Résection fémorale supérieure chez l’enfant polyhandicapé grabataire

Il s’agit d’une étude rétrospective issue des services de chirurgie pédiatrique rémois et stéphanois rapportant l’expérience de 21 résections fémorales supérieures tête et col (RFS). Ces patients, tous polyhandicapés et la plupart infirmes moteurs cérébraux (IMC) grabataires étaient au nombre de 16, et avaient au moins une hanche luxée irréductible et douloureuse, ce qui représente 21 hanches opérées par résection, 13 fois sous le petit trochanter et huit fois en zone basicervicale. Au moment de l’intervention, ils étaient âgés en moyenne de 12 ans (huit à 18 ans). Toutes les hanches opérées présentaient des signes macroscopiques de destruction de l’encroûtement cartilagineux des têtes fémorales. La libération concomitante des parties molles a été associée dans 69 % des résections diaphysaires et dans 33 % des résections basicervicales. Les soins postopératoires ont été soit une traction, soit un plâtre pelvipédieux pour une durée moyenne de quatre semaines. Trois reprises chirurgicales à moyen terme ont été nécessaires, pour cause de déformation avec rétraction douloureuse des parties molles. On a noté cinq cas de calcifications hétérotopiques. Les hanches initialement douloureuses ont été soulagées dans 86 % des cas, avec une nette facilitation pour l’installation en position assise, dans les changements de position, et pour les soins du périnée.

Introduction

Hip dislocation in nonambulatory multiply handicapped children (particularly in cerebral palsy [CP]) is a common and severe problem involving painful transportation and uneasy positioning, usually resulting from major anatomical osteoarticular and soft tissue disorders. Therefore, proximal femoral resection is seen as a salvage procedure whose primary purpose is to provide children and their caregivers with better comfort during activities of daily living thus allowing improved sitting tolerance in the wheelchair and painless nursing care.

Materials and methods

A series of 21 proximal femoral resections performed on 16 patients with a mean age at surgery of 12 years, and a follow-up period of 21 years (from 1984 to 2005) were retrospectively reviewed. All patients suffered from painful dislocation of the hip. Sixteen of the hips (76%) had been managed previously with bony and soft tissue surgery. Femoral resection was performed in the basicervical region in eight hips and distal to the lesser trochanter in 13 hips.

Results

At a mean follow-up of five years and eight months, 18 of the 21 painful hips reported to be painless (86%). All preoperative stiffness and deformity of the hip joints was corrected, resulting in floppy, mobile hips with an increased range of motion after surgery. Femoral stump, regarding the acetabulum was above in three hips, at the same level in 18 and never below. The proximal end of the femoral shaft could often been palpated but did not reveal any skin irritation. The formation of heterotopic bone was discernible in five hips (24%). However, it did not affect the functional outcomes.

Discussion

Soft-tissue releases combined with femoral and pelvic osteotomies have reported poor results with regard to their long-term inefficacy in children. The outcomes of our series support these findings, since surgical procedures had been performed previously in 76% of the hips. Therefore, we believe that proximal femoral resection is a promising and reliable surgical treatment option to address such failures, in case of severe and painful deformities of the hip. The success of our series corroborates Widemann, Mc Carthy and Abu-Rajab encouraging results on proximal femoral resection. Postoperatively, we advise placement of a hip spica cast immobilization with a soft cotton lining to prevent pressure sores from developing. This surgical procedure seems to be an appropriate management in nonambulatory multiply handicapped children reporting more promising results than other surgical treatment options such as rotational osteotomy, arthrodesis or even arthroplasty.