Proximal rectus femoris release surgery is not effective in normalizing hip and pelvic variables during gait in children with cerebral palsy

The purpose of this study was to determine the efficacy of the proximal rectus femoris release to treat hip flexor contractures and hip and pelvic gait deviations in children with spastic cerebral palsy. This study was a retrospective repeated-measures analysis of data collected on two matched groups of patients, those with and without proximal rectus femoris release surgery, seen in our Motion Analysis Laboratory. Proximal rectus release surgery did not improve hip extension, did not decrease anterior pelvic tilt, and did not improve temporal-distance measures of gait in children with cerebral palsy. A multivariate measure, the Hip Flexor Index, was also unchanged. The group of patients without any hip flexor surgery was not different from the rectus femoris release group on hip or pelvic variables before or after surgery. The findings of this study offer no evidence that the proximal rectus femoris release is successful in achieving desired gait outcomes at the hip and pelvis in children with cerebral palsy.     

Effects of intramuscular psoas lengthening on pelvic and hip motion in patients with spastic diparetic cerebral palsy

The effects of intramuscular psoas lengthening on gait in cerebral palsy patients have been the subject of debates, and the indications for such procedure are still controversial. The purpose of this study was to evaluate the effects of intramuscular psoas lengthening on sagittal plane pelvic and hip motion in patients with spastic diparetic cerebral palsy and identify the factors linked to the best possible outcome. A retrospective study was performed in 26 independent ambulatory patients. All of them had undergone an intramuscular psoas lengthening over the pelvic brim. The mean age at the time of surgery was 11.10 years, and most cases went through additional simultaneous procedures. A complete gait analysis was performed before and, on average, at 17.69 months (range, 6-39 months) after surgery. The Thomas test values, maximum hip extension in stance, and pelvic tilt were analyzed before and after surgical intervention, and the results were statistically compared. The most significant postoperative effect was the reduction of pelvic range of motion (P < 0.01). Reduction of anterior pelvic tilt was observed only in those patients with no previous need of an external aid (P < 0.01), and the studied group did not show a significant improvement of hip extension at terminal stance. According to the results, intramuscular psoas lengthening was useful in reducing pelvic range of motion at the sagittal plane, but this study also suggests that pelvic and hip disruptions of the same plane (sagittal) seem to have a multifactorial etiology. The use of external assistive devices in patients with balance problems may lead to increased anterior pelvic tilt as well as reduction of hip extension at terminal stance.     

Factors associated with internal hip rotation gait in patients with cerebral palsy

Internal rotation gait is common in children with cerebral palsy. Factors thought to contribute include femoral anteversion, hip flexor tightness, imbalance of hip rotators, and hamstring and adductor tightness. The exact cause of internal rotation must be defined before contemplating surgery. We investigated the prevalence of internal hip rotation and associated factors, which are considered to influence this walking pattern, in patients with cerebral palsy. Gait laboratory data of 222 patients with cerebral palsy were studied retrospectively. Two groups were selected; those with maximum dynamic hip internal rotation of more than 27 degrees and those with less than 20 degrees. Of 222 patients, 27.0% (diplegia, 61.7%; hemiplegia, 38.3%) had at least one hip with dynamic internal rotation of more than 27 degrees. This study suggests that dynamic hip internal rotation is multifactorial in origin. The most significant differences in clinical measures were found in values of passive hip external rotation range, femoral anteversion and hip flexor contracture. We discuss the role of early treatment of hip flexion contracture.     

The anteromedial approach to the psoas tendon in patients with cerebral palsy

Purpose Release of the psoas tendon for flexion deformity of the hip in children with cerebral palsy has traditionally been performed at the pelvic brim, lateral to the neurovascular bundle, or at its insertion into the lesser trochanter. As the psoas tendon is lateral to the pectineus, the traditional exposure of the tendon through an approach medial to the pectineus is limited by the extent to which the pectineus can be retracted proximally. Technical note We describe the use of the anteromedial approach used for the developmentally dislocated hip to expose the psoas tendon between the pectineus and the neurovascular bundle. This provides a much better visualisation of the tendon as it crosses the superior pubic ramus to its insertion. The use of this approach has not been described in cerebral palsy.     

