Open adductor longus, gracilis and selective brevis tenotomy with iliopsoas lengthening via medial groin approach | advanced
Surgical Imaging
Location: The anterior branch of the obturator nerve lies on the surface of adductor brevis, medial to the adductor longus insertion and courses distally in the interval between adductor longus and brevis.
Risk: Transection produces loss of adductor function and, if combined with posterior branch injury, complete adductor paralysis. Deliberate neurectomy is contraindicated because it leads to abduction contracture, poor sitting balance and perineal hygiene difficulties.
Protection: Identify the nerve under direct vision, gently retract it medially with a vessel loop, and preserve it throughout the release. Selective partial neurectomy is occasionally considered only in non-ambulatory patients with severe adductor spasticity after careful discussion of abduction contracture risk.
Location: The medial femoral circumflex artery runs along the inferior border of the adductor longus insertion and enters the thigh between adductor longus and magnus before ascending posteriorly to supply the femoral head via the retinacular vessels.
Risk: Laceration causes brisk bleeding and potential compromise of femoral head vascularity if the ascending branch is injured. The vessel is at greatest risk during distal extension of the adductor longus tenotomy.
Protection: Identify the artery at the distal edge of the adductor longus tendon before completing the tenotomy; ligate or cauterise small branches only after clear visualisation. Maintain a plane superficial to the vessel during gracilis release.
Location: The capsule lies deep to the adductor brevis and iliopsoas tendon at the level of the lesser trochanter. Excessive medial retraction or deep dissection can enter the joint.
Risk: Capsular violation leads to instability, heterotopic ossification, and potential septic arthritis if infection occurs. In spastic hips the capsule is often thickened and adherent to the spastic tendons.
Protection: Stay extra-capsular at all times. Use blunt dissection and direct visualisation when releasing fibres of adductor brevis near the joint. If the capsule is inadvertently entered, repair with absorbable suture and consider post-operative antibiotics.
Location: Excessive release of adductor brevis or combined anterior obturator neurectomy removes the last remaining adductor power.
Risk: Abduction contracture greater than 30-40 degrees prevents comfortable seating, perineal care and transfers. It is functionally worse than the original adduction contracture in non-ambulatory patients.
Prevention: Release only adductor longus, gracilis and the anterior 50-70 percent of adductor brevis fibres. Leave the posterior third of brevis and the full adductor magnus intact. Never perform complete anterior obturator neurectomy.
Location: The iliopsoas tendon inserts on the lesser trochanter; the tendon is palpated medial to the pectineus and deep to the adductor brevis interval.
Risk: Missing the tendon leads to persistent hip flexion contracture. Mistaking the rectus femoris tendon for iliopsoas produces incorrect lengthening and residual flexion deformity.
Identification: With the hip flexed and externally rotated, the iliopsoas tendon is the taut cord running from the pelvic brim to the lesser trochanter. Confirm by palpation of the lesser trochanter and by observing tension with hip flexion against resistance.
Location: The medial groin incision lies in a skin crease with high bacterial load and is subject to shear forces from spastic adductor tone and positioning devices.
Risk: Wound dehiscence, deep infection and heterotopic ossification are more common than in non-spastic patients. Malnutrition, gastrostomy dependence and poor skin quality compound the risk.
Prevention: Use meticulous layered closure, consider prophylactic antibiotics for 24 hours, delay aggressive abduction bracing for 10-14 days, and optimise nutrition pre-operatively. Monitor for early signs of wound breakdown at 48-72 hours.
A.D.D.U.C.T.O.RADDUCTOR — Surgical Goals and Limits
S.P.A.S.T.I.CSURVEILLANCE — Hip Displacement Monitoring in CP
Surgical Indications
Absolute Indications
- Progressive hip subluxation with migration percentage greater than 30-40 percent on serial surveillance radiographs despite optimised tone management
- Abduction less than 20-30 degrees with the hip extended, producing inability to maintain seating or perform perineal hygiene
- Painful spastic hip with radiographic displacement that limits quality of life or nursing care
- Established dislocation in a non-ambulatory patient when reduction and containment are still feasible (usually before skeletal maturity)
Relative Indications
- Borderline migration (25-35 percent) with rapidly increasing tone or loss of abduction on serial examinations
- Ambulatory patient with deteriorating Trendelenburg gait and abduction contracture less than 20 degrees
- Pre-operative optimisation before planned femoral or pelvic osteotomy in a child with established displacement
- Severe adductor spasticity interfering with orthotic wear or therapy participation
Contraindications
Absolute:
- Fixed abduction contracture greater than 30 degrees (release would worsen function)
- Active infection or untreated pressure sores in the groin or perineum
- Non-reducible dislocation with severe acetabular deficiency where containment is no longer possible
Relative:
- Very young age (less than 3-4 years) unless migration is rapidly progressive — trial of tone management first
- Severe osteopenia with high fracture risk during positioning
- Medical comorbidities that preclude safe anaesthesia for the combined procedure
Evidence for Soft-Tissue Release
Hip Surveillance and Timing
- Early identification of migration percentage greater than 30 percent allows soft-tissue release before irreversible acetabular dysplasia develops
- Delaying surgery until migration exceeds 50 percent or dislocation occurs significantly reduces the success rate of containment procedures
Adductor Release Outcomes
- Isolated adductor release reduces migration percentage by 10-20 percent in early subluxation (less than 40 percent) and improves abduction by 15-25 degrees in most series
- Success is highest when performed before 5-6 years of age and when combined with iliopsoas lengthening and post-operative abduction positioning
- In established displacement greater than 40 percent, soft-tissue release alone fails to maintain containment in greater than 60 percent of cases at 5 years — bony reconstruction is required
Combined Procedures
- Adductor release plus iliopsoas lengthening plus femoral varus derotation osteotomy achieves stable containment in 70-85 percent of children with migration 40-60 percent
- Addition of pelvic osteotomy (Dega, Salter or Pemberton) further improves acetabular coverage and reduces redislocation risk to less than 15 percent at 10 years
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 6-year-old non-ambulatory child with spastic quadriplegic cerebral palsy has a migration percentage of 38 percent on the right hip and 25 percent on the left. Abduction is 15 degrees on the right and 35 degrees on the left. The child has increasing difficulty with seating and perineal hygiene. What is your surgical plan?”
“During medial groin adductor release in a 5-year-old child you identify the anterior obturator nerve on the surface of adductor brevis. The assistant asks whether you should perform an anterior obturator neurectomy to improve the abduction gain. How do you respond and what is your rationale?”
“A 4-year-old ambulatory child with spastic diplegia has bilateral migration percentages of 32 percent, abduction of 18 degrees, and a 20-degree hip flexion contracture. The family reports deteriorating gait and increasing falls. Outline your surgical plan and the rationale for including or excluding iliopsoas lengthening.”