ORIGINAL ARTICLE
Failure of Hip Reconstruction in Children
With Cerebral Palsy: What Are the Risk Factors?
Arya Minaie, MD,* J. Eric Gordon, MD,† Perry Schoenecker, MD,†
and Pooya Hosseinzadeh, MD*†
Background: The rates and risk factors contributing to failure after
hip reconstruction among patients with cerebral palsy (CP) are not
well established. In analyzing a large cohort of children with CP
who underwent hip reconstruction, the objectives of this study are
to establish (1) the failure rates and (2) associated risk factors.
Methods: This retrospective study included chart and radio-
graphic review of patients between the ages of 1 to 18, with a
diagnosis of CP, who underwent a hip reconstructive procedure
at a single children’s hospital over a 9-year period (2010 to 2018).
Patients without at least 2 years of follow-up were excluded. Age
at time of surgery, sex, Gross Motor Function Classification
System (GMFCS), procedure(s) performed, preoperative migra-
tion percentage (MP), neck-shaft angle, and acetabular index
(AI) were recorded. Failure was defined as need for revision
surgery or a MP > 50% on follow-up radiographs. Logistic re-
gression and multiple-variable regression-type models were used
to test for significance of risk factors.
Results: Of the 291 hips in 179 patients (102 males, 77 females) that
met inclusion criteria, 38 hips (13%) failed. Significant differences in
the failure group were seen in age at time of surgery (6.2 ± 3.2 vs.
8.1 ± 3.2; P < 0.001), preoperative MP (62.3 ± 28.7 vs. 39.9 ± 24.1%;
P < 0.001) and preoperative neck-shaft angle (164.9 ± 8.2 vs.
157.3 ± 15.6 degrees; P < 0.001). Age below 6 at time of surgery
significantly increased failure rate (26% vs. 6.3%, P < 0.001) as did
preoperative MP > 70% (28.9% vs. 9.9%, P < 0.001). Receiving an
acetabular osteotomy was protective against failure (9.1% vs.
16.9%, P = 0.048), particularly in patients with a preoperative AI
> 25° (odds ratio = 0.236; confidence interval: 0.090-0.549).
Conclusions: In this case series, failure after hip reconstruction
for children with CP was determined to be 13.1%. There was a
higher risk associated with age under 6 at time of surgery or a
preoperative MP > 70%. Correction of acetabular dysplasia
when AI is more than 25 degrees with acetabular osteotomy at
time of hip reconstruction, exerted a protective effect against
subsequent failure.
From the Departments of *Orthpaedic Surgery; and †Pediatric and
Adolescent Orthopedic Surgery, Washington University School of
Medicine, St. Louis, MO.
The authors did not receive any funding for this study.
The authors declare no conflicts of interest.
Reprints: Pooya Hosseinzadeh, MD, Department of Orthopaedic Sur-
gery, Washington University School of Medicine, Pediatric and
Adolescent Orthopedic Surgery, Washington University Orthopae-
dics, 4S60, Suite 1B, One Children’s Place, St. Louis, MO 63110.
E-mail: hosseinzadehp@wudosis.wustl.edu.
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DOI: 10.1097/BPO.0000000000001989
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Level of Evidence: Level III—retrospective case series.
