ORIGINAL ARTICLE

Surgical Management of Hip Subluxation and

Dislocation in Children With Cerebral Palsy:
Isolated VDRO or Combined Surgery?
Kenneth Huh, MD,* Susan A. Rethlefsen, PT,w
Tishya A.L. Wren, PhD,wzy and Robert M. Kay, MDwz

hips with MP >50% were successfully managed with VDRO

Background: Controversy exists regarding surgical treatment of
hip subluxation/dislocation in children with cerebral palsy (CP).
The purpose of this study was to compare isolated varus
derotational osteotomy (VDRO) and VDRO combined with
open hip reduction and/or pelvic osteotomy in children with CP
and hip subluxation/dislocation.
Methods: Retrospective review was performed of 75 patients
with CP (116 hips) and hip subluxation/dislocation treated
surgically, with a minimum of 2 years follow-up. Ninety-two
hips had undergone VDRO alone, and 24 had undergone
VDRO and open reduction and/or pelvic osteotomy (with the
decision to proceed with open hip reduction and/or pelvic
osteotomy made intraoperatively based on fluoroscopy and
arthrogram). Clinical variables, functional level, radiographic
variables, and complications/revisions were compared between
groups.
Results: Patients requiring combined surgery (VDRO+) had
higher baseline migration percentages (MP) (84% ± 18 VDRO+,
51% ± 21 VDRO), higher acetabular indices (34 ± 10 VDRO+,
28 ± 7 VDRO), more negative center-edge angles (-36 ± 28
VDRO+, -0.3 ± 18 VDRO), and higher neck-shaft angles (162
± 12 VDRO+, 157 ± 10 VDRO) (all P < 0.02). Postoperative
radiographic variables were similar between groups. The percen-
tage of patients with MP >30% at final follow-up was similar
between groups (38% VDRO+, 33% VDRO). There were no
differences in complications or revision rates between groups. Of
the hips with MP >50% preoperatively and treated with VDRO
alone, 41% developed postoperative MP of Z30% and 21%
developed a MP of Z40%.
Conclusions: The study results confirm that combined proce-
dures should be considered in patients with high MP. However,
this study supports a sequential approach to surgical manage-
ment of subluxated/dislocated hips in patients with CP as many
From the *Starship Children’s Hospital, Grafton, Auckland, New
Zealand; wChildrens Orthopaedic Center, Childrens Hospital Los
Angeles; zDepartment of Orthopaedic Surgery, Keck School of
Medicine; and yDepartments of Radiology and Biomedical Engi-
neering, University of Southern California, Los Angeles, CA.
None of the authors received financial support for this study.
The authors declare no conflict of interest.
Reprint: Susan A. Rethlefsen, PT, Childrens Orthopaedic Center,
Childrens Hospital Los Angeles, 4650 Sunset Blvd., M.S. 69, Los
Angeles, CA, 90027. Email: srethlefsen@chla.usc.edu.
Copyright r 2011 by Lippincott Williams & Wilkins
alone. We recommend performing VDRO and soft tissue release
first, assessing reduction using fluoroscopy and arthrogram and
proceeding with open reduction and/or pelvic osteotomy if
reduction and/or femoral head coverage are inadequate.
Level of Evidence: Level III, retrospective comparative study.
Key Words: cerebral palsy, hip displacement, surgery, varus
derotational osteotomy
(J Pediatr Orthop 2011;31:858–863)
H ip subluxation and dislocation remain difficult
problems in children with cerebral palsy (CP). Hip
subluxation or dislocation has been reported in up to
45% of hips in patients with CP.1 Dislocation is thought
to be due to spastic muscles causing abnormal forces
across the hip joint resulting in progressive subluxation
and dislocation.1–3 Involved hips display femoral ante-
version, coxa valga, and posterolateral and superior
migration of the femoral head from the acetabulum.4
Treatment options include hip adductor stretching,
abduction bracing, botulinum toxin injections, soft tissue
releases, and reconstructive bony procedures involving
the proximal femur and/or acetabulum. Hip dislocation
can cause difficulty with perineal care and sitting balance
and may cause pain in up to 50% of patients.5 The goal of
any treatment is to create a reduced, stable, mobile, and
pain-free hip.
When treating subluxated or dislocated hips surgi-
cally, controversy exists regarding what procedures to
perform. Options include performing a proximal femoral
varus derotational osteotomy (VDRO) alone or in con-
junction with an open hip reduction and/or pelvic
osteotomy. The purpose of this study was to review the
long-term results of surgical hip reconstructions in children
with CP undergoing VDRO as part of the initial surgery
and to evaluate the results in 2 groups: (1) hips treated with
VDRO without an open hip reduction or pelvic osteotomy,
and (2) hips in which an open hip reduction and/or pelvic
osteotomy was performed concomitantly with the VDRO.
Preoperative variables were assessed to determine predic-
tors of surgical failure to help determine which patients
should undergo additional procedures at the initial surgery.

