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Received 17 February 2017 Surgical reduction of congenital hip dislocation is technically challenging. In our practice, surgical
Accepted 4 April 2017 reduc- tion is usually reserved for patients who have failed non-operative treatment, which is the
first-line strategy. However, primary surgery may be indicated if the dislocation is diagnosed late
Keywords:
and can be performed until 8 years of age. The reduction step is crucial. It starts with painstaking
Congenital dislocation of the hip exposure of the capsule. Identifying the lower part of the acetabulum is the key to accurate
Surgical reduction repositioning of the epi- physis. The main intra-articular procedures are resection of the ligament
Femoral shortening osteotomy teres, adipose tissue within the acetabular cavity, and transverse acetabular ligament; and eversion of
Innominate osteotomy the radially incised limbus. In patients younger than 1 year of age, surgical reduction can be
Acetabuloplasty performed via the anterior approach or, in some cases, the obturator approach. No complementary
Avascular necrosis steps are needed. If the diagnosis is made late, in contrast, reduction of the hip must be combined
with corrective procedures on the femur and acetabulum designed to stabilise the reduction before
the capsulorrhaphy, with the goal of optimising hip stability and minimising the risk of residual
dysplasia. Femoral shortening and derotation osteotomy was classically reserved for children older
than 3 years but has now been shown to be a useful and pru- dent procedure in younger patients.
This osteotomy decreases pressure on the epiphysis, facilitates the reduction, and diminishes the risk
of recurrence and avascular necrosis of the femoral head, which are the two dreaded complications.
The outcome depends on the care directed to the procedure and on the quality of postoperative
management.
© 2017 Elsevier Masson SAS. All rights reserved.
Fig. 1. Sandbag under the buttock and gel pad under the back to tilt the
pelvis in a three-quarter oblique position. Bikini incision, approach to the
tensor fasciae latae–sartorius gap and to the iliac crest. The rectus femoris is
exposed.
2.4.2. Anterior
approach
The child is supine with a large sandbag under the buttock
and a gel pad under the back to turn the pelvis in a three-quarter
oblique position. The bikini skin incision runs 1 cm below the
crest then crosses under the antero-superior iliac spine and
courses medially over a further 2 cm. The Smith–Petersen
approach is then per- formed: the gap between the tensor
fasciae latae and sartorius is identified, and the incision is kept
within the fascia of the tensor fasciae latae (Fig. 1). The lateral
femoral cutaneous nerve should not be identified, as it is within
a protective sheath. This gap leads to the rectus femoris and is
temporarily packed with a gauze pad. The wing of the ilium
(lateral iliac fossa) is exposed subperiosteally after detaching
the tensor fasciae latae anteriorly. The capsule is exposed
gradually by retracting the gluteal muscles (Fig. 2). This step is
challenging as the approach should be extended posteriorly
along a sufficient distance to ensure full exposure of the
capsule, in order to facilitate its re-tensioning. The rectus
femoris tendon is dissected, divided, and gently retracted
downwards. The iliopsoas muscle, which then becomes visible
outside the field, is isolated circumferentially and divided as
distally as possible, ideally at the white/red junction. Caution
requires that the femoral nerve be visu- alised. Thus, the antero-
Fig. 2. The gluteal muscles are detached to expose the iliac wing. The rectus
Fig. 3. T-shaped incision in the capsule and exposure of the acetabulum. The upper
femoris tendon is divided and the capsule exposed.
edge of the obturator foramen should be clearly visible. A double-angled retractor
is placed in the foramen. The ligament teres and transverse ligament become
visible and are resected. Radial incisions are made in the limbus, which is then
2.4.3. Lateral approach everted.
This is the Gibson approach. The child is lying on the side.
The skin incision is lateral, nearly rectilinear, with two-third of blood supply to the head via the circumflex artery. Posteriorly,
the length above the greater trochanter. The tensor fasciae latae the incision should extend far along the acetabular insertion in
is opened longitudinally and the gluteus muscle fibres are spread order to fully expose the dislocation pouch.
proximally. The fan-shaped gluteal muscles are then exposed. The capsular incision is performed using a cold blade. The
The posterior edge of the gluteus medius is identified by a suture inci- sion is T-shaped, with the vertical branch parallel to the axis
near its insertion and the muscle is detached gradually, moving of the neck and the horizontal branch 5 mm from the iliac
upwards to its tendon, which is left intact. The gluteus minimus insertion of the capsule, from anterior and downward to posterior
is identified in the same way and lifted. It is difficult to separate and upward (Fig. 3). Two flaps are thus obtained.
from the capsule, to which it adheres closely. The capsule is
exposed as described for the anterior approach. The rectus
femoris tendon, which is then visible medially, is divided. The 2.7. Intra-articular
iliopsoas muscle is identified and divided at the white/red steps
junction. Flexing the hip facilitates this step.
