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The outcomes of such treatment are, according to most of the authors, satisfactory, but it presents the challenge of finding uniform groups of patients for better evaluating and possibly comparing outcomes, with the major reason for this difficulty being the fact that those patients show spasticity. Among the 58 operated patients, 38 were unilateral, and 20 were bilateral cases, totaling 78 hips. All patients, with a follow-up period of at least 12 months, were reassessed clinically and radiographically for the present study in August At clinical evaluation, the following were recorded preoperatively: age by the time of surgery, gender, kind of involvement of Brain Palsy, functional status, and presence of pain at hip joint manipulation.
Distribution concerning gender was 30 male patients and 28 female patients. All the 58 patients had spastic Brain Palsy, with 48 quadriparetic patients, eight biparetic, and two hemiparetic. Functionally, 56 patients were non-ambulating, one ambulating at physical therapy and one communitarian. The averages for preoperative, early postoperative, and late postoperative were, respectively: Results were rated as satisfactory when clinical and functional improvement was reported, as well as normalization of X-ray parameters.
The average follow-up period was From a total of 58 patients 78 hips assessed, 46 patients 65 hips were rated as satisfactory and 12 patients 13 hips as unsatisfactory. From the 12 patients 13 hips evolving unsatisfactorily postoperatively, five were females and seven males, not showing any statistical differences, as well as for age of patients at surgery time, which was, in average, Concerning the kind of Brain Palsy, However, all patients managed to keep sit on a wheelchair postoperatively.
The combination of sub dislocation early detection and soft parts release may reduce the number of unsatisfactory outcomes 4,8. The combination of early release of the soft parts and hip reconstructive osteotomy yields normal hips to most of the children at late growth stages 4,8,9,13, The recurrence rate for dislocation is higher in cases where only soft parts release was used, which corroborates the indication for surgical reconstruction of the hip Many authors agree that this method is efficient, emphasizing that the reconstruction of a spastic hip lead to painless, moving and stable hips, however, few studies have emphasized which factors could lead to an unsatisfactory outcome, which would help on determining its indications and restraints on the use of the method 9.
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More interestingly, these authors noticed an apparent trend to femoral valgusing on serial X-ray analysis, considering this as one of the major recurrence factors and associating it to a higher prevalence of non-vascular necrosis of the femoral head There was no difference regarding follow-up time, since for cases with up to 24 months of follow-up or after 24 months up to months, the statistical analysis did not evidence significance. A higher degree of femoral varusing leads to a better accommodation of the femoral head to the acetabulum, as well as prevention of hip dislocation recurrence, as suggested by Pope et al.
Data for early postoperative CD angle did not show statistically significant differences between satisfactory and unsatisfactory hips groups, thus, being impossible to state that a lower degree of femoral varusing could lead to a higher recurrence rate and unsatisfactory results. The percentage of treatment failure due to dislocation recurrence, considered unsatisfactory, was Studies evaluating the natural development of spastic dislocation of the hip have evidenced the interdependence between hip dislocation, pelvic obliquity and scoliosis 8,12, We report only two patients requiring spine arthrodesis for scoliosis treatment.
Age is an important analysis factor for a paralytic hip. Some authors suggest a higher rate of surgical treatment failure in patients with severe spasticity and older by the time of surgery 6,11, The observation by Brunner and Baumann 9 that before the age of four to eight years, due to a higher remodeling potential, dislocation recurrence is higher, is not the same realized in the analysis of our patients, who, even after groups stratification one below the age of eight years - months - and the other, above eight years - months - did not present statistical significance when compared between satisfactory and unsatisfactory groups.
We believe that the distribution and severity of Brain Palsy contribute for correction failure, once Dislocation recurrence is associated to severe acetabular failure, deformity recurrence in inner rotation and contraction in adduction 4. This exaggerated inner rotation would be provided by a strong action of the anterior gluteus muscle, both median and minimum, which reaches to a mechanical advantage after femoral varusing, worsening clinical picture, which can be seen by an improved outer rotation when this musculature is released.