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Introduction: severe, rigid hip abduction deformity in individuals with cerebral palsy (CP) is an exceptionally uncommon condition. This posture hinders the positioning in the wheelchair and the completion of basic activities of daily living (ADL). Addressing such severe deformities can be quite challenging., Material and Methods: a 14-year-old male, with spastic-dystonic quadriplegic CP, developed rigid and severe flexion-abduction contractures in both hips, characterized by 90 degrees of flexion and 100 degrees of abduction. These contractures severely impeded his ability to comfortably use a wheelchair and even pass through doorways. Performing basic ADLs became a significant challenge for both the patient and his caregivers., Results: the treatment approach involved a two-stage surgical procedure, one for each hip, with a two-month interval between them. An extensive release of the fascia latae, gluteus maximus, external rotators, and hip flexors; in combination with a proximal femur osteotomy were performed. To maintain the corrections achieved, long-leg casts connected with two bars were employed, followed by orthotic support and physiotherapy. Following the procedure, lower limb adduction was achieved, and the patient and caregivers were highly satisfied, as ADLs and basic caregiving had been greatly facilitated., Conclusions: while the available literature on the management of severe rigid abduction hip contractures in non-ambulatory CP patients is limited, and treatment options are often complex, the present case underscores the effectiveness of a comprehensive approach involving soft tissue release and bone surgery. Achieving a more favorable wheelchair positioning and facilitating basic ADLs and care represents a significant success for patients and families.

Aim: The aim was to identify the prevalence of hip contractures and their association with gross motor function and pain in the lower extremities among Danish children with cerebral palsy (CP)., Methods: This cross-sectional study was based on data collected during regular clinical examinations in 2018-2019 and registered in the National Danish Clinical Quality Database of children with CP. The study population was 688 children (59% boys) aged five to 12 years across all Gross Motor Function Classification System (GMFCS) levels. Any associations between hip contracture and gross motor function and pain were investigated with logistic regression analysis and presented as odds ratios (OR) with 95% confidence intervals (95% CI)., Results: The prevalence of hip contracture was 22% across all five GMFCS levels, and the incidence varied across the five Danish regions. The odds ratios for hip contracture were significantly higher at GMFCS level IV (OR 1.99, 95% CI 1.10-3.62) and V (OR 5.49, 95% CI 3.33-9.07) compared with level I. Hip contractures were not significantly associated with pain in the lower extremities (OR 1.43, 95% CI 0.95-2.15)., Conclusion: Hip contractures were frequent and associated with low gross motor function, but not lower extremity pain, in children with CP., (©2020 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Despite significant pain relief following total hip arthroplasty (THA) in patients with ankylosing spondylitis, a small subset of patients presenting with extra-articular extension contracture of hips remains unsatisfied., Methods: We retrospectively evaluated the patients with ankylosing spondylitis who underwent simultaneous bilateral THA and had extensor tightness of both hips preoperatively. They were managed with modified Z-plasty of iliotibial band. Patients with windswept deformity, commonly seen in bilateral hip arthritis caused by ankylosing spondylitis, were excluded., Results: Between July 2011 and June 2015, out of 148 patients with bilateral hip involvement, 10 patients (20 hips) had extension contracture of both hips that was addressed during surgery. All patients were followed up for a minimum of 2 years. They could sit comfortably on a chair of height 18 inches with hips and knees flexed to at least 90°. The mean postoperative sum range of motion was 144.6° with an average hip flexion of 95° (range, 90°-105°). None of them had recurrence of extension contracture. There was significant improvement in range of motion and hence ambulation and function. No radiolucent lines exceeding 2 mm were seen in any of the zones around either of the components as evaluated in latest X-rays., Conclusion: Extension contracture of hip although rare is a noticeable problem and needs to be addressed during THA. Modified Z-plasty technique of iliotibial band is a reliable method in managing these patients., (Copyright © 2018. Published by Elsevier Inc.)

Background: Hip flexion contracture often occurs after femoral lengthening in patients with achondroplasia, but few studies have investigated its development in these patients. The purpose of this study was to analyze sustained hip flexion contracture in achondroplasia patients who underwent femoral lengthening and to identify contributing factors., Methods: This study included 34 patients with achondroplasia who underwent femoral lengthening (mean age at operation, 11.1 years). Sustained hip flexion was defined as flexion contracture lasting > 6 months postoperatively despite physiotherapy. Demographic data, spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, and sagittal vertical axis), and quantitative assessments of femoral lengthening were investigated. The associations among these factors and the development of sustained hip flexion contracture were assessed., Results: Sustained hip flexion contracture developed in 13 (38%) of 34 achondroplasia patients after femoral lengthening. Eight (62%) of these 13 patients concomitantly exhibited limitation of knee flexion. Excessive femoral lengthening (odds ratio [OR], 1.450; 95% confidence interval [CI], 1.064 to 1.975; p = 0.019) and forward sagittal vertical axis tilt (OR, 1.062; 95% CI, 1.001 to 1.127; p = 0.047) contributed to sustained hip flexion contracture., Conclusions: Sustained hip flexion contracture frequently occurs after femoral lengthening in achondroplasia patients. Both excessive femoral lengthening and preoperative forward SVA tilt may contribute to the development of sustained hip flexion contracture in these patients.

