Iliopsoas Transfer Research Articles

Operative treatment of paralytic hip dislocation in myelomeningocele by Dega transiliac osteotomy combined with iliopsoas transfer: technique and historical case series.

The technique of one stage procedure - open reduction, Dega transiliac with or without femoral subtrochanteric osteotomy combined with iliopsoas transfer according to Mustard - has been described for the treatment of paralytic dislocation of the hip in myelomeningocele patients. Historical series of 16 children (26 hips) operated on between 1987 and 2003 were analyzed retrospectively. There were nine boys and seven girls with upper and lower lumbar level lesions (15 with Sharrard groups 3 and 4 and one with Sharrard 2) and 20 dislocated and six subluxated hips. The mean age at operation was 5.1 years (3-12.3). Ten children were operated bilaterally. Follow-up ranged from 1 to 17 years (mean 10). Concentric reduction was achieved in 23 hips, subluxation in 1 and redislocation in 2. In one hip, acute avascular necrosis of the femoral head was visible early after operation. Immediately after the operation, most of the patients improved ambulation. After operation, 15 patients out of 16 became community ambulators. At the final follow-up, none of the patients worsened their ambulation due to operation. Open reduction and Dega transiliac osteotomy with or without subtrochanteric derotation/varus shortening osteotomy combined with iliopsoas transfer seem to be safe and valuable procedure for operative treatment of dislocated hip in myelomeningocele patients. Levels of evidence: level IV - case series.

Biomechanics analysis of the ilio-psoas transfer related to the lumbosacral myelomeningocele

Biomechanics analysis of the ilio-psoas transfer related to the lumbosacral myelomeningocele

Retrospective review of L3 myelomeningocele in three age groups: should posterolateral iliopsoas transfer still be indicated to stabilize the hip?

The data from 58 hips in 29 myelodysplastic children with L3 paralysis has been reviewed retrospectively. Posterolateral transfer of the iliopsoas (Sharrard technique) was performed on all hips to correct muscle imbalance between 1975 and 1992. The average length of follow-up was 21 years. Preoperatively, 58.6% of the hips were either subluxated or dislocated (these were surgically reduced at the same stage). Radiological assessment revealed that 91.4% of the hips were stable at preschool age and 84.5% in adolescence. Of the patients 86% were functional walkers at preschool age and 75.8% in adolescence. Downward transitions in seven patients were related to the presence of scoliosis, spasticity and obesity. All patients who were community walkers in adolescence maintained their function in adult life at the time of the review. We conclude that the procedure has value in obtaining hip stability and walking ability in carefully selected patients with myelomeningocele.

二分脊椎の不安定股に対する外腹斜筋移行術

We studied the results of external oblique muscle transfer for the lumbar spina bifida. We operated on 11 hips of 8 patients from 1994. The neurosegmental level of the patients were the first lumbar level with one patient, the third or fourth with five patients, and the fifth with five patients. Nine hips were subluxated and two hips were dislocated.External oblique muscle transfer is easier than iliopsoas transfer and does not weaken the flexor muscle compared with iliopsoas transfer.All the hips except two maintained concentric reduction after surgery in X-ray. Hip flexor power did not decrease and walking ability improved at the time of followup.

Clinical benefit of reconstruction of dislocated or subluxated hip joints in patients with spastic cerebral palsy.

Sixty-four dislocated hip joints in 47 patients with spastic cerebral palsy were reconstructed surgically for pain or physical impairment. The procedure included a femoral and pelvic osteotomy, an anterior iliopsoas transfer, and further soft-tissue surgery. The study was based on a research questionnaire (mean follow-up 6.8 years) and radiographs (3.0 years). Upon review of radiographs, it was discovered that three hips had redislocated and that 23 were insufficiently covered. Four complications (one deep infection, three femoral fractures) occurred. Pain was relieved fully in 28 of 37 patients and eased in 9 of 37. Weight-bearing improved sitting problems in 22 of 26 patients and enabled nine of 36 nonwalkers to take at least a few steps.

Long-Term Results of Combined Operative Reduction of the Hip in Older Children

Long-term results of open reduction, combined with femoral shortening, iliac osteotomy, reorientation of the upper femur, and medial iliopsoas transfer, are analyzed in 144 hips, according to patients' answers to follow-up questionnaires. Age at surgery ranged from 7 to 15 years with a follow-up of 9-24 years (mean 13 years). Two-thirds of patients had good results, one-fourth had fair results, and one-tenth had poor results. This was in accordance with radiologic rating in 225 hips, with a mean follow-up of 5 years. Quality of results decreased with age at surgery. The combined procedure is not advised after the appearance of pubertal signs. Since radiologic results favored Chiari's iliac osteotomy and subjective results favored the Pemberton type, individual choice is advised, according to the severity of acetabular dysplasia and the age of the patient. Redislocations, when left alone, had better results than did hips that were operated on again.

