JBJS | Pemberton Pericapsular Osteotomy to Treat a Dysplastic Hip in Cerebral Palsy*

The Journal of Bone & Joint Surgery, Volume 79, Issue 9

Articles | September 01, 1997

Pemberton Pericapsular Osteotomy to Treat a Dysplastic Hip in Cerebral Palsy*

KEVIN G. SHEA, M.D.†; SHERMAN S. COLEMAN, M.D.†; KRISTEN CARROLL, M.D.‡; PETER STEVENS, M.D.‡; DREW H. VAN BOERUM, B.A.†, SALT LAKE CITY, UTAH

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Investigation performed at University of Utah Medical Center and Shriners Hospital for Crippled Children, Intermountain Unit, Salt Lake City

The Journal of Bone & Joint Surgery. 1997; 79:1342-51

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Abstract

We reviewed the results of Pemberton pericapsular osteotomy in nineteen hips (fifteen patients) that were subluxated (fifteen hips) or dislocated (two hips) or had severe acetabular dysplasia (two hips) secondary to spastic cerebral palsy. At least one concomitant procedure was performed in fifteen hips. These procedures included an intertrochanteric osteotomy to correct excessive femoral anteversion or valgus deformity of the neck-shaft angle (thirteen hips), a soft-tissue release (nine hips), and an open reduction (three hips). Four hips had no concomitant procedure. Five of the nineteen hips were painful preoperatively.The average age of the patients at the time of the index operation was seven years and nine months (range, three years and five months to twelve years and three months). The average duration of follow-up was ten years and nine months (range, three years and one month to nineteen years and nine months).All osteotomy sites healed without complications. At the latest follow-up examination, all of the hips were pain-free and satisfactorily reduced and none of the patients had deterioration in function. The average center-edge angle was -5 degrees (range, -45 to 18 degrees) preoperatively and 38 degrees (range, 17 to 53 degrees) at the latest follow-up examination. The average migration index of Reimers was 55 per cent (range, 30 to 100 per cent) preoperatively compared with 12 per cent (range, 0 to 46 per cent) at the latest follow-up examination. Sixteen of the nineteen hips were followed until closure of the triradiate cartilage.There were no instances of posterior uncovering or osteonecrosis of the femoral head or premature closure of the triradiate physeal cartilage leading to deficient acetabular coverage. Our results suggest that good clinical and radiographic results can be achieved with the Pemberton pericapsular osteotomy, with simultaneous intertrochanteric osteotomy and soft-tissue release when indicated, as treatment for subluxation or dislocation of the hip or acetabular dysplasia in cerebral palsy.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The reported prevalence of subluxation and dislocation of the hip in spastic cerebral palsy ranges from 3 per cent (thirty-two of 1243 patients²⁹) to 27 per cent (274 of 1013 patients⁴³). The reported prevalence of dysplasia in more severe forms of spastic quadriplegia ranges from 45 per cent (209 of 464 patients²⁸) to 59 per cent (twenty-six of forty-four patients²¹). Pain related to the hip ultimately develops in many of these patients^4,9,19,25,41. Untreated dislocation of the hip is associated with pelvic obliquity, sitting imbalance, decubitus ulcers, problems with hygiene, and scoliosis^9,37,43. An internally rotated and adducted hip provides a fulcrum that predisposes a patient to fractures of the lower extremity²⁸. Because of these clinical problems, several authors have advocated early operative intervention in the form of lengthening or release of tendons to balance the spastic muscles and to promote more normal development of the hip as well as osteotomies of the pelvis and proximal aspect of the femur to correct osseous deformities^{4,13,20,31,41,43,44,46}.

Initial attempts to alter the natural history of dysplasia secondary to spasticity consisted primarily of soft-tissue procedures such as adductor release and obturator neurectomy³. These procedures may be successful if they are performed before substantial dysplasia develops; however, soft-tissue procedures alone are limited in their ability to correct osseous abnormalities in older children and those who have more advanced deformities^{3,16,22,33,43}. Intertrochanteric osteotomies have been advocated to correct valgus and anteversion deformities, but these procedures have not been successful in correcting acetabular dysplasia, especially in children who have more advanced deformities^2,20,48. Innominate osteotomies (such as Salter, Sutherland, and Steel osteotomies) that do not alter the shape of the acetabulum have limited application in the treatment of dislocation of the hip secondary to spasticity because of the substantial acetabular dysplasia. Root et al.⁴¹ reported postoperative subluxation of four of twenty-six spastic hips that had been treated with a Salter osteotomy. Recent studies¹⁸ of acetabular dysplasia in spastic conditions have demonstrated deficits in the posterior, superior, and anterior regions. For these reasons, Salter and Dubos⁴², as well as others^31,41, recommended that the innominate osteotomy not be used to treat dislocated hips secondary to spasticity.

Although the nature of the acetabular deficiency in dysplasia secondary to spasticity⁴⁷ is not fully understood, the Pemberton pericapsular osteotomy^15,34,35 has been criticized as providing inadequate posterior coverage³¹. Some authors have expressed concern that this osteotomy has the potential to induce premature closure of the triradiate cartilage^5,31 and that, with growth, this closure can result in insufficient acetabular coverage of the femoral head³². A recent study of Pemberton pericapsular osteotomy in dysplastic hips secondary to spastic cerebral palsy demonstrated excellent results at an average of four years¹⁷. We report our results at an average of ten years and nine months after the use of a combined approach (Pemberton pericapsular osteotomy, intertrochanteric osteotomy, and soft-tissue release) for severe dysplasia associated with spastic cerebral palsy.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedics, University of Utah Medical Center, 50 North Medical Drive, Salt Lake City, Utah 84132.

‡Primary Children's Medical Center, 100 North Medical Drive, Salt Lake City, Utah 84113.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopedics, University of Utah Medical Center, 50 North Medical Drive, Salt Lake City, Utah 84132.

‡Primary Children's Medical Center, 100 North Medical Drive, Salt Lake City, Utah 84113.

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TABLE I CLINICAL AND RADIOGRAPHIC DATA ON THE PATIENTS

*0 = none, and 2 = moderate.

