SUPPLEMENT
Management of Neuromuscular Hip Dysplasia in Children
With Cerebral Palsy: Lessons and Challenges
Jon R. Davids, MD
Abstract: Optimal clinical decision making and surgical manage-
ment of hip dysplasia in children with cerebral palsy (CP) requires
an understanding of the underlying pathophysiology (patho-
mechanics and pathoanatomy), incidence, and natural history. The
incidence of hip dysplasia in children with CP is directly related to
the degree of motor impairment. A subluxated or dislocated hip in
a child with CP can compromise the quality of life for both the
child and their caregivers. The goal of this article is to highlight the
events over the last 25 years that have had the greatest impact on
the management of hip dysplasia in children with CP. It is my
opinion that the 2 most significant advances during this time have
been the development of a classification system based upon motor
impairment (the Gross Motor Function Classification System), and
the development of surveillance programs for hip dysplasia in
children with CP. This article will contrast neuromuscular hip
dysplasia with developmental dysplasia of the hip. It will be shown
how the development and utilization of the Gross Motor Function
Classification System has contributed to our understanding of the
epidemiology and natural history of hip dysplasia in children with
CP, and to the assessment of outcomes following surgical man-
agement. The impact of hip surveillance programs on early soft
tissue surgeries, skeletal hip reconstructions, and the incidence of
hip dislocations and salvage surgeries will be reviewed. Challenges
in the implementation of hip surveillance programs in resource
poor and decentralized health care delivery systems will be con-
sidered, and innovative approaches identified.
Key Words: cerebral palsy, hip dysplasia, Gross Motor Function
Classification System, hip surveillance
(J Pediatr Orthop 2018;38:S21–S28)
O ptimal clinical decision making and surgical man-
agement of hip dysplasia in children with cerebral
palsy (CPHD) requires an understanding of the underlying
pathophysiology (pathomechanics and pathoanatomy),
incidence, and natural history. The underlying dynamic
From the Shriners Hospitals for Children Northern California, Sacramento,
CA.
The author did not receive any outside funding or grants in support of
their research for or in preparation of this work.
The author declares no conflicts of interest.
Reprints: Jon R. Davids, MD, Shriners Hospitals for Children—NCA, 2425
Stockton Boulevard, Sacramento, CA 95817. E-mail: jdavids@shrinenet.
org.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BPO.0000000000001159
J Pediatr Orthop  Volume 38, Number 6 Supplement 1, July 2018
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
muscle imbalance (ie, dominance of the hip flexors and
adductors over the hip extensors and abductors), occurring
in the setting of the growing hip, results in distinct pathoa-
natomy of both the proximal femur and acetabulum.1–4 The
incidence of CPHD is directly related to the degree of motor
impairment in children with cerebral palsy (CP).5 A sub-
luxated or dislocated hip in a child with CP can compromise
the quality of life of both the child and their caregivers.6–8
The goal of this article is to highlight the events over
the last 25 years that have had the greatest impact on the
clinical and surgical management of CPHD. Looking
back, it is my opinion that the 2 most significant advances
during this time have been the development of a classi-
fication system based upon motor impairment (the Gross
Motor Function Classification System—GMFCS), and
the development of hip surveillance programs for CPHD.
THE SAN DIEGO APPROACH
By the early 1990s, surgically oriented pediatric or-
thopaedic surgeons in North America generally believed
that early soft tissue surgery (ie, hip adductor and flexor
muscle lengthening) was unpredictable and frequently in-
effective in the management of CPHD, and that a single
event, comprehensive surgical hip reconstruction (including
hip adductor and flexor muscle lengthening; proximal fem-
oral varus and rotation osteotomy—VRO; acetabular os-
teotomy as described by Dega; and open reduction with
capsulorraphy), when done at the proper age (between 6 and
8 y of age) would be definitive (ie, no recurrence of sub-
luxation or dislocation).9,10 This approach was developed at
a center with significant technical expertise in the surgical
management of developmental dysplasia of the hip (DDH),
and a commitment to caring for children with CP. It was
this approach that guided my clinical decision making and
surgical management of CPHD in the early part of my
career (Fig. 1). The early results were generally successful,
and seemed to be consistent with my training and validate
the paradigm. However, with time there were a few poor
outcomes, which appeared to be related to recurrence of
CPHD with growth, particularly in younger children with
more severe CP.11,12 Critical analysis of these cases, and
advances in the understanding of CPHD from centers
around the world taught me the following lessons.
LESSONS LEARNED: PATHOPHYSIOLOGY
It is now clear that the pathophysiology of CPHD is
distinct from that associated with DDH. In CPHD there
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Davids J Pediatr Orthop  Volume 38, Number 6 Supplement 1, July 2018

