The natural history of hip development in cerebral palsy
Department of Orthopaedic Surgery, Oslo University Hospital, Rikshospitalet and University of Oslo, Oslo, Norway.
Correspondence to Dr Terje Terjesen at Department of Orthopaedic Surgery, Oslo University Hospital, Rikshospitalet and University of Oslo, NO-0027 Oslo, Norway.
This article is commented on by Rutz on page 878 of this issue.
Accepted for publication 14th May 2012.
Published online 13th August 2012.
AIM The purpose of this study was to evaluate a population-based radiographic hip surveillance
programme for children with cerebral palsy (CP) and to assess the natural history of hip displace-
METHOD The study comprised 335 children (188 males, 147 females), born during 2002 to 2006 in
the 10 south-eastern counties in Norway. Their mean age at the first radiograph was 3 years
(range 6mo–7y 11mo) and the mean age at the most recent follow-up was 5 years 5 months. Dis-
tribution according to CP type was spastic hemiplegia in 38%, diplegia in 27%, quadriplegia in
21%, dyskinesia in 10%, and ataxia in 3%; Gross Motor Function Classification System (GMFCS)
levels I to V were, 44%, 14%, 8%, 11%, and 23% respectively. Migration percentage (MP), acetabu-
lar index, and pelvic obliquity were measured on the radiographs.
RESULTS Hip displacement (MP>33%) occurred in 26% of all children (subluxation in 22% and dis-
location in 4%) and in 63% of those in GMFCS levels IV or V. Dislocation occurred in 14 children at
a mean age of 4 years 5 months (range 1y 10mo–9y 7mo). The mean migration percentage was
20.4% at the initial radiographs and 34.0% at the last follow-up. Mean progression in migration
percentage increased markedly with decreasing functional level, from 0.2% per year at GMFCS
level I to 9.5% at level V.
INTERPRETATION There is a pronounced trend towards hip displacement in nonambulant chil-
dren. Close surveillance from age 1 to 2 years is needed to find the appropriate time for preventive
surgery. Since 12% of the nonambulant children developed dislocation, our routines for hip sur-
veillance need improvement.
There is increased risk of hip dysplasia and dislocation in cere-
bral palsy (CP) and the risk is highest in children with the
most severe forms of CP and in patients without gait func-
tion.1–3Dislocation may lead to pain and severe problems
with ambulation, sitting balance, perineal nursing care, and
decubitus ulceration.4,5Therefore, special screening pro-
grammes aimed at early diagnosis and treatment of hip dis-
placement to prevent complete dislocation have been
developed.2,6These programmes have provided important
information regarding risk factors for hip discplacement and
the effect of early diagnosis. There is, however, still a need for
further research in this field, since the rate of deterioration of
the hips has not been established. This is important because
the effectiveness of preventive treatment cannot be properly
assessed unless the natural history of hip displacement is fully
Based on the experience from the Swedish CP hip surveil-
lance programme,6a systematic population-based registration
of children with CP was initiated in southeast Norway in
2006. The aims of the present prospective study on hip devel-
opment were to (1) evaluate the quality of this screening pro-
gramme; (2) assess the natural history of hip displacement
during the first years of life according to functional level and
type of CP, and (3) define risk factors for deterioration.
In January 2006 the CP follow-up programme (CPOP) for
southeast Norway was started, encompassing about 50% of
the population in the country. All children with CP born after
1 January, 2002 and living in one of the 10 south-eastern
counties were invited to participate in a follow-up programme
of motor function and were included in the programme after
informed consent from their parents. The follow-up pro-
gramme had approval from the Norwegian Data Inspectorate.
The programme is led and coordinated by two physiothera-
pists and an occupational therapist at our hospital, where the
database with patient information is stored. The diagnosis and
type of CP were determined by neuropaediatricians working
at the child habilitation centres (one in each county). The
CPOP programme includes a systematic clinical and radio-
ª The Authors. Developmental Medicine & Child Neurology ª 2012 Mac Keith Press DOI: 10.1111/j.1469-8749.2012.04385.x
DEVELOPMENTAL MEDICINE & CHILD NEUROLOGYORIGINAL ARTICLE
the radiographs were electronically transferred from the
local hospitals to the orthopaedic surgeon who performs the
measurements, but we have not reached that goal yet.
Another weakness was the excessively long waiting period
for surgery, which usually was more than 6 months and
sometimes over 12 months and contributed to complete dis-
location in some patients. Thus, the challenges for our
screening programme are improvement of the routines for
radiographic follow-up and increased resources for surgical
The author thanks physiotherapist Gerd Myklebust, who coordinated
the CPOP programme of the lower extremities and helped to collect
the radiographs. He is also grateful to the physiotherapists of the child
habilitation teams who coordinated the radiographic screening.
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In the article by Comi et al.1the list of contributing members of the Brain Vascular Malformation Consortium Struge-Weber
Syndrome National Workgroup were omitted from the Acknowledgements section. The complete section is as follows:
The following individuals are contributing members of the Brain Vascular Malformation Consortium Sturge–Weber Syndrome National
Workgroup: Warren D. Lo, Departments of Pediatrics and Neurology, The Ohio State University and Nationwide Children’s Hospital,
Columbus, OH; Douglas A. Marchuk, Duke University; Karen L. Ball, The Sturge-Weber Foundation; Jonathan Pevsner, Hugo Moser Ken-
nedy Krieger Research Institute; Marsha A. Moses, Harvard Medical Center; Csaba Juha’sz, Pediatric Neurology⁄PET Center, Children’s
Hospital of Michigan, Detroit, MI; Harry T. Chugani, Children’s Hospital of Michigan; Joshua B. Ewen, Kennedy Krieger Institute; Lori C.
Jordan, Vanderbilt University; and Anne M. Comi, Hugo Moser Kennedy Krieger Research Institute. The Brain Vascular Malformation Con-
sortium (BVMC; U54NS065705) is a part of the National Institutes of Health (NIH) Rare Disease Clinical Research Network (RDCRN), sup-
ported through a collaboration between the NIH Office of Rare Diseases Research (ORDR), and the National Institute of Neurological
Disorders and Stroke (NINDS).
We would like to thank Kira Lanier for her assistance in editing and preparing this manuscript for submission.
We apologise for the error.
Lo W, Marchuk DA, Ball KL, Juha ´sz C, Jordan LC, Ewen JB, Comi A and the Brain Vascular Malformation Consortium Sturge–Weber Syndrome National Workgroup. Updates and future horizons on
the understanding, diagnosis, and treatment of Sturge–Weber syndrome brain involvement. Dev Med Child Neurol 2012, 54: 214–23.
DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ERRATUM