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  • 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%
  • Botox A into spastic muscles (age <3) to delay surgery
  • Attempt to prevent dislocation with adductor release, psoas release, hamstring lengthening (age 3-4)
  • Avoid obturator neurectomy 
Hip subluxation
  • Reimers index >33%
  • Disrupted Shenton's line
  • Treat with adductor tenotomy if abduction is restricted.
  • If persistent subluxation, proximal femur varus derotational osteotomy (age 5-6)
  • Do pelvic osteotomies (Dega, Pemberton, Salter, PAO or Chiari) if significant acetabular insufficiency 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 resection-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% 
    • Castle resection-interposition arthroplasty or abduction osteotomy
      • indications
        • chronic painful dislocation
        • unable to walk, stand to transfer (GMFCS 5)
    • total hip arthroplasty
      • indications
        • ambulatory patients and wheelchair bound who can stand to transfer
      • results
        • 85% 10 year survival in CP patients
    • hip arthrodesis
      • indications
        • young patients
        • ambulatory patients and wheelchair bound who can stand to transfer
  • 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) 
  • Valgus support osteotomy (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
  • Castle resection-interposition arthroplasty
    • indication
      • chronically dislocated hips
    • technique
      • resect proximal femur at the level of lesser trochanter
      • oversew vastus over cut proximal femoral end
      • oversew abductors, psoas and hip capsule over acetabulum
        • this interposes a large mass of soft tissue between the acetabulum and proximal femur
  • Girdlestone procedure
    • uniformly causes pain because of lack of interposition of soft tissue between cut femur and acetabulum leads to proximal femoral migration
    • this technique no longer used

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Questions (2)

(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? Review Topic


GMFCS V: Open reduction with varus derotational osteotomy, femoral shortening, psoas release, and pelvic osteotomy




GMFCS I: Hip adductor and psoas release plus abduction bracing




GMFCS V: Open reduction with varus derotational osteotomy




GMFCS V: Proximal femoral resection




GMFCS I: Open reduction with femoral varus derotational and pelvic osteotomy



Select Answer to see Preferred Response


This patient would classify as a Gross Motor Function Classification System Level (GMFCS) V. Proximal femoral resection is indicated in a nonambulatory patient with cerebral palsy that has pain while sitting in his wheelchair.

The Gross Motor Function Classification System Level (GMFCS) is commonly used for cerebral palsy. Level V is characterized by physical impairment which restricts voluntary control of movement and the ability to maintain antigravity head and trunk postures. Children have no means of independent mobility and are transported. Hip instability is uncommon in the ambulatory CP patient, but it is very common in the nonambulatory CP patient. 50% to 75% of dislocated hips will become painful in CP patients.

Muthusamy et al. performed a Level 4 review of 27 CP patients that were followed for nearly 8 years following a proximal femoral resection. They found that hip pain, range of motion, activities of daily living, and quality of life after surgery were all improved.

Leet et al. also conducted a Level 4 review of patients that underwent femoral head resection with traction or a McHale procedure (femoral head resection and valgus osteotomy). They found that the McHale group had a shorter length of stay in the hospital, less postoperative superior migration, and lower surgical and medical complications. However, both groups had increased sitting tolerance and decreased pain, and overall satisfaction with the surgical outcome.

Figure A demonstrates a dislocated left hip. Illustration A shows the Gross motor function classification system (GMFCS) for patients aged 6-12 years with cerebral palsy. Illustration B demonstrates the Mchale procedure consisting of femoral head resection and valgus osteotomy.

Incorrect Answers:
Answer 1, 3, and 5: Open reduction is relatively contraindicated in the setting of a flattened head. Reducing a degenerative femoral head may cause hip pain.
Answer 2: Soft tissue releases and bracing would be unlikely to obtain a sustainable reduction.


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(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? Review Topic


Bilateral botox injections and physical therapy




Nighttime Pavlik harness




Bilateral abductor release and valgus femoral osteotomies




Bilateral adductor release, varus femoral osteotomies and acetabuloplasties




Observation with repeat radiograph in 6 months



Select Answer to see Preferred Response


Children with spastic cerebral palsy develop hip subluxation as the result of long term muscle imbalance. Subluxation can progress to hip dislocation with resulting difficulties in seating, hygiene or personal care, and/or hip pain. The patient has bilateral dislocated/near dislocated hips with acetabular dysplasia.

Flynn and Miller provide a thorough review of hip disorders in patients with cerebral palsy including etiology, physical exam and treatment guidelines. Recommendations included hip reconstruction for children over 4 years of age with severe subluxation or dislocation if severe degenerative changes are absent. Hip reconstruction consists of a one-stage soft-tissue lengthening with varus derotational femoral osteotomy and possible acetabuloplasty.

Spiegel and Flynn also have provided a comprehensive review of hip dysplasia in patients with cerebral palsy. The article discusses early intervention to prevent complications associated with subsequent hip dislocations. Surgical intervention in patients older than 4 years with hip dislocations was once again hip reconstruction with soft-tissue lengthening, femoral osteotomies and acetabuloplasties in patients in patients with marked acetabular abnormalities.

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