Case	Gender	Type of Cerebral Palsy	Side	Preop. Status of Hip	Age at Op. (Yrs. + Mos.)	Simultaneous Procedure	Subsequent Procedure	Duration of Follow-up (Yrs. + Mos.)	Pain*		Walking Ability		Center-Edge Angle⁴⁹ (Degrees)		Acetabular Index⁴⁷ (Degrees)		Migration Index of Reimers^38,39 (Per Cent)
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	F	Diplegia	R	Subluxated	3 + 6	None	None	14 + 11	0	0	About community with aids	About community without aids	-23	38	39	14	95	13
			L	Dislocated	3 + 5	None	None	15 + 0	0	0			-45	40	41	19	100	8
2	F	Hemiplegia	R	Subluxated	3 + 10	None	None	11 + 4	0	0	Unlimited	Unlimited	7	42	32	8	40	10
3	F	Hemiplegia	R	Dysplastic	5 + 11	Iliopsoas release	None	11 + 11	0	0	About community with aids	About community without aids	11	43	22	14	31	10
4	F	Hemiplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. release	None	10 + 6	2	0	Unlimited	Unlimited	14	39	18	4	40	8
5	M	Quadriplegia	L	Subluxated	5 + 5	Intertrochant. osteot.	Adduct. transfer, prox. hamstring release	11 + 8	0	0	Unable	Able to stand	-8	47	27	9	52	11
			R	Subluxated	4 + 3	Intertrochant. osteot., open reduct.	Adduct. transfer, prox. hamstring release	12 + 9	0	0			-15	39	29	8	50	9
6	F	Quadriplegia	R	Subluxated	8 + 4	Intertrochant. osteot.	Prox. hamstring release	9 + 4	2	0	About community with aids	About community with aids	12	41	27	11	41	21
7	F	Hemiplegia	L	Dislocated	6 + 2	Intertrochant. osteot., open reduct., iliopsoas release	Intertrochant. osteot.	10 + 1	0	0	Unlimited	Unlimited	-40	17	32	29	100	46
8	M	Quadriplegia	L	Subluxated	9 + 5	Intertrochant. osteot., adduct. & iliopsoas release, prox. hamstring release	None	3 + 1	2	0	Unable	About house	-16	53	25	8	58	0
9	M	Quadriplegia	L	Subluxated	7 + 10	Intertrochant. osteot., iliopsoas release, prox. hamstring release	None	8 + 9	0	0	About community with aids	About community with aids	0	29	31	15	50	10
10	M	Quadriplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. transfer, iliopsoas release	None	3 + 9	0	0	About community with aids	Unlimited	18	40	17	7	34	9
11	F	Diplegia	L	Dysplastic	7 + 11	Intertrochant. osteot., iliopsoas release	Adduct. transfer, distal hamstring release	14 + 1	0	0	About community with aids	About community with aids	18	32	18	9	30	7
12	F	Quadriplegia	R	Subluxated	10 + 2	Iliopsoas release	Adduct. transfer, prox. hamstring release	19 + 9	0	0	Unable	About house	5	47	32	6	42	8
13	F	Quadriplegia	L	Subuxated	8 + 2	Intertrochant. osteot.	Adduct. transfer, iliopsoas release	13 + 2	0	0	Able to stand	Able to stand	-2	30	33	6	48	23
			R	Subluxated	7 + 4	Intertrochant. osteot.	Adduct. release, prox. hamstring release	14 + 0	0	0			-2	43	27	8	56	8
14	M	Quadriplegia	R	Subluxated	10 + 0	None	Adduct transfer,. abduct. release, prox. hamstring release	8 + 0	0	0	About house	About house	17	33	24	15	33	16
15	M	Mixed	R	Subluxated	12 + 3	Intertrochant. osteot.	Adduct. transfer, iliopsoas release, distal hamstring release	5 + 4	2	0	Unable	Unable	-7	32	30	12	55	9
			L	Subluxated	10 + 9	Intertrochant.osteot., adduct. release, open reduct.	Adduct. transfer, iliopsoas release, distal hamstring release	6 + 10	2	0			-30	33	27	5	92	0
Average					7 + 9			10 + 9					-5	38	28	11	55	12

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TABLE I CLINICAL AND RADIOGRAPHIC DATA ON THE PATIENTS

*0 = none, and 2 = moderate.

Case	Gender	Type of Cerebral Palsy	Side	Preop. Status of Hip	Age at Op. (Yrs. + Mos.)	Simultaneous Procedure	Subsequent Procedure	Duration of Follow-up (Yrs. + Mos.)	Pain*		Walking Ability		Center-Edge Angle⁴⁹ (Degrees)		Acetabular Index⁴⁷ (Degrees)		Migration Index of Reimers^38,39 (Per Cent)
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	F	Diplegia	R	Subluxated	3 + 6	None	None	14 + 11	0	0	About community with aids	About community without aids	-23	38	39	14	95	13
			L	Dislocated	3 + 5	None	None	15 + 0	0	0			-45	40	41	19	100	8
2	F	Hemiplegia	R	Subluxated	3 + 10	None	None	11 + 4	0	0	Unlimited	Unlimited	7	42	32	8	40	10
3	F	Hemiplegia	R	Dysplastic	5 + 11	Iliopsoas release	None	11 + 11	0	0	About community with aids	About community without aids	11	43	22	14	31	10
4	F	Hemiplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. release	None	10 + 6	2	0	Unlimited	Unlimited	14	39	18	4	40	8
5	M	Quadriplegia	L	Subluxated	5 + 5	Intertrochant. osteot.	Adduct. transfer, prox. hamstring release	11 + 8	0	0	Unable	Able to stand	-8	47	27	9	52	11
			R	Subluxated	4 + 3	Intertrochant. osteot., open reduct.	Adduct. transfer, prox. hamstring release	12 + 9	0	0			-15	39	29	8	50	9
6	F	Quadriplegia	R	Subluxated	8 + 4	Intertrochant. osteot.	Prox. hamstring release	9 + 4	2	0	About community with aids	About community with aids	12	41	27	11	41	21
7	F	Hemiplegia	L	Dislocated	6 + 2	Intertrochant. osteot., open reduct., iliopsoas release	Intertrochant. osteot.	10 + 1	0	0	Unlimited	Unlimited	-40	17	32	29	100	46
8	M	Quadriplegia	L	Subluxated	9 + 5	Intertrochant. osteot., adduct. & iliopsoas release, prox. hamstring release	None	3 + 1	2	0	Unable	About house	-16	53	25	8	58	0
9	M	Quadriplegia	L	Subluxated	7 + 10	Intertrochant. osteot., iliopsoas release, prox. hamstring release	None	8 + 9	0	0	About community with aids	About community with aids	0	29	31	15	50	10
10	M	Quadriplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. transfer, iliopsoas release	None	3 + 9	0	0	About community with aids	Unlimited	18	40	17	7	34	9
11	F	Diplegia	L	Dysplastic	7 + 11	Intertrochant. osteot., iliopsoas release	Adduct. transfer, distal hamstring release	14 + 1	0	0	About community with aids	About community with aids	18	32	18	9	30	7
12	F	Quadriplegia	R	Subluxated	10 + 2	Iliopsoas release	Adduct. transfer, prox. hamstring release	19 + 9	0	0	Unable	About house	5	47	32	6	42	8
13	F	Quadriplegia	L	Subuxated	8 + 2	Intertrochant. osteot.	Adduct. transfer, iliopsoas release	13 + 2	0	0	Able to stand	Able to stand	-2	30	33	6	48	23
			R	Subluxated	7 + 4	Intertrochant. osteot.	Adduct. release, prox. hamstring release	14 + 0	0	0			-2	43	27	8	56	8
14	M	Quadriplegia	R	Subluxated	10 + 0	None	Adduct transfer,. abduct. release, prox. hamstring release	8 + 0	0	0	About house	About house	17	33	24	15	33	16
15	M	Mixed	R	Subluxated	12 + 3	Intertrochant. osteot.	Adduct. transfer, iliopsoas release, distal hamstring release	5 + 4	2	0	Unable	Unable	-7	32	30	12	55	9
			L	Subluxated	10 + 9	Intertrochant.osteot., adduct. release, open reduct.	Adduct. transfer, iliopsoas release, distal hamstring release	6 + 10	2	0			-30	33	27	5	92	0
Average					7 + 9			10 + 9					-5	38	28	11	55	12

