Abstract
No previous studies have suggested a reliable criterion for determining the addition of a concomitant pelvic osteotomy by using a large patient cohort with quadriplegic cerebral palsy and a homogenous treatment entity of femoral varus derotational osteotomies (VDRO). In this retrospective study, we examined our results of hip reconstructions conducted without a concomitant pericapsular acetabuloplasty in patients with varying degrees of hip displacement. We wished to investigate potential predictors for re-subluxation or re-dislocation after the index operation, and to suggest the indications for a simultaneous pelvic osteotomy. We reviewed the results of 144 VDROs, with or without open reduction, in 72 patients, at a mean follow-up of 7.0 (2.0 to 16.0) years. Various radiographic parameters were measured, and surgical outcomes were assessed based on the final migration percentage (MP) and the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS) grades. The effects of potential predictive factors on the surgical outcome was assessed by multivariate regression analysis. A receiver operating characteristic (ROC) curve analysis was also performed to determine whether a threshold of each risk factor existed above which the rate of unsatisfactory outcomes was significantly increased. In total, 113 hips (78.5%) showed satisfactory results, classified as MCPHCS grades I, II, and III. Thirty-one hips (21.5%) showed unsatisfactory results, including six hip dislocations. Age at surgery and preoperative acetabular index had no effects on the results. Lower pre- and postoperative MP were found to be the influential predictors of successful outcomes. The inflection point of the ROC curve for unsatisfactory outcomes corresponded to the preoperative MP of 61.8% and the postoperative MP of 5.1%, respectively; these thresholds of the pre- and postoperative MP may serve as a guideline in the indication for a concomitant pelvic osteotomy. Our results also indicate that the severely subluxated or dislocated hip, as well as the hip in which the femoral head is successfully reduced by VDRO but is still contained within the dysplastic acetabulum, may benefit from concomitant pelvic osteotomy.
Highlights
Hip displacement is one of the most common problems seen in patients with quadriplegic cerebral palsy (CP) [1]
We examined our results of hip reconstructions conducted without a concomitant pericapsular acetabuloplasty in patients with varying degrees of hip displacement
Six re-dislocations occurred in all cohorts; two painful hips were treated with subtrochanteric valgus osteotomy with or without femoral head resection, and the remaining four hips were left untreated, as the parents refused re-operation
Summary
Hip displacement is one of the most common problems seen in patients with quadriplegic cerebral palsy (CP) [1]. Hip subluxation or dislocation is attributed to asymmetrically increased muscle tone and spasticity in conjunction with increased femoral anteversion and progressive valgus deformity of the proximal femur [4]. If untreated, this condition may eventually lead to degenerative arthritis and induce intractable pain [4,5,6]. Hip surveillance programs for children with CP have been adopted to prevent dislocation by early detection and early preventive surgery [7] In both the Australian and Swedish settings, the prevalence of late dislocation had decreased, and the need for salvage surgery has been reduced [8,9]. Reconstructive surgeries to correct myostatic muscle deformities and femoral/acetabular malalignments are recommended when there is no severely deformed femoral head caused by a chronically dislocated hip [10]
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