Hip Fusion as Hip Salvage Procedure in Cerebral Palsy Patricia M. De Moraes Barros Fucs, MD, PhD and Helder H. Yamada, MD
Salvage procedures may be appropriate for hips that cannot be reconstructed; but, the key is to find the best surgical technique to suit each patient, according to his/ her functional status and x-ray findings. The most common procedures, in addition to soft-tissue releases, are: femoral head resection (Girdlestone procedure17),6 proximal femoral resection—interposition arthroplasty (Castle procedure18),7,9 femoral head resection and subtrochanteric valgus osteotomy (McHale procedure19), total hip replacement,2,20,21 and hip arthrodesis.9,21–23 The goal of this paper is to evaluate the long-term results of the treatment of spastic hip disease in CP with hip arthrodesis. The study was approved by the Institutional Review Board and Ethics Committee of the Santa Casa Medical School and Hospitals.
Abstract: The treatment of the spastic hip in Cerebral Palsy (CP) remains a challenge especially in cases of advance changes. Many options are available and the key for a good outcome is to find the best surgical procedure to an individualized patient. The hip fusion is one of the surgical options. The authors presented a group of spastic CP with painful chronic hip subluxation and dislocation treated with hip fusion with a mean follow-up period of 14.5 years. Surgical technique, post-operative management and outcomes were shown, also with the observations done regarding the evolution of the contralateral hip after the hip fusion. They concluded that the hip arthrodesis is an option for patients with spastic CP with painful subluxation or dislocated hips with the goal of pain relief maintain or improve functional status, and facilitating the care. The best candidate is a young ambulatory patient with normal contralateral hip and normal spinal alignment.
METHODS
Key Words: hip, hip fusion, cerebral palsy
From February 1994 to March 2013, 21 patients (21 hips) with spastic CP and painful chronic hip dislocation or subluxation were treated with hip arthrodesis and internal fixation. Thirteen patients were female and 8 male. The right hip was treated in 14 patients and the left in 7. One patient was hemiplegic, 2 patients had a mixed pattern (diplegia and dystonia), 6 patients were diplegic, and 12 were quadriplegic. Functionally, 4 were community ambulators (GMFCS III), 3 were household ambulators, and 14 were nonambulatoratory (GMFCS V) (5 sitters and 9 bedridden). The mean patient age at surgery was 18 years and 5 months, with a minimum of 10 years and 11 months, and a maximum of 30 years and 8 months. The surgical indications were: severe hip pain and radiographic joint deformity that precluded joint reconstruction. No scale for pain measurement was used, only questions posed to the patient or caregiver regarding the severity, frequency, impact of pain on functional status, and need for medication. The mean follow-up period was 14.5 years, with a minimum of 1 year and a maximum of 22 years and 5 months. Eight patients had previous procedures: 2 patients had soft-tissues releases (adductors and psoas), 1 and 6 years before; 3 patients had a McHale procedure19 with a mean time of 1 year prior; 2 patients had a valgus osteotomy of the femur, one of which was reoperated 1 year later, and the other almost 6 years later; 1 patient had a unilateral dislocated hip treated with a triple (Steel) pelvic osteotomy24 1 year prior. The results of the hip arthrodesis were considered satisfactory when the patient had bone union and pain relief.