FIGURE 1. Pelvis radiographs of a 6-year-old boy with cerebral palsy, Gross Motor Function Classification System IV, and hip
dysplasia in children with cerebral palsy, who underwent comprehensive, single stage surgical hip reconstructions. A, Preoperative
radiograph showing bilateral hip subluxation. B, Immediate postoperative radiograph after bilateral proximal femoral varus and
rotation osteotomies and Dega acetabulopasties. Open reduction was not required. C, Pelvis radiograph 1 year following surgery,
before proximal femoral hardware removal and drill hemiepiphyseodesis. D, Pelvis radiograph 4 years following surgery. Skeletal
hypercontainment of both hips has been maintained.

are rarely soft tissue obstacles to reduction (which are seen
more commonly in DDH). Even in cases of extreme
subluxation (ie, migration percentage—MP, up to 100%),
as long as a portion of the femoral head is in contact with
the margin of the acetabulum, there will not be soft tissue
obstacles to reduction of the femoral head within the
acetabulum following combined femoral and acetabular
osteotomies. Open reduction to remove soft tissue ob-
stacles is only necessary in cases with complete dislocation
where the femoral head has migrated proximally and has
no contact with the acetabulum (ie, MP > 100%). In such
cases the interposed iliopsoas tendon, and less frequently a
contracted capsule, are the soft tissue structures that need
to be addressed to facilitate reduction of the femoral head
within the acetabulum. The ligamentum teres may be de-
tached from the femoral head and atrophied, significant
pulvinar is infrequent, and tightness of the transverse
acetabular ligament is rare. Stability following open re-
duction is best achieved by the skeletal hypercontainment
that occurs by performing both femoral and pelvic osteotomies,
obviating the need for capsulorraphy.
The other significant pathophysiological difference
between CPHD and DDH relates to the role of growth
following surgical reconstruction of the hip. In DDH,
subsequent growth, particularly acetabular modeling, is a
necessary element for achieving a good long-term outcome.13,14
Subsequent growth is the surgeon’s friend in the management
of DDH. However, in CPHD, the underlying muscle im-
balance described above usually persists, even after soft tissue
or skeletal surgeries, and subsequent growth, particularly of the
proximal femur, has been shown to lead to recurrent deformity,
which may contribute to recurrent subluxation.15,16 The po-
tential for acetabular modeling in CPHD is less well under-
stood, and will be discussed below. In general, subsequent
growth is not the surgeon’s friend in the management of
CPHD. Recent animal and clinical studies suggest that there
may be a role for guided growth of the proximal femoral physis
to either prevent deformity early in the disease process or

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J Pediatr Orthop  Volume 38, Number 6 Supplement 1, July 2018 Management of Neuromuscular Hip Dysplasia

recurrence of deformity following VRO.17–19 Further study is
required before this procedure can be recommended with
confidence.
LESSON LEARNED: THE GMFCS
Development and utilization of the GMFCS, a
classification scheme based upon motor impairment level,
has contributed greatly to our understanding of the
epidemiology and natural history of CPHD, and to the
assessment of outcomes following surgical management
(Fig. 2).20,21 In children with CP, hips with MP > 30% are
at risk for the development of CPHD.22–25 Population-
based studies have shown that the incidence of CPHD
(defined as MP > 30%) in children with CP is directly
correlated with the degree of motor function impairment
as measured by the GMFCS.5 CPHD is very common in
children with CP, occurring in 69% and 89% of children at
the GMFCS levels IV and V, respectively. Outcomes
following surgical management of CPHD are improved
when performed earlier in the course of the disease process,
supporting efforts at early diagnosis in those groups at the
greatest risk for developing CPHD.23,24,26–28 Interestingly,
CPHD also occurs in 15% of children functioning at the
high motor levels (GMFCS I and II).5 Recent work has
identified a subset of children with hemiplegic type CP, with
gait kinematic deviations about the hip who are at risk for
CPHD.6,13,29 Appropriately timed assessment for CPHD in
this group of children is therefore recommended.
Understanding of the natural history of CPHD has
previously been focused upon the presence or absence of
pain associated with severe subluxated or dislocated hips in
adults with CP.6,13 This literature is inconsistent, due in part
to a lack of tools to accurately measure relevant clinical