The acetabulum can then be exposed (Fig. 3). First, the
ligament teres should be cut flush with the head, which can then
2.5. Criteria for selecting the approach be displaced upwards and posteriorly using a Lambotte bone
hook. The ligament teres is followed to the acetabular fossa,
The obturator approach is reserved for early reductions with where it is cut flush with the bone, where its insertion is a
no additional procedures. reliable landmark. The insertions of the transverse ligament on
The anterior approach, which has my preference, can be used the horns of the acetabulum are iden- tified and the ligament
in all situations. It has the advantages of clearly identifying all resected. The lower part of the acetabulum with its smooth
the extra-articular obstacles and of providing good exposure of cortex resembling the Niagara Falls is then visi- ble. A spatula
the acetabulum. This is undoubtedly the most appropriate or scissors can then be inserted into the upper part of the
approach for all concomitant procedures. obturator foramen, where a double-angled retractor is inserted.
The lateral approach provides the best exposure of the acetab- This step is key to exposure of the acetabulum and to the success
ulum but is further from the anterior obstacles and is not readily of the procedure.
combined with concomitant procedures on the acetabulum. We A curette can then be used to gently detach the fibro-fatty tis-
reserve this approach for early reductions, as an alternative to the sue, which adheres loosely to the acetabular cavity. Eversion of
obturator approach, and for revision procedures requiring the limbus then exposes the acetabular cartilage. Radial incisions
deepen- ing of the acetabulum (Colonna procedure) combined, if are made in the limbus at 15 mm intervals and the limbus
needed, with a femoral osteotomy. segments are then everted using a small Trelat hook or a small
curette. Leaving the limbus in place improves the ability of the
acetabulum to retain the femoral head. The head can then be
2.6. Capsulotomy reduced, if needed after a procedure on the femur (Fig. 4).
Fig. 6. A single S-shaped incision ensure good visibility for both the hip reduction
and the femoral osteotomy.
3. Additional procedures
Except when reduction is performed early, surgical reduction
Fig. 4. The femoral head can then be reduced. However, reduction is facilitated by
should always be combined with additional procedures on the
performing a femoral shortening and external derotation osteotomy.
femur and/or pelvis [12]. The objective is three-fold: to prevent
avascular necrosis [3], to facilitate the reduction, and to correct
the excessive femoral anteversion and acetabular dysplasia.
3.1. The
femur
3.2. The
pelvis
3.2.2. Innominate
osteotomy
After an approach to the iliac wing (internal and external
iliac fossae), the greater sciatic notch is cautiously exposed and
a Gigli saw is inserted through it. The osteotomy is performed in
the posterior-to-anterior direction with the cut ending above the
antero-inferior iliac spine. The acetabulum is redirected using a
small Müller toothed forceps. The acetabulum is tilted anteriorly
and laterally in the plane of the iliac wing. Care should be taken
to translate the distal segment anteriorly over 1 cm, to promote
its stabilisation on the proximal cut in the iliac wing. Ideally,
fixation is achieved by positioning threaded pins or screws in an
X configu- ration. Another widely-used option consists in
superior-to-inferior fixation using a row of three pins. A
bicortical iliac graft is harvested from the iliac wing posterior to
the pins or screw to avoid modifying the anterior iliac bone
contour (Fig. 7). The graft is used to fill the defect created by the
osteotomy. If a femoral shortening osteotomy was performed, the
removed femoral segment can be used as the graft. When pins
are used for fixation, the first pin is inserted under visual
guidance into the iliac wing in the direction of the posterior
column (with great care to avoid the joint) to allow implantation
of the triangular graft. One or two additional pins are then
inserted for definitive fixation of the osteotomy and stabilisation
of the graft.
In older children, when major redirection of the distal
fragment is required, a triple osteotomy technique is used. Our
preference goes to the Pol-Le-Coeur method as updated by Jean-
Paul Padovani. The approach is through the genito-femoral fold.
The inferior pubic ramus is exposed subperiosteally after
identification of the pos- terior attachment of the gracilis
muscle. The ramus is directed obliquely, downwards, laterally,
and posteriorly. A spatula is the best instrument for skirting the
ramus, identifying the medial edge of the obturator foramen,
graft can be harvested as described for the innominate
osteotomy.
