The Hip Joint in Cerebral Palsy | David S. Feldman, MD

HOSPITAL FOR JOINT DISEASES

THE HIP JOINT IN CEREBRAL PALSY
David S. Feldman, MD
Professor of Orthopedic Surgery and Pediatrics
Chief, Pediatric Orthopedic Surgery
NYU/Hospital for Joint Diseases

Hospital for Joint Diseases ● Department of Orthopaedic Surgery

Define the
Problem
(This review is meant to aid in knowledge but
is no way is intended to be a thorough and
comprehensive analysis of each topic)

Hospital for Joint Diseases Department of Orthopaedic Surgery
●

Why The Hip??

•Hip is particularly sensitive to
muscle imbalance.
•Large number of large muscles
crossing the joint.
•Psoas
•Adductors
•Rectus
•Hamstrings
•ITB
•G max/med/min
•Short Ext Rotators


Cerebral Palsy
•Children with CP develop hip subluxation
•80% of Patients with Spastic Quadraplegia develop hip
subluxation
•Spastic Diplegia and hemiplegia is associated with
Acetabular Dysplasia
•Excessive Femoral Antetversion is common. This often
causes the ambulating child to walk with his or her turned
in excessively.

●

Progressive Hip Subluxation

•Often Painful
•Leads to assymetry and pelvic obliquity
•Dislocated hips become contracted
•Wind Swept Deformity
•Sitting imbalance

●

HIP DYSPLASIA
(Acetabular Rim Syndrome)

●

Evaluation
•Contracture versus spasticity (R1 and R2)?
•Is there antagonist spasticity?
•Is there a dystonic or an athetoid component?
•Age of the patient and growth potential.
•Is there dynamic tone?
•Is there a contracture/spasticity a joint above or below the
joint you are dealing with?
•Is the joint subluxated, dislocated or at risk?

●

Evaluation
•Is there pain?
•When, where and with which
activities?
• Groin, thigh and buttock pain and
prolonged sitting or standing.

•Is there a limp?
• Trendelenburg

•Is the problem femoral,
acetabular, both or neither?
• I.e. Anteversion or Retroversion

•Is there joint congruency?

• If loss of congruity then type of surgery
will change.

•Does the Joint Reduce on the
abduction-internal rotation view
(Van Rosen)?

• Reducible hip is needed for Osteotomy


Evaluation

•PE – How much Flexion/
Extension of the hip?
Abduction/adduction? Pain
with IR? Gait
abnormalities? ROM?
LLD?
•X-ray- AP Pelvis, Judet
(false profile view), Van
Rosen
•CT scan for femoral
anteversion and acetabular
anatomy

What is femoral anteversion?

Internal rotation of the femur
•Children are born with 2530 degrees of femoral
anteversion
•Resolves to 10-15 degrees
by age 8
•CP –Increasing or nonresolved femoral
anteversion

●

1 yo female - Left dislocated
hip, Right subluxated hip

●

After open reduction - 3 yo

●

Age 14

●

Age 16 - s/p L VDO

●

Age 16 – s/p R VDO

●

Age 28

●

Age 43

●

Age 43 s/p THR

●

Goals

•SYMMETRY
• Agonist and antagonist complimentary function
• Protect joint
• Minimal or no immobilization
• NO SPICA CASTS ON CHILDREN WITH CP
• The spasticity does not tolerate casting
• Early return to standing and ambulation
• Minimize strength loss

●

GOALS

•Stable Reduced Joint
•Reduced Joint Contact
Pressures
•Painless Joint
•Functional Range of Motion
•Decrease incidence of
advanced OA


Working Together for Ambulation and
Function
•Physical/Occupational Therapist
•Geneticist
•Pediatrician
•Developmental Pediatrician
•Pediatric Neurologist
•Pediatric Physiatrist
•Pediatric Neurosurgeon
•Pediatric Urologist
•Pediatric Orthopedic Surgeon
•Pediatric Social Worker
●

Still More

•Pediatric Psychologist
•Nurse
•Orthotist
•Special Education Teacher
•Pediatric Speech Therapist
•Pediatric Nurse Specialist
•Parent or Caregiver
“SPARE THE PATIENT FROM TAKING PART IN
INTERPROFESSIONAL GAMES”

●

Choices

•Botox/PT
•Tenotomies
•NSAID and/or
Chondroitin/Glucosamine
•Intra-articular Steroid injection
•Hip Arthroscopy
•Femoral osteotomy/Acetbular
Osteotomy
•Trochanteric Advancement
•Total Hip Replacement


1 Yo Spastic Diplegic in 1999

●

1999

2000

2003

2005


2006

●

Surgical Options

•Percutaneous tendon releases (lengthening)
•Open tendon lengthening
•Muscle Recession
•Tendon Transfer Complete vs. Split
•Rhizotomy
•Baclofen pump
•Osteotomy
•Hip Reduction
•Bone/joint Resection
•Scoliosis Surgery

●

Which Procedure for Whom?

•Rhizotomy- Less than age 6, SPASTIC
DIPLEGIA. Good trunk control. NO DYSTONIA.
Orthopedic Surgery afterwards if there is
contracture.
•Baclofen Pump – When Spasticity is the main
issue. Can treat dystonic component with high
dosage. Will impair trunk stability if patient has
truncal hypotonia. May increase scoliosis. May
improve speec. May increase drooling.