Key Words: cerebral palsy, reoperation, hip reconstruction,
osteotomy, failure
(J Pediatr Orthop 2022;42:e78–e82)
T he hip is the second most affected joint (after ankle) in
children with cerebral palsy (CP). Chronic spasticity of
the hip adductors and flexors can cause progressive hip
subluxation ultimately leading to hip dislocation. Rates of
affliction have been described to range between 15% and
80%, with a generally accepted figure of one in three children
with CP affected.1–8 Hip subluxation can lead to difficulty
maintaining perineal hygiene, inability to sit comfortably,
difficulty ambulating, scoliosis development, and early onset
osteoarthritis in adulthood.2,3,5–7,9 To prevent subsequent
sequalae, treatment of hip subluxation is typically performed
in children and adolescents with CP. Treatment options in-
clude bracing, soft tissue releases (adductor muscle releases),
or bony reconstructive procedures such as varus derotational
osteotomies (VDRO), frequently in conjunction with ace-
tabular osteotomies.1,3,5,6,9,10
Failure can occur after hip reconstruction in children
with CP because of residual contractures, spasticity, or abnor-
mal bony anatomy. Failure has been defined as either a need
for revision surgery in the same hip after hip reconstruction or
radiographic imagining showing repeat subluxation or
dislocation.2,3,9 No definitive consensus on failure rates has
been reached in the literature with rates ranging between 8%
and 74%.3,5,8–11 While clear associations have not been estab-
lished, it has been suggested that preoperative migration per-
centage (MP), Gross Motor Function Classification System
(GMFCS), and age at time of surgery may be risk factors
leading to resubluxation after hip reconstructive surgery.2,4,6
Overall, hip reconstructive surgery has been shown to
be an effective procedure to treat hip dislocation. There are
relatively few studies that have investigated the causes and
rates of failure in a large cohort of children with CP after such
a procedure.6 With the risks associated with hip re-
construction, the specific risks associated with failure need to
be assessed in order to minimize the need for subsequent
surgery or hip dislocation. In analyzing a large cohort of
children with CP who underwent hip reconstruction, the ob-
jectives of this study are to establish (1) the failure rates and (2)
associated risk factors.
J Pediatr Orthop  Volume 42, Number 1, January 2022
J Pediatr Orthop  Volume 42, Number 1, January 2022 Factors Leading to CP Hip Failure

METHODS
After obtaining Institutional Review Board appro-
val, a preliminary cohort of CP patients presenting to a
single tertiary care children’s hospital for hip re-
constructive procedure(s) from 2010 to 2018 were identi-
fied. The initial cohort was refined using procedure codes
for femoral and acetabular osteotomies. Inclusion criteria
for the cohort were ages 1 to 18 years with at least 2 years
of radiographic follow-up. Age outside of desired range
(1 to 18 y) and lack of follow-up (< 2 y) were considered
exclusion criteria.
Medical records of patients were reviewed to record
age at time of index surgery, sex, GMFCS classification, and
procedure(s) performed. Preoperative anteroposterior (AP)
pelvis radiographs were reviewed to record MP, acetabular
index (AI), and femoral neck-shaft angle (NSA) (Fig. 1).
Failure of the index operation was defined as either MP
> 50% at the last follow-up or the need for subsequent
ipsilateral hip reconstruction (femoral or acetabular
osteotomy). We defined subluxation in this study as MP FIGURE 1. Anteroposterior pelvis radiograph of a Gross Motor
> 50%, as 1 in 3 hips will progress to frank dislocation and Function Classification System (GMFCS) IV patient with cere-
will no longer spontaneously reduce.7 All of the radiographic bral palsy showing measurements that were taken. Migration
measurements were performed by 1 author using 1 digital percentage (MP) measured as MP = (A/B)×100. Acetabular in-
imaging system. Random audits were done by other authors dex (AI) measured as the angle formed by Hilgenreiner’s line
to maintain precision of measurements. and a line draw from the lateral triradiate cartilage to the lateral
acetabular margin. Neck-shaft angle (NSA) measured as the
angle formed by a line bisecting the femoral head (crossing
Operative Technique the epiphysis at 90 degrees) and a line formed along the axis of
The lower extremity is prepared and draped to allow the femoral shaft.
access to the groin, lateral thigh, and iliac crest. In the
presence of limited hip abduction, medial soft tissue re- model of failure was used as a function of age above 6,
lease is performed in order to achieve 45 degrees of hip presence of acetabular osteotomy, MP > 70 degrees, and
abduction. AP radiograph of the hip is taken with the hip NSA > 150 degrees to determine odds ratios and Wald
joint in 25 degrees of flexion, 20 degrees abduction, and 20 confidence intervals. A logistic model was used to calcu-
degrees of internal rotation. Closed reduction can be at- late odds ratios and significance of subset populations
tempted. If attempted without success, open reduction can receiving AO as an independent risk factor for failure.