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J Pediatr Orthop  Volume 31, Number 8, December 2011
METHODS
A retrospective review was performed of all patients
with the diagnosis of CP and hip subluxation or
dislocation treated surgically by the senior author
between 1997 to 2007, with a minimum of 2 years clinical
and radiographic follow-up. None of the patients had
diseases of a progressive nature. Patients who had under-
gone prior femoral or pelvic osteotomies or had windswept
deformity were excluded. The patients were divided into 2
groups, one group had VDRO alone (VDRO group) and
the other group had combined VDRO with 1 or more of
the following: open reduction or pelvic osteotomy
(VDRO+ group). Seventy-five patients who had under-
gone 145 VDRO surgeries fit the inclusion criteria. Twenty-
nine hips (in 29 of these patients) were excluded from
statistical analysis, as they had undergone prophylactic
VDRO and had a migration percentage (MP) of r25%
preoperatively. As a result, the study population included a
total of 116 hips in 75 patients.
Detailed chart review was performed and the
following clinical variables were recorded for each patient:
age at time of surgery, distribution of CP involvement
(hemiplegia, diplegia, or quadriplegia), functional level as
determined by the Gross Motor Function Classification
System (GMFCS expanded and revised),6 side(s) of
operated hip, total time of follow-up, immediate post-
operative immobilization (spica cast vs. nonspica cast),
complications, and need for revision surgery.
Preoperative, postoperative, and follow-up radio-
graphs were analyzed. Radiographic variables measured
included neck-shaft angle, center-edge angle of Wiberg
(CEA), Reimers’ MP, and acetabular index (AI) or
Sharp’s angle. Hips were considered subluxated if the
MP was >30% and dislocated if the MP was >99%.
Surgical Decision-Making and Follow-up
All patients in the study had a VDRO performed to
address a subluxated or dislocated hip or hips. The
decision to proceed with open hip reduction and/or pelvic
osteotomy was made intraoperatively. After VDRO was
performed, the quality of the reduction was assessed with
fluoroscopy and arthrogram as indicated. If the femoral
head was not concentrically reduced or the hip remained
unstable after the VDRO, open reduction was performed.
If the femoral head was reduced but there was insufficient
coverage, pelvic osteotomy was performed. Dega osteot-
omy was performed almost uniformly in these patients.
Patients were immobilized postoperatively in either a
spica cast or A-frame cast for a total of 4 to 6 weeks. For
children undergoing VDRO without pelvic osteotomy or
open reduction, immobilization typically was for 4 weeks
compared with 6 weeks in the combined group. Once the
casts were removed, physical therapy was initiated and
patients were allowed to weight-bear as tolerated based
on radiographic evidence of healing. Patients were
typically seen postoperatively at 1 to 2 weeks, 4 or 6
weeks, 3 months, 6 months, and 12 months postopera-
tively. After 1 year, patients were seen semiannually or
annually.
r 2011 Lippincott Williams & Wilkins
Surgical Management of Hip Subluxation / Dislocation in CP
Statistical Analysis
Between group comparisons were made using
unpaired t tests for continuous variables, and w2 or
Fisher exact test in which appropriate for the remaining
variables. Statistical significance was set at Pr0.05.
RESULTS
There were 45 male and 30 female participants
included in the study. Overall, surgery was bilateral in 70
of 75 patients (93%) and unilateral in 5 of 75 (7%).
Surgery was performed bilaterally for bilateral hip
subluxation/dislocation in 41 patients (55%). Bilateral
surgery was also performed in an additional 29 patients,
with 1 side done prophylactically and/or for symmetry.
Only the subluxated/dislocated hip in this second group
of patients was included in the statistical analysis.
Average age at time of surgery was 7.0 years for both
groups, with a range of 2.1 to 12.1 years, and an average
follow-up of 4.6 years (range, 2.0 to 10.7 y). The
distribution of CP was hemiplegia for 2 patients (2 hips),
diplegia for 8 patients (13 hips), and quadriplegia for 65
patients (101 hips). Immobilization was accomplished
postoperatively with a spica cast for 76 hips (66%), and
with an A-frame cast or hip abduction pillow in the other
40 hips (34%). Subsequent hardware removal was
undertaken for 51 of the 116 hips (44%).
Radiographic Variables
Hips that underwent combined surgery (VDRO+)
had higher preoperative MP, higher AI, and more
negative CEA than those in the VDRO group, indicating
greater hip instability at baseline. All postoperative
radiographic variables were similar between groups.
(Table 1) The percentage of hips with MP >30% at
final follow-up (before any revision surgery) was similar
between groups. The distribution of preoperative MP
values for the 2 groups is compared in Table 2. Values at
final follow-up (before revision in 6 hips) are presented
in Table 3.
Twenty-nine hips had a preoperative MP of r25%
(average 19% ± 1%; range, 0% to 24%) and underwent
VDRO for purposes of prophylaxis and/or symmetry.
These hips were excluded from the statistical analysis. At
final follow-up the average MP in these hips was
15% ± 1%, an average of 4.2 ± 1.6 years later. To date,
none of these hips has undergone revision.
Complications
The complication rates are reported in Table 4.
Although there was no statistically significant difference
in the incidence of complications between VDRO and the
VDRO+ groups, all 8 major complications occurred in
the VDRO group (9% in the VDRO group versus 0% in
the VDRO+ group). These included 4 cases of avascular
necrosis, 3 fractures adjacent to hardware, and 1 case of
hardware infection requiring debridement and removal of
hardware. The minor complications occurred equally in
both groups (8% in each group) and involved 7 super-
ficial cast ulcers, 1 superficial wound infection, and 1 case
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Huh et al J Pediatr Orthop  Volume 31, Number 8, December 2011

