Hip Reconstruction for Neuromuscular Disorders

Hip reconstruction is an option to treat hip subluxation in children with neuromuscular disorders. Children with neurologic disorders like cerebral palsy may experience hip subluxation. This is when the ball of the hip progressively moves away from the socket. Progressive displacement of the hip can result in pain with motion, increasing deformity of the lower extremities, difficulty with tolerance of walking or standing, and difficulty in positioning. It can also sometimes lead to worsening scoliosis. If this deformity persists, the ball of the hip may lose its round shape, resulting in an inability to reconstruct the hips appropriately.

If the hip is no longer located appropriately in the socket, our team may recommend surgery for your child’s hip. Surgery is performed by a multidisciplinary care team that includes specialists from the Neuromuscular Orthopaedic Program, which is part of the Division of Orthopaedics at Children’s Hospital of Philadelphia (CHOP). This team is made up of nationally and internationally recognized physicians and surgeons who specialize in the treatment of cerebral palsy, spina bifida, spinal muscular atrophy (SMA), muscular dystrophy, Charcot-Marie-Tooth and other neuromuscular disorders.

Below are some of the hip reconstruction surgical options our team may recommend:

• Varus derotational osteotomy (VDRO) — This operation involves cutting the bone and reorienting the ball of the femur into the socket of the pelvis. The bone is fixed with a plate and screws.
• Pelvic osteotomy — If the socket is misshapen, the surgeon will reshape the pelvis by cutting the bone and placing a bone graft in to maintain the change.
• Open hip reduction — If the VDRO and pelvic osteotomy fail to produce an adequate relocation, the surgeon will open the hip joint and place the ball in the socket.
• Salvage — If the hip is misshapen and the child is older, a salvage operation may be offered, which often involves reorienting the femur bone to move worn surfaces away from one another.
• Bilateral surgery — Many of these operations will be recommended bilaterally (both hips simultaneously) even if the opposite side is less severely involved, because of leg length inequality and the potential for the opposite side to become involved at a later time.

CHOP is continually top-ranked by U.S. News and World Report as one of the best children’s hospitals for orthopaedic care in the United States. CHOP’s experienced professionals, excellent facilities, and commitment to safety make it a top choice for families locally, nationally and internationally.

While hip reconstruction is a rare procedure at most hospitals, it is common at CHOP. Our orthopaedic surgeons, anesthesiologists, pain experts, nurses and therapists guide several children each week through surgery and recovery. If necessary, we can consult world experts right here at CHOP in any pediatric medical specialty.

Our operating facilities, intensive care units, recovery rooms and patient rooms are state of the art.

Your child will be scheduled for a pre-operative clinic visit about one to two weeks prior to surgery.

This consultation will include:

• A review of the surgical procedure by your child’s surgeon and members of our anesthesia team
• A review of your child’s medical history, any medications they are taking, and results from their physical examination with the nurse practitioner or physician’s assistant
• A review of surgical complications. Although unusual, complications can include infection, vessel or nerve injury, failure of the bone to heal, extra bone formation at the surgical site, and other medical complications requiring readmission.
• Time to answer any questions you may have regarding the surgery, the hospitalization and the postsurgical rehabilitation

On the day of the procedure, your child will be given calming medication and be transported to the operating room. In the operating room, your child will be gently put to sleep and IVs will be placed. While under anesthesia, your child will receive a catheter and, in most cases, an epidural is placed for pain control.

The surgical team will then perform the procedure. All incisions are closed with absorbable sutures.

Members of our Family Services team will check in with you several times throughout the day to give you updates on the progress of surgery. Then, once complete, the surgeon will meet with you to let you know the outcome of surgery.

After surgery, your child will be transported to the post-anesthesia care unit (PACU), where they will be monitored by highly specialized nurses. When your child is sufficiently awake, Family Services will bring you to see your child.

A typical length of stay in the hospital is two to five days. Your child will be discharged home once they:

• Are able to sit comfortably
• Have good pain control by mouth or G tube
• Have a bowel movement

Before you leave the hospital, the floor nurse practitioner or resident will give you important information regarding medications, incisional care, and who to call with questions. Some children will require ambulance transportation which will be set up by case management.

Some children will require hospital beds, commodes, walkers or home nursing care. Our case managers will assist with these things while you are still in the hospital. If you think you will have difficulty caring for your child at home, be sure to talk to case management while at the hospital.

Typically, a child will be out of school for four to six weeks following hip reconstruction. Initial bracing or immobilization will typically last four to six weeks. Physical therapy initially will involve gentle range of motion exercises at around six weeks. Your child should be able to bear weight after six to12 weeks; and after 12 weeks, a more vigorous physical therapy program is allowed.