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The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
The Hip Joint in Cerebral Palsy | David S. Feldman, MD
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The Hip Joint in Cerebral Palsy | David S. Feldman, MD

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The effects of cerebral palsy and scoliosis on the hip.

The effects of cerebral palsy and scoliosis on the hip.

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  • 1. HOSPITAL FOR JOINT DISEASES THE HIP JOINT IN CEREBRAL PALSY David S. Feldman, MD Professor of Orthopedic Surgery and Pediatrics Chief, Pediatric Orthopedic Surgery NYU/Hospital for Joint Diseases Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 2. Define the Problem (This review is meant to aid in knowledge but is no way is intended to be a thorough and comprehensive analysis of each topic) Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 3. Why The Hip?? •Hip is particularly sensitive to muscle imbalance. •Large number of large muscles crossing the joint. •Psoas •Adductors •Rectus •Hamstrings •ITB •G max/med/min •Short Ext Rotators Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 4. Cerebral Palsy •Children with CP develop hip subluxation •80% of Patients with Spastic Quadraplegia develop hip subluxation •Spastic Diplegia and hemiplegia is associated with Acetabular Dysplasia •Excessive Femoral Antetversion is common. This often causes the ambulating child to walk with his or her turned in excessively. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 5. Progressive Hip Subluxation •Often Painful •Leads to assymetry and pelvic obliquity •Dislocated hips become contracted •Wind Swept Deformity •Sitting imbalance Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 6. HIP DYSPLASIA (Acetabular Rim Syndrome) Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 7. Evaluation •Contracture versus spasticity (R1 and R2)? •Is there antagonist spasticity? •Is there a dystonic or an athetoid component? •Age of the patient and growth potential. •Is there dynamic tone? •Is there a contracture/spasticity a joint above or below the joint you are dealing with? •Is the joint subluxated, dislocated or at risk? Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 8. Evaluation •Is there pain? •When, where and with which activities? • Groin, thigh and buttock pain and prolonged sitting or standing. •Is there a limp? • Trendelenburg •Is the problem femoral, acetabular, both or neither? • I.e. Anteversion or Retroversion •Is there joint congruency? • If loss of congruity then type of surgery will change. •Does the Joint Reduce on the abduction-internal rotation view (Van Rosen)? • Reducible hip is needed for Osteotomy Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 9. Evaluation •PE – How much Flexion/ Extension of the hip? Abduction/adduction? Pain with IR? Gait abnormalities? ROM? LLD? •X-ray- AP Pelvis, Judet (false profile view), Van Rosen •CT scan for femoral anteversion and acetabular anatomy Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 10. What is femoral anteversion? Internal rotation of the femur •Children are born with 2530 degrees of femoral anteversion •Resolves to 10-15 degrees by age 8 •CP –Increasing or nonresolved femoral anteversion Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 11. 1 yo female - Left dislocated hip, Right subluxated hip Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 12. After open reduction - 3 yo Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 13. Age 14 Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 14. Age 16 - s/p L VDO Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 15. Age 16 – s/p R VDO Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 16. Age 28 Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 17. Age 43 Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 18. Age 43 Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 19. Age 43 s/p THR Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 20. Goals •SYMMETRY • Agonist and antagonist complimentary function • Protect joint • Minimal or no immobilization • NO SPICA CASTS ON CHILDREN WITH CP • The spasticity does not tolerate casting • Early return to standing and ambulation • Minimize strength loss Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 21. GOALS •Stable Reduced Joint •Reduced Joint Contact Pressures •Painless Joint •Functional Range of Motion •Decrease incidence of advanced OA Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 22. Working Together for Ambulation and Function •Physical/Occupational Therapist •Geneticist •Pediatrician •Developmental Pediatrician •Pediatric Neurologist •Pediatric Physiatrist •Pediatric Neurosurgeon •Pediatric Urologist •Pediatric Orthopedic Surgeon •Pediatric Social Worker Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 23. Still More •Pediatric Psychologist •Nurse •Orthotist •Special Education Teacher •Pediatric Speech Therapist •Pediatric Nurse Specialist •Parent or Caregiver “SPARE THE PATIENT FROM TAKING PART IN INTERPROFESSIONAL GAMES” Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 24. Choices •Botox/PT •Tenotomies •NSAID and/or Chondroitin/Glucosamine •Intra-articular Steroid injection •Hip Arthroscopy •Femoral osteotomy/Acetbular Osteotomy •Trochanteric Advancement •Total Hip Replacement Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 25. 1 Yo Spastic Diplegic in 1999 Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 26. 1999 2000 2003 2005 Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 27. 2006 Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 28. Surgical Options •Percutaneous tendon releases (lengthening) •Open tendon lengthening •Muscle Recession •Tendon Transfer Complete vs. Split •Rhizotomy •Baclofen pump •Osteotomy •Hip Reduction •Bone/joint Resection •Scoliosis Surgery Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 29. Which Procedure for Whom? •Rhizotomy- Less than age 6, SPASTIC DIPLEGIA. Good trunk control. NO DYSTONIA. Orthopedic Surgery afterwards if there is contracture. •Baclofen Pump – When Spasticity is the main issue. Can treat dystonic component with high dosage. Will impair trunk stability if patient has truncal hypotonia. May increase scoliosis. May improve speec. May increase drooling. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 30. Types of Releases/Transfers •Percutaneous tenotomies- PERCS •Percutaneous lengthenings -PERCS •Open lengthening •Open intramuscular recession •Complete Transfer in Phase •Complete Transfer out of Phase •Split Transfer •Muscle Slide Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 31. Hip Soft Tissue Contractures •Hip Flexion - Psoas, Rectus and sartorius •Hip Extension – Gluteus Maximus •Adduction – Adductors and Medial Hamstring •Abduction - ITB and Gluteus Medius •Internal Rotation – Gluteus Medius and Medial Hamstring •External Rotation – Short External Rotators, and Gluteus Maximus Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 32. Hip Contracture Solutions •Hip Flexion – Psoas (Psoas Recession) •Hip Extension – Gluteus Maximus (Osteotomy) •Adduction – Adductors (Percutaneous tenotomy) •Abduction - ITB (Percutaneous tenotomy) •Internal Rotation – Gluteus Medius (Anterior Trochanteric Transfer) •External Rotation – Short External Rotators (Osteotomy) Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 33. Knee Contractures •Flexion – Medial and Lateral Hamstrings •Extension – Rectus Femoris and Vastus lateralis •Hadley et al. JPO 1992 •Abel et al JPO 1999 Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 34. Knee Contracture Solutions • Flexion – Medial and Lateral Hamstrings (Pecutaneous/Open Hamstring lengthening, tenotomies and possible osteotomy) • Extension – Rectus Femoris (Rectus transfer or possible proximal release) Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 35. SYMMETRY •Range of motion •Neck Shaft Angle •Limb length •Femoral Anteversion •Tibial rotation Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 36. Management of Acetabular Dysplasia
