Surgery for hip dislocation in cerebral palsy

In 10 children seriously disabled by cerebral palsy, 12 dislocated hips were surgically reduced. The main indications for surgery were impaired perineal care, decreasing sitting balance, and pain. Furthermore, the operations were considered in order to anticipate major problems in the future, such as the wind-swept hip phenomenon and pain in the hip. At follow-up, it appeared that all the children had profited from the surgical procedures.     

Untreated hip dislocation in cerebral palsy

The purpose of this study was to evaluate the problems associated with hip dislocation in adults with cerebral palsy. Twenty-nine subjects with dislocated hips and no prior hip surgery were identified. There were a total of 38 dislocated hips. Age range was 21 to 52 years (average 34). Seven dislocated hips (18%) were definitely painful and four hips (11%) produced only mild or intermittent pain. Twenty-seven hips (71%) were not painful. The seven painful hips underwent proximal femoral resection, resulting in excellent range of motion and no pain. In conclusion, for established nonpainful hip dislocation in the severely involved spastic quadriplegic patient, aggressive surgical treatment should be undertaken only after careful consideration of the natural history. If a dislocated hip becomes painful in adulthood or develops an adduction contracture interfering with perineal care, a proximal femoral resection can be performed with reliably good success.     

Open reduction of hip dislocation in children with cerebral palsy

Objectives  

Improvement of joint stability, reduction or elimination of pain and joint contracture, prevention of osteoarthritic changes.     

Factors affecting the incidence of hip dislocation in cerebral palsy

We have studied the natural history of spontaneous dislocation of the hip in cerebral palsy, with particular reference to the pattern of neurological involvement. In patients with bilateral hemiplegia and severe involvement of the upper limbs the incidence of dislocation was very high (59%), while in those with diplegia and little involvement of the upper limbs, only 6.5% were affected. There was no evidence of dysplasia or instability of the hip in any of the patients with unilateral hemiplegia. A strong correlation was found between the stability of the hip and the patients' ability to walk. These findings have a bearing on clinical surveillance and also on the indications for prophylactic surgery.     

Surgical prevention of paralytic dislocation of the hip in cerebral palsy

Summary Paralytic dislocation of the hip in cerebral palsy may be prevented by soft tissue surgery and the results of two procedures are reported. Twenty hips were treated by adductor tenotomy alone and this was unsuccessful in every case. An alternative method was carried out in 42 hips in 25 patients. The procedure combined adductor tenotomy with release of the hip muscles including iliac crest resection, tenotomy of the rectus femoris, recession of the iliopsoas and, when necessary, either release or transposition of the knee flexors. This was much more successful in decreasing migration of the femoral head.

---

Résumé Dans la paralysie cérébrale la luxation de la hanche peut être efficacement évitée grâce à des interventions chirurgicales portant sur les parties molles. Nous avons étudié les résultats de deux types d'opération: la ténotomie des adducteurs et cette même opération associée à la désinsertion de la hanche (avec transposition du psoas sur la partie proximale de la capsule) et éventuellement avec allongement des fléchisseurs du genou ou transposition de ceux-ci sur la partie distale du fémur. Soixante-deux hanches ont été opérées chez 45 malades. Les résultats de la ténotomie isolée des adducteurs ont été insuffisants dans les 20 cas opérés (âge moyen au moment de l'opération, 4, 5, ans, recul 6,5 ans). Les résultats du deuxième type d'intervention ont été meilleurs dans les 42 hanches opérées, le pourcentage migratoire de la tête fémorale a été réduit de 45% (âge moyen lors de l'opération 7 ans, recul 5 ans). Plus de la moitié des malades étaient capables de se déplacer.