(J Pediatr Orthop 2014;34:S32–S35)
T
he natural history of hip deformity in cerebral palsy (CP) is well documented in the literature.1–9 The incidence of hip subluxation or dislocation in CP is reported to be from 18% to 59%,3,5,6,9–11 and it most common in the higher Gross Motor Function Classification System (GMFCS) levels.8,12 As described by Miller8 the treatment of spastic hip disease is divided in 3 areas: (1) Prevention: treatment addresses the muscle imbalance around the hip joint with soft-tissue releases, especially in more severely compromised patients,6,8,13 such as those who are GMFCS level IV and V.13,14 (2) Reconstruction: bone deformities that need to be corrected with proximal femoral and/or pelvic osteotomies associated with soft-tissue releases. (3) Palliative: about one half of patients6,8 with untreated hip deformity will become painful in the adolescent years and with pain, the patient is even more functionally impaired.1–6,8,11,15,16 From the Orthopaedic Department, Neuromuscular Clinic, Santa Casa Medical School and Hospitals, Sa˜o Paulo, Brazil. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Patricia M. De Moraes Barros Fucs, MD, PhD, Orthopaedic Department, Neuromuscular Clinic, Santa Casa Medical School and Hospitals, R. Prof. Lu´cio Martins Rodrigues, 330 ap 22. Sa˜o Paulo, Brazil 05621-030. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins
S32 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 34, Number 1 Supplement, October/November 2014
J Pediatr Orthop
Volume 34, Number 1 Supplement, October/November 2014
Hip Fusion in Cerebral Palsy
Surgical Technique The procedures were performed under general anesthesia in the supine position with a soft pad under the gluteal region on the affected side. All patients had a softtissue release with adductor lengthening and psoas tenotomy and an additional hamstring lengthening was necessary in 4 patients. A longitudinal, lateral hip incision was used to expose the hip joint. After capsulotomy, it was evident that all femoral heads were deformed with loss of sphericity, large erosion of the articular cartilage were seen, and in some cases marginal osteophytes were found. Reconstruction planned was not done with the loosening of the femoral head surface. After resecting the ligamentum teres and pulvinar, a shallow, dysplastic acetabulum filled with fibrous tissue was usually found. Then the articular cartilage on the femoral head and acetabulum was removed and the acetabular cavity was prepared to receive the femoral segment. The fixation method was chosen based on the local bone width and quality, the size of the femoral head and neck, and the desired degree of hip flexion. Implants used to stabilize the arthrodesis were: the AO/ASIF Cobra plate (Synthes, Paoli, PA) in 8, an AO/ASIF DCP 4.5 mm (broad plate-Synthes) in 7, 6.5 mm cancellous screws in 3, only Kirschner wires in 1, and in the last 1 a AO/ASIF LCP (Synthes) plus 1 compression screw. In 1 case the first implant used in 1 patient was Kirschner wires, which was changed to an AO-Cobra plate after 6 months because of a nonunion. The arthrodesis position was a mean of 40 degrees of flexion, 15 degrees of abduction and neutral rotation. A hip spica cast was used in 8 patients for a mean time of 3 months postoperatively until bone healing was achieved.
RESULTS All patients in this long-term review demonstrated bone union, pain relief, and postural improvement with patient or caregiver satisfaction. Four of the 21 patients (19%) developed a pseudoarthrosis associated with aseptic loosening of the implant. All of them were reoperated successfully between 6 months and 3 years; the implant was changed to an AO/ ASIF DCP (Synthes) and the arthrodesis healed 3 months after the second procedure. The final results were considered satisfactory in all patients, although 4 patients needed a second procedure for bone union. Evaluation of the functional result demonstrated that the pain completely disappeared and the hips were in a better flexion-abduction position. Of the 9 bedridden patients, 3 remained as previously due to severe scoliosis but without pain. The other 6 improved to sitters. Of the 5 sitting patients, 1 returned to community, the other 4 were unchanged. Of the 3 preoperative household walkers 1 moved back to a community walker, their previous status before any hip procedures. The 2 others remained a household walker. The 4 previous community walkers r
2014 Lippincott Williams & Wilkins
FIGURE 1. Male patient, age 13+11, spastic diplegic, community ambulator, initial pelvic radiograph.
sustained their functional status after the surgery, 2 of them with a walker support and 1 with a stick (Figs. 1, 2).