Background: Lower extremity joint contractures have negative effects on gait in children with Duchenne muscular dystrophy (DMD). Thus, contracture prevention is essential for maintaining a patient's functional ability and an acceptable quality of life. This study investigated hip flexion (HF), knee flexion (KF), and ankle joint plantar flexion (APF) contractures among male patients with DMD, based on the patients' ambulatory status. Differences in major joint contractures, based on passive stretching exercise participation, were also investigated., Methods: A total of 128 boys with DMD, followed at the DMD clinic of a tertiary care hospital, were included in this cross-sectional study. The passive ranges-of-motion of the hip, knee, and ankle joints were measured, in the sagittal plane, using a goniometer. The Vignos Scale was used to grade ambulatory function. Boys with DMD who performed stretching exercises for more than 5 min/session, > 3 sessions/week, were classified into the stretching group., Results: The HF (23.5 o ), KF (43.5 o ), and APF (34.5 o ) contracture angles in the non-ambulatory group were more severe than those in the ambulatory group. APF contractures (41 patients, 52.6%) were more frequently observed early, even within the ambulatory period, than were hip (8 patients, 10.3%), and knee joint (17 patients, 21.8%) contractures. Passive stretching exercises > 3 sessions/week were not associated with the degree of lower extremity joint contractures in the ambulatory or non-ambulatory group., Conclusion: HF, KF, and APF contractures are more common and severe when there is deterioration of ambulatory function. Stretching exercises alone are unlikely to prevent lower extremity joint contractures.

Background: We describe a case of severe and progressive lumbar hyperlordosis (160°) in a 28-year-old female university student with cerebral palsy. Her main complaints were abdominal wall pain and increasing inability to sit in her custom wheelchair., Method: When deciding on our opinion about the most promising treatment strategy, we contemplated slow continued correction by means of percutaneously expandable magnetic rods (MAGEC) after the index surgery as a key component of a satisfactory correction in this severe and rigid curve. After an initial radical release and partial correction, a release and correction procedure was required for the bilateral hip flexion contracture. A final in situ posterior fusion was performed as a second spinal procedure, once the desired final correction at 66° of lumbar lordosis was achieved., Result: Three years after the completion of surgery, the patient has a stable clinical and radiological result as well as a solid posterior fusion on CT., Conclusion: This is the first case published in which percutaneous magnetic distraction was successfully used in an adult patient.

Treatment of chronic peripheral ischemic wounds in patients with spinal cord injury (SCI) can be technically challenging, especially if they have significant hip contracture. This article describes the endovascular aortoiliac revascularization of a paraplegic patient with hip contracture and a hostile abdomen. It also reviews the particularity of the peripheral arterial system in SCI patients., (Published by Elsevier Inc.)

Objectives: To analyse the correlation between the number of joint-contractures and other major clinical findings in a follow-up study of 131 patients with systemic sclerosis (SSc)., Methods: The range of motion of joints (ROM), HAQ-DI, and the major clinical characteristics were assessed., Results: A high frequency of contractures (ROM<75% of the normal) were present at baseline in small joints of the hand (82%), wrists (75%), and shoulders (50%). ROM of the dominant side hand was significantly more decreased compared to the non-dominant side. The number of the upper extremity contractures correlated positively with ESR (p<0.01), CRP (p<0.01), HAQ-DI (p<0.01), and negatively with forced vital capacity (FVC) (p<0.05). The number of contractures was not significantly different in cases with early (≤ 4 years) and late disease duration in both the limited and diffuse subgroups. During the three-year follow-up period, an increase in the number of joint contractures (ROM<75%) was associated with an increase of ESR, modified Rodnan's skin score, and the European Scleroderma Study Group Activity Index by multiple linear regression analysis. Univariate analysis over a six-year period demonstrated poor outcome in patients with more than ten contractures, or more than four contractures of unilateral hand-joints., Conclusions: Contractures predominantly develop during the early years following disease onset in both SSc subgroups. Inflammation and skin-involvement are significant contributing factors for the development of contractures. The dominant hand may be more pronouncedly impaired compared to the non-dominant side. A high number of joint-contractures might be an unfavourable prognostic factor in SSc.

Background: Adequate hip range of motion is required for the transfer of energy from the lower to the upper extremity along the kinetic chain. Repetitive rotational stresses in the lower extremities during tennis may lead to sport-specific range of motion adaptations, which may increase the risk of injury to other joints along the kinetic chain., Purpose: To assess whether such range of motion adaptations occur in the hip, and if so, to identify whether they are associated with injury., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 125 female professional tennis players, the majority of whom were ranked in the top 200 World Tennis Association singles rankings, underwent a comprehensive preparticipation physical health status examination. Hip range of motion was assessed using a digital inclinometer and side-to-side differences in rotational parameters calculated, and associations with previous injuries were identified., Results: A history of an abdominal strain was reported by 10% of players, and there was an association between abdominal strains and the presence of hip flexion contractures (odds ratio, 6.1; P = .006). Hip flexion contractures were bilateral in 85% of those found, affected only the nondominant side in 9%, and affected only the dominant side in 6%. We were unable to identify any specific side-to-side rotational adaptations in the dominant or nondominant hips, and no association between loss of hip range of motion and shoulder, lower back, hip, knee, or ankle injuries was found., Conclusion: We report an association in female professional tennis players between abdominal strains and flexion contractures of the hip with iliopsoas tightness. We did not find evidence of specific hip adaptations in rotational range of motion. If hip flexion contractures are found on clinical examination, a stretching program may be indicated. Further studies are required to assess whether such a program can reduce the risk of abdominal injury., (© 2014 The Author(s).)

Objective: Accurate understanding of the cause of the underlying pathology in children with diastrophic dysplasia would help in designing targeted management of their locomotion., Methods: Diastrophic dysplasia was diagnosed in twelve patients (nine girls and three boys; age range 1-14 years), all of whom presented with small stature and apparent short extremities. Club foot (mostly talipes equinovarus) was the most frequent and consistent abnormality. Concomitant abnormalities such as hip flexion contracture, flexion contractures of the knees with excessive valgus deformity and lateral patellar subluxation, were also encountered. Muscle ultrasound and muscle magnetic resonance imaging imaging showed no myopathic changes and muscle biopsies and the respiratory chain were normal. Serum choline kinase and plasma lactate concentrations were normal., Results: Surgical correction of the foot and ankle in patients with diastrophic dysplasia is extremely difficult because of the markedly distorted anatomy. In all of these children, plantigrade foot was achieved along with the improved function of the locomotor system. Mutations of the diastrophic dysplasia sulfate transporter (also known as solute carrier family 26 member 2) were encountered., Conclusion: Arthrogryposis multiplex is the usual terminology used to describe the abnormality in infants with multiple contractures. Diligent orthopaedic care should be provided based on an accurate understanding of the associated syndromes in such children., (© 2014 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd.)