3.2.3. Acetabulopl
asty
Acetabuloplasty to correct the acetabular dysplasia is
extremely useful in young children between 18 months and 3
years of age. The method described by Pemberton [14]
provides lateral and anterior correction and that described by
Dega lateral, posterior and, to a lesser degree, anterior
correction.
The sandbag under the buttock and gel pad under the back
of the patient are removed. Fluoroscopy is essential at this
point to identify the medial portion of the horizontal branch of
the triradi- ate cartilage, which indicates the proper orientation
of the chisel. On the fluoroscopy view, the axis of acetabular
fragment rotation needed to redirect the roof is determined. The
first step consists in determining the height at which the
osteotomy should start on the lateral table of the iliac wing.
The beginning of the cut should be at a sufficient height to
avoid necrosis of the acetabular fragment. A straight chisel is
used first to mark the line then a curved chisel to ensure a safe
distance from the acetabular roof and to reach the medial part
of the horizontal branch of the triradiate cartilage.
For the Pemberton acetabuloplasty, the osteotomy is
performed from anterior to posterior and from lateral to medial.
The hinge is medial and posterior and coverage is therefore
lateral and anterior (Fig. 8). For the Dega acetabuloplasty, the
hinge is medial. A Keris- son forceps is used to cut the
posterior column, which can then be redirected. This ensures
better posterior coverage. The graft is composed of femoral or
iliac bone (Fig. 9).
A segment of femur is inserted to maintain the opening
needed to correct the dysplasia. Alternatively, an iliac bone
C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157 S1
range of motion, the patient can assume the erect position. If the
acetabular dysplasia was corrected, the Petit abduction splint is
unnecessary.
Rehabilitation therapy is not required. Walking is sufficient.
The family should receive instruction about maintaining and
monitor- ing good hip mobility.
5. Strategy
The surgical strategy depends on the local sanitary and eco-
nomic resources for children [15]. In countries lacking the
resources needed for non-operative reduction by gradual
traction, surgical reduction is the method of choice.
In Scandinavian countries and in a few French centres, early
sur- gical reduction via the anterior or obturator approach is
standard practice in infants who have not yet started to walk.
However, this strategy carries a risk of residual acetabular
dysplasia.
When the dislocation is diagnosed in a child who has learned
to walk, or after failure of non-operative reduction by
Fig. 9. Dega acetabuloplasty, which improves lateral and posterior coverage.
Somerville- Petit-Morel traction, surgical reduction via the
anterior approach with the additional bony procedures (Fig. 10)
During closure, the crucial step is repositioning of the iliac is the best solution. Low morbidity rates can be achieved by
crest apophasis, which is then directly sutured to the gluteus complying scrupulously with all the surgical principles and steps.
muscles using wide stitches. Long-term outcomes are good [16] in the absence of severe
complications.
Economic and public health reasons may warrant broadening
4. Postoperative care the indications of this procedure, which must therefore continue
to be taught. Furthermore, surgeons who go on missions to
The hip is immobilised in a spica cast. After surgical countries with limited healthcare resources must be thoroughly
reduction alone in infants, the contralateral thigh should be familiar with this procedure and its technical variants.
immobilised in the cast. A duration of 3 weeks is sufficient when The age of the patient is the main factor in determining the
surgical reduction was performed alone. Ideally, upon removal surgical strategy.
of the cast, traction should be used, initially with the hip in the
same position as in the cast. The hip is then gradually mobilised
and straightened. After the period of traction, the patient wears
5.1. Infants younger than 1 year of
age
a Petit abduction splint allowing flexion–extension of the hip, to
ensure a gentle transition.
When surgery is deemed necessary either as the first-line
When procedures are performed on the bone in addition to the
treat- ment or after failure of non-operative reduction, the
reduction, the spica cast should be worn for 5 weeks, after which
obturator approach can be used in patients younger than 6
traction is preferably used, for 1 week. When the hip has
months of age. We have no experience with this approach [7,9–
recovered
11].
S2 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
Between 6 and 12 month of age, simple reduction via the experience, 50%
ante- rior approach is the technique of choice. In our
Fig. 11. Mary, aged 6 months at surgery: bilateral hip dislocation diagnosed at birth. At 2 weeks of age, no improvement despite triple-diapering. A. Traction failed to
achieve reduction. B. Bilateral surgical reduction via the anterior approach, in two separate procedures 1 month apart. C. Outcome at 15 years of age: in the Postel-
Merle d’Aubigné scoring system, mobility was 6, pain 6, and stability 6. No change at 17 years of age.