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FIG1-A:: Figs. 1-A, 1-B, and 1-C: Case 1. Anteroposterior radiographs of a girl, three years and five months old, who was seen for bilateral acetabular dysplasia and subluxation of the hip. Fig. 1-A: Preoperatively, there was marked acetabular dysplasia in both hips. The left hip had a migration index of 100 per cent and was considered to be dislocated; the right hip had an index of 95 per cent and was considered to be subluxated.

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FIG1-B:: Fig. 1-B Two months after bilateral Pemberton osteotomy, there was good coverage of the femoral heads, which were in a reduced position.

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FIG1-C:: Fig. 1-C Eleven years and four months postoperatively, the acetabula were well developed and there was spherical congruency of the femoral heads and the acetabula.

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FIG2-A:: Figs. 2-A, 2-B, and 2-C: Case 8. Anteroposterior radiographs of a boy, nine years and five months old, who had subluxation of the left hip with acetabular dysplasia. Fig. 2-A: Preoperatively, both hips were in marked valgus angulation.

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FIG2-B:: Fig. 2-B Four months after Pemberton osteotomy, corrective intertrochanteric osteotomy, proximal release of the hamstrings, and release of the iliopsoas and adductors, there was acetabular coverage and an altered neck-shaft angle.

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FIG2-C:: Fig. 2-C Three years and one month postoperatively, the acetabular roof and teardrop were well developed and the Shenton line was intact, indicating a stable hip.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

We reviewed the records of seventeen patients (twenty-two hips) who had Pemberton pericapsular osteotomy performed between 1976 and 1990 to treat a dysplastic hip secondary to spastic cerebral palsy. All of the procedures were performed at Shriners Hospital for Crippled Children, Intermountain Unit, by one of us (S. S. C.). Two patients (three hips) who were lost to follow-up after less than two years were excluded from the study. Thus, the results of the procedure in fifteen patients (nineteen hips) are reported here (Table I).

There were nine girls and six boys. The average age at the time of the index operation was seven years and nine months (range, three years and five months to twelve years and three months). Fifteen hips had at least one concomitant procedure: thirteen hips had an intertrochanteric osteotomy to correct excessive femoral anteversion or valgus deformity of the neck-shaft angle, nine had a soft-tissue release, and three had an open reduction.

We used the migration index of Reimers to classify the dysplasia^38,39. The migration index of a normal hip (the percentage of the femoral head that is uncovered) is 0 per cent from birth to the age of four years and less than 10 per cent between four and sixteen years. A subluxated hip has a migration index of 33 to 99 per cent, and a dislocated hip has a migration index of 100 per cent (Figs. 1-A, 1-B, and 1-C). On the basis of this classification, fifteen of the nineteen hips were subluxated, two were dislocated, and two had only acetabular dysplasia.

The indications for the Pemberton pericapsular osteotomy included acetabular dysplasia, subluxation, and dislocation. The principal prerequisite for the procedure is a reducible hip with an open triradiate cartilage. The osteotomy is usually performed before the child is ten years old, although it can be done in older children who have an underlying neuromuscular disease because the triradiate cartilage in such patients remains open several years longer. The technique for the Pemberton osteotomy has been well described^8,15,30,35. The acetabular dysplasia in our patients was severe and was characterized by an acetabular index that was usually more than 25 degrees⁴⁷, a break in the Shenton line⁴⁷, a center-edge angle of less than 25 degrees⁴⁹, and a migration index that was usually at least 33 per cent³⁸.

The indications for the intertrochanteric osteotomy included excessive femoral anteversion (more than 25 to 30 degrees) and abnormal valgus position of the femoral neck (a neck-shaft angle of more than 145 degrees) (Fig. 2-A). The femoral neck-shaft angle was measured on an anteroposterior radiograph of the pelvis made with the thighs in abduction and inward rotation. This position produces a more accurate representation of the neck-shaft angle. An attempt was made to achieve as normal a configuration of the proximal aspect of the femur as possible, with a neck-shaft angle of 120 to 125 degrees and anteversion of 10 to 15 degrees (Fig. 2-B).

Selective soft-tissue release of the iliopsoas, adductors, or hamstrings, or a combination of the three, was performed when passive abduction was less than 30 degrees with the hip and knee extended and straight-leg raising was restricted to 45 degrees or less.

