International Orthopaedics (SICOT) (2009) 33:503–508
DOI 10.1007/s00264-007-0462-2
ORIGINAL PAPER
A radiographic and clinical comparison of two soft-tissue
procedures for paralytic subluxation of the hip
in cerebral palsy
Goran Čobeljić & Zoran Bajin & Aleksandar Lešić &
Slavko Tomić & Marko Bumbaširević &
Henry Dushan E. Atkinson
Received: 8 July 2007 / Revised: 9 August 2007 / Accepted: 9 August 2007 / Published online: 26 September 2007
# Springer-Verlag 2007
Abstract This article summarises a comparative retrospec- with 96.8% good/average results. Long-term hip reduction
tive study (1983–2001) of 42 consecutive spastic–diplegic was achieved in 84.6% of group A and 80.6% of group B
ambulatory patients (aged 2–10 years) by examining the hips. Relative MP correction was superior in group B. No
radiographic and clinical results of two soft-tissue proce- patient had MP progression in either the PSH or non-PSH hip.
dures for paralytic hip subluxation (PSH). Group A com- Walking ability improved in 55% of group A and 86% of
prised 20 patients (26 PSHs) who were treated by iliopsoas group B patients (Functional Mobility Scale). In conclusion,
tenotomy, and group B comprised 22 patients (31 PSHs) we recommend release of all the principle hip flexors: rectus
who were treated by rectus femoris and iliopsoas tenotomy femoris, sartorius, and iliopsoas, coupled with adductor teno-
with iliac crest resection (sartorius release). All patients had tomies, in this patient group.
bilateral adductor tenotomies. At 8.8 years mean follow-up,
group A migration percentages (MP) improved from 39.8% to Résumé Une comparative rétrospective de 42 patients diplé-
24.7% with 92.3% good/average results. At a mean follow-up giques spatiques mais ambulatoirs âgés de 2 à 10 ans a été
period of 8.3 years, group B improved from 58.0% to 25.9% réalisée entre 1983 et 2001 avec évaluation des résultats. Deux
techniques de libération tissulaire étant pratiquées devant
l’existence d’une sub-luxation paralytique de la hanche. Le
No competing interests or funding declared in connection groupe A (20 patients, 26 hanches PSHs) ont été traités par
with this study. ténotomie de l’iliopsoas, dans le groupe B 22 patients, 31
G. Čobeljić : Z. Bajin : S. Tomić PSHs ont été traités par ténotomie du droit antérieur, de
Institute for Orthopaedic Surgery “Banjica”, l’iliopsoas avec résection de la crête iliaque libérant le sar-
Belgrade University School of Medicine,
Mihajla Avramovica 28,
torius. Tous les patients ont bénéficié également d’une
Belgrade 11000, Serbia ténotomie bilatérale des adducteurs. À 8,8 ans de suivi, dans
le groupe A, le pourcentage de migration de la tête MP est
A. Lešić : M. Bumbaširević amélioré de 39,8% à 24,7% avec 92,3% de bons résultats en
Institute for Orthopaedic Surgery and Traumatology,
Clinical Center of Serbia,
moyenne alors que dans le groupe B, à 8,3 ans la sub-luxation
Belgrade 11000, Serbia est améliorée de 58,0% à 25,9% avec 96,8% de bons résultats.
La réduction de la hanche est obtenue dans 84,6% des cas du
H. D. E. Atkinson groupe A et 80,6% des cas du groupe B. La correction de la
Department of Orthopaedics,
Royal National Orthopaedic Hospital,
migration de la tête est supérieure dans le groupe B, aucun
Brockley Hill, patient n’a vu sa migration augmenter. La marche a été
Stanmore HA7 4LP, UK améliorée de 55% dans le groupe A, à 86% dans le groupe B.
Nous recommandons la libération de tous les muscles
H. D. E. Atkinson (*)
9 Sutcliffe Close,
fléchisseurs de la hanche: droit antérieur, sartorius, iliopsoas
London NW11 6NT, UK en association avec une ténotomie des adducteurs chez ce type
e-mail: de patients.