TABLE 1. Preoperative and Postoperative Radiographic Variables

VDRO Only (n = 92) VDRO + Other Procedures (n = 24) P
Preoperative CEA (degree)  0.3 ( ± 18) 36 ( ± 28) < 0.0001
(range:  49-25) (range: –101-–6)
Preoperative AI (degree) 28 ( ± 7) 34 ( ± 10) 0.0013
(range: 7-47) (range: 16-48)
(N = 86) (N = 23)
Preoperative Sharp’s (degree) 46 ( ± 9) 55 NA
(range: 30-57) (N = 1)
(N = 6)
Preoperative NSA (degree) 157 ( ± 10) 162 ( ± 12) 0.02
(range: 135-178) (range: 142-178)
Preoperative MP (%) 51 ( ± 21) 84 ( ± 18) < 0.0001
(range: 25-100) (range: 53-100)
Final CEA (degree) 21 ( ± 15) 20 ( ± 21) 0.94
(range:  44-48) (range: 45-50)
Final AI (degree) 25 ( ± 6) 29 ( ± 13) 0.07
(range: 15-36) (range: 8-48)
(N = 42) (N = 13)
Final Sharp’s (degree) 44 ( ± 9) 42 ( ± 5) 0.47
(range: 5-58) (range: 34-50)
(N = 50) (N = 11)
Final NSA (degree) 129 ( ± 18) 128 ( ± 22) 0.83
(range: 76-163) (range: 85-178)
Final MP (%) 26 ( ± 17) 28 ( ± 29) 0.75
(range: 0-86) (range: 0-100)
AI indicates acetabular index; CEA, center-edge angle of Wiberg; MP, Reimers’ migration percentage; NSA, neck-shaft angle; VDRO, varus derotational osteotomy.

