THE HIP JOINT IN CEREBRAL PALSY

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1 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

2 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)

3 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

4 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.

5 Progressive Hip Subluxation Often Painful Leads to assymetry and pelvic obliquity Dislocated hips become contracted Wind Swept Deformity Sitting imbalance

6 HIP DYSPLASIA (Acetabular Rim Syndrome)

7 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?

8 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

9 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

10 What is femoral anteversion? Internal rotation of the femur Children are born with degrees of femoral anteversion Resolves to degrees by age 8 CP Increasing or nonresolved femoral anteversion

11 1 yo female - Left dislocated hip, Right subluxated hip

12 After open reduction - 3 yo

13 Age 14

14 Age 16 - s/p L VDO

15 Age 16 s/p R VDO

16 Age 28

17 Age 43

18 Age 43

19 Age 43 s/p THR

20 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

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

22 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

23 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

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

25 1 Yo Spastic Diplegic in 1999

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27 2006

28 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

29 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.

30 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

31 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

32 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)

33 Knee Contractures Flexion Medial and Lateral Hamstrings Extension Rectus Femoris and Vastus lateralis Hadley et al. JPO 1992 Abel et al JPO 1999

34 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)

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

36 Management of Acetabular Dysplasia

37 Pelvic Osteotomies Salter Ostetomy - Below age 8, 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

38 14 yo with Spastic Diplegia Subluxated Left hip Dysplastic Acetabulum

39 Arthrogram

40 4 yo with spastic Diplegia

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42 DO NOT IMMOBILIZE THE HIP AND KNEE

43 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

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53 16 yo with Spastic Diplegia

54 Commonly Asked Questions

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

56 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

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

58 5 yo Spastic Quadraplegia

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60 Surgical and 18 month f/u

61 14 yo Spastic Quadrplegia

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63 Etiology (CAUSE) of Internal Rotation Gait??

64 Internal Rotation Gait Medial Hamstring Adductors Gluteus Medius Spasticity Femoral Anteversion? Capsular tightness/hip anatomy

65 IS SURGERY ALWAYS BILATERAL??

66 Answer Always achieve Symmetry. Different sides may require different procedures.

67 9 yo boy with Spastic Diplegia

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

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

70 DYSTONIA and the Subluxed Hip??

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

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73 Lever Arm Disease?? What is it? Prevention?? Treatment??

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76 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.

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

78 SCOLIOSIS and the HIP

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

80 Cerebral Palsy Scoliosis Spastic quadriplegia highest risk Custom seats

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

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85 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

86 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