What is the procedure for osteotomy of the right hip due to hip pain in a patient with cerebral palsy?

Hip Osteotomy for Hip Pain in Cerebral Palsy

For patients with cerebral palsy experiencing hip pain due to subluxation or inadequate femoral head coverage, femoral varus-derotation osteotomy combined with soft tissue releases is the primary reconstructive procedure, while pelvic osteotomy (Dega-type or incomplete transiliac) is added when acetabular dysplasia is present. 1, 2, 3

Indications for Osteotomy

The principal indication for hip osteotomy in cerebral palsy is:

• Inadequate coverage of the femoral head (most common) 1
• Hip subluxation with migration percentage >30-40% 2, 3
• Hip pain that interferes with function or sitting 1, 2
• Valgus deformity of the femoral neck 1
• Hip dislocation in younger, potentially salvageable hips 1, 3

Surgical Procedure Components

Femoral Varus-Derotation Osteotomy

• Performed in combination with muscle releases (adductor and iliopsoas releases are typically required) 1
• Reduces the neck-shaft angle from approximately 155° preoperatively to 114° immediately postoperatively 1
• Includes derotation component to correct excessive femoral anteversion 2, 3
• Often includes femoral shortening (varus-shortening osteotomy) to facilitate reduction without excessive soft tissue tension 2, 3

Pelvic Osteotomy (When Acetabular Dysplasia Present)

Dega-type osteotomy:

• Can be performed even after triradiate cartilage closure in non-walking patients 2
• Involves incomplete cut through the ilium, leaving the sciatic notch intact 2
• Improves acetabular coverage by redirecting the acetabulum 2
• Reduces migration percentage from mean 70% to 10% postoperatively 2

Incomplete transiliac osteotomy:

• Effective even in skeletally mature adolescents after triradiate cartilage closure 3
• Hinges through intact sciatic notch 3
• Reduces Reimers' migration index from mean 52% to 7% at follow-up 3
• Reduces Sharp's angle from mean 52° to 35° 3

Surgical Technique Sequence

1. Soft tissue releases first (adductor tenotomy, iliopsoas lengthening/release) 1, 2, 3
2. Femoral varus-derotation-shortening osteotomy 2, 3
3. Pelvic osteotomy (Dega or transiliac type) if acetabular dysplasia present 2, 3
4. Internal fixation of osteotomy sites 2, 3

Expected Outcomes

• Pain relief achieved in 79-88% of patients (26 of 33 hips in one series) 3
• Maintenance of ambulatory status in walking patients 1
• Improved sitting tolerance and positioning in non-ambulatory patients 2
• Center-edge angle improves from mean -8° to +17° 1
• Most hips achieve well-centered femoral head position 1, 3

Complications to Monitor

• Acetabular fracture during pelvic osteotomy (occurred in 5 of 52 hips but without adverse functional outcome) 2
• Avascular necrosis of superior acetabular segment (rare) 2
• Persistent subluxation if migration percentage remains >25% postoperatively 2
• Recurrent hip displacement requiring revision surgery 1, 3

Age Considerations

• Optimal timing: Before skeletal maturity when triradiate cartilage is open 1
• Can still be performed after skeletal maturity (mean age 15 years in one series) with good results using incomplete transiliac osteotomy 3
• Younger patients (4-15 years) have excellent outcomes with combined procedures 1

When Osteotomy is NOT Appropriate

Consider salvage procedures instead when:

• Severe established dislocation with degenerative changes 4, 5
• Failed prior reconstructive surgery 5
• Older patients (>20 years) with chronic dislocation 4
• In these cases, total hip replacement or resection arthroplasty are alternatives 4, 5

Critical Pitfall to Avoid

Do not perform isolated femoral osteotomy without addressing acetabular dysplasia - the combination of femoral varus-derotation osteotomy with pelvic osteotomy and soft tissue releases provides superior outcomes compared to femoral osteotomy alone when acetabular coverage is inadequate 1, 2, 3