Neurologic Hip Disorders Treated by Femoral Shortening and Lesser Trochanter Detachment

Abstract

In a group of 40 children with cerebral palsy (CP), myelomeningocele, or sequelae of previous tenotomy and neurotomy, a specific surgical approach was used to correct various type of hip disorders: migrating hip, subluxated or luxated hip, compressed hip, and windblown hip, especially in quadriplegia. Osteotomy is performed at the intertrochanteric area, where a segment of femur (3–5 cm) is removed and the lesser trochanter is released, allowing the psoas muscle to reinsert in a more proximal position. Based on the concept of imbalance between predetermined bone growth and passive adaptation of muscles, we postulated in 1982 that a reduction in bone length should have an effect on surrounding muscles, allowing them the possibility of working in better anatomic conditions. With our procedure, we obtain major release of muscle tension around the hip—release of hamstring, psoas, and tensor of fascia lata—and consequently a wide range of passive motion of the hips as well as the knees. Long-lasting effects are preserved only by use of regular splinting for a prolonged time. In hip luxation, reduction can be obtained by this extraarticular approach, without need to open the joint. A pelvic procedure is performed only when the acetabulum shows marked changes. In five children with CP, the procedure was combined with shortening of the patellar tendon to reactivate the extensor mechanism of the knees. We consider this specific approach a safe procedure that leaves the neural anatomy undisturbed and allows early ambulation, usually at 4 weeks. It may be used as a salvage procedure and as the initial treatment step for various neurologic hip disorders.