Cerebral Palsy - Hip Conditions

Topic updated on 11/18/15 11:23pm
  • 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%

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
  • Radiographs needed in most cases
  • Physical exam in most cases
  • 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)
  • Castle procedure osteotomy, interposition arthroplasty
  • Usually total hip arthroplasty
  • 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
  • Radiographs
    • Reimers migration index 
      • percent of femoral head with no acetabular coverage
      • most accurate method to identify and monitor hip stability
  • 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
  • Hip adductor and psoas release plus abduction bracing
    • goals of treatment
      • prevent hip subluxation and dislocation
      • maintain comfortable seating
      • facilitate care and hygiene
    • correction
      • soft-tissue release alone is insufficient for older children and larger deformities
      • additional bony procedures are performed concurrently
        • may need salvage acetabular procedures to obtain coverage once triradiates are closed (i.e. Chiari, Shelf)
  • Proximal femoral osteotomy and soft-tissue release
    • correction
      • varus derotational osteotomy to correct increased valgus and anteversion
      • may need pelvic osteotomy to correct acetabular dysplasia in older patients (e.g. Dega)
  • Abduction osteotomy or girdlestone procedure 
    • technique
      • abduction osteotomy pulls proximal femur further away from pelvis and decreases the pain produced from forces on the ilium
      • girdlestone procedure (proximal femoral resection) leads to a painless floppy leg


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Qbank (3 Questions)

(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

(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

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