Psoas weakness following oblique lateral interbody fusion surgery: a prospective observational study with an isokinetic dynamometer

BACKGROUND CONTEXTAlthough the surgical corridor used for oblique lateral interbody fusion (OLIF) protects the intrapsoas nerves by causing minimal compression, transient weakness remains the most commonly reported postoperative complication.PURPOSEUsing a dynamometer to evaluate how the hip flexor strength changes following OLIF.STUDY DESIGN/SETTINGA prospective observational study.PATIENT SAMPLEForty-six patients who underwent single or multi-level OLIF for lumbar spondylolisthesis.OUTCOME MEASURESIsokinetic dynamometer values (peak torque, total work, average power), visual analogue scale (VAS) scores for leg pain, hypoesthesia, subjective weakness of the left hip flexor muscle, Oswestry disability index, body mass index, bone mineral density, radiologic findings of the psoas muscle (cross-sectional area, Hounsfield unit (HU), fat portion grade), and psoas retraction time.METHODSThe isokinetic muscle strength of the hip flexor was measured five times (preoperatively and postoperatively at 2 days, 1 week, 1 month, and 3 months) for both legs. The peak torque was defined as the postoperative strength of the left hip flexor muscles, and was compared to the preoperative baseline value. The strength of the left and right hip flexor muscles were also compared at each time point. For logistic regression analysis, when the peak torque was below the median value, it was defined as lower peak torque.RESULTSUp to 1 week after surgery, the strength of the left hip flexor muscle decreased significantly (paired difference in peak torque was 22.6%, p<.001). In the results of multivariate logistic regression analysis, diabetes (odds ratio [OR]=8.43, p=.020) and the HU of the psoas muscle (OR=0.916, p=.034) were associated with lower peak torque 1 week after surgery. From 1 month after surgery, postoperative weakness of the psoas muscle was not significant. In the questionnaire survey, subjective left hip flexion weakness was reported in 8.5% (4/47) of patients 1 week after surgery, and it remained in only 2.1% (1/47) of patients after 3 months of operation. The frequency of left anterior thigh pain and hypoesthesia decreased from 85.1% (40/47) at 1 week to 2.1% (1/47) at 3 months after surgery. The mean VAS score for left anterior thigh or groin pain decreased significantly at 1 month after surgery (PO2D: 4.04±1.84, PO1M: 1.67±1.10, p<.001).CONCLUSIONSDynamometer measurement showed that psoas strength declined significantly up to 1 week after OLIF surgery. Patients with diabetes or lower HU of the psoas muscle showed delayed recovery from postoperative weakness of the psoas muscle. However, the weakness was insignificant from 1 month after surgery. At 3 months after surgery, the other psoas-related problems (left anterior thigh pain and hypoesthesia) also disappeared.     

Multilevel surgery in spastic diplegia: evaluation by physical examination and gait analysis in 25 children

Gait improvement surgery was performed on 25 ambulatory children with the diplegic type of cerebral palsy. Multiple soft tissue and bony procedures were performed (mean 8.2 procedures) according to criteria defined on the basis of physical examination and gait analysis. Relevant physical examination findings and kinematic and kinetic data in the sagittal plane were evaluated before surgery and at least 3 years after surgery. Physical examination showed a reduction in the ankle plantar-flexor power and in the range of hip flexion and ankle plantarflexion after surgery. Analysis of gait data showed significant improvements in the sagittal plane kinematics and the power generation at the hip and the ankle. At the knee joint there was maintenance of power of the flexor and extensor group of muscles on physical examination, with significant improvements in the kinematics after surgery. The authors conclude that well-selected surgery improves function of the spastic muscle. The importance of assessing clinical, kinematic, and kinetic data together for proper evaluation of gait is stressed.     

