Aims
Prevent contractures
Prevent dislocations
Improve walking
Provide stable and painless sitting
Allow perineal care
Issues
Hip Dislocation
Adductor contractures
Flexion contractures
In-toeing
Windswept hips
Hip Dislocation
Natural History
Accepted that a dislocated hip in CP is painful
- unilateral dislocated hips should be reduced unless deformity of femoral head has developed
- less certain of management of bilateral hip dislocation
- importance of vigilant screening
Pathology
Excessive femoral anteversion
- ? due to tight hip flexors
Excessive neck valgus
- ? due to tight adductors
High Risk
GMFCS 3 / 4 / 5
Spastic quadriplegia
Those wheelchair bound at high risk
Rates Hip Dislocation associated with GMFCS
I 0%
II 15% - adductor surgery
III 41% VDRO
IV 70% VDRO
V 90% VDRO
Screening
Non-ambulators annual X-ray essential
- treat tight adduction early / <5 years
- minimum 40° abduction with knees flexed
X-ray
Reimer's Migration Percentage
- % of epiphysis lateral to acetabulum
- > 30% high risk & requires intervention
Guidelines
Early ST release +/- bony reconstruction
> 8 years require pelvic procedure (minimal remodelling)
Severely deformed hip - don't reduce
Severe pelvic obliquity / scoliosis - address first
Algorithm
1. < 5 years old + MP > 30%
- soft tissue procedure
- adductor +/- psoas if tight
- preventative measures
- can use botox
2. > 5 years old + MP > 30%
- likely to progress
- adductor release + VDRO / varising derotation oseotomy
3. > 8 years old
- must address acetabulum / add pelvic operation
- CP acetabulum is deficient posteriorly / DDH deficient anteriorly
- Salter worsens posterior deficiency
- Periacetabular osteotomy / Dega
4. Deformed femoral head / salvage
- Schanz osteotomy / pelvic support osteotomy
- excision deformed femoral head
- valgising osteotomy
- suture ligamentum teres to psoas tendon remnant
Adduction Contractures
Indication
Adduction < 30o
Treatment
Tenotomy adductor longus at groin
- open or percutaneous
Obturator Neurectomy
- may lead to abducted position and affect gait in ambulators
- not recommended
- it denervates adductor brevis which is an important antigravity muscle
- wide base gait
- no improvement with regard to hip stability with neurectomy over simple adductor tenotomy
Flexion Contracture
Indication
FFD > 20o
- lengthening psoas over pelvic brim
- must not do tenotomy if patient walks
- psoas is the main power driver for walking in these children
- may render them unable to walk
Options
Sutherland technique
- find and preserve femoral nerve
- leave iliacus to preserve hip flexor strength
Intoeing
Aetiology
Increased PFA
Management
Subtrochanteric FDRO
Windswept Hips
Definition
Pelvic obliquity
- elevated hip adducted and internally rotated
- lower hip is abducted and externally rotated
Soft tissue releases
Adducted Hip
- psoas / adductors / hamstrings
Abducted Hip
- ITB / abductors
Bony
- VRDO both sides