The hip in cerebral palsy part 1 of 2

THE HIP IN CEREBRAL

PALSY

Topic presentation by

Dr. Libin Thomas Manathara

Amala Institute of Medical Sciences

Topics

• Introduction

• Flexion deformities

• Adduction deformities

• Adductor tenotomy

• Iliopsoas recession

• Iliopsoas release at the lesser trochanter

• Subluxation and Dislocation

• Varus derotational osteotomy

• San Diego procedure

• Proximal femoral resection

• Hip arthrodesis

• Total Hip Arthroplasty

Introduction

• In patients with cerebral palsy, all hips

should be considered abnormal until

proved otherwise

• Deformities of the hip in patients with

cerebral palsy range from mild painless

subluxation to complete dislocation with

joint destruction, pain, and impaired

mobility

Introduction

• When a hip begins to subluxate, it rarely

improves without treatment

Introduction

• Progressive hip instability occurs in

approximately 15% of patients with

cerebral palsy, the causes of which

includes

– muscle imbalance,

– retained primitive reflexes,

– abnormal positioning, and

– pelvic obliquity

Introduction

• Beals (1969) described a practical

radiographic method for quantifying the

amount of hip subluxation present

• It was described by Reimers (1980) as the

“migration percentage”

Introduction

• The migration percentage is determinedby drawing the Hilgenreiner lineconnecting the two triradiate cartilagesand then perpendicular lines at the lateralmargins of the bony acetabula

Introduction

• The width of the femoral head uncovered

(lateral to the perpendicular line) is divided

by the total width of the femoral head and

multiplied by 100 to give the migration

percentage

• This index typically is 0 until age 4 years

and less than 5% from 4 years until

skeletal maturity

Subluxated left hip joint. Migration index (MI) is calculated by dividing width of uncovered

femoral head A by total width of femoral head B.

Acetabulum is dysplastic, with lateral corner of acetabulum above weight bearing dome.

Normal hip (left side) with acetabular index (AI) indicated. Lateral corner is sharp and

below weight-bearing dome.

H, horizontal axis.

Introductionhttp://www.orthobullets.com/pediatrics/4118/developmental-dysplasia-of-the-hip

• Perkin's line is a line perpendicular

line to Hilgenreiner's through a

point at the lateral margin of

acetabulum

• The Acetabular index (AI) is an

angle formed by a line drawn from

point on the lateral triradiate

cartilage (X) to point on lateral

margin of acetabulum (O) and

Hilgenreiners line and it should be

less than 25° in patients older than

6 months

Introduction

• Reimers described a migration of greater

than 33% as subluxation and greater than

100% as dislocation

• More important than the absolute value is

the change observed within a given patient

Flexion Deformities

• Excessive hip flexion brings the center of

gravity anteriorly and is compensated for

by

– increased lumbar lordosis

– knee flexion

– ankle dorsiflexion

Typical crouch posture caused by flexion deformities of hips or fixed

flexion deformities of knees.

Flexion Deformities

• It is important to determine whether the

increased hip flexion is primary or

secondary to knee or ankle contractures

because if unrecognized and a hip flexor

release is done, it can weaken the hip

further and increase hip flexion

Flexion Deformities

• Children with flexion-internal rotation

deformity sit with a wide base of support in

the W position

– hips flexed 90 degrees

– maximally internally rotated

– knees maximally flexed

– feet externally rotated

W postition

Flexion Deformities

• Single-stage multilevel procedures arepreferable to staged single-levelprocedures because

– hospitalization is reduced

– immobilization is a one time event

– rehabilitation time is reduced

– number of anesthetic exposures aredecreased

– minimize the effects of surgery on socialinteraction and education

Flexion Deformities

• Hip flexion contractures from 15 to 30

degrees are usually treated with psoas

lengthening through an intramuscular

recession over the pelvic brim

Flexion Deformities

• Contractures of more than 30 degrees may

require more extensive releases of the following

– rectus femoris

– tensor fasciae latae

– anterior fibers of the gluteus minimus

– anterior fibres of the gluteus medius

– sartorius

– iliopsoas

Adduction Deformities

• Adduction is the most common deformity

of the hip in children with cerebral palsy

and cause difficulties like

– scissoring of the legs during gait

– hip subluxation

– in severely affected children, difficulty with

perineal hygiene

Adduction Deformities

• For mild contractures, an adductortenotomy usually is sufficient

• More severe contractures often requirerelease of the gracilis and the anterior halfof the adductor brevis