     

Palliative Schanz osteotomy for irreducible hip dislocation in adolescent patients with cerebral palsy

PURPOSE OF THE STUDY: Palliative Schanz osteotomy is one of the options for treatment of irreducible hip dislocation in adolescent patients with cerebral palsy. MATERIAL: In 1992 to 2002, Schanz osteotomy was indicated on 46 occasions in 27 nonambulatory patients with the quadriplegic form of cerebral palsy aged 9 to 18 years. METHODS: In the postoperative evaluation, emphasis was placed on the clinical presentation, i.e., improved motion of the hip joints and pain alleviation. X-ray examination was carried out at 2 to 6 months after surgery. RESULTS In all patients, the range of motion in the hip increased in abduction or flexion according to the osteotomy technique used. Because of severe pain, one patient (2.17 %) had to undergo subsequent resection of the femoral head. Transient pain in the hip persisted in four patients (8.7%). DISCUSSION In patients older that 10 years, reconstructive surgery for neurogenic dislocations has an uncertain outcome and a palliative procedure is often the only method of choice for treatment of irreducible dislocations. Schanz angulation osteotomy can provide a better range of motion, alleviate pain and facilitate the care of patients, particularly if they are nonambulatory. CONCLUSIONS Schanz osteotomy is a less invasive method than resection of the proximal femur and should be used preferably in older children with neurogenic hip dislocation in whom reconstructive surgery is not indicated.     

The associated effects of untreated unilateral hip dislocation in cerebral palsy scoliosis

INTRODUCTION: The presence of a unilateral hip dislocation in children with cerebral palsy (CP) may cause problems with sitting imbalance, pressure ulcers, and hip pain. There is a dynamic interplay between hip dislocation, pelvic obliquity (PO), and scoliosis. The effect of an untreated unilateral hip dislocation on the rate of curve progression of CP scoliosis has not been defined in the literature. The purpose of this study is to investigate the effect of unilateral hip dislocation on PO and the rate of curve progression in children with spastic quadriplegic CP. METHODS: Patients with spastic quadriplegic CP who had spine radiographs at the time of initial presentation with scoliosis and at the latest follow-up were evaluated. Twenty-three children with spastic CP who had an untreated unilateral hip dislocation and scoliosis constituted the study group. The control group consisted of 83 quadriplegic CP patients with scoliosis and well-located hips. The rate of curve progression, incidence of PO, and the rate of PO progression at follow-up were compared between the 2 groups. RESULTS: The mean ages of patients with a unilateral dislocation and with well-located hips at initial radiograph were 10.4 and 10.5 years, respectively. The mean follow-up was 3.5 years. The mean rate of scoliosis curve progression in patients with a unilateral hip dislocation was 12.9 degrees per year. In the control group, the mean progression rate was 12.2 degrees per year. The incidence of PO at follow-up was 74% in scoliotic patients with a dislocation and 63% in scoliotic patients with normal hips. Using repeated-measures analysis of variance, unilateral hip dislocation was found to have no significant effect on scoliosis progression; however, progression of PO was significantly increased in the hip dislocation group (P < 0.05). Pelvic obliquity was corrected after posterior spinal fusion to the sacrum with pelvic fixation, without reducing the hip(s) at the same surgery. CONCLUSION: Unilateral hip dislocation causes a significant increase of PO but does not affect the rate of scoliosis curve progression.     

Neurogenic hip dislocation in cerebral palsy: quality of life and results after hip reconstruction

Background At birth, no difference exists between the hips of children with spastic cerebral palsy and the hips of other children. The typical pathologic deformities of the hips in children with spastic cerebral palsy develop as the child gets older. One of our goals was to evaluate the change in quality of life of children with cerebral palsy after hip reconstruction. For classification of the children’s condition, we assessed sitting and standing abilities and used the Gross Motor Function Classification System. To evaluate the effect of hip dislocation on the spine, we assessed symmetry while the patient was lying down, sitting, and standing. Methods The results of surgical reconstruction of hip joints in 54 patients with severe cerebral palsy who had 66 severely subluxated or dislocated hip joints were retrospectively analyzed. The study was based on a research questionnaire with a mean follow-up of 4 years 10 months. The purpose of the questionnaire was to evaluate the pain, functional abilities, symmetry, and independence of the patients by using the modified Barthel index. Results Pain was fully relieved in 62 and was eased in 35% of preoperatively painful hips. The functional abilities of sitting and standing were not influenced statistically significantly by the operation. An improvement in sitting symmetry was observed in 40% and improvement in lying symmetry was observed in 32% of the patients. The mean center-edge angle improved from −24.9° ± 39° (mean ± standard deviation) to 25.9° ± 14°. The acetabular index improved from 30.2° ± 8° to 17.1° ± 7°. Conclusions The independence of the patients, based on the modified Barthel index, did not change significantly after surgery. Most improvements in quality of life were observed in those patients who had pain in the hip before the operation as a result of reduction of pain and improved mobility of the hip. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Surgical prophylaxis of subluxation and dislocation of the hip in cerebral palsy.