Management of long toe flexor spasticity in the equinus foot in cerebral palsy

Toe flexor tightness becomes apparent in the plantigrade attitude achieved by isolated tendoachilles lengthening in cerebral palsy. This frequently persists, resulting in abnormal weight-bearing on the tips of the toes. To address this problem, at the time of limited tendoachilles lengthening, we performed Z-lengthenings of the flexor hallucis longus and the flexor digitorum longus tendons above the medial malleolus, preserving the pulley mechanism. From January 1998 to October 2001, 41 children (74 feet) with cerebral palsy underwent lengthening of the tendoachilles and long toe flexor tendons. The mean age at surgery was 7 years. The correction achieved was successfully maintained long-term, permitting a normal heel-metatarsal head weight-bearing pattern. Lengthening of the long toe flexors, in conjuction with tendoachilles lengthening, is an effective means of achieving a balanced foot in cerebral palsy.     

Hip surveillance in children with cerebral palsy. Impact on the surgical management of spastic hip disease

We studied prospectively the impact of a hip surveillance clinic on the management of spastic hip disease in children with cerebral palsy in a tertiary referral centre. Using a combination of primary clinical and secondary radiological screening we were able to detect spastic hip disease at an early stage in most children and to offer early surgical intervention. The principal effect on surgical practice was that more preventive surgery was carried out at a younger age and at a more appropriate stage of the disease. The need for reconstructive surgery has decreased and that for salvage surgery has been eliminated. Displacement of the hip in children with cerebral palsy meets specific criteria for a screening programme. We recommend that hip surveillance should become part of the routine management of children with cerebral palsy. The hips should be examined radiologically at 18 months of age in all children with bilateral cerebral palsy and at six- to 12-monthly intervals thereafter. A co-ordinated approach by orthopaedic surgeons and physiotherapists may be the key to successful implementation of this screening programme.     

The unstable paralytic hip: treatment by combined pelvic and femoral osteotomy and transiliac psoas transfer

Between 1970 and 1985, 26 pelvic and femoral osteotomies and transiliac psoas transfers were performed in one or two stages on 18 patients with progressive hip instability associated with flaccid or spastic paralysis. Average follow-up was 95 months. Twenty hips were located, two were subluxated, and none was dislocated. The acetabular index was 30 degrees preoperatively and 19 degrees at follow-up. The center edge angle was -24 degrees preoperatively and 15 degrees at follow-up. The combination of pelvic and femoral osteotomy and transiliac psoas transfer, now done in one stage, is an effective means of obtaining and maintaining location of the hip in patients with myelomeningocele and cerebral palsy.     

Is the psoas a hip flexor in the active straight leg raise?

Psoas function is a topic of considerable relevance in sports and clinical science. However, the literature on psoas function is not sufficiently consistent. Questions are, amongst others, if during hip flexion the psoas always has the same function as the iliacus, and if the psoas affects the hip more than the lumbar spine. In the present study, 17 healthy women, 20–40 years, performed the active straight leg raise (ASLR), with the right or the left leg (“Side”), and without or with weight added above the ankle (“Condition”). Electromyographic (EMG) activity of psoas and iliacus were recorded with fine-wire electrodes, and of rectus femoris and adductor longus with surface electrodes, all on the right side. Movements of the leg were recorded with active markers and a camera system. During ASLR, the iliacus, rectus femoris, adductor longus and psoas were active ipsilaterally, but psoas was also active contralaterally. All muscles started to contract before movement onset, the iliacus, rectus femoris, and adductor longus largely at the same time, before the psoas. There was no significant difference between the amplitude or time of onset of ipsilateral and contralateral psoas EMG activity, nor was there a significant interaction between Side and Condition for the psoas. Although ipsilateral psoas activity is consistent with the psoas being a hip flexor, contralateral activity is not. The most simplest explanation of the pattern found is that the psoas is bilaterally recruited to stabilize the lumbar spine, probably in the frontal plane.     

