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A balanced approach for stable hips in children with cerebral palsy: a combination of moderate VDRO and pelvic osteotomy.

Reidy K, Heidt C, Dierauer S, Huber H - J Child Orthop (2016)

Bottom Line: The mean pre-operative NSA angle of 152.3° was reduced to 132.6° post-operatively.Reimers' migration percentage (MP) was improved from 63.6 % pre-operatively to 2.7 % post-operatively and showed a mean of 9.7 % at the final review.This approach maintains good hip abduction and reduces soft-tissue surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland. kerstin.reidy@kispi.uzh.ch.

ABSTRACT

Background: Hip reconstructive surgery in cerebral palsy (CP) patients necessitates either femoral varus derotational osteotomy (VDRO) or pelvic osteotomy, or both. The purpose of this study is to review the results of a moderate varisation [planned neck shaft angle (NSA) of 130°] in combination with pelvic osteotomy for a consecutive series of patients.

Methods: Patients with CP who had been treated at our institution for hip dysplasia, subluxation or dislocation with VDRO in combination with pelvic osteotomy between 2005 and 2010 were reviewed.

Results: Forty patients with a mean follow-up of 5.4 years were included. The mean age at the time of operation was 8.9 years. The majority were non-ambulant children [GMFCS I-III: n = 11 (27.5 %); GMFCS IV-V: n = 29 (72.5 %)]. In total, 57 hips were treated with both femoral and pelvic osteotomy. The mean pre-operative NSA angle of 152.3° was reduced to 132.6° post-operatively. Additional adductor tenotomy was performed in nine hips (16 %) at initial operation. Reimers' migration percentage (MP) was improved from 63.6 % pre-operatively to 2.7 % post-operatively and showed a mean of 9.7 % at the final review. The results were good in 96.5 % (n = 55) with centred, stable hips (MP <33 %), fair in one with a subluxated hip (MP 42 %) and poor in one requiring revision pelvic osteotomy for ventral instability.

Conclusions: This approach maintains good hip abduction and reduces soft-tissue surgery. Moderate varisation in VDRO in combination with pelvic osteotomy leads to good mid-term results with stable, pain-free hips, even in patients with severe spastic quadriplegia.

No MeSH data available.


Related in: MedlinePlus

Example of intra-operative measurement of the neck shaft angle (NSA). For correct measurements and corrected anteversion, the growth plate of the greater trochanter must be fully visible (white arrow). The pre-operative NSA was measured on an image intensifier and correction was adjusted to the measured value
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Fig1: Example of intra-operative measurement of the neck shaft angle (NSA). For correct measurements and corrected anteversion, the growth plate of the greater trochanter must be fully visible (white arrow). The pre-operative NSA was measured on an image intensifier and correction was adjusted to the measured value

Mentions: Prior to surgical intervention, computed tomography (CT) scans with 3D reconstructions were performed to visualise the direction of migration, as well as the sphericity and the bony deformity. For the pelvic osteotomy, a Smith–Peterson approach was used. The type of osteotomy was adjusted to the predominant direction of instability: Dega osteotomy for a more posterior, Pemberton osteotomy for a more anterior instability or for a multi-directional instability. In all cases, VDRO was performed through a subvastus approach. It included a varisation, derotation and shortening. The amount of correction was adjusted to the individual situation: intra-operatively correct rotated a.p. X-rays of the proximal femur were obtained and the amount of femoral varisation was defined with a goal of an NSA of around 130° after varisation (Fig. 1). The amount of femoral shortening depended on the height of bone graft needed for inter-position on the pelvic osteotomy side. An additional 5 mm was taken to reduce tension for an easier and more gentle reduction of the hip joint. By reducing pressure on the hip joint and, thereby, on the femoral head, the risk of AVN can be decreased. Fixation was achieved with either an AO blade plate or as described by Rutz and Brunner with an LCP paediatric hip plate (Synthes, Grenchen, Switzerland) [17]. In all cases, an intra-pelvine lengthening of the iliopsoas tendon was performed. An additional adductor tenotomy was only done if intra-operative hip abduction was less than 20° after pelvic osteotomy and VDRO. If necessary, an abductor release was performed in the case of a fixed abduction contracture, mostly after reduction of an anterior hip dislocation. Post-operatively, hip spica cast was applied for at least 2 weeks, primarily for analgetic reasons, in some cases prolonged for 4–6 weeks, depending on bone quality and activity level. Walking patients older than 10 years at operation were not immobilised in a hip spica cast post-operatively.Fig. 1


A balanced approach for stable hips in children with cerebral palsy: a combination of moderate VDRO and pelvic osteotomy.