Complications Surgical complications were observed. There were no superficial or deep wound infections. One patient had skin breakdown in the sacral region due to a pressure sore in the cast period. It was treated successfully with local debridement and dressing changes. Another patient with a severe flexion-adduction deformity had an accidental femoral vein laceration during the surgical release of the adductor muscles. Repaired immediately and no further complications. There were 2 patients who presented with femoral fractures after surgery on the side of the arthrodesis. One patient fractured 9 months after surgery, and was treated with an open reduction and internal fixation. Six months later, the same patient had another
FIGURE 2. Same patient, age 29+11, postoperative 17+0 of left hip arthrodesis. www.pedorthopaedics.com |
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Volume 34, Number 1 Supplement, October/November 2014
FIGURE 3. Female patient, age 11+3, spastic quadriplegic, nonambulator, initial pelvic radiograph.
femoral fracture in the distal femur, which was treated by closed reduction and casting for 3 weeks, with subsequent healing without further complication. Another patient sustained a fracture just below the end of the plate on the first day after surgery, and was treated with external fixation.
Observations After the Arthrodesis In 5 patients, the contralateral hip became painful over time due to progressive subluxation/dislocation and required subsequent surgery. The first patient required a contralateral Dega osteotomy25,26 with a femoral varus derotational osteotomy 3 years and 8 months after hip arthrodesis (Figs. 3–5). The second patient had a contralateral Chiari osteotomy27 associated with a proximal femoral valgus osteotomy 6 years and 1 month after hip fusion. Two patients required a Castle procedure18: one 4 years and 9 months and the other 13 years and 8 months after hip fusion, both after spinal arthrodesis.
FIGURE 4. Same patient, age 14+10, postoperative right side 3+8 and preoperative of the left hip reconstruction.
S34 | www.pedorthopaedics.com
FIGURE 5. Same patient, age 17+3, postoperative right side 6+0 and 2+5 left side.
In the last case, a contralateral hip arthrodesis was performed in another hospital, 15 years and 6 months after the first arthrodesis. The pain after the second arthrodesis was not resolved and was associated with severe functional impairment, requiring total hip arthroplasty. After the last procedure the patient returned to be a community ambulator.
DISCUSSION Treatment of the painful dislocated/subluxated hip in patients with CP is a very challenging issue. Choosing the best technique for each patient is a hard decision. The salvage procedures have variable and unpredictable outcomes. The soft-tissue release, as an isolated procedure, did not show good results in long-term follow-up, especially in more severe spastic patients6–9,11–13,21,28 and when the goal is pain relief, not only the to stop the progression of the deformity. This study is a report of a long-term follow-up of patients treated with hip fusion,23 adding to the original group of patients treated with the same protocol and by the same group of surgeons. The keys to a successful hip arthrodesis is to prepare the bone surfaces; and, the internal fixation adds stability which may make the use of a spica cast unnecessary for some patients. In reviewing the literature, the first paper that discussed patients with CP treated with hip arthrodesis was from Root et al21 in 1986, reporting their experience with hip arthrodesis in 8 patients with unilateral painful dislocated hips. They recommended hip fusion for young patients with unilateral disease who were unable to walk. Our belief is that for young ambulatory patients, arthrodesis is the best option as a definitive treatment or one can wait for a total hip arthroplasty. Hip arthrodesis significantly improved the quality of life for these patients by removing their pain. The r
2014 Lippincott Williams & Wilkins
J Pediatr Orthop
Volume 34, Number 1 Supplement, October/November 2014
functional improvement observed in our patients was very important, considering the fact that a number of the bedridden patients became sitters and the ambulators maintained or improved their original functional status after the surgery. In some patients, hip arthrodesis may not be the only procedure. It is still possible to perform another salvage procedure, like the Castle18 procedure or a total hip arthroplasty if the first procedure fails. Two of our patients underwent the Castle18 procedure and another a total hip arthroplasty, obtained pain relief and functional improvement after these second procedures. Of important note is that the arthroplasty surgery was performed on the contralateral side to the previous arthrodesis. Another issue is the follow-up of these spastic patients, even in presence of a so-called normal contralateral hip by the time of the arthrodesis we should expect changes. In 5 of our patients, the contralateral hip was normal and developed a painful subluxation or dislocation, and in 2 of these cases there was associated development of severe scoliosis. It is hard to predict which patients’ hips and spines might have a complication from or due to the hip arthrodesis. Because of the spasticity in severely involved patients with CP, each patient has to be considered individually and scoliosis is common in the most involved, nonambulatory children. Hip arthrodesis is an option in the treatment of patients with spastic painful dislocation or subluxation of the hip when the reconstruction is not possible due to the femoral head deformity. The difficult choice in the CP hip is to find the best technique to an individual patient. When a patient is ambulatory, in our point of view the indication is easier and the functional improvement is more evident. When the patient is nonambulatory more option could be chosen. Important point in all cases is a careful and individualized evaluation, including the functional status of the patient, the contralateral hip, and the spine. After surgery, it is essential to keep close follow-up, clinical and radiographic at least once a year, monitor the contralateral hip and the spine, especially in more severe patients, the GMFCS IV and V, to detect any early changes and to treat the deformity before it is severe and fixed.
