rev bras ortop.2016;51(3):329–332
SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
Hip
dislocation
in
cerebral
palsy:
evolution
of
the
contralateral
side
after
reconstructive
surgery
夽
João
Caetano
Munhoz
Abdo
∗,
Edilson
Forlin
HospitalPequenoPríncipe,Curitiba,PR,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received7June2015
Accepted10July2015
Availableonline3May2016
Keywords:
Hipdislocation/etiology
Hipdislocation/pathology
Hipdislocation/surgery
Cerebralpalsy
Treatmentoutcome
a
b
s
t
r
a
c
t
Objective:Toevaluatetheprogressionofthecontralateralhipafterunilateralreconstruction
ofhipdislocationinpatientsclassifiedasGMFCSIV–V;andtoidentifypotentialprognostic
factorsfortheirevolution.
Methods:Thiswasaretrospectivestudyon17patientswithspasticcerebralpalsy,whowere
classifiedontheGMFCSscale(GrossMotorFunctionalClassificationSystem)asdegreesIV
andV,andwhounderwentunilateralreconstructionsurgerytotreathipdislocation
(adduc-torrelease,femoralvarusosteotomyandacetabuloplasty).Theminimumpostoperative
follow-upwas30months.Theclinicalparametersevaluatedweresex,ageattimeofsurgery,
lengthoffollow-upaftersurgeryandrangeofabduction.Thetreatmentparameterswere
use/nonuseoffemoralshortening,applicationofbotulinumtoxinandanypreviousmuscle
releases.TheradiographicparameterswereReimer’sextrusionindex(REI),acetabularangle
(AA)andthecontinuityofShenton’sline.
Results:Amongthe17patientsevaluated,eightpresenteddislocation(groupI)andnine
didnot(groupII).GroupIcomprisedthreemalesandfivefemales;groupIIcomprisedone
maleandeightfemales.ThemeanageatthetimeofsurgeryamongthegroupIpatients
was62monthsandthemeanfollow-upwas62months.IngroupII,thesewere98and83
months,respectively.Therewasatrendinwhichpatientsofgreateragedidnotevolve
withcontralateraldislocation.AmongtheninepatientswiththecombinationofREI<30%
andAA<25◦,onlyonepresenteddislocationduringthefollow-up.Contralateralsubluxation
occurredwithinthefirsttwoyearsafterthesurgery.
Conclusion: HipspresentingREI<30◦andAA<25◦donottendtoevolvetosubluxationand
canbekeptunderobservation.Preoperativeclinicalandradiographicmeasurementsalone
arenotusefulforindicatingthenaturalevolutionofnon-operatedhips.Thecriticalperiod
forsubluxationisthefirsttwoyearsaftersurgery.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
夽
StudyconductedattheDepartmentofOrthopedyandTraumatology,HospitalPequenoPríncipe,Curitiba,PR,Brazil.
∗ Correspondingauthor.
E-mail:joaocaetanoabdo@icloud.com(J.C.M.Abdo).
http://dx.doi.org/10.1016/j.rboe.2015.07.012
2255-4971/©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle
330
rev bras ortop.2 0 1 6;51(3):329–332Luxac¸ão
do
quadril
na
paralisia
cerebral:
a
evoluc¸ão
do
lado
contralateral
após
cirurgia
reconstrutiva
Palavras-chave:
Luxac¸ãodoquadril/etiologia
Luxac¸ãodoquadril/patologia
Luxac¸ãodoquadril/cirurgia
Paralisiacerebral
Resultadodotratamento
r
e
s
u
m
o
Objetivo: Avaliaraevoluc¸ãodoquadrilcontralateral apósa reconstruc¸ãounilateral de
luxac¸ãodequadrilem pacientesclassificadoscomo GMFCSIV-Ve identificarpossíveis
fatoresprognósticosdaevoluc¸ão.
Métodos: Estudoretrospectivode17pacientesportadoresdeparalisiacerebralespástica,
classificadospelaescalaGMFCS(GrossMotorFunctionalClassificationSystem)emgraus
IVeV,submetidosacirurgiadereconstruc¸ãounilateraldeluxac¸ãodequadril(liberac¸ãode
adutores,osteotomiavarizantefemoraleacetabuloplastia).Oseguimentopós-operatório
mínimofoide30meses.Foramavaliadosparâmetrosclínicos(sexo,idadenaocasiãodo
procedimentocirúrgico,tempodeseguimentoapósacirurgiaeamplitudedeabduc¸ão),de
tratamento(afeituraounãodeencurtamentofemoral,aplicac¸ãodetoxinabotulínicaese
houveprocedimentosmuscularesprévios)eradiográficos(índicedeextrusãodeReimers
[IR],ânguloacetabular[AC]econtinuidadedoarcodeShenton[AS]).