• Adductor tenotomies usually are donebilaterally to prevent a “windswept” pelvis

Windswept pelvis (Dr Henry Knipe and Dr Behnam Shayegi et al.) http://radiopaedia.org/articles/windswept-pelvis

Wind-swept pelvis fracture is a combination a unilateral AP compression (open book) injury with a contralateral lateral

compression injury

It occurs when the internal rotation of one iliac wing causes a unilateral sacral compression fracture, while the same

forces cause external rotation of the opposite hemipelvis, resulting in diastasis of the sacro-iliac joint

This causes classic “wind-swept pelvis” appearance

Case courtesy of Dr Matt A. Morgan, Radiopaedia.org, rID: 37825

Adduction Deformities-

Adductor tenotomy• Adductor tenotomy is indicated for a

patient with a mild adduction contracture,as indicated by a scissoring gait or earlyhip subluxation

• This procedure should be done earlybecause damage to the developingacetabulum from abnormal hip muscleforces is greatest before 4 years of age


Adductor tenotomy• The ideal candidate for soft tissue

lengthening is an ambulatory child

younger than 8 years, and preferably

younger than 4 years, who has

– hip abduction of less than 30 degrees and

– a migration index of less than 50%


Adductor tenotomy• Neurectomy of the anterior branch of the

obturator nerve should be avoided toprevent iatrogenic hip abductioncontracture

Obturator nerve

• The obturator nerve arises

from the ventral divisions of

L2, L3 and L4

• It passes through the

obutrator formane to enter

the thigh

• It divides into an anterior

and posterior branch in

thigh

Obturator nerve


Adductor tenotomy• Early soft tissue release alone may be

insufficient to prevent long-term hipsubluxation and dislocation

• It may delay major bony surgery, however,until the risk of recurrence is decreasedand the bone stock for reconstruction isimproved


Adductor tenotomy• Procedure

• Place the patient supine on the operating

table, and prepare the area from the toes

to the inferior costal margin, isolating the

perineum

A: Patient positioning


Adductor tenotomy• Identify the adductor longus by palpation,

and make a 3-cm transverse incision over

the adductor longus tendon approximately

1 cm distal from its origin

• Dissect through the subcutaneous tissue,

and identify the adductor longus fascia

B: Skin incision and subcutaneous dissection to identify adductor

longus fascia


Adductor tenotomy• Make a longitudinal incision in the

adductor fascia; identify the tendinous

portion of the adductor longus, and resect

it with electrocautery


Adductor tenotomy• Release with electrocautery any remaining

muscle fibers of the adductor longus asnecessary.

• Avoid injury to the anterior branch of theobturator nerve, which is in the intervalbetween the adductor longus and brevis

C: Hemostat placed under anterior branch of obturator nerve


Adductor tenotomy• Gradually abduct the hip, and determine the

amount of correction obtained

• If further correction is required, slowly releasethe anterior half of the adductor brevis usingelectrocautery and avoiding injury to thebranches of the obturator nerve

• It is important not to release an excessiveamount of the adductor brevis and to protect theposterior branch of the obturator nerve toprevent an abduction contracture


Adductor tenotomy• If the gracilis muscle is found to be tight,

release it with electrocautery

• When the final correction is obtained,

close the wound in layers

D: Release of tight gracilis muscle with electrocautery


Adductor tenotomy• Take care to close the adductor fascia to

help prevent skin dimpling postoperatively

E: Closure of adductor fascia

Iliopsoas Recession

• Bleck recommended iliopsoas recessionwhen the hip internally rotates duringwalking or when passive external rotationis absent with the hip in full extension andpresent when the joint is passively flexedto 90 degrees

Iliopsoas Recession

• This procedure usually is done inconjunction with other soft tissue releasesof the lower extremities

• Iliopsoas recession is used morecommonly than complete tenotomy at thelevel of the lesser trochanter to avoidcausing excessive hip flexion weakness

