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Hindawi Publishing Corporation Advances in Orthopedic Surgery Volume 2014, Article ID 813719, 6 pages http://dx.doi.org/10.1155/2014/813719 Clinical Study McHale Operation in Patients with Neglected Hip Dislocations: The Importance of Locking Plates 1 1 1 2 Mark Eidelman, Alexander Katzman, Michael Zaidman, and Yaniv Keren Pediatric Orthopedic Surgery Unit, Rambam Health Care Campus, P.O. Box 9602, 31096 Haifa, Israel Department of Orthopedic Surgery, Rambam Health Care Campus, P.O. Box 9602, 31096 Haifa, Israel Correspondence should be addressed to Yaniv Keren; y email@example.com Received 13 September 2013; Accepted 29 November 2013; Published 29 January 2014 Academic Editor: Padhraig O’Loughlin Copyright © 2014 Mark Eidelman et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Neglected hip dislocation in patients with cerebral palsy is a challenge for the pediatric orthopedic surgeon. Many patients experience pain, limitation of hip motion, and sitting and hygiene problems. Arthrodesis, proximal femoral head resection, and subtrochanteric valgus osteotomy are eeff ctive salvage procedures for patients with painful hip dislocation and restricted hip motion when reconstruction of the hip is not possible. Osteopenia is one of the problems that can complicate the postoperative course in these patients. Postoperative cast immobilization may further worsen the osteopenia and can predispose to fractures of the femur aer ft cast removal. Standard plating of the proximal osteotomy may not always provide adequate stability of the fixation. In order to prevent postoperative osteoporotic fractures we use locking plates, without casting. Since 2003 until 2011, we operated on 9 patients (14 hips) with painful neglected hip dislocations. eTh first three patients (five hips) were operated on using standard nonlocking plates. All other patients (nine hips) were operated on using locking plates. During the followup, the hardware failed in one of these cases. All patients treated with locking plates had not been casted postoperatively, and none had loss of fixation or fractures during the followup. 1. Introduction subtrochanteric valgus osteotomy in 5 patients with spastic quadriplegia . All patients were nonambulators and all Neglected hip dislocation in patients with cerebral palsy is achieved reasonable results aeft r the procedure. This proce- notanunusual probleminpatientswithsevereneurological dure became popular in cases in which hip reconstruction involvement [1–4]. Usually these patients are nonambulators is not feasible. The technique involves using standard non- categorized as gross motor function classicfi ation system locking plates and spica casting postoperatively to further (GMFCS) of vfi e. Nearly 90 percent of GMFCS IV patients secure the xa fi tion. Known complications aeft r the McHale develop some degree of hip displacement . The ideal procedure are persistent pain, femur fracture, and hardware treatment for hip displacement (dislocation or subluxation) failure . is hip reconstruction combining soft tissue release, varus Patients with severe cerebral palsy frequently sueff r from derotational osteotomy of the femur, and pelvic osteotomy osteopenia, disuse osteoporosis, and bone fragility [18, 19]. In [5–8]. When the femoral head is severely deformed and the fact, cerebral palsy is the most prevalent childhood condition acetabulum is too shallow for hip reduction, salvage proce- associated with osteoporosis . Furthermore, bone volu- dures might be indicated. These patients usually experience metric density decreases with increasing GMFCS level . hip pain, and their condition does not allow appropriate This condition may lead to hardware loosening and failure. sitting or adequate nursing and hygiene (Figure 1). Described salvage procedures for nonreconstructible hips include prox- In addition, application of a spica cast following surgery imal femoral head resection [4, 9, 10], valgus osteotomy in cerebral palsy patients may be associated with osteopenic [11–13], hip arthrodesis [14, 15], and total hip arthroplasty disuse fractures, mostly distal femur and proximal tibia [5, 7, . In 1990, McHale et al. described their technique of 22, 23]. 2 Advances in Orthopedic Surgery An abduction pillow is used for the rst fi 3 weeks after the operation. Gentle passive range of motion and sitting in a wheelchair is allowed immediately following surgery. 