, 504 International Orthopaedics (SICOT) (2009) 33:503–508
Introduction spastic diplegia preoperatively. Mean age at the time of the
surgery was 6.65 years (range 3–10 years). Mean postoper-
Paralytic subluxation of the hip (PSH) occurs in patients ative follow-up was 8.8 years (range 3–16 years). Group A
with cerebral palsy (CP) because of a muscle imbalance patients underwent iliopsoas tenotomies of the subluxed hip
between the stronger hip flexors and adductors and the in addition to bilateral hip adductor tenotomies (adductor
weaker hip extensors and abductors. This imbalance causes longus and gracilis). Two patients also underwent medial
joint contractures which then lead to migration of the hamstring elongation (of gracilis, semitendinosus, semi-
femoral head out of the acetabulum, subsequently causing membranosus) following the iliopsoas tenotomies; four pa-
impairment to mobility, pelvic obliquity, and scoliosis [7]. tients required triceps surae elongation prior to iliopsoas
The contribution of other factors to the development of tenotomies (three on the ipsilateral hip, and one bilateral hip)
PSH, such as a valgus femoral neck, increased femoral neck and one patient following iliopsoas tenotomy.
anteversion, pelvic obliquity and scoliosis, remains uncer- Group B comprised 22 CP patients: 9 female and 13 male
tain; some authors emphasise these factors, while others with 31 operated PSH hips. Nine patients had both hips
question their significance [4, 5, 7, 10, 17]. operated synchronously. All patients were ambulatory with
There is however a general consensus that soft tissue spastic diplegia preoperatively. Mean age at the time of the
surgery should be performed in treating PSH in CP patients surgery was 5.6 years (range 2–8 years). Mean follow-up
[3, 12]; however, success rates vary. The aim of surgery is was 8.3 years (range 4–18 years). Group B patients under-
to regain a more normal muscle balance, reduce the sub- went rectus femoris tenotomy and iliac crest resection [8] in
luxed hip joint, and prevent recurrence of PSH. This paper addition to iliopsoas tenotomy and bilateral hip adductor
compares the radiographic and clinical results of a standard tenotomy. No other procedures were performed either before
soft tissue procedure for PSH in CP patients to that of a or after the hip surgery.
new and more extensive technique. All patients had pre- and postoperative assessments (at
final follow-up) of their walking abilities which were clas-
sified according to the Functional Mobility Scale (FMS)
Patients and methods [6], in preference to the Gross Motor Function Classifica-
tion System (GMFCS) [13]. The FMS is a performance
This is a comparative retrospective study of 57 hips in 42 measure that classifies mobility according to the need for
consecutive patients with cerebral palsy and PSH who were assistive devices over the distances 5.50 and 500 metres
operated at the Institute for Orthopaedic Surgery "Banjica" (chosen to represent mobility in the home, at school, and in
in Belgrade, Serbia between 1983 and 2001. All patients the wider community).
met inclusion criteria of being able to walk independently During the operation patients were positioned in a lateral
with or without support, being aged between 2 and 10 years position (lying on the nonoperative side). The anterior
at the time of surgery, and with spastic diplegia and para- iliofemoral approach to the hip was used in all patients.
lytic subluxation of one or both hips. Iliopsoas tenotomy was made approximately 3 cm proximal
Subluxed hips were defined as having a Reimers migra- to the lesser trochanter insertion (at the point where the
tion percentage (MP) of greater than 33% [16]. We chose tendon was surrounded by the muscle belly); intramuscular
Reimers MP (which represents the percentage of the sub- tenotomy was performed with the purpose of also weakening
luxed femoral head uncovered by the acetabulum) to be our the iliopsoas muscle. Those patients undergoing rectus
radiological criterion because it is a widely accepted param- femoris tenotomy had release of both the straight and
eter in the assessment of PSH in CP patients [2, 21]. In reflected heads of the muscle. Iliac crest resection was made
addition, CP patients are often difficult to control during 2 cm below the anterior–superior iliac spine and continued
radiographic imaging, and hip rotation during imaging does posteriorly and superiorly to the junction of the middle and
not influence the final MP value, unlike other radiographic posterior thirds of the iliac crest. The iliac apophyses were
parameters [16]. The medical records and radiographs of then closed without tension, with the hips in a fully extended
these 42 patients were reviewed retrospectively. MP values position [8], thus releasing sartorius.
for each patient were determined by two independent ortho- Postoperatively, patients had both legs placed on skin
paedic surgeons not affiliated to the unit, who were blinded traction for 3 weeks. Three patients in each group were also
to the performed procedures. The selected patients were administered 2 mg of oral Tizanidine (Zanaflex, Elan Phar-
then subdivided into two groups according to the surgical maceuticals, USA) daily, to prevent spasticity during trac-
procedures performed. tion. The legs were positioned in abduction of 10–20° with
Group A comprised 20 CP patients: 12 female and 8 male 1–2.5 kg of weight on each limb. Traction was followed by
with 26 operated PSH hips. Six patients had both hips a rehabilitation programme with an emphasis on vertical
operated synchronously. All patients were ambulatory with stance and weight bearing on the operated leg.