6.1. Recurrent
dislocation
5.2. From 18 months to 4
years 6.1.1. Caus
es
This is the period of choice for a combined procedure that The dislocation may recur immediately if some obstacles to
cor- rects all the bone abnormalities, as described by Klisic and reduction were left in place and the bony abnormalities were
Jankovic [12]. Presence of the femoral head ossification centre insufficiently corrected. Another cause of recurrent dislocation
has been reported to be associated with a lower risk of is inappropriate hip position during the period of postoperative
vascular compli- cations [19–21]. We recommend waiting until immobilisation [23,24]. In every case, the cause of the
18 months of age for this combined procedure, and the femoral recurrence must be identified and revision surgery performed
osteotomy improves safety. Sankar et al. [22] demonstrated that immediately.
femoral shortening was usually required if the vertical The recurrence may become apparent upon removal of the
displacement of the femoral head was greater than 30% of the cast. The situation should be analysed in detail. Early recurrences
acetabular width, as well as in patients older than 3 years of age. usually require the same treatment as immediate recurrences.
For the acetabuloplasty, the Pemberton procedure is probably Delayed recurrences are more challenging. The most common
preferable over the Dega procedure, as it provides better causes are presence within the acetabulum of soft tissue or bone,
coverage laterally and anteriorly, where the defi- ciency is exaggerated anteversion or retroversion due to excessive derota-
greatest (Fig. 12). In older children, the Salter innominate tion, and insufficient acetabular correction resulting in
osteotomy is simple and effective [15]. This osteotomy is always inadequate containment of the femoral head.
feasible, even without fluoroscopy.
Fig. 13. Samir, 8 years of age at surgery. A. Bilateral dislocation. Treatment was started at 8 years of age. B. Bilateral surgical reduction with femoral osteotomy and triple
pelvic osteotomy, in two separate procedures 2 months apart. C. Outcome at 26 years of age. D. Excellent range of motion, pain with prolonged standing.
Fig. 15. Colonna procedure: approach, wrapping of the femoral head, and
deepening of the acetabular cavity.
Fig. 14. A. Recurrent dislocation after surgery with no femoral osteotomy. B. Repeat
surgical reduction.
Avascular necrosis of the femoral epiphysis is a dreaded addition to hip reduction, correction of the femoral and acetabu-
compli- cation if it causes a severe deformity of the proximal lar abnormalities is needed to ensure that the reduction is stable
femur [27,28]. This complication is iatrogenic: it does not occur
in untreated con- genital hip dislocation. Severity varies from a
minor disturbance in epiphyseal growth, occasionally with coxa
magna of good progno- sis, to complete necrosis with deformity
of the femoral head and shortening or a change in orientation of
the femoral neck.
Avascular necrosis may be due to excessive traction or direct
surgical injury to the posterior blood vessels [29]. Another cause
is excessive hip abduction during the period of immobilisation.
Finally, when the femur is not shortened, excessive pressure on
the femoral head may result in avascular necrosis (Fig. 18).
The prevention of avascular necrosis relies on preoperative
trac- tion and, above all, shortening of the femur, which is a
simple and effective measure that has no adverse effects. The
femur can cor- rect the length discrepancy by a growth spurt due
to deperiostation during the osteotomy and to removal of the
fixation material.
The adverse consequences of avascular necrosis of the
femoral epiphysis vary. However, the risk of early osteoarthritis
is high [30].
7. Conclusion
Ideally, the treatment of congenital hip dislocation is non-
operative. If this method fails, surgical reduction is required.
In patients aged 6 to 12 months, surgical reduction can be
achieved via the anterior or obturator approach. No additional
pro- cedures are needed. In our experience, about half of the
patients subsequently require treatment for residual dysplasia.
In patients older than 4 years of age who require surgery, in
before performing the capsulorrhaphy. These additional bony
pro- cedures ensure optimal hip stability and minimise the
risk of residual dysplasia. Femoral shortening and derotation
osteotomy (classically reserved in the past for patients older
than 3 years) is a useful and prudent measure that lessens
the pressure on the femoral epiphysis, facilitates reduction,
and decreases the risk of recurrent dislocation and avascular
necrosis. We there- fore recommend combining this osteotomy
with the surgical reduction.
Disclosure of
interest
Fig. 18. Severe avascular necrosis of the femoral epiphysis after surgical
reduction without femoral shortening.
The author declares that he has no competing interest.
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