Scoliosis and hip subluxation/dislocation are common and often coexistent problems encountered in patients with cerebral palsy (CP). The underlying mechanism may be related to muscle imbalance. Surgical correction may become necessary in severe symptomatic cases. The effect of surgical correction of one deformity on the other is not well understood. We retrospectively reviewed a series of 17 patients with total body cerebral palsy with diagnoses of both scoliosis and hip subluxation who had undergone either surgical correction of their scoliosis (9 patients) or a hip reconstruction to correct hip deformity (8 patients). In all patients, the degree of progression of both deformities was measured, radiographically, using the Cobb angle for the spine and the percentage migration index for hip centre of rotation at intervals before and at least 18 months post surgery. All patients who underwent scoliosis correction had a progressive increase in the percentage of hip migration at a rate greater than that prior to scoliosis surgery. Similarly, patients who underwent a hip reconstruction procedure demonstrated a more rapid increase in their spine Cobb angles post surgery. There may be a relationship between hip subluxation/dislocation and scoliosis in CP patients. Surgery for either scoliosis or hip dysplasia may in the presence of both conditions lead to a significant and rapid worsening of the other. The possible negative implications on the overall functional outcome of the surgical procedure warrants careful consideration to both hip and the spine before and after surgical correction of either deformity. In selected cases there may be an indication for one procedure to follow soon after the other

Objective: To review the hip subluxations or dislocations occurring during femoral lengthening in patients with congenital longitudinal lower limb deficiencies. Methods: Sixty-three patients with congenital longitudinal lower limb deficiencies underwent femoral lengthening using either De Bastiani, Villarubias or Ilizarov technique. Acetabular index, medial joint space, CE angle of Wiberg, acetabular angle of Sharp and neck-shaft angle were measured on anteroposterior radiographs of hip before, during and after lengthening. The Acetabulum was considered dysplastic when the Sharp angle was more than 45 degrees. Hip was considered to be subluxed when the medial joint space increased during lengthening. Results: During femoral lengthening, eleven hips sub-luxed as measured by the increase in medial joint space and one hip dislocated. All these hips had a preoperative acetabular index more than 25 degrees, CE angle less than 20 degrees and Sharp angle more than 45 degrees. The average neck-shaft angle was 75 degrees. Following subluxation, lengthening was stopped and the hips were reduced in hip spica after adductor and sartorius tenotomies. In one patient femoral shortening and acetabulo-plasty had to be done to reduce the subluxation. No case of avascular necrosis was noted. Conclusion: Hip subluxation during femoral lengthening of congenital longitudinal lower limb deficiencies tends to occur when the acetabular index is more than 25 degrees, Sharp angle is more than 45 degrees, CE angle is less than 20 degrees and when there is associated femoral coxa vara. Careful preoperative assessment is required, and if need be hip reconstruction prior to lengthening. Close monitoring during lengthening is recommended

Aims: To review the hip subluxations or dislocations occurring during femoral lengthening in patients with congenital longitudinal lower limb deficiencies. Methods: Sixty-three patients with congenital longitudinal lower limb deficiencies underwent femoral lengthening using either De Bastiani, Villarubias or Ilizarov technique. Acetabular index, medial joint space, CE angle of Wiberg, acetabular angle of Sharp and neck-shaft angle were measured on anteroposterior radiographs of hip before, during and after lengthening. Acetabulum was considered dysplastic when the Sharp angle was more than 45 degrees. Hip was considered to be subluxed when the medial joint space increased during lengthening. Results: During femoral lengthening, eleven hips subluxed as measured by the increase in medial joint space and one hip dislocated. All these hips had a pre-operative acetabular index more than 25 degrees, CE angle less than 20 degrees and Sharp angle more than 45 degrees. The average neck-shaft angle was 75 degrees. Following subluxation, lengthening was stopped and the hips were reduced in hip spica after adductor and sartorius tenotomies. In one patient femoral shortening and acetabuloplasty had to be done to reduce the sub-luxation. No case of avascular necrosis or chondrolysis was noted. Conclusions: Hip subluxation during femoral lengthening of congenital longitudinal lower limb deficiencies tends to occur when there is associated ace-tabular dyplasia and femoral coxa vara. Careful preoperative assessment, if need be hip reconstruction prior to lengthening and close monitoring during lengthening is recommended