3. Results Mean follow-up period was 74.8 weeks. The first 3 patients were operated on using standard nonlocking broad DCP plates (dynamic compression plate, Synthes). No spica cast was applied following surgery. One patient with bilateral procedure (Figure 3(a)) had lost plate xa fi tion on the right Figure 1: Neglected hip dislocation complicated by hip contracture, side two weeks postoperatively. The patient was reoperated on nursing difficulties, and subsequent pressure sores. using a LCP plate, and a spica cast was applied postoperatively for 3 weeks (Figure 3(b)). After removal of the spica cast pain and swelling were noted over the distal thigh and radiographs In modern fracture surgery, locking plates gained increas- revealed a supracondylar femoral fracture (Figure 3(c)). Since ing popularity due to increased rigidity and fracture site then, we changed our protocol and the last six patients were stability. These benefits can be precious when treating severe operated on using 4.5 mm LCP plates (Figures 4(a) and osteoporotic bones, as seen in nonambulatory cerebral palsy 4(b)). Spica cast was not applied postoperatively. All nine patients achieved the preoperative goal: prolonged sitting, patients. Moreover, using these plates might eliminate the need for further securing the xfi ation with casts and may lead unrestricted abduction with easier change of diapers, and to decreased morbidity following surgery. es Th e plates have perineal care. In the LCP group, none had loss of fixation or post operative fractures. been described as alternatives to traditional nonlocking plates in cerebral palsy patients undergoing proximal femoral varus osteotomy . eTh se plates provided stable xfi ation and are 4. Discussion advantageous in osteoporotic bone. In this study we describe a modification of the original Hip displacement is common in nonambulatory cerebral McHale procedure. Insteadofusing standard plates,weuse palsy patients with severe neuromuscular involvement. locking plates, which in turn allow us not to use spica casts According to Soo et al. , the incidence of hip displacement postoperatively. ranges from 0% in patients with gross motor function classification system level 1 (GMFCS) to 90% in patients 2. Patients and Methods with GMFCS level 5. Restriction of abduction, pain, pressure sores, and difficulty with sitting and perineal hygiene are During 9 years (2003–2011) we operated on 9 patients (14 well described [2, 3, 12, 25]. However, some advocate that hips), with neglected hip dislocations (Table 1). All patients the incidence of pain in patients with hip dislocation is low hadcerebralpalsy with spasticdiplegia. Allpatientswere and neither hip displacement nor osteoarthritis is associated GMFCS level 5. Mean age at the time of operation was 18.3 with hip pain. Noonan et al. suggested that surgical treatment years (range 14–23). All patients sueff red from limitation of should be based on the presence of pain and contracture and abductiononthesiteofthedislocatedhip,painduringsitting, not on radiographic appearance of dislocation . and hygiene problems. Five patients were never operated The treatment of hip subluxation and dislocation might on before, two underwent adductor release, and two others be challenging. Early careful monitoring may prevent dislo- underwent soft tissue release and varus derotation osteotomy. cation . However, neglected hip displacement is still com- moninseverelydisabledpatientswithcerebralpalsy.Surgical 2.1. Operative Technique. Abumpshouldbeplacedunder- treatment for neglected hip dislocations includes constructive neath the sacrum in order to improve access to the or salvage procedures, from total hip arthroplasty , to affected hip joint. Anterolateral Watson-Jones approach gives hip reconstruction [6, 7], subtrochanteric valgus osteotomy excellent exposure to the hip joint and proximal femur without resection of the femoral head , resection of the (Figure 2(a)). Resection of the femoral head (Figure 2(b)) femoral head [9, 28, 29], resection of the femoral head with is performed while the ligamentum teres is preserved for articulated hip distraction , and subtrochanteric valgus further attachment to the iliopsoas tendon. Subtrochanteric osteotomy with femoral head resection [11, 12]. Arthrodesis open wedge valgus osteotomy is performed distal to the  is another option for nonreconstructible hips. lesser trochanter taking into account that 3 holes of the LCP In 1978 Castle and Schneider  described proxi- plateshouldbeproximaltothe createdosteotomy.Aeft r mal femoral resection and interposition arthroplasty in 12 attachment of the ligamentum teres to the iliopsoas tendon, as patients and 14 hips (Castle procedure). eTh proximal femoral originally described by McHale, a 4.5 mm LCP plate (locking head was resected below the lesser trochanter, and a capsular compression plate, Synthes) is prebent and contoured to flap across the acetabulum was constructed. eTh quadriceps accommodate to the shape of the femur after the osteotomy. muscle was sutured around the resected end of the femur. The plate is then xfi ed to the femur using locking screws. Postoperatively all patients were placed in Russell’s traction Advances in Orthopedic Surgery 3 ft fi ft Table 1 Previous hip Age/sex Diagnosis/GMFCS Fixation side Postoperative spica cast Followup (weeks) Complications surgeries Spastic diplegia Nonlocking plate 114/F Bilateral hip dislocation STR and VDRO No 108 No Unilateral GMFCS 4 Nonlocking plating Initially no 3 Loss of fixation on the right femur Spastic diplegia Bilateral 216/F STR weeks of spica following 103 Reoperation and supracondylar GMFCS 5 Reoperation