be sought using either an anterior approach or medial
approach. The varus rotational osteotomy is performed
using a lateral approach with the femoral osteotomy cut RESULTS
between the medial and inferior margins of the lesser Inclusion criteria was met by 291 hips in 179 (102 male,
trochanter. It is done inferiorly to avoid traumatic injury 77 female) children. Patient demographics (Table 1) included
to the medial circumflex vessels supplying the femoral a mean age at time of surgery of 7.8 ± 3.3 years with a mean
head. The femur is resected to achieve a goal of 45 degrees follow-up of 3.9 ± 2.1 years and nearly equal distribution of
of abduction. Typically, this calls for 1 to 2 cm of short- hip side and sex of patients. GMFCS distribution (Fig. 2) was
ening. A blade plate or locking plate is then used for fix- skewed towards patients with lower functional abilities
ation to establish a NSA between 115 and 125 degrees and (GMFCS of III-V). At the time of index operation, 148
a corresponding anteversion of 0 to 10 degrees. Both ra- (51%) hips underwent only a femoral osteotomy compared
diographic as well as intraoperative examination are used
to demonstrate hip stability. At this point, an acetabular
TABLE 1. Full Cohort Patient Demographics
osteotomy can be sought if indicated. Indications for
acetabular osteotomy include pelvic dysplasia or in- Patients Meeting
stability with the presence of an open triradiate cartilage.12 Inclusion Criteria
Number of patients 179
Statistical Analysis Sex distribution 1.32:1 (M:F)
Statistical data were analyzed using SAS software Number of operated hips 291
Side distribution 0.93:1 (left:right)
(Version 8; SAS Institute Inc., Cary, NC). Descriptive Age at surgery (y) 7.8 ± 3.3
statistics are presented as means ± SD and categorical LOS (d) 4.9 ± 2.8
variables are presented as counts and percentages. Uni- Follow-up (y) 3.9 ± 2.1
variate analysis of continuous variables was performed F indicates female; LOS, length of stay; M, male.
using 1-sample t tests. Multivariate logistic regression

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Minaie et al J Pediatr Orthop  Volume 42, Number 1, January 2022

FIGURE 2. Gross Motor Function Classification System (GMFCS) distributions in patients with failure versus patients without
subsequent failure. A, Breakdown of GMFCS by absolute numbers versus (B) GMFCS of the failure versus nonfailure cohort as a
percentage of the total showing no significant differences observed.

with 118 (41%) had both a femoral osteotomy and a

concurrent acetabular osteotomy. The remaining 25 (8%) TABLE 2. Nonfailure Versus Failure Group Characteristics
underwent an isolated acetabular osteotomy. Nonfailure Cohort Failure Cohort
A total of 38 hips (13.1%) (22 right, 16 left) from 28 (n = 253) (n = 38) P
(13.6%) patients met our definition of failure. Seventeen (45%) Age (y) 8.1 ± 3.2 6.0 ± 3.2 < 0.001
patients met the definition of failure because they required Preoperative MP (%) 39.8 ± 24.0 64.0 ± 28.3 < 0.001
reoperation. For the remaining 21 (55%) failure patients fol- Preoperative NSA 157.3 ± 15.5 165.4 ± 8.0 < 0.001
low-up AP pelvis radiographs showed an MP > 50%. (degrees)
Analysis comparing the 2 groups for failure criteria Preoperative AI 24.7 ± 7.6 29.6 ± 6.7 < 0.001
(degrees)
(Table 2) revealed significant cohort differences in preoperative
age, NSA, and MP. Age at time of initial surgery < 6 years of Clinical significance values are in bold.
AI indicates acetabular index; MP, migration percentage; NSA, neck-shaft
age, was a significant risk factor for subsequent failure (26% angle.