Purpose. Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21 and we describe long-term outcomes following the precise use of femoral varus derotation osteotomy. Methods. 16 consecutive hips, 9 children, with Trisomy 21 aged =10 years, were identified from hospital databases. Clinical notes and radiographs from presentation to final follow-up were reviewed. Results. Mean age at first known hip dislocation was 4.1 years (range 3, 7 years). All had a femoral varus derotation osteotomy (VDRO). In 2 hips, significant intraoperative instability persisted and a periacetabular osteotomy and capsulorraphy were required. Mean Femoral neck shaft angle (NSA) fell from 166.7° (+/-6.9°) to 106.0° (+/-5.4°). Mean follow-up was 5.9 years (+/-2.9). 1 hip (6.2%) developed painful arthritis. 14 hips developed peri-trochanteric varus deformities. 2 (12.5%) developed periprosthetic fractures 4 and 8 years post-operatively. Conclusion. Prevention of long term disabling pain from habitually dislocating or recurrently subluxed hips, in patients with Trisomy 21, requires surgical intervention to increase hip containment. In those aged =9 who have not developed hip incongruency, a VDRO with adequate varisation and minimal derotation was sufficient. Reducing the femoral NSA to approximately 100°, intraoperatively stabilised most hips. If instability persisted, a periacetabular osteotomy and capsulorraphy were performed. The 2 hips requiring additional procedures had the least corrected NSAs (115° and 122°) in our series. These patients were also older, aged 7 and 10, a factor that may have also contributed to the need for acetabular correction. We believe surgical management of habitually subluxed or dislocated Trisomy 21 hips allows for a predictable result. We recommend a varus producing proximal femoral osteotomy to correct the NSA to 100-110°. This should be performed before either the age of 8 years or teardrop development. In our experience this has been effective in maintaining hip stability

Subluxation of the hip is common in patients with intermediate spinal muscular atrophy. This retrospective study aimed to investigate the influence of surgery on pain and function, as well as the natural history of subluxed hips which were treated conservatively. Thirty patients were assessed clinically and radiologically. Of the nine who underwent surgery only one reported satisfaction and four had recurrent subluxation. Of the 21 patients who had no surgery, 18 had subluxation at the latest follow-up, but only one reported pain in the hip. We conclude that surgery for subluxation of the hip in these patients is not justified.

Introduction: We compared femoral head resection (FHR) and traction with femoral head resection and valgus osteotomy (the McHale procedure), in order to determine the effectiveness of these two procedures in the treatment of painful hip subluxation in severely involved individuals with cerebral palsy. Methods: Retrieval of demographic patient information, operative technique, post-operative complications, and migration of the femoral shaft was obtained from a retrospective review of charts and radiographs. Caregivers were then contacted by telephone and queried regarding post-operative changes in pain, sitting tolerance, and hygiene as well as overall satisfaction with surgical intervention. Results: 27 patients, 36 hips comprise the study cohort; 26 patients have quadriplegia, one has diplegia and is the only patient who is ambulatory. 16 patients underwent FHR, 11 patients underwent McHale procedures. The average age of surgery was 19 years, range from 8 to 42 years. Average follow-up was 3.4 years from time of surgery. The majority of patients (17) had not undergone reconstructive hip surgery because they were lost to orthopedic follow-up, and missed the opportunity to have the hip relocated before femur was significantly deformed. Six patients had painful hips despite previous attempts at surgery, three patients refused reconstructive surgery, and one patient was not deemed medically stable enough for reconstructive surgery. Post-operative complications were numerous and included skin breakdown, wound dehiscense, hardware infection or failure, heterotopic ossification, and death. The complication rate was significantly higher in patients who had undergone FHR and traction (13/16) compared with the patients who had a McHale procedure (3/11). The average length of hospitalization was almost twice as long for the FHR group (7 days) as for the McHale group (4 days). Telephone surveys of caregiv-ers often demonstrated equivalent overall satisfaction with surgery in both groups with average scores of 8/10 for the FHR and 7.6/10 for the McHale group (on a scale from 1 to 10, 10 being the most satisfied). Only two of the respondents (one from the FHR group, one McHale) we contacted regretted having had surgery. Caregivers felt that post-operatively pain relief was achieved in almost all patients. The average time to achieve a more pain-free state was three months. Sitting tolerance improved variably between individual patients, while few caregivers felt that hygiene improved after surgery, although they also felt that hygiene had not been a significant problem pre-operatively