The clinical and radiological state of the hips of a group of children with cerebral palsy treated without operation is compared with that in a group treated by operation to correct adduction and flexion deformity and to obtain balanced action in the hip muscles. In the first group, 11 per cent of hips were dislocated, 28 per cent subluxated, 46 per cent dysplastic and 15 per cent normal. In the second group no hip was dislocated, 13 per cent were subluxated, 35 per cent dysplastic and 52 per cent normal. Surgical intervention is indicated clinically for a range of abduction diminishing to less than 45 degrees and--on radiological criteria--for early dysplastic changes, especially a break in Shenton's line, irrespective of the patient's age, severity of involvement or neurological maturity. Prevention of subluxation or dislocation improves function and diminishes the liability to develop a painful hip in adolescence or early adult life.     

Prevention of hip dislocation in cerebral palsy by early psoas and adductors tenotomies

The effectiveness of psoas and adductor tenotomies for the prevention of hip dislocation was investigated in 40 hips of 24 total-body-involved children. Age at operation ranged from 1.6 to 10 years. Results were evaluated by the Reimers migration percentage (MP). Average follow-up was 3 years. An overall good result was observed in 67% of cases. Results were correlated with age and MP at operation. Successful results were obtained in 90% of patients under age 4 who had an MP less than 33%. Preventive surgery should be performed at 2 or 3 years of age, before the onset of hip dysplasia.     

Habitual anterior dislocation of the hip in cerebral palsy: a case report

Habitual anterior dislocation of the hip joint is extremely rare. We believe this is the first case reported of a habitual anterior dislocation of the hip occurring in a child with cerebral palsy. The dislocation was painless, voluntary and used to occur every time the child would extend and externally rotate the limb. Operative intervention in the form of a varus derotation femoral osteotomy and anterior capsulorraphy was planned, but the caregivers of the patient were unwilling for the same. Hence, the patient was given an adduction and internal rotation brace and was counselled not to perform the activity needed to dislocate the hip. This case report calls attention to a unique problem previously not reported in cerebral palsy.     

Proximal femoral excision with interposition myoplasty for cerebral palsy patients with painful chronic hip dislocation

Purpose

Proximal femoral excision is a salvage procedure for painful chronic hip dislocation in cerebral palsy (CP) patients. The primary objective of this article is to describe our experience of an amplified interposition myoplasty, with appropriate peri-operative pain and tone management strategies, in a cohort of non-ambulatory CP patients with painful chronic hip dislocation. Our secondary objective is to present the clinical outcomes of these patients.

Methods

We describe our experience in 20 CP patients (25 procedures) at mean 54-month (range 27–169) follow-up with a surgical technique that includes an augmented interposition myoplasty and tone management. The indications for surgery were pain (21 hips), poor sitting tolerance (11) and difficulty with perineal care (8).

Results

The mean age was 22 years (range 10–40) with 11 patients Gross Motor Function Classification Scale (GMFCS) IV and 9 patients GMFCS V. Mean length of stay was 13 days (3–35). One procedure required revision at 12 months. Mean pain score improved from 7.8 (5–10) pre-operatively to 2.8 (1–5) post-operatively (p < 0.001). Sitting tolerance improved in all patients and in 75 % (15) perineal care was easier.

Conclusions

Our interposition myoplasty technique with individualised pain/tone management has good outcomes in this cohort of patients with multiple co-morbidities.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-015-0662-z) contains supplementary material, which is available to authorized users.     

