DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY REVIEW

Surgical treatment for hip pain in the adult cerebral palsy patient
LEON ROOT MD

Hospital for Special Surgery, New York, NY, USA.

Correspondence to Leon Root at Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. E-mail: rootl@hss.edu

LIST OF ABBREVIATIONS Hip subluxation or dislocation in the cerebral palsy population is an acquired
HSS Hospital for Special Surgery condition that can result in pain and limitation of function. The incidence is
THA Total hip arthroplasty reported to be from 18 to 59%. Awareness of the factors that cause the problem
VRO Varus rotation osteotomy are essential in order to prevent this condition. Early treatment consists of appro-
priate muscle lengthening or releases, varus rotation hip osteotomies and in
CONFLICTS OF INTEREST
some cases pelvic osteotomies to provide acetabular coverage for the femoral
The author declares no conflicts of interest.
head. For painful hip subluxation or dislocation with arthrosis in the adolescent
or adult salvage procedures such as hip arthrodesis, valgus osteotomy, proximal
femoral resection, or total hip arthroplasty have all been done to relieve pain.
The author recounts his experience of the surgical management of the hip in the
individual with cerebral palsy.

The ability to stand and walk or to sit comfortably in a
wheelchair depends in large part on the stability and
mobility of the hips. Hip subluxation in cerebral palsy
(CP) is an acquired condition resulting from muscle imbal-
ance, persistent femoral anteversion and coxa valga, and
delayed weight bearing. The incidence of hip subluxation
or dislocation in the CP population is reported to be from
18 to 59%. Approximately 50% of these hips become pain-
ful, which decreases the person’s ability to walk or stand,
and in the non-ambulatory patient, to sit comfortably or to
stand for transfers. The more severely involved patients
have a greater incidence of hip subluxation or dislocation.
In a review of over 2000 patients at the Hospital for Special
Surgery (HSS) the incidence of subluxation was 37% and
dislocation was 8%. In the totally involved quadriplegic
patient, subluxation occurred in 38% and dislocation in
15.5%. In the partially involved patient (hemiplegic,
diplegic, monoplegic) subluxation occurred in 9.5% and
dislocation occurred in 1%. Early treatment involves
appropriate muscle releases before subluxation occurs and
when subluxation is documented on radiographs, varus
rotation hip osteotomies are necessary to redirect the fem-
oral head into the acetabulum. If there is acetabular insuffi-
ciency, a pelvic osteotomy is added in order to obtain
coverage for the femoral head. A review of the literature
and recommendations are made for the surgical treatment
of these patients.
For the mature adolescent or adult in whom the hip
cannot be reduced due to deformity of the femoral head
or acetabulum, salvage procedures are utilized to relieve
pain and restore function (i.e. the ability to stand walk,
or to sit comfortably) and to allow for the ability of
standing transfers. Among the procedures most com-
monly performed are proximal femoral resections, valgus
osteotomies, hip arthrodesis or total hip arthroplasty. All
these methods shall be reviewed with indications and
contraindications.
Another disabling hip disorder in the adult CP is persis-
tent femoral anteversion in the ambulatory individual.
Three cases are presented to illustrate this problem.
SURGICAL TREATMENT FOR HIP SUBLUXATION
AND DISLOCATION IN THE CHILD WITH CP
Hip subluxation or dislocation is an acquired problem in
the CP population. The incidence varies from 18 to
59%.1–5 In my review of more than 2000 patients treated
at the Hospital for Special Surgery (HSS) in New York
City the incidence of dislocation and subluxation was 8%
and 37% respectively. The incidence was much higher in
the totally involved quadriplegic patient, with dislocation
occurring in 15.5% of these patients and subluxation
occurring in 38%. In the partially involved patient (hemi-
plegic ⁄ diplegic ⁄ monoplegic), dislocation was present in
1%.of patients and subluxation in 9.5 %.