FIGURE 2. Descriptors and illustrations of the levels of the Gross Motor Function Classification System (GMFCS). Reproduced with
permission from H. Kerr Graham. Copyright [H. Kerr Graham], [Royal Children's Hospital, Melbourne, AU]. All permission requests
for this image should be made to the copyright holder.

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Davids
FIGURE 3. Graph of change in motor function [as measured
by the Gross Motor Function Measure (GMFM-66)], by age, in
children with cerebral palsy segregated by Gross Motor Func-
tion Classification System (GMFCS) level. The plots (solid lines)
show that all children with cerebral palsy, regardless of GMFCS
level, show improvement in gross motor up to 7 years of age.
For children at the higher functional GMFCS levels, gross
motor function level is maintained into young adult life (solid
lines within solid circle). For children at the lower functional
GMFCS levels, gross motor function level deteriorates
throughout the second decade of life (solid and dashed lines
within dashed circle). Modified with permission from Hanna
et al.30 Copyright [Wiley and Sons], [San Francisco, CA]. All
permission requests for this image should be made to the
copyright holder. *Indicates GMFCS levels in which motor
function deteriorates during the second decade of life.
status and outcomes. The most reasonable interpretation of
these studies is that the longer a subject survives, the greater
the likelihood of pain associated with a subluxated or dis-
located hip. However, the impact of CPHD on motor
function (which is a significant element of quality of life) in
subjects with CP can be seen when Gross Motor Function
Measure scores relative to age are evaluated with the sub-
jects segregated by GMFCS level (Fig. 3).30 Motor function
improves across all GMFCS levels up to 7 years of age. For
those children functioning at the highest motor levels (ie,
GMFCS I and II), motor function level remains stable into
young adulthood. For those at the GMFCS III, IV, and V
levels there is deterioration of motor function level
beginning in the teenage years and progressing into young
adulthood. The distribution of these changes across
GMFCS levels closely mirrors the incidence of CPHD
between GMFCS levels, suggesting that CPHD may be a
contributing factor to the deterioration of motor function in
teenagers and young adults with CP.
The GMFCS has also contributed to improved un-
derstanding of technical domain outcomes following the
surgical management of CPHD. The effectiveness of early
soft tissue surgery (lengthening of the hip adductor and
flexor muscles) has been shown to be related to the degree
of motor impairment present at the time of surgery, with
the successful outcomes (ie, maintenance of MP <30%)
seen in 94% of children at GMFCS level II, 49% at
GMFCS level III, 27% at GMFCS level IV, and only 14%
at GMFCS level V.31 As noted by the investigators,
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J Pediatr Orthop  Volume 38, Number 6 Supplement 1, July 2018
unfortunately those that need it the most (ie, children at
GMFCS IV and V) benefit the least from early soft tissue
surgery for CPHD. Despite these poor results, I still offer
early soft tissue surgery to children at the GMFCS IV and
V levels as the improved hip range of motion achieved by
the surgery facilitates diapering and perineal hygiene. In
addition, this relatively simple surgery provides an op-
portunity for the family and child to experience anesthesia,
surgery, and recovery, which can help in deciding whether
to undergo the more rigorous skeletal hip reconstruction
surgery in the future.
Outcomes following skeletal hip reconstruction sur-
gery for CPHD are best understood through the filter of
the GMFCS. Early reports, that did not classify patients
by motor functional level, described 95% success rates (ie,
maintenance of reduction, no further surgery required)
following skeletal hip reconstruction at 7.5 years follow-
up.9,32 A subsequent study, which classified patients by
GMFCS level, noted a 75% success rate in GMFCS IV
and V patients at 5 years of follow-up.33 Several recent
reports evaluating acetabular response following isolated
VRO for CPHD have shown that measurable remodeling
does occur, more commonly in GMFCS II and III pa-
tients, but rarely in GMFCS IV and V patients.34–36
Combining this information with previous studies doc-
umenting recurrent femoral deformity with growth fol-
lowing VRO for CPHD supports the surgical paradigm of
skeletal hypercontainment with combined femoral and
pelvic osteotomies for CPHD in GMFCS IV and V pa-
tients, and suggests that a second skeletal reconstruction
may be necessary when hip reconstructive surgery is re-
quired in younger children (ie, between 4 and 6 y of age)
with severe CP.
Assessment of health-related quality of life (HRQOL)
in children with severe CP (GMFCS IV and V) has been
improved by the development of tools such as the Caregiver
Priorities and Child Health Index of Life with Disabilities
(CPCHILD).37 A recent study of children severe CP under-
going hip reconstruction surgery found a negative correlation
between MP and CPCHILD scores both preoperatively and
postoperatively, with improved CPCHILD scores following
surgery.7 These finding suggest that CPHD negatively im-
pacts HRQOL in children with CP, and that HRQOL is
improved following hip reconstructive surgery.
The GMFCS can provide clinical decision making
guidelines for the management of CPHD based upon the
subject’s motor impairment level. CPHD is rare at
GMFCS I and II levels, but when identified early should
be managed by soft tissue surgery. Cases identified later
should be managed by skeletal reconstruction with VRO;
acetabular osteoteomy is indicated when significant dys-
plasia is present. Excellent outcomes should be antici-
pated. CPHD in children at the GMFCS III and IV levels
should be managed by early soft tissue surgery, with the
family counseled that subsequent skeletal reconstruction
surgery will be likely. In cases where hip reconstruction
is required at a relatively young age, a second skeletal
reconstruction may be required in the future due to re-
currence of femoral deformity with growth. Management
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J Pediatr Orthop  Volume 38, Number 6 Supplement 1, July 2018 Management of Neuromuscular Hip Dysplasia