Dega's transiliac osteotomy in the treatment of spastic hip subluxation and dislocation in cerebral palsy

The study presents the long-term results of operative treatment of spastic subluxation and dislocation of hip joints in cerebral palsy children with open reduction and pelvic transiliac osteotomy by Dega. The subjects were 25 patients (30 hips) and the follow-up lasted from 3 to 25 years (average 12 years). Final examinations were carried out after the end of body growth. Detailed analysis covered a patient's function, occurrence and intensity of pain in the hip joint, value of radiological parameters such as angle of centre-edge of the roof after Wiberg (CE), acetabular index (AI), neck-shaft angle (NS) and migration percentage (MP). The final evaluation of radiological results was carried out in accordance with Severin's classification. The clinical and radiological results obtained showed gradual deteriorations in comparison with the early postoperative results (dating from 12 months after surgery). In the final examination, in one patient a recurrent dislocation of the hip joint was diagnosed and subluxation was diagnosed in six patients (23%). Only the values of the CE angle went up (from -16 degrees in the early postoperative examination to 20 degrees in the final assessment), which we consider to be due to the change of sphericity of the head of femur. The remaining radiological parameters did not change significantly: AI from 22 degrees to 23 degrees, MP from 11% to 23%, NS from 133 degrees to 140 degrees. The surgical method presented is currently applied in a modified form, with a wider release within the soft tissues, more radical varusderotation osteotomy and greater shortening of the femur.     

Hip dislocation and subluxation in cerebral palsy

Four hundred sixty-four patients with cerebral palsy were reviewed. They were placed in four function groups: independent ambulators (n = 76), dependent ambulators (n = 43), independent sitters (n = 41), and dependent sitters (n = 304). The percentage of subluxated or dislocated hips increased from 7% for independent ambulators to 60% for dependent sitters. In the dependent sitters, a level pelvis or different degrees of pelvic obliquity did not correlate with whether the hip was located, subluxated, or dislocated. The subluxated or dislocated hip did not correlate with the high side or the amount of pelvic obliquity. Muscle imbalance around the hip and not the pelvic obliquity is the cause of the hip subluxation or dislocation.     

Extensor tendon dislocation in cerebral palsy.

An 18-year-old man with cerebral palsy presented with a flexion deformity of the middle finger particularly at the metacarpophalangeal joint and ulnar dislocation of the extensor tendon. Releasing the tight ulnar sagittal band and imbricating the attenuated radial sagittal band allowed centralization of the extensor tendon. For complete correction of other deformities intrinsic release and extrinsic flexor muscle lengthening were done. Extensor tendon instability in this case was due to the combined forces of the extrinsic and intrinsic muscles on the retinacular system of the extensor mechanism.     

Radiographic threshold values for hip screening in cerebral palsy

Purpose To analyse the consequences of using different radiographic measurements and different threshold values for hip screening in children with cerebral palsy (CP). Methods In a total sample of children with CP a standardised radiological follow-up of the hips was carried out as a part of a hip prevention programme. Acetabular index (AI) and migration percentage (MP) were measured on all radiographs. In this study, 1,067 radiographs of 272 children born 1992–1998 were analysed. Results Lateral displacement of the femoral head was common without acetabular dysplasia, and acetabular dysplasia occurred at a later stage than femoral head lateralisation. Hip dysplasia without lateral displacement of the femoral head was rare. In 16 of the 56 hips (29%) with AI ≥ 27° and in 23 of the 71 (32%) hips with MP ≥ 33% the values decreased below the threshold value without operative treatment. In hips with AI ≥ 30° only 2 of 31 hips (6%) and in hips with MP ≥ 40% only 5 of 44 hips (11%) decreased below the threshold values without operative treatment. Conclusions Radiographic follow-up with only measurement of the MP seems sufficient in screening for dislocation in children with CP. MP ≥ 33% is recommended as threshold for reaction or intensified observation. In children with MP ≥ 40%, the lateral displacement increased over time in most hips, thus indicating the need for operative intervention. In children with MP 33–40%, treatment should be based on other clinical signs and the progression of MP over time.