CONCLUSIONS Hip arthrodesis is an option for patients with spastic CP with painful subluxation or dislocated hips with the goal of pain relief maintain or improve functional status, and facilitating the care. It is primarily useful if the patient is a young ambulatory with normal contralateral hip and normal spine. REFERENCES 1. Moreau M, Drummond DS, Rogala E, et al. Natural history of the dislocated hip in spastic cerebral palsy. Dev Med Child Neurol. 1979;21:749–753. 2. Pritchett JW. The untreated unstable hip in severe cerebral palsy. Clin Orthop Relat Res. 1983;173:169–172.
r
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Hip Fusion in Cerebral Palsy
3. Bleck EE. Orthopaedic Management in Cerebral Palsy. Philadelphia: MacKeith; 1987;497. 4. Cooperman DR, Bartucci E, Dietrick E, et al. Hip dislocation in spastic cerebral palsy: long-term consequences. J Pediatr Orthop. 1987;7:268–276. 5. McCarthy RE, Simon S, Douglas B, et al. Proximal femoral resection to allow adults who have severe cerebral palsy to sit. J Bone Joint Surg Am. 1988;70:1011–1016. 6. Bagg MR, Farber J, Miller F. Long-term follow-up of hip subluxation in cerebral palsy patients. J Pediatr Orthop. 1993;13:32–36. 7. Root L. Treatment of the hip problems in cerebral palsy. AAOS Instruc Course Lect. 1996;45:475–490. 8. Miller F. Cerebral Palsy. New York: Springer; 2005. 9. Root L. Surgical treatment for hip pain in the adult cerebral palsy patient. Dev Med Child Neurol. 2009;51(suppl 4):84–91. 10. Gabos GP, Miller F, Galban MA, et al. Prosthetic interposition arthroplasty for the palliative treatment of end stage spastic hip disease in nonambulatory patients with cerebral palsy. J Pediatr Orthop. 1999;19:796–804. 11. Tosi LL, Maher N, Moore DW, et al. Adults with cerebral palsy: a workshop to define the challenges of treating and preventing secondary musculoskeletal and neuromuscular complications in this rapidly growing population. Dev Med Child Neurol. 2009; 51(suppl 4):2–11. 12. Soo B, Howard JJ, Boyd RN, et al. Hip displacement in cerebral palsy. J Bone Joint Surg Am. 2006;88:121–129. 13. Shore BJ, Yu X, Desai S, et al. Adductor surgery to prevent hip displacement in children with cerebral palsy: the predictive role of the Gross Motor Function Classification System. J Bone Joint Surg Am. 2012;94:326–334. 14. Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214–223. 15. Drummond DS, Moreau M, Cruess RL. The results and complications of surgery for the paralytic hip and spine in myelomeningocele. J Bone Joint Surg Br. 1980;62:49–53. 16. Kalen V, Bleck EE. Prevention of spastic paralytic dislocation of the hip. Dev Med Child Neurol. 1985;27:17–24. 17. Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. Lancet. 1943;3: 419–421. 18. Castle ME, Schneider C. Proximal femoral resection—interposition arthroplasty. J Bone Joint Surg Am. 1978;60:1051–1054. 19. McHale KA, Bagg M, Nason SS. Treatment of the chronically dislocated hip in adolescents with cerebral palsy with femoral head resection and subtrochanteric valgus osteotomy. J Pediatr Orthop. 