DOI 10.1007/s00264-007-0462-2
ORIGINAL PAPER
A radiographic and clinical comparison of two soft-tissue
procedures for paralytic subluxation of the hip
in cerebral palsy
Goran Čobeljić & Zoran Bajin & Aleksandar Lešić &
Slavko Tomić & Marko Bumbaširević &
Henry Dushan E. Atkinson
Received: 8 July 2007 / Revised: 9 August 2007 / Accepted: 9 August 2007 / Published online: 26 September 2007
# Springer-Verlag 2007
Abstract This article summarises a comparative retrospec- with 96.8% good/average results. Long-term hip reduction
tive study (1983–2001) of 42 consecutive spastic–diplegic was achieved in 84.6% of group A and 80.6% of group B
ambulatory patients (aged 2–10 years) by examining the hips. Relative MP correction was superior in group B. No
radiographic and clinical results of two soft-tissue proce- patient had MP progression in either the PSH or non-PSH hip.
dures for paralytic hip subluxation (PSH). Group A com- Walking ability improved in 55% of group A and 86% of
prised 20 patients (26 PSHs) who were treated by iliopsoas group B patients (Functional Mobility Scale). In conclusion,
tenotomy, and group B comprised 22 patients (31 PSHs) we recommend release of all the principle hip flexors: rectus
who were treated by rectus femoris and iliopsoas tenotomy femoris, sartorius, and iliopsoas, coupled with adductor teno-
with iliac crest resection (sartorius release). All patients had tomies, in this patient group.
bilateral adductor tenotomies. At 8.8 years mean follow-up,
group A migration percentages (MP) improved from 39.8% to Résumé Une comparative rétrospective de 42 patients diplé-
24.7% with 92.3% good/average results. At a mean follow-up giques spatiques mais ambulatoirs âgés de 2 à 10 ans a été
period of 8.3 years, group B improved from 58.0% to 25.9% réalisée entre 1983 et 2001 avec évaluation des résultats. Deux
techniques de libération tissulaire étant pratiquées devant
l’existence d’une sub-luxation paralytique de la hanche. Le
No competing interests or funding declared in connection groupe A (20 patients, 26 hanches PSHs) ont été traités par
with this study. ténotomie de l’iliopsoas, dans le groupe B 22 patients, 31
G. Čobeljić : Z. Bajin : S. Tomić PSHs ont été traités par ténotomie du droit antérieur, de
Institute for Orthopaedic Surgery “Banjica”, l’iliopsoas avec résection de la crête iliaque libérant le sar-
Belgrade University School of Medicine,
Mihajla Avramovica 28,
torius. Tous les patients ont bénéficié également d’une
Belgrade 11000, Serbia ténotomie bilatérale des adducteurs. À 8,8 ans de suivi, dans
le groupe A, le pourcentage de migration de la tête MP est
A. Lešić : M. Bumbaširević amélioré de 39,8% à 24,7% avec 92,3% de bons résultats en
Institute for Orthopaedic Surgery and Traumatology,
Clinical Center of Serbia,
moyenne alors que dans le groupe B, à 8,3 ans la sub-luxation
Belgrade 11000, Serbia est améliorée de 58,0% à 25,9% avec 96,8% de bons résultats.
La réduction de la hanche est obtenue dans 84,6% des cas du
H. D. E. Atkinson groupe A et 80,6% des cas du groupe B. La correction de la
Department of Orthopaedics,
Royal National Orthopaedic Hospital,
migration de la tête est supérieure dans le groupe B, aucun
Brockley Hill, patient n’a vu sa migration augmenter. La marche a été
Stanmore HA7 4LP, UK améliorée de 55% dans le groupe A, à 86% dans le groupe B.
Nous recommandons la libération de tous les muscles
H. D. E. Atkinson (*)
9 Sutcliffe Close,
fléchisseurs de la hanche: droit antérieur, sartorius, iliopsoas
London NW11 6NT, UK en association avec une ténotomie des adducteurs chez ce type
e-mail: de patients.