Osteochondroma (or osteocartilaginous exostosis) is the most common bone tumor of childhood, with an incidence ranging from 1 to 1.4 per 1,000,000. In the lumbar spine, osteochondromata usually arise from the posterior column at the secondary ossification center and grow away from the spinal canal without causing neurologic deficits. This article reports a rare intraspinal lumbar osteochondroma that compressed the thecal sac, resulting in a hip flexion contracture in an 11-year-old boy. This lumbar, intraspinal, extradural exostosis was confluent with the L3 inferior articular process and compressed the L3 nerve root and thecal sac severely. The patient underwent an en bloc resection of the tumor with a right-sided hemilaminectomy of L3 and L4, a right-sided partial facetectomy at L3 to L4, and an extended resection from the pars intra-articularis of the L2 to the L5 vertebrae. The tumor specimen measured 4.8×3.7×2.5 cm with clear margins. Instrumented posterolateral fusion was completed from L2 to L5 due to iatrogenic instability from the resection. The patient had an uneventful recovery and returned to his normal activities of daily living, including sports. He remains asymptomatic at 54-month follow-up. A solitary lumbar osteochondroma that compresses the spinal cord, resulting in a motor neurological deficit, has not been reported in a pediatric patient. Orthopedic surgeons should be aware of potential intraspinal presentation of osteochondromas. Magnetic resonance imaging is the modality of choice in diagnosing and screening for spinal osteochondromas. These cases can be treated with resection surgery., (Copyright 2014, SLACK Incorporated.)

Introduction: Adductor spasticity at hips is the main barrier in functional activities and rehabilitation of spastic cerebral palsy patients. The aim of this study is to evaluate the results of percutaneous adductor release under general anaesthesia., Methods: From July 2005 to July 2010, 64 hips in 32 patients (19 males and 13 females) were recruited from outpatient department having adductor contracture at hips in cerebral palsy children. All children were operated under general anaesthesia. All children were followed for twenty-four months. The clinical results were evaluated radiologically, including measurement of CE- angle, AC-index and femoral head coverage and in terms of activity level of children., Results: Of the thirty-two children, twenty-eight showed marked and immediate improvement. None of our children was functionally worse at follow-up. The CE-angle and femoral head coverage did not change significantly. The AC-index improved significantly (P = 0.01).The results were excellent in 12.5% children, good in 50%, fair in 25% and poor in 12.5%., Conclusions: Bilateral mini-invasive adductor release can be an effective treatment for children suffering from adductor contracture refractory to nonoperative management and early adductor release can prevent subluxation and possibly the need for future bony procedure on the proximal femur and pelvis.

Mucopolysaccharidosis and other lysosomal storage diseases are rare, chronic, and progressive inherited diseases caused by a deficit of lysosomal enzymes. Patients are affected by a wide variety of symptoms. For some lysosomal storage diseases, effective treatments to arrest disease progression, or slow the pathologic process, and increase patient life expectancy are available or being developed. Timely diagnosis is crucial. Rheumatologists, orthopedics, and neurologists are commonly consulted due to unspecific musculoskeletal signs and symptoms. Pain, stiffness, contractures of joints in absence of clinical signs of inflammation, bone pain or abnormalities, osteopenia, osteonecrosis, secondary osteoarthritis or hip dysplasia are the alerting symptoms that should induce suspicion of a lysosomal storage disease., (Copyright © 2013 Elsevier Inc. All rights reserved.)

This study used the random forest algorithm to predict outcomes of intramuscular psoas lengthening as part of a single event multi-level surgery in patients with cerebral palsy. Data related to preoperative medical history, physical exam, and instrumented three-dimensional gait analysis were extracted from a historic database in a motion analysis center. Data from 800 limbs of patients with diplegic cerebral palsy were analyzed. An index quantifying the overall deviation in pelvic tilt and hip flexion was used to define outcome categories. The random forest algorithm was used to derive criteria that predicted the outcome of a limb. The criteria were applied to limbs that underwent psoas lengthening with outstanding results (accuracy=.78, sensitivity=.82, specificity=.73). The criteria were then validated using an extended retrospective case-control design. Case limbs met the criteria and underwent psoas lengthening. Control limbs met the criteria, but did not undergo psoas lengthening. Over-treated limbs failed the criteria and underwent psoas lengthening. Other-treated limbs failed the criteria and did not undergo psoas lengthening. The rate of good outcomes among Cases exceeded that observed among controls (82% vs. 60%, relative risk=1.37), and far exceeded that observed in Over-treated limbs (27%). Other-treated limbs had good outcomes 52% of the time. Application of the criteria in the future is estimated to increase the overall rate of good pelvis-hip outcomes from 58% to 72% among children with diplegia who undergo single-event multi-level surgery (SEMLS)., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Treatment of chronic hip instability in children and young adults is challenging. Proximal femoral osteotomy had been suggested to provide pelvic stability and improved abductor function. Total hip replacement after pelvic support osteotomy can be challenging due to altered anatomy due to angulation of the proximal femur in both frontal and sagittal planes. This is a 29-year-old woman who had total hip replacement after pelvic support osteotomy. The patient had pelvic support at the age of 14 years. Pelvic support osteotomy delayed the need for total hip replacement for 15 years. Preoperative planning for total hip replacement with model was used for proper understanding of the anatomy of the proximal femur. Revision of femoral component was necessary due to penetration of the proximal femur. In conclusion, total hip replacement after pelvic support osteotomy is a technically demanding procedure, and careful attention to surgical details is necessary for successful outcome.