1990;10:504–509. 20. Buly RL, Huo M, Root L, et al. Total hip arthroplasty in cerebral palsy. Clin Orthop Relat Res. 1993;296:148–153. 21. Root L, Goss JR, Mendes J. The treatment of the painful hip in cerebral palsy by total hip replacement or hip arthrodesis. J Bone Joint Surg Am. 1986;68:590–598. 22. Hoffman M. Proximal femoral resection or total hip replacement in severely disabled cerebral-spastic patients. Orthop Clin North Am. 1981;12:91–100. 23. de Moraes Barros Fucs P, Svartman C, Assumpc¸a˜o RMC, et al. Treatment of the painful chronically dislocated and subluxated hip in cerebral palsy with hip arthrodesis. J Pediatr Orthop. 2003;23: 529–534. 24. Steel HH. Triple osteotomy of the innominate bone. J Bone Joint Surg Am. 1973;55:343–350. 25. Dega W. Surgical treatment of congenital dislocation of the hip in children. J Bone Joint Surg Am. 1958;40:725. 26. Dega W. Anatomical and functional restitution in congenital hip dislocation by one stage surgical procedure [German]. Orthop Unfall Chir. 1966;60:16–29. 27. Chiari K. Pelvic osteotomy for hip subluxation. J Bone Joint Surg Br. 1970;52:174. 28. Fucs PMMB, Svartman C, Assumpc¸a˜o RMC, et al. Is arthrodesis the end in spastic hip disease? J Pediatr Rehabil Med. 2011;4: 163–169.
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Salvage procedures may be appropriate for hips that cannot be reconstructed; but, the key is to find the best surgical technique to suit each patient, according to his/ her functional status and x-ray findings. The most common procedures, in addition to soft-tissue releases, are: femoral head resection (Girdlestone procedure17),6 proximal femoral resection—interposition arthroplasty (Castle procedure18),7,9 femoral head resection and subtrochanteric valgus osteotomy (McHale procedure19), total hip replacement,2,20,21 and hip arthrodesis.9,21–23 The goal of this paper is to evaluate the long-term results of the treatment of spastic hip disease in CP with hip arthrodesis. The study was approved by the Institutional Review Board and Ethics Committee of the Santa Casa Medical School and Hospitals.
Abstract: The treatment of the spastic hip in Cerebral Palsy (CP) remains a challenge especially in cases of advance changes. Many options are available and the key for a good outcome is to find the best surgical procedure to an individualized patient. The hip fusion is one of the surgical options. The authors presented a group of spastic CP with painful chronic hip subluxation and dislocation treated with hip fusion with a mean follow-up period of 14.5 years. Surgical technique, post-operative management and outcomes were shown, also with the observations done regarding the evolution of the contralateral hip after the hip fusion. They concluded that the hip arthrodesis is an option for patients with spastic CP with painful subluxation or dislocated hips with the goal of pain relief maintain or improve functional status, and facilitating the care. The best candidate is a young ambulatory patient with normal contralateral hip and normal spinal alignment.