vs. 6.3%; P < 0.001). In other words, operative intervention

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J Pediatr Orthop  Volume 42, Number 1, January 2022 Factors Leading to CP Hip Failure

after age 6 had a significant decrease in associative effect reported an association between increased annual MP in
[odds ratio (OR) = 0.18; confidence interval (CI): 0.08-0.38]. children with GMFCS IV and V (2.0% and 3.5%, re-
Similarly, preoperative MP > 70% was a risk factor for failure spectively) after hip reconstruction suggesting that
(28.9% vs. 7.6%; P < 0.001) as seen in (Table 3). Specifically, GMFCS level may be contributing to subluxation and
patients with preoperative MP > 70 were at almost a 4 times therefore failure. While our study did not find GMFCS to
higher risk of failure (OR = 3.90; CI: 1.78-8.58). In addition, be a significant factor in failure rate, we did see a similar
patients with severe valgus deformity (preoperative NSAs trend to what was reported by Bayusentono and col-
> 150°) were more likely to fail (OR = 10.3; CI: 1.38-76.99). leagues. Namely, only preoperative GMFCS III-V pa-
Similar to age at time of surgery, receiving an acetabular tients reached a failure endpoint. It is possible that our
osteotomy was found to be associated with a decrease in study did not capture enough patients with GMFCS I-II
“failure” (9.1% vs. 16.9%; P = 0.048). A logistic model used to to find the same association. On average, GMFCS V pa-
analyze which population would benefit most from an ace- tients had a significantly higher preoperative MP than
tabular osteotomy found that in those with a preoperative AI patients GMFCS I-IV patients combined (48.7% vs.
> 25 degrees, a concurrent AO provided an OR = 0.24 37.9%, P < 0.001). GMFCS certainly influences hip sub-
(CI: 0.09-0.55; P < 0.001), decreasing the failure rate over 4-fold. luxation and therefore preoperative MP,1–7 thus while
hard to ascertain the direct influence of each on failure,
both could contribute to some degree.
DISCUSSION
In addition to GMFCS, Shore et al1 previously re-
With nearly one-third of children with CP dealing ported additional risk factors for failure including low sur-
with hip displacement and its sequelae, hip re- gical volume of the operating surgeon and younger age of
construction is a common mainstay of treatment for the patient at time of surgery. We found younger age to also
subluxated hips.5 Risk factures leading to failure of index increase the odds of failure in this population. One potential
surgery need to be investigated to minimize risk of future reason could be because of strong remodeling potential in
surgery and identify children who would benefit most the femur of the young child to offset any surgical correc-
from reconstruction. This study demonstrated a failure tions that have been made during hip reconstruction. Over
rate of 13% in 179 patients with 291 operative hips over time, after VDRO, the CP femur can remodel and reestab-
nine years. Increased rate of failure was associated with lish a valgus deformity. The remodeling potential has been
age below 6 years at time of surgery and increased pre- shown to be more in younger children.13 We do not advocate
operative MP, NSA, and AI. On the basis of our study, for delaying treatment of dislocated hips in children with CP
hip reconstruction after age 6 and a concurrent ace- and agree that hip reconstruction maybe needed in some
tabular osteotomy (if AI > 25) at the time of surgery are children younger than age 6 depending on the degree of
associated with a reduced risk of subsequent surgical dislocation and symptoms but treating physicians should be
intervention for hip subluxation. aware of the potential higher rate of failure in this young
Preoperative MP has been previously shown in the group of patients.
literature to contribute to failure risk independently from Ruzbarsky and colleagues analyzed failure rates after
other confounders such as NSA or AI. Terjesen et al re- hip reconstruction in nonambulatory (GMFCS IV and V)
ported that a preoperative MP ≥ 50% was associated with CP patients and found a similar association. They defined
an increase in failure (relative risk: 3.6; CI: 1.1-13)2 similar “failure to cure” as a follow-up MI > 60%. A final cohort of
to our findings. Going 1 step further, Bayusentono et al6 93 hips was assessed over 5.9 years (range: 2.1 to 15.9). In
total, 8 (8.6%) were found to have a follow-up MP > 60%,
TABLE 3. Variables That Predict Failure this number increases to 16 (17.2%) if our failure cutoff of
MP > 50% is used. Risk factors leading to increased MP
Failure No Failure
(n = 38), (n = 253), Odds
postoperatively were found to be surgery at age below
Variable n (%) n (%) Ratio P 6 years (P = 0.013) and children with a tracheostomy
(P = 0.004). Similarly, to the association between pre-
Age above 6 at surgery 0.20 < 0.001
operative MP and GMFCS, possession of a tracheostomy
Yes 12 (32) 179 (71)
No 26 (68) 74 (29) may be a sign of greater neurological impairment and hence
AO 0.49 0.048 lead to greater levels of failure.8 This perhaps can be an area
Yes 13 (34) 130 (51) of further research, as well as presence of gastrostomy tubes.