Iliopsoas Recession

• SKAGGS et al

• Place the patient supine with a roll under

the buttock of the operative side

• Palpate the course of the femoral artery,

and mark it on the skin, keeping in mind

that the femoral nerve is lateral to it

Iliopsoas Recession

• For an isolated iliopsoas recession, make a 5cm

“bikini” incision

• This incision can be modified as needed if other

procedures are going to be done at the same

time

• Center the incision medial to and 2 cm below the

anterior superior iliac spine

Bikini incision

Iliopsoas Recession

• Identify and develop the interval between

the tensor fasciae latae and sartorius to

expose the direct head of the rectus

femoris with its origin at the anterior

inferior iliac spine

• It is not necessary to identify the femoral

neurovascular structures

Iliopsoas Recession

• Palpate the pelvic brim just medial and

inferior to the rectus femoris origin to

locate the iliopsoas tendon in a shallow

groove

• Slightly flex the hip to relax the soft tissuestructures around the hip

Iliopsoas Recession

• Place a right-angle retractor on the lateral

aspect of the iliopsoas muscle, and pull

the retractor medially and anteriorly,

exposing the posteromedial aspect of the

muscle and the psoas tendon (see Fig)

• The retractor is protecting the femoral

nerve, which is medial to it

Skaggs et al. surgical approach for iliopsoas recession

When procedure is done alone, much smaller incision is adequate

Iliopsoas Recession

• Dissect the surrounding muscle fascia,

and isolate the tendon from the muscle

with a right-angle clamp

• Verify that there is enough muscle

remaining at that level so that continuity is

maintained after tendon release

Iliopsoas Recession

• Under direct vision, carefully internally and

externally rotate the hip to see the tendon

loosen and tighten

• If there is any doubt as to the identification

of the tendon, use an elevator to dissect

around the tendon proximally until its

muscle fibers are identified

Iliopsoas Recession

• An electrical nerve stimulator or careful

brief stimulation with electrocautery also

can be used to help confirm that the

tendon has been found and that the

femoral nerve has not been mistakenly

identified

Iliopsoas Recession

• Release the tendinous portion, leaving the

muscle fibers in continuity

• Extend and internally rotate the hip to

separate the tendon ends

• Close the wound in layers, and apply

sterile dressings

Iliopsoas Recession

• Postoperative Care

• Patients with an isolated iliopsoas release arestarted immediately in a physical therapyprogram emphasizing hip extension and externalrotation

• Patients, especially those who are unable tocooperate with physical therapy, are placedprone at bed rest to help improve hip extension

Iliopsoas Release at the Lesser

Trochanter

• Iliopsoas release at its insertion on thelesser trochanter is better fornonambulatory patients than forambulatory patients because of the risk ofcausing excessive hip flexion weakness,which can severely affect an ambulatorypatient

• It often is done at the same time asanother procedure, such as an adductorrelease or varus derotational osteotomy


Trochanter

• Additional release of the secondary hip

flexors including the sartorius and rectus

femoris also may be used for severe

deformities


Trochanter

• Procedure

• Make a transverse incision 1 to 3 cm distal to the

inguinal crease

• If an adductor release is to be done at the same

time, make a longitudinal incision in the adductor

longus fascia and transect the adductor longus

with electrocautery; perform a myotomy of the

gracilis if necessary


Trochanter• Resect as much of the adductor brevis as

necessary to obtain 45 degrees of

abduction

• Develop the interval between the residual

adductor brevis and the pectineus or

between the pectineus and the

neurovascular bundle until the femur is

identified


Trochanter

• Open the bursa over the iliopsoas and itssheath

• Place a retractor into the tendon sheath,and retract the tendon medially


Trochanter

• Pass a right-angle clamp under the tendon

of the iliopsoas, which can be completely

released with electrocautery in a

nonambulatory child

• Release the iliopsoas as far proximally as

possible in an ambulatory child to preserve

the iliacus muscle attachment to the

iliopsoas tendon


Trochanter• Postoperative Care

• Physical therapy is started 2 days after

surgery, emphasizing range-of-motion

exercises of the hips and knees


Trochanter• Leg-knee immobilizers are used 8 to 12

hours a day for 1 month

• Parents are encouraged to have the child

sleep prone as much as possible

THANK YOU

Health & Medicine

The hip in cerebral palsy part 1 of 2