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Surgery for both hips in severe cerebral palsy

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Up to 60% of children with quadriplegic cerebral palsy have unstable hips. Bilateral subluxation or dislocation of the hip may ensue and is often accompanied by pelvic obliquity and spinal deformity. The “windswept” deformity frequently develops with posterior subluxation of the adducted hip and anterior displacement of the opposite, abducted, hip. Hip pain may become intractable and care difficult. An orthopaedic team in Bristol (

) has assessed the results of bilateral hip surgery.

They reviewed the notes of 30 children (60 operated hips, 18 girls, mean age 7.7 years) who had simultaneous bilateral combined soft tissue and bone surgery between 1991 and 1997. In 19 children the cerebral palsy was classified as dystonic and in 11 hypertonic. All had windswept deformity, 20 to the right and 10 to the left. The indications for surgery were increased asymmetry, radiological subluxation or dislocation, or pain. All patients had bilateral femoral varus derotation osteotomies and selected patients had bilateral or unilateral (adducted hip) acetabuloplasty. All hips were fully reduced at the end of operation. Most patients had release procedures involving psoas, adductor, gluteus maximus, or tensor fascia lata muscles. A full hip spica was applied for 6 weeks after operation and each patient went home with a spica transporter.

Follow up assessments were made at an average of 3 years. The mean range of combined abduction and adduction in flexion increased from 97° to 135° and fixed flexion decreased from 15° to 8°. In most patients, however, the windswept deformity did not change significantly. Of 50 hips with complete pre- and postoperative x rays 36 were subluxed or dislocated before operation and eight were subluxed afterwards. The overall level of mobility improved in a few patients. Thirteen patients had hip pain before operation but only two of these continued to have pain after operation. Three patients had supracondylar fractures of the femur postoperatively, one had trochanteric bursitis, one a sinus over a plate, and one a plaster sore. Twenty-three of 25 carers said the child was easier to handle and 22 expressed overall satisfaction with the management of their child.

Bilateral bone and soft tissue surgery may relieve pain and make care easier for children with severe quadriplegia, windswept deformity, and displaced hips.

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