Resultados: Dos17pacientesavaliados,oitodeslocaram(grupoI)enovenão(grupoII).O
grupoIcontavacomtrêspacientesdosexomasculinoecincodofeminino;grupoII
apre-sentouumpacientedosexomasculinoeoitodofeminino.Amédiadeidadenomomento
dacirurgiadospacientesdogrupoIfoide62meseseotempodeseguimentomédiofoide62
meses.NogrupoIIforamde98e83meses,respectivamente.Houvetendênciadospacientes
operadoscommaioridadenãoevoluíremcomluxac¸ãocontralateral.Dosnovepacientes
queapresentavamacombinac¸ãodeIR<30%eAC<25◦,apenasumapresentouluxac¸ãono
seguimento.Asubluxac¸ãocontralateralocorrenosdoisprimeirosanosdepós-operatório.
Conclusão: Quadris queapresentamum IR<30◦ e AC<25◦ nãotendem a evoluir para
subluxac¸ãoepodemsermantidosemobservac¸ão.Medidasclínicaseradiográficasisoladas
nopré-operatórionãoforamúteisparaindicaraevoluc¸ãonaturaldoquadrilnãooperado.
Operíodocríticoparasubluxac¸ãosãoosdoisprimeirosanosdopós-operatório.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Hipdislocation or subluxation in non-ambulatorypatients
withspastic cerebral palsy can leadto pain, difficulties to
performperineal hygiene,pressure ulcers,lower limb
frac-tures, and loss of balance to sit, especially in unilateral
orasymmetriccases.1,2 Preventionand earlytreatmentare
recommended.2,3Incasesofsubluxation/dislocation,
recons-tructive surgery is indicated, usuallyconsisting of femoral
varus osteotomy, withor without acetabuloplasty and soft
tissuerelease.4–6
Inunilateraldislocations, thereiscontroversy regarding
treatment for the contralateral hip. Some studies indicate
bilateralreconstructionduetotheriskofprogressionto
sub-luxationandtheasymmetrythatmayresultfromunilateral
reconstruction.7Conversely,performingsurgeryinanormal
hipincreasestheoperativetimeandbleeding,andmaylead
tocomplications.8
This study aimed to assess the evolution of the
con-tralateralhipafterunilateralreconstructiveprocedure with
varusosteotomyoftheproximalfemurandDegatransiliac
osteotomy(withorwithoutthereleaseofsofttissue)andthe
possiblefactorsassociatedwiththedevelopment(ornot)of
subluxation.
Material
and
methods
Thiswasaretrospectivestudybasedontheanalysisofcharts
ofnon-ambulatorypatientswithspasticcerebralpalsyand
functionallyclassifiedbytheGrossMotorFunctional
Classifi-cationSystem(GMFCS)aslevelsIVandV.Patientsunderwent
unilateral hip reconstruction surgerydue to dislocation or
subluxationinthishospital,from March1999toApril2009.
TheisstudywasapprovedbytheResearchEthicsCommittee
ofthisdepartment.
For inclusion in the study, patients with cerebral palsy
needed to have undergone unilateral hip reconstruction
surgery (varus osteotomy of the femur, Dega transiliac
osteotomywithorwithoutsofttissuerelease),and present
a minimum follow-up period of 30 months and clinical
andradiographicdocumentationtoenableanalysisinthree
time-points:atthetimeofsurgery(immediatepre-and
post-operativeperiods),approximatelytwoyearsaftersurgery,and
atlastfollow-upvisit.
Clinicalparametersevaluatedwere:sex,previoussurgery
or botulinum toxin application, age at surgery, follow-up
time aftersurgery,and abductionatthe threetime-points.
Regarding the procedure, it was assessedwhether femoral
rev bras ortop.2 0 1 6;51(3):329–332
331
Radiographic evaluation was done on the anteroposterior
pelvicincidenceandconsistedoffemoralheadmigration
per-centage(Reimer’sextrusionindex[RI]),acetabularangle(AC),
andShenton’sline(SL)continuity.
Toevaluatetheassociatedfactors,patientsweredivided
intotwogroups:thosewhoshowedprogressionoftheRIin
thecontralateralhip(groupI),andthosewhodidnotpresent
suchprogression(groupII).Progressionwasconsideredwhen
RIwas40%inthelastfollow-up.
Statistical analysis was performed with tests selected
basedonthetypeofvariablestudied.
Results
Seventeenpatientsmettheinclusioncriteria.Eightevolved
withcontralateralhipsubluxation(groupI),whilenine did
not(groupII).
GroupIhadthreemalesandfivefemales;groupIIhadone
maleandeightfemales(non-significantdifference).
ThemeanageattimeofsurgeryingroupIwas62months
(28–110)andmeanfollow-up timewas62 months(31–125).
GroupIIhadmeanageattimeofsurgeryof98months(64–159)
andmeanfollow-uptimeof83months(32–150).These
differ-enceswerenotsignificant.
Regardinginterventionspriortothereconstructive
proce-dure,threepatientsfromgroupIandtwofromgroupIIhad
alreadyundergonebotulinumtoxinapplicationinadductor
and/or flexor muscles. Previous soft tissue release surgery
wasobservedintwo(25%)patientsfromgroupIandinfour
(44%)fromgroupII.Femoralshorteningduringreconstructive
procedurewasperformedinfive(63%)patientsfromgroupI
andinseven(78%)fromgroupII.Thesedifferenceswerenot
significant.