An open reduction was done when there was an irreducible dislocation of the hip.

After the operation, each patient was managed with a spica cast for six weeks with the thigh in 30 degrees of flexion, 30 degrees of abduction, and neutral rotation.

Preoperative and postoperative clinical data, including the type of cerebral palsy, walking ability, pain in the hip, complications, and previous and subsequent procedures, were recorded (Table I). Walking ability was classified as unable to walk, able to walk about the house, able to walk in the community with aids, able to walk in the community without aids, or able to walk an unlimited distance. Pain was rated as none, mild (mild pain with activities or movement but no pain at rest), moderate (moderate pain with activities or movement with or without pain at rest), or severe (severe pain with activities or movement and pain at rest).

Measurements were made on the anteroposterior radiographs by the senior one of us (K. G. S.), who had not performed the operations. Measurements included the center-edge angle of Wiberg⁴⁹, the acetabular index of Hilgenreiner⁴⁷, and the migration index of Reimers^38,39; in addition, the integrity of the Shenton line⁴⁷ was evaluated. The postoperative radiographs were also reviewed for any evidence of early closure of the triradiate cartilage.

Results

Introduction | Materials and Methods | Results | Discussion | References

The average duration of follow-up was ten years and nine months (range, three years and one month to nineteen years and nine months) (Table I). The average operative time was one hour and fifteen minutes (range, one hour to one hour and twenty minutes) for the Pemberton osteotomies that were performed alone and two hours and eight minutes (range, one hour and thirty minutes to two hours and thirty-five minutes) for the combined procedures. The time needed for application of the cast was not recorded. The average blood loss was nine milliliters per kilogram of body weight (range, five to twenty-three milliliters per kilogram of body weight). Three patients had transfusion of one unit (450 milliliters) of packed red blood cells postoperatively.

Subsequent procedures: No additional procedure was performed in eight hips. Ten hips had an additional soft-tissue procedure because of tightness or contracture of the adductor, hamstring, or iliopsoas muscles. The decision to perform these procedures was based on the absence of at least 30 degrees of abduction and straight-leg raising to 45 degrees. The recurrent contractures were not associated with subluxation or dislocation of the hip. A second intertrochanteric osteotomy was performed in one hip, three years and nine months after the index procedure, because of recurrence of the valgus deformity.

Clinical results: Preoperatively, five hips were moderately painful. At the latest follow-up examination, none of the hips were painful and all were stable both clinically and radiographically. Preoperatively, four patients were unable to walk; one was able to walk about the house; six were able to walk about the community; three were able to walk an unlimited distance; and one, who was unable to walk, was able to stand and to help with transfers. Two of the patients who had been unable to walk preoperatively were able to walk about the house postoperatively, and one patient who had been able to walk about the community preoperatively was able to walk an unlimited distance postoperatively. None of the patients had a deterioration in walking ability postoperatively (Table I).

Radiographic results: Preoperatively, none of the hips had an intact Shenton line (Fig. 2-C). Postoperatively, all of the Shenton lines were intact. The average acetabular index was 28 degrees (range, 17 to 41 degrees) preoperatively and 11 degrees (range, 4 to 29 degrees, with only one hip having an index of more than 19 degrees) at the latest follow-up examination. The average preoperative migration index was 55 per cent (range, 30 to 100 per cent) compared with 12 per cent (range 0 to 46 per cent) at the latest follow-up examination (Table I). The average center-edge angle was -5 degrees (range, -45 to 18 degrees) preoperatively and 38 degrees (range, 17 to 53 degrees) at the latest follow-up examination. Eighteen of the nineteen hips had a center-edge angle of at least 29 degrees at the latest follow-up examination. It is important to note that the center-edge angle is increased by both the Pemberton and the intertrochanteric osteotomy. The Pemberton osteotomy usually increases the lateral acetabular coverage of the femoral head, and the intertrochanteric osteotomy can shift the femoral head medially.

Results according to age: Five patients (six hips) were at least ten years old (range, ten years to twelve years and three months) at the time of the index procedure. Three of the six hips in these older children and two of the thirteen hips in the younger children were painful before the operation. The clinical results were excellent in each group, and the radiographic parameters of the acetabular configuration were comparable at the latest evaluation. The average center-edge angle was 37 degrees, the acetabular index was 8 degrees, and the migration index was 8 per cent for the hips in the older children, and the values were 38 degrees, 12 degrees, and 14 per cent, respectively, for the hips in the younger children at the latest evaluation.

Complications: All of the osteotomy sites healed without complications. There was no evidence of osteonecrosis of the femoral head, femoral fracture, or postoperative infection. Physiological closure of the triradiate cartilage occurred in sixteen of the nineteen hips by the time of the latest follow-up evaluation. There was no evidence of premature closure of the triradiate cartilage on the radiographs.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

There is a wide spectrum of hip dysplasia in spastic cerebral palsy, ranging from a hip at risk^33,36,40,45 (usually associated with muscle contractures and increased valgus angulation and excessive anteversion of the femoral neck) to dislocation. Many of these hips become painful, and if the hip is not treated a shallow acetabulum eventually develops, with notching of the superolateral portion of the femoral head^1,43. In addition to pain in the hip, problems related to perineal care, decubitus ulcers, walking, and sitting balance may develop⁴³. In order to prevent or at least to decrease the prevalence of these complications, some authors^{4,13,20,31,41,44} have emphasized the need for early operative intervention.

The characteristics of acetabular deficiency in dysplasia of the hip secondary to spasticity have not been well established⁴⁷, although attempts have been made recently to clarify the anatomy of the acetabulum in this condition. Zimmermann and Sturm⁵⁰ as well as Gugenheim et al.¹⁸ analyzed spastic hips with use of two-dimensional computerized tomography scans and found anterior acetabular deficiency, whereas Buckley et al.⁶ found posterior deficiency. Kim and Wenger²⁴ performed three-dimensional computerized tomography studies of forty-one hips (twenty-four patients) with dysplasia secondary to spasticity: fifteen hips (37 per cent) had posterior acetabular deficiency, twelve (29 per cent) had anterior deficiency, six (15 per cent) had mid-superior deficiency, and eight (20 per cent) had mixed deficiency²⁴. Abel et al.¹, using three-dimensional computerized tomography, identified global acetabular deficiencies (in the anterior and posterior walls and the acetabular roof). The configuration of the acetabulum in dysplastic hips secondary to spasticity requires additional study.

