Friday, May 17, 2013

Ortho Roundup: Let's Talk About Hips

Elena had her regular checkup with her orthopaedic doctor a few weeks ago.  Overall he was pleased with her progress.  He thinks that her flexibility is decent (maybe the night splints are helping?), her range of motion is pretty good, and he is glad she is an active, happy kid.

He looked at her spine, and quickly looked at her arm strength/core (hold arms straight and out, several directions, in a sitting position--check; hold arms straight above head in streamline position--almost check; and he unsuccessfully tried to tip her over--check) and was pleased.

Then we got into a discussion about hips.  I brought it up--basically, I use these visits to try to prepare myself for any future surgeries/interventions as best I can.  I don't like the "bad surprise", when you show up at the ortho and all of the sudden you've been told that your kid needs XYZ surgery or else something terrible is going to happen.  So, I'd rather hear WAY in advance, in order to try to prepare myself and Elena.

I already knew that she was at higher risk for scoliosis (she's fine so far).  I also know that she may have hip issues due to her spasticity/crouch.  She hadn't had a hip x-ray since age three (before her SDR).  So, they decided it was about time she got one.

I don't know a lot about hips, but here goes...

At E's 3rd year X-ray, she didn't have much of an established hip ball-and-socket joint.  As kids grow and bear weight (and walk), the femur head angles itself into position into the hip, and carves out a socket (something like that).  Due to E's delayed mobility, her hip at age 3 didn't look much like a ball-and-socket.  Kids with SDCP like Elena (knees caving in, tibial and femoral anteversion) don't develop the right femur head angle and the socket tends to be shallow (imagine what W-sitting does to a hip joint).  This results in something called coxa valga.

If the socket is shallow enough and the spasticity tight enough, the femur head can wear away cartilage at the joint and even come out (subluxation).  This can be, but is not always, painful.  The most common surgical fix for this is a hip osteotomy (which wasn't as terrible as I had thought it was) where they remove a small triangular piece from the stem of the femur head and make the angle of the femur head more acute so it fits/stays better in the socket.  This is better for stability, but as with any surgery, there is a net increase in weakness due to cutting through the tissue and bone.

It was my understanding that kids who move like Elena (pretty well, but not great) didn't get hip subluxation and didn't need the hip osteotomy.  That is not true.  We'll have to wait and see if Elena complains of hip or leg pain and then see what's going on (at this time, she does not have pain).  The best thing we can do is try to keep her posture as close to normal as possible and keep her active (bearing weight as close to properly as possible).  I think we are doing that.

I asked if there was the possibility at this point in her life (a small age 8) that with proper exercise/training, we could deepen her hip socket over time.  He said that is unlikely.  Overall he thinks her hips look better than he had originally expected--she may not need any intervention at all.  That sure would be nice, right?

He did say it was almost a given that with her hip joint the way it is, she would develop early arthritis of the hip (early being ~50 years of age).  That made me sad...but I can't do anything about it.

The good news is E is moving well and still making gains.  Her doctor doesn't want to surgically intervene for fear of making things worse.  Wait and see is the plan, and right now, that sounds pretty sweet.


Anonymous said...

Glad to hear E doesn't need least not yet. A friend of mine had the femoral osteotomy at 21 and it went well for her. However I'd like to avoid hip surgery at all costs if possible(I have the same type of CP as Elena). As for the early joint issues I'd start her on joint supplements. I take different joint supplements(the kind you find at a health food store)as well as something called "Napolea". Napolea is a drink made from cactus fruit and it prevent the joints from becoming inflamed. When you have the CP the strange joint alignment we have can cause the joints to get inflamed and that leads to degenerative joint problems later on but you might be able to decrease Elena's risk naturally instead of via surgery.

TheCzarsOf45 said...

CP is very hard on hips. Especially with the spasticity and crouch gait. I am notorious for this as well. As I am also a SDCP person (I have spina bifida too) it is a tough life. I have one hip and one leg shorter, the hip on the left was also badly rotated outward to extreme. My issues didn't get diagnosed until mid 20's. Took a podiatrist to get it diagnosed correctly. I need a new hip joint or revision just to get the stress off of my body. E is biomechanically challenged. I was preemie and the hip issue and it liking to subluxate should have gotten me assessed correctly sooner. My hip joints stay inflamed. So, remember her hips are under excess load and strain as mine are. Due to that and the tiredness, I am a wheelchair user some of the time. Out of necessity. Also can give her more sports options (E loves thrills I see)