Journal of Orthopedic Research & Physiotherapy Category: Medical Type: Case Report
Hip Dislocation in Cerebral Palsy: Treatment Options
- Eldessouky A1*, Smeda G2
- 1 Spr Trauma And Orthopaedics, Alexandra Hospital, Redditch, United Kingdom
- 2 Department Of Trauma And Orthopaedics, Royal Shrewsbury Hospital, United Kingdom
*Corresponding Author:Eldessouky A
Spr Trauma And Orthopaedics, Alexandra Hospital, Redditch, United Kingdom
Tel:+44 1215741676; +44 7462223365,
Received Date: Mar 21, 2016 Accepted Date: Aug 10, 2016 Published Date: Aug 24, 2016
Hip displacement in cerebral palsy is a common problem. The muscle imbalance and spasticity can lead to abnormal deforming forces which act on the hip joint resulting in acetabular dysplasia and femoral head migration. The patients suffer painful seating, abnormal gait and difficulty in personal hygiene.
There are various treatment options to address this problem depending on the patient’s age, GMFCS level and the degree of hip subluxation. Careful individual assessment is paramount in choosing the suitable treatment. The aim of this paper is to review the most common treatments of hip problems in cerebral palsy patients.
Hip instability and gait abnormalities are common hip problems in Cerebral palsy patients. Hip subluxation and dislocation develops in response to muscle imbalance and spasticity . The patient’s problems vary from abnormal gait to painful seating and difficulty in personal hygiene. The goal of treatment in those patients is to provide a painless hip that allows stable sitting and positioning.
The reported incidence of hip displacement in children with cerebral palsy has ranged from 1% to 75% and has been linked with the severity of involvement and the ambulatory status. Incidence of hip displacement is low in patients with mild involvement and who can walk independently, whereas those with more severe involvement and who are unable to walk have the greatest risk of hip displacement . The lowest incidence of hip displacement was found in the children with GMFCS level-I and the highest incidence, in those with level-V . Per Larnet and colleagues analysed the risk of hip displacement in relation to age and gross motor function in a total population of children with CP at GMFCS levels III-V. The data was collected from the Swedish CP registry and follow-up Program (CPUP) and included annual radiographic examinations of 353 children. They found that Children at GMFCS V have a significantly higher risk of hip displacement compared with children at GMFCS III–IV. The risk thought to be highest at 2-3 years of age .
Cerebral palsy can be classified according to the motor type which includes spastic, dystonic, mixed, ataxic, or hypotonic. Another classification depends on the topographical distribution which could be either spastic hemiplegia, spastic diplegia or spastic quadriplegia .
The creation of the Gross Motor Function Classification System (GMFCS) has made a huge impact on the way cerebral palsy is classified. The GMFCS is a grading system that describes the gross motor function of children and youth with cerebral palsy. Distinctions between levels are based on functional limitations, the need for walking aids or assistive equipment and the quality of movement .
ETIOLOGY AND PATHOLOGY
The resulting hip subluxation causes erosion of the lateral lip of the acetabulum and as acetabular changes continue, an increase in the acetabular angle is noted.
Finally, deformity of the femoral head occurs as a result of pressure from the capsule, the rim of the acetabulum, the abductors, and the ligamentum teres . Also, the position of the hip in adduction may contribute to the development of pelvic obliquity and subsequent scoliosis.
Physical examination is then followed by radiological assessment. The earliest signs of hip instability include subtle break in shenton’s line and uncovering of the most lateral aspect of the femoral head by a shallow acetabulum. The amount of femoral head protruding past the lateral border of the acetabulum can be qualified by Reimers’ migration percentage, or the percentage of transverse diameter of the femoral head that lies lateral to Perkins’ line, which is drawn at the edge of the acetabulum  (Figure 1). The acetabular index will be increased because of acetabular dysplasia. Coxa valga and increased femoral anteversion is demonstrated by increased neck shaft angle.In Bagg et al., series, he showed that hips with Migration Index (MI) < 50% may reduce spontaneously or at least remain subluxated. Hips with MI > 50% remained subluxated or progressed to dislocation .
