questions
4

Cerebral Palsy - Hip Conditions

Topic updated on 05/03/16 6:10am
Introduction
  • Cerebral Palsy General 
  • Epidemiology
    • progressive hip subluxation occurs in up to 50% of children with spastic quadriparesis (cerebral palsy)
  • Pathoanatomy
    • subluxation
      • strong tone in hip adductor and flexors leads to scissoring and predisposes to hip subluxation and dislocation
    • dislocation
      • dislocation is typically posterior and superior
    • degeneration
      • in time dysplastic and erosive changes in the cartilage of the femoral head can develop and lead to pain
  • Prognosis
    • grade of hip subluxation is correlated with the GMFCS level 
      • minimal in level I and up to 90% in level V
    • natural history studies have shown that hips will dislocate in the absence of treatment if Reimers index >60-70%
Classification
 

Stages of Hip Deformity in Cerebral Palsy
Hip at risk
  • Hip abduction of <45° with partial uncovering of the femoral head on radiographs
  • Reimers index <33%
  • Attempt to prevent dislocation with adductor release + psoas release, avoid obturator neurectomy
   
Hip subluxation
  • Reimers index >33%
  • Disrupted Shenton's line
  • Treat with adductor tenotomy if abduction is restricted.
  • Consider proximal femur and pelvic osteotomies if significant dysplasia is present
  
Spastic dislocation
  • Frankly dislocated hip 
  • Reimers index >100%
  • Open reduction with varus derotational osteotomy, + femoral shortening, and pelvic osteotomies
  
Windswept hips
  • Abduction of one hip with adduction of the contralateral hip
  • Brace adducted hip with or without tenotomy and release abduction contracture of abducted hip
  
 
Comparison of Spastic Hip Dysplasia and Developmental Dysplasia of the Hip
Factor Spastic Developmental
Findings at birth
  • Hip usually normal
  • Hip usually abnormal
Age at risk
  • Usually normal in 1st year of life; recognized after age 2yr
  • Most often recognized in 1st year of life
Detection
  • Radiographs needed in most cases
  • Physical exam in most cases
Etiology
  • Spastic muscles drive femoral head out of normal acetabulum, pelvic obliquity
  • Mechanical factors (breech), ligamentous laxity, abnormal acetabular growth
Childhood progression
  • Progressive subluxation common
  • Progressive subluxation rare
Natural history
  • Pain in many subluxated/dislocated hips by 2nd or 3rd decade
  • Pain in many subluxated hips by 4th or 5th decade
Acetabular deficiency
  • Usually posterosuperior
  • Usually anterior
Early measures
  • Muscle lengthening
  • Pavlik harness or closed reduction
Missed or failed early measures
  • Hip osteotomies, often without open reduction
  • Closed or open reduction, often without osteotomies (before 18mth of age)
Salvage
  • Castle procedure osteotomy, interposition arthroplasty
  • Usually total hip arthroplasty
 
Presentation
  • Symptoms
    • hip and/or groin pain
    • difficulty with sitting
    • difficulty with hygiene
  • Physical Exam
    • decreased hip ROM
    • pain with hip motion
    • gait difficulty due to lever arm dysfunction
      • hip subluxation/dislocation rare in ambulatory patients
Evaluation
  • Radiographs
    • Reimers migration index 
      • percent of femoral head with no acetabular coverage
      • most accurate method to identify and monitor hip stability
Treatment
  • Nonoperative
    • observation
      • mild cases
  • Operative
    • hip adductor and psoas release plus abduction bracing
      • indications 
        • children < 4 years and Reimers index > 40% 
          • this is one exception to the general rule of avoiding surgery in CP patient < 3 years of age
    • proximal femoral osteotomy and soft-tissue release
      • indications
        • children > 4 years old or Reimers index > 60% 
    • abduction osteotomy or girdlestone procedure
      • indications
        • chronic painful dislocation
Techniques
  • Hip adductor and psoas release plus abduction bracing
    • goals of treatment
      • prevent hip subluxation and dislocation
      • maintain comfortable seating
      • facilitate care and hygiene
    • caveat
      • soft-tissue release alone is insufficient for older children and larger deformities
  • Proximal femoral osteotomy and soft-tissue release, possible acetabular osteotomy
    • technique
      • varus derotational osteotomy to correct increased valgus and anteversion
      • may need pelvic osteotomy to correct acetabular dysplasia; the indications to combine pelvic osteotomy remains controversial
      • may need salvage acetabular procedures to obtain coverage once triradiates are closed (i.e. Chiari, Shelf) 
  • Femoral head resection +/- valgus subtrochanteric femoral osteotomy (E.g McHale Technique)  
    • indication
      • salvage technique for symptomatic and chronically dislocated hips in cerebral palsy
    • technique
      • anterolateral approach to remove femoral head and neck leaving ligamentum teres attached to acetabulum
      • perform a closing wedge subtrochanteric osteotomy and fix with lateral plate
      • attach ligamentum teres to psoas tendon or anterior capsule

 

Please Rate Educational Value!
3.0
Average 3.0 of 24 Ratings

Qbank (4 Questions)

TAG
(OBQ12.201) A 15-year-old, non-ambulatory patient with cerebral palsy who is unable to maintain an upright head position against gravity, has pain while sitting in his wheelchair. An AP pelvis radiograph is shown in Figure A and attempted frogleg lateral view in Figure B. A preoperative CT scan (Figure C) demonstrates significant femoral head flattening. What is the most accurate Gross Motor Function Classification System level, and what is the most appropriate surgical intervention? Topic Review Topic
FIGURES: A   B   C      

1. GMFCS V: Open reduction with varus derotational osteotomy, femoral shortening, psoas release, and pelvic osteotomy
2. GMFCS I: Hip adductor and psoas release plus abduction bracing
3. GMFCS V: Open reduction with varus derotational osteotomy
4. GMFCS V: Proximal femoral resection
5. GMFCS I: Open reduction with femoral varus derotational and pelvic osteotomy

PREFERRED RESPONSE ▶
TAG
(OBQ09.208) The parents of a wheelchair-bound 8-year-old boy with cerebral palsy present with difficulty during diaper changes and with hygiene care. His physical exam demonstrates 5° of hip abduction on the left hip and 15° on the right. An AP pelvis radiograph is shown in figure A. What is the most appropriate treatment? Topic Review Topic
FIGURES: A          

1. Bilateral botox injections and physical therapy
2. Nighttime Pavlik harness
3. Bilateral abductor release and valgus femoral osteotomies
4. Bilateral adductor release, varus femoral osteotomies and acetabuloplasties
5. Observation with repeat radiograph in 6 months

PREFERRED RESPONSE ▶
Sorry, this question is available to Virtual Curriculum members only.

Click HERE to learn more and purchase the Virtual Curriculum today!





Cases

http://upload.orthobullets.com/cases/2623/6603c457-9029-425c-805b-d4b969b6cb8d_ct-3d.jpg
HPI - 17yoM with quadriplegic CP GMFCS level 5, with chronic right hip dislocation suf...
poll
7/3/2016
98 responses
See More Cases

Evidence



Topic Comments