ª 2009 The Author Journal compilation ª Mac Keith Press 2009 Developmental Medicine & Child Neurology 2009, 51 (Suppl. 4): 84–91
84 DOI: 10.1111/j.1469-8749.2009.03421.x
 The etiology of hip subluxation and dislocation in
children is persistent fetal femoral anteversion and neck
shaft valgus because of delayed weight bearing and abnor-
mal muscle imbalance about the hip. The muscle imbal-
ance occurs because strong hip flexors overpower weaker
hip extensors and strong hip adductors overpower weaker
abductors. As a result of these abnormal forces, the hip
will subluxate, or even dislocate, over time. Subluxation
and dislocation in the young child can lead to femoral head
deformity and result in hip pain as well as significant limita-
tion of motion. In spite of braces and physical therapy, the
process tends to be progressive. Early treatment consists of
releasing contracted hip adductors and hip flexors as well as
varus rotation osteotomy (VRO) to correct excessive neck
shaft valgus and femoral anteversion.1,6,7 (Fig. 1a,b,c)
When surgery is done at an early stage, the hips can be
preserved and function maintained. However, when the
subluxation is advanced with a shallow acetabulum, more
extensive procedures are necessary. These procedures may
include proximal femoral derotation osteotomies with fem-
oral shortening and a pelvic procedure to provide coverage
for the femoral head. Muscle tendon lengthening or
releases are often necessary, usually involving adductors,
hamstrings and or hip flexors. With pelvic obliquity or
wind-swept deformity, the located or contralateral hip may
require a VRO to improve pelvic obliquity and to maintain
equal leg lengths. (Fig. 2a,b,c,d)
In our study at HSS, and confirmed by a review of the
literature, reduction of the subluxated ⁄ dislocated hip in the
CP patient can result in a painless and functional hip joint.
For ambulatory patients, a stable painless hip ensures con-
tinued ability to walk. For wheelchair-bound patients, a
stable hip is essential for comfortable and secure sitting.
These complex procedures are best performed at an early
Figure 1: Management of early hip subluxation: (a) Pre-op: mild sub-
luxation right and bilateral femoral anteversion (b) 18 month following
bilateral VRO, and (c) 2 years post-op.
age, before the onset of femoral head deformity. However,
even in the young adolescent who is skeletally mature and
who has mild-to-moderate femoral head deformity, the
procedure can be a great benefit in providing painless hips
and stable sitting.
Highlights of the extensive experience with such surgery
over the past 20 years are as follows:
(1) Carr and Gage8 reported on 36 patients (ages 4–16)
who underwent unilateral hip surgery and found that non-
ambulatory patients were at greater risk of deterioration of
the non-operated hip than ambulatory patients. They also
found that those patients operated on before 9 years of age
had a significant worsening of femoral head coverage of
the non-operated hip in comparison with those over
9 years of age.
(2) Jerosch et al. 9 reported on 11 patients (mean age was
14.4 SD 3.7y) who had combined VRO and triple pelvic
osteotomy with good reduction, were pain-free on follow-up.
(3) Root et al.10 followed 31 patients (35 hips) with
severely subluxated or dislocated hips.10 The patients were
treated with open reduction, femoral VRO, femoral short-
ening, or pelvic osteotomy. Average follow-up was 7 years,
all patients had at least a 2-year follow-up. Mean age was
12 years, age range 4 to 23 years. Although some patients
had pain for up to 8 months, by 1 year after surgery all
were pain-free and remained so at last follow-up. Good
femoral head coverage was obtained. One hip required a
repeat VRO. Four hips resubluxated but were painless on
follow-up. Eight hips developed a degree of avascular
necrosis with subsequent premature closure of the femoral
capital physis. In spite of the complications, the extensive
reconstruction was justified for these patients.
(4) Atar et al.11 reported on 17 hips in 14 patients, age
range: 2.5 to 17 years (average age 10), who had VRO,
Figure 2: Management of right dislocated hip with windswept defor-
mity: (a) Pre-op (b) 10 weeks following Salter innominate osteotomy
right, adductor tenotomies and bilateral VROs, (c) 10 months post-op,
and (d) 9 years post-op.
Surgical Treatment for Hip Pain in Adult CP Leon Root 85
open reduction, innominate osteotomy, adductor release,
and psoas recession. Most patients had spastic quadriple-
gia. Sixteen of the hips were stable at a minimum follow-
up of 3 years.
