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In the assessment of the postoperative range of abduction, data from 1 hip per child was used. These values were obtained before and at 6–18 months and 18–36 months after the operation. The mean value, standard deviation (SD), and 95% confidence interval (CI) were calculated for variables for all children. Hips operated on with VDRO in combination with pelvic osteotomy were analyzed separately. For VDRO, we recorded whether the operation was performed uni- or bilaterally. Sex, GMFCS level, and age at the time of surgery were registered. Those operated on with a second operation before the 18–36-month examination were excluded. For children who underwent VDRO, those who were operated on with simultaneous APL and those who had been operated on with APL before the index operation were also included. For children who underwent APL, only those who had this operation as their 1st hip operation were included. This study included all children in CPUP in GMFCS levels II–V who underwent surgery with APL or VDRO before the age of 14 years and who had data reported for the range of hip abduction preoperatively and 6–18 and 18–36 months postoperatively. However, there are no specific recommendations regarding when APT or VDRO should be performed, nor when VDRO should be combined with pelvic osteotomy or whether VDRO should be performed uni- or bilaterally in children with unilateral displacement. Preventive surgery is recommended when the migration percentage (MP) ( 5) exceeds 40%. In Sweden, surgical procedures to prevent hip dislocation in children with CP are performed in 7 university hospitals and 5 regional hospitals ( 10). The abduction of the hip is done slowly ( 2). The stationary arm is placed along a line joining the 2 anterior superior iliac spines, and the movable arm is placed parallel to the longitudinal axis of the femur. Hip abduction is measured in the supine position with the hips extended and knees flexed. The examination includes measurement of hip abduction with a goniometer according to a manual that describes the positions of the child and the goniometer arms.
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Children in levels II–V are examined twice a year until age 6 years and thereafter annually until age 18 years. In CPUP, children are examined by their local physiotherapist at intervals based on age and gross motor function according to the Gross Motor Function Classification Scale (GMFCS), a 5-point scale in which level V indicates the greatest disability ( 14). This was a longitudinal register-based study that used data from CPUP. We compared the individual differences in abduction between sides between children operated on unilaterally and bilaterally. We used CPUP data to compare the development of the range of hip abduction after APL and VDRO. In CPUP, the hips are examined with repeated measurements of passive range of hip motion. CPUP started in southern Sweden (1.2 million inhabitants) in 1994 and, since 2006, has included > 95% of all children and adolescents with CP in Sweden (10.4 million inhabitants) born in 2000 and later ( 13). The Swedish Surveillance Programme for CP (CPUP) is a follow-up program and register for individuals with CP. After both APL and VDRO, there is a risk of recurrent hip displacement and the need for repeated surgery ( 10– 12). Opinions differ as to whether VDRO should be performed bilaterally, even in patients with unilateral hip displacement ( 7– 9). This varization can reduce the range of abduction and, to compensate for this, VDRO is often combined with APL and shortening of the femur. Proximal femoral varus derotation osteotomy (VDRO), sometimes combined with pelvic osteotomy, is a reconstructive surgery that aims to correct the displacement momentarily. There is a consensus that this operation should be performed bilaterally to prevent later contralateral dislocation ( 4– 6). Lengthening of the adductor and iliopsoas muscles or tendons (APL) is a preventive surgery that aims to reduce the muscle imbalance and increase the capacity for abduction. There are 2 principal surgical methods to treat hip dislocation in CP: preventive and reconstructive surgery. As a consequence, spasticity may inhibit growth in the length of the muscle, which results in the development of muscle contracture as measured by a decreasing range of joint motion ( 3). A spastic muscle will not allow stretch to the same degree as a muscle with normal tone. The passive range of hip abduction normally decreases with age in children with CP ( 2). The stronger and more spastic adductor and flexor muscles shift the force vector from the anteromedial to posterolateral direction during hip positioning in adduction, flexion, and inward rotation ( 1). Hip dislocation in cerebral palsy (CP) is caused by altered muscle forces on the hip joint.