Femoral head resection in dislocated hip in cerebral palsy children]

The purpose of this study is to assess the outcome of proximal femoral resection in dislocated hip in cerebral palsy patients. Between 1993-2003 we treated 5 nonambulatory patients with quadriplegic form of cerebral palsy. We performed 6 resection of the proximal part of the femur. The average age at the surgery was 15.8 years (9-19.5 years) and average follow-up was 69 months (12-144 months). The indication to surgery was persistent hip pain. The results were good--the pain relieved, the movement in ,,the hip" was better and hygiene improved. Femoral head resection is radical, invasive method but we recommended it for selected group of severly spastic nonambulatory cerebral palsy patients with painful hip dislocation.     

Long-term results of hip arthroplasty in ambulatory patients with cerebral palsy

Osteoarthritis (OA) secondary to dislocation and dysplasia is a common problem in patients with cerebral palsy. The purpose of this study was to evaluate the results of total hip replacement (THR) in ambulatory patients with cerebral palsy. Eighteen total hip arthroplasties were performed in 16 ambulatory patients with cerebral palsy. The patient's mean age at surgery was 42 ± 8 years (range 32–58 years), and the mean follow-up was 10 ± 6 years (range 2–18 years). Data were obtained by a standardised telephone interview. There was a significant postoperative reduction in pain on the NAS (narrative analogue scale) from 8.4 preoperatively to 1.1 postoperatively (p = 0.002). At follow-up no stem had been revised. Three cups were revised for aseptic loosening at two and six years, and one cup was revised for recurrent dislocation of the hip. One hip was revised for infection 12 years after the index surgery. One hip dislocated (three months postoperatively) and was treated by closed reduction. In ambulatory patients with cerebral palsy and secondary osteoarthritis of the hip THR can provide long-term pain relief and improved function. The rate of long term complications was moderate in this series; however, the dislocation rate was higher than in standard OA cases.     

Heterotopic ossification after hip surgery in cerebral palsy

Heterotopic ossification is a post-surgery complication occasionally observed in patients with infantile cerebral palsy. In the majority of the cases such lesions are found at the hip after surgery on the skeleton and the soft tissues. At our Institute in the last five years, this complication has been observed four times, in 39 patients, who underwent mainly soft tissue releases because of flexion and adduction contracture of the hip. In these cases, as in a further patient with myelomeningocele, the periarticular heterotopic ossification appeared in the hip after tenotomy of the ilio-psoas at the lesser tronchater associated to other surgical procedures. Conversely, no cases of ossification have been found after tenotomy of the adductors or the gracilis or selective tenotomy of the psoas at the pelvic brim. The exact causes of this complication are still unclear, but after an analysis of the literature and patient history it can be hypothesised that it may be related to the surgical procedures carried out.     

The psoas muscle as cause of low back pain in infantile cerebral palsy

Psoas muscle spasticity is hypothesised as a rare cause of low back pain in patients with infantile cerebral palsy. The authors describe a new manoeuvre for the study of psoas tenderness and ultrasound (US)-guided transabdominal botulinum toxin injection technique. A possible causal relationship between psoas tension and low back pain was found incidentally in two examined cases. In subsequent patients, botulinum toxin was injected and, in cases of disappearance of symptoms, the psoas tendon was sectioned at the pelvic brim with definitive disappearance of pain. The relationship between psoas tension and low back pain in patients with infantile cerebral palsy seems likely, given the result in the four patients.     

Lengths of hamstrings and psoas muscles during crouch gait: Effects of femoral anteversion

Recent studies of muscle lengths measured by means of gait analysis data and musculoskeletal models have suggested that in many cases of crouch gait in patients with cerebral palsy, the hamstrings are of normal length and the psoas muscles are short. In these studies, however, muscle lengths were calculated by applying kinematic data from a child's joint to a normal adult model. Children with cerebral palsy and other disorders generally do not have normal bone architecture but instead have muscle attachment points and muscle paths altered by osseous deformities. In this study, we explored the consequences of using normal adult musculoskeletal models to calculate hamstring and psoas lengths for children with cerebral palsy. Specifically, for a group of subjects with cerebral palsy who walk with a crouch gait, we investigated the changes in muscle lengths that arise when a patient-specific representation of clinically measured femoral anteversion was added to a model of normal musculoskeletal geometry. The calculation of psoas muscle length was found to be very sensitive to femoral anteversion, whereas the calculation of hamstrings length was found to be relatively insensitive to this osseous deformity.     