Reidy K, Heidt C, Dierauer S, Huber H - J Child Orthop (2016)

Example of intra-operative measurement of the neck shaft angle (NSA). For correct measurements and corrected anteversion, the growth plate of the greater trochanter must be fully visible (white arrow). The pre-operative NSA was measured on an image intensifier and correction was adjusted to the measured value
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4940248&req=5

Fig1: Example of intra-operative measurement of the neck shaft angle (NSA). For correct measurements and corrected anteversion, the growth plate of the greater trochanter must be fully visible (white arrow). The pre-operative NSA was measured on an image intensifier and correction was adjusted to the measured value
Mentions: Prior to surgical intervention, computed tomography (CT) scans with 3D reconstructions were performed to visualise the direction of migration, as well as the sphericity and the bony deformity. For the pelvic osteotomy, a Smith–Peterson approach was used. The type of osteotomy was adjusted to the predominant direction of instability: Dega osteotomy for a more posterior, Pemberton osteotomy for a more anterior instability or for a multi-directional instability. In all cases, VDRO was performed through a subvastus approach. It included a varisation, derotation and shortening. The amount of correction was adjusted to the individual situation: intra-operatively correct rotated a.p. X-rays of the proximal femur were obtained and the amount of femoral varisation was defined with a goal of an NSA of around 130° after varisation (Fig. 1). The amount of femoral shortening depended on the height of bone graft needed for inter-position on the pelvic osteotomy side. An additional 5 mm was taken to reduce tension for an easier and more gentle reduction of the hip joint. By reducing pressure on the hip joint and, thereby, on the femoral head, the risk of AVN can be decreased. Fixation was achieved with either an AO blade plate or as described by Rutz and Brunner with an LCP paediatric hip plate (Synthes, Grenchen, Switzerland) [17]. In all cases, an intra-pelvine lengthening of the iliopsoas tendon was performed. An additional adductor tenotomy was only done if intra-operative hip abduction was less than 20° after pelvic osteotomy and VDRO. If necessary, an abductor release was performed in the case of a fixed abduction contracture, mostly after reduction of an anterior hip dislocation. Post-operatively, hip spica cast was applied for at least 2 weeks, primarily for analgetic reasons, in some cases prolonged for 4–6 weeks, depending on bone quality and activity level. Walking patients older than 10 years at operation were not immobilised in a hip spica cast post-operatively.Fig. 1

Bottom Line: The mean pre-operative NSA angle of 152.3° was reduced to 132.6° post-operatively.Reimers' migration percentage (MP) was improved from 63.6 % pre-operatively to 2.7 % post-operatively and showed a mean of 9.7 % at the final review.This approach maintains good hip abduction and reduces soft-tissue surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland. kerstin.reidy@kispi.uzh.ch.

ABSTRACT

Background: Hip reconstructive surgery in cerebral palsy (CP) patients necessitates either femoral varus derotational osteotomy (VDRO) or pelvic osteotomy, or both. The purpose of this study is to review the results of a moderate varisation [planned neck shaft angle (NSA) of 130°] in combination with pelvic osteotomy for a consecutive series of patients.

Methods: Patients with CP who had been treated at our institution for hip dysplasia, subluxation or dislocation with VDRO in combination with pelvic osteotomy between 2005 and 2010 were reviewed.

Results: Forty patients with a mean follow-up of 5.4 years were included. The mean age at the time of operation was 8.9 years. The majority were non-ambulant children [GMFCS I-III: n = 11 (27.5 %); GMFCS IV-V: n = 29 (72.5 %)]. In total, 57 hips were treated with both femoral and pelvic osteotomy. The mean pre-operative NSA angle of 152.3° was reduced to 132.6° post-operatively. Additional adductor tenotomy was performed in nine hips (16 %) at initial operation. Reimers' migration percentage (MP) was improved from 63.6 % pre-operatively to 2.7 % post-operatively and showed a mean of 9.7 % at the final review. The results were good in 96.5 % (n = 55) with centred, stable hips (MP <33 %), fair in one with a subluxated hip (MP 42 %) and poor in one requiring revision pelvic osteotomy for ventral instability.

Conclusions: This approach maintains good hip abduction and reduces soft-tissue surgery. Moderate varisation in VDRO in combination with pelvic osteotomy leads to good mid-term results with stable, pain-free hips, even in patients with severe spastic quadriplegia.

No MeSH data available.


Related in: MedlinePlus