participant data that underlie the results from the GUIDANCE study and the study protocol will be shared if requested. Trial registration number Clinical Trial Registry number: NCT06118736. Registered on 3 November 2023.

Background: Up to one-third of children with cerebral palsy (CP) develop migration of the hip, and the risk increases with a higher Gross Motor Function Classification System (GMFCS). In progressive hip migration in young children, adductor tenotomy is an accepted treatment option to delay or prevent progressive hip migration. However, there is quite a large variability in reported results. This systematic review aims to determine the effectiveness of a soft-tissue release in the prevention of progressive hip migration in children with CP. Methods: This systematic review was performed in accordance with the guidelines of the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statements. Our inclusion criteria were studies describing pediatric, skeletally immature patients with CP and a “hip at risk” of progressive hip migration. Exclusion criteria were simultaneous bony reconstructions, case reports, technical notes, published abstracts, or studies with a follow-up under 1 year postoperatively. The primary outcomes were defined as failure rate (progressive hip migration and/or need for bony surgery, as defined by each paper) and change in migration percentage (MP) at final follow-up. As secondary analyses, we evaluated the outcome after specific subtypes of surgeries and assessed whether performing lengthening of iliopsoas, neurectomy of the anterior branch of the obturator nerve, age at the time of surgery, GMFCS level, and postoperative management impact the outcome. Results: Our literature search identified 380 titles. Eighty-four articles underwent full-text review, of which 27 met our inclusion/exclusion criteria and were subsequently selected for quantitative analysis. A prevalence meta-analysis was performed including 17 studies (2,213 hips). Mean follow-up ranged from 12 to 148.8 months. The mean preoperative MP was 33.4% (2,740 hips) and 29.9% at follow-up. The overall reported failure rate was 39% (95% confidence interval, 26%-52%). Performing a release of only adductor longus had a failure rate of 87%, whereas more extensive soft-tissue releases showed significantly better results with failure rates ranging from 0 to 44% (p < 0.001). Lengthening of the iliopsoas had no significant impact on failure rate (p = 0.48), nor did performing an obturator neurectomy (p = 0.92). Conclusion: The failure rate of adductor tenotomies to prevent progressive hip migration appears to be as high as 39% in studies with a varying follow-up. The failure rates are significantly higher when isolated release of the adductor longus is performed. This systematic review supports clinical decision making in children with CP and early hip migration. Level of Evidence: Level IIA. See Instructions for Authors for a complete description of levels of evidence.