, 504 International Orthopaedics (SICOT) (2009) 33:503–508
Introduction spastic diplegia preoperatively. Mean age at the time of the
surgery was 6.65 years (range 3–10 years). Mean postoper-
Paralytic subluxation of the hip (PSH) occurs in patients ative follow-up was 8.8 years (range 3–16 years). Group A
with cerebral palsy (CP) because of a muscle imbalance patients underwent iliopsoas tenotomies of the subluxed hip
between the stronger hip flexors and adductors and the in addition to bilateral hip adductor tenotomies (adductor
weaker hip extensors and abductors. This imbalance causes longus and gracilis). Two patients also underwent medial
joint contractures which then lead to migration of the hamstring elongation (of gracilis, semitendinosus, semi-
femoral head out of the acetabulum, subsequently causing membranosus) following the iliopsoas tenotomies; four pa-
impairment to mobility, pelvic obliquity, and scoliosis [7]. tients required triceps surae elongation prior to iliopsoas
The contribution of other factors to the development of tenotomies (three on the ipsilateral hip, and one bilateral hip)
PSH, such as a valgus femoral neck, increased femoral neck and one patient following iliopsoas tenotomy.
anteversion, pelvic obliquity and scoliosis, remains uncer- Group B comprised 22 CP patients: 9 female and 13 male
tain; some authors emphasise these factors, while others with 31 operated PSH hips. Nine patients had both hips
question their significance [4, 5, 7, 10, 17]. operated synchronously. All patients were ambulatory with
There is however a general consensus that soft tissue spastic diplegia preoperatively. Mean age at the time of the
surgery should be performed in treating PSH in CP patients surgery was 5.6 years (range 2–8 years). Mean follow-up
[3, 12]; however, success rates vary. The aim of surgery is was 8.3 years (range 4–18 years). Group B patients under-
to regain a more normal muscle balance, reduce the sub- went rectus femoris tenotomy and iliac crest resection [8] in
luxed hip joint, and prevent recurrence of PSH. This paper addition to iliopsoas tenotomy and bilateral hip adductor
compares the radiographic and clinical results of a standard tenotomy. No other procedures were performed either before
soft tissue procedure for PSH in CP patients to that of a or after the hip surgery.
new and more extensive technique. All patients had pre- and postoperative assessments (at
final follow-up) of their walking abilities which were clas-
sified according to the Functional Mobility Scale (FMS)
Patients and methods [6], in preference to the Gross Motor Function Classifica-
tion System (GMFCS) [13]. The FMS is a performance
This is a comparative retrospective study of 57 hips in 42 measure that classifies mobility according to the need for
consecutive patients with cerebral palsy and PSH who were assistive devices over the distances 5.50 and 500 metres
operated at the Institute for Orthopaedic Surgery "Banjica" (chosen to represent mobility in the home, at school, and in
in Belgrade, Serbia between 1983 and 2001. All patients the wider community).
met inclusion criteria of being able to walk independently During the operation patients were positioned in a lateral
with or without support, being aged between 2 and 10 years position (lying on the nonoperative side). The anterior
at the time of surgery, and with spastic diplegia and para- iliofemoral approach to the hip was used in all patients.
lytic subluxation of one or both hips. Iliopsoas tenotomy was made approximately 3 cm proximal
Subluxed hips were defined as having a Reimers migra- to the lesser trochanter insertion (at the point where the
tion percentage (MP) of greater than 33% [16]. We chose tendon was surrounded by the muscle belly); intramuscular
Reimers MP (which represents the percentage of the sub- tenotomy was performed with the purpose of also weakening
luxed femoral head uncovered by the acetabulum) to be our the iliopsoas muscle. Those patients undergoing rectus
radiological criterion because it is a widely accepted param- femoris tenotomy had release of both the straight and
eter in the assessment of PSH in CP patients [2, 21]. In reflected heads of the muscle. Iliac crest resection was made
addition, CP patients are often difficult to control during 2 cm below the anterior–superior iliac spine and continued
radiographic imaging, and hip rotation during imaging does posteriorly and superiorly to the junction of the middle and
not influence the final MP value, unlike other radiographic posterior thirds of the iliac crest. The iliac apophyses were
parameters [16]. The medical records and radiographs of then closed without tension, with the hips in a fully extended
these 42 patients were reviewed retrospectively. MP values position [8], thus releasing sartorius.
for each patient were determined by two independent ortho- Postoperatively, patients had both legs placed on skin
paedic surgeons not affiliated to the unit, who were blinded traction for 3 weeks. Three patients in each group were also
to the performed procedures. The selected patients were administered 2 mg of oral Tizanidine (Zanaflex, Elan Phar-
then subdivided into two groups according to the surgical maceuticals, USA) daily, to prevent spasticity during trac-
procedures performed. tion. The legs were positioned in abduction of 10–20° with
Group A comprised 20 CP patients: 12 female and 8 male 1–2.5 kg of weight on each limb. Traction was followed by
with 26 operated PSH hips. Six patients had both hips a rehabilitation programme with an emphasis on vertical
operated synchronously. All patients were ambulatory with stance and weight bearing on the operated leg.
