Develop. Med. Child Neurol. 1979, 21, 749-753

Natural History of the Dislocated Hip in Spastic Cerebral Palsy

Marc Moreau Denis S . Drummond Eugene Rogala A . Ashworth T . Porter

Introduction One of the more challenging problems

related to the care of spastic cerebral palsy patients is paralytic dislocation of the hip. The incidence of this complication vanes widely in the literature. Mathews and associates (1953) found hip dislocations in 2.6 per cent of an ambulatory cerebral- palsy group; Gherlinzoni and Pais (1950) reported an incidence of 4.2 per cent in a similar group. Samilson ef al. (1972) reviewed 1013 institutionalized patients, most of whom were unable to walk, and found hip dislocations or subluxations in 28 per cent. Banks and Green (1960) have reported successful prevention of this complication by earlier adductor myotomy and anterior obturator neurec- tomy, but Phelps (1957) and Baker et al. (1962) have noted that this procedure not infrequently fails to achieve permanent hip stability.

Although most authors agree that this complication should be prevented, the management of the already dislocated hip in a child with spastic cerebral palsy remains controversial, particularly for those children who are severely spastic, bed-bound and neurologically immature. It is generally believed that the untreated dislocated hip in a patient with spastic

cerebral palsy will invariably become painful and lead to problems with nursing care and decubitus ulcers. Samilson and associates (1 972) found in their institutionalized patients that difficulty with perineal nursing care was a more frequent problem than pain.

We have undertaken this review because uncertainty persists as to whether or not pain and other complications occur frequently following paralytic dislocation of the hip in spastic cerebral palsy. We were particularly interested in the natural history of the untreated dislocation in the more severely involved patients for two reasons: (1) they are the patients most likely to develop this complication; and (2) treating the unstable hip in these patients is frequently difficult.

Methods We reviewed 88 adult .cerebral-palsy

patients from two government-run chronic hospitals for the mentally handi- capped. All had disabling spastic cerebral palsy, with contractural deformity of both hips. The hospital records were reviewed to obtain details of the patients’ IQ, social activity and general health. Each patient underwent a physical examination and the presence or absence of scoliosis, pelvic

Correspondence lo Denis S . Drummond, M. D. Present address: Division of Orthopedic Surgery, Room G5/319, Clinical Sciences Center, 600 Highland Avenue, Madison, Wisconsin 53792.

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DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1979, 21

obliquity, hip deformity and decubitus ulcers were recorded. During the examin- ation we particularly noted the presence or absence of pain during passive move- ment of the hips. The nursing staff were interviewed to determine whether perineal care problems existed. The func- tional capacity for sitting, standing and ambulation was also assessed: the 'neurological maturity' of each patient was determined by noting his intelligence and his ability to communicate, feed him- self and either sit or stand independently (Table I).

Each patient had an anteroposterior radiograph taken of the hips, pelvis and spine to confirm the presence or absence of dislocation or subluxation of the hip, pelvic obliquity or scoliosis. The stability of the hip was assessed radiologically by determining the amount of lateral acetabular cover of the femoral head. If the femoral head was uncovered by one- third or less of its diameter the hip was radiologically defined as dysplastic; uncovering of the head by more than one-third of its diameter was defined as a subluxation, and absence of any contact be tween the f emora l h e a d a n d acetabulum was defined as a dislocation. We also measured the centre-edge angle of Wiberg (using a normal value range of 20-46"), the femoral neck-shaft angle (determining the upper normal value to be 140"), the acetabular index (using 25" as the upper normal angle) and the con- tinuity of Shenton's line.

Results Of the 88 patients examined (33 males,

55 females), 74 had either spastic diplegia or quadriplegia and 14 were both spastic and athetoid. The average age was 26.5 years (range 17 to 68 years), and one-half of the patients were also epileptic. There were 41 patients with unstable hips (Group I); 21 of these with 24 dislocations

(23.9 per cent of the total group), nine with subluxation (10.2 per cent), and 11 with dysplasia (12.5 per cent). 42 of the remaining 47 patients with stable hips (Group 11) had extensive flexion- adduction contractures of the hip but good radiological coverage of the femoral head (Table 11).