Selective lengthening of the psoas and rectus femoris and preservation of the iliacus for flexion deformity of the hip in cerebral palsy patients

Between 1978 and 1983, 52 Japanese patients with cerebral palsy underwent operative correction of flexion deformity of the hip. The results of lengthening of the psoas, rectus femoris, and proximal hamstrings were satisfactory. The iliacus was left intact. Improvement in gait and activities of daily living was attained. Concentric reduction was obtained in 27 of 33 dislocated or subluxated hips. Sitting and perineal care were facilitated, and pain was alleviated. We conclude that preservation of the iliacus is important.     

Bilateral hip surgery in severe cerebral palsy a preliminary review.

When cerebral palsy involves the entire body pelvic asymmetry indicates that both hips are 'at risk'. We carried out a six-year retrospective clinical, radiological and functional study of 30 children (60 hips) with severe cerebral palsy involving the entire body to evaluate whether bilateral simultaneous combined soft-tissue and bony surgery of the hip could affect the range of movement, achieve hip symmetry as judged by the windsweep index, improve the radiological indices of hip containment, relieve pain, and improve handling and function. The early results at a median follow-up of three years showed improvements in abduction and adduction of the hips in flexion, fixed flexion contracture, radiological containment of the hip using both Reimer's migration percentage and the centre-edge angle of Wiberg, and in relief of pain. Ease of patient handling improved and the satisfaction of the carer with the results was high. There was no difference in outcome between the dystonic and hypertonic groups.     

Determinants of hip pain in adult patients with severe cerebral palsy

The purpose of our investigation was to study the relationship between radiographic results of the femoral head and pain in people with severe cerebral palsy. We conducted a cross-sectional study on hip radiography results and pain in 160 patients with severe cerebral palsy. Eighteen percent of our patients had hip pain in hip-loading situations. Migration and deformity were closely related. There was a significant association with hip pain (odds ratio, 2.79; 95% confidence interval 1.01-7.70). There is a high prevalence of hip pain after unsuccessful femoral bone surgery. Migration and deformity of the femoral head are strongly interrelated, and are associated with pain.     

Prevention of dislocation of the hip in children with cerebral palsy. The first ten years of a population-based prevention programme

In 1994, a register for cerebral palsy and a health-care programme were started in southern Sweden with the aim of preventing dislocation of the hip in children with cerebral palsy. It involved all children with cerebral palsy born in 1992 or later. None of the 206 affected children born between 1992 and 1997 has developed a dislocation following the introduction of the prevention programme. Another 48 children moved into the area and none developed any further dislocation. Of the 251 children with cerebral palsy, aged between five and 11 years, living in the area on January 1, 2003, only two had a dislocated hip. One boy had moved into the area at age of nine with a dislocation and a girl whose parents chose not to participate in the programme developed bilateral dislocation. One boy, whose condition was considered to be too poor for preventative surgery, developed a painful dislocation of the hip at the age of five years and died three years later. Eight of 103 children in a control group, consisting of all children with cerebral palsy living in the area between 1994 and 2002, and born between 1990 and 1991, developed a dislocation of the hip before the age of six years. The decreased incidence of dislocation after the introduction of the prevention programme was significant (p < 0.001). Dislocation of the hip in cerebral palsy remains a serious problem, and prevention is important. Our screening programme and early intervention when lateral displacement of the femoral head was detected appear to be successful.     

Hip dysplasia in spastic cerebral palsy

Previous reports have noted a relationship between pelvic obliquity and hip dysplasia in spastic cerebral palsy but did not confirm its existence by scientific study. A study is reported that confirms the association of pelvic obliquity with hip dysplasia in spastic cerebral palsy. At presentation of subluxation or dislocation prior to surgery, 80 patients were indexed into five body alignment types. Reclassifications were performed with passage of time in order to study the natural history and effects of surgery. In all cases, hip dysplasia was found to be consistent with the forces related to pelvic obliquity.