A radiographic and clinical comparison of two soft-tissue procedures for paralytic subluxation of the hip in cerebral palsy

Abstract

This article summarises a comparative retrospective study (1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001) of 42 consecutive spastic-diplegic ambulatory patients (aged 2-10 years) by examining the radiographic and clinical results of two soft-tissue procedures for paralytic hip subluxation (PSH). Group A comprised 20 patients (26 PSHs) who were treated by iliopsoas tenotomy, and group B comprised 22 patients (31 PSHs) who were treated by rectus femoris and iliopsoas tenotomy with iliac crest resection (sartorius release). All patients had bilateral adductor tenotomies. At 8.8 years mean follow-up, group A migration percentages (MP) improved from 39.8% to 24.7% with 92.3% good/average results. At a mean follow-up period of 8.3 years, group B improved from 58.0% to 25.9% with 96.8% good/average results. Long-term hip reduction was achieved in 84.6% of group A and 80.6% of group B hips. Relative MP correction was superior in group B. No patient had MP progression in either the PSH or non-PSH hip. Walking ability improved in 55% of group A and 86% of group B patients (Functional Mobility Scale). In conclusion, we recommend release of all the principle hip flexors: rectus femoris, sartorius, and iliopsoas, coupled with adductor tenotomies, in this patient group.Résumé Une comparative rétrospective de 42 patients diplé-giques spatiques mais ambulatoirs âgés de 2 à 10 ans a été réalisée entre 1983 et 2001 avec évaluation des résultats. Deux techniques de libération tissulaire étant pratiquées devant l'existence d'une sub-luxation paralytique de la hanche. Le groupe A (20 patients, 26 hanches PSHs) ont été traités par ténotomie de l'iliopsoas, dans le groupe B 22 patients, 31 PSHs ont été traités par ténotomie du droit antérieur, de l'iliopsoas avec résection de la crête iliaque libérant le sartorius. Tous les patients ont bénéficié également d'une ténotomie bilatérale des adducteurs. À 8,8 ans de suivi, dans le groupe A, le pourcentage de migration de la tête MP est amélioré de 39,8% à 24,7% avec 92,3% de bons résultats en moyenne alors que dans le groupe B, à 8,3 ans la sub-luxation est améliorée de 58,0% à 25,9% avec 96,8% de bons résultats. La réduction de la hanche est obtenue dans 84,6% des cas du groupe A et 80,6% des cas du groupe B. La correction de la migration de la tête est supérieure dans le groupe B, aucun patient n'a vu sa migration augmenter. La marche a été améliorée de 55% dans le groupe A, à 86% dans le groupe B. Nous recommandons la libération de tous les muscles fléchisseurs de la hanche: droit antérieur, sartorius, iliopsoas en association avec une ténotomie des adducteurs chez ce type de patients.

Reliability of Radiologic Measures of Hip Displacement in a Cohort of Preschool-aged Children With Cerebral Palsy

“…Unlike other common measures on AP pelvis x-ray (MP and AI), 15 interrater reliability was not significantly lower than intrarater reliability; the use of multiple raters in future applications of this measure would be appropriate. Experienced raters found this as an easy measurement to make, except in rare instances when knees were raised significantly to counteract anterior pelvic tilt in children with fixed flexion deformity of the hips.…”

“…18 As the pelvis and its radiographic appearance changes extensively between birth and skeletal maturity, 19,20 early surveillance may be impacted by bony growth and ossification, particularly if measurements are based on landmarks that are difficult to identify or absent in the immature skeleton. The reliability of MP has been investigated in relatively small studies to date, [14][15][16]21 and reliability data in very young children is infrequent. 15 Hilgenreiner epiphyseal angle (HEA) is a radiographic measure previously applied to assessment of coxa valga, 20,22 but may offer prognostic information for hips at risk in CP.…”

“…The reliability of MP has been investigated in relatively small studies to date, [14][15][16]21 and reliability data in very young children is infrequent. 15 Hilgenreiner epiphyseal angle (HEA) is a radiographic measure previously applied to assessment of coxa valga, 20,22 but may offer prognostic information for hips at risk in CP. It is the acute angle between a line drawn parallel to and through the proximal femoral epiphysis and Hilgenreiner line (HL) (Fig.…”

Long-term results of hip arthroplasty in ambulatory patients with cerebral palsy

“…Painful osteoarthritis of the hip after acquired hip subluxation or dislocation following dysplasia remains a common problem in cerebral palsy [6,7,10]. If treatment procedures to prevent osteoarthritis are not effective and the hip has reached the point of painful degeneration, therapy options vary from different forms of resection arthroplasty, redirectional osteotomies, arthrodesis and total hip arthroplasty [1, 2, 4, 11-13, 16, 17, 19, 21].…”

“…In cerebral palsy painful subluxation or dislocation of the hip joint is common and one of the most significant treatment challenges [6,7,9,10,11]. The extent depends on the status of neuromuscular deficits and early treatment.…”