Aims

Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app).

This is a retrospective study describing four patients who developed symptomatic subluxation of the hip after stabilisation to the pelvis for myopathic scoliosis in Duchenne Muscular Dystrophy (DMD).

Fusion to the pelvis is recommended for treatment of scoliosis in DMD. Non-spinal extra-pulmonary complications following this have not been described.

4 patients (average age: 14 years) out of a cohort of patients who have undergone spinal stabilisation for DMD between 1991 and 1998 developed symptomatic subluxation of the hip at an average of three months after fusion from the upper thoracic spine to the pelvis. All four had pain and three noticed clicking in the hip.

X-rays revealed subluxation of the hip in all patients, and conservative treatment by adjustment of seating position in the wheelchair was successful in reducing the symptoms in all patients.

Flexion-abduction contractures of the hip, which are a feature of DMD, are known to cause uncovering of the contralateral hip. We postulate that the spine compensates for this uncovering to a large degree, and that spinopelvic fusion for scoliosis in patients with pre-existent abduction contractures negates the capacity of the spine to provide compensation. This leads to uncovering of the hip with the lesser degree of contracture, and the resultant symptoms.

We recommend screening for, and treatment of, flexion-abduction contractures of the hip in all patients undergoing spinal fusion for DMD, to avoid the possibility of development of symptomatic subluxation of the hip.

Aim: The aim of the study was to assess the correlation of CE angle to the ratios of medial hip joint space width and femoral head diameter to acetabular width.

Material and metod: Measurements were done on 196 AP pelvic radiographs of 10 years old and 20 years old males and females obtained with “siemens lconos r 200 axion^®”. The patients were placed in the supine position with their hips extended and internally rotated 15°. Medial hip joint space width (mJSW), CE angle, femoral head diameter (FD) and acetabular width (AW) were measured. The intraobserver reproducibility was assessed by a randomly chosen subset of 50 radiographs and these were read 1 month apart. The levels of agreement were qualified using the intraclass correlation coefficient. The ratios of mJSW to AW and FD to AW were calculated.

Results: Mean CE angles in 10 years old females and males were 33.87±3.64 ve 32.74±4.21 degrees respectively. CE angle was correlated to mJSW/AW in 10 years old females (r = − 0.446, p=0.043). CE angle was not correlated to mJSW/AW in 10 years old males (r = − 0.293, p=0.146). CE angle was not correlated to mJSW/AW in 20 years old females while CE angle was correlated to mJSW/AW in 20 years old males (r = 0. 694, p=0.001). CE angle was correlated to FD/AW only in 20 years old males (r=0.553, p= 0.002).

Discussion: Ratios of medial hip joint space width and femoral head diameter to acetabular width are not correlated to CE angle in both preadelocent and postade-locent terms depending on sex. The expected inverse correlation of these parameters to CE angle was not dedected, so these parameters can be used in radiologic assessement of subluxation of the hip and acetabular dysplasia together with CE angle.

