Hip problems are a serious and common condition in patients with cerebral palsy (CP). The frequency of hip problems due to CP is reported to be 2-75%. These can present in a wide range from simple stiffness or inability to open the legs to high hip dislocation.
Hip problems due to stiffness are quite different from developmental hip dislocation (DDH). In CP, the hip is usually normal at birth. Hip problems develop over time due to muscle contractures (muscle stiffness adhesion) or other problems such as scoliosis (curvature of the spine).
The level of involvement in the brain of the patient with CP is one of the most effective factors in the development of hip dislocation. While rates of hip dislocation are reported as 7% in patients with CP who can walk independently, this rate rises to 60% in bedridden patients.
Delay in walking is another factor that increases the chance of encountering hip problems. The risk of hip dislocation is higher in patients who cannot walk until the age of three.
Hip Problems in SP
1. Adduction contracture (inability to open legs)
2. Flexion-adduction contracture (inability to stretch the legs but not to the abdomen)
3. Mismatches to increased femur angular positions
4. Subluxation (Semi-dislocation)
5. Hip dislocation
PARALITIC HIP DISPLACEMENT MECHANISM
In most children with CP, the hip is normal at birth. In particular, stiffness in the muscles causes problems over time in patients with CP who have normal hip development. Semi-dislocations and full-height dislocations can be seen in patients whose physical therapy is not performed properly or who have adaptation problems. Muscle stiffness is one of the most important factors in the formation of bony deformities, and of course, delay in walking.
Causes of Hip Dislocation in SP
1. Inability to walk or walk late
2. Severe cerebral involvement
3. Location of damage to the brain
4. Scoliosis (curvature of the spine)
Systemic examination in patients with CP is perhaps more important than all diseases. The patient should be evaluated as a whole. All examination findings should be recorded, the condition of the patient and the progression of the disease should be monitored. Hip examination is very important in patients with CP. Antero-posterior hip radiography should be taken in cases with crossed legs and in all patients with CP presenting for the first time.
Perhaps the most important problem in patients with CP is those of the hip. Especially in cases where hip dislocation develops, the treatment method changes and grows.
For this reason, hip anteroposterior X-ray should be requested for patients who are at risk, who come to the examination for the first time, and who are suspected. Hip X-ray should be taken as close to the standard as possible.
APPROACH TO HIP IN PATIENT WITH CP
The type of involvement seems to be the most effective factor in encountering hip dislocation in patients with CP. Patients who have never walked are the most at risk group. There is almost no hip dislocation problem in some semi-involved groups.
“Hip problems are most common in patients with CP between the ages of 2-6.”
A program has been developed to evaluate patients with CP in Scandinavian countries. The patients are evaluated according to their age and gross motor function classification system levels. We follow up our patients according to these classifications.
TREATMENT APPROACH AND METHODS IN HIPS WITH CP
The most important thing in patients with CP is not the treatment of the dislocated hip, but the prevention of the dislocation of the hip. Therefore, compliance of the patient and his family with physical therapy, regular evaluation of the patient at regular intervals and a multidisciplinary approach should be applied. In physical therapy, it is very important to keep the patient in the right position, strengthen the muscles, ensure the balance between the antagonist muscles, relax the tense muscles, equip the patient and try to preserve the range of motion of the joint. These rehabilitation practices, conscious and compliant family, patients with mild involvement who do not resist treatment as much as possible, and periodic orthopedic controls and radiological evaluations are the most important factors preventing hip dislocation.
The main purpose in hip problems of the patient with CP;
It is to ensure that the hip is fully seated, to relieve the pain, if any, to provide the patient’s sitting balance and perineal hygiene.
Treatment Methods Applied in Hip Problems Caused by CP
1. Soft tissue releases
2. Bone surgeries
3. Rescue surgeries
A body cast is applied after surgery. The plaster is removed after 30–45 days, and partial or full loading is started, depending on the exercise and degree of union. If there is a semi-dislocation or dislocation of the hip and soft tissue releases have not been successful or are thought to be unsuccessful, all surgical treatment should be performed in one step. In this way, very successful results are reported. Bone surgeries and larger interventions are required in very delayed and painful cases.
As a result; Hip problems in cerebral palsy is a condition that occurs later, due to muscle stiffness, is preventable, and causes major surgical interventions when it occurs.