(5) McNerney et al.12 reported one-stage correction
of the dislocated hip with the San Diego arthroplasty
combined with VRO and soft-tissue releases (age range
1.10–19.16y). Average follow-up was 6.7 years. Ninety-
nine of 104 hips were reduced at follow-up; there were no
redislocations. Eight hips (8%) had avascular necrosis of
the femoral head. These authors concluded that even
hips with some deformity of the femoral head can be
successfully treated with this combined approach.
(6) Noonan et al.13 reported the results of VRO in the
treatment of subluxation or dislocation in 65 patients (age
range 1.1–18.4y) who had 79 hip surgeries for incongruity
and some deformity of the femoral head. At follow-up,
72% of the hips were stable. They found that subluxated
hips were likely to remain stable more than dislocated hips,
and that children under 7.2 years of age were significantly
more likely to be stable on follow-up than those who were
over 10 years of age. Figure 3: Dislocation with severe femoral head deformity.

SURGICAL TREATMENT FOR HIP SUBLUXATION

AND DISLOCATION IN THE SKELETALLY MATURE
PATIENT
Introduction
Some have expressed concern that reduction of the hips in
the skeletally mature patient would not be successful in
relieving pain. Inan14 in 2007 reported on performing 33
incomplete transiliac osteotomies on 27 skeletally mature
patients that resulted in a painless and stable hip in 26
patients.
Figure 4: Head-neck resection (Girdlestone). (a) Pre-op and (b) 1y
In the adult CP person with a painful subluxated or
post-op.
dislocated hip, reconstruction procedures are not
successful (Fig. 3). When conservative therapy no longer
provides relief from pain or improvement in care,
treatment consists of surgical salvage procedures. Hip pain postoperative skeletal traction, these patients continued
has been reported to be as high as 50% in those adult to have pain. Kalen and Gamble23 reported their results
patients with hip dysplasia, and generally those patients of 18 hips in 15 non-ambulatory patients who had
who are most severely involved have the most significant resection of the proximal femur at a level above the lesser
problems.5,15–22 trochanter. Thirteen patients had spastic dislocation due
Surgical options for adult CP patients include head and to CP and nine patients had painful hips. Seven of the
neck resection; interposition arthroplasty (Castle proce- hips had good pain relief, but three required reoperation
dure); valgus osteotomy as described by Schantz and for pain caused by proximal migration of the proximal
Haas,27,28 or the McHale modification30; hip arthrodesis; femur. Twelve of the 15 patients developed heterotopic
and total hip replacement. ossification. Koffman19 reported on 10 proximal femoral
resection in six non-ambulatory CP patients with pain-
Head and neck resection ful dislocations. Most procedures were done at the level
Head and neck resection, or the Girdlestone procedure of the lesser trochanter.19 Every patient continued to
(Fig. 4), has not been successful in relieving pain as have pain. Orthopedic surgeons no longer use this proce-
reported by Hoffer17 and Perlmutter et al.22 Even with dure.

86 Developmental Medicine & Child Neurology 2009, 51 (Suppl. 4): 84–91

 Figure 5: Painful windswept hips (a) Pre-op (b) post-op following
bilateral proximal resections and muscle interposition.
Interposition arthroplasty
Interposition arthroplasty, or proximal femoral resection,
has been a major salvage procedure for patients with
painful hips who are wheelchair-bound and non-
ambulatory.
Castle et al.24 described a more radical approach to this
problem. His technique involves excising the proximal
femur below the level of the lesser trochanter (Fig. 5a,b).
The vasti muscles are sewn over the proximal end of the
femur, and the abductor and psoas muscles and hip joint
capsule are sewn over the acetabulum. In this manner, a
large mass of soft tissue is interposed between the proximal
end of the femur and the pelvic area. In many cases, the
femur migrates proximally.
Widmann et al.25 reported the results at HSS of resec-
tion arthroplasty in 13 patients (18 hips). Average age at
surgery was 26.6 years, with an average follow-up of 7.4
years. All patients had significant improvement in subjec-
tive assessment of pain after surgery. Upright sitting toler-
ance improved in all patients. Heterotopic ossification was
reduced with single-dose radiation therapy to the operative
area. These patients were treated with postoperative skin
traction and early mobilization.