Arthrogryposis represents a group of heterogeneous disorders, characterized by contractures of multiple joints at birth. Involvement of the hip is very common (55-90% of patients) ranging from soft tissue contractures to subluxation and dislocation. Isolated contracture of the hip can usually be managed conservatively: compensative mechanisms and contractures of other joints should be evaluated before planning surgery. For unilateral dislocations, open reduction is indicated to provide a level pelvis, even though the risk of stiffness, avascular necrosis and redislocation is significant. Indications for surgical reduction of bilateral dislocations are more controversial: an adequate evaluation of ambulatory potential of the child (muscular weakness, involvement of upper extremities, etc.) and of stiffness of the hips is suggested. An extensive and long-lasting programme of bracing, physiotherapy and multiple surgery may lead to some measure of functional ambulation in most cases, but high need for surgery and considerable risk of complications must be considered. This paper summarizes problems and principles of treatment for hip contractures and dislocations in arthrogryposis and provides a review of the current literature.

Background: this study was undertaken to determine the validity and reliability of the physical examination tests commonly used to measure hip flexion contracture in patients with cerebral palsy who are able to walk., Methods: thirty-six consecutive patients (twenty-two male and fourteen female patients), with a mean age (and standard deviation) of 9.8 ± 3.9 years, who had cerebral palsy (level I, II, or III on the Gross Motor Function Classification System) and thirty-seven children without cerebral palsy (nineteen male and eighteen female subjects), with a mean age of 10.0 ± 3.0 years, were enrolled prospectively for this study. Hip flexion contracture was determined by three physical examination tests: the Thomas test, the prone hip extension test (the Staheli test), and the hamstring shift test. Three-dimensional gait analysis was performed in all subjects. The interobserver reliabilities of the three physical examination tests were determined with use of three observers. Convergent validity was assessed by evaluating the relationships between the findings on physical examination and kinematic and kinetic gait variables (maximum hip extension during stance and hip flexor index) and three-dimensional modeled psoas lengths., Results: the Thomas test showed the highest intraclass correlation coefficient (0.501 in patients and 0.207 in controls) and the smallest mean absolute difference (5.8° in patients and 1.2° in controls). The Staheli test was found to be the most valid method in the patient group (r = 0.568 with hip flexor index), whereas the Thomas test was the most valid in the control group (r = 0.526 with maximum hip extension in stance, and r = 0.532 with the hip flexor index). The hamstring shift test had the lowest intraclass correlation coefficient and the lowest convergent validity., Conclusions: while the Thomas test showed the highest intraclass correlation coefficient and the smallest mean absolute difference, the Staheli test was the most valid method for detecting hip flexion contractures in patients with cerebral palsy. Although the Staheli test cannot be used for intraoperative assessment, we recommend that this test be included in preoperative physical examinations to determine the role of a hip flexion contracture in the abnormal gait of patients with cerebral palsy.

Background: Excessive hip flexion in gait is thought to be associated with hip flexion contracture, but has also been associated with excessive anterior pelvic tilt, knee flexion, internal hip rotation, and muscular factors. The purpose of this study was to examine the contributors to excessive hip flexion during gait in children with cerebral palsy, with and without hip flexion contractures., Methods: A retrospective chart review was conducted of 155 children with cerebral palsy. Potential contributors to excessive hip flexion in stance were evaluated, including static and dynamic range of motion, strength measurements, and patient factors including age, previous surgery, distribution of involvement (hemiplegia, diplegia, and quadriplegia), and Gross Motor Function Classification System level. Univariate analysis was performed using simple linear regression and analysis of variance, with appropriate post-hoc tests. All variables were then included in a stepwise linear regression using forward selection., Results: Univariate analysis demonstrated a significant relationship (P<0.05) between excessive hip flexion in stance and all predictive variables except static dorsiflexion range of motion with the knee flexed and maximum dorsiflexion in stance. Results of stepwise regression revealed that 3 variables accounted for 65% of the variance: passive hip extension range of motion, average pelvic tilt during the gait cycle, and knee extension achieved in the stance phase of gait. Twenty-two of 45 (49%) exhibiting hip flexion contractures of greater than 10 degrees did not exhibit excessive hip flexion in stance phase., Conclusions: Hip extension in stance in children with static encephalopathy depends primarily on hip extension passive range of motion, the amount of pelvic tilt, and knee extension in stance phase. These 3 variables account for 65% of variance in these 155 patients, whereas other factors (age, dorsiflexion in stance, and hamstring range) each account for only 2% to 3% of the variance. Careful clinical examination, including computerized gait analysis when available, is recommended before surgical intervention to determine whether excessive hip flexion is a primary or compensatory deviation., Level of Evidence: Level IV, case series.

Painful adductor muscle contracture is an important cause of failure during rehabilitation following total hip arthroplasty (THA). Adductor muscle contracture may be caused by postoperative muscle retractions, adhesive capsulitis, postoperative leg-length inequalities caused by implant failure, or preexisting hip pathologies. A 34-year-old woman experienced a persistent painful contracture into the left adductor magnus muscle after THA. She had no leg-length inequalities and, according to the Medical Research Council scale (grades 0-5), muscle strength of the quadriceps was 5/5 for the right side and 3/5 for the left. The degree of functionality according to the Harris hip score (HHS) was 16/100 in the left hip. The pain level, measured with the visual analog scale (VAS), was 7/10. The patient was unable to fully adhere to the rehabilitation program and walked with a limp during the stance phase of gait. After 7 days of treatment with injections of botulinum toxin type A into the left adductor magnus muscle (dose, 150 UM) and subsequent rehabilitation, a great reduction of painful contracture was observed (VAS score, 2/10). The procedure was well tolerated and no adverse effects were noted. After 20 days, hip articular range of motion and gait had improved (HHS score, 75/100). The clinical effects of botulinum toxin type A were present at 2-month follow-up. This treatment may be a viable alternative for the management of painful adductor muscle contracture after THA, without significant side effects.

