Yatsuliak M. Clinical and radiological criteria of hip joint structure in patients with cerebral palsy.

The work is based upon the usage of clinical cases of patients treated in the Department of Joint Diseases in Children and Adolescents and in the Department of Pediatric and Adolescent Orthopedics and Traumatology (now the Department of Reconstructive Orthopedics and Pediatric and Adolescent Traumatology). The thesis is dedicated to solving the actual research task in orthopedics and traumatology – improving the diagnosis and prognosis of spastic hip dislocation among patients with cerebral palsy (CP) by studying the clinical and radiological criteria of the hip joint (HJ) formation. To solve the task, a method of clinical and radiological study of the hip joint's diseases in patients with cerebral palsy was developed, which is an improvement of the proposed (by Ruwe et al., 1992) method of clinical assessment of FT. With the help of the "odds ratio" method, we determined that the sensitivity of measuring femoral torsion according to Ruwe's method Se = 0.7, specificity Sp = 0.83, OR = 11.67 CI [1.94 – 70.18] suggest that that the chance of obtaining a match by measuring femoral torsion according to Ruwe's method is 11.67 times higher than according to Koval's method, when compared with intraoperative data. The precisely determined value of the femoral torsion ensures obtaining the exact and true parameters of the HJ by the developed by us method. Subsequently, we analyzed the existing clinical and radiological criteria for assessing the formation of HJ in patients with cerebral palsy and, based upon the proposed method of clinical and radiological examination, established the factors influencing the formation of the studied parameters. In particular, factors such as age, Gross Motor Function Classification System (GMFCS) level, ambulatory status, medical history of adductor myotomy have a statistically significant effect upon the NSA parameter. Factors such as the level of lesion's and developmental dysplasia of the hip do not have a statistically significant effect. The FT parameter is statistically significantly influenced by the following factors: GMFCS level, ambulatory status, lesion's level, and there is no statistically significant influence of the following factors: age, adductor myotomy in medical history, developmental dysplasia of the hip. A statistically significant positive influence of the ambulatory function upon the true parameters of the hip joint was revealed: NSA, FT, acetabular angle (AA), Sharpe's angle (SA), Reimers' index (RI), Wiberg's angle (WA). In 2016, a scientific group from Switzerland proposed a new parameter for the diagnosis of unstable or stable HJ with borderline dysplasia and entitled it the Femoro-Epiphyseal Acetabular Roof (FEAR index), that demonstrated good reliability in detecting instability among patients with developmental dysplasia of the hip. For the first time, we established the diagnostic value of the FEAR index in determining the instability of the hip joint in patients with cerebral palsy using mathematical modeling, and also analyzed the factors affecting it. With the help of mathematical models of CS instability, we found that the Reimers' index is currently the most accurate parameter. Based upon the refined indices of the clinical and radiological examination of the hip joint in patients with cerebral palsy obtained by the developed by us method, a mathematical model was created to determine the expediency for surgical intervention on HJ in cerebral palsy (accuracy of the model 90.6%), and a simplified mathematical model for HJ screening in cerebral palsy (accuracy of the model 87.06%). A mathematical model was also created to determine the expediency for performing femoral and pelvic osteotomy and for isolated femoral osteotomy in patients with cerebral palsy (accuracy of the model 91.1%). For all models, ROC data analysis was performed to determine the prognostic value of indices. On the basis of these mathematical models, a differentiated approach to the choice of therapeutic tactics on HJ in patients with cerebral palsy has been developed. Taking into account our study, primary care doctors, who know how to determine HJ radiographic parameters and the clinical assessment of FT according to the Ruwe's method, will be able to screen HJ, as well as determine the expediency for reconstructive surgical interventions with the accuracy of the specified models, that takes into account the experience of specialists of the Children clinic of the State Institution "Institute of Traumatology and Orthopedics of the National Academy of Medical Sciences of Ukraine".