Spasticity used to be considered a contraindication for total hip replacement (THR) procedures. Due to the development of implants as well as surgical skills, THR became an option for the treatment of painful dislocation of the hip joint in patients with spastic plegia. The aim of this study was an evaluation of mid-term results of THR in spastic CP adolescent patients with painful hips with hip joint subluxation or dislocation.

In 2014–2022, 18 pts (19 hips) with CP aged 16 to 20 years underwent THR in our department. The mean follow-up was 4 years (range: 1 – 9 years). Results were evaluated using the Gross Motor Function Scale, VAS scale in accordance with the Ashworth scale, types of implants used (dual mobility cup and not dual mobility cup), and radiological assessment (Crowe scale). Complications have been thoroughly analyzed.

In 10 pts there has been an improvement in the GMFSC scale average from 1 to 2 points observed after the surgery. All pts have improved in the VAS scale average of 8 points (from 10 to 7). According to the Crowe scale repositioning of preoperative dislocation to primary acetabulum was achieved in all cases. Complications occurred in 4 cases: dislocations of 2 THR with dual mobility cup and 2 THR with non-dual mobility cup requiring revision surgery with good final result. No statistical significance was noted according to the type of cup (Mann-Whitney U Test).

The most important risk factor for complications is severe spasticity. We believe, that CP pts with painful hips should be treated using THR. We didn't observe any significant differences between the types of implants.

These findings may serve as a basis for the prediction of outcomes of THR treatment in this specific group of pts.

Level of evidence: Case-control or retrospective comparative study-Level III

The aims of this study were to report functional outcomes of salvage procedures for patients with cerebral palsy (CP) who have chronic dislocation of the hip using validated scoring systems, and to compare the results of three surgical techniques. We reviewed 37 patients retrospectively. The mean age at the time of surgery was 12.2 years (8 to 22) and the mean follow-up was 56 months (24 to 114). Patients were divided into three groups: 14 who underwent proximal femoral resection arthroplasty (PFRA group 1), ten who underwent subtrochanteric valgus osteotomy (SVO group 2), and 13 who underwent subtrochanteric valgus osteotomy with resection of the femoral head (SVO with FHR group 3). All patients were evaluated using the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) and the Pediatric Quality of Life Inventory (PedsQL). Significant improvements occurred in most CPCHILD and PedsQL subsection scores following surgery in all patients, without significant differences between the groups. There were 12 post-operative complications. Less severe complications were seen in group 1 than in groups 2 and 3. Salvage surgery appears to provide pain relief in patients with CP who have painful chronic dislocation of the hip. The three salvage procedures produced similar results, however, we recommend the use of PFRA as the complications are less severe. Take home message: Salvage surgery can be of benefit to patients with CP with chronic painful hip dislocation, but should be limited to selected patients considering complications. Cite this article: Bone Joint J 2016;98-B:137–43

Proximal femoral resection (PFR) is a proven pain-relieving procedure for the management of patients with severe cerebral palsy and a painful displaced hip. Previous authors have recommended post-operative traction or immobilisation to prevent a recurrence of pain due to proximal migration of the femoral stump. We present a series of 79 PFRs in 63 patients, age 14.7 years (10 to 26; 35 male, 28 female), none of whom had post-operative traction or immobilisation.

A total of 71 hips (89.6%) were reported to be pain free or to have mild pain following surgery. Four children underwent further resection for persistent pain; of these, three had successful resolution of pain and one had no benefit. A total of 16 hips (20.2%) showed radiographic evidence of heterotopic ossification, all of which had formed within one year of surgery. Four patients had a wound infection, one of which needed debridement; all recovered fully. A total of 59 patients (94%) reported improvements in seating and hygiene.

The results are as good as or better than the historical results of using traction or immobilisation. We recommend that following PFR, children can be managed without traction or immobilisation, and can be discharged earlier and with fewer complications. However, care should be taken with severely dystonic patients, in whom more extensive femoral resection should be considered in combination with management of the increased tone.

Cite this article: Bone Joint J 2014; 96-B:701–6.

In patients with severe quadriplegic cerebral palsy and painful hip dislocation proximal femoral resection arthroplasty can reduce pain, but the risk of heterotopic ossification is significant. We present a surgical technique of autologous capping of the femoral stump in order to reduce this risk, using the resected femoral head as the graft. A retrospective study of 31 patients (43 hips) who had undergone proximal femoral resection arthroplasty with (29 hips) and without autologous capping (14 hips) was undertaken. Heterotopic ossification was less frequent in patients with autologous capping, and a more predictable pattern of bony overgrowth was found. For a selected group of non-ambulatory patients with long-standing painful dislocation of the hip, we recommend femoral resection arthroplasty over more complicated reconstructive operations. The risk of heterotopic ossification, which is a major disadvantage of this operation, is reduced by autologous capping

Purpose of the study: In the spastic quadriplegic non-ambulatory child, hip dislocation with severe adduction is a painful situation compromising perineal hygiene and local care as well as positioning in bed or wheel chair. We describe a method of treatment using Castle’s femoral resection-interposition arthroplasty and an external fixator to prevent proximal migration of the remnant femur. Description: Resection of the proximal femur with articulated distraction of the hip using an external fixator was performed in eight children (11 hips) with cerebral palsy. All patients (five boys, three girls, mean age 15 years) had painful neurological disorders with chronic hip dislocation incompatible with the sitting position and compromising perineal hygiene. The operation, described by Castle, consisted in subtrochanteric resection and suture of the quadriceps muscle around the femoral cut. The capsule detacted from the femur was closed around the acetabulum. The abductors were sutured between the shaft and the acetabulum in order to ensure interposition of enough soft tissue. An external fixator (Orthofix®) was installed for 90 days. This method has the advantage of producing the necessary distraction while allowing immediate mobility (hip extension flexion) and good balance in the sitting position as well as better perineal hygiene compared with the preoperative situation. At six months, there was a clear clinical improvement in terms of pain relief, tolerance to the sitting position, and perineal hygiene with a significant increase in joint motion (flexion, extension, abduction). Proximal migration of the femur was observed in one case after removing the external fixator. There were no cases of recurrent adduction deformity, stiffness or bone hypertrophy. Conclusion: Proximal resection of the femur with capsular interposition arthroplasty and articulated distraction with an external fixator decreases the pain of the dislocated spastic hip. This method is a reliable salvage alternative for painful hip dislocation in cerebral palsy children. Use of an articulated external fixator for the distraction enables immediate postoperative mobilization and the sitting position in a wheel chair, improving patient comfort compared with the classical Russell also described by Castle

We describe a patient with cerebral palsy, of normal intelligence, who could not walk but who by the age of 16 had been successfully managed with a staged bilateral total hip arthroplasty using a constrained liner.