Joint contractures, subluxation and dislocation are common problem in children with neuromuscular disorders. Medical, surgical and rehabilitative approaches can be used to maintain patient function and comfort. Contracture release, hip dysplasia correction and procedures to address or prevent hip subluxation or dislocation, are not always necessary since patients can be asymptomatic and surgical treatment will not always be successful in maintaining a reduced hip. In fact, controversy surrounds the management of hip disorder in children with Duchenne Muscular Dystrophy, Spinal Muscular Atrophy, Charcot-Marie-Tooth Disease and Arthrogryposis Multiplex Congenita. Patients with neuromuscular disorders also frequently develop a progressive scoliosis with pelvic obliquity which may affect sitting balance and become painful. Most subluxations and dislocations have the tendency to occur on the high side of a tilted pelvis. Spinal stabilisation is sometimes necessary to improve the pelvic tilt and to prevent further increase. The present article provides an overview of the current strategies of hip management in neuromuscular disorders.

Hip reduction in cerebral palsy patients with a soft tissue procedure was analysed during operative procedure. Eleven patients with unilateral dislocation of the hip and a quadriplegic form of cerebral palsy underwent soft tissue operation on the hips. Tenotomy of the adductor and flexor muscles of the hip was performed. The contralateral hip sustained only tenotomy of the adductor muscles. The average age of the patient study group was 8.5 and the follow-up period was 4 years. In all patients, repositionings of the hip were achieved and stabilization was maintained postoperatively at the regular outpatient follow-up. The range of extension and abduction motion were increased postoperatively compared to the preoperative range of motion. Retention of the hip was maintained within 20 degrees of abduction. Tenotomy of the adductor and flexor muscles enables hip reduction without opening the joint capsule in quadriplegic cerebral palsy patients. The hip became painless and the improvement in the hygiene was evident.

Eleven patients with spastic cerebral palsy were evaluated preoperatively, and 3 and 9 months postoperatively after soft tissue surgery. Evaluation included clinical examination, the Functional Mobility Scale questionnaire, and instrumented gait and center of mass trajectory analysis. A decrease in time-distance parameters after 3 months was followed by progress in all parameters at 9 months postoperatively. Push-off range of ankle motion decreased after surgery and was not restored to preoperative level until 9 months later. The center of mass vertical displacement improved significantly. The Functional Mobility Scale showed gait improvement. Despite the normalization of range of motion after surgery, there is an obvious period of functional gait deterioration in the early postoperative period and the push-off range of motion at the ankle did not recover to preoperative level until 9 months later.

Background: Prolonged immobility during a critical illness may predispose patients to the development of joint contracture. We sought to document the incidence of, the risk factors for and the reversibility of joint contractures among patients who stayed in a tertiary intensive care unit (ICU) for 2 weeks or longer., Methods: We conducted a chart review to collect data on the presence of and risk factors for joint contractures in the shoulders, elbows, hips, knees and ankles among patients admitted to the ICU between January 2003 and March 2005., Results: At the time of transfer out of the ICU, at least 1 joint contracture was recorded in 61 (39%) of 155 patients; 52 (34%) of the patients had joint contractures of an extent documented to impair function. Time spent in the ICU was a significant risk factor for contracture: a stay of 8 weeks or longer was associated with a significantly greater risk of any joint contracture than a stay of 2 to 3 weeks (adjusted odds ratio [OR] 7.09, 95% confidence interval (CI) 1.29-38.9; p = 0.02). Among the variables tested, only the use of steroids conferred a protective effect against joint contractures (adjusted OR 0.35, 95% CI 0.14-0.83; p = 0.02). At the time of discharge to home, which occurred a median of 6.6 weeks after transfer out of intensive care, 50 (34%) of the 147 patients not lost to follow-up still had 1 or more joint contractures, and 34 (23%) of the patients had at least 1 functionally significant joint contracture., Interpretation: Following a prolonged stay in the ICU, a functionally significant contracture of a major joint occurred in more than one-third of patients, and most of these contractures persisted until the time of discharge to home.

We report on a 76-year-old man suffering from cerebral palsy who underwent coronary artery bypass grafting. Limitation of available bypass grafts and the approach of intra-aortic balloon pump insertion are of great concern because of his specific posture resulting from multiple articular contractures. We describe our planning to survive coronary surgery in this specific situation.

Joint contractures are the second major impairment affecting the locomotor system of children with Duchenne muscular dystrophy (DMD). While the negative influence of joint contractures has been documented, the passive moments produced by joint contractures could benefit the gait of patients with muscle weakness. We describe a biomechanical model that quantifies the mechanical contribution of ankle and hip flexion contractures to the gait of DMD children. Kinematic and kinetic parameters were measured under the same experimental conditions during the gait and passive resistance assessment of two subjects: one healthy child as a control, and one child with DMD. The child with DMD had a plantar flexion contracture and a greater ankle stiffness coefficient than the control child. During gait, the contribution of the ankle passive moment to the net moment was more important for the child with DMD than for the control child. At the hip, passive joint moments and passive moment contribution were more important for the control child but this was not related to the presence of hip flexion contracture. These preliminary results suggest the model might be used to evaluate contractures effect on a larger cohort of subjects.

Windswept hip deformity describes an abduction and external rotation position of one hip with the opposite hip in adduction and internal rotation. Windswept hip deformity may occur in association with hip dislocation and scoliosis. We analysed the prevalence of this deformity in a total population of children with cerebral palsy, and the impact of hip prevention and early treatment of contractures on the prevalence and severity of windswept hip deformity. The frequency of windswept hip deformity was 12% in the control group and 7% in the study group, comprising children in the hip prevention programme. The children with this deformity in the study group had a lower frequency of scoliosis and none had hip dislocation. It thus seems that the hip prevention programme results in a decrease in the number of children with windswept hip deformity, and a decrease in the severity of the deformity.

The objective of this study was to assess the correlation between hip flexion contracture (HFC) and the sagittal alignment of the lumbar spine in ambulatory children with myelomeningocele. Ambulatory patients with myelomeningocele are generally free of scoliosis or kyphosis. Among them, some develop increased lumbar lordosis. It is postulated that HFC and increased lumbar lordosis may be correlated. Thirty-eight patients, with a mean age of 12.7 years, were evaluated. Standing lateral spine films were obtained and the lumbar lordosis was measured using the Cobb method. HFC was measured using the Thomas test. A statistically significant correlation was found between the lumbar curve and HFC. High values of lumbar Cobb angle (hyperlordosis) were correlated with high values of HFC. These results show a correlation between HFC and increased lumbar lordosis in ambulatory myelomeningocele patients.

