Dear Sir

Re: Spasticity in children and young people with non-progressive brain disorders: summary of NICE guidance. BMJ 2012;345:e4845

We were surprised to note in the Practice Guideline by Mugglestone et al, the old myth that hip displacement in children and young people with non-progressive brain disorders should be diagnosed on the basis of symptoms or signs on physical examination (Box 1). By the time symptoms or signs are apparent, the vast majority of hips will have severe displacement and irreversible changes in the shape of the femoral head and/or acetabulum with extensive loss of cartilage i.e. premature degenerative arthritis.

We note that this summary of the NICE guidelines mentions “offering hip radiography to assess for hip displacement if there are clinical concerns about possible hip displacement or at 24 months in children with bilateral cerebral palsy”. However, this does not go far enough. The only way to reduce the severe long-term sequelae of neglected hip displacement in children with cerebral palsy and other non-progressive brain disorders is for regular radiographic surveillance and early intervention.[1,2] The risk of hip displacement according to GMFCS is now well known. From this, guidelines for regular clinical and radiographic surveillance can be established based on the patient’s specific risk.[3] For the majority of children who are non-ambulant, this involves radiographic examination every 6-12 months, beginning at 12-24 months of age and continuing to skeletal maturity.[1,2] The summary of the NICE guidelines fails to highlight this important aspect of surveillance. A single radiographic examination at 24 months would be falsely reassuring in many children and fail to reduce the preventable morbidity associated with neglected hip displacement.

References:
[1] Dobson F, Boyd RN, Parrott J, Nattrass GR, Graham HK. Hip surveillance in children with cerebral palsy: Impact on the surgical management of spastic hip disease. J Bone Joint Surg 2002;84-B;5:720-726

[2] Hagglund G, Andersson S, Duppe H, Lauge-Pedersen, Nordmark E, Westbom L. Prevention of dislocation of the hip in children with cerebral palsy. The first ten years of a population-based prevention programme. J Bone Joint Surg 2005;87-B:95-101.

[3] Soo B, Howard J, Boyd RN, Reid S, Lanigan A, Wolfe R, Reddihough D, Graham HK. Hip displacement in cerebral palsy: A population based study of incidence in relation to motor type, topographical distribution and gross motor function. J Bone Joint Surgery 2006;88-A:121-129

Competing interests: None declared