Figure 1: Measurement of Migration Percentage (MP).
A study of 39 patients by Foroohar and colleagues demonstrated that Head Shaft angle is greater in children with CP than in typically developing children and this is more pronounced in patients who are at risk for eventual subluxation .
Miller and Bagg studied the prevalence of progression of subluxation based on the age of the patients. Their study involved 143 untreated hips in patients with cerebral palsy. 75% of the hips with Reimer’s migration indices of less than 30% did not progressively subluxate and those that did progress were individuals younger than 18 years. All hips with migration indices of greater than 60% eventually dislocated .
Non-operative treatments for hip displacement are preventive in nature. Various braces and postural alignment systems have been used aiming to maintain adequate hip abduction and to prevent progressive contractures of the muscles and consequent hip dislocation. However, several studies have shown that fixed abduction braces are not well tolerated in children with cerebral palsy .
Other treatment measures used is Intrathecal Baclofen Pump (ITBP) and Selective Dorsal Rhizotomy (SDR). Silva and colleagues found no significant difference in the rate of secondary hip reconstructive surgery or dislocation between non-ambulatory cerebral palsy patients who underwent SDR versus ITBP. Reconstruction was still required for 25% to 32% of the hips .
CATEGORIES OF SURGICAL TREATMENT
• Soft tissue release.
• Hip reconstruction surgery which include femoral and pelvic osteotomies.
• Salvage surgery for long-standing painful hip dislocations .
Soft tissue release
A hip at risk is defined as a hip with significant amount of muscle contractures but minimal subluxation and a migration index of less than 30% . Soft tissue release is indicated in a child who is preferably not older than 5 years with hip abduction less than 30 degrees, flexion contracture more than 45 degrees and a migration index which is greater than 25% to 30% .
In the treatment of a spastic hip a variety of soft tissue procedures is recommended, including partial or total tenotomy of the adductors and iliopsoas. The goal of these procedures is to achieve the optimum muscular balance. Tenotomies of the hip adductor muscle in patients with spastic cerebral palsy are the most common soft tissue procedures in the treatment of hip contractures .
Presedo and colleagues reviewed the results of adductor and iliopsoas release for patients with mild hip subluxation. With 10 years follow up their study concluded that soft-tissue release was effective for long-term prevention of hip dislocation in 67% (forty-three of sixty five) of children with spastic hip subluxation. Two preoperative factors were related to a favourable outcome: spastic diplegic pattern of involvement and the ability to walk. The hip migration percentage at one year postoperatively was a good predictor of final outcome . On the other hand Turker and colleagues found that 58% of patients who had adductor myotomy and were followed for 8 years required further surgery for hip subluxation or dislocation after soft tissue release .
Anterior branch obturator neurectomy is performed if children have greater than 60% migration and are not expected to have ambulatory ability in the future.
Reconstruction surgery for subluxated or dislocated hips
The aim is to achieve a neck-shaft angle of 90 to 100 degrees. Various methods of internal fixation have been used but the most common ones are a hip screw with a side plate and a 90-degree blade plate .
The osteotomy is usually accompanied with release of soft tissue contractures in order to balance the forces across the hip. Patient is then immobilized in a spica cast .
Several studies have compared the outcomes of hips treated with Varus Derotational Osteotomy (VDRO) only and hips treated with VDRO and pelvic osteotomy. Al Ghadir and colleagues found superior results with addition of pelvic osteotomy, and the authors recommended against VDRO alone . Song and Carroll advocated pelvic osteotomy if the preoperative migration index is greater than 70% .
A study done by Mubarak and colleagues reported the outcomes following Dega osteotomy combined with adductor, iliopsoas and proximal hamstring release as well as a shortening femoral VDRO. Results showed that 95% of the 104 hips remained stable after 7 years follow-up, although AVN occurred in 8% of hips. The study concluded that with Dega’s osteotomy excellent correction of the superior and lateral deficiency was achievable .