Gabos et al.26 reported on using a prosthetic arthro-
plasty in 14 painful degenerative hips in 11 patients with an
age range of 11 to 20 years. They combined proximal
resection with insertion of a non-cemented shoulder pros-
thesis into the femoral canal. Seven of these patients also
had a glenoid component inserted. Complete pain relief
was achieved in 10 patients (13 hips). Sitting tolerance
improved in every patient.
Valgus support osteotomy
Valgus support osteotomy was originally described for
osteoarthritis, non-union fractures of the hip, or late con-
genital hip dysplasia.29–32 Samilson et al.1 described valgus
osteotomy for painful subluxation ⁄ dislocation of the hip in
severely involved CP patients.
McHale et al.30 reported on their results of combining
femoral head resection and subtrochanteric valgus osteoto-
my on six hips in five non-ambulatory adolescent CP
Figure 6: Valgus osteotomy (McHale procedure).
patients with painful dislocated hips (Fig. 6). They
reported few complications and good pain relief.
Leet et al.31 compared the results of the McHale proce-
dure with results of proximal femoral resection and trac-
tion. This was a retrospective study of 36 hips in 27
patients, all of whom except one had severe quadriplegia.
Their goals were to obtain pain relief, improve sitting tol-
erance, and facilitate perineal hygiene care. Sixteen patients
(23 hips) had femoral neck resection below the lesser tro-
chanter with muscle interposition (FHRT), as described by
McCarthy;32 11 patients (15 hips) had the McHale proce-
dure.33 Complications were higher for the FHRT group.
Patients or caregivers were asked to evaluate their overall
satisfaction with the surgery. Seven of the FHRT group
and eight of the McHale group responded to the question-
naire. Pain was reduced in both groups, but more so in the
FHRT group than in the McHale group. Patients in both
groups were satisfied with the surgery. Both groups took a
long time to be pain-free. Hospital stay and complications
were less in the McHale group than the FHRT group, but
end results were equally satisfactory.
More recently, Hogan et al.33 reported on their modi-
fied Haas valgus-subtrochanteric osteotomy in 31 hips in
24 patients. Although they had 15 complications, the
majority of the patients were doing well at an average of 44
Surgical Treatment for Hip Pain in Adult CP Leon Root 87
months after surgery. Twenty of these patients were spastic
quadriplegics. These authors did not recommend concur-
rent femoral head resection in combination with a valgus
osteotomy. Sixteen caregivers of these patients responded
to a questionnaire; 14 of those who responded were satis-
fied with the operative procedure. In all 16 patients
improvement was noted in sitting tolerance. Twelve of the
patients had no pain with transfers.
Neither valgus osteotomies nor McHale procedures
have been done at HSS. For wheelchair-bound patients
who are non-ambulatory and cannot stand to transfer, we
prefer a proximal femoral resection with interposition mus-
cle, early radiation to the operative area, postoperative skin
traction, and early mobilization. Postoperative pain is a
major problem in all these patients but usually resolves in
several months, after which time caregivers and patients
are pleased with the surgical result.
Hip arthrodesis
Arthrodesis of the hip is a time-honored procedure in
orthopedics. I performed my first hip arthrodesis on a CP
patient in 1971. Over the years, I performed the procedure
in eight patients (eight hips) between the ages of ages 13 to
34 years.35 Follow-up was from 8 to 33 years. Two of the
patients required revisions; one had one revision, and the
other required two. Both patients ultimately received a
total hip replacement. The basic technique for arthrodesis
is an interarticular denuding of the acetabulum and femo-
ral head cartilage and fixation of the femoral head into the
acetabulum with large screws or blade plate. A subtrochan-
teric osteotomy is necessary to promote fusion. Copious
iliac bone graft is utilized. Immobilization in a spica cast is
necessary for 3 to 6 months (Fig. 7a,b,c)
Figure 7: Painful left hip subluxation in ambulatory 26 yo male (a)
Pre-op (b) 5 years post hip arthrodesis with solid fusion, no pain and
walking without external support (c) 30 years post-op.