of CPHD in children with the most severe level of motor
impairment (GMFCS V) requires preliminary moral and
ethical discussion of proactive versus reactive treatment
strategies with the family, due to significant medical co-
morbidities that increase the risk of perisurgical compli-
cations and shorten anticipated lifespan. When a proactive
strategy is selected, management of CPHD is similar to
that described above for GMFCS III and IV levels. When
a reactive strategy is selective, soft tissue release for range
of motion and palliative skeletal salvage surgeries are
utilized.38
LESSONS LEARNED: HIP SURVEILLANCE
Systematic hip surveillance programs designed to
promote early detection and treatment of CPHD in chil-
dren with CP have been developed in Australia and
Sweden.24,25,27,28 These programs have established that
hips with MP > 30% are at risk for progressive sub-
luxation, that the incidence of CPHD is related to the
degree of motor impairment as described by the GMFCS,
that the skeletal pathoanatomy of CPHD is related to the
degree of motor impairment as described by the GMFCS,
and that botulinum toxin injection into the hip adductor
and flexor muscle groups is not effective in preventing
progression of CPHD.5,22,39,40 Implementation of com-
prehensive hip surveillance results in an increase in early
soft tissue surgeries and skeletal hip reconstructions, and
decreases the incidence of hip dislocations and salvage
surgeries after 10 to 20 years of screening.27,28 The
implementation of hip surveillance results in a switch from
a reactive to proactive treatment paradigm, which is
beneficial from a population perspective and presumably
cost effective from a system perspective.
Australia and Sweden both have comprehensive,
centralized health care delivery systems, which facilitate
the implementation and utilization of hip surveillance for
CPHD in children with CP. The program may be deliv-
ered by trained professionals working at tertiary referral
centers where children with CP are concentrated to receive
specialized care and services; or mandated centrally and
implemented in regional centers designated to provide
health care services to children with CP. Implementation
in countries with limited resources, or with decentralized,
market driven health care delivery systems is challenging.
In centralized systems, change is general initiated from
above, mandating the implementation below. In decen-
tralized systems, change is frequently initiated from below.
In this circumstance, any advocate for the child (eg, pri-
mary care provider, physical therapist, or parent) may
promote hip surveillance.
Several smartphone apps have been developed to
educate and empower such advocates. The CPUP Hip
Score, developed in Sweden, predicts the risk of develop-
ing progressive CPHD, defined as an MP > 40%, within
5 years.41–43 The CPUP Hip Score is calculated using 4
variables: the subject’s GMFCS level, age, and 2 x-ray
measures of hip dysplasia (MP; and head shaft angle)
(Fig. 4). The hipscreen app, developed in the United States,
provides educational materials about hip surveillance,