Aims. Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature. Methods. We retrospectively evaluated 17 patients (18 hips) who underwent the modified Dunn procedure for the treatment of slipped capital femoral epiphysis. Outcome measurement included standardized scores. Clinical assessment included ambulation, leg length discrepancy, and hip mobility. Radiographically, the quality of epiphyseal reduction was evaluated using the Southwick and Alpha-angles. Avascular necrosis, heterotopic ossifications, and osteoarthritis were documented at follow-up. Results. At a mean follow-up of more than nine years, the mean modified Harris Hip score was 88.7 points, the Hip Disability and Osteoarthritis Outcome Score (HOOS) 87.4 , the Merle d’Aubigné Score 16.5 points, and the UCLA Activity Score 8.4. One patient developed a partial avascular necrosis of the femoral head, and one patient already had an avascular necrosis at the time of delayed diagnosis. Two hips developed osteoarthritic signs at 14 and 16 years after the index operation. Six patients needed a total of nine revision surgeries. One operation was needed for postoperative hip subluxation, one for secondary displacement and implant failure, two for late femoroacetabular impingement, one for femoroacetabular impingement of the opposite hip, and four for implant removal. Conclusion. Our series shows good results and is comparable to previous published studies. The modified Dunn procedure allows the anatomic repositioning of the slipped epiphysis. Long-term results with subjective and objective hip function are superior, avascular necrosis and development of osteoarthritis inferior to other reported treatment modalities. Nevertheless, the procedure is technically demanding and revision surgery for secondary femoroacetabular impingement and implant removal are frequent. Cite this article: 2020;1-4:80–87

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 June 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Proximal femoral unicameral bone cysts: is ESIN the answer?; Hybrid-mesh casts in the conservative management of paediatric supracondylar humeral fractures: a randomized controlled trial; Rate and risk factors for contralateral slippage in adolescents treated for slipped capital femoral epiphysis; CRP predicts the need to escalate care after initial debridement for musculoskeletal infection; Genu valgum in paediatric patients presenting with patellofemoral instability; Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: what about spine and hip?; The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children.

Hip impingement causes clinical problems for both the native hip, where labral or chondral damage can cause severe pain, and in the replaced hip, where subluxation can cause squeaking/metallosis through edge loading, or can cause dislocation. There is much research into bony/prosthetic hard impingements showing that anatomical variation/component mal-positioning can increase the risk of impingement. However, there is a lack of basic science describing the role of the hip capsule and its intertwined ligaments in restraining range of motion, ROM, and so it is unclear if careful preservation/repair of the capsular ligaments would offer clinical benefits to young adults, or could also help prevent edge loading in addition to reducing the postoperative dislocation rate in older adults. This in-vitro study quantifies the ROM where the capsule passively stabilises the hip and compares this to hip kinematics during daily activities at risk for hip subluxation. Ten cadaveric left hips were skeletonised preserving the joint capsule and mounted in a testing rig that allowed application of loads, torques and rotations in all six-degrees of freedom (Figure 1). At 27 positions encompassing a complete hip ROM, the passive rotation resistance of each hip was recorded. The gradient of the torque-rotation profiles was used to quantify where the capsule is taut/slack and after resecting the capsule, where labral impingement occur. The ROM measurements were compared against hip kinematics from daily activities. The capsule tightly restrains the hip in full flexion/extension with large slack regions in mid-flexion. Whilst ligament recruitment varies throughout hip ROM, the magnitude of restraint provided is constant (0.82 ± 0.31 Nm/degree). This restraint acts to prevent or reduce loading of the labrum in the native hip (Figure 2). The measured passive rotational stability envelope is less than clinical ROM measurements indicating the capsule does provide restraint to the joint within a relevant ROM. Activities such as pivoting, stooping, shoe tying and rolling over in bed all would recruit the capsular ligaments in a stabilising role. The fine-tuned anatomy of the hip capsule provides a consistent contribution to hip rotational restraint within a functionally relevant ROM for normal activities protecting the hip against impingement. Capsulotomy should be kept to a minimum and routinely repaired in the native hip to maintain natural hip mechanics. Restoring its native function following hip replacement surgery may provide a method to prevent subluxation and edge loading in the replaced hip

Aims

The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed.