of prolonged postoperative pain. All minor complications
resolved without additional surgical intervention.
Revision Surgery
There was no difference between the groups in rates
of surgical revision for remigration. (Table 4) Seven hips
underwent surgical revision, 1 of 24 (4%) in the VDRO+
group and 6 of 92 (7%) in the VDRO only group.
Revisions were done an average of 4.5 ± 2.1 years after
initial surgery (range, 1.8 to 7.4 y). Average MP in these
hips before initial surgery was 68% ± 27%, ranging from
28% to 100%. All but 2 had preoperative MP of >60%.
Average CEA before initial surgery for revised hips was
-18 ± 24 degrees, ranging from -57 to +14 degrees. These
values are closer to those of the VDRO+ group than the
VDRO only group. However, statistical analysis could
not be conducted for comparison due to the small number
of patients undergoing revision surgery. Only 1 patient
requiring revision used ambulation as a primary means of
mobility (GMFCS III). All others functioned at GMFCS
level IV (1 patient) or V (4 patients).
Dislocated Versus Subluxed Hips
Nineteen hips were dislocated before initial surgery.
There was a higher rate of combined surgery among these
hips (58%) than the subluxated hips (13%). Of the 19
dislocated hips, 8 (42%) were treated with VDRO alone,
with no acute complications. Of these 8 hips, 1 (13%) was
revised 3 years later for remigration of 86%. Among the
11 dislocated hips that underwent combined VDRO and
open reduction and/or pelvic osteotomy, there were
2 minor complications (superficial cast ulcers). Two of

TABLE 2. Preoperative Migration Index Values TABLE 3. Migration Percentage Values at Final Follow-up
Preoperative MP VDRO VDRO+ (Before Revision in 6 Cases)
(%) (n = 92) (n = 24) P Final MI (%) VDRO (n = 92) VDRO+ (n = 24) P
>30 77 (84%) 24 (100%) 0.04 >30 30 (33%) 9 (38%) 0.64
4 revised (5%) 1 revised (4%) 5 revised (16%) 1 revised (11%)
>40 49 (53%) 24 (100%) < 0.0001 >40 12 (13%) 7 (29%) 0.07
4 revised (8%) 1 revised (4%) 5 revised (38%) 1 revised (14%)
>50 34 (37%) 24 (100%) < 0.0001 >50 8 (9%) 3 (13%) 0.69
4 revised (12%) 1 revised (4%) 3 revised (38%) 1 revised (33%)
>60 24 (26%) 20 (83%) < 0.0001 >60 4 (4%) 2 (8%) 0.60
4 revised (17%) 1 revised (5%) 2 revised (50%) 1 revised (50%)
>70 18 (20%) 17 (71%) < 0.0001 >70 3 (3%) 2 (8%) 0.28
2 revised (11%) 1 revised (6%) 1 revised (33%) 1 revised (50%)
MP indicates Reimers’ migration percentage; VDRO, varus derotational MP indicates Reimers’ migration percentage; VDRO, varus derotational
osteotomy osteotomy.

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J Pediatr Orthop  Volume 31, Number 8, December 2011 Surgical Management of Hip Subluxation / Dislocation in CP

MP of at least 40% at final follow-up. Seven others (21%)