No 25 (66) 123 (49) Our study confirms the work of some prior studies
Preoperative migration 3.69 < 0.001
percentage > 70%*
which have found that acetabular osteotomies are pro-
Yes 13 (36) 32 (13) tective against failure. Zhang et al3 concluded that in their
No 23 (64) 209 (87) cohort of GMFCS IV and V patients, combined femoral
Preoperative NSA > 150°† 11.12 0.0187 and pelvic osteotomies had the lowest failure rates with
Yes 37 (97) 193 (77) only 10.5% failing, compared with their overall 26% failure
No 1 (3) 58 (23)
rate. This is further supported by Song et al,9 study
*14 missing values. showing a resubluxation rate of 13% with a combined
†2 missing values.
AO indicates acetabular osteotomy; NSA, neck-shaft angle. femoral and pelvic osteotomy compared with 24% in pa-
tients that received a VDRO alone. Acetabular osteotomies

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Minaie et al
are found to be at times necessary to correct acetabular
dysplasia in addition to the VDRO but the literature is not
clear on when acetabular osteotomies are needed. Overall,
we found a significant, albeit small (P = 0.048) difference,
echoing the above sentiment that dysplasia many times
should be corrected at the time of hip reconstruction to
decrease repeat subluxation. However, the clinically sig-
nificant difference was found in isolating a group of pa-
tients with a preoperative AI of 25 degrees. In this
population, the associated decrease in failure after AO was
much more pronounced, a 4-fold decrease in failure rates.
This specific subgroup of patients may provide a valuable
threshold where acetabuloplasty, at the time of hip con-
struction, could greatly improve outcomes.
This study is not without limitations. Primarily, any
retrospective study can introduce selection bias and con-
founders because of the lack of randomization of subjects.
Because of the retrospective nature of the study, we cannot
completely define the reason for all of the revision procedures.
As far as we know they reoperations were done likely because
of subluxation, symptomatic nature of condition, or continued
dysplasia, however, there is no way to go back and question
the surgeons regarding the absolute indication. Cutoff values
that were selected for radiographic parameters were based on
previous values in the literature that have been shown to play
a large role in risk factors of failure. Moreover, all patients
were seen at a single institution and therefore may not be
representative of the general CP population. Since this cohort
is one of the largest that has been studied with up to nine years
of follow-up, we feel that the large number patients help to
mitigate selection bias. Furthermore, measurements by 1
reader do not allow for intraclass correlation coefficients to
assess interobserver and intraobserver reliability; however, the
reliability of MP (0.95), NSA (0.92 to 0.96), and AI (0.84)
have been established and are excellent when taught
properly.7,14,15 For this reason, an instructional session before
data collection was done to assess proper, literature-based
collection of measurements and aid in alleviating as much
reader bias as possible. Multiple audits were done by other
authors to ensure consistency and agreement of measurements
throughout the study.
In conclusion, we have found that younger age and
higher preoperative MP, AI, and NSA were associated with
higher rates of failure, while acetabular osteotomies at time of
surgery may be protective, when indicated. This sheds light on
the importance of managing preoperative expectations when
discussing outcomes with parents. In the setting of advanced
severity either seen on radiographs (high MP, AI, NSA), or
clinically significant disease in a young patient, parents should
be aware that their children may be at an increased risk of need
for subsequent surgery. In our case series of 291 operative hips
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J Pediatr Orthop  Volume 42, Number 1, January 2022
from 179 patients with CP, we found that the initial hip
reconstruction operation failed in 13% of cases. As this is one
of the largest case studies in the literature on this topic with the
aim to establish a more accurate failure rate, we believe the
reported 13% in this study gives a better estimate than the 15%
to 80% rate currently in the literature.1–7 On the basis of the
findings of this paper, we suggest that waiting until 6 years of
age, if possible, and correcting acetabular dysplasia with an
acetabuloplasty in patients with a preoperative AI > 25 de-
grees, could reduce hip reconstruction failure. Future research
should be aimed at further identifying risk factor that increase
and are protective against failure with the ultimate goal in
developing a quantitative algorithm to guide management.
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