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Adductor Surgery to Prevent Hip Displacement in Children with Cerebral Palsy: The Predictive Role of the Gross Motor Function Classification System
Benjamin J. Shore, MD, FRCSC1; Xavier Yu, MBBS, BA2; Sameer Desai, MS, MRCS(Ed)2; Paulo Selber, MD, FRACS2; Rory Wolfe, BSc, PhD3; H. Kerr Graham, MD, FRCS(Ed), FRACS2
1 Department of Orthopaedic Surgery, Children's Hospital Boston, Hunnewell 221, 300 Longwood Avenue, Boston, MA 02115
2 Department of Orthopaedic Surgery (X.Y., S.D., and H.K.G.), The Hugh Williamson Gait Laboratory (P.S.), The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia
3 Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, 99 Commercial Road, Melbourne, Victoria 3004, Australia
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Investigation performed at the Royal Children's Hospital, Parkville, Australia

A commentary by Robert J. Bielski, MD, is linked to the online version of this article at jbjs.org.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Feb 15;94(4):326-334. doi: 10.2106/JBJS.J.02003
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The purpose of this study was to evaluate the relationship between walking ability, as determined with use of the Gross Motor Function Classification System (GMFCS), and the outcome of hip adductor surgery used to prevent hip displacement in children with cerebral palsy.


We performed a retrospective review of the records of all children with cerebral palsy whose index surgery, performed between January 1994 and December 2004 at one tertiary-level pediatric hospital, was bilateral hip adductor releases. All children had a hip migration percentage of >30% in at least one hip prior to the adductor surgery, and the minimum duration of follow-up was twenty-four months. Kaplan-Meier survivorship curves were generated by determining the time from the index surgery to “failure,” defined as either the need for subsequent surgical procedures or a migration percentage of ≥50% in either hip. Hazard ratios were calculated for sex, migration percentage at the time of the index surgery, age at the time of the index surgery, and GMFCS level.


Three hundred and thirty children were included in the study; 73% (242) were nonambulatory (GMFCS level IV or V). The mean age at the time of the index surgery was 4.2 years, the mean migration percentage was 43%, and the mean duration of postoperative follow-up was 7.1 years. Surgery consisted of open lengthening of the adductor longus and gracilis muscles in all children, with additional procedures as deemed necessary. “Success” was defined as the absence of subsequent surgical procedures during the study period and a migration percentage of <50% in both hips at the time of follow-up. One hundred and six children (32%) met these criteria for success. The success rate was 94% (thirty-one of thirty-three) in children at a GMFCS level of II, 49% (twenty-seven of fifty-five) in children at a level of III, 27% (twenty-eight of 103) in children at a level of IV, and 14% (twenty of 139) in children at a level of V.


Walking ability, as defined with use of the GMFCS level, is a strong predictor of success or failure after hip adductor surgery in children with cerebral palsy. The paradox of hip adductor surgery for children with cerebral palsy is that the children who are most severely affected and need the surgery the most have the poorest results.

Level of Evidence: 

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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