Two patients with hemangioendothelioma and elevated plasma vascular endothelial growth factor (VEGF) levels are presented. A reduction in the plasma VEGF level after therapeutic intervention correlated with a successful clinical response. Conversely, a stable plasma VEGF level correlated with therapeutic failure.

Despite the increasing popularity of nonorthopaedic treatment alternatives for children with cerebral palsy, bony and soft-tissue surgery remains a common component in the management of ambulatory patients. Multisite simultaneous tendon surgery provides improvement in gait by addressing hip, knee, and ankle contractures together. Careful preoperative physical examination is required; computerized gait analysis can be useful in confirming a plan for multiple tendon surgeries. Rotational osteotomies can improve transverse-plane malalignment. Shorter periods of immobilization and aggressive postoperative gait training and strengthening may optimize improvements in gait.

There are two main problems with muscle tendon lengthening: thinness created by the technical procedure weakens the tendon, and in short tendons, lengthening may not provide enough length for the amount of joint motion required. In proximal rectus femoris lengthening, the distal ends of the reflected and straight heads are sutured together. Using this technique, the tendon will not be thinned, and a later second lengthening is possible.

Purpose of the Study: How effective are the hip adductors and flexors tenotomies for the correction of unstable hip joint in cerebral palsy?, Material: The study included 45 children with contractures of the hip adductors and flexors and hip subluxations due to spastic cerebral palsy. Thirty three of them were boys and 12 were girls. Their ages ranged from 2 to 13 years. Preoperative and postoperative roentgenograms of 82 hip joints were investigated., Methods: Open tenotomies of m. adductor longus and brevis, m. gracilis, m. rectus femoris and m. psoas major. The immobilisation by POP casts lasted for 6 weeks. Abduction and extension bracing followed the plaster removal in all children. The hip joints were radiographed in neutral rotation both before and at least 6 months after the operation. Reimers migration percentage (MP) and Wiberg angle (CE angle) known as the parameters of hip instability were assessed. The obtained data were statistically analysed., Results: The preoperative MP was below 25% in 25 hips, between 25 and 39% in 33 hips, between 40 and 59% in 14, and over 59% in 10 hips. The analysis of postoperative roentgenograms showed the following MP distribution: 56 less than 25%, 23 between 25 and 39%, and 3 greater than 40%. No postoperative MP was higher than 49%. 54% formerly subluxated hips achieved normal MP. The difference between preoperative and postoperative MP was statistically significant (P < 0.001). Before the tenotomies 24 hips were normal with CE angle over 20 degrees. It was between 20 degrees and 11 degrees in 28 cases and between 10 degrees and 1 degree in 17 cases. The preoperative CE angle was negative in 13 cases. Postoperatively CE angle was higher than 20 degrees in 53 hips. It was between 20 degrees and 11 degrees in 22 cases and between 10 degrees and 1 degree in 7 cases. The minimum CE angle after soft-tissue release was 4 degrees. The difference between preoperative and postoperative CE angles was statistically significant (P < 0.001). MP improved in 93% and CE angles in 96% of cases., Discussion: Classical tenotomies of the spastic hip adductors used to be recommended in prevention of the hip subluxation in cerebral palsy patients. MP improved in 70% of cases in the Reimers' study (1980) based on selective adductors tenotomies. If the soft tissue release was unsuccessful bony operation was indicated. Kalen and Black claimed in 1985 that if psoas tenotomy was performed in addition to adductors tenotomies MP improvement was attained in 80-100% of cases., Conclusion: Adductors and flexors tenotomies can correct the spastic hip joint instability fully and permanently if the operation is performed prior to bony changes of the hip. The operation being followed by appropriate immobilisation and physiotherapy increases the percentage of good results.

Walking and standing capacity in myelomeningocele is highly dependent on the level of the neurological lesion. Deformities, mainly flexion deformities, of the hip can severely interfere with mobility. In a retrospective study, undertaken in our hospital, we evaluated the role of soft tissue release of the hip in patients with hip flexion contractures. A special surgical technique was performed in 55 hips. The results show a good effect on verticalization, even if the hip joints cannot be extended actively. A subluxated or dislocated hip did not influence the final outcome. During the mean follow-up of approximately 4 years, only a slight recurrence of the former deformity was observed. Most of the patients obtained great advantage from the operation.

Eighty-five patients with cerebral palsy had modified adductor muscle transfers. A study of associated patient characteristics suggests that comparing adductor transfer with adductor release using postoperative radiographs, need for subsequent surgery, or postoperative motor skills is flawed by multiple variables. Adductor release and adductor transfer are best compared by measuring the abduction obtained at surgery and maintained over time. A follow-up of 141 modified adductor transfers with no prior or concomitant hip surgery demonstrated an averaged initial improvement in abduction of 43 degrees and maintenance of abduction with a low incidence of recurrence.

Recent reports have suggested a relationship between release of lower-extremity contractures and the development of hypertension in cerebral palsy and poliomyelitis patients. A retrospective study was performed on 119 cerebral palsy patients who had undergone lower-extremity contracture releases. Temporary elevation of systolic blood pressure in the perioperative and intraoperative periods occurred in 46 patients (39%), and temporary elevation of diastolic blood pressure occurred in 14 patients (12%). Type of cerebral palsy, patient age, patient sex, type of anesthesia, and type of procedure were not significantly correlated with the temporary blood pressure elevations. No patient developed sustained elevation of systolic and diastolic blood pressure. We conclude that lower-extremity contracture release in pediatric patients is not associated with an increased incidence of postoperative hypertension.

