D.D.S.H.: developmental dysplasia of the spastic hip: strategies of management in cerebral palsy. A new suggestive algorithm

Hip Int. Jan-Mar 2009;19 Suppl 6:S69-74. doi: 10.1177/112070000901906s12.


Hip problems in cerebral palsy are relatively frequent (25-75%). Subluxation and dislocation of the hip is proportional to the neuromuscular involvement and is often due to alteration caused by spastic muscle forces acting on the femoral head in the acetabular cavity. The EMMA approach (Early Multilevel Minimally-invasive Approach) has been designed to restore muscle balance, decrease hip migration and prevent bone deformities thereby avoiding future pain with minimal biological cost to the patient. EMMA is suitable for most patients, especially those with increased tone, poor muscle control and selectivity, Reimer Index (R.I.) 20%. We consider age and R.I crucial prerequisites for treatment steps. EMMA 1) age 2-4 years, RI 20%: multilevel injection of botulinum toxin in case of muscular hyperactivity without morphological alterations of the couple muscle-tendon (contractures). EMMA 2) age 4-6, RI 20%: multilevel aponeurectomies in case of muscular hyperactivity with morphological alterations of the couple muscle-tendon (retraction). EMMA 3) early bone surgery (growth plates). This approach has been adopted in the last 4 years to prevent bone deformities and give early mobilisation and early control of the pain. EMMA is simple to apply even in infants, both for hip containment and to decrease spasticity.

Publication types

  • Review

MeSH terms

  • Algorithms
  • Botulinum Toxins / therapeutic use
  • Cerebral Palsy / complications
  • Cerebral Palsy / rehabilitation*
  • Child
  • Child, Preschool
  • Hip Dislocation, Congenital / diagnostic imaging
  • Hip Dislocation, Congenital / rehabilitation*
  • Hip Joint / diagnostic imaging
  • Hip Joint / physiopathology*
  • Hip Joint / surgery
  • Humans
  • Infant
  • Muscle Spasticity / etiology
  • Muscle Spasticity / therapy*
  • Physical Therapy Modalities
  • Posture
  • Radiography
  • Range of Motion, Articular
  • Recovery of Function


  • Botulinum Toxins