  • 37. Pelvic Osteotomies •Salter Ostetomy - Below age 8, 15-20 degrees of Antero-lateral coverage •Pemberton/Dega- Used for a voluminous acetabulum, The tri-radiate cartilage must be open •Tonnis/Steel/Sutherland Osteotomy- Triple Ostetomies with varying degrees of freedom, ages 6 to adulthood. •Ganz/Dial Osteotomy- Marked ability to move acetabulum, Triradiate closure to adulthood •Chiari/Shelf- Incongruous hip coverage, Salvage, metaplasia Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 38. 14 yo with Spastic Diplegia •Subluxated Left hip •Dysplastic Acetabulum Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 39. Arthrogram Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 40. 4 yo with spastic Diplegia Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 41. Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 42. DO NOT IMMOBILIZE THE HIP AND KNEE Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 43. Periacetabular Osteotomy (PAO) •Bern Periacetabular Osteotomy •Described in CORR in 1988 by Reinhold Ganz •Periacetabular Osteotomy that leaves the posterior column intact •Allows for medialization of the hip----Biomechanically Advantageous •Allows for immediate weight bearing •Need a Congruous and Reducible Hip Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 44. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 45. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 46. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 47. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 48. Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 49. Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 50. Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 51. Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 52. Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 53. 16 yo with Spastic Diplegia Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 54. Commonly Asked Questions Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 55. What Age Does One Go form Botox or Soft Tissue Peocedures to Osteotomies? Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 56. ANSWER •Historically age 6-8 •If there are boney changes, i.e flattening or misshapen femoral head then age is irrelevant. •Often early Botox and/or Percs may prevent the need for boney surgery Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 57. HIP DISLOCATION SHOULD WE PREVENT? YES SHOULD WE REDUCE/ Resect? IF PAINFUL Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 58. 5 yo Spastic Quadraplegia Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 59. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 60. Surgical and 18 month f/u Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 61. 14 yo Spastic Quadrplegia Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 62. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 63. Etiology (CAUSE) of Internal Rotation Gait?? Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 64. Internal Rotation Gait •Medial Hamstring •Adductors •Gluteus Medius Spasticity •Femoral Anteversion •? Capsular tightness/hip anatomy Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 65. IS SURGERY ALWAYS BILATERAL?? Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 66. Answer Always achieve Symmetry. Different sides may require different procedures . Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 67. 9 yo boy with Spastic Diplegia Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 68. May a Child with Hip Subluxation: Bear Weight? Be in a Stander? Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 69. YES There are no special precautions needed for these children aside from avoiding painful positioning Hospital for Joint Diseases ● Department of Orthopaedic Surgery
  • 70. DYSTONIA and the Subluxed Hip?? Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 71. Unanswered Question ??S.L.O.B. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 72. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 73. Lever Arm Disease?? •What is it? •Prevention?? •Treatment?? Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 74. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 75. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 76. •Lever arm disease is the adolescent with calcaneus feet, knee flexion contractures, hip flexion contractures and lumbar lordosis. •Should we stop doing heel cord lengthenings in diplegics and use extensive serial casting? •Definitely DO NOT OVER LENGTHEN THE HEEL CORD!!!!!!!! •Treat before patella alta occurs. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 77. Lever Arm Disease •Most likely Osteotomies unless caught very early is the only solution. •Hip and knee extension osteotomies. •Patella tendon imbrication. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 78. SCOLIOSIS and the HIP Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 79. SCOLIOSIS IN CEREBRAL PALSY SURGICAL INDICATIONS: Progressive deformity Sitting imbalance Pelvic obliquity Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 80. Cerebral Palsy Scoliosis Spastic quadriplegia highest risk Custom seats Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 81. SCOLIOSIS IN CEREBRAL PALSY •SURGICAL MANAGEMENT ASF/PSF vs. PSF •only Segmental fixation •Fuse to the pelvis (Galveston) Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 82. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 83. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 84. Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 85. ROM of the HIP •Particularly important if the the Spine is being fused to the pelvis •Be especially cognizant of lack of true flexion of the hip Hospital for Joint Diseases Department of Orthopaedic Surgery ●
  • 86. DO NOT!!!!!! •Lengthen a muscle without addressing the antagonist •Miss the dynamic, dystonic or athetoid component •Miss a joint subluxation or dislocation •Miss the opportunity to correct a problem before secondary changes occur. •Over lengthen heel cords or hamstrings •Create assymetry •Immobilze the knee and hip of a child with CP for a prolonged period Hospital for Joint Diseases Department of Orthopaedic Surgery ●

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