PREVENTION OF HIP DISLOCATION IN CEREBRAL PALSY : EARLY MULTILEVEL MINIMALLY-INVASIVE APPROACH (E.M.M.A.)

Introduction Hip problems in Cerebral Palsy are frequent (25-75%). Subluxation and dislocation of the hip is proportional to the neuromuscular involvement and is often due to the alterate spastic muscles forces acting on the femoral head in the acetabular cavity. Aim: E.M.M.A approach (Early Multilevel Minimally-invasive Approach) has been designed in 3 different steps and applayed to decrease imbalanced forces due to spasticity acting on the femoral head and therefore to decrease hip migration progression, bone deformities and future pain with the minimal biological cost for the patients. We consider age and R.I. as crucial discriminants for treatment steps. All muscles around the hip joint are addressed simultaneously (dductor longus, ileopsoas, medial hamstrings and rectus femoris). Material and method E.M.M.A. 1: age 2 - 4 years, RI ≤ 20%: multilevel injection of botulinum toxin in case of muscular hyperactivity without morphological alterations of the couple muscle-tendon (contractures) E.M.M.A 2: age 4 - 6 , RI ≥ 20%: multilevel aponeurectomies in case of muscular hyperactivity with morphological alterations of the couple muscle-tendon (retraction) E.M.M.A. 3: AGE 6-8 EMMA 2 associated to early bone surgery (proximal femoral temporary epiphysiorisis with cannulated screw to achieve a progressive correction of valgus deformity). We adopted this approach to prevent bone deformities with early mobilisation and early control of the pain in the same time Result In our department were treated 40 children with hip subluxation and a mean follow-up of 28 months. None of our patients have had a progression to reach hip dislocation. Conclusion E.M.M.A seems to be a practical and little invasive approach to achieve hip containment, decrease spasticity and also appears to be satisfactory to prevent progressive acetabular displasia and hip dislocation.