1. Hip Subluxation in Cerebral Palsy Ciara Hupp Mark Gormley, MD Supreet Desphande, MD Gillette Children’s Specialty Healthcare St. Paul, MN 10/2

2. Disclosures Drs. Gormley and Deshpande participate in research with Allergan (Botox) and Ipsen (Dysport)

3. Hip Subluxation in CP One of the most common musculoskeletal problems in CP Can lead to pain, impaired function, poor positioning, altered cares, etc. More common in the more severely involved patients If not treated early then late care or salvage procedures provide less benefit

4. Hip Subluxation in CP Less risk if ambulatory and have less spasticity Should follow with serial x-rays Keep track of hip migration percentage (MP) and acetabular index (AI) depending on risk (q 1-4 years) MP >30% and AI >30 degrees high risk for dislocation

5. Hip Subluxation in CP Normal hipsCP quad 7 y/o CP quad 9 y/o CP quad 9+ y/o, post VDO

6. Hip Subluxation by GMFCS Hip displacement ≈ MP >30 %

7. Hip Subluxation and Spasticity Spasticity of hip adductors, hamstrings, and hip flexors increases the risk of subluxation AE 4 mon postAE 8 mon post

8. Hip Subluxation and Spasticity Does spasticity reduction help prevent or slow hip subluxation? – Soft tissue releases – probable in short-term, questionable long-term – SDR – probable – ITB – questionable – Botulinum toxin/phenol - questionable

9. Graham, et al, JBJS ‘08 “Does botulinum Toxin A Combined with Bracing Prevent Hip Displacement in Children with Cerebral Palsy and “Hips at Risk”? A Randomized, Controlled Trial” 47 (3y2m) treated with Botox 1:1 4U/kg/muscle into each hip adductor and medial hamstring q6mon x 3 yrs and HAb brace 6hrs/d 44 (2y11M) controls followed

10. Graham, et al, JBJS ‘08 Migration percentage – Treated – 2.6% – Controls – 5.7% Surgery – Treated – 23% over 3 years – Controls – 43% within 1 year, 50% over 3 years Conclusion – small clinical benefit, hip migration continued, couldn’t recommend treatment for hip subluxation

11. Willoughby, et al, DMCN ‘12 “The impact of botulinum toxin A and abduction bracing on long-term hip development in children with cerebral palsy” 10 year follow-up to Graham study Botox for only 3 years in treatment group

12. Gormley, Deshpande, Hupp, AAPMR abstract ‘15 “Influence of Phenol and Botulinum Toxin Injections on the Need for Hip Surgery in Children with Cerebral Palsy” Random retrospective chart review 457 patients, >12 y/o, no history of SDR, ITB Injection group – Phenol or botulinum toxin into proximal LE’s Grouped by GMFCS, +/- injections, and +/- bony hip surgery

13. Hip measurements

14. Hip surgery +/- injections GMFCS I – Injections: 35% – No-injections: 54% p=0.08, N=114 GMFCS II – Injections: 45% – No-injections: 80% p<0.001, N=97 GMFCS III – Injections: 59% – No-injections: 89% p=0.001, N=90 GMFCS IV – Injections: 31% – No-injections: 82% p<0.001, N=79 GMFCS V – Injections: 51% – No-injections: 97% p<0.001, N=77

15. Hip surgery percentage +/- injections GMFCS p=0.08 N=114 p<0.001 N=97 p=0.001 N=90 p<0.001 N=79 p<0.001 N=77

16. Age (months) at surgery +/- injections GMFCS p=0.08p=0.33p=0.11p=0.31p=0.89

17. Hip Migration

18. Acetabular Index

19. Conclusions Phenol/botulinum toxin injections may slow hip migration Injections may decrease the need for hip surgery More analysis of hip migration and acetabular index, and injections done in cohort needs to be evaluated Prospective studies needed to better understand impact