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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
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%
Early experiences
- Improved collaboration
- Detection of hip displacements
- Early detection of contractures
The natural history of hip dislocation
in cerebral palsy
About 15% of the total population
of children with CP would develop
hip dislocation
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?
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
N = 7500
+ 600 new
cases/year
General
Country-specific
Challenges and obstacles
Identify all individuals with CP
Identify all individuals
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
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
General
Country-specific
Challenges and obstacles
Country-specific:
Economy – funding
Health care organisation
Laws and regulations
Challenges and obstacles
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