In a study reported by Pope and associates, 3 different types of pelvic osteotomies were performed on 21 patients with cerebral palsy. Five of seven hips treated with VDRO and a Chiari osteotomy remained stable. They advocated the use of Chiari osteotomy in the presence of severe subluxation or if there is moderate incongruity on arthrography after the femoral osteotomy .
Shelf acetabular augmentation
The operation is not recommended if dysplastic hip is suitable for redirectional osteotomy or if there is a need for supplementary stability following open reduction. Also patients who are not suitable for spica cast immobilisation are not candidates for this procedure .
Bernese peri-acetabular osteotomy
Although bernese periacetabular osteotomy was more common in the treatment of adolescent hip dysplasia, modifications of this osteotomy have been used in patients with cerebral palsy. More studies have shown that better coverage can be obtained because of the ability to redirect the acetabulum with great ease .
Salvage surgery for dislocated hips
Proximal femoral resection-interposition arthroplasty
It is essential to perform the femoral resection at a level no more proximal than the level of the inferior aspect of the ipsilateral ischial ramus, or 3 cm distal to the lesser trochanter . A more proximal resection can lead to increased pain after surgery due to the proximal migration of the femoral shaft as a result of spasticity .
Another problem reported following proximal femoral resection is heterotopic bone formation with substantial stiffness of the resected hip. Egermann and colleagues published their results following the use of femoral head to cap the proximal femur and showed a decreased rate of heterotopic ossification .
Although several studies have reported good outcomes after the surgery, it can take up to 6 to 9 months before obtaining proper pain relief .
Total hip arthroplasty
Few technical aspects need to be considered while performing the procedure for cerebral palsy patients: first, flexing the acetabular component will provide more posterior stability in sitting position. Second, bone grafting may be required to compensate for the bone loss in the superolateral aspect of the acetabulum . Root and colleagues recommended the use of spica for 4 weeks after surgery .
Raphael and colleagues reported on 59 hips who underwent total hip arthroplasty. Complete pain relief was obtained by 48 of 59 patients (81%), and reduction of preoperative pain was achieved by all patients. The 2-year survival was 95% (56 of 59). Revision rate was 15% (9 of 59). There were 8 dislocations (14%) .
Hip resurfacing with femoral osteotomy for painful, subluxated or dislocated hips in patients with cerebral palsy has been reported, Prosser and colleagues showed a series of 19 patients (20 hips) treated with hip resurfacing and proximal femoral osteotomy. The mean follow-up was 8 years. Pain was relieved in 16 of the 18 surviving hips (89%) at the last follow-up, and the GMFCS level had improved in seven (37%) patients .
Valgus osteotomy of the proximal end of the femur
However, pain relief following the osteotomy may not be predictably achieved and patients may continue to have problems with sitting because of the abduction position of the leg post-operatively. The femoral head may also be prominent causing pressure problems .
Another option is combining the valgus osteotomy with a femoral head resection as described by McHale and associates . Leet and colleagues compared the outcomes of McHale procedure (valgus osteotomy and femoral head resection) and femoral head resection and traction. They found that with valgus osteotomy and proximal femoral resection, the superior migration of the femoral head was less pronounced although there was no significant difference in the long-term caregiver satisfaction .
Root and colleagues reported on the outcomes of hip arthrodesis for CP patients. They used a combined intra-articular and extra-articular technique with subtrochanteric osteotomy of the femur to promote fusion. Two of the eight patients developed pseudoarthrosis and underwent revision. Their recommendation for hip arthrodesis is a young adult with normal contralateral hip and no lumbo-sacral spine deformity .
A study by De Moraes Barros Fucs and associates found that hip arthrodesis had good results in ambulatory patients especially those with unilateral hip involvement. The mean position of fusion was 40 degrees of flexion, 15 degrees of abduction, and neutral rotation. Among the seven bedridden patients, five were able to remain seated and two were able to walk .
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Citation:Eldessouky A, Smeda G (2016) Hip Dislocation in Cerebral Palsy: Treatment Options. J Orthop Res Physiother 2: 026.
Copyright: © 2016 Eldessouky A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.