Intheimmediatepostoperativeperiod,50%(4/8)ofthe
X-raysfromgroupIshowedSLdiscontinuity;inturn,thisfinding
wasobservedin33%ofcasesingroupII(non-significant
dif-ference).Inthesecondevaluation(twoyearsaftersurgery),
SLdiscontinuitywasobservedin100%(8/8)ofpatientsfrom
groupIandin22%(2/9)ofthosefromgroupII.Thisdifference
wasstatisticallysignificant.
Mean abduction in group I was 28◦ in the immediate
preoperativeperiod,36◦intheassessmentattwoyears
post-operative,and24◦ onthelastvisit.IngroupII,thesevalues
were27◦,36◦,and34◦,respectively.Therewasnostatistical
differencebetweengroups.
MeanAC in group I was 23◦, 26◦, and 29◦ atthe three
abovementionedperiods.GroupIIshowed18◦,15◦,and17◦,
respectively.Thesedifferenceswerenotsignificant.RIinthe
immediatepostoperativeperiod,twoyearsaftersurgery,and
atthelastvisitwas34%,68%,and84%,respectively,ingroup
I;itwas20%,17%,and13%ingroupII.Thedifferenceinthe
lasttwoevaluationswassignificant.Combiningthedatafrom
RIandAC,weobservedthat,outofninehipsthatpresented
RI<30andAC<25intheimmediatepostoperativeperiod,only
oneevolvedtocontralateralsubluxation(p<0.05).
Discussion
Hipsubluxation or dislocation in non-ambulatorypatients
withspasticcerebralmaycausepain,difficultyinpositioning
and hygiene, and contribute to thedevelopment of
scolio-sis and contractures in the lower limbs.9 Therefore, when
diagnosed in skeletally immaturepatients, surgical
recon-struction is indicated. In this institution, the adductor
muscles are released (and usually, the iliopsoas muscles),
and femoral varus osteotomy and Dega acetabuloplasty
are performed.4–6 When unilateral, some authors
recom-mend soft tissue procedure and varus osteotomy in the
contralateral hip. Thisindication would bejustifiedby the
increased risk of subluxation and the possible
asymme-try as a result of the unilateral procedure, which would
causedifficultiesinpositioningandwouldchangethespinal
alignment.7
The riskofimpairment ofthe contralateral side ranges
from4%to75%.Noonanetal.7studied35patients,33
non-ambulatory,who underwentunilateralsurgery.Ofthese,26
(74.3%)developedsubluxation.Theyrecommendedthatthe
procedureshouldbeperformedbilaterally,especiallyifsome
degreeofacetabulardysplasiaisobserved.Despitebelieving
thatthebilateralboneprocedureisjustified,CarrandGage10
found only 20% ofprogression tosubluxation. Park et al.8
developedadecisionanalysismodelwithdatafromthe
liter-atureandconcludedthatthebilateralprocedurehassuperior
outcomes.
In thepresent study,approximately halfofthe patients
developedcontralateralsubluxation.Theauthorsunderstand
that this finding does not make a prophylactic procedure
mandatoryforall patients, asitisa majorprocedurewith
somerisks.Thisstudyalsoaimedtoidentifyfactors
associ-atedwiththeoccurrence(ornot)ofcontralateralsubluxation.
Aship dislocationisknown tobeassociatedwithpatients
withmoresevereimpairment,thisstudyonlyincluded
non-ambulatorypatients(GMFCSIVorV).11,12
Surgery in younger patients may be associated
with increased risk for development of contralateral
subluxation.9,12 Although no significant associations were
observed, there was a tendency for hip contralateral
sub-luxationinoperatedpatientsunder8yearsofage(62;±25
months).
Individually,noneofthemeasures–eitherclinicalor
radio-logical,intheimmediatepre-andpost-operativeperiods–was
abletoindicatetheevolutionofthecontralateralhipinthe
presentstudy.Themostsignificantfindingwasthathipsthat
showedRI<30%associatedwithAC<25◦hadlower
probabil-ityoffuturedislocation.Thisfindingsomewhatcorroborates
thosebyNoonanetal.,whoobservedthathipswithdysplastic
changeswereathigherriskforsubluxation.7
An important factor is that the hips that developed
subluxation presented it within the first two years of the
procedure.Therefore,thecontralateralhipshouldbeclosely
monitoredinthispostoperativeperiodincaseofunilateral
surgery.
The present study had some limitations.In addition to
theretrospectivedesign,themeanfollow-upperiodwas73
months, and not all patients had reached skeletal
matu-rity at the last assessment. The multitude of surgeons
who performedthese proceduresover the tenyears ofthe
study mayhaveaffectedtheresults.Thesmallsamplesize
alsodecreasesthestatisticalstrength ofthevariousfactors
332
rev bras ortop.2 0 1 6;51(3):329–332Conclusion
The study suggests that prophylactic surgery in the
con-tralateral hip is not justified for all patients, especially
in those older than 8 years of age with RI<30% and
AC<25◦. Contralateral subluxation occurs in the first two
postoperative years; parents should be advised about this
risk, and patients should beclosely monitored duringthis
time.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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