88 Developmental Medicine & Child Neurology 2009, 51 (Suppl. 4): 84–91
Successful hip arthrodesis for the painful subluxated ⁄
dislocated hip in CP was also reported by deMoraes Barros
Fucs et al.35 They evaluated 14 arthrodesis patients with
a mean age at surgery of 15.5 years of age and a mean
follow-up of 5.3 years. Bone union was obtained in all
cases, as was relief of pain and postural improvement.
Hip arthrodesis can be successful for the younger adult
who has a normal contralateral hip and a normal lumbo-
sacral spine. Ambulatory patients with a hip fusion func-
tion very well, and wheelchair patients can sit and stand
comfortably. Nevertheless, in today’s world, it is difficult
to convince someone to accept a fused hip over having the
mobility of a total hip replacement.
Total hip arthroplasty
Total hip arthroplasty (THA) has changed the life of
millions of people with painful hips since the early 1960s
when Sir John Charlney reported on his outstanding
results. 39,40 However, orthopaedic surgeons have been
reluctant to recommend the procedure for a CP person
with a painful subluxed or dislocated hip. The questions
were: Would a hip replacement in a CP patient dislocate
or loosen prematurely because of spasticity or athetosis?
And would the procedure reduce pain and restore function
in this group of patients? In 1971, PD Wilson, Jr., per-
formed the first total hip replacement on a CP patient at
HSS. The operation was successful in relieving hip pain
and restoring function to a 57-year-old male who remained
active in the community and pain-free until his death many
years later.
Weber and Cabarela36 reported on 16 patients with 16
hip replacements. Eighty-seven percent of the patients
had pain relief, and ambulatory function improved in
79%. They had no dislocations, and complications were
rare.
Schorle et al.37 reported on 19 CP patients who had
painful hips. Following THA, 84% were pain-free and all
walked better.
We published our results on THA in CP in 198634 and
again in 1993 (Buly et al.).38 In September 2007, we
presented the last follow-up on 65 hip replacements in
62 patients at the annual meeting of the American
Academy for Cerebral Palsy and Developmental Medicine
in Vancouver Canada, and at the March 2008 meeting
of the American Academy of Orthopedic Surgeons in
San Francisco. The survivorship was 85% for 10 years
and preoperative pain was relieved in all patients.
(Figs 8a,b,c and 9a,b,c)
These studies confirm that THA is a safe and successful
procedure for painful hips in the cerebral palsy population,
even in the younger age groups and even in those who
function mainly in a wheelchair.

Figure 8: 27 yo male with spastic diplegia and painful left hip (a) Pre-
op (b) 1 year post-op, femoral head used to augment acetabulum (c)
22 years post-op with no pain, walking without external support.
SURGICAL TREATMENT OF FEMORAL
ANTEVERSION IN THE ADULT CP PATIENT:
THREE CASE STUDIES
It is not just painful subluxated hips that cause difficulty for
the adult CP patient. A significant number of ambulatory
and high-functioning diplegic and hemiplegic adults have
increasing difficulty in walking as a result of an internal
rotation gait pattern and gradually increasing tightness or
contracture of their hips, knees, or ankles. The primary
problem is excessive anteversion, and the secondary prob-
lem is muscle contractures. To illustrate this problem, I
present three adult patients who had stable hips but had
increasing difficulty in walking because of an internally
rotated and spastic gait pattern.
Figure 9: Painful right hip in 16 yo male previously able to stand for
transfers (a) pre-op (b) 1 year post-op right THR and left VRO, no pain
and able to stand for transfers (c) 8 years post-op, no pain, good sit-
ting tolerance, continues to stand for transfers.
KP was 41-year-old female with spastic diplegia who
presented with increasing difficulty in walking and carrying
out her work as a nurse. She had three children and
had been totally independent. As a child, she had multiple
soft-tissue procedures and a left hip osteotomy. Upon first
presentation, radiographs revealed stable hips, and clinical
examination revealed significant increased internal rotation
of the hips with limited external rotation. She also had
contractures of the Achilles’ tendons and over-pull of the
posterior tibial muscles. A gait study was performed. She
underwent bilateral VROs, heel cord lengthening, and split
tendon transfers in her feet. Her postoperative rehabilita-
tion was lengthy and difficult, but after 1 year, she had no
pain and was able to walk erect, but she had significant
muscle weakness. It took almost 2 years before she was
able to resume most of her normal activities. At her 5 year
follow-up, she continued to use a cane for long distances.