Pain was present in 11 of the 21 patients with a hip dislocation (52.4 per cent, Table 111). In eight cases the pain was of a mild to moderate intensity, arising particularly when the hip was manipulated, but the

TABLE I Details of 41 adult patients with unstable hips

No. Retardation: mild 7

moderate 17 severe 17

Communication: coherent, logical 12 incoherent but logical 4 sign language 6 aphasia 17 incoherent 2

house hold 2 non-functional 2 no ambulation 22 stands to transfer 4 uses wheelchair 6

Arnbulation: community 5

Able to feed self yes no

Socializes: yes no

20 21

18 23

Incontinent: yes 22 no 19

TABLE I1 Hip problems in 88 patients examined

~~

Group I No. Dislocated hip 21 Subluxed hip 9 Dysplastic hip 1 1

Group I1 Severe contracture:

sitting or ambulatory bed-bound

Mild contracture Total

22 20

5 88

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MARC MOREAU DENIS S. DRUMMOND EUGENE ROGALA A. ASHWORTH T. PORTER

other three patients had severe, disabling pain. Only three of the 11 patients with painful dislocations were severely retarded and spastic. The eight others were more intelligent and ‘neurologically mature’. Two of the nine patients with subluxation experienced pain and one with dysplasia had a painful hip. All three of these patients were among the most ‘neurologically mature’ in this series.

In contrast, the Group I1 patients with stable hips and contractural deformities frequently did not develop pain (Table

Athetosis added another dimension to the problem of the unstable hip in cerebral palsy, 14 of the 88 patients examined had both spasticity and athetosis. We noted three with dislocated hips, one with a subluxation and two with hip dysplasia. Four of these six patients had pain associ- ated with their hip problem. It is notewor- thy that severe, disabling pain associated with dislocation of the hip was present in only two patients, both of whom were athetoid. 35 of 74 with spasticity experi- enced some form of hip problem, com- pared with six of 14 with athetosis. It appears significant that two-thirds of the patients with athetosis had pain, com-

IV) .

pared with less than one-third of the spastic group.

Decubitus ulcers were found in nine of the 30 patients with either a dislocated or a subluxated hip, all of whom were bed- bound. Only two of the sores were open at the time of review; the rest were healed. In contrast, pressure sores were found in 10 of the 42 patients in Group 11; nine of whom were completely bed-bound.

One-third of the patients with either dislocated or subluxated hips presented problems with perineal care, but only three represented truly difficult nursing problems. Five of the Group I1 patients presented problems with perineal care; four of the five were completely bed- bound. Pelvic obliquity and scoliosis were found in 14 of the 30 patients with either dislocation or subluxation of the hip; these deformities contributed to a loss of sitting balance in nine cases.

Discussion In this study the patients with a painful

dislocated or subluxated hip were often more ‘neurologically mature.’ In contrast, the dislocation was usually painless in the less intelligent, bed-bound and severely spastic quadriplegic patients. It appears

TABLE I11 Group I-unstable hip

No. of Pain Decubitus Perineal Functional patients ulcer care disability

Dislocation Subluxation D ysplasia Total ’

21 1 1 I 8 I 9 2 2 3 2

1 1 1 0 1 2 41 14 9 12 1 1

TABLE IV Group II-stable hips with contractures

Functional No. of Pain Decubitus Petineal Functional capacity patients ulcer care disability

Sitting and ambulatory 22 0 1 1 0 Bedridden 20 2 9 4 1 Total 42 2 10 5 1

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DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1979, 21

that the less the neurological maturity, the greater the pain threshold. Pain with dis- location or subluxation of the hip was also associated with the presence of athetosis. Aggressive surgery to reduce a dislocated hip in spastic cerebral palsy is indicated primarily for the more ‘neurologically mature’ patients, particularly if athetosis is present.

Samilson et al. (1972), and others, have observed difficulties in perineal care and the presence of decubitus ulcers in associ- ation with dislocation of the hip in spastic cerebral palsy. In this series, decubitus ulceration was correlated more with con- tractural deformity of the hip and with the bed-bound patient than with stability of the hip. The incidence of problems with perineal care appears to be higher in Group I patients (with either subluxation or dislocation) than in Group I1 patients (with contractures and stable hips). Poss- ibly the contractures associated with dis- location are more difficult to manage because the normal fulcrum of the reduced femoral head is absent; there- fore a more severe contracture develops.

In both groups, perineal care problems and, particularly, decubitus ulcers are associated with a lack of neurological maturity and a bed-bound state.

Pelvic obliquity and scoliosis led to a loss of sitting balance in one-third of the patients with a spastic dislocated or sub- luxed hip. The ability to sit greatly influ- ences daily living for these institutional- ized patients, enhances nursing care, and lowers the incidence of decubitus ulcer- ation. Patients who otherwise can sit may become unable to do so because of the pelvic obliquity and scoliosis. The import- ance of obtaining and maintaining sitting function for these patients cannot be overemphasised.

AUTHORS’ APPOINTMENTS Marc Moreau, M.D., Children’s Orthopedics, Edmonton, Alberta. Denis S. Drummond, M.D., Director of Pediatric Orthopedics, University of Wisconsin-Madison. Eugene Rogala, M.D., Assistant Chief Surgeon, Shriner’s Hospital and Queens Mary’s Veteran Hos- pital, Montreal. A . Ashworth, M.D., Director of Children’s Orthopedics, Queens University, Kingston, Ontario. T. Porter, M.D., Orthopedic Surgeon, Barrie, Ontario.

