Proximal femoral resection without post-operative traction for the painful dislocated hip in young patients with cerebral palsy

Abstract

Proximal femoral resection (PFR) is a proven pain-relieving procedure for the management of patients with severe cerebral palsy and a painful displaced hip. Previous authors have recommended post-operative traction or immobilisation to prevent a recurrence of pain due to proximal migration of the femoral stump. We present a series of 79 PFRs in 63 patients, age 14.7 years (10 to 26; 35 male, 28 female), none of whom had post-operative traction or immobilisation. A total of 71 hips (89.6%) were reported to be pain free or to have mild pain following surgery. Four children underwent further resection for persistent pain; of these, three had successful resolution of pain and one had no benefit. A total of 16 hips (20.2%) showed radiographic evidence of heterotopic ossification, all of which had formed within one year of surgery. Four patients had a wound infection, one of which needed debridement; all recovered fully. A total of 59 patients (94%) reported improvements in seating and hygiene. The results are as good as or better than the historical results of using traction or immobilisation. We recommend that following PFR, children can be managed without traction or immobilisation, and can be discharged earlier and with fewer complications. However, care should be taken with severely dystonic patients, in whom more extensive femoral resection should be considered in combination with management of the increased tone.

Proximal femoral excision with interposition myoplasty for cerebral palsy patients with painful chronic hip dislocation

“…Pain and muscle spasm are frequently major problems in the early post-operative period, before the true benefits of proximal femoral excision and interposition myoplasty can be realised. As a result, various management strategies should be employed to control these symptoms including the use of analgesic medications, anxiolytics, botulinum toxin injections and skin traction [ 35 ]. We know of no study in which a valid and accepted quality of life measure has been used to describe the outcome of salvage surgery for hip dislocation in young patients with CP.…”

Hip health at skeletal maturity: a population‐based study of young adults with cerebral palsy

“…7,9 Population-based hip surveillance is effective, and when combined with an effective surgical programme may lead to a reduction or elimination of painful dislocations and the need for salvage surgery. 6,[12][13][14] The relationship between hip morphology and pain in individuals with CP is not clear and remains controversial. 11 Hip surveillance is essential in detecting silent progressive hip displacement, because missed dislocation can cause deteriorating gait, loss of sitting ability, limitations in hip movement, impact on positioning and personal care, and significant pain.…”

“…10 The Swedish CPUP surveillance programme is the leading example of this approach. 6,[12][13][14] Other studies report limited or no association between hip displacement, arthrosis, and pain. 6,[12][13][14] The relationship between hip morphology and pain in individuals with CP is not clear and remains controversial.…”

“…11 Hip surveillance is essential in detecting silent progressive hip displacement, because missed dislocation can cause deteriorating gait, loss of sitting ability, limitations in hip movement, impact on positioning and personal care, and significant pain. 6,[12][13][14] The relationship between hip morphology and pain in individuals with CP is not clear and remains controversial. Some studies have reported high levels of pain in individuals with dislocated hips, with many teenagers requiring 'salvage surgery', defined as loss of the hip joint.…”

“…Some studies have reported high levels of pain in individuals with dislocated hips, with many teenagers requiring 'salvage surgery', defined as loss of the hip joint. 6,[12][13][14] Other studies report limited or no association between hip displacement, arthrosis, and pain. 15 The prevalence of pain is difficult to determine from cohort studies when the population denominator is not known.…”