(Fig. 10a,b)
BK was a 49-year-old female with left hemiplegia.
She was single and worked full-time as a secretary. She
complained of knee pain and increased difficulty walking
due to marked internal rotation of her left leg. As a child
she had a left heel cord lengthening. X-rays revealed a
stable hip, and clinical examination demonstrated an
internal rotation pattern of the left leg with stiff knee gait
and tightness of her hamstrings.
Internal rotation of the left hip was 60 and external was
0. A gait study was performed, and she underwent a left
VRO, adductor tenotomy, bilateral hamstring lengthen-
ing, and distal left rectus femoris transfer. Although her
osteotomy was slow to heal, she was pain-free at 1 year
after surgery. At 9 years after surgery, she had no pain and
Figure 10: Management of femoral anteversion Case KP: (a) pre-op
(b) immediate post-op (c) 3 years post-op.
Surgical Treatment for Hip Pain in Adult CP Leon Root 89

Figure 11: Case BK: (a) Pre-op (b) immediate post-op (c) post-op 1
year with delayed union, (d) 9 years post-op.
walked with straight hip ⁄ knee ⁄ foot progression, but she
used a cane for outdoor stability. (Fig. 11a,b)
At time of presentation, the third patient, MH, a
34-year-old female, had been experiencing increasing
difficulty in walking and pain in her left knee and foot. She
had mild spastic diplegia. She walked with a mild crouch
gait and marked internal rotation of her left leg and foot.
In the past she had multiple soft-tissue procedures. She
was single and worked full-time as a librarian. X-rays
revealed stable hips, and clinical examination revealed sig-
nificant internal rotation of the left hip with bilateral con-
tractures of the adductors and hamstring muscles as well as
a contracture of the left heel cord and tendency for equi-
novarus of the left foot. Gait analysis was done. She subse-
quently had a left VRO, bilateral adductor tenotomies,
bilateral hamstring lengthening, left tendo-Achilles length-
ening, left split anterior tibial tendon transfer, and left
posterior tibial tendon recession. The postoperative
rehabilitation was long and laborious, but she was able to
return to work full-time by 18 months after surgery. At
the latest follow up, 4 years after surgery, she had straight
alignment of her left leg, no pain, but continued to use a
cane for long distances. (Fig. 12a,b)
SUMMARY
My approach to the child with CP and hips at risk is to
perform early adductor releases, hamstring lengthening,
and psoas tenotomies over the brim of the pelvis. These
90 Developmental Medicine & Child Neurology 2009, 51 (Suppl. 4): 84–91
Figure 12: Case MH: (a) Pre-op (b) immediate post-op (c) 3 years
post-op.
procedures can be delayed until 3 to 4 years of age by the
judicious use of botulinum toxin A into the muscle in order
to relieve spasticity. Yearly hip radiographs in hips at risk,
particularly in the quadriplegic patient, are essential. Once
hip subluxation is documented in spite of muscle proce-
dures and conservative care, VRO is indicated for reduc-
tion. Generally, I prefer to wait until the child is 5 or
6 years of age but if there is progression of the subluxation,
VRO should be done at an earlier age. If acetabular insuffi-
ciency is present, a pelvic osteotomy (Dega, Pemberton,
Salter or Chiari or Peri-acetabular osteotomy) must be
added to obtain femoral head coverage and preserve hip
stability. Even in the presence of femoral head deformity,
as long as the femoral physis is open, reduction can result
in a painless functional hip. If the child is followed closely,
and hip subluxation is aggressively corrected, the problem
of a painful hip in the adult CP can be successfully
averted.
For the older adolescent or adult patient who is wheel-
chair bound and is unable to walk or stand to transfer, we
prefer the Castle interposition arthroplasty. For the ambu-
latory patient or the wheelchair patient who can at least
stand to transfer, THA is safe and reliable. Hip arthrodesis
in the younger population is a reasonable option.