Muscle releases alone are limited in their capacity to influence the normal development of a hip that is subluxated secondary to spasticity, particularly in a child who is more than five years old^{3,16,22,33,43}, and are contraindicated if the dislocation is irreducible. Subluxation of the hip secondary to spasticity is usually associated with increased femoral valgus angulation and excessive anteversion and is best treated with an intertrochanteric femoral osteotomy combined with soft-tissue procedures^13,20,48.

The intertrochanteric osteotomy is designed to correct the abnormal anteversion and valgus deformities of the proximal aspect of the femur and, in so doing, to promote more normal development of the acetabulum. On the basis of studies of congenital dysplasia of the hip, some authors have believed that the acetabulum has the potential to remodel after reduction of a dislocated hip if the reduction is performed before the child is four years old^11,20,23; others have believed that remodeling of the acetabulum can occur until the age of eight or nine years²⁷. Both short and long-term follow-up studies of the results of intertrochanteric osteotomy for dysplasia in spastic cerebral palsy have demonstrated a limited potential for establishment of a more normal center-edge angle and for acetabular remodeling. Hoffer et al.²⁰ reported good clinical results an average of eleven years and six months after femoral varus-derotation osteotomy and muscle releases for spastic cerebral palsy. However, the average center-edge angle at the latest follow-up evaluation was only 17 degrees, suggesting that acetabular remodeling was substantially limited after the osteotomy. Those authors noted that hips that had been dislocated preoperatively did not exhibit acetabular remodeling after an open or closed reduction, and they recommended a Chiari pelvic osteotomy⁷ to correct acetabular dysplasia. Bagg et al.² noted recurrent subluxation of seven of twenty-four spastic hips an average of nineteen years (range, eight to thirty years) after soft-tissue release and varus derotation osteotomy.

In recognition of the limitations of acetabular remodeling in dysplasia secondary to spasticity, authors of several recent studies have advocated the use of pelvic or pericapsular osteotomy in conjunction with appropriate muscle-balancing procedures and intertrochanteric osteotomy^17,41,51. Dietz and Knutson¹² reported good clinical results with the Chiari osteotomy although seven of twenty-four hips in their series had a migration index of more than 30 per cent at the most recent follow-up examination. Mubarak et al.³¹ stated that the Chiari osteotomy is contraindicated in hips that are dysplastic secondary to spasticity, as the elongated, ovoid acetabulum makes it difficult to perform the osteotomy. Those authors believed that native articular cartilage can be used to reconstruct the acetabulum in most abnormal hips in spastic cerebral palsy. They reported a good or excellent result for seventeen of eighteen hips an average of six years and ten months after appropriate soft-tissue release, intertrochanteric osteotomy, and Dega acetabuloplasty^10,30. Although the shelf osteotomy^50,51 can provide adequate coverage of a hip that is dysplastic secondary to spasticity, the femoral head is not covered with articular cartilage. After a shelf procedure, the hip capsule is relied on for weight-bearing, and satisfactory results have been reported in older patients⁵¹; in younger patients, however, we advocate reconstructive procedures that involve the use of hyaline cartilage as there is the theoretical potential for longer-lasting results.

Zuckerman et al.⁵¹ and Root et al.⁴¹ advocated a combined approach (muscle release or lengthening, pelvic osteotomy or a shelf procedure, and proximal femoral osteotomy) for the treatment of dysplasia of the hip secondary to spastic cerebral palsy. We agree with the combined approach for a subluxated or dislocated dysplastic hip secondary to spasticity because of the limitations of acetabular remodeling in older children. In our experience, approaches that do not include proximal femoral and acetabular osteotomies when there is subluxation or severe acetabular dysplasia have poor results and lead to subsequent corrective osseous operations. The need for repeat operations, immobilization, and application of a spica cast often has deleterious physical and psychological effects on the patient and his or her family.

The Pemberton pericapsular osteotomy is thought to be contraindicated for dysplasia of the hip secondary to spasticity by those who believe that the primary acetabular deficiency is posterior^26,30,31. Mubarak et al.³¹ as well as Morrissy³⁰ advocated the use of Dega acetabuloplasty¹⁰ for dysplasia secondary to spasticity because this osteotomy increases posterior acetabular coverage of the femoral head. In contrast, the Pemberton osteotomy provides more direct anterior and lateral acetabular coverage of the femoral head; however, it does not sacrifice posterior coverage. In addition, the Pemberton osteotomy permits alteration of the direction of coverage from almost purely anterior to almost purely lateral by adjusting the level of the cuts on the inner and outer tables of the pelvis^8,17,35. Furthermore, appropriate levering of the anterolateral portion of the acetabulum can result in a change in the more posterolateral aspect of the acetabulum as well. At an average of four years after a Pemberton pericapsular osteotomy, Gordon et al.¹⁷ found no complications related to posterior uncovering of the femoral head in forty-four patients (fifty-two hips) who had dysplasia of the hip secondary to spasticity. In the present study, there were no complications related to inadequate posterior coverage of the femoral head and there was no subsequent subluxation or dislocation of the femoral head.

Some authors have expressed concern that the Pemberton osteotomy has the theoretical potential to injure the triradiate cartilage, resulting in premature closure and incomplete acetabular development^5,31. We have not observed this complication and do not think that it is a risk because the Pemberton osteotomy extends to but does not traverse the triradiate cartilage. This osteotomy is performed under controlled, low-energy conditions and does not result in complications due to premature closure of the triradiate cartilage^14,15,32.

The combined approach advocated by several authors for the treatment of a subluxated dysplastic hip secondary to spasticity^{16,17,31,41,51} is similar to ours. We believe that the acetabular dysplasia has limited potential for remodeling in most of these hips because of abnormal muscle forces that are not normalized with muscle-lengthening or releases. A pelvic osteotomy should be performed in most hips with dysplasia secondary to spasticity, and it should be combined with an intertrochanteric osteotomy and soft-tissue releases when indicated. The shelf osteotomy^50,51 is a good salvage alternative for acetabular dysplasia in older patients, especially when concentric reduction is not feasible. For younger patients who have an open triradiate cartilage, we believe that reconstructive acetabular procedures that involve the use of normal articular cartilage are best. In neuromuscular conditions, skeletal maturity is frequently delayed; therefore, reconstructive procedures that rely on the flexibility of the triradiate cartilage can be performed in an older child who has dysplasia of the hip secondary to spasticity. The difference between our approach and that of Mubarak et al.³¹ is the type of pelvic osteotomy used to treat the acetabular dysplasia. In both their series and ours, the clinical results were good or excellent and the most recent radiographic measurements were similar.