SUMMARY A review was made of 88 adult institutionalized patients with spastic cerebral palsy and

contractural deformity of the hips. 21 were untreated for dislocated hip, and 1 1 of these suffered from hip pain.

The degree of pain was directly related to neurological maturity and to the coexistence of athetosis and spasticity. Decubitus ulcers and perineal care problems were more associated with contractures than with dislocation alone.

It is concluded that dislocation and subluxation should be prevented by surgical means, but that surgical treatment of the already dislocated hip should be reserved for the neurologically mature and athetoid patient.

R E S U m Histoire naturelle de la lwation de hanche dans l’infirmitt? motrice cerkbrale

Une revue a etk faite de 88 cas dadultes en placement avec infirmite motrice cerebrale, dkformation de la hanche sous contracture. 21 n’avaient pas ete traitks pour luxation de hanche et parmi eux 11 souffraient de leur hanche.

Le degrk de la douleur etait directement relie h la maturite neurologique et h la coexistence d‘athktose et de spasticite. Les escarres de decubitus et les probk mes de soins pkrinkaux etaien t plus souvent associks aux contractures qu’h la seule luxation.

752

MARC MOREAU DENIS S. DRUMMOND EUGENE ROGALA A. ASHWORTH T. PORTER

Les auteurs concluent que la luxation et la sub-luxation devraient &re prkvenues par intervention chirurgicale mais que le traitement chirurgical d’une hanche dkjh lwke devrait &re rkservk aux sujets neurologiquement matures et athktosiques.

ZUSAMMENFASSUNG

Klinischer Verlau f der Huftluxation bei spastischer Cerebralparese 88 erwachsene Heimpatienten mit spastischer Cerebralparese und Kontrakturen der

Hiiftgelenke wurden in einer Ubersichtsstudie zusammengefaBt. Bei 21 war die Hiiftluxa- tion unbehandelt und 11 davon litten unter Schmerzen in den Huftgelenken.

Der Schweregrad der Beschwerden stand direkt in Relation zum neurologischen Bild und zum gleichzeitigen Auftreten von Athetose und Spastik. Decubitalulcera und Probleme bei der Analhygiene traten bei Kontrakturen haufiger als bei Luxationen auf.

Man hat die SchluBfolgerung gezogen, daB Dislokation und Subluxation durch chirurgische MaBnahmen vermindert werden sollten; die chirurgische Behandlung der Hiiftluxation jedoch sollte erst bei Patienten vorgenommen werden, die das volle neurologische Bild und eine Athetose haben.

RESUMEN

Historia natural de la luxacibn de cadera en la pardlisis cerebral espdstica Se hizo una revisi6n de 88 adultos ingresados en una Instituci6n afectos de parhlisis

cerebral y con deformidad por contractura de las caderas. 21 fueron tratados por luxaci6n de cadera, y 11 sufrian de dolor a este nivel.

El grado de dolor estaba en relaci6n directa con la madurez neurol6gica y con la persistencia de atetosis y espasticidad. Las ulceras de decubito y 10s problemas del cuidado perineal estaban mhs asociadas con las contracturas que con la luxaci6n sola.

Se concluye que la, lwaci6n y la subluxaci6n deberian ser prevenidas por medios quinirgicos per0 el tratamiento quinirgico de la dislocaci6n ya establecida debena estar reservado para 10s pacientes neurol6gicamente maduros y 10s atetoideos.

REFERENCES Baker, L.D., Dodelin, R., Bassett, F. H. (1962) ‘Pathological changes in the hip in cerebral palsy: incidence,

patho enesis and treatment.’ Journal of Bone and Joint Surgery,44A, 1331-1342. Banks, 8. H.. Green, W. T. (1960) ‘Adductor tenotomy and obturator neurectomy for the correction of

adduction contracture of the hip in cerebral palsy.’ Journal of Bone and Joint Surgery, 42A, 11 1-126. Gherlinzoni, G., Pais, C. (1950) ‘Trattameato della lussazioni patologica dell’anca. Indicazioni, technica e

resultati lontani.’ La Chirurgia degli Organi di Movimento, 34, 335-427. Mathews, S . S., Jones M. H., Sperling, S. C. (1953) ‘Hip derangements seen in cerebral palsied children.’

American Jounal o Physical Medicine, 32, 213-221. Phelps, W. M. (1957f’Long-term results of orthopedic surgery in cerebral palsy.‘ Journal of Bone and Joint

Surgery, 39A, 53-59. Samilson, R. L., Tsou, P., Aamoth, G., Green, W. M. (1972) ‘Dislocation and subluxation of the hip in cerebral

palsy.’ Journal of Bone and Joint Surgery, 54A, 863-872.

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