Persistent femoral anteversion in the adult ambulatory
patient, even when the hips are stable, can lead to
decreased function and pain. Although hip rotation osteot-
omies can improve walking ability and relieve pain in the
adult patient, the recovery is difficult and prolonged. I
strongly recommend that significant femoral anteversion
that causes an internal rotation gait pattern be surgically
corrected in the younger patient.
REFERENCES 73 hips. J Pediatr Orthop B 2001; 10: 279– latory patients with cerebral palsy. J Pedi-
1. Samilson RL, Tsou P, Aamoth G, Green 86. atr Orthop 1999; 19: 796–804.
WM. Dislocation and subluxation of the 14. Inan M, Gabos PG, Domzalski M, Miller 27. Schantz A. Zur Behanlung der veralteten
hip in cerebral palsy. Pathogenesis, natu- F, Dabney KW. Incomplete transiliac os- angeborenen Huftverrenkung. Munchen
ral history and management. J Bone Joint teotomy in skeletally mature adolescents Med Wochenschr 1992; 69: 930.
Surg Am 1972; 54: 863–73. with cerebral palsy. Clin Orthop Relat Res 28. Haas JA. A subtrochanteric osteotomy for
2. Baker LD, Dodelin R, Basset FH. Patho- 2007; 462: 169–74. pelvic support. J Bone Joint Surg Am
logical changes of the hip in cerebral palsy: 15. Horstmann HH, Bleck EE. Orthopaedic 1943; 25: 281–91.
incidence, pathogenesis and treatment. J Management in Cerebral Palsy, 2nd edn. 29. Milch H. Subtrochanteric osteotomy. Clin
Bone Joint Surg Am 1962; 44: 1331–42. Clinics in Developmental Medicine Orthop 1962; 22: 145–56.
3. Cooke PH, Cole WG, Carey RP. Disloca- No. 173 ⁄ 174. London: MacKeith Press, 30. McHale KA, Bagg M, Nason SS. Treat-
tion of the hip in cerebral palsy. Natural 2007: 350–53. ment of the chronically dislocated hip in ado-
history and predictability. J Bone Joint 16. Gamble JG, Rinsky LA, Bleck EE. Estab- lescents with cerebral palsy with femoral head
Surg Br 1989; 71: 441–46. lished hip dislocations in children with resection and subtrochanteric valgus osteo-
4. Lonstein JE, Beck K. Hip dislocation and cerebral palsy. Clin Orthop Relat Res 1990; tomy. J Pediatr Orthop 1990; 10: 504–09.
subluxation in cerebral palsy. J Pediatr 253: 90–99. 31. Leet AI, Chhor K, Launay F, Kier-York J,
Orthop 1986; 6: 521–26. 17. Hoffer MM. Management of the hip in Sponseller PD. Femoral head resection for
5. Moreau M, Drummond DS, Rogala E, cerebral palsy. J Bone Joint Surg Am 1986; painful hip subluxation in cerebral palsy: is
Ashworth A, Porter T. Natural history of 68: 629–31. valgus osteotomy in conjunction with fem-
the dislocated hip in spastic cerebral palsy. 18. Cooperman DR, Bartucci E, Dietrick E, oral head resection preferable to proximal
Dev Med Child Neurol 1979; 21: 749–53. Millar EA. Hip dislocation in spastic cere- femoral head resection and traction? J Pe-
6. Sharrard WJ, Allen JM, Heaney SH. Sur- bral palsy: long term consequences. J Pedi- diatr Orthop 2005; 25: 70–73.
gical prophylaxis of subluxation and dislo- atr Orthop 1987; 7: 268–76. 32. McCarthy RE, Simon S, Douglas B,
cation of the hip in cerebral palsy. J Bone 19. Koffman M. Proximal femoral resection or Zawacki R, Reese N. Proximal femoral
Joint Surg Br 1975; 57: 160–66. total hip replacement in severely disabled resection to allow adults who have severe
7. Reimers J. The stability of the hip in chil- cerebral-spastic patients. Orthop Clin cerebral palsy to sit. J Bone Joint Surg Am
dren. A radiological study of the results of North Am 1981; 12: 91–100. 1988; 70: 1011–16.
muscle surgery in cerebral palsy. Acta Ort- 20. Hodgkinson I, Jindrich ML, Duhaut P, 33. Hogan KA, Blake M, Gross RH. Subtro-
hop Scand Suppl 1980; 184: 1–100. Vadot JP, Metton G, Bérard C. Hip pain chanteric valgus osteotomy for chronically
8. Carr C, Gage JR. The fate of the nonoper- in 234 non-ambulatory adolescents and dislocated, painful spastic hips. J Bone
ated hip in cerebral palsy. J Pediatr Orthop young adults with cerebral palsy: a cross- Joint Surg Am 2006; 88: 2624–31.