Paralytic hip instability in poliomyelitis.

A retrospective study was made of the results of surgical treatment of subluxation or dislocation of the hip in patients who had suffered from poliomyelitis. Good results were achieved in 46% and satisfactory results in 24%. The key factors for success are muscle balance, the femoral neck-shaft and anteversion angles, and the acetabular geometry. Iliopsoas transfer can augment the hip abductor power by an average of one MRC grade. Varus derotation femoral osteotomy is important to re-establish a normal neck-shaft angle and anteversion. The results of pelvic osteotomy are variable and the importance of a posterior acetabular defect is emphasised.

Ilio-psoas transfers in children with myelomeningocele: W.H. Bunch and W. Hakalam. J Bone Joint Surg 66A:24–227, (February), 1984

Ilio-psoas transfers in children with myelomeningocele: W.H. Bunch and W. Hakalam. J Bone Joint Surg 66A:24–227, (February), 1984

Iliopsoas transfers in children with myelomeningocele.

Thirty-two paralytic hips in seventeen children with myelomeningocele and a neural deficit at the fourth lumbar level were treated with iliopsoas transfers. Four to fourteen years later, all of the hips were reduced and nineteen had a center-edge angle of more than 25 degrees. This result was more consistent in the hips of the ten patients who had had a combined varus osteotomy and transfer. All but three of the transferred muscles were active: twenty-one had abduction and fifteen had extension against gravity. We concluded that the procedure has value, but that it does not produce a normal hip.

Iliopsoas transfer in the management of established dislocation and refractory progressive subluxation of the hip in cerebral palsy

The authors have reviewed 25 hips in 23 patients with cerebral palsy in which iliopsoas transfer had been performed for established dislocation or refractory progressive subluxation of the hip. The iliopsoas tendon was transferred either postero-laterally or antero-laterally, depending upon the degree of fixed flexion of the hip. An adductor release was performed in all cases and an open reduction when necessary. A painfree stable joint was produced except for one hip in which the iliopsoas tendon had become detached because of sepsis. The loss of flexor power at the hip due to the transfer is thought to be a small price to pay for the relief of pain and spasm and the increase in function.

POSTERIOR ILIOPSOAS TRANSFER: A TREATMENT FOR SOME MYELODYSPLASTIC HIPS

A retrospective study of our 16-year experience in utilizing posterior iliopsoas transfer as treatment for the neurogenic dislocated hip is presented. Fifty-four surgically treated hips are compared with 20 hips treated nonoperatively. Maintenance of location was achieved in 84% of the operated hips. All of the postoperative dislocations can be explained by failure of the surgeon to adhere to the essentials of tendon transfer.

Abstracts

Functional results of iliopsoas transfer in myelomeningocele hip dislocations by H. Sherk and M. AmesNeonatal hip instability by B. Almby, A. Hjelmstedt and T. LonnerholmLanguage differences between institutionalised and non‐institutionalised retarded children by J. C. McNutt and S. M. LeriDevelopment of visually directed reaching: the approach phase by Claes VON HofstenNeonatal convulsions: incidence and causes in the Stockholm area by M. Eriksson and R. Zetterstrom

Results of Posterior Iliopsoas Transfer for Hip Instability Caused by Cerebral Palsy

Results of Posterior Iliopsoas Transfer for Hip Instability Caused by Cerebral Palsy

Reply to Results of Posterior Iliopsoas Transfer for Hip Instability Caused by Cerebral Palsy

Associate Professor Division of Orthopedics Department of Surgery University of Kentucky Lexington, Kentucky 40506

Myelodysplasia. The influence of the quadriceps and hip abductor muscles on ambulatory function and stability of the hip.

