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The Neuromuscular Hip

The Neuromuscular Hip. w mccormick june 2010. neuromuscular disorders hip development diagnosis focus on the hip history exam management nonoperative operative complications summary. Neuropathic Upper Motor Neuron CP Spinocerebellar Friedreich’s Ataxia

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The Neuromuscular Hip

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  1. The Neuromuscular Hip w mccormick june 2010

  2. neuromuscular disorders hip development diagnosis focus on the hip history exam management nonoperative operative complications summary

  3. Neuropathic Upper Motor Neuron CP Spinocerebellar Friedreich’s Ataxia Syringomyelia Spinal Cord Tumour Trauma Myelomeningocele Lower Motor Neuron HMSN (Charcot Marie Tooth) Poliomyelitis Viral Myelitides Traumatic Spinal Muscular Atrophy Dysautonomia (Riley-Day syndrome) Myopathic Arthrogryposis Muscular Dystrophy DMD Limb-girdle Fascioscapulohumeral Fiber-type disproportion Congenital hypotonia Myotonia Dystrophica neuromuscular disorders

  4. the problem concentric joint + balanced forces = stable hip DDH = non concentric joint starts wonky development mostly ok NM = unbalanced forces starts normal develops into wrong shape

  5. diagnosis • spasticity/floppiness • which limbs/muscles • static vs. progressive • physical • posturing, enlarged calves, gower sign • neuro exam

  6. testing • EMG • fibrillation with neuropathy • muscle biopsy • myopathy: variable fiber size, degeneration • neuropathy: atrophy • MR spine • for myelomengocele, syrinx

  7. the hip - history • age • development • sypmtoms • previous treatments • MHx

  8. the hip - exam • look • sitting/gait • check spine • movement quality • feel • tone

  9. move • ROM • hips • abd • extension • knees • ankles

  10. the hip - imaging • supine AP pelvis in neutral add/abd • MI • AI • femoral changes • acetabular changes • brain/spine for workup prn

  11. treatment - nonoperative • PT for ROM monitor hip abduction ages 2-8 exam + XR q6mo • hip at risk if abd < 45deg and MI > 25% • medical baclofen/botox/valium

  12. treatment - operative • indications progression of MI, AI decreasing abd

  13. soft tissue lengthening indications for subluxation with reducible hip <8 yrs abd<30 deg MI 25-60% contraindications >4yrs with MI 60-100%

  14. Sp.Quad. Age 18 mo.

  15. 2+2yrs Sublux Lt.

  16. Age 2+4 Post op bilat. Adduc,& Prox. Hams. Left only

  17. Age 3+5 13months post op. Lt. Rt. now subluxed Hams. were not released on Rt.

  18. Age 5 +4 2 yrs. Post operative Hams. Release on Rt.

  19. lengthening – post op • spica for 2-3 weeks • abduction orthosis at night

  20. lengthening - results • Cornell • MI <40%, 83% • MI =40%, 23% • MI >60% all failed • AI >27° highly predictive of failure • Age not a significant predictor • Miller • 147 hips • MI <40%, 88% good or fair

  21. bony procedures - recon • >4yrs but before degenerative changes • failed lengthening • <8yrs with MI >40% 12 mo post op

  22. recon options correct deformities, redirect head • femur • varus • derotation • +/- shortening • acetabulum • dega • redirectional

  23. single stage • Soft tissue lengthening • iliopsoas • add longus • add brevis • gracilis • VDRO • peri-ilial acetabuloplasty

  24. dega

  25. VDRO

  26. single stage - outcomes • 95% stable > 2 yrs • 82% pain free • 14% partial relief • 4% persistent pain

  27. JRP Tracing of x-rays Spastic Diparesis Bilat. Sublux Lt.> Rt.

  28. Pelvis Side View Triradiate Cartilage Osteotomy Location

  29. Osteotome Initial entry Transv. Then curve to Trirad. JRP K-wire

  30. JRP Multiple Osteotomes outline cut & lever laterally, Posterior part 1st

  31. Post bone graft insertion Better head coverage Lt.

  32. JRP Additional) Derotation (not Varus) osteotomy

  33. bony procedures - salvage • indications • older pt with painful disloc • options • resection • redirection • interposition • arthrodesis • arthroplasty

  34. complications obturator neurectomy • Hyper-ABD osteonecrosis femoral head • 0 – 11% after reconstruction • femoral osteotomy • increased pressure on the femoral head • during psoas tenotomy

  35. HO • Miller • 192 patients • worse with both hip and spine surgery • prophylaxis • NSAIDS • rads

  36. fracture • bone density • higher risk if prolonged casting

  37. summary • PAIN by late adolescence • few salvage options • GOAL early detection/treatment • ST lengthening <8 yrs, abd<30, MI 25-60 • single stage recon > 4yrs but no degeneration

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