FIGURE 4. CPUP Hip Score. A, Traditional measurement of the migration percentage (MP) on an anteroposterior radiograph of the
pelvis. The horizontal black dotted line is drawn through the triradiate cartilage of both hips. The vertical white line is drawn at the
lateral margin of the femoral head. The vertical black line is drawn at the medial margin of the femoral head. The vertical black
dashed line is drawn at the lateral margin of the acetabulum. The MP equals A/B×100. The MP of the right hip is 47%. The MP of
the left hip is 23%. B, Anteroposterior radiograph of the left hip in a 6-year-old boy with cerebral palsy Gross Motor Function
Classification System level IV, showing the measurement of the head shaft angle (angle indicated by dashed line), which is one of
the predictor variables for the CPUP calculator. C, Example of use of CPUP to predict the risk of progressive hip dysplasia in a child
with cerebral palsy. In this example, the child's Gross Motor Function Classification System level is IV, the head shaft angle is 170
degrees, MP is 34%, and the age is 6 years. The risk of developing progressive hip dysplasia within 5 years is 20% to 30%.

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Davids J Pediatr Orthop  Volume 38, Number 6 Supplement 1, July 2018

FIGURE 5. The hipscreen app. A, The smartphone camera is used to take a photograph of the anteroposterior pelvis radiograph.
The rotate function is used to align the image. B, The pan and zoom functions are used to align the hip with the calculator grid. C,
When the lateral margin of the femoral head is aligned with the white line (solid white arrow), and the medial margin of the
femoral head is aligned with the black line (solid black arrow), the head is divided into 10% increments (vertical gray lines). The
location of lateral margin of the acetabulum is assessed (gray arrow), and a numerical value, corresponding to the MP, is
determined. If the lateral margin falls within the black box (as seen in this example), the hip is at risk or in need of treatment and
referral to the appropriate physician or center is indicated.

proper techniques for obtaining and measuring x-rays of the
hips, definitions of GMFCS levels, and summaries of all
published hip surveillance programs for CPHD.44 The app
provides a specific, detailed hip surveillance schedule based
upon age and GMFCS level, to guide providers and
advocates that can be applied to individual subjects. The
final and most innovative element of the hipscreen app is the
Migration Percentage Ruler, which facilitates calculation of
the MP from a pelvis x-ray (Fig. 5). The smartphone camera
is used to photograph the x-ray, which is then aligned and
manipulated using the pan and zoom functions. The ruler
function contains guidelines for continued surveillance or
referral to a treatment center based upon the calculated MP.
SUMMARY
Management of the hip in children with CP over the
last 25 years has been enhanced by improved understand of
the pathophysiology and pathoanatomy of CPHD. Devel-
opment and utilization of the GMFCS, a classification
system for children with CP, based upon degree of motor

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J Pediatr Orthop  Volume 38, Number 6 Supplement 1, July 2018
impairment, has improved our understanding of the
epidemiology and natural history of CPHD; and improved
the assessment of technical domain and HRQOL outcomes
following surgery. Development and implementation of hip
surveillance programs for CPHD leads to earlier diagnosis
and treatment, resulting in better outcomes. Implementation
of hip surveillance programs in resource poor and decen-
tralized health care delivery systems is challenging and will
require innovating thinking and processes.
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