TABLE 4. Complications and Revisions
had MPs between 30% and 39% at final follow-up. Thus,
VDRO VDRO + Other for hips with a MP of >50% preoperatively that
only (n = 92) procedures (n = 24) P
underwent VDRO alone, 21% either required revision
Complications 15 (16%) 2 (8%) 0.52 surgery or had a final MP of at least 40%. The remaining
Major 8 (9%) 0 0.20 79% remained stable an average of 4.4 ± 1.8 years
Minor 7 (8%) 2 (8%) >0.99
Revision surgery 6 (7%) 1 (4%) >0.99 (range, 2 to 10 y) postoperatively, without requiring
further surgical intervention. These findings suggest
VDRO indicates varus derotational osteotomy. medium-term effectiveness of VDRO without additional
pelvic surgery for many hips with marked displacement.
However, as the patients were relatively young at final
these 11 hips (18%) experienced redislocation, one of follow-up and had likely not yet reached skeletal
which was revised. The other was not revised after maturity, there is a possibility of future remigration or
discussion by the patient’s physician and family, due to redislocation. Further follow-up is needed to determine
the medically fragile state of the patient. long-term results.
At final follow-up there was no statistically sig-
nificant difference in the rate of recurrent subluxation/
Gross Motor Function dislocation in the patients who underwent VDRO versus
The vast majority of patients in both groups were VDRO plus open reduction and/or pelvic osteotomy (4%
GMFCS level IV or V. However, there was a significant to 5% in both groups). At the final follow-up (before any
difference in the distribution of gross motor functional of the 6 revisions which were performed), 33% of patients
levels between groups, with more ambulatory children in the VDRO group and 38% in the VDRO+ group had
tending to undergo VDRO alone. Twenty-three of 24 hips a MP >30%, and 13% of patients in the VDRO group
(96%) which required combined surgery (VDRO+) were and 29% of patients in the VDRO+ group had final MP
in children who were minimally ambulatory or nonam- >40%. This is comparable to previously reported rates
bulatory, functioning at GMFCS level IV or V, versus 69 of postoperative hip instability of 15% to 40% after
of 92 (75%) in the VDRO group (Table 5). VDRO alone.7–9
The combined group had a higher resubluxation
rate than previous studies have reported.10,11 One possible
DISCUSSION reason for this discrepancy is the way in which patients
Surgical management of hip subluxation or disloca- were allocated into the VDRO only or VDRO+ group.
tion in patients with CP is challenging. The decision of Previous studies included less severely involved hips with
when to perform a VDRO alone or with open hip combined VDRO and pelvic osteotomy, thus potentially
reduction and/or pelvic osteotomy has been debated. In biasing those studies toward a less involved patient
this study, the decision to perform open reduction and/or population (and therefore lower remigration rates) than
pelvic osteotomy was made intraoperatively based on this study. Rather than performing combined procedures
fluoroscopy, including arthrographic evaluation of hip on all patients who met specific preoperative radiographic
stability and coverage after VDRO. Using this ‘a la carte’ criteria, our decision was made based on intraoperative
approach, hip stability was achieved with VDRO alone in findings. As noted, 34 of 58 hips (59%) with preoperative
a large percentage of cases, including several with MP >50% had VDRO only (without either open hip
complete dislocations. There were a total of 58 hips with reduction or pelvic osteotomy). This likely led to some
a MP of >50% preoperatively. Thirty-four of the 58 patients undergoing VDRO only who would have
(59%) underwent VDRO without either open reduction received additional procedures based on preoperative
or pelvic osteotomy. Of these 34 hips, 12% (4 of 34) radiographic values in other studies.
underwent revision surgery, and another 3 (9%) had a Patients who required additional procedures after
VDRO had been performed had the most severely
affected hips in our study. Nonetheless, at final follow-
up the revision rate for remigration was similar between
TABLE 5. Gross Motor Functional Level Distribution as
the 2 groups (4% to 7% in both groups) and low in both
Measured by the GMFCS
groups compared with other reports. Measurements of
VDRO VDRO + Other migration at “final” follow-up in this series may appear
GMFCS Only (n = 92) Procedures (n = 24) P
worse than those in other series. One possible reason for
1 0 0 0.02 this is the way “final” follow-up is defined in different
2 4 (4%) 0 studies. In this study, final hip migration was determined
3 19 (21%) 1 (4%)
4 31 (34%) 5 (21%) at final follow-up if no secondary surgery was performed,
5 38 (41%) 18 (75%) or immediately before a revision surgery when performed.
In contrast, McNerney et al12 reported that 99 of 104 hips
GMFCS indicates Gross Motor Function Classification System; VDRO, varus
derotational osteotomy. “remained well-reduced at follow-up” 6.9 years after
VDRO, pelvic osteotomy, soft tissue release ± open hip