On the basis of our results, we believe that a combination of the Pemberton pericapsular osteotomy and selective application of muscle release, intertrochanteric osteotomy, and open reduction when necessary provides effective treatment for subluxation or dislocation of the hip and acetabular dysplasia secondary to spastic cerebral palsy.

References

Introduction | Materials and Methods | Results | Discussion | References

Abel, M. F.; Wenger, D. R.; Mubarak, S. J.; and Sutherland, D. H.: Quantitative analysis of hip dysplasia in cerebral palsy: a study of radiographs and 3-D reformatted images. J. Pediat. Orthop.,14: 283-289, 1994.14283 1994

Bagg, M. R.; Farber, J.; and Miller, F.: Long-term follow-up of hip subluxation in cerebral palsy patients. J. Pediat. Orthop.,13: 32-36, 1993.1332 1993

Banks, H. H., and Green, W. T.: Adductor myotomy and obturator neurectomy for the correction of adduction contracture of the hip in cerebral palsy. J. Bone and Joint Surg.,42-A: 111-126, Jan. 1960.42-A111 1960

Bleck, E. E.: The hip in cerebral palsy. Orthop. Clin. North America,11: 79-104, 1980.1179 1980

Bucholz, R. W.; Ezaki, M.; and Ogden, J. A.: Injury to the acetabular triradiate physeal cartilage. J. Bone and Joint Surg.,64-A: 600-609, April 1982.64-A600 1982

Buckley, S. L.; Sponseller, P. D.; and Magid, D.: The acetabulum in congenital and neuromuscular hip instability. J. Pediat. Orthop.,11: 498-501, 1991.11498 1991

Chiari, K.: Pelvic osteotomy for hip subluxation. In Proceedings of the British Orthopaedic Association. J. Bone and Joint Surg.,52-B(1): 174, 1970.52-B(1)174 1970

Coleman, S. S.: Congenital Dysplasia and Dislocation of the Hip, p. 285. St. Louis, C. V. Mosby, 1978.

Cooperman, D. R.; Bartucci, E.; Dietrick, E.; and Millar, E. A.: Hip dislocation in spastic cerebral palsy: long-term consequences. J. Pediat. Orthop.,7: 268-276, 1987.7268 1987

Dega, W.: Osteotomis trans-iliakalna w leczeniu wrodzonej dysplazji biodra. Chir. Narzadow Ruchu Ortop. Polska,38: 601-613, 1974.38601 1974

Dega, W.; Król, J.; and Polakowski, L.: Surgical treatment of congenital dislocation of the hip in children. A one-stage procedure. J. Bone and Joint Surg.,41-A: 920-934, July 1959.41-A920 1959

Dietz, F. R., and Knutson, L. M.: Chiari pelvic osteotomy in cerebral palsy. J. Pediat. Orthop.,15: 372-380, 1995.15372 1995

Eilert, R. E., and MacEwen, G. D.: Varus derotational osteotomy of the femur in cerebral palsy. Clin. Orthop.,125: 168-172, 1977.125168 1977 [PubMed]

Eyre-Brook, A. L.; Jones, D. A.; and Harris, F. C.: Pemberton's acetabuloplasty for congenital dislocation or subluxation of the hip. J. Bone and Joint Surg.,60-B(1): 18-24, 1978.60-B(1)18 1978

Faciszewski, T.; Kiefer, G. N.; and Coleman, S. S.: Pemberton osteotomy for residual acetabular dysplasia in children who have congenital dislocation of the hip. J. Bone and Joint Surg.,75-A: 643-649, May 1993.75-A643 1993

Gamble, J. G.; Rinsky, L. A.; and Bleck, E. E.: Established hip dislocations in children with cerebral palsy. Clin. Orthop.,253: 90-99, 1990.25390 1990 [PubMed]

Gordon, J. E.; Capelli, A. M.; Strecker, W. B.; Delgado, E. D.; and Schoenecker, P. L.: Pemberton pelvic osteotomy and varus rotational osteotomy in the treatment of acetabular dysplasia in patients who have static encephalopathy. J. Bone and Joint Surg.,78-A: 1863-1871, Dec. 1996.78-A1863 1996

Gugenheim, J. L.; Gerson, L. P.; Sadler, C.; and Tullos, H. S.: Pathologic morphology of the acetabulum in paralytic and congenital hip instability. J. Pediat. Orthop.,2: 397-400, 1982.2397 1982

Hoffer, M. M., and Koffman, M.: Cerebral palsy: the first three years. Clin. Orthop.,151: 222-227, 1980.151222 1980 [PubMed]

Hoffer, M. M.; Stein, G. A.; Koffman, M.; and Prietto, M.: Femoral varus-derotation osteotomy in spastic cerebral palsy. J. Bone and Joint Surg.,67-A: 1229-1235, Oct. 1985.67-A1229 1985

Howard, C. B.; McKibbin, B.; Williams, L. A.; and Mackie, I.: Factors affecting the incidence of hip dislocation in cerebral palsy. J. Bone and Joint Surg.,67-B(4): 530-532, 1985.67-B(4)530 1985

Kalen, V., and Bleck, E. E.: Prevention of spastic paralytic dislocation of the hip. Devel. Med. and Child Neurol.,27: 17-24, 1985.2717 1985

Kasser, J. R.; Bowen, J. R.; and MacEwen, G. D.: Varus derotation osteotomy in the treatment of persistent dysplasia in congenital dislocation of the hip. J. Bone and Joint Surg.,67-A: 195-202, Feb. 1985.67-A195 1985

Kim, H. T., and Wenger, D. R.: Location of acetabular deficiency and associated hip dislocation in neuromuscular hip dysplasia: a three-dimensional computed tomography analysis. J. Pediat. Orthop.,17: 143-151, 1997.17143 1997

