need surgery for dysplasia?

[Anton Vladzymyrskyy]

Dear colleagues!

Would you be so kind to give advice in this case.

 

Girl, 11 y.o.

Cerebral palsy, spastic diplegia, double-side dysplasia and subluxation of the hips, double-side club-foot.

She is studing in usual school, has friends. She can walk with with stick or with hand-rail.

 

Does she need emergency reconstructive surgery for dysplasia and subluxation of the hips?

What treatment tactics could be suggested?

 

Thank you very much!

 

Best wishes,

Anton Vladzymyrskyy, M.D.

Donetsk R&D Institute of Traumatology and Orthopedics

Donetsk, Ukraine

[Dr Murali Poduval]

dear Anton

difficult decision.
I would go about it this way.
The right is well contained still but the left hip seems to be moving out quite a bit, i would focus my attention at the moment on the left hip. I cannot see the proximal femur well. but i do feel she will need only an acetabular procedure, probably a pemberton type osteotomy only.
you can however take this electively and early rather than on an emergent basis.
the right hip can wait.

 
Dr Murali Poduval
Associate Professor
Department Of orthopedics
Pondicherry Institute of medical sciences
Kalapet
Pondicherry

[Dr.Vishwanath Iyer]

What about the correction of the feet? Can we have info about the feet?

V M Iyer

B106, Kumaradhara, N G V, Bangalore. 560047
91 80 25712134 919742399481

103, Railway lines,Solapur.413001
91 217 2317597/2316783   919822394597

[Vincenzo de Rosa]

Dear Collegue,

the question is : if she had an X-ray like this-one since longtime, don’t touch. If left hip is going out, it would be better to do surgery. The surgery I would do is : femoral bilateral varisation and bilateral pelvic osteotomy (Pemberton or similar).

 

Il the hip is going out now, she’ll have pain in one or two years.

If the x-Ray was the same since longtime, no problems, no surgery.

If surgery, it’s better to do surgery to both hips to avoid to put the left hip inside and to have after the right hip out.

Thank you for the interesting case.

 

V. de Rosa

Pediatric orthopedic surgeon

Bellinzona

Switzerland

 

Da: orth...@googlegroups.com [mailto:orth...@googlegroups.com] Per conto di Anton Vladzymyrskyy
Inviato: venerdì 6 novembre 2009 10.51
A: orth...@googlegroups.com
Oggetto: [Orthopod] need surgery for dysplasia?
Priorità: Alta

[Sandeep Vaidya]

Dear freinds,

 

Before embarking on any treatment, I would like to do following investigations:

(1) X-ray Pelvis with both hips with hips abducted and internally rotated. If the hips are concentrically reduced on this view it means there is no need for opening the hip joint. On the other hand if the hips are not concentrically reduced it indicates that there is fibrofatty tissue in the acetabulum floor which needs excision to facilitate concentric reduction of the hip.

 

(2) CT Scan with 3D recon of boh hips. This will help to define the location of the acetabular deficiency. Many times in cerebral palsy, unlike in DDH the acetabular deficiency is posterolateral rather than anterolateral. In these cases osteotomy should provide posterolateral rather than anterolateral coverage. Also CT scan will help calculate the angle of femoral neck shaft angle and anteversion of the femoral neck.

 

On the basis of these investigations, my choice of procedue would be 

(1) Adductor tenotomy

(2) Psoas tenotomy at the pelvic brim

(3) Open reduction capsulorrhaphy if hips not reducing concentrically on abduction internal rotation view (most probably won't be needed)

(4) Varus derotation osteotomy (angles of varization, derotation to be calculated on CT scan)

(5) Dega's osteotomy with wedge placed at site of acetabular deficiency (most probably posterolateral)

 

I feel surgery should not be delayed, because natural history studies show that such hips in cerebral palsy if left alone invariably dislocate over a period of time. Also femoral surgery cannot be avoided because unlike in DDH, in CP the primary abnormality is excess valgus and anteversion of the proximal femur due to spastic adductors and iliopsoas. The acetabular abnormality comes later. 

 

Do keep us posted on the followup.

Regards
_Sandeep.
 

Observer ped ortho CHOP, USA
Consultant Pediatric Orthopaedic Surgeon.
Jupiter Hospital, Thane
SL Raheja Fortis Hospital, Mahim, Mumbai
Mobile:9833285817.
Tel: 21718695.