METHODS
Key Words: hip, hip fusion, cerebral palsy
From February 1994 to March 2013, 21 patients (21 hips) with spastic CP and painful chronic hip dislocation or subluxation were treated with hip arthrodesis and internal fixation. Thirteen patients were female and 8 male. The right hip was treated in 14 patients and the left in 7. One patient was hemiplegic, 2 patients had a mixed pattern (diplegia and dystonia), 6 patients were diplegic, and 12 were quadriplegic. Functionally, 4 were community ambulators (GMFCS III), 3 were household ambulators, and 14 were nonambulatoratory (GMFCS V) (5 sitters and 9 bedridden). The mean patient age at surgery was 18 years and 5 months, with a minimum of 10 years and 11 months, and a maximum of 30 years and 8 months. The surgical indications were: severe hip pain and radiographic joint deformity that precluded joint reconstruction. No scale for pain measurement was used, only questions posed to the patient or caregiver regarding the severity, frequency, impact of pain on functional status, and need for medication. The mean follow-up period was 14.5 years, with a minimum of 1 year and a maximum of 22 years and 5 months. Eight patients had previous procedures: 2 patients had soft-tissues releases (adductors and psoas), 1 and 6 years before; 3 patients had a McHale procedure19 with a mean time of 1 year prior; 2 patients had a valgus osteotomy of the femur, one of which was reoperated 1 year later, and the other almost 6 years later; 1 patient had a unilateral dislocated hip treated with a triple (Steel) pelvic osteotomy24 1 year prior. The results of the hip arthrodesis were considered satisfactory when the patient had bone union and pain relief.
(J Pediatr Orthop 2014;34:S32–S35)
T
he natural history of hip deformity in cerebral palsy (CP) is well documented in the literature.1–9 The incidence of hip subluxation or dislocation in CP is reported to be from 18% to 59%,3,5,6,9–11 and it most common in the higher Gross Motor Function Classification System (GMFCS) levels.8,12 As described by Miller8 the treatment of spastic hip disease is divided in 3 areas: (1) Prevention: treatment addresses the muscle imbalance around the hip joint with soft-tissue releases, especially in more severely compromised patients,6,8,13 such as those who are GMFCS level IV and V.13,14 (2) Reconstruction: bone deformities that need to be corrected with proximal femoral and/or pelvic osteotomies associated with soft-tissue releases. (3) Palliative: about one half of patients6,8 with untreated hip deformity will become painful in the adolescent years and with pain, the patient is even more functionally impaired.1–6,8,11,15,16 From the Orthopaedic Department, Neuromuscular Clinic, Santa Casa Medical School and Hospitals, Sa˜o Paulo, Brazil. None of the authors received financial support for this study. The authors declare no conflicts of interest. Reprints: Patricia M. De Moraes Barros Fucs, MD, PhD, Orthopaedic Department, Neuromuscular Clinic, Santa Casa Medical School and Hospitals, R. Prof. Lu´cio Martins Rodrigues, 330 ap 22. Sa˜o Paulo, Brazil 05621-030. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins
S32 | www.pedorthopaedics.com
J Pediatr Orthop
Volume 34, Number 1 Supplement, October/November 2014
J Pediatr Orthop
Volume 34, Number 1 Supplement, October/November 2014
Hip Fusion in Cerebral Palsy
Surgical Technique The procedures were performed under general anesthesia in the supine position with a soft pad under the gluteal region on the affected side. All patients had a softtissue release with adductor lengthening and psoas tenotomy and an additional hamstring lengthening was necessary in 4 patients. A longitudinal, lateral hip incision was used to expose the hip joint. After capsulotomy, it was evident that all femoral heads were deformed with loss of sphericity, large erosion of the articular cartilage were seen, and in some cases marginal osteophytes were found. Reconstruction planned was not done with the loosening of the femoral head surface. After resecting the ligamentum teres and pulvinar, a shallow, dysplastic acetabulum filled with fibrous tissue was usually found. Then the articular cartilage on the femoral head and acetabulum was removed and the acetabular cavity was prepared to receive the femoral segment. The fixation method was chosen based on the local bone width and quality, the size of the femoral head and neck, and the desired degree of hip flexion. Implants used to stabilize the arthrodesis were: the AO/ASIF Cobra plate (Synthes, Paoli, PA) in 8, an AO/ASIF DCP 4.5 mm (broad plate-Synthes) in 7, 6.5 mm cancellous screws in 3, only Kirschner wires in 1, and in the last 1 a AO/ASIF LCP (Synthes) plus 1 compression screw. In 1 case the first implant used in 1 patient was Kirschner wires, which was changed to an AO-Cobra plate after 6 months because of a nonunion. The arthrodesis position was a mean of 40 degrees of flexion, 15 degrees of abduction and neutral rotation. A hip spica cast was used in 8 patients for a mean time of 3 months postoperatively until bone healing was achieved.
