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.

Purpose of study: To compare the medial gastrocnemius (MG) muscle belly length and volume in children with spastic diplegic cerebral palsy (SDCP) with that of normally developing (ND) children, and to assess the effect of gastrocnemius recession (GR) on MG muscle belly length and volume in the SDCP group.

Method: The MG muscle belly length and volume at the resting ankle angle were assessed with 3D ultrasound in 10 ND children, mean age 9.4 years, and in 7 children (9 limbs) with SDCP (mean age 8.1 years) who had fixed equinus deformities (mean 24 degrees). The children with SDCP were assessed just before, and at 7 weeks and 1 year after GR surgery. Muscle length was normalised to fibular length, and muscle volume was normalised to body mass.

Results: In both the ND and SDCP groups, muscle length was significantly related to fibular length (p=0.001) and muscle volume was significantly related to body mass (p< 0.001). The MG in the SDCP group had a mean reduction in normalised length of 19% and in normalised volume of 59% when compared to the ND group (p< 0.001). GR surgery lead to a further reduction in MG length (p=0.014) and a mean reduction of MG volume of 10% at 7 weeks (p=0.025). However, there was an increase in muscle volume of 39% (24% increase compared to the preoperative assessment) at 1 year following surgery (p< 0.001).

Conclusions: The MG belly is significantly shorter and thinner in children with SDCP compared to ND children. GR surgery reduces MG length but leads to an improvement in MG volume and thus in the ability of the MG to generate power.

We reviewed the outcome in 24 children with bilateral spastic cerebral palsy aged seven years or younger for whom surgery was recommended between 1999 and 2005 following gait analysis. A total of 13 children (operative group) had surgery and the remaining 11 (control group) did not, for family or administrative reasons. The operative group had at least two post-operative gait analyses at yearly intervals, with eight children having a third and six children a fourth. The control group had a second analysis after a mean interval of 1.5 years (95% confidence interval 1.1 to 1.9). In the operative group, the Gillette gait index, the ranges of movement in the lower limb joint and knee extension in stance improved following surgery, and this was maintained overall at the second post-operative analysis. The minimum knee flexion in stance in the control group increased between analyses.

These results suggest that surgical intervention in selected children can result in improvements in gait and function in the short to medium term compared with non-operative management.