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Hip Reconstruction in Patients With Cerebral Palsy

March 01, 2019

Contributors: Mara Karamitopoulos, MD; Dylan Lowe, MD; Kartik Shenoy, MD; Karim Zikar Masrouha, MD; Karim Zikar Masrouha, MD

Progressive hip subluxation and subsequent dislocation is common in patients who have cerebral palsy, with an increased risk associated with a higher Gross Motor Function Classification System level. Although cerebral palsy is a static encephalopathy, persistently increased muscle tone around the hip leads to progressive deformity of the femoral head and acetabulum, ultimately resulting in instability. The typical hip deformity observed in patients with cerebral palsy includes increased femoral anteversion, coxa valga, increased acetabular index, and decreased posterolateral coverage. The severity of hip pathology is related to the severity of spasticity. In patients who are nonambulatory, the risk of hip subluxation is higher than 60%. If hip subluxation is not managed, dislocation can occur, resulting in pain, stiffness, and functional decline. Soft-tissue releases, such as adductor or iliopsoas tenotomy, may be helpful in patients in the early stages of disease and patients with mild subluxation; however, a combination of soft-tissue and bony procedures may be necessary in patients with more severe subluxation or dislocation. Pelvic and femoral osteotomies with soft-tissue releases can result in the remodeling of incongruent hips in patients with cerebral palsy and may be associated with stable results over time. This video provides an overview of the pathogenesis and management of hip subluxation and dislocation in patients with cerebral palsy. The video discusses the case presentation of an 11-year-old boy with spastic quadriplegia cerebral palsy (Gross Motor Function Classification System level IV) who has bilateral hip pain, particularly with sitting. He had difficulty finding a comfortable position. Physical examination revealed windswept lower extremities with the right side adducted. The patient’s hip abduction was limited to 20°. The patient underwent soft-tissue and bony reconstruction of the hip joint via an adductor tenotomy, varus derotation osteotomy, and Dega osteotomy. Excellent alignment and a congruent joint were achieved intraoperatively. Adequate varus and correction of excessive anteversion were attained on the femoral side, and the acetabular index and posterolateral coverage were improved on the acetabular side. Release of the adductors allowed for increased hip abduction. Combined pelvifemoral osteotomies and soft-tissue releases are appropriate for the management of subluxated or dislocated hips in patients with cerebral palsy. Remodeling of the joint can occur after reduction with improved femoral and pelvic parameters, affording for a pain-free, reduced joint.

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