1987; 7: 262–67. sectional multicentre study. Dev Med Child 34. Root L, Goss JR, Mendes J. The treat-
9. Jerosch J, Senst S, Hoffstetter I. Com- Neurol 2001; 43: 806–08. ment of the painful hip in cerebral palsy by
bined realignment procedure (femoral and 21. Noonan KJ, Jones J, Pierson J, Honkamp total hip replacement or hip arthrodesis.
acetabular) of the hip joint in ambulatory NJ, Leverson G. Hip function in adults J Bone Joint Surg Am 1986; 68: 590–98.
patients with cerebral palsy and secondary with severe cerebral palsy. J Bone Joint 35. de Moraes Barros Fucs PM, Svartman C,
hip dislocation. Acta Orthop Belg 1995; 61: Surg Am 2004; 86-A: 2607–13. de Assumpção RM, Kertzman PF. Treat-
92–99. 22. Perlmutter MN, Snyder M, Miller F, Bis- ment of the painfull chronically dislocated
10. Root L, Laplaza FJ, Brourman SN, Angel bal R. Proximal femoral resection for older and subluxated hip in cerebral palsy with
DH. The severely unstable hip in cerebral children with spastic hip disease. Dev Med hip arthrodesis. J Pediatr Orthop 2003; 23:
palsy. Treatment with open reduction, Child Neurol 1993; 35: 525–31. 529–34.
pelvic osteotomy, and femoral osteotomy 23. Kalen D, Gamble JG. Resection arthro- 36. Weber M, Cabanela ME. Total hip
with shortening. J Bone Joint Surg Am plasty of the hip in paralytic dislocations. arthroplasty in patients with cerebral palsy.
1995; 77: 703–12. Dev Med Child Neurol 1984; 26: 341–46. Orthopedics 1999; 22: 425–27.
11. Atar D, Grant AD, Bash J, Lehman WB. 24. Castle ME, Schneider C. Proximal femo- 37. Schörle CM, Fuchs G, Manolikakis G.
Combined hip surgery in cerebral palsy ral resection-interposition arthroplasty. J Total hip arthroplasty in cerebral palsy.
patients. Am J Orthop 1995; 24: 52–55. Bone Joint Surg Am 1978; 60: 1051–54. Orthopade 2006; 35: 823–33.
12. McNerney NP, Mubarak SJ, Wenger DR. 25. Widmann RF, Do TT, Doyle SM, Burke 38. Buly RL, Huo M, Root L, Binzer T, Wil-
One-stage correction of the dysplastic hip SW, Root L. Resection arthroplasty of the son PD Jr. Total hip arthroplasty in cere-
in cerebral palsy with the San Diego acetab- hip for patients with cerebral palsy: an out- bral palsy. Long-term follow-up results.
uloplasty: results and complications in 104 come study. J Pediatr Orthop 1999; 19: Clin Orthop Relat Res 1993; 296: 148–53.
hips. J Pediatr Orthop 2000; 20: 93–103. 805–10. 39. Charnley J. Arthorplasty of the hip: a new
13. Noonan KJ, Walker TL, Kayes KJ, Fein- 26. Gabos PG, Miller F, Galban MA, Gupta operation. Lancet 1961; 1: 1129.
berg J. Varus derotation osteotomy for the GG, Dabney K. Prosthetic interposition 40. Charnley J, Kupic Z. Nine and ten year
treatment of hip subluxation and disloca- arthroplasty for the palliative treatment of results of low frictrion arthroplasty of the
tion in cerebral palsy: statistical analysis in end-stage spastic hip disease in nonambu- hip. Clin Orthop Relat Res 1973; 95: 9.

Surgical Treatment for Hip Pain in Adult CP Leon Root 91