The fate of 89 patients with meningomyelocele operated at the Institute of Orthopedics and Rehabilitation in Poznań between 1970 and 1989 due to paretic deformities of lower extremities has been traced by the authors. Deformities prevented nursing, standing or ambulating; their type and results of treatment have been related to the level of neurosegmental lesion. Modified Sharrard's classification served to group the patients. The level of lesion established during lower extremities muscles testing has been verified after neurological examination supplemented with electrophysiological tests: sensory response within L3-S2 dermatomes, afferent conduction velocity of the peroneal nerve and selected muscles of lower extremity electromyogram. Deformities due to inadequate nursing (hip and knee contractures and equinus foot) were the main obstacle in the rehabilitation in patients with spinal Th12-L2 lesion. In patients with L3-L5 lesion hip contractures were accompanied by dislocation or subluxation of the hip due to muscular imbalance. Knee contracture was less frequent in this group and foot deformities were diverse. Surgical correction of paretic deformity of the hip was the last stage of management designed to promote rehabilitation, following previous foot and knee surgery. In patients with Th12-L2 lesion recurrence of contractures made standing and walking impossible. In patients with L3-L5 neurosegmental lesion surgery for paretic dislocation or subluxation of the hip inclusive of open reduction, varus-derotation osteotomy of the proximal femur, transiliac osteotomy and iliopsoas transfer to the greater trochanter according to Mustard resulted in stable hip. Seventy percent of patients with L3-L4 lesion and all patients with L5 lesion profited from hip surgery with reduced orthotic use and effective gait.

This study reviewed 57 hips in 30 children (18 girls and 12 boys) with cerebral palsy who had undergone an adductor tenotomy alone or in combination with an anterior obturator neurectomy (23 hips). Results were evaluated by the Reimers migration percentage (MP). The hips were split into three groups: group A (12 hips) a preoperative MP of less than 20%, group B (25 hips) between 20 and 40%, and group C (20 hips) more than 40%. The mean age at the time of surgery was 6 years and 1 month (range: 2.5-13 years). The mean period of review was 6 years and 3 months (2-20 years). The results were considered as "good" when radiographs at the longest follow-up showed a decrease of > 10% of the MP, as "bad" when they showed an increase of > 10%, and as "stable" when the MPs varied less than 10%. At the latest review of group A, 11 were stable (92%) and 1 was bad. In group B, 12 were stable (48%), 7 were good (28%), and 6 were bad (24%). In group C, 7 were stable (35%), and 13 were bad (65%). The preoperative migration percentage provided to be the only predictor of outcome. Age at the time of surgery had no constant significant effect on the outcome, neither had the addition of an anterior neurectomy.

Release of static and dynamic contractures around the hip provides significant immediate benefits for the patient and accelerates postoperative rehabilitation. Knee pain is decreased, groin pain is eliminated, range of motion of the hip is increased, and functional leg-length difference is reduced. This article emphasizes the importance of techniques used to ensure soft tissue balance.

Hip flexion contractures are a common complication in disabled patients. However, no previous study has examined reduced hip motion during gait. This retrospective analysis evaluates the relationship between the degree of hip flexion contracture found on static testing and the degree found during gait and also assesses the strength of the association between hip flexion contractures and compensatory mechanisms such as anterior pelvic tilting, increased knee flexion, and decreased contralateral step length. Clinical and quantitative gait laboratory data were obtained from 41 consecutive patients with mostly neurologically based impairments who presented with bilateral hip flexion contractures on Thomas testing (82 limbs). Correlation studies demonstrated a relatively weak association between the degree of peak hip extension during gait and hip flexion contracture by Thomas testing (r = 0.41, P < 0.0001). Limited hip extension was most closely associated with anterior pelvic tilting (r = 0.60, P < 0.0001), whereas Thomas test measurements yielded a correlation with anterior pelvic tilt of only r = 0.36 (P < 0.001) and were insignificant predictor variables of anterior pelvic tilting in regression analysis. Thus, peak hip extension and anterior pelvic tilting assessed during gait were poorly associated with the static Thomas test measurements, and anterior pelvic tilt was most strongly correlated with reduced hip extension during gait compared with the other compensatory mechanisms.

More than 250 cases of Cornelia de Lange syndrome have been reported in the medical literature, but not have described the use of hip reconstruction to correct the congenital dysplasia that may be associated with this condition. This article reports the application of a bipolar hemiarthroplasty and acetabular allograft reconstruction for a 32-year old woman with congenital dysplasia and degenerative joint disease of the hip secondary to de Lange's syndrome. On admission, she was in considerable pain and unable to bear weight on the affected extremity. Her Harris hip score was 25. Following surgical intervention and a well-designed plan of rehabilitation, the patient's functional status improved markedly. Her Harris hip score was 72, and her pain was alleviated.

Hip flexion contractures accompanying various orthopedic and neurologic conditions not only limits the physical activities of the patients but also distorts their postures and gait patterns. The purposes of this study were to characterize the appearance patterns of flexion contracture at the hip joints and to elucidate how this disability affects their postural and gait abnormalities. Seventy-eight patients (mean age of 68.1 +/- 10.5 years) with hemiplegia, femoral neck fractures, osteoarthritis of the hip and other conditions causing hip flexion contractures were studied. The presence and degree of hip flexion contracture were estimated in the supine position using the Thomas maneuver with a goniometer. Relationship between appearance patterns and 12-survey variables was also analyzed statistically. As a result, it was revealed that whether lack of mobility caused by hip flexion contracture was compensated for by pelvic tilt an an increase of lumbar lordosis or not was affected by four factors. It was also revealed that whether it appeared unilaterally or bilaterally was affected by five factors. In addition, some postural and gait abnormalities caused by hip flexion contracture were observed in many patients. These results suggest that clinical pictures of the patient's posture and gait abnormality depend on his ability to regulate the position of the trunk and knees as well as the mobility of his spine.