Koffman, M.: Proximal femoral resection or total hip replacement in severely disabled cerebral-spastic patients. Orthop. Clin. North America,12: 91-100, 1981.1291 1981

Lasda, N. A.; Levinsohn, E. M.; Yuan, H. A.; and Bunnell, W. P.: Computerized tomography in disorders of the hip. J. Bone and Joint Surg.,60-A: 1099-1102, Dec. 1978.60-A1099 1978

Lindstrom, J. R.; Ponseti, I. V.; and Wenger, D. R.: Acetabular development after reduction in congenital dislocation of the hip. J. Bone and Joint Surg.,61-A: 112-118, Jan. 1979.61-A112 1979

Lonstein, J. E., and Beck, K.: Hip dislocation and subluxation in cerebral palsy. J. Pediat. Orthop.,6: 521-526, 1986.6521 1986

Mathews, S. S.; Jones, M. H.; and Sperling, S. C.: Hip derangements seen in cerebral palsied children. Am. J. Phys. Med.,32: 213-221, 1953.32213 1953 [PubMed]

Morrissy, R. T.: Atlas of Pediatric Orthopaedic Surgery, pp. 181-188. Philadelphia, J. B. Lippincott, 1992.

Mubarak, S. J.; Valencia, F. G.; and Wenger, D. R.: One-stage correction of the spastic dislocated hip. Use of pericapsular acetabuloplasty to improve coverage. J. Bone and Joint Surg.,74-A: 1347-1357, Oct. 1992.74-A1347 1992

Ogden, J. A.: Skeletal Injury in the Child, pp. 645-658. Philadelphia, Lea and Febiger, 1982.

Onimus, M.; Allamel, G.; Manzone, P.; and Laurain, J. M.: Prevention of hip dislocation in cerebral palsy by early psoas and adductors tenotomies. J. Pediat. Orthop.,11: 432-435, 1991.11432 1991

Pemberton, P. A.: Osteotomy of the ilium with rotation of the acetabular roof for congenital dislocation of the hip. In Proceedings of The American Academy of Orthopaedic Surgeons. J. Bone and Joint Surg.,40-A: 724-725, June 1958.40-A724 1958

Pemberton, P. A.: Pericapsular osteotomy of the ilium for treatment of congenital subluxation and dislocation of the hip. J. Bone and Joint Surg.,47-A: 65-86, Jan. 1965.47-A65 1965

Phelps, W. M.: Prevention of acquired dislocation of the hip in cerebral palsy. J. Bone and Joint Surg.,41-A: 440-448, April 1959.41-A440 1959

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Reimers, J.: The stability of the hip in children. A radiological study of the results of muscle surgery in cerebral palsy. Acta Orthop. Scandinavica, Supplementum,184: 1980.184 1980

Reimers, J., and Bialik, V.: Influence of femoral rotation on the radiological coverage of the femoral head in children. Pediat. Radiol.,10: 215-218, 1981.10215 1981 [PubMed]

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Root, L.; Laplaza, F. J.; Brourman, S. N.; and Angel, D. H.: The severely unstable hip in cerebral palsy. Treatment with open reduction, pelvic osteotomy, and femoral osteotomy with shortening. J. Bone and Joint Surg.,77-A: 703-712, May 1995.77-A703 1995

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Tönnis, D.: Congenital Dysplasia and Dislocation of the Hip in Children and Adults, pp. 76-77, 117. Berlin, Springer, 1987.

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FIG1-B:: Fig. 1-B Two months after bilateral Pemberton osteotomy, there was good coverage of the femoral heads, which were in a reduced position.

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FIG1-C:: Fig. 1-C Eleven years and four months postoperatively, the acetabula were well developed and there was spherical congruency of the femoral heads and the acetabula.

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FIG2-C:: Fig. 2-C Three years and one month postoperatively, the acetabular roof and teardrop were well developed and the Shenton line was intact, indicating a stable hip.

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TABLE I CLINICAL AND RADIOGRAPHIC DATA ON THE PATIENTS

*0 = none, and 2 = moderate.

Case	Gender	Type of Cerebral Palsy	Side	Preop. Status of Hip	Age at Op. (Yrs. + Mos.)	Simultaneous Procedure	Subsequent Procedure	Duration of Follow-up (Yrs. + Mos.)	Pain*		Walking Ability		Center-Edge Angle⁴⁹ (Degrees)		Acetabular Index⁴⁷ (Degrees)		Migration Index of Reimers^38,39 (Per Cent)
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	F	Diplegia	R	Subluxated	3 + 6	None	None	14 + 11	0	0	About community with aids	About community without aids	-23	38	39	14	95	13
			L	Dislocated	3 + 5	None	None	15 + 0	0	0			-45	40	41	19	100	8
2	F	Hemiplegia	R	Subluxated	3 + 10	None	None	11 + 4	0	0	Unlimited	Unlimited	7	42	32	8	40	10
3	F	Hemiplegia	R	Dysplastic	5 + 11	Iliopsoas release	None	11 + 11	0	0	About community with aids	About community without aids	11	43	22	14	31	10
4	F	Hemiplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. release	None	10 + 6	2	0	Unlimited	Unlimited	14	39	18	4	40	8
5	M	Quadriplegia	L	Subluxated	5 + 5	Intertrochant. osteot.	Adduct. transfer, prox. hamstring release	11 + 8	0	0	Unable	Able to stand	-8	47	27	9	52	11
			R	Subluxated	4 + 3	Intertrochant. osteot., open reduct.	Adduct. transfer, prox. hamstring release	12 + 9	0	0			-15	39	29	8	50	9
6	F	Quadriplegia	R	Subluxated	8 + 4	Intertrochant. osteot.	Prox. hamstring release	9 + 4	2	0	About community with aids	About community with aids	12	41	27	11	41	21
7	F	Hemiplegia	L	Dislocated	6 + 2	Intertrochant. osteot., open reduct., iliopsoas release	Intertrochant. osteot.	10 + 1	0	0	Unlimited	Unlimited	-40	17	32	29	100	46
8	M	Quadriplegia	L	Subluxated	9 + 5	Intertrochant. osteot., adduct. & iliopsoas release, prox. hamstring release	None	3 + 1	2	0	Unable	About house	-16	53	25	8	58	0
9	M	Quadriplegia	L	Subluxated	7 + 10	Intertrochant. osteot., iliopsoas release, prox. hamstring release	None	8 + 9	0	0	About community with aids	About community with aids	0	29	31	15	50	10
10	M	Quadriplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. transfer, iliopsoas release	None	3 + 9	0	0	About community with aids	Unlimited	18	40	17	7	34	9
11	F	Diplegia	L	Dysplastic	7 + 11	Intertrochant. osteot., iliopsoas release	Adduct. transfer, distal hamstring release	14 + 1	0	0	About community with aids	About community with aids	18	32	18	9	30	7
12	F	Quadriplegia	R	Subluxated	10 + 2	Iliopsoas release	Adduct. transfer, prox. hamstring release	19 + 9	0	0	Unable	About house	5	47	32	6	42	8
13	F	Quadriplegia	L	Subuxated	8 + 2	Intertrochant. osteot.	Adduct. transfer, iliopsoas release	13 + 2	0	0	Able to stand	Able to stand	-2	30	33	6	48	23
			R	Subluxated	7 + 4	Intertrochant. osteot.	Adduct. release, prox. hamstring release	14 + 0	0	0			-2	43	27	8	56	8
14	M	Quadriplegia	R	Subluxated	10 + 0	None	Adduct transfer,. abduct. release, prox. hamstring release	8 + 0	0	0	About house	About house	17	33	24	15	33	16
15	M	Mixed	R	Subluxated	12 + 3	Intertrochant. osteot.	Adduct. transfer, iliopsoas release, distal hamstring release	5 + 4	2	0	Unable	Unable	-7	32	30	12	55	9
			L	Subluxated	10 + 9	Intertrochant.osteot., adduct. release, open reduct.	Adduct. transfer, iliopsoas release, distal hamstring release	6 + 10	2	0			-30	33	27	5	92	0
Average					7 + 9			10 + 9					-5	38	28	11	55	12