●

Types of Releases/Transfers

•Percutaneous tenotomies- PERCS
•Percutaneous lengthenings -PERCS
•Open lengthening
•Open intramuscular recession
•Complete Transfer in Phase
•Complete Transfer out of Phase
•Split Transfer
•Muscle Slide

●

Hip Soft Tissue Contractures

•Hip Flexion - Psoas, Rectus and sartorius
•Hip Extension – Gluteus Maximus
•Adduction – Adductors and Medial Hamstring
•Abduction - ITB and Gluteus Medius
•Internal Rotation – Gluteus Medius and Medial
Hamstring
•External Rotation – Short External
Rotators, and Gluteus Maximus

●

Hip Contracture Solutions

•Hip Flexion – Psoas (Psoas Recession)
•Hip Extension – Gluteus Maximus (Osteotomy)
•Adduction – Adductors (Percutaneous
tenotomy)
•Abduction - ITB (Percutaneous tenotomy)
•Internal Rotation – Gluteus Medius (Anterior
Trochanteric Transfer)
•External Rotation – Short External Rotators
(Osteotomy)

●

Knee Contractures

•Flexion – Medial and Lateral Hamstrings
•Extension – Rectus Femoris and Vastus
lateralis
•Hadley et al. JPO 1992
•Abel et al JPO 1999

●

Knee Contracture Solutions
• Flexion – Medial and Lateral Hamstrings (Pecutaneous/Open Hamstring
lengthening, tenotomies and possible osteotomy)
• Extension – Rectus Femoris (Rectus transfer or possible proximal release)

●

SYMMETRY

•Range of motion
•Neck Shaft Angle
•Limb length
•Femoral Anteversion
•Tibial rotation

●

Management of Acetabular
Dysplasia

Pelvic Osteotomies
•Salter Ostetomy - Below age 8, 15-20
degrees of Antero-lateral coverage
•Pemberton/Dega- Used for a voluminous
acetabulum, The tri-radiate cartilage must be
open
•Tonnis/Steel/Sutherland Osteotomy- Triple
Ostetomies with varying degrees of
freedom, ages 6 to adulthood.
•Ganz/Dial Osteotomy- Marked ability to
move acetabulum, Triradiate closure to
adulthood
•Chiari/Shelf- Incongruous hip
coverage, Salvage, metaplasia


14 yo with Spastic Diplegia

•Subluxated Left hip
•Dysplastic Acetabulum


Arthrogram


4 yo with spastic Diplegia


DO NOT IMMOBILIZE THE HIP AND KNEE


Periacetabular Osteotomy (PAO)

•Bern Periacetabular
Osteotomy
•Described in CORR in 1988 by
Reinhold Ganz
•Periacetabular Osteotomy
that leaves the posterior
column intact
•Allows for medialization of
the hip----Biomechanically
Advantageous
•Allows for immediate weight
bearing
•Need a Congruous and
Reducible Hip

●

16 yo with Spastic Diplegia


Commonly Asked
Questions
●

What Age Does One Go form Botox or Soft
Tissue Peocedures to Osteotomies?

●

ANSWER

•Historically age 6-8
•If there are boney changes, i.e flattening or
misshapen femoral head then age is
irrelevant.
•Often early Botox and/or Percs may
prevent the need for boney surgery

●

HIP DISLOCATION
SHOULD WE PREVENT? YES
SHOULD WE REDUCE/ Resect? IF PAINFUL

●

5 yo Spastic Quadraplegia

●

Surgical and 18 month f/u

●

14 yo Spastic Quadrplegia

●

Etiology (CAUSE) of Internal Rotation Gait??

●

Internal Rotation Gait

•Medial Hamstring
•Adductors
•Gluteus Medius Spasticity
•Femoral Anteversion
•? Capsular tightness/hip
anatomy


IS SURGERY ALWAYS BILATERAL??

●

Answer

Always achieve Symmetry. Different
sides may require different
procedures
.

●

9 yo boy with Spastic Diplegia


May a Child with Hip Subluxation: Bear Weight?
Be in a Stander?


YES
There are no special precautions
needed for these children aside from
avoiding painful positioning


DYSTONIA and the Subluxed Hip??

●

Unanswered Question
??S.L.O.B.

●

Lever Arm Disease??

•What is it?
•Prevention??
•Treatment??

●

•Lever arm disease is the adolescent with
calcaneus feet, knee flexion contractures, hip
flexion contractures and lumbar lordosis.
•Should we stop doing heel cord lengthenings in
diplegics and use extensive serial casting?
•Definitely DO NOT OVER LENGTHEN THE
HEEL CORD!!!!!!!!
•Treat before patella alta occurs.

●

Lever Arm Disease

•Most likely Osteotomies unless caught very
early is the only solution.
•Hip and knee extension osteotomies.
•Patella tendon imbrication.

●

SCOLIOSIS and the HIP

●

SCOLIOSIS IN CEREBRAL PALSY
SURGICAL
INDICATIONS:
Progressive deformity
Sitting imbalance
Pelvic obliquity

●

Cerebral Palsy
Scoliosis
Spastic quadriplegia
highest risk
Custom seats

●

SCOLIOSIS IN CEREBRAL PALSY
•SURGICAL
MANAGEMENT
ASF/PSF vs.
PSF
•only
Segmental
fixation
•Fuse to the
pelvis
(Galveston)

●

ROM of the HIP

•Particularly important if the the Spine is
being fused to the pelvis
•Be especially cognizant of lack of true
flexion of the hip

●

DO NOT!!!!!!

•Lengthen a muscle without addressing the
antagonist
•Miss the dynamic, dystonic or athetoid
component
•Miss a joint subluxation or dislocation
•Miss the opportunity to correct a problem before
secondary changes occur.
•Over lengthen heel cords or hamstrings
•Create assymetry
•Immobilze the knee and hip of a child with CP for
a prolonged period
●

The Hip Joint in Cerebral Palsy | David S. Feldman, MD

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