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Huh et al
reduction in children with CP, though 31% of the patients
in that series had undergone reoperation for problems of
pelvic obliquity and/or hip asymmetry before final follow-
up. In the same study, there were an additional 12% of
hips with MP Z30% at final follow-up, including 5%
with Z40% migration.
Radiographically, preoperative MP was significantly
higher in the VDRO+ group than in the VDRO alone
group. The greater MP indicates greater hip instability and it
is logical that these patients required additional proce-
dures to stabilize the hip. Higher preoperative MP has been
previously recommended as an indication to perform a
pelvic osteotomy. The average preoperative MP for patients
in the VDRO+ group was 84% compared with 51% for the
VDRO only group. Song and Carroll13 recommended that
patients with MP >70% undergo concomitant acetabular
procedures. Oh et al 14 and Settecerri and Karol15 noted that
preoperative MP >50% was predictive of poor outcome
and Oh et al14 recommended performing acetabuloplasty for
MP >80%. Our results confirm the recommendations that
in patients with a high MP, combined procedures should be
considered. However, combined procedures were not per-
formed in 34 of 58 patients (59%) in this study with
preoperative MP of >50% and only 21% of those went on
to require reoperation or develop a postoperative MP of
40%. Therefore, pelvic osteotomy does not seem requisite
for hip stability in all such patients. The findings of this study
suggest that extensive surgery can be avoided for many
patients by using intraoperative imaging to determine the
need for open reduction and pelvic osteotomy.
Preoperative AI was also identified as a statistically
significant variable in our study. The VDRO+ group had
an average preoperative AI of 34 degrees, which is higher
than accepted normal values. An elevated AI is indicative
of the severity of hip dysplasia. Some have advocated
preoperative AI as an indication for performing acetabu-
loplasty. Roye et al,10 recommended performing pelvic
osteotomies for AI>35. Miller et al,11 advocated acet-
abuloplasty in patients with a type 2 (up-sloping) sourcil
and McNerney et al,12 recommended acetabuloplasty in
patients with AI >25 and other signs of severe dysplasia.
Although the complication rate between the 2
groups was not significantly different, it should be noted
that all of the major complications occurred in the VDRO
only group. There is no reason to suspect that the major
complications that occurred (fractures, avascular necro-
sis, hardware infection) should be specific to the VDRO
only group. VDROs were performed in similar manner in
all patients and all patients followed a similar post-
operative regimen. This finding seems to be an incidental
one and may be related to the unequal sample sizes of the
2 groups. Revision surgery was required in similar
percentages of hips in both groups, an average of
4.5 ± 2.1 years after initial surgery. The patients treated
with VDRO alone who went on to require revision had
preoperative radiographic values similar to the rest of the
patients in that group. There was no radiographic
indication either preoperatively or immediately post-
operatively for acetabuloplasty in any of the patients. It
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J Pediatr Orthop  Volume 31, Number 8, December 2011
is felt that remigration in these patients occurred because
of soft tissue rather than bony deformities.
A limitation of this study is that because the
patients were not randomized, the groups were not
equivalent preoperatively. The surgical approach for each
patient was selected based on an intraoperative decision-
making process. Although intraoperative fluoroscopy and
arthrogram were used to help decide which patients
underwent combined procedures, the ultimate decision
was based on the senior author’s interpretation of these
data. Thus, it is not possible to give strict criteria for when
to perform a combined procedure versus VDRO alone. In
addition, while our overall number of hips included was
large, the VDRO+ group included a relatively small
number of patients, which may have limited our ability to
detect differences that may have been present between the
2 groups. The study included patients of varying ages and
varying lengths of follow-up. Not all patients had reached
skeletal maturity at the time of final assessment. There-
fore, the results can only be interpreted to reflect medium-
term outcome of either surgical approach. Further study
is needed to determine long-term outcome.
The results of this study suggest that extensive hip
reconstruction surgery can be avoided for many patients
by using intraoperative imaging after VDRO to deter-
mine the need for subsequent open reduction and pelvic
osteotomy. The results support a sequential “a la carte”
approach to the surgical management of the subluxated
or dislocated hip in patients with CP. We recommend
performing the VDRO and soft tissue release first. After
this is done, reduction can be assessed with fluoroscopy;
arthrogram often assists in this assessment. If there is
inadequate reduction and/or femoral head coverage, open
reduction and/or pelvic osteotomy can then be performed
as indicated. The results of this study demonstrate com-
parable results in terms of final radiographic variables
and the need for revision surgery. Although preoperative
MP, AI, and CEA can help predict which patients may
need combined procedures, we recommend going through
a step-by-step process and tailoring the procedure for
each hip when deciding whether to proceed with addi-
tional procedures concomitantly with a VDRO in
children with CP.
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