We present the 2 year results for the first 54 patients after Selective Dorsal Rhizotomy (SDR) delivered in Bristol, concentrating on change in Reimers' migration index. Eligible patients are selected at the SDR multidisciplinary meeting. Physiotherapy assessment is performed pre-operatively and at 6, 12 and 24 months post-surgery. Data collected includes GMFCS, Gross Motor Function Measure (GMFM) 88 and Modified Ashworth score for spasticity for major lower limb muscle groups, amongst other data. Pelvic radiographs are taken pre-operatively and at 2 years post-operatively. Reimers' migration index was measured using the hospital picture archiving and communication system (PACS). The mean age was 7.2 (3.9–17.5) at the time of surgery. Pre- and post-operative pelvic radiographs were available for 30 patients (60 hips). 57% (n=34) hips showed an increase in migration percentage (mean 5.4%, range 0.1–17.5%) and 43% (n=26) hips showed a decrease (mean 4.0%, range 0–15.5%). Overall no significant difference was found in Reimers' migration index at 2 year follow up (mean increase 1.3% (95% CI −0.3–3.0), p=0.12). There was an improvement in GMFCS category (by 1 grade) for 9 patients and a worsening for 1 patient at 2 year follow up. The Modified Ashworth score for spasticity improved in all patients. There was a mean improvement of 1.7 in the hip adductors and 2.4 in the ankle plantar flexors. There was a statistically significant improvement in the GMFM 88 D and E domains of 14.7 (95% CI 11.3–18.1), p<0.0001 and 11.4 (95% CI 7.4–15.7), p<0.0001 respectively. We found no evidence that SDR leads to worsening hip subluxation at 2 year follow up. All patients had improvement in lower limb spasticity. Overall there was a statistically significant improvement in function, as shown by GMFM 88 domains for standing, walking, running and jumping

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Aim. To assess the results of Castles procedure performed at our hospital compared with those available in literature. Introduction. Fifteen patients (19 hips) with severe disability and hip subluxation/dislocation underwent proximal femoral resection arthroplasty (Castles procedure) over a 10 year period under the care of 2 paediatric orthopaedic surgeons. We conducted a retrospective study of case series whether the surgery (Castles procedure) improved the pain levels, sitting tolerance, ability to use commode/nappy change, ease of dressing and the carers overall satisfaction with the procedure. Patients and methods. We reviewed the surgeons' and theatre log books for patients' details. We then contacted the patients' parents/guardian by telephone, and using a set questionnaire, we obtained valuable information on how successful the surgery had been in their opinion. Results. Out of 15 patients, 14 had severe cerebral palsy and one had severe brain damage secondary to trauma. The average age at surgery was 4.23 years (range 6–118 months). 14 patients obtained significant pain relief but one patient remained the same. 13 patients were found to have both sitting tolerance and sleeping improved. One patient suffered a pressure sore which has healed with conservative management. 2 patients had additional trimming procedure for heterotopic ossification excision. Apart from this there were no cases of skin breakdown. All patients found the bathing and dressing change was easier post operatively. 2 carers required extra help as the limbs were floppy but not a major issue compared to the overall benefits from the Castles procedure. Overall 13 carers were very satisfied with the procedure, two were satisfied and none were unsatisfied. Conclusion. Our telephone survey shows the Castles procedure was a successful salvage procedure for painful dislocated hips in non-ambulatory patients with severe disability

Between 1980 and 1988, displacement bone-marrow transplantation was performed on 25 children with Hurler's syndrome (type-1 mucopolysaccharidosis). We describe the musculoskeletal development of 11 of the 12 surviving children and the orthopaedic procedures undertaken to treat progressive thoracolumbar kyphosis, hip subluxation and carpal tunnel syndrome. We found abnormal bone modelling, focal failures of ossification and an avascular disorder of the femoral head in every patient and offer an explanation for these phenomena. Increasing valgus deformity of the knees and progressive generalised myopathy caused loss of mobility as the children entered adolescence. The benefit of bone-marrow transplantation as a treatment for the skeletal disorders of Hurler's syndrome is limited by the poor penetration of the musculoskeletal tissues by the enzyme derived from the leucocytes