Although the primary defect of Duchenne muscular dystrophy has been found, there is no causal treatment to alter the natural course of this disease. Based on the recommendations by Glorion and Rideau with early treatment of contractures of the hips and the lower limbs we performed a modified release of the spina muscles, resection of tensor fasciae latae muscle and a lengthening of the tendo calcaneus in 32 patients. The mean age of DMD patients at time of operation was 6.1 years. The mean follow-up was 3.4 years. All children underwent mobilisation the day after surgery. Complete correction of all contractures was immediately achieved after operation and kept in all but two cases up to the follow-up examination after 3.4 years. No loss of ambulation was observed. Our results demonstrate that early selective surgery in DMD patients just at or better before the onset of contractures without performing an additional aponeurectomy of the iliotibial band and percutaneous tenotomy of the hamstrings according to the original Glorion-Rideau technique safely prevents severe contractures and thereby delays the progression of scoliosis.

Five pediatric patients who presented with hip contractures are described. There were 3 boys and 2 girls ranging in age from 7 to 14. None had morning stiffness and one complained of no pain at all. Each had undergone several diagnostic procedures and had seen an average of 2.5 doctors before receiving the diagnosis of arthritis. All were antinuclear antibody negative and HLA-B27 positive, and they had excellent responses to treatment with nonsteroidals and physical therapy. HLA-B27 positive arthritis should be considered in the differential diagnosis of otherwise unexplained hip contractures in children.

Abduction contracture of the hip has been treated by two methods; the results of both have been compared. Modified Campbell's procedure has been performed in 5 children (6 hips). In 8 patients (9 hips) gluteal fascia and fibrotic scarring within the gluteal muscles has been transversely dissected. The mean follow-up was 26 months in either group. Dissection of the fascia and the scars resulted in doubled range of adduction and better cosmetic result compared to Campbell's method.

Introduction: Restricted passive hip abduction in children with cerebral palsy (CP) may be caused by uninhibited resting contractions and/or retractions, i.e., shortened muscle body or tendons. Pathological short tendons require surgical intervention, but lack of muscle body elasticity responds to physiotherapy or a postural splinting. Clinical examination can distinguish between short tendons and short muscle body. The thigh is slowly and passively extended while palpating the tendon. Tension is detected in the tendon when the leg is at angle Ao. The elastic tension of the muscle body then increases until no further movement is possible, at angle Amax. The difference Amax-Ao is an index of the structural length of the muscle body. If this difference is reduced during passive straightening there is shortening of the muscle body; if it is displaced it indicates shortening of the tendon. The value Ao indicates the muscular or tendon origin of the retraction for a given passive limitation (Amax). This study defines the physiological values of Ao and the relative precisions of chemical and instrumental measurements., Materials and Methods: A total of 30 children aged 9-11 years, 10 CP patients (7 girls and 3 boys, mean age 10.3 years) and 20 controls (11 girls and 9 boys, mean age 10.5 years) were studied. All the CP children had lower limb spasticity and adopted an adduction posture. None had undergone hip muscle surgery. Ao and Amax were measured clinically with a goniometer and EMG to monitor muscle silence, and experimentally using a deformable parallelogram and force transducers., Results: The minimum physiological value of Ao was 8 degrees with the knee flexed and 0 degree with the knee extended. Smaller values of this angle indicated tendon retraction. The difference between Ao and Amax in the controls and CP children was < or = 10 degrees; the reproducibilities of the clinical measurement of Ao and Amax were very similar., Discussion: Clinical examination provides an acceptably accurate method of distinguishing between tendon and muscle body retraction of adductor muscles in CP children. The conditions required for successful measurement are: careful examination with strict positional reference and sufficiently relaxed pelvic muscles. A hip extension angle Ao of less than 8 degrees with the knee flexed or 0 degree with the knee straight indicates tendon retraction requiring tendon surgery, otherwise, the retraction involves only the muscle body. This reduced elasticity can be overcome by prolonged extension (at least 6 hours/24). Effective muscle extension may be hindered by non-suppressed adductor contractions. This must be overcome prior to physiotherapy by surgery of the ramus ant. n. obturatorii., Conclusion: Clinical measurement of Ao of adductor muscles is a reliable way of distinguishing between tendon retractions requiring surgery and muscle body retractions resulting from staying too long in a position with the muscle shortened. This muscle body shortening can be due to lack of physiotherapy or a stretching apparatus treatment, pathological contractions, or compensation for disorders of the controlateral limb.

We studied 1061 children with myelomeningocele, reviewing 3184 pelvic radiographs from 802 patients. Hip dislocation had occurred by the age of 11 years in 28% of children with a thoracic neurosegmental level, 30% of those with an L1/2 level, 36% of L3, 22% of L4, 7% of L5 and only 1% of those with sacral levels. Hip dislocation was not inevitable even when there was maximal muscle imbalance about the hip. The average hip flexion contracture in children aged 9 to 11 years was significantly greater in those with thoracic (22 degrees) and L1/2 (33 degrees) levels than in those with L4 (9 degrees), L5 (5 degrees) or sacral (4 degrees) levels. Our findings indicate that muscle imbalance is not a significant factor in the production of flexion deformity or dislocation of the hip; both are commonly seen in the absence of imbalance. The restoration of muscle balance should no longer be considered to be the principal aim of the management of the hip in children with myelomeningocele.

To assess the effect of subcutaneous (s.c.) lower limb tenotomies on the ambulatory ability of patients with Duchenne muscular dystrophy (DMD), 54 patients were followed. Twenty-nine patients underwent hip, knee, and ankle tenotomies at a mean age of 10 2/12 years and were followed postoperatively for an average of 3 9/12 years. These children continued ambulation in long-leg braces to a mean age of 12 8/12 years and stood to an average of 13 5/12 years. Contracture correction was 49% at the hip, 58% at the knee, and 100% at the ankle. A separate group of 25 children to whom operation was offered but declined, was followed: these children ceased ambulating at a mean age of 10 years and ceased standing at a mean age of 10 2/12 years. Thus, we propose that s.c. tenotomy is effective in allowing braced ambulation well beyond what the natural history would allow.