RESULTS All patients in this long-term review demonstrated bone union, pain relief, and postural improvement with patient or caregiver satisfaction. Four of the 21 patients (19%) developed a pseudoarthrosis associated with aseptic loosening of the implant. All of them were reoperated successfully between 6 months and 3 years; the implant was changed to an AO/ ASIF DCP (Synthes) and the arthrodesis healed 3 months after the second procedure. The final results were considered satisfactory in all patients, although 4 patients needed a second procedure for bone union. Evaluation of the functional result demonstrated that the pain completely disappeared and the hips were in a better flexion-abduction position. Of the 9 bedridden patients, 3 remained as previously due to severe scoliosis but without pain. The other 6 improved to sitters. Of the 5 sitting patients, 1 returned to community, the other 4 were unchanged. Of the 3 preoperative household walkers 1 moved back to a community walker, their previous status before any hip procedures. The 2 others remained a household walker. The 4 previous community walkers r
2014 Lippincott Williams & Wilkins
FIGURE 1. Male patient, age 13+11, spastic diplegic, community ambulator, initial pelvic radiograph.
sustained their functional status after the surgery, 2 of them with a walker support and 1 with a stick (Figs. 1, 2).
Complications Surgical complications were observed. There were no superficial or deep wound infections. One patient had skin breakdown in the sacral region due to a pressure sore in the cast period. It was treated successfully with local debridement and dressing changes. Another patient with a severe flexion-adduction deformity had an accidental femoral vein laceration during the surgical release of the adductor muscles. Repaired immediately and no further complications. There were 2 patients who presented with femoral fractures after surgery on the side of the arthrodesis. One patient fractured 9 months after surgery, and was treated with an open reduction and internal fixation. Six months later, the same patient had another
FIGURE 2. Same patient, age 29+11, postoperative 17+0 of left hip arthrodesis. www.pedorthopaedics.com |
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De Moraes Barros Fucs and Yamada
J Pediatr Orthop
Volume 34, Number 1 Supplement, October/November 2014
FIGURE 3. Female patient, age 11+3, spastic quadriplegic, nonambulator, initial pelvic radiograph.
femoral fracture in the distal femur, which was treated by closed reduction and casting for 3 weeks, with subsequent healing without further complication. Another patient sustained a fracture just below the end of the plate on the first day after surgery, and was treated with external fixation.
Observations After the Arthrodesis In 5 patients, the contralateral hip became painful over time due to progressive subluxation/dislocation and required subsequent surgery. The first patient required a contralateral Dega osteotomy25,26 with a femoral varus derotational osteotomy 3 years and 8 months after hip arthrodesis (Figs. 3–5). The second patient had a contralateral Chiari osteotomy27 associated with a proximal femoral valgus osteotomy 6 years and 1 month after hip fusion. Two patients required a Castle procedure18: one 4 years and 9 months and the other 13 years and 8 months after hip fusion, both after spinal arthrodesis.
FIGURE 4. Same patient, age 14+10, postoperative right side 3+8 and preoperative of the left hip reconstruction.
S34 | www.pedorthopaedics.com
FIGURE 5. Same patient, age 17+3, postoperative right side 6+0 and 2+5 left side.
