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Cerebral Palsy Should Not Be a Barrier to Total Hip Replacement Surgery

November 30, 2021
by John Ready

Individuals with neurological conditions can face obstacles when seeking medical treatment. Patients with cerebral palsy (CP) may experience painful symptoms of hip osteoarthritis as adults and may potentially be overlooked for consideration as surgical candidates for total hip replacement (arthroplasty).

A recent study by Yale researchers found that those with and without CP had comparable 5-year outcomes after total hip replacement surgery. The authors hope the results will lend a voice and support for patients with CP who may be searching for relief of hip pain.

CP occurs in 3 per 1,000 individuals each year and affects muscle tone, movement, or posture, and can vary widely from those who are only slightly affected to others who require wheelchairs for mobility. People with CP were classically treated children’s hospitals and, in the past, the medical care they received in adulthood was poorly organized.

The Yale Cerebral Palsy Program is one of only a handful of programs in the country that comprehensively address CP, youth-onset brain injury, and other neurodevelopmental disorders that affect the musculoskeletal system through the entire lifespan. It focuses on patient-centered care that offers the latest advancements in treatment and a research-based approach to maximize function, regardless of age.

“We maximize the physical and psychosocial functions of our patients, and work to enable and empower their successful integration into the world,” said Assistant Professor of Orthopaedics & Rehabilitation David Frumberg, MD, who directs the program and is an author of the study. “Our multidisciplinary team of Yale doctors, nurses, and therapists collaborate to offer advanced solutions to all people.”

As all people age, they may experience hip osteoarthritis, which is routinely treated with total hip replacement, also known as total hip arthroplasty. For patients with neurodevelopmental disorders such as CP, this joint replacement surgery may not be made available as an option due to potential concerns about post-operative complications.

“It’s common for those with CP to not receive the treatment they need, especially as adults, and there are many levels of barriers,” Frumberg added. “Some orthopaedic surgeons prefer not to accept patients with CP under the assumption that complications such as dislocation risk related to the condition may be more prevalent or that functional outcomes will not be comparable to those without CP. Patients may also not know where to go for adequate treatment, having been turned away before. It’s really a perfect storm of health equity disparities.”

The results of this research show that, compared to patients without CP, patients with CP undergoing a total hip replacement were found to have higher odds of perioperative urinary tract infection, pneumonia, and periprosthetic fracture, but not other perioperative complications or differences in the overall five-year implant survival. These findings reinforce the notion that total hip replacement is safe to be performed on those with CP and that the barriers to undergoing this surgical operation should be removed since the outcomes are similar.

There is often a perceived risk involved with performing total hip replacements in patients with cerebral palsy but that perception simply does not match the data.

David Frumberg, MD

“There is no reason for those with CP to be restricted in receiving the appropriate care they need,” Frumberg said. “There is often a perceived risk involved with performing total hip replacements in patients with CP but that perception simply does not match the data.”

“At Yale, we have been performing total hip replacements on patients with CP for a considerable amount of time now,” he concluded. “I’m proud that our institution is actively working to remove barriers to health care that prevent surgery that improves quality of life from being considered. I hope other institutions will do the same.”

Lee E. Rubin, MD, associate professor of orthopaedics & rehabilitation and the chief of the Yale-New Haven Hospital Total Joint Replacement Program, agrees wholeheartedly. “The overall safety of hip replacement surgery has continued to improve dramatically,” he said. “We are now routinely able to preserve all of the muscles around the hip joint during surgery, which is especially important to ensure the recovery for patients with neuromuscular diseases such as CP.”

“Surgeons should take special consideration during the postoperative period when treating candidates for hip replacement with CP to ensure their balance and proprioception [the body’s ability to sense its movements] are restored to prevent falls, but should have confidence in the durability of the hip replacements in the longer term,” Rubin continued. “It is critically important to treat each patient in a holistic manner. Joint replacement surgeons should offer CP patients with advanced hip arthritis the same equitable access to joint replacement surgery as would normally be provided to neurotypical patients when appropriate.”

Jonathan Grauer, MD, professor of orthopaedics & rehabilitation and director of the Orthopaedic Spine Service, served as the lead author of the publication. “Our research group leverages large, national datasets to address questions such as the ones reported here,” he said. “I’m thrilled to have been able to work with outstanding medical students and faculty from multiple disciplines within orthopaedics on this study.”

The research publication appeared in the October 2021 issue of The Journal of Arthroplasty and was also selected for the 2021 Best Adult Paper Award by The American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) at its 75th Annual Meeting, which was held from October 7-9, 2021 in Quebec City, Canada.

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Submitted by John Ready on November 30, 2021