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TABLE I CLINICAL AND RADIOGRAPHIC DATA ON THE PATIENTS

*0 = none, and 2 = moderate.

Case	Gender	Type of Cerebral Palsy	Side	Preop. Status of Hip	Age at Op. (Yrs. + Mos.)	Simultaneous Procedure	Subsequent Procedure	Duration of Follow-up (Yrs. + Mos.)	Pain*		Walking Ability		Center-Edge Angle⁴⁹ (Degrees)		Acetabular Index⁴⁷ (Degrees)		Migration Index of Reimers^38,39 (Per Cent)
Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.	Preop.	Postop.
1	F	Diplegia	R	Subluxated	3 + 6	None	None	14 + 11	0	0	About community with aids	About community without aids	-23	38	39	14	95	13
			L	Dislocated	3 + 5	None	None	15 + 0	0	0			-45	40	41	19	100	8
2	F	Hemiplegia	R	Subluxated	3 + 10	None	None	11 + 4	0	0	Unlimited	Unlimited	7	42	32	8	40	10
3	F	Hemiplegia	R	Dysplastic	5 + 11	Iliopsoas release	None	11 + 11	0	0	About community with aids	About community without aids	11	43	22	14	31	10
4	F	Hemiplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. release	None	10 + 6	2	0	Unlimited	Unlimited	14	39	18	4	40	8
5	M	Quadriplegia	L	Subluxated	5 + 5	Intertrochant. osteot.	Adduct. transfer, prox. hamstring release	11 + 8	0	0	Unable	Able to stand	-8	47	27	9	52	11
			R	Subluxated	4 + 3	Intertrochant. osteot., open reduct.	Adduct. transfer, prox. hamstring release	12 + 9	0	0			-15	39	29	8	50	9
6	F	Quadriplegia	R	Subluxated	8 + 4	Intertrochant. osteot.	Prox. hamstring release	9 + 4	2	0	About community with aids	About community with aids	12	41	27	11	41	21
7	F	Hemiplegia	L	Dislocated	6 + 2	Intertrochant. osteot., open reduct., iliopsoas release	Intertrochant. osteot.	10 + 1	0	0	Unlimited	Unlimited	-40	17	32	29	100	46
8	M	Quadriplegia	L	Subluxated	9 + 5	Intertrochant. osteot., adduct. & iliopsoas release, prox. hamstring release	None	3 + 1	2	0	Unable	About house	-16	53	25	8	58	0
9	M	Quadriplegia	L	Subluxated	7 + 10	Intertrochant. osteot., iliopsoas release, prox. hamstring release	None	8 + 9	0	0	About community with aids	About community with aids	0	29	31	15	50	10
10	M	Quadriplegia	L	Subluxated	11 + 2	Intertrochant.osteot., adduct. transfer, iliopsoas release	None	3 + 9	0	0	About community with aids	Unlimited	18	40	17	7	34	9
11	F	Diplegia	L	Dysplastic	7 + 11	Intertrochant. osteot., iliopsoas release	Adduct. transfer, distal hamstring release	14 + 1	0	0	About community with aids	About community with aids	18	32	18	9	30	7
12	F	Quadriplegia	R	Subluxated	10 + 2	Iliopsoas release	Adduct. transfer, prox. hamstring release	19 + 9	0	0	Unable	About house	5	47	32	6	42	8
13	F	Quadriplegia	L	Subuxated	8 + 2	Intertrochant. osteot.	Adduct. transfer, iliopsoas release	13 + 2	0	0	Able to stand	Able to stand	-2	30	33	6	48	23
			R	Subluxated	7 + 4	Intertrochant. osteot.	Adduct. release, prox. hamstring release	14 + 0	0	0			-2	43	27	8	56	8
14	M	Quadriplegia	R	Subluxated	10 + 0	None	Adduct transfer,. abduct. release, prox. hamstring release	8 + 0	0	0	About house	About house	17	33	24	15	33	16
15	M	Mixed	R	Subluxated	12 + 3	Intertrochant. osteot.	Adduct. transfer, iliopsoas release, distal hamstring release	5 + 4	2	0	Unable	Unable	-7	32	30	12	55	9
			L	Subluxated	10 + 9	Intertrochant.osteot., adduct. release, open reduct.	Adduct. transfer, iliopsoas release, distal hamstring release	6 + 10	2	0			-30	33	27	5	92	0
Average					7 + 9			10 + 9					-5	38	28	11	55	12