In the last case, a contralateral hip arthrodesis was performed in another hospital, 15 years and 6 months after the first arthrodesis. The pain after the second arthrodesis was not resolved and was associated with severe functional impairment, requiring total hip arthroplasty. After the last procedure the patient returned to be a community ambulator.
DISCUSSION Treatment of the painful dislocated/subluxated hip in patients with CP is a very challenging issue. Choosing the best technique for each patient is a hard decision. The salvage procedures have variable and unpredictable outcomes. The soft-tissue release, as an isolated procedure, did not show good results in long-term follow-up, especially in more severe spastic patients6–9,11–13,21,28 and when the goal is pain relief, not only the to stop the progression of the deformity. This study is a report of a long-term follow-up of patients treated with hip fusion,23 adding to the original group of patients treated with the same protocol and by the same group of surgeons. The keys to a successful hip arthrodesis is to prepare the bone surfaces; and, the internal fixation adds stability which may make the use of a spica cast unnecessary for some patients. In reviewing the literature, the first paper that discussed patients with CP treated with hip arthrodesis was from Root et al21 in 1986, reporting their experience with hip arthrodesis in 8 patients with unilateral painful dislocated hips. They recommended hip fusion for young patients with unilateral disease who were unable to walk. Our belief is that for young ambulatory patients, arthrodesis is the best option as a definitive treatment or one can wait for a total hip arthroplasty. Hip arthrodesis significantly improved the quality of life for these patients by removing their pain. The r
2014 Lippincott Williams & Wilkins
J Pediatr Orthop
Volume 34, Number 1 Supplement, October/November 2014
functional improvement observed in our patients was very important, considering the fact that a number of the bedridden patients became sitters and the ambulators maintained or improved their original functional status after the surgery. In some patients, hip arthrodesis may not be the only procedure. It is still possible to perform another salvage procedure, like the Castle18 procedure or a total hip arthroplasty if the first procedure fails. Two of our patients underwent the Castle18 procedure and another a total hip arthroplasty, obtained pain relief and functional improvement after these second procedures. Of important note is that the arthroplasty surgery was performed on the contralateral side to the previous arthrodesis. Another issue is the follow-up of these spastic patients, even in presence of a so-called normal contralateral hip by the time of the arthrodesis we should expect changes. In 5 of our patients, the contralateral hip was normal and developed a painful subluxation or dislocation, and in 2 of these cases there was associated development of severe scoliosis. It is hard to predict which patients’ hips and spines might have a complication from or due to the hip arthrodesis. Because of the spasticity in severely involved patients with CP, each patient has to be considered individually and scoliosis is common in the most involved, nonambulatory children. Hip arthrodesis is an option in the treatment of patients with spastic painful dislocation or subluxation of the hip when the reconstruction is not possible due to the femoral head deformity. The difficult choice in the CP hip is to find the best technique to an individual patient. When a patient is ambulatory, in our point of view the indication is easier and the functional improvement is more evident. When the patient is nonambulatory more option could be chosen. Important point in all cases is a careful and individualized evaluation, including the functional status of the patient, the contralateral hip, and the spine. After surgery, it is essential to keep close follow-up, clinical and radiographic at least once a year, monitor the contralateral hip and the spine, especially in more severe patients, the GMFCS IV and V, to detect any early changes and to treat the deformity before it is severe and fixed.
CONCLUSIONS Hip arthrodesis is an option for patients with spastic CP with painful subluxation or dislocated hips with the goal of pain relief maintain or improve functional status, and facilitating the care. It is primarily useful if the patient is a young ambulatory with normal contralateral hip and normal spine. REFERENCES 1. Moreau M, Drummond DS, Rogala E, et al. Natural history of the dislocated hip in spastic cerebral palsy. Dev Med Child Neurol. 1979;21:749–753. 2. Pritchett JW. The untreated unstable hip in severe cerebral palsy. Clin Orthop Relat Res. 1983;173:169–172.
r
2014 Lippincott Williams & Wilkins
Hip Fusion in Cerebral Palsy
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