on the Rt side using reoperation fracture aer cast removal locking plate Spastic diplegia Nonlocking plating 319/M No For 4 weeks 95 No GMFCS 5 Bilateral Spastic diplegia 417 STR and VDRO Bilateral LCP No 87 No GMFCS 5 Spastic diplegia Unilateral 523 No No 81 No GMFCS 5 LCP Spastic diplegia Bilateral 619 No No 69 No GMFCS 5 LCP Spastic diplegia Unilateral 721 No No 56 No GMFCS 5 LCP Spastic diplegia Unilateral Skin irritation 819 STR No 49 GMFCS 5 LCP that resolved after plate removal Spastic diplegia Bilateral 917 No No 26 No GMFCS 5 LCP STR: so tissue release. VDRO: varus derotational osteotomy. GMFCS: gross motor function classication system. F: female. M: male. 4 Advances in Orthopedic Surgery (a) (b) Figure 2: (a) Watson-Jones approach; note wide exposure of the femoral head and proximal shaft. (b) Resection of the femoral head with preservation of ligamentum teres. (a) (b) (c) Figure 3: (a) Bilateral procedure with fixation failure on the right side two weeks postoperatively. (b) Reoperation using a LCP plate and a spica cast. (c) Supracondylar femoral fracture aeft r removal of spica cast. (a) (b) Figure 4: (a) Preoperative radiograph of bilateral hip displacement. Dislocation on the right hip and subluxation on the left hip. (b) Postoperative radiograph of bilateral modified McHale operation, using locking compression plates, and no spica cast. until healing of soft tissues. es Th e measures were taken described procedures, especially proximal migration of the in order to prevent recurrence of pain and deformity and femur. In their method, placement of the lesser trochanter proximal migration with gradual adduction deformity. Knaus in the acetabulum prevents proximal migration. Removing and Terjesen andWidmannetal. described a similar the femoral head prevents the pressure generated from the procedure utilizing interposition of the iliopsoas and gluteal prominence of the femoral head. Furthermore, this technique muscles to the hip capsule with improvement of pain, sitting moves the abductor force laterally. This in turn directs the ability, and perineal care. remaining femur strongly into the acetabulum. According to McHale et al. presented their technique in 1990 in Leet et al., in the McHale operation, compared to proximal order to lessen the problems associated with the previously head resection and traction, the length of stay in the hospital Advances in Orthopedic Surgery 5 is shorter, the postoperative superior migration of the femoral  M. Inan, P. G. Gabos, M. Domzalski, F. Miller, and K. W. Dabney, “Incomplete transiliac osteotomy in skeletally mature head is less pronounced, and the surgical and medical adolescents with cerebral palsy,” Clinical Orthopaedics and complications are lower . Related Research,no. 462, pp.169–174,2007. To our view, the main drawbacks of the McHale proce-  M. E. Castle and C. Schneider, “Proximal femoral resection- dure arethe useofnonlockingplatesinosteoporoticbones interposition arthroplasty,” eTh Journal of Bone & Joint Surgery , and the need for spica casting postoperatively. Using modern vol. 60, no. 8, pp. 1051–1054, 1978. locking plates provides better stability and eliminates the  S. Ackerly, C. Vitztum, B. Rockley, and B. Olney, “Proximal need for spica casting, with its potential for femur fractures femoral resection for subluxation or dislocation of the hip after cast removal. in spastic quadriplegia,” Developmental Medicine and Child Neurology,vol.45, no.7,pp. 436–440, 2003. 5. Conclusion  K. A. McHale, M. Bagg, and S. S. Nason, “Treatment of the chronically dislocated hip in adolescents with cerebral The McHale procedure is widely used due to its eeff ctiveness palsy with femoral head resection and subtrochanteric valgus in achieving the goals of pain relief, increased range of osteotomy,” Journal of Pediatric Orthopaedics,vol.10, no.4,pp. motion, and improved seating ability. This technique was 504–509, 1990. proved to be safe with few complications compared to  A. I. Leet,K.Chhor,F.Launay, J. Kier-York, andP.D.Sponseller, other salvage procedures. Still, loosening and post spica “Femoral head resection for painful hip subluxation in cerebral casting fracture are, to our view, the major drawbacks of the palsy: is valgus osteotomy in conjunction with femoral head procedure, due to decreased bone mass in these patients. resection preferable to proximal femoral head resection and We suggest a modification of using locking plates with no traction?” Journal of Pediatric Orthopaedics,vol.25, no.1,pp. casting postoperatively. To our experience, this change in 70–73, 2005. the technique is reliable and useful and provides the benefits  K.A.Hogan,M.Blake,andR.H.Gross,“Subtrochantericvalgus of the original McHale procedure, with lessened morbid- osteotomy for chronically dislocated, painful spastic hips,” The Journal of Bone & Joint Surgery,vol.88, no.12, pp.2624–2631, ity. eTh refore we believe that locking plate stabilization of subtrochanteric valgus osteotomy provides the most stable  L. 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