In an analysis of motor function, ambulatory function, and hip stability in sixty-five patients with myelodysplasia, four motor-function groups based on the strength of the quadriceps and hip abductor muscles were identified. Retrospectively, it was evident that based on these groups, it would have been possible to predict which hips would remain stable, what level of ambulatory function the patients could achieve, and whether treatment to reduce and stabilize the hips was indicated. Fifty-seven of fifty-eight hips in the twenty-nine patients with functioning quadriceps muscles but non-functioning hip-abductor muscles were either subluxated or dislocated. Thirty-nine of the remaining forty-six patients with functioning quadriceps muscles could walk. In this series, three operative procedures were used to treat hip subluxation: varus osteotomy, varus osteotomy combined with iliopsoas transfer, and iliopsoas transfer alone. One shelf procedure was also done. Varus osteotomy was the best procedure for hip subluxation while posterior iliopsoas transfer, either alone or in combination with a varus osteotomy, was of questionable value. Treatment of hip instability (subluxation or dislocation) in patients without quadriceps function was not necessary.

The Adductor Transfer in the High-Risk Hip in Myelodysplasia

Hip instability occurs in meningomyelocele patients with lumbar level paralysis because of muscle imbalance. Transferring the hip adductor origins to the ischium can be used as the primary procedure to restore muscle balance and prevent hip instability in myelodysplasia patients if performed by the age of one year. Twelve lumbar meningomyelocele patients underwent bilateral adductor transfers. Secondary procedures, such as iliopsoas release or transfer or varus derotation osteotomy, were done in 14 hips. Ten hips needed no further surgery. Twenty of 24 hips were clinically and roentgenographically stable and showed roentgenographic evidence of improving hip development. Instability was associated with scoliosis, congenital dislocation, and age greater than one year at the time of the transfer.

Results of Posterior Iliopsoas Transfer for Hip Instability Caused by Cerebral Palsy

The incidence of subluxation or dislocation of the hip in 185 cerebral palsied patients was 25.4%. Posterior iliopsoas transfer will decrease hip deformities but complications such as weakness of hip flexion or abduction contracture are to be expected in some cases. Posterior iliopsoas transfer did not give uniformly satisfactory results; 9 out of 17 patients were fair to poor even combined with innominate osteotomy and/or versus derotation osteotomy of the femur. Early prophylactic surgery of lesser extent such as adductor release is desirable since treatment of established subluxation or dislocation is often unsatisfactory.

Reconstructive surgery in the myelomeningocele hip.

In 17 myelomeningocele patients with subluxating or dislocated hips, 31 posterolateral iliopsoas were treated by transfers, as described by Sharrard, in addition to complimentary procedures to balance muscle power and center the hip joint. Surgical goals are to stablize the hips within the acetabulum and prevent the occurrence of severe fixed flexion and adduction contractures of the hip and secondary lumbar lordosis. Surgery is performed at about 1 year of age with bilateral adductor transfer to the ischium, followed in 2 weeks by the posterolateral transfer of the iliopsoas muscle, first on one hip and 2 weeks later following with the other hip. Adductor transfer to the ischium reduces the adductor and secondary flexor power of the adductor longus and anterior fibers of the adductor brevis. After transfer it provides some extensor power. The range of abduction is increased. The transferred iliopsoas muscle has a better mechanical advantage in its new function as an abductor and extensor, and the hips were better centered radiographically than the cases with iliopsoas transfer alone. Fewer bony procedures were required to center the hips when the iliopsoas transfer was performed in children before the age of 1 1/2 years.

Paralytic dislocation of the hip in myelodysplasia. The role of the adductor transfer

In thirty-nine patients with myelodysplasia at the third, fourth, or fifth lumbar level and subluxation or dislocation of the hip (fifty-nine hips involved), the following surgical approaches were utilized to balance the muscles about the hip: In one group (twenty hips in eleven patients) the origins of the adductors longus, brevis, and gracilis were transferred to the ischial tuberosity, and in fifteen hips in that group the iliopsoas also was transferred to the greater trochanter when the abductors were severely weakened. In the second group (thirty-nine hips in twenty-eight patients), only the iliopsoas transfer was done. Group I patients demonstrated improved muscle balance with less severe flexion-adduction contractures; increased power in abduction and extension; and a higher incidence of stable hips at follow-up.

Proceedings: The treatment of myelomeningocele patients with paralytic hip deformities by iliopsoas transfer.

Patients with myelomeningocele pose many problems. Muscle imbalance about the hip described in this communication is only one. The correction of this imbalance by removing a deforming force and using the iliopsoas transfer to provide active abductor power and greater stability of the hip usually resulted in improved function and better gait.The problems of myelomeningocele are sometimes overwhelming and require proper facilities and specially trained personnel. It is a unique medical disorder and deformities of the hip must be treated as such. The application of principles learned for the treatments of other hip deformities do not apply.